Myers Donahue v. Commissioner of Social Security

Filing 31

OPINION AND ORDER: The decision of the Commissioner is AFFIRMED. Clerk is directed to enter judgment in favor of Dft Commissioner of Social Security and against Pla Valerie R Myers Donahue. Signed by Magistrate Judge Susan L Collins on 3/31/2016. (lns)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
FORT WAYNE DIVISION
VALERIE R. MYERS DONAHUE,
Plaintiff,
v.
COMMISSIONER OF SOCIAL
SECURITY, sued as Carolyn W.
Colvin, Acting Commissioner of SSA,
Defendant.

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CAUSE NO. 1:14-cv-00387-SLC

OPINION AND ORDER
Plaintiff Valerie R. Myers Donahue appeals to the district court from a final decision of
the Commissioner of Social Security (“Commissioner”) denying her application under the Social
Security Act (the “Act”) for a period of disability and Disability Insurance Benefits (“DIB”) and
Supplemental Security Income (“SSI”).1 (DE 1). For the following reasons, the Commissioner’s
decision will be AFFIRMED.
I. PROCEDURAL HISTORY
Myers Donahue applied for DIB and SSI in February 2012, alleging disability as of
January 1, 2010, which she later amended to September 1, 2010. (DE 11 Administrative Record
(“AR”) 32, 159-60, 163-69). She was last insured for DIB on September 30, 2012. (AR 247);
see Stevenson v. Chater, 105 F.3d 1151, 1154 (7th Cir. 1997) (explaining that with respect to a
DIB claim, a claimant must establish that she was disabled as of her date last insured in order to
recover DIB). The Commissioner denied Myers Donahue’s application initially and upon

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All parties have consented to the Magistrate Judge. (DE 14); see 28 U.S.C. § 636(c).

reconsideration. (AR 92-99, 103-16). After a timely request, a hearing was held on May 30,
2013, before Administrative Law Judge William D. Pierson (“the ALJ”), at which Myers
Donahue, who was represented by counsel; her sister-in-law; and a vocational expert, Marie
Kieffer (the “VE”), testified. (AR 30-87). On July 23, 2013, the ALJ rendered an unfavorable
decision to Myers Donahue, concluding that she was not disabled because despite the limitations
caused by her impairments, she could perform a significant number of unskilled light jobs in the
economy. (AR 12-24). The Appeals Council denied Myers Donahue’s request for review (AR
1-8, 276-78), at which point the ALJ’s decision became the final decision of the Commissioner.
See 20 C.F.R. §§ 404.981, 416.1481.
Myers Donahue filed a complaint with this Court on December 11, 2014, seeking relief
from the Commissioner’s final decision. (DE 1). Myers Donahue advances just one argument in
her appeal—that the ALJ improperly evaluated the medical source statement of Randal Podoll,
P.A., and Scott Gutowski, D.O., dated October 30, 2012. (DE 20 at 9-11).
II. FACTUAL BACKGROUND2
At the time of the ALJ’s decision, Myers Donahue was 51 years old (AR 159); had a high
school education (AR 37); and possessed past work experience as a machine operator, stocker,
rehabilitation aide, saw operator, material handler, and plastics handler (DE 20 at 2; AR 199,
275). She alleges disability due to lumbar spondylosis, lumbar degenerative disc disease, small
enthesophyte of the greater trochanters (left greater than right), chronic back pain, right shoulder
pain, major depressive disorder, anxiety, and post traumatic stress disorder (“PTSD”). (DE 20 at

2

In the interest of brevity, this Opinion recounts only the portions of the 443-page administrative record
necessary to the decision.

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2). Myers Donahue does not challenge the ALJ’s consideration of her mental impairments, and
thus, the Court will focus on the evidence pertaining to her physical limitations. (DE 20 at 9-11;
DE 30).
A. Myers Donahue’s Testimony at the Hearing
At the hearing, Myers Donahue testified that she lives in a house with her boyfriend; she
had obtained Medicaid as of January 2013 and receives food stamps. (AR 36-37, 61, 64). She
drives a car, but not more than 30 minutes at a time due to her back pain. (AR 37). She can
dress herself, but her daughter helps her to wash her back and shave her legs; her family also
assists her with household chores. (AR 68-69, 74-75). On a typical day, Myers Donahue
performs light household tasks, including vacuuming and laundry, interspersed with frequent
periods of rest. (AR 60-61, 69-70). She goes shopping with others because she needs help
lifting heavy items. (AR 62).
Myers Donahue cited her shoulder and back pain as the primary ailments that prevent her
from working. (AR 45). She has pain in her right shoulder if she lifts 10 pounds; she can raise
her right arm just halfway up. (AR 46-47). She is right-hand dominant; she can no longer play
horseshoes or lift pans out of the oven with her right arm, but she can keyboard, write, cook, and
feed herself with her right hand. (AR 46, 49-50, 63). She tries not to use her right arm much
because of the pain, and the pain interferes with her sleep. (AR 45-46, 49). On a ten-point scale,
she rated her shoulder pain at rest as a two or three with pain medication and a five or six without
medication; when using her shoulder, the pain increases to a seven with medication. (AR 17-18).
Myers Donahue stated that her chronic back pain is a bigger problem than her shoulder
pain. (AR 50). Her back pain is constant and interferes with her sleep (AR 51-52); the pain also
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shoots to her feet (AR 55). She stated that she gets three hours of sleep on a good night and 15
minutes of sleep on a bad night; she has five bad nights a week. (AR 51-52). She naps three
times a day on the couch or in the recliner from 15 minutes to two hours at a time. (AR 52-53).
To help relieve her pain, she uses heat and ice, reclines, and takes about 90 Vicodin tablets a
month; the Vicodin helps reduce her pain for about an hour, but then the pain returns at a higher
intensity. (AR 53-54, 69). She rated her back pain as a nine or 10 even when taking Vicodin.
(AR 54). Her back pain worsens if she sits longer than 20 minutes or stands longer than 30
minutes; she estimated that she could walk for 20 minutes, but walking does not help to relieve
her pain. (AR 55). She avoids climbing stairs and has difficulty bending over to reach her feet.
(AR 63, 68-69).
Additionally, Myers Donahue testified that she experiences pain at least once a day in her
left hand and about two to three times a day in her right hand; her hand pain feels “like needles or
being poked.” (AR 56). She was not taking any medication for her hand complaints. (AR 5556). She also complained of difficulty gripping items with her right hand and stated that she
often drops things.3 (AR 62).
B. Summary of the Relevant Medical Evidence
On August 27, 2010, Myers Donahue sustained an injury on the job when attempting to
maneuver an occupied wheelchair over a curb. (AR 285-86). She initially complained of low
back pain. (AR 285-86).
Myers Donahue was treated at Prompt Care Express in September 2010 for complaints of

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Myers Donahue’s sister-in-law also testified at the hearing, essentially corroborating her testimony. (AR

73-78).

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low back pain and right shoulder pain. (AR 309). An X-ray of her back showed mild lumbar
spondylosis, but no acute abnormality, and an X-ray of her shoulder showed no acute
abnormality. (AR 309-11, 322-23). She went to physical therapy for a low back strain; by the
end of September, her back pain was improving, although she still experienced some pain. (AR
309, 315-18). She also was diagnosed with acute tendinitis of the right shoulder; she received a
shoulder injection, which resulted in some improvement. (AR 312, 314).
Myers Donahue underwent an initial evaluation at NovaCare Rehabilitation in October
2010 for a right shoulder sprain. (AR 302-05). She complained of throbbing pain in her right
shoulder with tingling to her right hand; the pain worsened at night. (AR 302). She reported
difficulty with donning a shirt. (AR 302). She was avoiding doing household chores for fear that
they would increase her pain. (AR 302). She had a moderate limitation in range of motion of her
right shoulder, tenderness to palpation, and slightly decreased strength; she was instructed in
exercises and received ultrasound treatment. (AR 303, 349). She rated her pain as a five on a
ten-point scale. (AR 349). She had a good prognosis and was expected to reach her goals in six
weeks of therapy. (AR 358). However, Myers Donahue was discharged from therapy after just
three visits due to an insurance issue. (AR 349).
In January 2011, Myers Donahue saw Randal Podoll, P.A., a physician’s assistant with
Jonesville Health Care, for her shoulder and back pain. (AR 294-95). He noted that her pain
persisted despite physical therapy, a cortisone injection, oral pain medications, and work
restrictions. (AR 294). He indicated that she had experienced shoulder bursitis in 2007, which
resolved with conservative treatment. (AR 294). An examination revealed pain with shoulder
abduction and dullness to pinprick on the right arm, but normal reflexes and pulses in the right
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arm. (AR 294). She had normal reflexes and sensation to pinprick in her lower extremities.
(AR 295). A straight leg raise test was painful on the left lower back at full extension of the left
leg. (AR 295). Range of motion of her back was normal, but caused some discomfort. (AR
295). Mr. Podoll prescribed Elavil, Naprosyn, and Vicodin, and recommended that she undergo
an MRI and see an orthopedist. (AR 295). He assigned temporary work restrictions of no
repetitive lifting, bending, reaching overhead, or lifting more than 20 pounds. (AR 295). He
further recommended that Myers Donahue undergo a functional capacity examination once the
MRIs and consults were completed to assign more definitive work restrictions, if any were
needed after completion of the work up. (AR 295).
In March 2011, Myers Donahue saw Dr. Kevin Anderson, an orthopedist, at Mr. Podoll’s
request for evaluation of her right shoulder pain. (AR 291-92). On examination, Myers
Donahue was quite hyperactive to pain in various regions of her right shoulder, but she had no
significant pain in her hand, wrist, or elbow. (AR 291). She had 35 degrees of active shoulder
abduction and 65 degrees passive abduction; she reported pain and tenderness with all maneuvers
of her shoulder. (AR 291). Dr. Anderson found it difficult to perform a detailed examination
due to her discomfort, and he was “unsure of the validity” of her pain. (AR 291). An X-ray of
her right shoulder was unremarkable and “[w]ithin normal limits for the patient’s age.” (AR 291,
293). Dr. Anderson diagnosed her with right shoulder pain, administered a shoulder injection,
prescribed anti-inflammatories, and referred her to therapy for instruction in a home exercise
program. (AR 292).
Myers Donahue returned to Dr. Anderson in May 2011. (AR 290). He found it
“interesting[]” that, this time, she complained more of pain in her left, rather than her right,
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shoulder. (AR 290). He also noted that her back was giving her more issues. (AR 290).
Otherwise, her right shoulder was unchanged and still limited in range of motion. (AR 290). He
noted that Naprosyn did not appear to be helping; Myers Donahue inquired about narcotic pain
medication, and Dr. Anderson referred her to a pain clinic. (AR 290). He stated that he would
like to get her involved in therapy, but she had no insurance. (AR 290). He noted that she had
litigation pending. (AR 290).
Myers Donahue returned to Mr. Podoll in May 2011 for her chronic back and shoulder
problems. (AR 333). Mr. Podoll’s goal was to get her involved in therapy and to obtain an MRI;
he noted that she had an upcoming court hearing. (AR 333). In July 2011, an examination
revealed a positive straight leg raise test on the left, as well as “poor” shoulder abduction. (AR
332). In November 2011, Mr. Podoll documented that Myers Donahue had ongoing shoulder
and back pain; he hoped that she could get coverage for an MRI as a result of her court hearing.
(AR 329-30). In February 2012, Mr. Podoll noted that Myers Donahue’s court cases relating to
her shoulder and back pain were still ongoing; he reiterated his hope that coverage for an MRI
would be approved. (AR 329). He described her shoulder pain as “poor,” but did not include
specific measurements. (AR 330).
In April 2012, David Ringel, D.O., examined Myers Donahue at the request of the state
agency. (AR 365-67). He noted that she had not had an MRI because worker’s compensation
refused to pay for it. (AR 365). She was currently on a 15-pound lifting restriction. (AR 365).
She initially reported that she needed help with dressing, bathing, cooking, and cleaning, but later
clarified that she could perform most of these tasks independently, provided that she takes her
time. (AR 365). She had a normal gait, could lie straight back on the examining table, had no
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difficulty getting on and off the exam table, and was able to dress and undress for the
examination. (AR 366). She could stand on her heels and toes, but could not take steps; she
performed a partial squat due to back pain. (AR 367). Her grip strength was 4/5 bilaterally; she
could button and zip without difficulty. (AR 367). An examination of her back revealed spasms
in the thoracic area, more on the right than the left; she also had pain in the left lumbar and upper
right thoracic region. (AR 367). She had reduced range of motion in her shoulders (more
distinctly decreased in the right shoulder as compared to the left), hips, and back; her muscle
strength was 5/5 in all four extremities, and her sensation was intact. (AR 367).
That same month, R. Fife, M.D., a state agency physician, reviewed Myers Donahue’s
record and completed a physical residual functional capacity (“RFC”) form. (AR 390-97). Dr.
Fife concluded that Myers Donahue could lift up to 10 pounds frequently and up to 20 pounds
occasionally; stand or walk about six hours in an eight-hour workday; sit for six hours in an
eight-hour workday; perform unlimited pushing or pulling (within her lifting restrictions); and
occasionally climb, balance, stoop, kneel, crouch, and crawl; but should avoid concentrated
exposure to wetness and hazards. (AR 394). Dr. Fife’s opinion was later affirmed by a second
state agency physician, J. Sands, M.D. (AR 407).
In July 2012, Myers Donahue underwent a lumbar MRI, which showed a small left
foraminal disc bulge at L3-4 with mild narrowing of the inferomedial neural foramina and disc
degeneration at L4-5 accompanied by a left foraminal bulge-annular tear and facet hypertrophy
with mild to moderate left foraminal compromise. (AR 401-02). That same month, Myers
Donahue saw Mr. Podoll for her back pain, stating that it “radiates down her legs and up into her
neck and arms.” (AR 403). She had tenderness of her right shoulder and “poor” shoulder
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abduction; a straight leg raise test was more painful on the left. (AR 405). Her grip strength was
normal, but she was dull to pinprick on her right hand and left lower leg. (AR 405).
On October 30, 2012, Myers Donahue brought disability forms to Mr. Podoll (AR 43133), and Mr. Podoll and Scott Gutowski, D.O., completed a physical medical source statement at
Myers Donahue’s request (AR 409-12).4 They listed diagnoses of degenerative disc disease in
the low back with herniation and right shoulder pain, indicating that her prognosis was guarded.
(AR 409). Her symptoms were chronic pain in her right shoulder and left low back. (AR 409).
Clinical findings and objective signs were a positive straight leg raise test on the left at 35
degrees, “duller to pinprick,” slow up and down from the table, poor abduction of the right
shoulder, and decreased grip strength. (AR 409). They indicated that she could walk less than
one block, sit for 30 minutes at a time and up to six hours in an eight-hour workday, stand for 15
minutes at a time and stand or walk less than two hours in an eight-hour workday, and lift less
than 10 pounds occasionally and never more than 10 pounds. (AR 410-11). They further opined
that she would have to walk around for eight minutes every 30 minutes, and that she would need
to take up to a 10-minute break every hour due to pain, paresthesias, and numbness. (AR 410).
They indicated that she could rarely twist, stoop, bend, squat, or climb stairs, and should never
climb ladders. (AR 411). They also concluded that she could not use her right arm, hand, or
fingers at all for grasping, fine manipulations, or reaching, but that she could use her left arm,
hand, and fingers 80 percent of the time for such activities. (AR 411). Finally, Mr. Podoll and
Dr. Gutowski stated that she would be off task from even simple tasks at least 25 percent of the

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At the hearing, Myers Donahue testified that although she had seen Dr. Gutowski, she had been treated by
Mr. Podoll more often. (AR 65). The Court notes that the only document in the record from Dr. Gutowski is the
physical medical source statement dated October 30, 2012. (DE 409-12).

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time due to her symptoms. (AR 412).
In January 2013, Myers Donahue went to an urgent care clinic complaining of “pain from
head to toes (including toes).” (AR 425). It was noted that she had been receiving 90 Vicodin a
month for the past year. (AR 425). The following month, Myers Donahue asked Mr. Podoll for
“refills on her pain medications or something stronger,” reporting that her pain was worsening.
(AR 416). In April 2013, Myers Donahue visited Mr. Podoll for ear pain and to complete
disability paperwork. (AR 428-30).
In April 2013, Myers Donahue went to the emergency room for her back pain. (AR 418).
Thomas Huntington, M.D., observed that she could move her arms and legs well and that she had
intact strength, tone, and senses; however, he noted lumbar spine tenderness. (AR 419). X-rays
showed mild lumbar spondylosis and degenerative changes at L5-S1. (AR 421-22). Dr.
Huntington wrote that Myers Donahue had not reported that she was taking Vicodin, but the
pharmacy discovered this information. (AR 421). He advised her to use her Vicodin and to see
her primary care physician if she needed pain management. (AR 421). On June 20, 2013, Myers
Donahue told Mr. Podoll that she had been having pain down both of her legs for the past month
and that sometimes her legs swell. (AR 442-43).
III. STANDARD OF REVIEW
Section 405(g) of the Act grants this Court “the power to enter, upon the pleadings and
transcript of the record, a judgment affirming, modifying, or reversing the decision of the
[Commissioner], with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). The
Court’s task is limited to determining whether the ALJ’s factual findings are supported by
substantial evidence, which means “such relevant evidence as a reasonable mind might accept as
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adequate to support a conclusion.” Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir. 2005)
(citation omitted). The decision will be reversed only if it is not supported by substantial
evidence or if the ALJ applied an erroneous legal standard. Clifford v. Apfel, 227 F.3d 863, 869
(7th Cir. 2000) (citation omitted).
To determine if substantial evidence exists, the Court reviews the entire administrative
record but does not reweigh the evidence, resolve conflicts, decide questions of credibility, or
substitute its judgment for the Commissioner’s. Id. Rather, if the findings of the Commissioner
are supported by substantial evidence, they are conclusive. Jens v. Barnhart, 347 F.3d 209, 212
(7th Cir. 2003) (citation omitted). “In other words, so long as, in light of all the evidence,
reasonable minds could differ concerning whether [the claimant] is disabled, we must affirm the
ALJ’s decision denying benefits.” Books v. Chater, 91 F.3d 972, 978 (7th Cir. 1996).
IV. ANALYSIS
A. The Law
Under the Act, a claimant is entitled to DIB or SSI if she establishes an “inability to
engage in any substantial gainful activity by reason of any medically determinable physical or
mental impairment which can be expected to . . . last for a continuous period of not less than 12
months.” 42 U.S.C. §§ 416(i)(1), 423(d)(1)(A), 1382c(a)(3)(A). A physical or mental
impairment is “an impairment that results from anatomical, physiological, or psychological
abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.” 42 U.S.C. §§ 423(d)(3), 1382c(a)(3)(D).
The Commissioner evaluates disability claims pursuant to a five-step evaluation process,
requiring consideration of the following issues, in sequence: (1) whether the claimant is currently
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unemployed; (2) whether the claimant has a severe impairment; (3) whether the claimant’s
impairment meets or equals one of the impairments listed by the Commissioner, see 20 C.F.R. §
404, Subpt. P, App’x 1; (4) whether the claimant is unable to perform her past work; and (5)
whether the claimant is incapable of performing work in the national economy.5 See Dixon v.
Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001) (citations omitted); 20 C.F.R. §§ 404.1520,
416.920. An affirmative answer leads either to the next step or, on steps three and five, to a
finding that the claimant is disabled. Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001)
(citation omitted). A negative answer at any point other than step three stops the inquiry and
leads to a finding that the claimant is not disabled. Id. (citation omitted). The burden of proof
lies with the claimant at every step except the fifth, where it shifts to the Commissioner.
Clifford, 227 F.3d at 868 (citation omitted).
B. The Commissioner’s Final Decision
On July 23, 2013, the ALJ issued the decision that ultimately became the Commissioner’s
final decision. (AR 12-24). The ALJ noted at step one of the five-step analysis that Myers
Donahue had not engaged in substantial gainful activity since her alleged onset date of
September 1, 2010. (AR 14). At step two, the ALJ found that Myers Donahue had the following
severe impairments: mild lumbar spondylosis, lumbar degenerative disc disease, small
enthesophyte of the greater trochanters (left greater than right), chronic back pain, right shoulder
pain, major depressive disorder, anxiety, and PTSD. (AR 14).

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Before performing steps four and five, the ALJ must determine the claimant’s RFC or what tasks the
claimant can do despite her limitations. 20 C.F.R §§ 404.1520(e), 404.1545(a), 416.920(e), 416.945(a). The RFC is
then used during steps four and five to help determine what, if any, employment the claimant is capable of. 20
C.F.R. §§ 404.1520(e), 416.920(e).

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At step three, the ALJ concluded that Myers Donahue did not have an impairment or
combination of impairments severe enough to meet or equal a listing. (AR 15-16). Before
proceeding to step four, the ALJ determined that Myers Donahue’s symptom testimony was not
credible to the extent it was inconsistent with the following RFC:
[T]he claimant has the [RFC] to perform light work . . . except she can only
occasionally reach overhead with dominant upper extremity and only occasionally
use ramps or stairs. Additionally, she is limited to simple, routine, repetitive tasks
and low stress work activity, which is defined as only involving occasional
decision-making and occasional changes in the work setting.
(AR 17).
Based on this RFC and the VE’s testimony, the ALJ concluded at step four that Myers
Donahue could not perform any of her past relevant work. (AR 22). At step five, however, the
ALJ found that Myers Donahue could perform a significant number of unskilled light jobs in the
economy, including small products assembler, electronics worker, and electrical accessories
worker.6 (AR 23). Therefore, Myers Donahue’s applications for DIB and SSI were denied. (AR
23-24).
C. The ALJ’s Consideration of Mr. Podoll’s and Dr. Gutowski’s Physical
Medical Source Statement Is Supported by Substantial Evidence
Myers Donahue’s sole argument on appeal is that the ALJ improperly discounted the
physical medical source statement penned by Mr. Podoll and Dr. Gutowski on October 30, 2012.
Myers Donahue’s argument, however, is unpersuasive, as the ALJ’s decision to assign “little
weight” to the medical source statement is supported by substantial evidence. (AR 20).

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The ALJ incorporated additional restrictions in the hypotheticals posed to the VE at the hearing, including
occasional kneeling, crouching, crawling, squatting; frequent bending and stooping; and no use of ropes, ladders, or
scaffolds. (AR 80-81).

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The Seventh Circuit Court of Appeals has stated that “more weight is generally given to
the opinion of a treating physician because of his greater familiarity with the claimant’s
conditions and circumstances.” Clifford, 227 F.3d at 870; see 20 C.F.R. §§ 404.1527(c)(2),
416.927(c)(2). However, this principle is not absolute, as “a treating physician’s opinion
regarding the nature and severity of a medical condition is [only] entitled to controlling weight if
it is well supported by medical findings and not inconsistent with other substantial evidence in
the record.”7 Clifford, 227 F.3d at 870; see Johansen v. Barnhart, 314 F.3d 283, 287 (7th Cir.
2002); 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). The Commissioner must always give good
reasons for the weight ultimately applied to the treating source’s opinion. Clifford, 227 F.3d at
870; 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2).
Although an ALJ may decide to adopt the opinions in a medical source statement
concerning the ability of a claimant to perform work-related activities, the RFC assessment is an
issue reserved to the ALJ. 20 C.F.R. §§ 404.1545(e), 416.945(e); SSR 96-5p, 1996 WL 374183,
at *2 (July 2, 1996) (“[A] medical source statement must not be equated with the administrative
finding known as the RFC assessment.”). The RFC is a determination of the tasks a claimant can
do despite her limitations. 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). The RFC assessment:
is based upon consideration of all relevant evidence in the case record, including
medical evidence and relevant nonmedical evidence, such as observations of lay
witnesses of an individual’s apparent symptomology, an individual’s own
statement of what he or she is able or unable to do, and many other factors that
could help the adjudicator determine the most reasonable findings in light of all
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In the event the treating physician’s opinion is not well supported or is inconsistent with other substantial
evidence, the Commissioner must apply the following factors to determine the proper weight to give the opinion: (1)
the length of the treatment relationship and frequency of examination; (2) the nature and extent of the treatment
relationship; (3) how much supporting evidence is provided; (4) the consistency between the opinion and the record
as a whole; (5) whether the treating physician is a specialist; and (6) any other factors brought to the attention of the
Commissioner. See Books, 91 F.3d at 979; 20 C.F.R. §§ 404.1527(c), 416.927(c).

14

the evidence.
SSR 96-5p, 1996 WL 374183, at *5; see 20 C.F.R. §§ 404.1545, 416.945. Thus, a medical
source opinion concerning a claimant’s work ability is not determinative of the RFC assigned by
the ALJ. See Thomas v. Colvin, 745 F.3d 802, 808 (7th Cir. 2014) (“[T]he determination of a
claimant’s RFC is a matter for the ALJ alone—not a treating or examining doctor—to decide.”
(citation omitted)); see SSR 96-5p, 1996 WL 374183, at *5.
To review, Mr. Podoll’s and Dr. Gutowski’s medical source statement indicated that
Myers Donahue could walk less than one block; could sit up to six hours in an eight-hour
workday; could stand or walk less than two hours in an eight-hour workday; could lift less then
10 pounds occasionally and never more than 10 pounds; must walk for eight minutes every 30
minutes; must take up to a 10-minute break every hour; could never use her right arm, hand, or
fingers; could use her left arm, hand, and fingers up to 80 percent of the time; and could rarely
twist, stoop, bend, squat, or climb stairs, but never climb ladders. (AR 410-11). They also
indicated that her symptoms would cause her to be off task from even simple tasks at least 25
percent of a workday. (AR 412).
The ALJ ultimately afforded Mr. Podoll’s and Dr. Gutowski’s medical source statement
“little weight.” (AR 20). The ALJ provided two reasons for doing so: the restrictions imposed in
the statement “stand apart from the rest of the medical records”; and the conclusions were
“unsupported by diagnostic imaging and objective medical findings in the treatment notes.” (AR
20). The Court will discuss the ALJ’s reasoning in two parts: the restrictions pertaining to Myers
Donahue’s right shoulder problems and the restrictions pertaining to her low back impairment.

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1. The Conclusions Pertaining to Myers Donahue’s Right Upper Extremity
Myers Donahue does not contest the ALJ’s finding that the severe conclusions in the
medical source statement with respect to her right upper extremity are unsupported by diagnostic
imaging. X-rays of her right shoulder were unremarkable and within normal limits for her age,
and there is no MRI or other imaging evidence of her right shoulder. (AR 291, 293, 311); see
Scheck v. Barnhart, 357 F.3d 697, 702 (7th Cir. 2004) (“It is axiomatic that the claimant bears
the burden of supplying adequate records and evidence to prove [her] claim of disability.” (citing
20 C.F.R. § 404.1512(c); Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987))).
Myers Donahue argues, rather, that the medical source statement and Mr. Podoll’s
treatment notes reveal objective medical findings supportive of the right upper extremity
restrictions. See 20 C.F.R. §§ 404.1528(b), 416.928(b) (“Signs are anatomical, physiological, or
psychological abnormalities which can be observed, apart from your statements (symptoms).
Signs must be shown by medically acceptable clinical diagnostic techniques.”). These signs are
“poor” range of motion of the shoulder, particularly abduction; dullness to pinprick on the right
arm; and grip strength “loss.” (AR 294, 330, 332, 433, 443). A treating physician’s opinion,
however, is entitled to controlling weight only “if it is well supported by medical findings and not
inconsistent with other substantial evidence in the record.” Clifford, 227 F.3d at 870 (emphasis
added) (citation omitted); see 20 C.F.R. §§ 404.1527(d)(2) 416.927(d)(2). Here, the minimal
objective medical findings cited by Mr. Podoll and Dr. Gutowski do not support a restriction
precluding all use of Myers Donahue’s right arm, hand, and fingers.8 As such, the opinion is not

8

Even Myers Donahue admitted during her testimony at the hearing that she could do many things with her
right arm and hand, although she could no longer play horseshoes or lift pans out of the oven with her right arm.
(AR 46, 49-50, 63).

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entitled to controlling or significant weight. See 20 C.F.R §§ 404.1527(d), 416.927(d) (“[T]he
more a medical source presents relevant evidence to support an opinion . . . the more weight is
given to that opinion.”).
Furthermore, as the ALJ observed, the severe conclusions in the medical source statement
concerning Myers Donahue’s right upper extremity “stand apart,” that is, are inconsistent with,
other substantial evidence of record and Mr. Podoll’s own treatment notes. See Skarbek v.
Barnhart, 390 F.3d 500, 503 (7th Cir. 2004) (“An ALJ may discount a treating physician’s
medical opinion if it is inconsistent with the opinion of a consulting physician, or when the
treating physician’s opinion is internally inconsistent, as long as he minimally articulate[s] his
reasons for crediting or rejecting evidence of disability.” (alteration in original) (citation
omitted)). As the ALJ discussed, Dr. Anderson, the orthopedist, indicated that he was “unsure of
the validity” of Myers Donahue’s shoulder pain at his initial evaluation in March 2011; he also
documented that Myers Donahue had no significant pain in her hand, wrist, or elbow. (AR 19,
291-92). At her second appointment, Dr. Anderson found it “interesting” that she complained
more about pain in her left, rather than her right, shoulder. (AR 19, 290). The ALJ also
discussed Dr. Ringel’s April 2012 consultative examination in which Dr. Ringel documented
findings that Myers Donahue had distinctly decreased range of motion in the right shoulder,
normal extremity strength, 4/5 grip strength, intact sensation, and good thumb-finger opposition;
could fasten buttons and zippers without difficulty; and had no difficulty dressing or undressing
for the examination. (AR 20, 367). The ALJ further observed that Myers Donahue told Dr.
Ringel that she could do nearly all of her household chores, including vacuuming, provided that
she takes her time and avoids heavy lifting. (AR 21, 365).

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Additionally, the ALJ considered that Myers Donahue was not frequently reported to be
in acute pain at medical appointments or to exhibit significant pain behaviors such as
uncomfortable movement. (AR 21). The ALJ also observed that Myers Donahue had not
followed through on pain management referrals; had not sought free or low cost healthcare;
visited the emergency room on only one occasion; and that her treatment had been quite
conservative, including heat, ice, reclining, and medications. (AR 21-22).
Finally, the ALJ contrasted the severe limitations in the medical source statement with
Mr. Podoll’s own treatment notes, demonstrating an internal inconsistency in Mr. Podoll’s own
documentation. (AR 20); see Clifford, 227 F.3d at 871 (explaining that medical evidence may be
discounted if it is internally inconsistent). In January 2011, Mr. Podoll restricted Myers Donahue
from performing repetitive lifting, reaching overhead, or lifting more than 20 pounds. (AR 20).
The ALJ found Mr. Podoll’s January 2011 opinion more consistent with the substantial evidence
of record, and thus, he assigned that opinion significant weight, rather than the severe limitation
precluding all use of her right arm, hand, and fingers as opined in the medical source statement.
(AR 20).
In sum, the conclusions reached by Mr. Podoll and Dr. Gutowski in the medical source
statement pertaining to Myers Donahue’s right upper extremity are not well supported by the
objective medical evidence and are inconsistent with other substantial evidence of record. As
such, the ALJ’s discounting of the medical source statement is supported by substantial
evidence.9

9

When considering the medical source statement with respect to Myers Donahue’s right shoulder problem,
the ALJ additionally stated: “To date, these providers have been unable to confirm an etiology for the claimant’s
right upper extremity pain and have thus failed to provide a medically determinable impairment.” (AR 20). As

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2. The ALJ’s Conclusions Pertaining to Myers Donahue’s Back Impairment
Myers Donahue argues that the ALJ’s rationale for discounting Mr. Podoll’s and Dr.
Gutowski’s conclusions in the medical source statement pertaining to her back problems are not
supported by substantial evidence. More specifically, she contends that the conclusions in the
medical source statement are supported by the July 2012 MRI of her spine, as well as the
objective findings in the medical source statement and Mr. Podoll’s treatment notes.
Myers Donahue emphasizes that Mr. Podoll ordered the MRI and that the test results
were in his file. But Mr. Podoll and Dr. Gutowski never mentioned, much less discussed, in their
medical source statement how the MRI results support the limitations they assigned. In fact, the
diagnosis on the medical source statement indicates degenerative disc disease, low back “with
herniation” (AR 409), but the MRI results do not reveal a disc herniation (AR 401-02).
Furthermore, X-rays of Myer Donahue’s lumbar spine revealed just mild degenerative disc
disease. (AR 322, 422). Nor did Mr. Podoll alter Myers Donahue’s treatment after the MRI, as
he continued her conservative treatment course. (AR 414-16, 428-30, 443). Here, the ALJ
thoughtfully considered the MRI results, specifically noting that the state agency physicians did
not have an opportunity to review them. (AR 21). The ALJ observed that the MRI findings did

Myers Donahue points out, the ALJ contradicted himself in finding that her right shoulder pain was a severe
impairment at step two and later stating that Mr. Podoll and Dr. Gutowski failed to provide a medically determinable
impairment with respect to her right shoulder pain. For a condition to constitute a severe impairment at step two, the
condition must be a medically determinable impairment. See 20 C.F.R. § 404.1520(a)(4)(ii) (At step two, “[i]f you
do not have a severe medically determinable physical or mental impairment that meets the duration requirement in §
404.1509, or a combination of impairments that is severe and meets the duration requirement, we will find that you
are not disabled.” (emphasis added)); 20 C.F.R. § 416.920(a)(4)(ii) (same). However, because the ALJ’s
discounting of the medical source statement is well supported on other grounds, the ALJ’s mis-statement is harmless.
See Shramek v. Apfel, 226 F.3d 809, 814 (7th Cir. 2000) (affirming the ALJ’s decision despite errors because none
of the errors affected the outcome).

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not document “severe compromise, such as severe canal stenosis, cord indentation or severe
nerve root impingement,” and as such, did not support the severe restrictions penned by Mr.
Podoll and Dr. Gutowski in the medical source statement. (AR 20).
Myers Donahue argues that the ALJ inappropriately “played doctor” by evaluating the
MRI results as he did and concluding that they were inconsistent with the back restrictions
assigned in the medical source statement. See Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996)
(“ALJs must not succumb to the temptation to play doctor and make their own independent
medical findings.” (citations omitted)). She emphasizes that the ALJ did not rely on any of the
state agency physicians because those doctors never reviewed the MRI results. However, the
ALJ did not interpret the MRI; he simply summarized the impression of Dr. Ross Benjoya, who
reviewed the MRI. (AR 401-02); see, e.g., Mitchell v. Colvin, No. 10 C 7464, 2013 WL
3729722, at *10 (N.D. Ill. July 11, 2013) (“Because the ALJ made an informed decision on the
basis of the interpreting physician’s impression [of the MRI] and the record as a whole, the ALJ
did not play doctor.”); Brown v. Barnhart, 298 F. Supp. 2d 773, 791 (E.D. Wis. 2004) (stating
that the ALJ did not interpret the MRI, but simply paraphrased the reviewing physician’s
impression of the MRI). While ALJs are forbidden to play doctor and make their own medical
findings, they must discuss and weigh the medical evidence. See Olsen v. Colvin, 551 F. App’x
868, 875 (7th Cir. 2014) (“The ALJ did not ignore relevant evidence and substitute her own
judgment here. To the contrary, the ALJ summarized the results of each MRI and drew a
conclusion from those diagnostic tests that [the claimant’s] abnormalities mostly were mild.”).
Here, the ALJ accurately discussed and weighed the MRI results, as interpreted by Dr. Benjoya,
and the ALJ reasonably concluded that they did not support imposing a more restrictive RFC.
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(AR 20).
Myers Donahue also argues that the ALJ was incorrect when stating that the conclusions
in Mr. Podoll’s and Dr. Gutowski’s medical source statement pertaining to her back impairment
lacked the support of objective medical findings. She emphasizes that the medical source
statement and Mr. Podoll’s treatment notes reflect positive straight leg raise tests, duller
sensation to pinprick in the left leg, and slowness in getting up and down on the examining table.
(AR 295, 416, 443). But to reiterate, a treating physician’s opinion is entitled to controlling
weight “if it is well supported by medical findings and not inconsistent with other substantial
evidence in the record.” Clifford, 227 F.3d at 870 (emphasis added) (citation omitted); see 20
C.F.R. §§ 404.1527(d)(2), 416.927(d)(2). Here, the minimal findings cited by Mr. Podoll and
Dr. Gutowski do not offer the support necessary to undermine the ALJ’s decision. See 20 C.F.R
§§ 404.1527(d), 416.927(d) (“[T]he more a medical source presents relevant evidence to support
an opinion . . . the more weight is given to that opinion.”); see also Knight v. Chater, 55 F.3d
309, 314 (7th Cir. 1995) (“The ALJ was allowed to conclude that [the treating doctor’s] notes do
not provide adequate clinical support for [the doctor’s] opinion on the residual capacity form.”
(collecting cases)).
Furthermore, the conclusions in the medical source statement concerning Myers
Donahue’s back impairment are not particularly consistent with other substantial evidence of
record. See Skarbek, 390 F.3d at 503. The ALJ discussed the consultative examination of Dr.
Ringel indicating that Myers Donahue’s gait was completely normal, her strength in all
extremities was 5/5, her sensation was intact, and she had no difficulty getting on and off the
examination table or dressing or undressing. (AR 20, 367). The ALJ also observed that during
the examination Myers Donahue responded positively to a straight leg raise test while supine, but
21

responded negatively while sitting. (AR 20, 367). The ALJ further considered that Myers
Donahue told Dr. Ringel that she could do nearly all of her household chores, including
vacuuming, provided that she takes her time and avoids heavy lifting. (AR 21). Similarly, in
April 2013, Dr. Huntington observed that while Myers Donahue had lumbar spine tenderness,
she demonstrated good movement of her extremities as well as intact strength and sensation.
(AR 418-19).
To reiterate, Myers Donahue was not frequently reported to be in acute pain at medical
appointments or to exhibit significant pain behaviors such as uncomfortable movement. (AR
21). The ALJ also considered that Myers Donahue had not followed through on pain
management referrals; had not sought free or low cost healthcare; visited the emergency room on
only one occasion; and her treatment had been quite conservative, including heat, ice, reclining,
and medications. (AR 21-22).
In sum, the ALJ’s decision to give little weight to the conclusions penned by Mr. Podoll
and Dr. Gutowski in the medical source statement dated October 30, 2012, is supported by
substantial evidence. Mr. Podoll and Dr. Gutowski did not cite the MRI results in support of
their conclusions; the objective medical findings identified in the medical source statement and
Mr. Podoll’s treatment notes were minimal; and their conclusions were not consistent with other
substantial evidence of record. Accordingly, the ALJ’s decision will be affirmed.
V. CONCLUSION
For the foregoing reasons, the decision of the Commissioner is AFFIRMED. The Clerk

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is directed to enter a judgment in favor of the Commissioner and against Myers Donahue.
SO ORDERED.
Enter for this 31st day of March 2016.
/s/ Susan Collins
Susan Collins,
United States Magistrate Judge

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