United States District Court, M.D. Tennessee, Northeastern Division
Honorable Waverly D. Crenshaw, Jr., Chief United States
REPORT AND RECOMMENDATION
BROWN UNITED STATES MAGISTRATE JUDGE
before the court is Plaintiff's motion for judgment on
the administrative record (Docket Entry No. 16), to which
Defendant Commissioner of Social Security
(“Commissioner”) filed a response (Docket Entry
No. 22). Upon consideration of the parties' filings and
the transcript of the administrative record (Docket Entry No.
10),  and for the reasons given herein, the
Magistrate Judge RECOMMENDS that
Plaintiff's motion for judgment be
GRANTED and that the decision of the
Commissioner be REVERSED and REMANDED for
further administrative proceedings consistent with this
Report and Recommendation.
John Thomas Trobaugh, filed an application for Disability
Insurance Benefits (“DIB”) under Title II and an
application for Supplemental Security Income
(“SSI”) under Title XVI of the Social Security
Act on May 20, 2015, alleging disability onset as of April 1,
2014, due to back, shoulder, carpal tunnel, and diabetes.
(Tr. 10, 68, 249, 254). Plaintiff's claim was denied at
the initial level on September 15, 2015, and on
reconsideration on December 10, 2015. (Tr. 10, 128, 138).
Plaintiff subsequently requested de novo review of
his case by an administrative law judge (“ALJ”).
(Tr. 10, 145). The ALJ heard the case on April 17, 2017, when
Plaintiff appeared with counsel and gave testimony. (Tr. 10,
29-67). Testimony was also received by a vocational expert.
(Tr. 64-66). At the conclusion of the hearing, the matter was
taken under advisement until October 31, 2017, when the ALJ
issued a written decision finding Plaintiff not disabled.
(Tr. 10-24). That decision contains the following enumerated
1. The claimant meets the insured status requirements of the
Social Security Act through June 30, 2020.
2. The claimant has not engaged in substantial gainful
activity since April 1, 2014, the alleged onset date (20 CFR
404.1571 et seq., and 416.971 et seq.).
3. The claimant has the following severe impairments: right
shoulder dysfunction, lumbar degenerative disc disease,
bilateral carpal tunnel syndrome (CTS), diabetes mellitus,
obesity, affective disorder, anxiety disorder, and alcohol
abuse disorder (20 CFR 404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of
impairments that meets or medically equals the severity of
one of the listed impairments in 20 CFR Part 404, Subpart P,
Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526,
416.920(d), 416.925 and 416.926).
5. After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform light work as defined in 20
CFR 404.1567(b) and 416.967(b) except he can only occasional
push, pull, and reach with his right upper extremity and he
can only occasionally climb ladders, ropes, or scaffolds.
Mentally, he can perform simple and detailed, 1-4 step tasks.
Additionally, he can sustain occasional contact with
supervisors, coworkers, and the public and he can adapt to
gradual and infrequent changes in the work routine.
6. The claimant is unable to perform any past relevant work
(20 CFR 404.1565 and 416.965).
7. The claimant was born on June 6, 1972 and was 41 years
old, which is defined as a younger individual age 18-49, on
the alleged disability onset date (20 CFR 404.1563 and
8. The claimant has at least a high school education (20 CFR
404.1564 and 416.964).
9. Transferability of job skills is not material to the
determination of disability because using the
Medical-Vocational Rules as a framework supports a finding
that the claimant is “not disabled, ” whether or
not the claimant has transferable job skills (See SSR 82-41
and 20 CFR Part 404, Subpart P, Appendix 2).
10. Considering the claimant's age, education, work
experience, and residual functional capacity, there are jobs
that exist in significant numbers in the national economy
that the claimant can perform (20 CFR 404.1569, 404.1569(a),
416.969, and 416.969(a)).
11. The claimant has not been under a disability, as defined
in the Social Security Act, from April 1, 2014, through the
date of this decision (20 CFR 404.1520(g) and 416.920(g)).
(Tr. 12, -13, 14-15, 22-23, 24).
April 24, 2018, the Appeals Council denied Plaintiff's
request for review of the ALJ's decision (Tr. 1-5),
thereby rendering that decision the final decision of the
Commissioner. This civil action was thereafter timely filed,
and the Court has jurisdiction. 42 U.S.C. §§ 405(g)
REVIEW OF THE RECORD
following summary of the medical record is taken from the
The medical record shows the claimant sought treatment for
his right shoulder following his injury. Initially he
reported pain and intermittent burning. However, on
examination he had only mild tenderness with full range of
motion, normal strength, and negative orthopedic signs. An
x-ray of his shoulder was also negative (Ex. 3F, p. 31). The
claimant also had a magnetic resonance imaging (MRI) scan of
his shoulder that showed his rotator cuff was intact and he
had only mild acromioclavicular degeneration. However, the
study also showed a superior labral abnormality with a lesion
and paralabral cyst (Ex. 1F, p. 3). He started physical
therapy but was discharged due to non-compliance (Ex. 4F, pp.
16-17). Subsequently, he met with an orthopedic surgeon who
recommended surgery (Ex. 4F, p. 8).
In July 2014, the claimant had arthroscopic surgery on his
right shoulder, including labral repair with decompression
and debridement (Ex. 4F, p. 18). During his follow up
examinations, he showed limited range of motion and residual
weakness. However, his doctor also noted that he had not
started physical therapy as advised. The doctor also noted
that his lack of physical therapy was compromising his
recovery (Ex. 4F, p. 10). When the claimant finally started
physical therapy, he showed improvement (Ex. 4F, p. 11).
In February 2015, the claimant attended his last treatment
appointment for his right shoulder. He continued to report
residual pain and limited range of motion. However, he showed
no joint instability and he had a negative O'Brien's
test. The claimant's surgeon also released him to return
to work but gave him a permanent lifting restriction of 35
pounds with only 15 pounds lifting overhead (Ex. 4F, p. 14).
The claimant testified at the hearing that he has not
returned to see his surgeon since February 2015, and he
attributed this lack of treatment to financial difficulties
In July 2015, Thomas Dake, M.D., an independent consultant,
examined the claimant. The claimant reported residual right
shoulder pain, as well as lower back pain, chronic joint
pain, bilateral wrist pain, and elevated blood sugars.
However, on examination, Dr. Dake noted the claimant had good
blood pressure, normal cardiovascular findings, and he
admitted he had not taken his diabetes medication for several
months. Dr. Dake also found the claimant had limited range of
motion in his right shoulder but otherwise full range of
motion in all extremities. Additionally, the claimant was
missing reflexes, but he had a normal gait, his sensation was
normal, and he had 5/5 motor strength throughout (Ex. 5F, pp.
The claimant also started treatment for his back pain in
November 2015. An x-ray of his back showed only mild
spondylosis and loss of disc height at the L3-5 vertebra (Ex.
13F, p. 3). When he started physical therapy he had bilateral
radiculopathy and mild weakness, but his therapist noted he
had an excellent prognosis (Ex. 22F, pp. 1-3). The only
additional back pain treatment that the claimant has received
has been conservative medication management. He has not
required any epidural steroid injections, emergency room
visits, or surgical intervention (Hearing Testimony).
In January 2016, he had an MRI scan of his lumbar spine. That
study showed disc degeneration at the L3-5 vertebra with a
protrusion at the L4-5 level resulting in mild to moderate
stenosis (Ex. 13F, p. 1).
In March 2016, the claimant reported worsening back pain to
his primary care physician, but he also admitted he was not
taking any medication. His doctor recommended medication and
gave him a referral for a surgical consultant (Ex. 16F, p.
6). The surgeon noted some lumbar tenderness and decreased
range of motion, but also found the claimant had normal
sensation, negative straight leg raising, and 5/5 motor
strength throughout. He concluded that there was nothing in
the radiographic imaging to correlate to the claimant's