Soileau v. Social Security Administration

Filing 15

MEMORANDUM RULING re 1 Complaint, filed by Rose Marie Soileau. For the reasons herein, this Court finds that the decision of the Commissioner is AFFIRMED, and this matter is DISMISSED WITH PREJUDICE. Signed by Magistrate Judge Patrick J Hanna on 1/25/2017. (crt,Alexander, E)

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF LOUISIANA
LAFAYETTE DIVISION
ROSE MARIE SOILEAU

CIVIL ACTION NO. 6:15-cv-02634

VERSUS

JUDGE HANNA

U.S. COMMISSIONER,
SOCIAL SECURITY
ADMINISTRATION

BY CONSENT OF THE PARTIES

MEMORANDUM RULING
Before the Court is an appeal of the Commissioner’s finding of non-disability.
In accordance with the provisions of 28 U.S.C. § 636(c) and Fed. R. Civ. P. 73, the
parties consented to have this matter resolved by the undersigned Magistrate Judge
(Rec. Doc. 7-2), and this matter was referred to the undersigned Magistrate Judge for
all proceedings, including the entry of judgment (Rec. Doc. 7). Considering the
administrative record, the parties’ briefs, and the applicable law, the Commissioner’s
decision is affirmed.
ADMINISTRATIVE PROCEEDINGS
The claimant, Rose Marie Soileau, fully exhausted her administrative remedies
before filing this action. She filed an application for disability insurance benefits
(“DIB”), alleging disability beginning on April 21, 2011.1 Her application was

1

Rec. Doc. 5-1 at 124.

denied.2 She requested a hearing,3 which was held on February 26, 2014 before
Administrative Law Judge Carol L. Latham.4 The ALJ issued a decision on May 21,
2014,5 concluding that the claimant was not disabled within the meaning of the Social
Security Act from April 11, 2011 through the date of the decision. The claimant
asked for review of the decision,6 but the Appeals Council concluded that there was
no basis for review.7 Therefore, the ALJ’s decision became the final decision of the
Commissioner for the purpose of the Court’s review pursuant to 42 U.S.C. § 405(g).
The claimant then filed this action, seeking review of the Commissioner’s decision.
SUMMARY

OF

PERTINENT FACTS

The claimant was born on August 21, 1959.8 At the time of the ALJ’s decision,
she was fifty-four years old. She obtained a high school equivalency diploma,9

2

Rec. Doc. 5-1 at 62.

3

Rec. Doc. 5-1 at 84.

4

Rec. Doc. 5-1 at 38-61.

5

Rec. Doc. 5-1 at 20-32.

6

Rec. Doc. 5-1 at 16.

7

Rec. Doc. 5-1 at 4.

8

Rec. Doc. 5-1 at 40, 124.

9

Rec. Doc. 5-1 at 42, 149.

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completed two years of vocational training in medical transcription,10 and has relevant
work experience as a Medicaid biller, secretary, receptionist, and transcriptionist in
a hospital and in doctors’ offices.11 She alleges that she has been disabled since April
21, 201112 due to back surgery, knee surgery, mitral valve prolapse, aortic spasms,
stomach pain, arthritis, memory problems, depression, and a cervical disk fusion that
makes her unable to keep her head down for more than an hour.13
On January 11, 2011, the claimant saw Dr. M. Lawrence Drerup of Alexandria
Neurosurgical Clinic for a neurosurgical consultation.14 She reported that she had
experienced mild neck discomfort with some numbness and tingling in her right arm
for about five years, which became severe after wrapping Christmas presents on
December 10, 2010. She described pinching, hurting, sharp pain and pressure,
extending from her lower cervical spine into the interscapular region and extending
up into the occipital region, provoking headaches.

She complained of daily

headaches since the onset of pain. She denied any new numbness, tingling, or
weakness in her arms but had persistent right arm tingling in a C7 dermatomal pattern
10

Rec. Doc. 5-1 at 42, 149.

11

Rec. Doc. 5-1 at 42, 150, 173.

12

Rec. Doc. 5-1 at 124.

13

Rec. Doc. 5-1 at 148.

14

Rec. Doc. 5-1 at 288-294.

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as well as intermittent weakness in her left arm. She rated her pain as 2 out of 5 and
stated that her pain worsens with activity and driving. She complained of severe pain
when turning her head from side to side and stated that this causes a headache. She
was treated with analgesics and a Prednisone dosepak, which improved her pain for
about one week, but the pain returned and was worsening. In addition to neck pain,
the claimant reported stomach pain, urinary stress incontinence, constipation, thyroid
problems, mitral valve prolapse, depression, sleep apnea, a nervous stomach,
gallbladder trouble, and asthma. She reported having had tonsil and adenoid surgery,
thyroidectomy, cholecystectomy, appendectomy, hysterectomy with removal of the
fallopian tubes and ovaries, Ceasarean section, and lumbar spine surgery.
Dr. Drerup’s physical examination of the claimant showed decreased strength
in her left biceps and decreased triceps reflexes. Hoffman’s sign was present in her
right arm. Dr. Drerup noted that an MRI of the cervical spine performed on
December 13, 2010 showed a large disc herniation at C6-7. Following discussion,
the claimant indicated that she wanted to proceed with surgery. Preganglionic nerve
conduction studies of the arms were performed, which were normal.
A cervical MRI was obtained on January 20, 2011 at Central Louisiana
Surgical Hospital.15 The MRI showed multilevel degenerative disc disease with a left
15

Rec. Doc. 5-1 at 232-233.

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paracentral disc extrusion at the C6-7 level, causing severe spinal canal stenosis and
mild deformity of the spinal cord as well as mild spinal canal stenosis at C5-6.
The claimant again saw Dr. Drerup on January 20, 2011.16 He reviewed the
MRI findings. His plan was to perform an anterior cervical discectomy and fusion
at C6-7 with anterior cervical fixation. The surgery was performed on January 26,
2011,17 and the claimant was discharged from the hospital with a prescription for
Lorcet Plus and instructions to follow up with Dr. Drerup in a week.
The claimant returned to Dr. Drerup on February 10, 2011.18 She indicated that
she had done quite well since surgery and had no neck or arm pain. Range of motion
in the cervical spine was mildly limited in lateral rotation bilaterally but was
otherwise unremarkable. X-rays of the cervical spine showed the spinal fusion.
The claimant saw Dr. Drerup again on March 24, 2011.19 X-rays showed a
solid fusion, and the claimant reported only mild posterior cervical soreness.
Voltaren Gel was prescribed for that complaint.

16

Rec. Doc. 5-1 at 219-221.

17

Rec. Doc. 5-1 at 222-226, 280-282.

18

Rec. Doc. 5-1 at 277-279.

19

Rec. Doc. 5-1 at 273-276.

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On December 14, 2011, the claimant underwent arthroscopic surgery on her
right knee, following failed conservative treatment including two injections.20
The record contains no evidence that the claimant visited Dr. Drerup between
March 2011 and February 2013, a period of almost two years. When the claimant
returned to Dr. Drerup on February 7, 2013,21 she reported intermittent, progressive,
lower posterior cervical pain radiating into her right arm and hand with tingling and
numbness of her left hand but no left arm pain. She stated that her symptoms began
two to three months earlier after lifting a grandchild and affected her sleep. X-rays
showed a stable postsurgical cervical spine and mild degenerative changes at C4-5
and C5-6. Her gait and posture were normal, there were no paraspinal muscle
spasms, and her strength and sensation were normal in both arms. Dr. Drerup
diagnosed status post anterior cervical discectomy and fusion at C6-7 with a solid
anterior cervical fixation, posterior cervical pain with bilateral upper extremity
sensory changes of unclear etiology with known mild cervical spondylosis at C5-6,
history of mitral valve prolapse, status post lumbar spine procedure performed many
years ago, chronic use of aspirin, and a stated allergy to Sulfa drugs. He planned to

20

Rec. Doc. 5-1 at 235-238.

21

Rec. Doc. 5-1 at 267-294.

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obtain preganglionic nerve conduction studies of her arms and an MRI of the cervical
spine.
The cervical MRI obtained on February 18, 201322 showed interval anterior
discectomy at C6-7 with relief of central stenosis. It also showed degenerative
changes at other levels with facet arthropathy but no significant stenosis. The EMG
of the same date was normal.23
On February 26, 2013, the claimant was examined by Dr. Michael A. Hall at
the request of Disability Determination Services.24 The claimant gave Dr. Hall a
detailed history including lumbar spine surgery in 2001, cervical spine surgery in
2011, right knee surgery in 2011, a diagnosis of mitral valve prolapse in 1992, ulcers,
nervous stomach, a diagnosis of major depressive disorder in 2007 for which she
takes medication, chest pain, and spasms of the aorta. She stated that in the previous
six to twelve months, she had no lumbar problems but subjective crepitus in her
posterior cervical spine with sharp cramping pain and radiation to the arms, greater
on the right than the left. She stated that she had an MRI on February 18, 2013 and
was scheduled for an EMG. Physical examination revealed a normal range of motion

22

Rec. Doc. 5-1 at 265-266.

23

Rec. Doc. 5-1 at 263-264.

24

Rec. Doc. 5-1 at 242-245.

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in the lumbrosacral spine and cervical spine, appropriate strength in the upper and
lower extremities, normal fine and gross dexterity, and no evidence of sensation or
motor abnormality in the upper or lower extremities. Dr. Hall also found that the
claimant had a normal range of motion in both knees without tenderness to palpation.
The claimant was able to bear weight on her toes and heels and to do heel-to-toe
maneuvers, spinning, and squatting. Dr. Hall did not detect an auscultative murmur
upon examination of the claimant’s heart, and he found no end-organ damage
secondary to her mitral valve prolapse. Dr. Hall detected no enlargement of the
claimant’s stomach, no rebound, guarding, or fluid waves during examination. He
also found no clinical evidence of memory loss. The claimant told Dr. Hall that she
can dress and feed herself, can stand for thirty minutes at a time and for four hours
of a work day, can walk on level ground for twenty minutes, and can sit for thirty
minutes at a time. She stated that she can lift twenty pounds, can drive for two hours,
can sweep, shop, mop, climb stairs, vacuum, cook, and do dishes. Dr. Hall concluded
that there was no clinical evidence of a decrease in functionality secondary to the
claimant’s alleged impairments.
Two days later, on February 28 2013, the claimant returned to Dr. Drerup.25
She complained of low posterior cervical pain radiating into the right trapezius, the
25

Rec. Doc. 5-1 at 260-262.

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right shoulder, the posterior aspect of her right upper arm, and the lateral aspect of her
right forearm and thumb. She also reported numbness and tingling in her right hand
primarily affecting the thumb. She stated that her symptoms worsened when lying
supine or working overhead, and the pain affected her sleep. Her gait and posture
were normal, there was no paraspinal muscle spasm, strength in her arms was normal,
and the nerve conduction studies were normal. Dr. Drerup’s plan was to perform a
diagnostic and therapeutic selective nerve root block at C6. The nerve root block was
performed on March 8, 2013.26
At the claimant’s next visit with Dr. Drerup on April 4, 2013, she reported that
she no longer had neck or right arm pain but still had numbness in her right hand.
The numbness was more pronounced at night and affected her sleep patterns.
The claimant returned to Dr. Drerup’s office on June 6, 2013.27 She was
continuing to experience numbness and tingling in her right hand. Dr. Drerup noted
that an EMG and nerve conduction study of the arms performed on May 16, 2013
showed severe and significant right carpal tunnel syndrome and mild carpal tunnel
syndrome on the left. He also noted a positive Phalen’s sign and a positive Tinel’s
sign. Dr. Drerup recommended that the claimant use bilateral wrist splints. His

26

Rec. Doc. 5-1 at 259.

27

Rec. Doc. 5-1 at 253-255.

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diagnoses were: status post anterior cervical discectomy and fusion C6-7 with
anterior cervical fixation, C6 radiculopathy right worse than left secondary to mild
cervical spondylosis at C5-6 (improved with selective root block at C6 bilaterally),
history of mitral valve prolapse, status post lumbar spine procedure performed many
years ago, chronic use of aspirin, stated allergy to Sulfa drugs, severe carpal tunnel
syndrome on the right, and mild carpal tunnel syndrome on the left.
On February 26, 2014, the claimant testified at a hearing regarding her
symptoms and her medical treatment. At that time, she was taking the following
prescription medications: Protonix and Reglan for her stomach, Synthroid for her
thyroid, Norvasc and Toprol for mitral valve prolapse, Buspar for anxiety, Effexor for
depression, Estrotest for hormones, Vitamin E for breast problems, Aspirin for her
heart, Ibuprofen as needed for pain, Celebrex as needed for arthritis, and Imetrex as
needed for migraine headaches.
The claimant testified that she returned to work as a Medicaid biller for a
hospital following cervical spine surgery but was unable to perform her job duties,
which included extensive use of a computer to enter data, typing, and using the
telephone. She stated that holding the telephone, typing, writing, and holding her
head down to read and type caused neck pain and headaches. Although she altered
her work station at her own cost by raising her monitor, using a stand for her papers,
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and slanting her keyboard, these changes resulted in only minor improvement in her
symptoms. She tried using a speakerphone, but this disrupted her coworkers, and her
employer did not offer her a headset. Her productivity slowed, and she took more
frequent breaks. Headaches interfered with her ability to stay on task, and she had
to leave work early and miss work due to migraine headaches. Lying down and
applying an ice pack to her neck after work were helpful, but she said her doctor told
her that the problems she was having at work were an expected effect of the cervical
surgery because keeping her head down puts pressure on the fusion site. After six to
eight weeks, she concluded that she was unable to do the job and voluntarily
terminated her employment.
The claimant reported that, since leaving work, she lies down for
approximately one hour most days to help alleviate neck pain; when she does not, her
neck pain increases. She explained that driving for more than thirty to forty-five
minutes is painful, and that she cannot turn her head from side-to-side but must turn
her whole body instead. She reportedly purchased a recliner with specific pillows to
hold her head up. She testified that any type of activity can trigger neck pain, so she
limits her activities to no more than an hour in length. She still does her housework,
but had to acquire a lightweight vacuum cleaner, a different style of mop, and a
lighter purse. She still does her grocery shopping but carries only a few light bags at
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a time. She stated that neck pain interrupts her sleep, and stress causes chest pain due
to mitral valve prolapse. She stated that the nerve block injection “helped a good bit”
but lasted for only three months. She testified that the nerve block did not help her
to such an extent that she would be capable of performing her past work. She
testified that she has carpal tunnel syndrome in her right hand, which goes numb and
is painful. She stated that she takes medication for depression and anxiety but was
recently able to reduce the dosages of both of those medications. She avoids narcotic
medication and primarily takes Ibuprofen for pain.
ANALYSIS
A.

STANDARD

OF

REVIEW

Judicial review of the Commissioner's denial of disability benefits is limited
to determining whether substantial evidence supports the decision and whether the
proper legal standards were used in evaluating the evidence.28 “Substantial evidence
is more than a scintilla, less than a preponderance, and is such relevant evidence as
a reasonable mind might accept as adequate to support a conclusion.”29 Substantial
evidence “must do more than create a suspicion of the existence of the fact to be

28

Villa v. Sullivan, 895 F.2d 1019, 1021 (5th Cir. 1990); Martinez v. Chater, 64 F.3d
172, 173 (5th Cir. 1995).
29

Hames v. Heckler, 707 F.2d 162, 164 (5th Cir. 1983).

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established, but ‘no substantial evidence’ will only be found when there is a
‘conspicuous absence of credible choices' or ‘no contrary medical evidence.’”30
If the Commissioner's findings are supported by substantial evidence, they are
conclusive and must be affirmed.31 In reviewing the Commissioner's findings, a court
must carefully examine the entire record, but refrain from re-weighing the evidence
or substituting its judgment for that of the Commissioner.32

Conflicts in the

evidence33 and credibility assessments34 are for the Commissioner to resolve, not the
courts. Four elements of proof are weighed by the courts in determining if substantial
evidence supports the Commissioner's determination: (1) objective medical facts, (2)
diagnoses and opinions of treating and examining physicians, (3) the claimant's
subjective evidence of pain and disability, and (4) the claimant's age, education, and
work experience.35

30

Hames v. Heckler, 707 F.2d at 164 (citations omitted).

31

42 U.S.C. § 405(g); Martinez v. Chater, 64 F.3d at 173.

32

Hollis v. Bowen, 837 F.2d 1378, 1383 (5th Cir. 1988); Villa v. Sullivan, 895 F.2d at

33

Scott v. Heckler, 770 F.2d 482, 485 (5th Cir. 1985).

34

Wren v. Sullivan, 925 F.2d 123, 126 (5th Cir. 1991).

35

Wren v. Sullivan, 925 F.2d at 126.

1022.

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B.

ENTITLEMENT

TO

BENEFITS

The Disability Insurance Benefit (“DIB”) program provides income to
individuals who are forced into involuntary, premature retirement, provided they are
both insured and disabled, regardless of indigence.36 A person is disabled “if he is
unable to engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be expected to result in death
or which has lasted or can be expected to last for a continuous period of not less than
twelve months.”37 A claimant is disabled only if his physical or mental impairment
or impairments are so severe that he is unable to not only do his previous work, but
cannot, considering his age, education, and work experience, participate in any other
kind of substantial gainful work which exists in significant numbers in the national
economy, regardless of whether such work exists in the area in which the claimant
lives, whether a specific job vacancy exists, or whether the claimant would be hired
if he applied for work.38

36

See 42 U.S.C. § 423(a).

37

42 U.S.C. § 1382c(a)(3)(A).

38

42 U.S.C. § 1382c(a)(3)(B).

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C.

EVALUATION PROCESS

AND

BURDEN

OF

PROOF

The Commissioner uses a five-step inquiry to determine whether a claimant is
disabled. This process requires the ALJ to determine whether the claimant (1) is
currently working; (2) has a severe impairment; (3) has an impairment listed in or
medically equivalent to those listed in the Social Security regulations; (4) is able to
do the kind of work he did in the past; and (5) can perform any other work.39
Before going from step three to step four, the Commissioner assesses the
claimant's residual functional capacity40 by determining the most the claimant can still
do despite his physical and mental limitations based on all relevant evidence in the
record.41 The claimant's residual functional capacity is used at the fourth step to
determine if he can still do his past relevant work and at the fifth step to determine
whether he can adjust to any other type of work.42
The claimant bears the burden of proof on the first four steps; at the fifth step,
however, the Commissioner bears the burden of showing that the claimant can

39

20 C.F.R. § 404.1520.

40

20 C.F.R. § 404.1520(a)(4).

41

20 C.F.R. § 404.1545(a)(1).

42

20 C.F.R. § 404.1520(e).

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perform other substantial work in the national economy.43 This burden may be
satisfied by reference to the Medical-Vocational Guidelines of the regulations, by
expert vocational testimony, or by other similar evidence.44 If the Commissioner
makes the necessary showing at step five, the burden shifts back to the claimant to
rebut this finding.45 If the Commissioner determines that the claimant is disabled or
not disabled at any step, the analysis ends.46
D.

THE ALJ’S FINDINGS AND CONCLUSIONS
In this case, the ALJ determined, at step one, that the claimant has not engaged

in substantial gainful activity since April 21, 2011.47 This finding is supported by
substantial evidence in the record.
At step two, the ALJ found that the claimant has the following severe
impairments: cervical degenerative disc disease/spondylosis and radiculopathy,
status post anterior cervical discectomy and fusion at C6-7, carpal tunnel syndrome,

43

Graves v. Colvin, 837 F.3d 589, 592 (5th Cir. 2016); Bowling v. Shalala, 36 F.3d 431,
435 (5 Cir. 1994).
th

44

Fraga v. Bowen, 810 F.2d 1296, 1304 (5th Cir. 1987).

45

Perez v. Barnhart, 415 F.3d 457, 461 (5th Cir. 2005); Fraga v. Bowen, 810 F.2d at

1302.
46

Greenspan v. Shalala, 38 F.3d 232, 236 (5th Cir. 1994), cert. den. 914 U.S. 1120
(1995) (quoting Lovelace v. Bowen, 813 F.2d 55, 58 (5th Cir. 1987)).
47

Rec. Doc. 5-1 at 22.

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a history of mitral valve prolapse, torn meniscus, and status post right knee surgery.48
This finding is supported by substantial evidence in the record.
At step three, the ALJ found that the claimant has no impairment or
combination of impairments that meets or medically equals the severity of a listed
impairment.49 The claimant does not challenge this finding.
The ALJ found that the claimant has the residual functional capacity to perform
light work except that her work should be limited to no more than occasional reaching
overhead with bilateral upper extremities.50 The claimant challenges this finding.
At step four, the ALJ found that the claimant is capable of performing her past
relevant work as a medical secretary and medical transcriptionist/biller.51 The ALJ
made alternative findings at step five, particularly under Medical-Vocational Rule
202.14, and found that the claimant was not disabled from April 21, 2011 through
May 21, 2014 (the date of the decision).52 The claimant challenges this finding.

48

Rec. Doc. 5-1 at 22.

49

Rec. Doc. 5-1 at 25.

50

Rec. Doc. 5-1 at 25.

51

Rec. Doc. 5-1 at 30.

52

Rec. Doc. 5-1 at 32.

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E.

THE ALLEGATIONS

OF

ERROR

The claimant contends that the ALJ erred (1) in failing to account for her
severe carpal tunnel syndrome in her residual functional capacity evaluation; (2) in
failing to account for her limitations in maintaining neck flexion (looking down) in
her residual functional capacity evaluation; and (3) in failing to provide specific
reasons supporting her credibility findings.
F.

DID THE ALJ ERR IN FAILING TO ACCOUNT FOR THE CLAIMANT’S CARPAL
TUNNEL SYNDROME IN THE RESIDUAL FUNCTIONAL CAPACITY
ASSESSMENT?
Under the regulations and the jurisprudence, the determination of residual

functional capacity is a task that is the sole responsibility of the ALJ.53 In making that
determination, the ALJ is required to consider the medical and nonmedical evidence,
including a claimant’s descriptions of symptoms and limitations.54 In this case, the
ALJ found that the claimant has the residual functional capacity to perform light work
with the exception that she is limited to no more than occasional reaching overhead
with her arms. The claimant argues that this conclusion failed to take her carpal
tunnel syndrome into account.

53

Taylor v. Astrue, 706 F.3d 600, 602-03 (5th Cir. 2012).

54

20 C.F.R. § 404.1545.

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The Social Security regulations define light work as involving the ability to lift
no more than 20 pounds at a time with frequent lifting or carrying of objects weighing
up to 10 pounds.55 A job may fall into the light work category if it requires a good
deal of walking or standing, or when it involves sitting most of the time with some
pushing and pulling of arm or leg controls, even if the weight required to be lifted is
very little.56 When a person is capable of performing light work, he is also usually
capable of doing sedentary work; if there are limiting factors such as an inability to
sit for long periods of time or a loss of fine dexterity, however, a person may be
capable of light work but not capable of sedentary work.57
The claimant was diagnosed with severe carpal tunnel syndrome in her right
arm and mild carpal tunnel syndrome in her left arm in June 2013, eight months
before the hearing. The record contains no evidence that, during that eight month
period following diagnosis, she had any further treatment for her carpal tunnel
syndrome. At the time of the diagnosis, Dr. Drerup recommended that she use splints
on her arms but he did not recommend surgery, and there is no indication in the
medical records showing an objective decrease in the claimant’s ability to use her

55

20 C.F.R. § 404.1567.

56

20 C.F.R. § 404.1567.

57

20 C.F.R. § 404.1567.

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arms in pushing, pulling, fingering, or manipulating objects due to the carpal tunnel
syndrome. When the claimant was examined by Dr. Hall just a few months before the
diagnosis, in February 2013, she was found to have “two-point discrimination and
fine and gross dexterity that was noted to be normal. The patient was noted to have
no evidence of sensation or motor abnormality . . . at the bilateral upper . . .
extremities.”58 Although the claimant had not yet been diagnosed with carpal tunnel
syndrome, Dr. Hall concluded that the claimant’s functionality was not impaired by
her complaints concerning her arms and hands. A month later, consultant Dr. Emily
Eisenhauer concluded that the claimant was unable to work with her arms over her
head, based on the claimant’s function report, where she indicated that she could not
look down for more than an hour at a time, could not work with her arms over her
head, and could not lift more than twenty pounds but could still sew and work in her
flower beds for limited amounts of time, prepare full meals, do laundry and
housework, and do her grocery shopping.59 The claimant also told Dr. Drerup, in
February 2013, that lifting her arms up over her head was painful, and she repeated
that at the hearing. The ALJ incorporated this limitation in her residual functional
capacity finding.

58

Rec. Doc. 5-1 at 244.

59

Rec. Doc. 5-1 at 164-171.

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In the ruling, the ALJ noted that objective testing had revealed carpal tunnel
syndrome, and she reviewed Dr. Drerup’s treatment note concerning that diagnosis.
The ALJ also expressly considered the claimant’s hearing testimony, noting in
particular that the claimant testified that it is painful for her to hold her arms out or
overhead and has experienced hand and arm pain and numbness. The ALJ also noted
that the claimant’s carpal tunnel syndrome “has been considered and accounts for the
lifting and carrying limitations in the . . . residual functional capacity assessment.”60
There is no evidence in the record suggesting that carpal tunnel syndrome restricts the
claimant’s functionality in any ways other than that recognized by the ALJ in the
ruling.
Accordingly, this Court finds that the ALJ considered the claimant’s carpal
tunnel syndrome diagnosis and took the evidence concerning limitations attributable
to that condition into account when evaluating the claimant’s residual functional
capacity. This Court further finds that the ALJ’s residual functional capacity
determination is based on substantial evidence in the record.

60

Rec. Doc. 5-1 at 30.

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G.

DID THE ALJ ERR IN FAILING TO ACCOUNT FOR THE CLAIMANT’S
INABILITY TO MAINTAIN NECK FLEXION IN THE RESIDUAL FUNCTIONAL
CAPACITY ASSESSMENT?
The claimant contends that, since undergoing cervical spine surgery, she is

unable to hold her head down – in other words, in a flexed position – for more than
an hour at a time without pain and resulting headaches. She argues that the ALJ
failed to take this into account when concluding that she is capable of performing a
limited range of light work.
As noted above, however, there is nothing in the definition of light work that
requires a person to be able to look down at something for more than an hour at a
time. Further, while the claimant testified at the hearing that she was unable to
successfully return to her prior job following neck surgery because of this, there is no
indication in the record that she communicated this problem to Dr. Drerup. Dr.
Drerup did not place any restrictions related to neck flexion on the claimant’s
activities following surgery. The record indicates that the claimant saw Dr. Drerup
for two follow-up visits after surgery then did not return to see him again for two
years. At the first follow-up visit, the claimant stated that her neck pain was gone,
and Dr. Drerup noted only a mild limitation in lateral rotation bilaterally. At the
second follow-up visit, the claimant reported only mild soreness and the mildly
limited lateral rotation was again noted. When the claimant returned to Dr. Drerup
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two years later, after experiencing renewed neck pain after picking up a grandchild,
a nerve root block injection was administered in March 2013. The claimant reported
no neck pain to Dr. Drerup in April or June 2013, and the record contains no evidence
of any further treatment for her neck despite the fact that she testified at the hearing
that her neck pain was resolved for only about three months following the nerve root
block injection. The ALJ expressly noted the claimant’s complaint regarding neck
flexion in her residual functional capacity evaluation and found it to be inconsistent
with the claimant’s description of her daily activities.
Accordingly, this Court finds that the ALJ’s residual functional capacity
assessment took the claimant’s subjective complaint regarding pain following neck
flexion into consideration and further finds that the ALJ’s residual functional capacity
assessment is supported by substantial evidence in the record.
H.

DID THE ALJ ERR IN FAILING TO PROVIDE SPECIFIC REASONS SUPPORTING
HER CREDIBILITY FINDINGS?
The ALJ concluded that the claimant has medically determinable impairments

that could reasonably be expected to cause her alleged symptoms, but opined that the
claimant’s statements regarding the intensity, persistence, and limiting effects of her

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symptoms were not entirely credible.61 The claimant now argues that the ALJ erred
because she failed to set forth specific reasons supporting her credibility findings.
“[T]he ALJ is entitled to determine the credibility of medical experts as well
as lay witnesses and to weigh their opinions and testimony accordingly.”62 More
particularly, “[i]t is within the ALJ's discretion to determine the disabling nature of
a claimant's pain,” and “considerable deference” is accorded to such a
determination.63 When an ALJ's credibility determination is supported by substantial
evidence, it is entitled to judicial deference.64
In this case, the ALJ set forth a detailed summary of the medical and
nonmedical evidence in the record. She then noted that the reason she found the
claimant lacking in credibility as to the limitations resulting from her carpal tunnel
syndrome and her alleged inability to flex her neck for more than an hour at a time
is because her activities of daily living are inconsistent with the alleged limitations.65
Thus, the ALJ did provide specific reasons in support of her credibility findings and
did cite evidence in support of her credibility findings, as required by the Social
61

Rec. Doc. 30 at 294.

62

Moore v. Sullivan, 919 F.2d 901, 905 (5th Cir. 1990).

63

Chambliss v. Massanari, 269 F.3d 520, 522 (5th Cir. 2001).

64

Villa v. Sullivan, 895 F.2d at 1024.

65

Rec. Doc. 5-1 at 30.

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Security regulations. Therefore, this Court further finds that the ALJ’s conclusion
regarding the claimant’s credibility is supported by substantial evidence in the record.
CONCLUSION
For the foregoing reasons, this Court finds that the decision of the
Commissioner is AFFIRMED, and this matter is DISMISSED WITH PREJUDICE.
Signed at Lafayette, Louisiana, on this 25th day of January 2017.

____________________________________
PATRICK J. HANNA
UNITED STATES MAGISTRATE JUDGE

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