Watkins v. Social Security Administration, Commissioner

Filing 11

MEMORANDUM OPINION Signed by Chief Judge Karon O Bowdre on 3/20/17. (SAC )

FILED
2017 Mar-20 PM 01:24
U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF LABAMA
SOUTHERN DIVISION
NATHANIEL WATKINS,

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CLAIMANT,
v.

NANCY A. BERRYHILL,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
RESPONDENT.

CIVIL ACTION NO.
2:15-CV-1508-KOB

MEMORANDUM OPINION
I. INTRODUCTION
On September 28, 2012, the claimant, Nathaniel Watkins, protectively applied for
disability benefits under Title II of the Social Security Act. (R. 62, 116-17). In his
application, the claimant alleged disability beginning on June 25, 2011, because of
degenerative joint disease, osteoarthritis in his left knee, lumbar degenerative disc
disease, obesity, chronic and severe pain, hypertension, and diabetes mellitus. (R. 14-15).
The Commissioner denied the claims on December 12, 2012. The claimant filed a timely
request for a hearing before an Administrative Law Judge, and the ALJ held a video
hearing on March 10, 2014. (R. 24-45).
In a decision dated April 11, 2014, the ALJ found that the claimant was not
disabled as defined by the Social Security Act and was, therefore, ineligible for social
security benefits. (R. 12-20). On August 6, 2015, the Appeals Council denied the
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claimant’s requests for review. (R. 1-5). Consequently, the ALJ’s decision became the
final decision of the Commissioner of the Social Security Administration. The claimant
has exhausted his administrative remedies, and this court has jurisdiction pursuant to 42
U.S.C. §§405(g) and 1383(c)(3). For the reasons stated below, this court affirms the
decision of the Commissioner.
II. ISSUE PRESENTED
Whether substantial evidence supports the little weight that the ALJ gave to the
opinion of the claimant’s treating physician Dr. William Hall.
III. STANDARD OF REVIEW
The standard for reviewing the Commissioner’s decision is limited. This court
must affirm the ALJ’s decision if she applied the correct legal standards and if substantial
evidence supports her factual conclusions. See 42 U.S.C. § 405(g); Graham v. Apfel, 129
F.3d 1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
“No…presumption of validity attaches to the [Commissioner’s] legal conclusions,
including determination of the proper standards to be applied in evaluating claims.”
Walker, 826 F.2d at 999. This court does not review the Commissioner’s factual
determinations de novo. The court will affirm those factual determinations that are
supported by substantial evidence. “Substantial evidence” is “more than a mere scintilla.
It means such relevant evidence as a reasonable mind might accept as adequate to support
a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971).
The court must keep in mind that opinions, such as whether a claimant is disabled,
the nature and extent of a claimant’s residual functional capacity, and the application of
vocational factors, “are not medical opinions,…but are, instead, opinions on issues
reserved to the Commissioner because they are administrative findings that are
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dispositive of a case; i.e., that would direct the determination or decision of disability.”
20 C.F.R. §§ 404.1527(d), 416.927(d). Whether the claimant meets a Listing and is
qualified for Social Security disability benefits is a question reserved for the ALJ, and the
court “may not decide facts anew, reweigh the evidence, or substitute [its] judgment for
that of the Commissioner.” Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005).
Thus, even if the court were to disagree with the ALJ about the significance of certain
facts, the court has no power to reverse that finding as long as substantial evidence in the
record supports it.
The court must “scrutinize the record in its entirety to determine the
reasonableness of the [Commissioner]’s factual findings.” Walker, 826 F.2d at 999. A
reviewing court must not only look to those parts of the record that support the decision
of the ALJ, but also must view the record in its entirety and take account of evidence that
detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180
(11th Cir. 1986).
IV. LEGAL STANDARD
Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when
the person is unable to “engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in
death or which has lasted or can be expected to last for a continuous period of not less
than 12 months….” 42 U.S.C. § 423(d)(1)(A). To make this determination the
Commissioner employs a five-step, sequential evaluation process:
(1) Is the person presently unemployed?
(2) Is the person’s impairment severe?
(3) Does the person’s impairment meet or equal one of the specific
impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?
(4) Is the person unable to perform his or her former occupation?
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(5) Is the person unable to perform any other work within the economy?
An affirmative answer to any of the above questions leads either to the
next question, or, on steps three and five, to a finding of disability. A
negative answer to any question, other than step three, leads to a
determination of “not disabled.”
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986); 20 C.F.R. §§ 404.1520,
416.920.
V. FACTS
The claimant was sixty-three years old at the time of the ALJ’s final decision (R.
27); has a college education (R. 174); has past relevant work as a customer service
representative (R. 42-43); and alleges disability based on degenerative joint disease,
osteoarthritis in his left knee, lumbar degenerative disc disease, obesity, chronic and
severe pain, hypertension, and diabetes mellitus (R. 14-15).
Physical Impairments
In 2008, the claimant sought treatment with Dr. William Hall at Arlington Health
Center on February 4 and September 25 for chronic neck and back pain that resulted from
a prior car accident. 1 He also returned to Dr. Hall on December 19 complaining of hand
cramps, shoulder pain, and tingling in his left leg. Dr. Hall prescribed Neurontin for
nerve pain. (R. 242-47).
The claimant saw Dr. Hall on March 16, April 21, and September 30, 2009,
complaining of hand cramps or pain, shoulder pain, and leg swelling. At the September
30 visit, the claimant indicated that he fell a month prior, but the record gives no details
regarding the fall. (R. 237-241).

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The record does not reflect the date of the prior car accident.
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On December 13, 2009, Dr. Hall ordered a CT of the claimant’s abdomen after he
presented to the Emergency Department at Baptist Princeton complaining of abdominal
pain, back pain, nausea, and vomiting. The CT images revealed that the claimant had
inflammation of his gallbladder and degenerative disc disease at L4-L5 and L5-S1. (R.
231-234).
In 2010, the claimant sought treatment with Dr. Hall on April 22 and December
30, both times complaining of neck pain. He also complained of knee, leg, and back pain
at the December visit. Under “Review of Systems: Musc.,” Dr. Hall noted that the
claimant’s musculoskeletal system was abnormal, stating “usual back, neck pain.” (R.
226-228).
The claimant saw Dr. Hall once in 2011, and the notes for that June 14 visit show
that the examination of the claimant’s musculoskeletal system was “normal” and revealed
no issues. (R. 225).
From January to May, 2012, the claimant sought treatment with Dr. Hall on four
occasions for cough-related symptoms, but the claimant did not mention back or neck
pain during any those visits. The claimant did complain of hand and foot cramps during
the April 10 visit. However, Dr. Hall marked the claimant’s musculoskeletal system as
“normal” for all four visits. (R. 217-224).
On August 29, 2012, the claimant presented to Dr. Hall complaining of tingling in
his left leg unrelated to activity and upper leg pain that radiated down his leg. Dr. Hall
ordered an x-ray of the claimant’s left knee that showed degenerative joint disease and
osteoarthritis, with no explanation as to any limitations based on these findings. When
The Disability Examiner Tracy Gulledge wrote Dr. Hall a letter asking him to explain his
finding based on the x-ray, Dr. Hall responded that the claimant had “limited flexion” in
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his knee because of his pain; that the pain increased with standing and walking; and that
he had a limp in his left leg. (R. 216, 259).
A few months later on November 14, 2012, Dr. Hall treated the claimant for back
pain that the claimant stated “hurt all the time.” Dr. Hall noted that the claimant had an
unsteady gait and that he could not sit, stand, or walk without pain and that he had not
started the Neurontin for his tingling. (R. 260).
At the request of the Social Security Administration, Dr. Celtin Robinson, an
internal medical doctor, evaluated the claimant’s physical condition. Dr. Robinson
personally examined the claimant and reviewed his records from Baptist Princeton and
Arlington Health. The claimant reported generalized joint pain “all over” resulting from
a car accident in 2004, including pain in his cervical neck region, left shoulder, hip joint,
knee joint, and lower back. He also stated that his pain is “3-4/10” at rest; that he has
“severe” pain of “6-7/10” in his knee when he stands or walks for more than fifteen
minutes; that he has “been on opioids and acetaminophen since the accident;” and that he
had to discontinue physical therapy and chiropractic help after “the loss of his job” when
the company downsized because he could no longer afford the treatment. (R. 266-267).
Regarding his activities of daily living, the claimant told Dr. Robinson that he
takes care of his personal needs; prepares coffee; watches television for a couple of
hours; prepares a simple meal, but usually eats at a restaurant. He can sweep a room and
make his bed, but his sister does the other household chores. He also reported going to a
restaurant daily and talking to customers.
Dr. Robinson listed the claimant’s medications as Cyclobenzaprine for muscle
spasms; Atenolol/Chlorthalidone, Spironolactone, and Losartan for high blood pressure;
Simvastatin for high cholesterol; and Glyburide for diabetes. In the “Review of Systems”
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section, Dr. Robinson noted that the claimant has “[o]ccasional paresthesias of the left
hand in a glove distribution, which feels like numbness” and that he has “no motor or
sensory deficits.” (R. 267).
During his physical examination of the claimant, Dr. Robinson noted that the
claimant was able to walk into the exam room without assistance; could sit with “mild”
body pain; could get on and off the table; had a normal gait; could toe-heel walk and
squat and rise; had full range of motion in his spine and knees; had no tenderness to
palpation of his hands, legs or joints; had normal motor strength of 5/5; and had a
negative straight leg test. Dr. Robinson’s diagnoses included “Joint pain all over, as per
claimant” and diabetic neuropathy, but he provided no limitations for the claimant. (R.
267-269).
At the request of the claimant’s attorney, Dr. Hall completed a “Physical
Capacities Evaluation” and a “Clinical Assessment of Pain” for the claimant on February
19, 2013. Dr. Hall assessed that the claimant could lift and carry ten pounds occasionally
or less frequently; could sit three hours and stand two hours during an eight-hour work
day; could drive a car; could never push or pull with arm or leg controls, climb ladders,
or stoop; and could occasionally use gross and fine manipulation, bend, and reach. Dr.
Hall marked that the claimant was a “Class II” based on the “New York Heart
Association Classification.” 2 He assessed the claimant’s pain as “present to such an
extent as to be distracting to adequate performance of daily activities or work” and
indicated that physical activity increases the claimant’s pain “to such an extent that

2

A Class II classification indicates a patient with “cardiac disease resulting in slight
limitation of physical activity. They are comfortable at rest. Ordinary physical activity
results in fatigue, palpitation; dyspnea, or angina pain.”
https://www.sunshineheart.com/patients/classifications-of-heart-failure/
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bedrest and/or medication is necessary.” Dr. Hall concluded that the side effects of the
claimant’s medications “totally restrict him” and make him unable to “function at a
productive level of work.” (R. 271-272).
Between April and December 2013, the claimant returned to Dr. Hall on eight
occasions complaining of back, neck and leg pain on April 3, April 10, May 16, June 20,
August 20, October 2, November 4, and December 16. On the physical examination
section of his reports, Dr. Hall marked the claimant’s musculoskeletal system as
“normal” for all these visits except the April 4 and August 20 visits. The claimant
reported limited mobility in his back on April 3, and Dr. Hall gave him trigger point
injection in his back on April 10. The claimant reported severe lumbar disc and cervical
disc pain on May 16, and on August 20 he stated that his leg pain had increased and
worsened when he walked. On November 4, the claimant indicated his back and leg
ached all day and reported “aggravated pain” in his left hip and leg on December 16. (R.
288-299).
The claimant returned to Dr. Hall on January 3, 6, and 16, 2014, complaining of
continued pain in his back that kept him in bed for several days. He received a steroid
and anti-inflammatory shot on January 3, but Dr. Hall marked his musculoskeletal system
physical examination as “normal” during the January 3 and 6 visits. A bone scan of his
spine performed on January 6 was normal. The claimant stated on January 16 that his
back pain initially improved after his shot, but had returned, and Dr. Hall marked his
musculoskeletal system as “abnormal” on this date and gave him a trigger pinpoint
injection in his back. (R. 276-287).
On January 16, 2014, the claimant completed a current medication list. He
indicated he was taking Cyclobenzaprine for muscle spasms; Atenalol and
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Spironolactone for high blood pressure; Lasartan Potassium to protect his kidneys;
Simyastatin for high cholesterol; Glyburide for diabetes; and 800 mg of Ibuprofen and
200 mg of Advil as needed for pain. (R. 207).
The claimant visited Dr. Hall on February 17, 2017, stating that his back pain was
“stable but still present.” Dr. Hall marked the “Musc” section of the “Review of
Systems” as “normal,” but did not check either “normal” or “abnormal” under the
“Musc” section under physical examination. (R. 276).
The ALJ Hearing
At the hearing before the ALJ on March 10, 2014, the claimant testified that he
worked at AT&T as a customer service representative until around June or July 2011. He
said he did not “resign,” but he came out of his job “through the downsizing.” The
claimant stated that he started receiving Social Security in February 2013, and that he
received unemployment benefits for about a year, from 2011 when he stopped working
until sometime in 2012. According to the claimant, he told someone at the
unemployment office that he was unable to work because of his “medical problems,” but
he wanted to work, and they still gave him unemployment benefits. He still has health
insurance through his former employer but has to pay for the benefits. (R. 30-32).
When asked why he cannot work, the claimant testified that has “so many
problems with my back and taking my medicine for my different problems.” He stated
that his medicines “sometimes” make him drowsy, causing him to take longer to do
things in the morning and at work. He testified that he takes Cyclobenzaprine when
needed; he took that medication before he stopped working; and “it makes [him] so
drowsy. He also takes medications that control his high blood pressure. He stated that he
also takes Simvastatin for his cholesterol and Metformin for his diabetes, but his diabetes
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currently is under control. For pain, he takes 800 mgs of Ibuprofen that he says “helps my
pain,” and he sometimes takes 200 mg of Advil in between his Ibuprofen doses. When
the ALJ specifically asked the claimant “Do you have any side effects of your
medication?” he replied “Not that I know of.” He also stated that he changes positions a
lot and uses a heat pad to help with the pain. (R 33-35, 39).
The claimant testified that he weighs about 280 pounds and that he lives with his
brother and sister. Describing a typical day, he stated that he gets up, showers, eats, reads
a little, goes to get coffee at Waffle House for about an hour, and goes back home to
watch television. He can sit and watch a television program for about a half hour, but has
to get up and walk around to loosen his back and then sit back down. Standing for too
long hurts his back and causes pains to go down his left leg, and he can stand in one place
for about ten to fifteen minutes before he starts hurting. (R. 27, 37-38).
He drives to a laundromat a few blocks away every two to three weeks to do his
laundry. The claimant testified that he does not “go out too much,” and the last time he
went on a trip was to Selma about a year ago for a funeral. He does go to the grocery
store and can lift “necessary stuff” but does not do any heavy lifting. (R. 27-30, 39).
A vocational expert, Dr. Russell, 3 testified concerning the type and availability of
jobs that the claimant was able to perform. Dr. Russell testified that the claimant’s past
relevant work was as a customer service representative, classified as sedentary, skilled
work. The ALJ asked Dr. Russell to assume a hypothetical individual the same age,
education, and experience as the claimant with a residual functional capacity to perform
work who can occasionally balance, stoop, kneel, crouch, crawl, and climb ramps and
stairs; never use ladders, ropes, or scaffolds; and can occasionally push and pull with
3

The record does not contain Dr. Russell’s first name.
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bilateral lower extremities. Dr. Russell testified that individual could perform the
claimant’s past work. (R. 41-43).
In his second hypothetical, the ALJ asked Dr. Russell to assume all of the prior
limitations except the individual can only perform sedentary work and must be allowed to
stand and stretch for a minute or two at his work station every hour as needed while
remaining at task. Dr. Russell testified that individual could perform the claimant’s past
work (R. 43-44).
The ALJ’s Decision
On April 11, 2014, the ALJ issued a decision finding that the claimant was not
disabled under the Social Security Act. (R. 12-20). First, the ALJ found that the claimant
met the insured status requirements of the Social Security Act through September 30,
2016, and had not engaged in substantial gainful activity since his alleged onset date of
June 25, 2011. (R. 14).
Next, the ALJ found that the claimant had the severe impairments of degenerative
joint disease and osteoarthritis of the left knee, lumbar degenerative disc disease, and
obesity. However, the ALJ found that the claimant’s diabetes mellitus, hypertension,
cervical disc disease, and generalized joint pain were non-severe impairment. The ALJ
acknowledged his diabetes, but stated that no electrodiagnostic or other objective reports
confirm his diabetic neuropathy. He noted that the claimant had full strength and
sensation in all of his extremities on physical examinations and that he was noncompliant
with taking his Neurontin for the tingling. (R. 14-15).
Regarding his hypertension, the ALJ found that the record does not reflect any
adverse symptoms from his high blood pressure and that the claimant testified that his
medications control it.
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The ALJ acknowledged that the claimant complains of neck pain and that Dr. Hall
diagnosed him with cervical disc disease. However, the ALJ found no objective imaging
in the record to support that diagnosis and stated that no physical examinations of the
claimant revealed any abnormalities in his cervical spine. Therefore, the ALJ concluded
that the claimant’s cervical disc disease was “not medically determinable.” (R. 15).
Likewise, the ALJ found that the claimant’s generalized “joint pain” all over his
body was not a medically determinable impairment because no objective imaging tests
supporting joint pain in any other locations other than the claimant’s knees and lumbar
spine. (R. 15).
The ALJ next found that the claimant did not have an impairment or combination
of impairments that met or medically equaled the severity of one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 17-18). The ALJ
considered whether the claimant met the criteria for Listings 1.02 and 1.04, involving
musculoskeletal and spine disorders and found that the claimant’s impairments met
neither listing because no evidence exists in the record that the claimant has nerve root
compression with motor, sensory, or reflex loss; spinal arachnoiditis; or lumbar spinal
stenosis resulting in an inability to ambulate effectively. The ALJ also considered the
claimant’s obesity in making his determination. (R. 15-16).
Next, the ALJ determined that the claimant has the residual functional capacity to
perform sedentary work except that the claimant can occasionally balance, stoop, kneel,
crouch, crawl, and climb stairs; can never climb ladders, ropes, or scaffolds; can
occasionally push and pull with the bilateral extremities; and must be allowed to stand
and stretch for one to two minutes at his workstation every hour as needed, while
remaining on task. (R. 16).
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In making this finding, the ALJ considered the claimant’s symptoms and
corresponding medical record. The ALJ concluded that, although the claimant’s
medically determinable impairments could reasonably be expected to cause his
symptoms, the claimant’s allegations regarding the intensity, persistence, and limiting
effects of those symptoms were not fully credible when compared with the evidence.
Specifically, the ALJ noted that the objective evidence, treatment history, and physical
examination findings of Dr. Hall do not support the debilitating nature of the claimant’s
alleged degenerative joint disease and osteoarthritis of his left knee. The ALJ
acknowledged the August 2012 x-ray and diagnosis, but he noted that Dr. Hall did not
document any objective signs of any limitations based on those diagnoses.
Regarding the claimant’s lumbar degenerative disc disease, the ALJ noted that the
claimant’s treatment records fail to show the type of “significant clinical and laboratory
abnormalities one would expect if the claimant were in fact disabled.” The ALJ
acknowledged the December 2009 CT that revealed the diagnosis, but noted that the
January 2014 bone scan appeared normal. The ALJ noted that Dr. Hall’s physical
examinations of the claimant “did not document signs of back pain”; that Dr. Hall
repeatedly noted that the claimant’s “musculoskeletal system was normal”; that “even
without signs of pain or limitations on physical examination,” Dr. Hall gave the claimant
a trigger point injection in April 2013; and that the claimant said he was in pain, but Dr.
Hall’s “examinations were negative for any objective signs of limitations.” The ALJ
stated that “no clinical abnormalities [were] documented on physical examination.” (R.
17-18).
The ALJ took into account the claimant’s obesity in finding that it could
reasonably exacerbate his pain in his knee and back, which could cause some limitations.
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Therefore, the ALJ found that, in combination with all of his impairments, the claimant’s
obesity warranted a reduction to sedentary work. (R. 18).
In assessing the intensity of the claimant’s pain, the ALJ noted that the claimant’s
treatment was limited to Ibuprofen and a muscle relaxer, which he claimed he did not
take regularly. The ALJ also referenced the claimant’s hearing testimony that he took
opioid medication for several years while he continued to work; drives; frequents
restaurants with friends; sweeps; and fixes simple meals despite his allegations.
The ALJ gave little weight to the claimant’s treating physician Dr. Hall because
his own treatment records did not support the degree of limitation he attributed to the
claimant. The ALJ pointed out that Dr. Hall’s treatment records showed normal physical
findings despite the claimant’s complaints of pain. After discussing the consulting
examiner Dr. Robertson’s findings in detail, the ALJ noted that Dr. Robertson’s findings
also showed no abnormalities in his physical examination of the claimant.
Based on the record as a whole, his finding that the claimant can perform
sedentary work with the limitations listed in the residual functional capacity, and the
vocational expert’s testimony at the hearing, the ALJ found that the claimant is capable
of performing his past relevant work as a customer service representative. Therefore, the
ALJ concluded that the claimant was not disabled as defined in the Social Security Act.
VI. DISCUSSION
The claimant argues that the ALJ erred in the little weight he gave to the
claimant’s treating physician Dr. Hall. The court disagrees and finds that substantial
evidence supports the ALJ’s reasons for discrediting Dr. Hall’s opinion.
The ALJ must give the testimony of a treating physician substantial or
considerable weight unless “good cause” is shown to the contrary. Crawford v.
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Commissioner, 363 F.3d 1155, 1159 (11th Cir. 2004). The Commissioner may reject any
medical opinion if the evidence supports a contrary finding. Sryock v. Heckler, 764 F.2d
834, 835 (11th Cir. 1985).
An ALJ may discount a treating physician’s opinion when it is conclusory; when
the treating physician fails to provide objective medical evidence to support it; when the
opinion is inconsistent with the record as a whole; or when the evidence otherwise
supports a different conclusion. See 20 C.F.R. § 404.1527(c). Where the ALJ articulates
specific reasons for failing to give the opinion of a treating physician controlling weight
and substantial evidence supports those reasons, the ALJ does not commit reversible
error. Moore v. Barnhart, 405 F.3d 1208, 1212 (11th Cir. 2005).
In the present case, the court finds that substantial evidence supports the reasons
the ALJ gave to discredit the opinion of Dr. Hall. The ALJ gave Dr. Hall’s opinion
regarding the claimant’s limitations little weight because those limitations were
inconsistent with Dr. Hall’s own treatment records. The ALJ pointed out several times
that, although the claimant complained of pain in his knees, back, and legs, Dr. Hall
repeatedly noted the claimant’s musculoskeletal system as “normal” on the physical
examination portion of the treatment records. He also noted that Dr. Hall’s treatment
records showed no clinical abnormalities resulting from his physical examination of the
claimant. Although Dr. Hall’s treatment records do not reflect what he actually did
during his physical examination of the claimant during each visit, his records showed no
indication of any tenderness, limited range of motion, or any other objective sign of
limitations because of the pain for almost all of these visits. Dr. Hall’s assessment of the
claimant’s musculoskeletal system as “normal” even when the claimant reported pain

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supports the ALJ’s finding that Dr. Hall’s records are inconsistent with the severe
limitations he attributed to the claimant based on that pain.
In addition to Dr. Hall’s opinion being inconsistent with his own treatment
records, the ALJ articulated that Dr. Hall’s opinion also contradicted Dr. Robinson’s
findings upon his physical examination of the claimant. Dr. Robinson’s notes indicate
that he performed specific, objective physical examinations of the claimant that showed
the claimant had full range of motion in his spine and knees; had no tenderness to
palpation in his legs or joints; had a normal gait; could toe-heel walk and squat and rise;
and had a negative straight leg test. Interestingly, the claimant reported to Dr. Robinson
that he considered a pain level of “6-7/10” as “severe” pain in his knee when he stands or
walks for more than fifteen minutes. The court notes that the ALJ’s residual functional
capacity determination of sedentary work accounts for the claimant’s complaint regarding
his pain.
The ALJ also noted the conservative nature of Dr. Hall’s treatment of the claimant
for his pain. Dr. Hall treated the claimant’s pain with Ibuprofen and a muscle relaxer,
which the claimant admitted he did not take regularly. The ALJ also noted that Dr. Hall
on several occasions ordered trigger point injections even though his treatment records
showed a “normal” musculoskeletal system during his physical examinations of the
claimant. As of February 17, 2014, the claimant noted his back pain was stable even with
this conservative treatment.
Furthermore, the court notes that Dr. Hall indicated in his assessment that the
claimant could drive, but also assessed that the claimant should “never” push or pull with
arm or leg controls. Dr. Hall’s findings seem inconsistent because driving a car
necessarily involves the use of both arm and leg controls. Moreover, although the
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claimant testified at the hearing that the muscle relaxant Cyclobenzaprine made him
drowsy, Dr. Hall’s treatment records make no mention of the claimant reporting any side
effects of his medication. Also, the claimant testified at the hearing that he had no side
effects from his medications.
The ALJ referenced the claimant’s testimony that he allegedly took opioid
medications for his pain after his accident while he continued to work for years, and that
the claimant continues to drive and frequents the Waffle House daily to have coffee with
his friends. The court agrees with the ALJ that these facts support that Dr. Hall’s opinion
regarding the claimant’s alleged extreme limitations are inconsistent with his own
treatment records and with the record as a whole. Additionally, the court agrees with the
ALJ that, contrary to Dr. Hall’s opinion, the claimant can perform his past relevant work
at a sedentary level.
The claimant argues that the ALJ had the duty to re-contact Dr. Hall because of
these inconsistencies. The court disagrees. An ALJ has a duty to fully and fairly develop
the record. See Lucas v. Sullivan, 918 F.2d 1567, 1573 (11th Cir. 1990). However, the
ALJ is not obligated to re-contact a physician if he finds his medical opinion to be
inconsistent with the record. The Social Security regulations provide that the ALJ “may
[not must] recontact your treating physician, psychologist, or other medical source” to
resolve inconsistencies or insufficiencies in the record. 20 C.F.R. § 404.1520b(c)(1).
In this case, despite Dr. Hall’s inconsistent opinion, the ALJ had substantial
evidence in the record on which to base his opinion that the claimant could perform work
at the sedentary level. The claimant’s testimony, the conservative nature of Dr. Hall’s
treatment of the claimant, and Dr. Robinson’s consultative examination results provided

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substantial evidence in the record, and the ALJ did need to re-contact Dr. Hall to make a
determination.
VII. CONCLUSION
For the reasons as stated, this court concludes that the decision of the
Commissioner is due to be AFFIRMED.
The court will enter a separate Order in accordance with the Memorandum
Opinion.
DONE and ORDERED this 20th day of March, 2017.

____________________________________
KARON OWEN BOWDRE
CHIEF UNITED STATES DISTRICT
JUDGE

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