Lennox v. Commissioner of Social Security

Filing 23

ORDER adopting 21 REPORT AND RECOMMENDATIONS by Commissioner of Social Security. The final decision of the Commissioner of the Social Security Administration denying the claim for Disability Insurance Benefits and Supplemental Security Income benefits is AFFIRMED pursuant to sentence four of 42 U.S.C. § 405(g). The Clerk is directed to enter judgment, accordingly, and CLOSE the file. Signed by Judge Anne C. Conway on 2/21/2017. (JLC)

UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
ORLANDO DIVISION
KIMBERLY ANNE LENNOX,
Plaintiff,
v.

Case No: 6:15-cv-2061-Orl-22MRM

COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

ORDER
This cause is before the Court on Plaintiff Kimberly Anne Lennox’s (“Plaintiff”)
Complaint for review of the final decision of the Commissioner of Social Security (the
“Commissioner”) denying benefits to Plaintiff.
The United States Magistrate Judge submitted a report recommending that the decision of
the Commissioner be AFFIRMED. Doc. 21.
After an independent de novo review of the record in this matter, including the objections
filed by Kimberly Anne Lennox (Doc. 22)1, the Court agrees entirely with the findings of fact and
conclusions of law in the Report and Recommendation.
I. BACKGROUND
The Court briefly sets forth the relevant procedural history. In 2012, Plaintiff filed an
application for supplemental security income, alleging disability beginning on October 2, 2005. R.
at 111, 197-200. After her applications were denied initially and on reconsideration, on May 6,
2014, an Administrative Law Judge (“ALJ”) held a hearing at Plaintiff’s request. R. 36-59, 111,
127. On July 8, 2014, the ALJ issued a decision finding Plaintiff not disabled. R. at 11-30. Based

1 The Commissioner did not file a response to the Objections.

on the ALJ’s residual functional capacity (“RFC”) assessment and the testimony of the vocational
expert, the ALJ found that Plaintiff could perform other work available in the national economy.
R. 29. Plaintiff appealed the ALJ’s decision to the Appeals Council, which denied Plaintiff’s
request for review. R. 1-5. Thereafter, on December 8, 2015, Plaintiff filed her Complaint in this
Court. Doc. 1.
II. LEGAL STANDARDS
A. Review of Magistrate Judge’s Report & Recommendation
In the Eleventh Circuit, a district judge may accept, reject or modify a magistrate judge’s
report and recommendation after conducting a careful and complete review of the findings and
recommendations. 28 U.S.C. § 636(b)(1); Williams v. Wainwright, 681 F.2d 732, 732 (11th Cir.
1982), cert. denied, 459 U.S. 1112, 103 S.Ct. 744, 74 L.Ed.2d 964 (1983). A district judge must
conduct a de novo review of the portions of a magistrate judge’s report and recommendation to
which a party objects. 28 U.S.C. § 636(b)(1) (C). The district judge “may accept, reject, or modify,
in whole or in part, the findings or recommendations made by the magistrate.” Id. This requires
that the district judge “give fresh consideration to those issues to which specific objection has been
made by a party.” Jeffrey S. v. State Bd. of Educ., 896 F.2d 507, 512 (11th Cir.1990) (citing
H.R.Rep. No. 94–1609, 94th Cong., 2nd Sess., reprinted in 1976 U.S.Code Cong. & Admin. News
6162, 6163). A district judge reviews legal conclusions de novo, even in the absence of an
objection. See Cooper–Houston v. Southern Ry., 37 F.3d 603, 604 (11th Cir.1994).
B. Social Security Sequential Evaluation Process
When an ALJ makes a disability determination, the ALJ follows a five-step evaluation
process: (1) whether Plaintiff is currently performing substantial gainful activity; (2) whether
Plaintiff has a severe impairment; (3) whether the severe impairment meets or exceeds an
impairment in the listings; (4) whether the Plaintiff can perform her past relevant work; and (5)
whether Plaintiff can perform other jobs that exist in the national economy. See Wright v. Comm’r
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of Soc. Sec., 327 F. App’x 135, 136–37 (11th Cir. 2009) (per curiam) (citations omitted). The
Plaintiff has the burden of proof on the first four steps; the Commissioner carries the burden on
the fifth step. Id. at 137 (citation omitted).
When reviewing the ALJ’s findings of fact, the Social Security Act mandates that “findings
of the Secretary as to any fact, if supported by substantial evidence, shall be conclusive.” Foote v.
Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (per curiam) (citation omitted). Substantial evidence
is evidence that is “more than a scintilla, i.e., evidence that must do more than create a suspicion
of the existence of the fact to be established, and such relevant evidence as a reasonable person
would accept as adequate to support the conclusion.” Id. at 1560 (citations omitted). The Court
also reviews de novo the ALJ’s conclusions of law. Ingram v. Comm’r of Soc. Sec., 496 F.3d 1253,
1260 (11th Cir. 2007). If the ALJ fails to apply the correct law or provide the Court with sufficient
reasoning for determining that the proper legal analysis was conducted, then the Court must
reverse. Id. (citation omitted).
III. PLAINTIFF’S OBJECTIONS
Plaintiff’s objections are limited to the findings of the Administrative Law Judge (“ALJ”)
regarding her subjective statements of pain and limitations in her arms and hand from carpal tunnel
syndrome. Doc. 22 at 2-3. At step two of the sequential evaluation, the ALJ found that Plaintiff
suffered from bilateral carpal tunnel syndrome and bilateral ulnar neuropathy in the elbows (in
addition to other impairments about which Plaintiff does not raise an objection). Doc. 21 at 2-3
(citing R. 13). At step four, the ALJ determined that Plaintiff had the residual functional capacity
(“RFC”) to perform a reduced range of light work based on certain limitations, but with “no
limitations regarding manipulation.” Id. at 3-4 (citing R. 18-19). Considering Plaintiff’s age,
education, work experience, and RFC, the ALJ determined that there were jobs that exist in
significant numbers in the national economy that Plaintiff was capable of performing including

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garment sorter, fingerprint clerk, and ticket taker. Id. at 4 (R. at 29). The ALJ accordingly
concluded that Plaintiff had not been under a disability from May 29, 2012. Id (R. at 30).
Plaintiff contends the ALJ erred in finding at step two of the sequential evaluation process
that her carpal tunnel syndrome was a severe impairment (R. 13), but then discounted her
testimony regarding her hand limitations in assessing her credibility. As the Magistrate Judge
found, “Plaintiff relies, almost exclusively, on her own subjective testimony to support her claim
that her carpal tunnel syndrome renders her unable to perform work.” Doc. 21 at 6 (citing Doc. 19
at 10-11). The Magistrate Judge discussed the relevant medical records related to Plaintiff’s arm
and hand complaints at some length and determined that her condition had improved:
The ALJ noted that on September 4, 2012, upon a physical examination,
Plaintiff was found to have positive bilateral Tinel’s and Phalen’s signs. (Tr. at 20).
Further, the ALJ cited to Dr. Jaleel’s September 26, 2010 records showing Plaintiff
was diagnosed with bilateral carpal tunnel syndrome. (Tr. at 20, 25). The ALJ found
that “[n]one of the claimant’s treating physicians have identified any specific jobrelated limitations.” (Tr. at 24).
The [Magistrate Judge has] reviewed the medical records cited by the ALJ.
On July 18, 2012, Plaintiff saw Fiaz Jaleel, M.D. at Florida Pain Solutions, LLC
complaining of chronic pain, including pain in the neck, lower back, and left elbow.
(Tr. at 648). Dr. Jaleel diagnosed Plaintiff with, inter alia, carpal tunnel syndrome.
(Tr. at 650). Dr. Jaleel prescribed medication for the pain and numbness in
Plaintiff’s hands. (Tr. at 650). Plaintiff returned on August 1, 2012, for chronic
pain, including pain in her hands. (Tr. at 646). Dr. Jaleel found Plaintiff’s upper
extremities “revealed a vaguely positive Tinel’s signs for the median nerve at the
wrist. She had a positive Tinel’s sign for the ulnar nerve at the elbow bilaterally,
but more so on the left side. Strength testing in the hands was within normal limits.”
(Tr. at 647). Dr. Jaleel prescribed a different medication for the numbness, tingling,
and pain in Plaintiff’s upper extremities. (Tr. at 647). On August 29, 2012, Plaintiff
returned to Dr. Jaleel reporting continued pain, numbness, and tingling in her hands.
(Tr. at 644). Dr. Jaleel administered two injections, one in the left ulnar nerve area
and one in the right carpal canal. (Tr. at 645). Plaintiff stated that these injections
appeared to help. (Tr. at 645).
On September 4, 2012, Plaintiff visited the Central Florida Family Health
Center in Sanford, Florida and a physical examination resulted in positive Phalen
and Tinel signs bilaterally. (Tr. at 827). On September 26, 2012, Plaintiff saw Dr.
Jaleel and reported that the injections helped. (Tr. at 644). On Plaintiff’s October
31, 2012 visit, Plaintiff did not report any problems with her hands. (Tr. at 643).
Thereafter, Plaintiff saw Dr. Jaleel for various appointments through March 26,
2014. (Tr. at 720-27). During this time period, Plaintiff was assessed with carpal
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tunnel syndrome problems only on November 15, 2013. (Tr. at 719-20). Dr. Jaleel
changed Plaintiff’s prescription and asked Plaintiff to use a carpal tunnel brace on
her right hand every night for about six weeks and then on an as-needed basis. (Tr.
at 720).
In rendering his decision, the ALJ relied on and afforded significant weight
to the January 4, 2013, Residual Functional Capacity Assessment of Efren Baltazar,
M.D., a state agency physician 2 . (Tr. at 25, 120-26). The Residual Functional
Capacity assessment indicated that Plaintiff is able to occasionally lift and/or carry
including pulling 20 pounds; and frequently lift and/or carry including pulling 10
pounds. (Tr. at 120-21). Dr. Baltazar determined that Plaintiff has no manipulation
limitations. (Tr. at 122).
The Court finds that the medical records show that Plaintiff was diagnosed
with carpal tunnel syndrome, but the medical records fail to show that Plaintiff has
any limitations as to this diagnosis. Moreover, a diagnosis alone “is insufficient to
establish that a condition caused functional limitations.” Wood v. Astrue, No. 8:10CV-2373-T-17AEP, 2012 WL 834137, at *5 (M.D. Fla. Feb. 14, 2012), report and
recommendation adopted, No. 8:10-CV-2373-T-17AEP, 2012 WL 834132 (M.D.
Fla. Mar. 13, 2012) (citing Moore v. Barnhart, 405 F.3d 1207, 1213 n.6 (11th Cir.
2005)). The medical records show that Dr. Jaleel found Plaintiff’s strength in her
hands was normal. (See Tr. at. 647). Further, Dr. Jaleel reported that after injections
and medication, Plaintiff’s symptoms improved. (See Tr. at 644, 645). Plaintiff
failed to cite to any medical evidence in support of her position. Thus, the Court
finds that the medical evidence supports the ALJ’s decision that Plaintiff did not
have manipulation limitations.

Doc. 21 at 7-9 (footnotes omitted).
Plaintiff argues that the Magistrate Judge erred in recommending affirmance of the ALJ’s
decision based on the medical records the Magistrate Judge cited in support of the ALJ’s credibility
finding because these specific records related to Plaintiff’s allegations of “back and neck pain,”
and not her hand and arm pain. Doc. 21 at 2-3. The Court has reviewed all of the medical records
cited by the Magistrate Judge, particularly those from Dr. Jaleel at Florida Pain Solutions, and they
do support the Magistrate Judge’s determination that, after receiving injections in late 2012,
Plaintiff’s complaints regarding carpal tunnel pain were non-existent; her sporadic complaints of
arm pain related to “radiating pain” from her neck and upper back down her right side, including

2 Dr. Baltazar’s January 4, 2013 Residual Functional Capacity opinion was based on a review of the medical
records, including Dr. Jaleel’s records from August, September, and October 2012. See R. 122.

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in her right arm, when she decided to stop taking her medicine “several months” before. See R.
719 (November 15, 2013). Dr. Jaleel changed and increased the medication to “help with the
radiating pain down the right arm”; he recommended use of a carpal tunnel brace to her right hand
every night for about six weeks and then on an as-needed basis. R. 720. During the same time
period she reported she had “radiating pain” in the right arm “occasionally.” R. 722 (September 4,
2013), 723 (May 22, 2013); see also R. 725 (February 6, 2013) (“occasional” radiating pain in
right arm, “not as much” on left side).
The records from Florida Pain Solutions are not exclusively “neck and back pain” records
as Plaintiff argues. Rather, they are records from the doctor treating her for chronic pain and,
although Dr. Jaleel was initially treating Plaintiff for pain from carpal tunnel syndrome, the records
reflect that Plaintiff stopped complaining about carpal tunnel syndrome symptoms and mentioned
only “occasional” right arm symptoms which were related to her neck and back issues that Dr.
Jaleel was also treating. As the Magistrate Judge accurately noted: “Dr. Jaleel reported that after
injections and medication, Plaintiff’s symptoms improved.” Doc. 21 at 9 (citing R. 644-45: “The
patient reported that these injections seem to help, especially with the carpal canal injection.”).
Based on these medical records, the ALJ properly discounted Plaintiff’s subjective testimony
related to limitations from Plaintiff’s alleged arm and hand pain, and his omission of
“manipulative” limitations from the RFC is supported by substantial evidence.
Therefore, it is ORDERED as follows:
1.

The Report and Recommendation filed January 11, 2017 (Doc. 21), is ADOPTED

and CONFIRMED and made a part of this Order.
2.

Plaintiff’s objections are OVERRULED.

3.

The final decision of the Commissioner of the Social Security Administration

denying the claim for Disability Insurance Benefits and Supplemental Security Income benefits
is AFFIRMED pursuant to sentence four of 42 U.S.C. § 405(g).
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4.

The Clerk is directed to enter judgment, accordingly, and CLOSE the file.

DONE and ORDERED in Orlando, Florida on February 21, 2017.

Copies furnished to:
Counsel of Record

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