Henderson v. Social Security Administration, Commissioner
MEMORANDUM OPINION For the reasons discussed above, the Court finds that the ALJs decision is supported by substantial evidence, and the ALJ applied proper legal standards. The Court may not reweigh the evidence, and the Court may not substitute its judgment for that of the Commissioner. Accordingly, the Court affirms the Commissioner. The Court will enter a separate final judgment consistent with this memorandum opinion. Signed by Judge Madeline Hughes Haikala on 7/30/2016. (KMG)
2016 Jul-30 AM 08:44
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
CAROLYN W. COLVIN,
Commissioner of the
Social Security Administration,
Case No.: 4:14-cv-02141-MHH
Pursuant to 42 U.S.C. § 405(g), plaintiff Marvin Dewayne Henderson seeks
judicial review of a final adverse decision of the Commissioner of Social Security.
The Commissioner denied Mr. Henderson’s claim for disability insurance benefits.
After careful review, the Court affirms the Commissioner’s decision.
Mr. Henderson applied for disability insurance benefits on October 20, 2011.
(Doc. 5-6, p. 13). Mr. Henderson alleges that his disability began on December 23,
2005. (Doc. 5-6, p. 13). The Commissioner initially denied Mr. Henderson’s
claim on December 6, 2011. (Doc. 5-5, p. 2). Mr. Henderson requested a hearing
before an Administrative Law Judge (ALJ). (Doc. 5-5, p. 12). The ALJ issued an
unfavorable decision on March 7, 2013. (Doc. 5-3, pp. 15-24). On September 4,
2014, the Appeals Council declined Mr. Henderson’s request for review (Doc. 5-3,
p. 2), making the Commissioner’s decision final and a proper candidate for this
Court’s judicial review. See 42 U.S.C. § 405(g).
STANDARD OF REVIEW
The scope of review in this matter is limited. “When, as in this case, the
ALJ denies benefits and the Appeals Council denies review,” the Court “review[s]
the ALJ’s ‘factual findings with deference’ and [his] ‘legal conclusions with close
scrutiny.’” Riggs v. Comm’r of Soc. Sec., 522 Fed. Appx. 509, 510-11 (11th Cir.
2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).
The Court must determine whether there is substantial evidence in the record
to support the ALJ’s findings. “Substantial evidence is more than a scintilla and is
such relevant evidence as a reasonable person would accept as adequate to support
a conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir.
2004). In making this evaluation, the Court may not “decide the facts anew,
reweigh the evidence” or substitute its judgment for that of the ALJ. Winschel v.
Comm’r of Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011) (internal
quotations and citation omitted). If the ALJ’s decision is supported by substantial
evidence, the Court “must affirm even if the evidence preponderates against the
Commissioner’s findings.” Costigan v. Comm’r, Soc. Sec. Admin., 603 Fed. Appx.
783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158).
With respect to the ALJ’s legal conclusions, the Court must determine
whether the ALJ applied the correct legal standards. If the Court finds an error in
the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide
sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis,
then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d
1143, 1145-46 (11th Cir. 1991).
SUMMARY OF THE ALJ’S DECISION
To determine whether a claimant has proven that he is disabled, an ALJ
follows a five-step sequential evaluation process. The ALJ considers:
(1) whether the claimant is currently engaged in substantial gainful
activity; (2) whether the claimant has a severe impairment or
combination of impairments; (3) whether the impairment meets or
equals the severity of the specified impairments in the Listing of
Impairments; (4) based on a residual functional capacity (“RFC”)
assessment, whether the claimant can perform any of his or her past
relevant work despite the impairment; and (5) whether there are
significant numbers of jobs in the national economy that the claimant
can perform given the claimant’s RFC, age, education, and work
Winschel, 631 F.3d at 1178.
In this case, the ALJ found that Mr. Henderson did not engage in substantial
gainful activity from December 23, 2005, the alleged onset date, through
September 30, 2011, the date on which Mr. Henderson was last insured. (Doc. 5-3,
The ALJ determined that Mr. Henderson suffers from the severe
impairment of “status post right hand amputation below the elbow.” (Doc. 5-3, p.
The ALJ also noted that Mr. Henderson has the following non-severe
impairments: low back strain, mild degenerative disc disease, depression, and
anxiety. (Doc. 5-3, pp. 18-19). Based on a review of the medical evidence, the
ALJ concluded that Mr. Henderson does not have an impairment or combination of
impairments that meets or medically equals the severity of the listed impairments
in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Doc. 5-3, pp. 19-20).
Next, the ALJ evaluated Mr. Henderson’s residual functional capacity in
light of his impairments. The ALJ determined that through the date last insured,
Mr. Henderson had the residual functional capacity to:
perform light work as defined in 20 CFR 404.1567(b) except that he
cannot push/pull with the right upper extremity. He is also unable to
engage in gross or fine manipulation (handling, finger, or feeling)
with the right upper extremity. He can frequently climb ramps and
stairs but never climb ladders, ropes, or scaffolds. He can frequently
balance, stoop, kneel, and crouch but only occasionally crawl. He
should avoid operation and control of hazardous and moving
machinery and should also avoid exposure to unprotected heights.
[Mr. Henderson’s] right arm can be used for guiding and supporting.
(Doc. 5-3, p. 20). Based on this RFC, the ALJ concluded that through the date last
insured, Mr. Henderson was unable to perform his past relevant work as a press
operator. However, relying on testimony from a vocational expert, the ALJ found
that through the date last insured, jobs existed in the national economy that Mr.
Henderson could perform, including cashier, ticket seller/taker, and cleaner. (Doc.
5-3, pp. 22-23). Accordingly, the ALJ determined that Mr. Henderson is not
disabled within the meaning of the Social Security Act. (Doc. 5-3, p. 24).
Mr. Henderson argues that he is entitled to relief from the ALJ’s decision
because the ALJ failed to properly consider the opinion of treating physician, Dr.
Paul Sykes, and because the ALJ failed to properly apply the Eleventh Circuit pain
standard. The Court examines each issue in turn.
Substantial evidence supports the ALJ’s decision to give little
weight to the opinion of Dr. Sykes.
The ALJ “must state with particularity the weight given to different medical
opinions and the reasons therefor.”
Winschel, 631 F.3d at 1179. “Absent good
cause, an ALJ is to give the medical opinions of treating physicians substantial or
considerable weight.” Id. (internal quotation marks and citations omitted). Good
cause exists when “(1) [the] treating physician’s opinion was not bolstered by the
evidence; (2) [the] evidence supported a contrary finding; or (3) [the] treating
physician’s opinion was conclusory or inconsistent with the doctor’s own medical
records.” Phillips v. Barnhart, 357 F.3d 1232, 1240-41 (11th Cir. 2004); see also
Crawford, 363 F.3d at 1159. “With good cause, an ALJ may disregard a treating
physician’s opinion, but he must clearly articulate the reasons for doing so.”
Winschel, 631 F.3d at 1179 (internal quotation marks and citation omitted).
In this case, the ALJ articulated specific reasons for affording Dr. Sykes’s
opinion little weight. The ALJ stated that Dr. Sykes’s opinion “is inconsistent with
the doctor’s own treatment records of the claimant, inconsistent with the claimant’s
travels abroad during the time he was being treated by Dr. Sykes, and inconsistent
with the claimant’s functional independence in his activities of daily living.” (Doc.
5-3, p. 22). Substantial evidence supports this determination.
Dr. Sykes completed a physical capacities evaluation (PCE) form for Mr.
Henderson on January 27, 2012. (Doc. 5-8, p. 77). Dr. Sykes indicated that Mr.
Henderson can lift and carry 10 pounds occasionally or less frequently, sit for up to
8 hours, stand or walk for up to 8 hours, and occasionally perform pushing and
pulling, climbing, fine and gross manipulation, bending and reaching. (Doc. 5-8,
p. 77). According to Dr. Sykes, Mr. Henderson can operate a motor vehicle, but he
cannot work around hazardous machinery or stoop. (Doc. 5-8, p. 77).
Dr. Sykes also completed a clinical assessment of pain (CAP) form on
January 27, 2012. (Doc. 5-8, pp. 78-79). Dr. Sykes opined that Mr. Henderson has
pain that is distracting to adequate performance of daily activities and work, that
physical activity would cause greatly increased pain, and that Mr. Henderson has
some side-effects from medication but not to such a degree as to create serious
problems in most instances. (Doc. 5-8, pp. 78-79).
Mr. Henderson first saw Dr. Sykes on August 9, 2011. (Doc. 5-8, p. 63).
Mr. Henderson complained that he had experienced phantom limb pain since 2006
after doctors amputated his right hand in 2005. Mr. Henderson had just returned
from an extended visit to the Philippines, and he was re-establishing residency in
the Birmingham, Alabama area. (Doc. 5-8, p. 63). Mr. Henderson reported that
his pain was constant, but the intensity of the pain varied. Dr. Sykes found that
Mr. Henderson had good range of motion at the right elbow and allodynia, or a
painful sensation, in the right forearm to light touch. (Doc. 5-8, p. 63). Mr.
Henderson had full strength in his upper left arm and both lower extremities. His
gait was steady and unstressed.
(Doc. 5-8, p. 63). Dr. Sykes instructed Mr.
Henderson to continue using his TENS unit for pain relief, and Dr. Sykes increased
Mr. Henderson’s Gabapentin dosage. Dr. Sykes asked Mr. Henderson to return in
six to eight weeks. (Doc. 5-8, p. 63).
On October 14, 2011, Mr. Henderson saw Dr. Sykes again. (Doc. 5-8, p.
62). Mr. Henderson was scheduled to return to the Philippines for about three
weeks to announce his engagement with his fiancé’s family. (Doc. 5-8, p. 62).
Mr. Henderson reported that his TENS unit and medication were somewhat helpful
in relieving his pain. (Doc. 5-8, p. 62). Mr. Henderson intermittently used Pritiq
to help his mood. Mr. Henderson explained that he was planning to start school to
become a pharmacy technician. (Doc. 5-8, p. 62).
During the October 2011 visit, Dr. Sykes found that with the exception of
his upper right extremity, Mr. Henderson had full strength. His gait was steady
and unstressed. Dr. Sykes noted that Mr. Henderson was awake, alert, and in no
acute distress. (Doc. 5-8, p. 62). Dr. Sykes recommended that Mr. Henderson take
Pristiq as prescribed because Dr. Sykes believed the medication might help with
Mr. Henderson’s neuropathic pain and his mood swings. Dr. Sykes refilled Mr.
Henderson’s Gabapentin and added Baclofen. Dr. Sykes instructed Mr. Henderson
to follow up in two to three months. (Doc. 5-8, p. 62).
On January 16, 2012, Mr. Henderson reported to Dr. Sykes that he was
“doing okay on the whole.” (Doc. 5-8, p. 61). Mr. Henderson had just returned
from the Philippines and was engaged. He was having some panic attacks and
anxiety, but he was not using Pristiq as Dr. Sykes had ordered. Upon examination,
Mr. Henderson had “[f]ull strength in all 4 extremities except for right upper
extremity. . . .”
(Doc. 5-8, p. 61).
Mr. Henderson’s gait was steady and
unstressed. (Doc. 5-8, p. 61). Dr. Sykes instructed Mr. Henderon to resume
Pristiq, participate in an exercise program, and follow up in four months. (Doc. 58, p. 61).
On May 16, 2012, Mr. Henderson reported to Dr. Sykes that his medication
had helped his symptoms. (Doc. 5-8, p. 60). Mr. Henderson reported no side
effects or sedation from the medication. Mr. Henderson explained that he was in
the process of making arrangements for his fiancé to move to the United States.
Dr. Sykes recorded unremarkable examination findings other than Mr.
Henderson’s strength in his right upper extremity. Dr. Sykes continued Baclofen
and Pritiq and instructed Mr. Henderson to return in six months. (Doc. 5-8, p. 60).
Dr. Sykes’s treatment records suggest that Mr. Henderson responded to pain
medication. Mr. Henderson was able to spend several months out of the country.
Dr. Sykes suggested that Mr. Henderson exercise. With the exception of his right
upper extremity, Mr. Henderson consistently demonstrated a full range of motion
in all extremities, and his gait was normal. The record contains no evidence
suggesting that Mr. Henderson’s pain was so extreme that he required follow-up
visits other than the visits that Dr. Sykes recommended every three to six months.
Mr. Henderson’s desire to return to school to become a pharmacy technician
suggests that he considers himself capable of attending classes and finding
Moreover, until he became engaged in 2012, Mr. Henderson lived alone and
cared for all of his personal needs. Mr. Henderson testified that he could perform
household chores and cook. (Doc. 5-3, p. 47). Mr. Henderson cleans, does
laundry, dusts, washes dishes, and takes out the trash. (Doc. 5-7, p. 44). Mr.
Henderson also indicated that he has no trouble writing with a pen or pencil, typing
on a keyboard, or grasping and turning a doorknob. (Doc. 5-7, p. 41).
Dr. Sykes’s evaluation of Mr. Henderson in the PCE and CAP forms is
inconsistent with Dr. Sykes’s treatment records and the evidence regarding Mr.
Henderson’s daily activities. Thus, the Court finds good cause to give less weight
to the PCE and CAP forms that Dr. Sykes completed; the ALJ’s decision is
supported by substantial evidence. See e.g., Phillips, 357 F.3d at 1241 (substantial
evidence supported the ALJ’s decision to give less weight to the treating
physician’s opinion because the treating physician’s assessment conflicted with his
treatment notes and the claimant’s testimony regarding her daily activities);
Crawford, 363 F.3d at 1159-61 (finding that substantial evidence supported the
ALJ’s decision to discredit the opinions of the claimant’s treating physicians where
those physicians’ opinions regarding the claimant’s disability were inconsistent
with the physicians’ treatment notes); see also Evans v. Comm’r of Soc. Sec.
Admin., 551 Fed. Appx. 521, 524 (11th Cir. 2014) (substantial evidence supported
the ALJ’s decision to reject the treating physician’s opinion because the opinion
was not supported by the physician’s medical findings and was inconsistent with
the claimant’s self-reported daily activities, which included various household
chores, driving, shopping, and visiting with friends and family).
As part of his argument concerning the ALJ’s treatment of Dr. Sykes’s
opinion, Mr. Henderson cites a January 2, 2013 report from Dr. Matthew Berke.
(Doc. 7, p. 6). Dr. Berke examined Mr. Henderson at Dr. Sykes’s request. (Doc.
5-9, p. 12).
Mr. Henderson complained of “significant symptoms of aching,
numbness, pins and needles, burning, stabbing, and hypersensitivity.” (Doc. 5-9,
p. 12). Mr. Henderson rated his pain as a 10 on a 10-point pain scale. Dr. Berke
noted that Mr. Henderson had a history of epidural blocks that provided little relief
and that Mr. Henderson had visited a pain clinic. Dr. Berke also noted that Mr.
Henderson’s TENS unit did not help relive his pain. Dr. Berke reviewed an MRI
that revealed “mild narrowing of the right C4-5 neural foramen secondary to mild
lateral disc bulge.” (Doc. 5-9, p. 12).
Dr. Berke found that Mr. Henderson had a painful range of motion of the
cervical spine with left and right rotation and giveaway weakness with right elbow
Mr. Henderson’s left upper extremity
flexion and sensitivity to light touch.
strength was 5/5. Dr. Berke concluded that Mr. Henderson “appears to have
significant complex regional pain syndrome w[ith] phantom limb pain.
Henderson’s] pain is poorly compensated for an[d] is not [responsive] to
medications or injections. This is a very difficult problem to manage.” (Doc. 5-9,
p. 12). Dr. Berke changed Mr. Henderson’s pain medication and observed that Mr.
Henderson might need to go to a pain clinic again to see a pain psychologist who
could teach Mr. Henderson biofeedback and relaxation skills. Dr. Berke planned
to follow-up with Mr. Henderson in one month to see if the new prescription pain
medication was helping Mr. Henderson and to decide whether Mr. Henderson
would also benefit from treatment at a pain clinic. (Doc. 5-9, p. 12).
The ALJ did not mention Dr. Berke’s records in his opinion. This may be
because Dr. Berke examined Mr. Henderson approximately 15 months after
September 11, 2011, the date on which Mr. Henderson was last insured.
Therefore, Dr. Berke’s report is “relevant only for the light it sheds, if any, on [Mr.
Henderson’s] condition as it existed” on September 30, 2011.
Schweiker, 651 F.2d 306, 310 n.3 (5th Cir. Unit A. July 1981).1 It is not clear from
Dr. Berke’s report whether he believed that Mr. Henderson had suffered the same
degree of pain for years or whether he determined that Mr. Henderson’s pain had
worsened over the years. Moreover, the administrative record contains no other
medical records from Dr. Berke, so the ALJ would not have been able to determine
whether the adjustment that Dr. Berke made to Mr. Henderson’s prescription
medication relieved Mr. Henderson’s pain. Consequently, Dr. Berke’s belated
diagnosis (for purposes of Mr. Henderson’s application) is not sufficient to cause
the ALJ to adjust his assessment of the PCE and CAP evaluation forms that Dr.
Anderson is binding in the Eleventh Circuit. See Bonner v. City of Prichard, 661 F.2d 1206,
1209 (11th Cir. 1981) (en banc) (explaining that the Eleventh Circuit adopted as binding
precedent all decisions of the former Fifth Circuit handed down before October 1, 1981).
Disability insurance benefits claimants “must show that they were disabled on or before their
last-insured date.” Mason v. Comm’r of Soc. Sec., 430 Fed. Appx. 830, 831 (11th Cir. 2011)
(citing Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005).
Sykes completed after Mr. Henderson’s last-insured date and nearly one year
before Mr. Henderson visited Dr. Berke.
The ALJ properly evaluated Mr. Henderson’s subjective
complaints of pain.
“To establish a disability based on testimony of pain and other symptoms,
the claimant must satisfy two parts of a three-part test by showing ‘(1) evidence of
an underlying medical condition; and (2) either (a) objective medical evidence
confirming the severity of the alleged pain; or (b) that the objectively determined
medical condition can reasonably be expected to give rise to the claimed pain.’”
Zuba-Ingram v. Commissioner of Social Sec., 600 Fed. Appx. 650, 656 (11th Cir.
(2015) (quoting Wilson v. Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002) (per
curiam)). A claimant’s testimony coupled with evidence that meets this standard
“is itself sufficient to support a finding of disability.” Holt v. Sullivan, 921 F.2d
1221, 1223 (11th Cir. 1991) (citation omitted). If the ALJ discredits a claimant’s
subjective testimony, the ALJ “must articulate explicit and adequate reasons for
doing so.” Wilson, 284 F.3d at 1225. “While an adequate credibility finding need
not cite particular phrases or formulations[,] broad findings that a claimant lacked
credibility . . . are not enough. . . .” Foote v. Chater, 67 F.3d 1553, 1562 (11th Cir.
1995) (per curiam).
In this case, the ALJ summarized Mr. Henderson’s testimony. (Doc. 5-3, p.
The ALJ then properly recited the pain standard and found that Mr.
Henderson’s “medically determinable impairments could reasonably be expected
to cause some of the alleged symptoms.”
(Doc. 5-3, p. 21).
The ALJ also
articulated adequate reasons for rejecting Mr. Henderson’s testimony about the
severity of his pain.
At his hearing, Mr. Henderson testified that he could not work because of
phantom limb pain, PTSD, anxiety, and sleep apnea. (Doc. 5-3, p. 38). Mr.
Henderson explained that the burning associated with his phantom limb pain
“never stops. It never. It never lets down, and it’s worse in the wintertime because
it’s very sensitive to hot and cold.” (Doc. 5-3, pp. 38-39). According to Mr.
Henderson, taking a shower is painful, and “it hurts to lift my arm. Any kind of
movement or lifting. It’s very, it’s very hypersensitive to touch.” (Doc. 5-3, p.
39). Mr. Henderson testified that his pain is “constant” and averaged an eight on a
ten point scale. (Doc. 5-3, p. 40). Mr. Henderson stated that he spends about six
hours a day lying on the couch because he “hate[s] to move.” (Doc. 5-3, p. 42).
Mr. Henderson testified that his medication provides little relief. (Doc. 5-3, pp.
When evaluating a claimant’s subjective symptoms, the ALJ may consider:
(1) the claimant’s daily activities; (2) the nature and intensity of pain and other
symptoms; (3) precipitating and aggravating factors; (4) effects of medications; (5)
treatment or measures taken by the claimant for relief of symptoms; and (6) other
factors concerning functional limitations. Moreno v. Astrue, 366 Fed. Appx. 23,
28 (11th Cir. 2010) (citing 20 C.F.R. § 404.1529(c)(3)). With respect to Mr.
Henderson’s subjective complaints, the ALJ explained:
In terms of the claimant’s alleged disability, the undersigned points
out that the claimant’s treatment records document that he was
hospitalized for five days following his initial injury, then attended
physical therapy and was discharged in June 2006. Since that time,
and through his date last insured, his pain has been managed by
medication and his activities were not significantly compromised. For
example, he met a woman on the internet, traveled to the Philippines
on two separate occasions for extended periods of time, and was
recently married to her. He lived alone during the entire relevant
period until his wife arrived in the United States. He was independent
in all activities of daily living and remains so – personal care,
cooking, driving, housework, shopping, paying bills and handling
household finances . . . . Further, he reported that he was able to
manage his pain to such a degree that he could travel alone and stay
for multiple weeks outside of the United States. He has effectively
managed his workers’ comp settlement to the degree to be able to live
off of it for several years. While he does not use his prosthetic, he
learned how to use it and had, through occupational therapy wherein
he learned to be proficient with his non-dominant left hand and again,
live independently. His physical examinations, with the exception of
the amputation, have been essentially unremarkable. Pain
Management’s records reflect that his pain was controlled by
medication. Records obtained from Dr. Sykes indicate continuation
of pain control without report of any findings or concerns about the
impairment caused limitation of function, including traveling abroad.
The claimant’s depression and anxiety appeared to be nothing more
than situational, and not chronic, acute, or requiring anything other
than occasional medication. While he has had some mild problems
and additional medical treatment after his date last insured, there is
nothing to suggest that they were the result of any significant,
undiscovered problems existing through his date last insured.
(Doc. 5-3, pp. 21-22).
The ALJ found that Mr. Henderson’s complaints of pain were not credible in
light of his daily activities, ability to travel, and relatively conservative treatment
history. Substantial evidence supports the ALJ’s adverse credibility finding. See
e.g., Moore, 405 F.3d at 1212 (substantial evidence supported the ALJ’s credibility
determination where the ALJ questioned the claimant’s contention that she could
not perform light work “in light of her ability to drive, provide childcare, bathe and
care for herself, exercise, and perform housework”); Crow v. Comm’r of Soc. Sec.
Admin., 571 Fed. Appx. 802, 805, 808 (11th Cir. 2014) (substantial evidence
supported ALJ’s adverse credibility finding where the claimant’s “treatment was
largely medication management, with few, if any, recommendations for more
aggressive treatment”; the claimant’s treating physician did not indicate any
significant physical limitations; and the claimant testified that he “had no personal
care issues, and was capable of driving and shopping at least once a week”).
For the reasons discussed above, the Court finds that the ALJ’s decision is
supported by substantial evidence, and the ALJ applied proper legal standards.
The Court may not reweigh the evidence, and the Court may not substitute its
judgment for that of the Commissioner.
Accordingly, the Court affirms the
Commissioner. The Court will enter a separate final judgment consistent with this
DONE and ORDERED this July 30, 2016.
MADELINE HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE
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