Washington v. Commissioner of Social Security Administration
OPINION AND ORDER: The decision of the Commissioner of Social Security is AFFIRMED. Clerk DIRECTED to enter judgment in favor of Defendant Commissioner of Social Security and against Plaintiff Dinah C Washington. Signed by Magistrate Judge Susan L Collins on 9/14/16. (cer)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
FORT WAYNE DIVISION
DINAH C. WASHINGTON,
COMMISSIONER OF SOCIAL
SECURITY, sued as Carolyn W.
Colvin, Acting Commissioner of SSA,
CAUSE NO. 1:15-cv-00189-SLC
OPINION AND ORDER
Plaintiff Dinah C. Washington 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 Disability Insurance Benefits (“DIB”) and Supplemental Security
Income (“SSI”).1 (DE 1). For the following reasons, the Commissioner’s decision will be
I. PROCEDURAL HISTORY
Washington applied for DIB and SSI in August 2012, alleging disability as of February
12, 2012.2 (DE 11 Administrative Record (“AR”) 228-35). The Commissioner denied
Washington’s application initially and upon reconsideration. (AR 160-85). After a timely
request, a hearing was held on October 7, 2013, before Administrative Law Judge William D.
Pierson (“the ALJ”), at which Washington, who was represented by counsel; her husband; and a
All parties have consented to the Magistrate Judge. (DE 14); see 28 U.S.C. § 636(c).
Washington had previously applied for DIB and SSI; however, her prior applications were denied after a
hearing by an administrative law judge, and she did not appeal the decision. (AR 24).
vocational expert, Marie Kieffer (the “VE”), testified. (AR 38-86). On January 17, 2014, the
ALJ rendered an unfavorable decision to Washington, concluding that she was not disabled
because despite the limitations caused by her impairments, she could perform her past work as a
hairdresser and a production assembler, as well as a significant number of other light jobs in the
economy. (AR 24-33). The Appeals Council denied Washington’s request for review (AR 116), at which point the ALJ’s decision became the final decision of the Commissioner. See 20
C.F.R. §§ 404.981, 416.1481.
Washington filed a complaint with this Court on July 24, 2015, seeking relief from the
Commissioner’s final decision. (DE 1). Washington advances just one argument in her
appeal—that the ALJ improperly rejected the permanent restrictions assigned by her treating
physician, Alex Meyers, M.D. (DE 19 at 8-10).
II. FACTUAL BACKGROUND3
At the time of the ALJ’s decision, Washington was 52 years old (AR 124); had a high
school education (AR 44, 257); and possessed past work experience as a warehouse worker,
machine operator, and hairdresser (AR 298). She alleges disability due to left shoulder
impingement syndrome/tendinopathy, left clavicular degenerative joint disease, fibromyalgia,
cervical degenerative joint disease, post left CS injection at carpal canal, post left shoulder
arthroscopy, post left shoulder distal clavicle excision, and renal dysfunction. (DE 19 at 2).
A. Washington’s Testimony at the Hearing
At the hearing, Washington, who is left handed, testified that she stopped working due to
problems with her left shoulder. (AR 53). Although her shoulder has improved over time, she
In the interest of brevity, this Opinion recounts only the portions of the 480-page administrative record
necessary to the decision.
still experiences aching in her shoulder, as well as intermittent numbness in her left arm. (AR
54-55). She can reach overhead with her left arm, but it is difficult to do so and causes her
discomfort. (AR 55). Washington takes Cymbalta for her shoulder, which “calms it down,” and
also has prescription pain medication; however, she takes the pain medication sparingly (just
three times in two weeks) and instead takes Tylenol. (AR 60).
Washington uses her left arm to clean her house, but she does so in spurts. (AR 56, 7576). She used to be able to clean her house in one day; now it takes her several days. (AR 56).
She uses her left arm to sweep, cook, and wash dishes; however, she uses her right arm to lift
heavier items. (AR 57, 70). Stirring and gripping with her left hand causes her pain, so she
makes simple meals. (AR 58). She can perform her own self care. (AR 70). She has difficulty
holding her grandchildren longer than 30 minutes. (AR 59). She drives up to three times a week
to go shopping and to doctor appointments, but her husband drives if they go out of town. (AR
Washington also complained of pain in her low back and in her feet. (AR 60-61). She
stated that her foot pain has improved since getting different shoes; when her foot pain does flare
up, she can “walk it out” in about six minutes. (AR 61-62). She does not take pain medication
for her feet. (AR 65). She had been walking up to three miles a day in an effort to lose weight,
but her physician cut her back to 30 minutes on flat surfaces only. (AR 62-64). She props her
feet up five hours a day. (AR 75). Washington takes pain medication for her back sparingly;
about four times a month, she lies on a hard surface with a heating pad on her back and her feet
up on a stool. (AR 64).
Washington also complained of fibromyalgia symptoms, stating that Cymbalta helps with
those as well. (AR 64-65). On a scale of one to 10, Washington rated her fibromyalgia pain as a
“four” when taking Cymbalta and an “eight” when without Cymbalta. (AR 66). She complained
of “memory fog,” fatigue, difficulty sleeping, and pain when touched. (AR 65-67, 69). She
takes medication to aid her sleep, which helps, but it also causes her some daytime drowsiness.
(AR 67-68). She lies on the couch watching television for eight or nine hours a day. (AR 67).
Washington also complained of neck pain, which causes a “tired feeling” and sometimes a
burning sensation. (AR 69). In the past, she received injections for her neck, which were
helpful. (AR 69).
Washington estimated that she could walk up to 20 minutes and stand for 10 minutes
before her back, left knee, and left foot start aching and swelling. (AR 70-71). She can lift five
pounds with her left arm and 10 pounds with both arms. (AR 71, 73). She complained of
difficulty gripping items and writing with her left hand. (AR 73-74). She uses pillows behind
her back when she sits in a chair, and she puts her feet up. (AR 72). Sitting at a computer screen
bothers her neck. (AR 72). She reported medication side effects of dizziness, drowsiness, rapid
heart rate, poor eyesight, and headaches.4 (AR 68, 73).
B. Summary of the Relevant Medical Evidence
In July 2011, Washington saw Sarah Thomas, M.D., twice for complaints of pain in her
low back, knees, and “all over.” (AR 400). Injections in her left knee and elbow were
administered at her first visit, and she was referred to physical therapy and prescribed nonsteroidal anti-inflammatory drugs (“NSAIDs”). (AR 404). Dr. Thomas put her off work for two
weeks. (AR 404). At her second visit, Thomas stated that she had not taken the NSAIDs as
Washington’s husband also testified at the hearing, essentially corroborating her testimony. (AR 77-80).
prescribed at her previous visit. (AR 400). She felt that she could not return to work and was
considering applying for disability. (AR 400). On exam, her muscle strength and tone were
normal, but she had tenderness in her elbows and in her lower spine. (AR 401).
In September 2011, Washington returned to Dr. Thomas complaining of pain in her feet
and pain in her left shoulder which radiated down her left arm to her index finger. (AR 397).
On exam, Washington exhibited full range of motion of her shoulder, but abduction and external
rotation were painful; impingement was noted with abduction and flexion. (AR 398). She was
assessed with lateral epicondylitis of the left elbow, low back pain, cervicalgia, and rotator cuff
tendonitis. (AR 399). She was given an injection in her left shoulder and instructed to avoid
lifting more than five pounds with her left arm for two weeks. (AR 399).
In January 2012, Washington saw Alex Meyers, M.D., a hand surgeon, for a three-year
history of left arm pain. (AR 336). He noted that she had undergone five injections in her
shoulder, several series of physical therapy, and an MRI. (AR 336). On exam, Washington had
some tenderness to palpation over the greater tuberosity and pain with resisted external rotation.
(AR 336). Her strength was 4+/5, limited only by pain. (AR 336). She had moderate tenderness
over the acromio-clavicular joint, and cross body abduction was painful. (AR 336). A
dorsomedial nerve compression test, Phalen’s and reverse Phalen’s tests, and a Tinel’s test were
all positive. (AR 336). An MRI showed supraspinatus anterior tendinopathy and edema that
indicated at least a partial thickness tear, if not a full thickness tear. (AR 336). Associated
acromioclavicular arthropathy and subacromial bursitis were present. (AR 336). Dr. Meyers’s
impression was left shoulder pain consistent with rotator cuff tendinopathy and peripheral
compressive neuropathy with reported EMG positive carpal tunnel syndrome. (AR 336).
Because non-operative treatment had failed and the symptoms were affecting Washington’s
sleep and daily living activities, Dr. Meyers recommended Washington undergo an arthroscopic
rotator cuff repair, as well as a left carpal tunnel release. (AR 336). However, he wanted to
review her MRI and EMG reports before proceeding. (AR 337).
On February 2, 2012, Dr. Meyers performed a left shoulder arthroscopy and left shoulder
distal clavicle excision on Washington. (AR 362). Because an EMG report was normal, Dr.
Meyers opted to administer a cortisone injection into her left carpal tunnel, rather than perform a
surgical release. (AR 362). Several days after surgery, Washington was doing well,
demonstrating passive forward flexion to 120 degrees and 40 degrees external rotation. (AR
338). Dr. Meyers encouraged her to participate in physical therapy. (AR 338).
Later that month, Washington was seen by Dr. Thomas for followup. (AR 394). She was
receiving physical therapy three times a week for her left shoulder. (AR 394). She complained
of low back pain and “hurting all over,” that she had pain upon touch, and that she had difficulty
sleeping due to pain; Mobic helped reduce her pain. (AR 394). She demonstrated restricted
range of motion in her left shoulder, and fibromyalgia trigger points were positive in all 18
regions. (AR 396). Dr. Thomas’s impression was fibromyalgia, low back pain, left rotator cuff
tendonitis and subacromial bursitis, and left carpal tunnel syndrome. (AR 396).
In March 2012, Washington saw Eugene MacDonald, M.D., a podiatrist, for heel pain
when weight bearing. (AR 378). He indicated that Washington could return to work on May 2,
2012, but must avoid prolonged standing and any squatting, bending, stooping, or using ladders.
Also in March 2012, Washington returned to Dr. Thomas for followup on her plantar
fasciitis. (AR 391-93). She had been prescribed an orthotic and medication, but had stopped
taking at least one medication on her own; she was still participating in physical therapy. (AR
391). She also complained of tightness in her back and shoulder muscles, and she continued to
have pain and restriction of movement in her left shoulder. (AR 391). She complained of twoday “flares” in her pain, where she hurts all over and stays in bed. (AR 391). Upon exam, 13 of
18 fibromyalgia trigger points were positive. (AR 392). Dr. Thomas adjusted her medications
and recommended that she perform stretches and apply heat. (AR 393).
During a March 26, 2012, appointment, Dr. Meyers noted that Washington was seven
weeks post surgery, that she was progressing in therapy, and that her pain was improving. (AR
339). She demonstrated active flexion to 130 degrees, active abduction to 120 degrees, external
rotation to 70 degrees, and internal rotation to the lumbar spine; she demonstrated good cuff
strength. (AR 339). Dr. Meyers instructed Washington to continue therapy, stating that passive
range of motion exercises with progressive strengthening would help to reduce her shoulder
stiffness. (AR 339).
On April 23, 2012, Washington told Dr. Meyers that she had good days and bad days and
that a Medrol dosepak had helped her significantly. (AR 340). She had used all of the physical
therapy visits afforded by her insurance and was performing a home exercise program. (AR
340). Dr. Meyers and Washington agreed that she was sufficiently improving from week to
week and that she did not need an injection or an MRI. (AR 340). She demonstrated active
flexion to 140 degrees with pain after 90 degrees, active abduction to 130 degrees with pain after
90 degrees, external rotation to 70 degrees, and internal rotation to the buttock; she had 4+/5 cuff
strength. (AR 340). Dr. Meyers indicated that Washington was doing well for being 10 weeks
post shoulder arthroscopy. (AR 340). He planned to see her back in a few weeks and stated that
he may release her to return to work at that time. (AR 340).
On May 16, 2012, Dr. Meyers wrote that Washington was doing well post shoulder
capsulectomy and decompression. (AR 341). She still had some limitations overhead with
respect to discomfort, but overall her functional arc of motion was well maintained, and she had
good cuff strength throughout. (AR 341). He instructed her to continue her home exercise
program for three to six months and to call him if she reached a plateau; she was to return only
as needed. (AR 341). Dr. Meyers stated that he thought it would be in Washington’s best
interest “to limit herself overhead and to give her a permanent overhead lifting restriction.” (AR
341). In that regard, he completed a “Patient Work/School Status” form, assigning Washington
the following permanent restrictions with respect to her left upper extremity: no use above the
shoulder; no repetitive pushing, pulling, grasping, or twisting; and no lifting over two pounds.
(AR 371). Although there are no further treatment notes from Dr. Meyers, two additional
“Patient Work/School Status” forms dated May 30, 2012, and July 18, 2012, are of record,
reiterating the same permanent restrictions. (AR 364, 366).
Also in May 2012, Washington saw Dr. Thomas for back pain that was radiating to her
left hip. (AR 388-90). Washington denied any neck pain; she was working on improving the
range of motion of her left shoulder, but it was still restricted. (AR 388). Her muscle strength
and tone were normal. (AR 389). She received another hip injection. (AR 390).
In July 2012, Washington was seen by Dr. Thomas for left heel pain, but she denied any
pain in other joints. (AR 385-86). She had started exercising and had felt much better until her
heel flared up. (AR 385). She demonstrated 5/5 strength in all muscles and full range of motion
in all extremities. (AR 386). For Washington’s left heel pain, Dr. Thomas recommended icing,
stretching exercises, and a night splint. (AR 387). As to Washington’s fibromyalgia, Dr.
Thomas encouraged her to keep exercising as much as her heel would allow, noting that the
exercise was causing her to feel better. (AR 387).
Dr. MacDonald saw Washington for her heel pain several times in June and July 2012.
(AR 372-76). By the end of July, Washington reported to Dr. MacDonald that her left heel had
improved and was just “a little sore.” (AR 372).
In September 2012, Washington donated a kidney to a family member. (AR 456).
In October 2012, Joshua Eskonen, D.O., a state agency physician, reviewed
Washington’s record and concluded that she could lift 10 pounds frequently and 20 pounds
occasionally; stand or walk up to six hours in an eight-hour workday; sit for six hours in an
eight-hour workday; perform unlimited pushing and pulling within the lifting restrictions; and
occasionally balance, stoop, kneel, crouch, crawl, and climb. (AR 132-33). In December 2012,
R. Bond, M.D., another state agency physician, reviewed Washington’s record and assigned the
same limitations. (AR 148-49).
In February 2013, Washington returned to Dr. Thomas after a lengthy absence; she had
lost her job and her health insurance. (AR 456). She had been exercising, doing zumba twice a
week, and walking three miles a day on a treadmill; however, she was having difficulty with pain
in her neck and left hip and knee. (AR 456). She was taking certain medications just “off and
on.” (AR 456). On a scale of one to 10, she rated her pain as a “three” and her fatigue as a
“four.” (AR 456). She demonstrated normal muscle strength and full range of motion in her
extremities; however, 16 of 18 fibromyalgia trigger points were positive. (AR 457). Dr. Thomas
administered several injections, encouraged stretching and aerobic exercise regimen, and
prescribed Cymbalta and Tramadol. (AR 458).
In March 2013, Washington was seen by Susan Draves, a nurse practitioner at the Family
Medicine Center, for followup on her hypertension. (AR 445-46). She demonstrated normal
range of motion in all extremities, and no medication side effects were noted. (AR 442-43, 437).
In April 2013, Washington reported that she was feeling much better since losing weight
and taking Cymbalta. (AR 453). She was exercising and had lost 12 pounds since her last visit.
(AR 453). She again rated her pain as a “three” and her fatigue as a “four.” (AR 454). She
demonstrated full range of motion in all extremities, but reported pain with abduction of her
shoulders bilaterally. (AR 454-55). Dr. Thomas assessed that Washington’s myofascial pain
syndrome was much better with the addition of Cymbalta and recommended that she continue
exercising. (AR 455). In May 2013, Washington complained of increasing cramping pain in her
knees, calves, and left hip, and her medications were adjusted. (AR 463).
In July 2013, Washington saw Dr. Thomas for a routine followup on her left knee pain,
which she rated as a “four.” (AR 460). Her symptoms worsened upon weight bearing, but
improved with NSAIDs. (AR 461). She exhibited full range of motion of her extremities, but
reported pain with abduction of her left shoulder and mild tenderness in her left knee. (AR 462).
Washington was found to have a renal insufficiency, and thus, Dr. Thomas prescribed a Medrol
dose pack, rather than NSAIDs, together with icing and stretching exercises. (AR 462).
In September 2013, Washington told Ms. Graves at the Family Medicine Center that she
was doing well and was without complaints; she denied any medication side effects. (AR 473).
She had normal range of motion in all extremities, but complained of fibromyalgia pain. (AR
474). Ms. Graves encouraged Washington to try water exercises. (AR 474).
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
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).
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
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).
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).
B. The Commissioner’s Final Decision
On January 17, 2014, the ALJ issued the decision that ultimately became the
Commissioner’s final decision. (AR 24-33). The ALJ noted at step one of the five-step analysis
that Washington had not engaged in substantial gainful activity since her alleged onset date.
(AR 26). At step two, the ALJ found that Washington had the following severe impairments:
fibromyalgia, bursitis, residuals of left shoulder surgery, cervical degenerative joint disease, and
recent renal dysfunction. (AR 27).
At step three, the ALJ concluded that Washington did not have an impairment or
combination of impairments severe enough to meet or equal a listing. (AR 27-28). Before
proceeding to step four, the ALJ determined that Washington’s symptom testimony was not
credible, and the ALJ assigned her the following RFC:
[T]he claimant has the [RFC] to perform light work . . . except she can sit 6 of 8
hours, stand and/or walk 6 of 8 hours, lift and carry 10 pounds frequently and 20
pounds occasionally, cannot climb ladders, ropes, and scaffolds; and can
occasionally climb ramps and stairs.
Based on this RFC and the VE’s testimony, the ALJ concluded at step four that
Washington could perform her past relevant work as a hairdresser and production assembler.
(AR 32). Alternatively, the ALJ found that because the additional limitations assigned in the
RFC had little to no effect on the occupational base of unskilled light work, Washington was not
disabled under grid rules 202.13 through 202.15. (AR 33). Therefore, Washington’s
applications for DIB and SSI were denied. (AR 33).
C. The RFC Assigned by the ALJ Is Supported by Substantial Evidence
Washington’s sole argument on appeal is that the ALJ improperly rejected the permanent
restrictions assigned by Dr. Meyers with respect to her left upper extremity. To review, these
restrictions were no use above the shoulder; no repetitive pushing, pulling, grasping, or twisting;
and no lifting over two pounds. (AR 364, 366). Having considered the record and the parties’
arguments, the Court finds that the RFC assigned by the ALJ is supported by substantial
The Seventh Circuit Court of Appeals has explained 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 (citations omitted); 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.” Clifford, 227 F.3d at 870 (citation omitted); see Johansen v. Barnhart,
314 F.3d 283, 287 (7th Cir. 2002); 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2).
In the event the treating physician’s opinion is not well supported or is inconsistent with
other substantial evidence, the Commissioner applies 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). 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
SSR 96-5p, 1996 WL 374183, at *5 (July 2, 1996); 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.” (citing 20 C.F.R. § 404.15279d)); see SSR 96-5p, 1996 WL 374183, at *5
(July 2, 1996).
Here, the ALJ thoroughly considered the permanent restrictions assigned by Dr. Meyers,
penning four paragraphs about them. (AR 27-31). In doing so, the ALJ observed that the
restrictions were inconsistent with other material evidence of record. (AR 27, 29, 31). Upon
weighing the evidence, the ALJ concluded that the restrictions were entitled to little weight for
the following reasons: (1) Washington’s ability to use her left upper extremity improved after
May 2012; (2) Tinel’s and Phalen’s signs were negative after surgery; (3) examinations after
May 2012 revealed normal strength in her hands and arms and full range of motion in her fingers
and elbows bilaterally with no swelling or synovitis; (4) Washington saw Dr. Meyers for about
four months, and the limits he assigned are not supported by treatment notes for 12 months in
duration; and (5) Washington did not complain of any carpal tunnel syndrome symptoms or
neuropathy in her left arm to Dr. Meyers after May 2012. (AR 27-31). Succinctly, the ALJ
stated: “While [the restrictions] may have been an accurate reflection of the claimant’s limits for
a few months after her left shoulder surgery, [they] do not accurately reflect the claimant’s
residual functional capacity 12 months in duration.” (AR 30).
Washington challenges the ALJ’s rationale for rejecting the permanent restrictions
assigned by Dr. Meyers. First, she asserts that Dr. Thomas observed in both April and July 2013
that she experienced pain with shoulder abduction (AR 454-55, 462), but that the ALJ selectively
ignored these findings. Second, Washington argues that the ALJ “played doctor” by making a
medical judgment beyond his ken in rejecting the permanent restrictions. And third, Washington
contends that the ALJ failed to give due weight to Dr. Meyers’s speciality as a hand surgeon
when considering the checklist factors in 20 C.F.R. §§ 404.1527(c) and 416.927(c).
With respect to her first argument, Washington is correct that the ALJ did not specifically
discuss Dr. Thomas’s observation that Washington reported “pain with abduction” of her
shoulders bilaterally in April 2013 and with respect to her left shoulder in July 2013. (AR 45455, 462). “The ALJ’s failure to address these specific findings, however, does not render his
decision unsupported by substantial evidence because an ALJ need not address every piece of
evidence in his decision. The ALJ need only build a bridge from the evidence to his
conclusion.” Sims v. Barnhart, 309 F.3d 424, 429 (7th Cir. 2002) (citations and internal
quotation marks omitted); see also Simila v. Astrue, 573 F.3d 503, 516 (7th Cir. 2009). Here
these two observations, standing alone, do not materially undermine the bulk of evidence
supporting the ALJ’s observation that Washington’s use of her left arm improved after May
2012, as she consistently demonstrated full upper extremity range of motion and strength at
medical visits from July 2012 to September 2013. (See, e.g., AR 386, 443, 454, 457, 462, 474).
Furthermore, the April 2013 note indicated that abduction was painful bilaterally, which tends to
undercut Washington’s assertion that her pain was attributable to her history of left shoulder
surgery. (AR 454-55). Consequently, on the record presented, the Court cannot conclude that
the ALJ unfairly evaluated the record by not expressly discussing this evidence.
Next, Washington argues that the ALJ “played doctor” by making a medical judgment
beyond his ken when he assigned little weight to the permanent restrictions assigned by Dr.
Meyers. Indeed, “[a]n ALJ cannot play the role of doctor and interpret medical evidence when
he or she is not qualified to do so.” Murphy v. Astrue, 496 F.3d 630, 634 (7th Cir. 2007)
(citations omitted)). Here, however, the ALJ did not “play doctor” by improperly interpreting
medical evidence. Rather, the ALJ considered the permanent restrictions for purposes of
determining Washington’s RFC—a responsibility which is reserved to the Commissioner. 20
C.F.R. §§ 404.1545(e), 416.945(e).
In that regard, “[t]he ALJ is charged with making an RFC determination that reflects the
entire record, not just one doctor’s opinion.” Lemere-Jackson v. Colvin, No. 3:13-cv-912-CAN,
2014 WL 4656567, at *8 (N.D. Ind. Sept. 17, 2014) (emphasis added). Accordingly, an ALJ
does not impermissibly “play doctor” when defining what limitations should be included in and
excluded from a claimant’s RFC. Id.; see Rudicel v. Astrue, 282 F. App’x 448, 453 (7th Cir.
2008) (rejecting the claimant’s argument that the ALJ impermissibly “played doctor” by
affording more weight to the limitations opined by the state agency physicians than the
limitations opined by her treating specialist); Jones v. Colvin, No. 11 C 1608, 2014 WL 185087,
at *11 (N.D. Ill. Jan. 13, 2014) (concluding that the ALJ did not “play doctor” by failing to adopt
physicians’ opinions of the claimant’s RFC, where the ALJ offered adequate reasons for
rejecting their conclusions).
In considering Dr. Meyers’s opinion, the ALJ observed—and correctly so—that the
permanent restrictions were inconsistent with the limitations opined by Dr. Eskonen in October
2012 and by Dr. Bond in December 2012, indicating that Washington could lift 10 pounds
frequently and 20 pounds occasionally and perform unlimited pushing and pulling. The ALJ
also viewed the permanent restrictions as inconsistent with, and unsupported by, the physical
findings at Washington’s visits to Dr. Thomas and the Family Medicine Center from July 2012
to September 2013, which consistently reflected normal upper extremity range of motion and
strength.6 In the face of these inconsistencies, the ALJ correctly concluded that Dr. Meyers’s
opinion was not entitled to controlling weight. See Hofslien v. Barnhart, 439 F.3d 375, 376 (7th
Cir. 2006) (explaining that the “treating physician rule” directs the ALJ to give controlling
weight to a treating physician’s opinion only if it is “well-supported by medically acceptable
clinical and laboratory diagnostic techniques” and “not inconsistent with the other substantial
In fact, Washington testified at the hearing that she could lift five pounds with her left arm and 10 pounds
with both arms (AR 71, 73), and thus, even her own testimony is inconsistent with the two-pound lifting restriction
assigned by Dr. Meyers.
Once an ALJ determines that a treating physician’s opinion is not entitled to controlling
weight, the Commissioner must apply the factors articulated in 20 C.F.R. §§ 404.1527(c) and
416.927(c) to determine the proper weight to apply to the opinion. See Henke v. Astrue, 498 F.
App’x 636, 639 (7th Cir. 2012) (“[T]he ALJ need not blindly accept a treating physician’s
opinion—she may discount it if it is internally inconsistent or contradicted by other substantial
medical evidence in the record.”). An ALJ need not explicitly weigh every factor when
analyzing what weight to attribute to the treating source’s opinion. Id. at 640 n.3. Here, the ALJ
adequately applied the factors in weighing Dr. Meyers’s opinion. Although Washington
suggests otherwise, the ALJ did indeed consider that Dr. Meyers was Washington’s treating
upper extremity specialist. (AR 28). Yet, the ALJ ultimately found it more significant that Dr.
Meyers had treated Washington for a relatively brief period of time—only about four
months—and that he had not seen her since mid-2012. (AR 27, 29-31). The ALJ also
considered that Dr. Meyers’s opinion was not consistent with the limitations opined by Drs.
Eskonen and Bond, and neither consistent with, nor supported by, the normal physical findings
documented at Washington’s visits to Dr. Thomas and the Family Medicine Center from July
2012 to September 2013.7 (AR 27-31).
“[W]hen the record contains conflicting medical evidence, the ALJ has an affirmative
responsibility to resolve that conflict.” Bailey v. Barnhart, 473 F. Supp. 2d 842, 849 (N.D. Ill.
2006) (citing Stephens v. Heckler, 766 F.2d 284, 287 (7th Cir. 1985)). In that vein, the ALJ
confronted, and then resolved, the conflict between the opinions of Dr. Meyers and Drs. Eskonen
The Court notes that when Dr. Meyers assigned the restrictions in May 2012, Washington was still
working on improving her range of motion and had some difficulty with overhead discomfort. (AR 341, 388).
Within two months, however, Washington was demonstrating full range of motion of her left shoulder at medical
appointments. (AR 386).
and Bond concerning Washington’s upper extremity limitations. The ALJ articulated several
good reasons for discounting the permanent restrictions assigned by Dr. Meyers, and
Washington does not challenge these reasons with any particularity. These reasons include that:
(1) Dr. Meyers treated Washington for only about four months; (2) Washington’s left upper
extremity function improved after Dr. Meyers assigned the restrictions; (3) Washington
demonstrated full upper extremity range of motion and strength from July 2012 through
September 2013; and (4) Washington no longer complained of any carpal tunnel syndrome
symptoms or neuropathy in her left arm to Dr. Meyers after May 2012. Therefore, because the
ALJ provided a “sound explanation” for assigning little weight to the permanent restrictions
assigned by Dr. Meyers, the ALJ adequately bore his responsibilities when considering the
opinion.8 See Jelinek v. Astrue, 662 F.3d 805, 811 (7th Cir. 2011) (“An ALJ who chooses to
reject a treating physician’s opinion must provide a sound explanation for the rejection.”
(citations omitted)); 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) (citations and internal quotation marks omitted)).
In sum, because the permanent restrictions assigned by Dr. Meyers were inconsistent
Additionally, Washington suggests that Drs. Eskonen and Bond never saw the permanent restrictions
assigned by Dr. Meyers because in their documentation they indicated there was no “opinion evidence” from any
source. (AR 133, 149). But Dr. Meyers’s treatments records, including the restrictions, were received by the Social
Security Administration on August 24, 2012, and the records were characterized as “medical evidence of record,”
rather than “opinion evidence.” (AR 130, 138, 146, 154, 364, 366). Consequently, it is reasonable to infer that Dr.
Eskonen considered all of Dr. Meyers’s records, including the restrictions, when reviewing the record in October
2012, and that Dr. Bond did so as well in December 2012.
with other opinion evidence and substantial medical evidence of record, the ALJ properly denied
the opinion controlling weight. After determining that the opinion was not entitled to controlling
weight, the ALJ adequately considered the opinion under the factors in 20 C.F.R. §§ 404.1527(c)
and 416.927(c) and articulated several good reasons for assigning it little weight. As such, the
ALJ’s decision to discount the permanent restrictions assigned by Dr. Meyers is adequately
articulated and supported by substantial evidence. The Court will not engage in reweighing the
evidence at this juncture. Clifford, 227 F.3d at 869 (The Court “do[es] not reweigh the evidence,
resolve conflicts, decide questions of credibility, or substitute [its] judgment for that of the
Commissioner’s.”). Accordingly, the Commissioner’s final decision will be AFFIRMED.
For the foregoing reasons, the decision of the Commissioner is AFFIRMED. The Clerk
is directed to enter a judgment in favor of the Commissioner and against Washington.
Entered this 14th day of September 2016.
/s/ Susan Collins
United States Magistrate Judge
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