Harris v. Colvin
MEMORANDUM AND ORDER... IT IS HEREBY ORDERED that the final decision of the Commissioner denying social security benefits is AFFIRMED. An appropriate Judgment shall accompany this Memorandum and Order. Signed by District Judge Ronnie L. White on 9/9/2015. (NEB)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
CHARDELL PATRICE HARRIS,
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
No. 4:14CV1064 RLW
MEMORANDUM AND ORDER
This is an action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of
Defendant's final decision denying Plaintiffs applications for Disability Insurance Benefits
("DIB") under Title II of the Social Security Act and for Supplemental Security Income ("SSI")
under Title XVI of the Act. For the reasons set forth below, the Court affirms the decision of the
I. Procedural History
On April 20, 2012, Plaintiff filed an application for a period of disability and Disability
Insurance Benefits, as well as an application for Supplemental Security Income. (Tr. 11, 127-39)
Plaintiff alleged that she became unable to work on March 1, 2012 due to lower back pain and
knee pain. (Tr. 58, 127, 133) The applications were denied, and Plaintiff filed a request for a
hearing before an Administrative Law Judge ("ALJ"). (Tr. 57-62, 65) On July 18, 2013,
Plaintiff testified before an ALJ. (Tr. 28-41) On August 15, 2013 , the ALJ determined that
Plaintiff had not been under a disability from March 1, 2012, through the date of the decision.
(Tr. 11-24) Plaintiff then filed a request for review, and on April 2, 2014, the Appeals Council
denied said request. (Tr. 2-4) Thus, the decision of the ALJ stands as the final decision of the
II. Evidence Before the ALJ
At the July 18, 2013 hearing before the ALJ, Plaintiff was represented by counsel. Upon
examination by the ALJ, Plaintiff testified that she was 53 years old and graduated from high
school. She previously worked for the Knights Inn motel as a housekeeper; for various lounges,
where she was paid in cash; and for White Castle as a cashier, cook, and cleaner. Plaintiff
testified that she worked for White Castle from 2007 to 2011 but was fired after her employer
accused her of sealing. She then received unemployment benefits for two years. (Tr. 30-32)
Plaintiff further stated that she weighed 185 pounds and measured 5 feet one inch. She
complained of back problems, including spasm and herniated discs. In 2012, Plaintiff underwent
an MRI and was also examined by a neurologist. The neurologist did not recommend surgery
and told Plaintiff to try and live with the conditions. When her back symptoms worsened, she
used a walker. (Tr. 32-33)
Plaintiff also testified to experiencing depression or mood swings. She sat by herself and
thought about things that depressed her. She did not take medication for depression, and she did
not receive care from a psychiatrist or psychologist. Plaintiff stated that she was unable to sit for
a long time due to back pain. She would get up and try to walk to relieve the pain. (Tr. 33-34)
Plaintiff's attorney also questioned Plaintiff regarding her impairments. Plaintiff testified
that her doctor advised her to walk for exercise. Plaintiff walked every day for about one block.
She was unable to walk further due to pain in her back. When she returned home after her walk,
she tried to do exercises to loosen her back. Plaintiff stated that she could walk a half hour
before needing to rest. To relax her muscles she sat with a pillow behind her or curled up in a
ball. She could stand in one place for five minutes. Plaintiff experienced back spasms every
other day. She testified that the spasms felt as though her two muscles are playing tug-of-war.
One muscle pulled in one direction while the other pulled the opposite way. Plaintiff was unable
to move during these episodes. The spasms lasted a half hour to an hour. Plaintiff took
prescribed muscle relaxers when her spasms flared up. The medication eased the pain, and the
spasms eventually went away. However, the muscle relaxers caused drowsiness, so Plaintiff
only took the medication when she was home. (Tr. 35-37)
A vocational expert ("VE") also testified at the hearing. The ALJ set forth two
hypotheticals for the VE's consideration. The ALJ first asked the VE to assume a 51-year-old
claimant with 12 years of education and 2 past jobs that were considered substantial gainful
activity. The claimant could lift and carry 20 pounds occasionally and 10 pounds frequently;
stand or walk for 6 out of 8 hours; sit for 6 hours; occasionally climb stairs and ramps; never
climb ropes, ladders, or scaffolds; occasionally stoop, kneel, and crouch; and should avoid
concentrated exposure to extreme cold and unprotected heights. Given this hypothetical, the VE
testified that the individual could perform both prior jobs as a housekeeper and fast food worker.
For the second hypothetical, the ALJ asked the VE to assume the first hypothetical with
an additional sit/stand option to allow the claimant to briefly change positions every 30 minutes
and resume working. The VE responded that the individual could not perform her past relevant
work. However, she would be able to perform other jobs such as tanning salon attendant and
parking lot attendant. (Tr. 39-40)
Plaintiffs attorney also questioned the VE, asking whether an employer would tolerate
the need for an extra half hour break every other day. The VE answered that this factor would
preclude all competitive employment. (Tr. 40)
In a Disability Report - Adult, Plaintiff listed her conditions that limited her ability to
work as lower back pain and knee pain. Plaintiff reported that she stopped working on April 30,
2011 because she was fired. She believed her conditions became severe enough to keep her from
working on March 1, 2012. Plaintiff completed the 12th grade and had business training. The
interviewer noted that Plaintiff used a walker for assistance, wore glasses when signing her
name, and held onto the desk when standing. (Tr. 158-67)
Plaintiff also completed a Function Report - Adult, reporting that she did mostly nothing
from the time she woke up until going to bed. She needed 10 to 15 minutes to get out of bed due
to pain in her lower back. She would then fix a bowl of cereal. Plaintiff took pain medication
and tried to exercise. She could only be on her feet for about 5 to 10 minutes at a time. She saw
her doctor once a month and felt her back condition was deteriorating. Plaintiff was able to care
for her personal needs but experienced pain. She could prepare cereal, sandwiches, and oatmeal.
However, she did not prepare full meals because she was unable to stand longer than 5 minutes
due to pressure and severe pain in her lower back. Her mother and brother performed the
household chores and yard work. Plaintiff reported that she never went outside because she
could not stand or sit for more than 5 to 10 minutes. She did not feel pain if she lay on her side.
She was able to ride in a car but needed help getting in and out. She did not drive, and her
mother did all the shopping. Plaintiff was able to handle money. Her only hobby was watching
TV, but only when she was not in pain. (Tr. 176-80)
Plaintiff claimed that her conditions affected her ability to lift, squat, bend, stand, reach,
walk, sit, kneel, and stair climb. She could walk about 114 block before needing to rest for 15 to
20 minutes. She did not finish what she started but was able to follow written and spoken
instructions, get along with authority figures, handle stress, and handle changes in routine.
Plaintiff used a walker, but it was not prescribed by any doctor. (Tr. 182-83)
III. Medical Evidence
On September 26, 2011 , Plaintiff was examined at the North Central Community Health
Center for complaints of chronic back pain. She reported that her back pain began 2 to 3 years
earlier as a result of a car accident. Plaintiff stated that the pain ran from her shoulder blades to
her mid-lower back on both sides. She took Tylenol, Advil, and Aleve to relieve the pain. She
also reported numbness and tingling in her hands and arms. She smoked less than a pack of
cigarettes a day. Examination revealed back spasms to shoulders and upper anterior chest.
Plaintiff had full range of motion of shoulder and neck, with some mild stiffness. Dr. Mecca T.
McDonald assessed muscle spasm and prescribed medication. (Tr. 212-13)
On November 2, 2011 , Plaintiff reported that the muscle relaxants helped, but the pain
was worse with bending and sneezing. Physical examination revealed flexion to greater than 90
degrees and no paraspinal muscle tenderness. Dr. McDonald assessed back muscle spasm and
prescribed Cyclobenzaprine and Naprosyn. (Tr. 211)
Plaintiff returned to Dr. McDonald on January 30, 2012, complaining of depression,
mood swings, and not wanting to be around people. Psychiatric review noted anxiety,
depression, irritation, frequent crying, and difficulty falling asleep. Suicidal ideation and suicidal
planning were not present. Dr. McDonald assessed depression and referred Plaintiff to Social
Services. (Tr. 210)
On February 6, 2012, Plaintiff saw Doris King, MSW. Plaintiff reported being a loner
and wanting to stay by herself. She kept things bottled up, which made her angry. She was
afraid she would "explode," and she mentioned that she lost jobs because she "goes off' on
managers. On examination, Plaintiff alternated between being visibly upset and needing to talk
about her situation. Ms. King noted that Plaintiff required an initial evaluation to diagnose her
symptoms and stabilize her on the appropriate medications. Ms. King referred Plaintiff to a
psychiatry program and counseling services, noting that counseling could help Plaintiff deal with
possible schizoaffective diagnosis and symptoms. (Tr. 209)
Plaintiff returned to Dr. McDonald on February 27, 2012 for complaints of lower back
pam. She had not started counseling, and her medication for depression upset her stomach.
Review of systems demonstrated back pain, back ache, and depression. Examination revealed
muscle spasm bilaterally, lumbar spine paraspinally. She had forward flexion to 90 degrees, as
well as normal gait and station and normal posture. Dr. McDonald assessed back muscle spasm
and depression. (Tr. 207)
On March 5, 2012, Plaintiff complained of back pain and an upset stomach from the
medication samples given for depression. She reported that the Naproxen helped the pain and
that she had three scheduled counseling appointments. Plaintiff was in no acute distress. Dr.
McDonald again diagnosed back muscle spasms and depression and advised Plaintiff to return in
three months. (Tr. 206)
On April 16, 2012, Harris reported severe pain and requested stronger pain medication.
She was using a walker. Plaintiff stated that she did not go to her psychiatric appointments
because she could not get out of bed. Dr. McDonald found no generalized swelling or edema of
extremities, no digital clubbing or cyanosis and neurovascularly intact globally with deep tendon
reflexes. Her gait, station, and posture were normal. Dr. McDonald ordered an MRI and
assessed back muscle spasm and depression. (Tr. 204) An MRI of the Lumbar Spine without
contrast showed spinal stenosis at L4-5 and L3-4 secondary to a bulging disc at L3-4 and L4-5;
and disc herniation at L4-5 and L5-Sl with nerve encroachment on the left. (Tr. 203, 252)
Plaintiff complained of back pain, left knee pain, and a bladder infection during a clinic
visit on April 19, 2012. She reported that medications did not help her back pain at all, and she
was having trouble walking. Dr. Neesha D. Kurian noted that Plaintiff did not have a history of
a fall that caused the symptoms. Review of systems showed joint pain in the left knee but no
swelling. Plaintiff made an appointment with psychiatry. Dr. Kurian also noted moderate
tenderness in Plaintiffs lower back with bilateral pain, muscle spasm, and limited forward
flexion and extension secondary to pain. Dr. Kurian diagnosed back spasms, spinal stenosis at
multiple levels, urinary tract infection, and depression. (Tr. 201-02)
When Plaintiff returned to Dr. Kurian on May 21 , 2012, she reported feeling much better
since her last office visit. She still had pain in the middle of her back and could not sleep flat on
her back. She requested a note for work, as she was looking for a job with less manual labor.
She no longer used a walker and was doing exercises. Examination revealed mild lumbar
tenderness. Dr. Kurian assessed back spasms, much better; disc herniation; and depression. Dr.
Kurian prescribed medication and back exercises, as well as advised Plaintiff to wean off the
muscle relaxant as tolerated. (Tr. 228)
During a follow up visit on August 8, 2012, Plaintiff reported that her back pain flared up
with certain movements and positions. She requested stronger pain medication. She reported no
numbness or tingling in the legs and no weakness. She smoked every day but was considering
quitting. Examination again revealed mild tenderness in the bilateral lumbar region. Dr. Kurlan
assessed muscle spasm and advised Plaintiff to lose weight. In addition, Dr. Kurlan diagnosed
back muscle spasm, spinal stenosis of the lumbar region at multiple levels, and disc herniation.
Dr. Kurlan also referred Plaintiff to a dietician. Plaintiff was to return for a routine medical
exam with blood testing. (Tr. 226-27)
On August 15, 2012, Plaintiff presented to the clinic for a routine physical. She had been
walking recently for exercise. She continued to smoke. Her back pain was better since her last
visit with medication. She had no joint or muscle pain. Physical exam was normal, and Dr.
Kurlan ordered a routine colonoscopy and blood work. (Tr. 223-24)
On August 31 , 2012, Plaintiff visited a neurosurgeon regarding her back pain. She
reported back pain and spasms, as well as difficulty lying down, picking up things, sitting, and
standing. She further reported numbness and tingling in her back and fingers. The spasms in her
thoracolumbar region radiated around her trunk and were exacerbated by bending, walking, and
lying on her back. Her symptoms had been successfully treated with medication. Physical
examination revealed focal tenderness at T6, L4. The student examiner recommended physical
therapy and an MRI. Plaintiffs intake information revealed no functional limitations. Plaintiff
reported no difficulty walking, getting dressed, grooming, remembering, eating, or speaking.
She did have some problems with falling. Plaintiff had no difficulty with activities of daily
living including cooking, cleaning, shopping, and driving. (Tr. 242-49)
Plaintiff returned to Dr. Kurlan on September 5, 2012 for a follow up appointment.
Plaintiff reported intermittent pain. She ate hamburgers daily and smoked every day. Dr. Kurlan
noted mild tenderness in bilateral lumbar. Plaintiff had decreased range of motion secondary to
pain, flexion to shin, and difficulty straightening up secondary to pain. Dr. Kurlan assessed high
cholesterol and advised Plaintiff to decrease red meat in her diet. Dr. Kurlan also assessed disc
herniation, spinal stenosis, and depression. (Tr. 221-22)
On October 24, 2012, Plaintiff saw a dietitian to help with weight loss. Plaintiff
acknowledged that if she lost weight, her back would probably feel better. Goals included
exercise, changing from sugar sweetened beverages to sugar free, and adding more vegetables
into daily meal plan. (Tr. 220)
Plaintiff followed up with the neurosurgeon regarding back pain on October 26, 2012.
The physician prescribed 12 weeks of physical therapy and discharged Plaintiff from the clinic.
On December 3, 2012, Plaintiff saw Dr. Kurlan for a follow up examination. She
complained of back pain from disc herniation. Plaintiff needed a medical exemption to be
covered under Medicaid and attend physical therapy. She was doing exercises 20 minutes a day.
Physical exam revealed mild tenderness in bilateral lumbar, decreased range of motion
secondary to pain, difficulty straightening, and limited flexion. Dr. Kurlan assessed disc
herniation, high cholesterol, back muscle spasm, and tobacco dependence. Dr. Kurlan
prescribed back exercises and noted that, while physical therapy would be beneficial to Plaintiff,
it was not covered with insurance. (Tr. 218-19)
On January 7, 2013 , Dr. Kurlan treated Plaintiff for high cholesterol. (Tr. 217)
IV. The ALJ's Determination
In a decision dated August 15, 2013 , the ALJ found that Plaintiff met the insured status
requirements of the Social Security Act through December 31 , 2016. She had not engaged in
substantial gainful activity since March 1, 2012, alleged onset date. The ALJ determined that
Plaintiff had the severe impairments of degenerative disc disease of the lumbar spine and
obesity. However, she did not have an impairment or combination of impairments that met or
medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P,
Appendix 1. (Tr. 11-17)
After considering the record, the ALJ found that the Plaintiff had the residual functional
capacity ("RFC") to perform light work with the additional limitations of only occasionally
stooping, kneeling, crouching, and climbing ramps and stairs; no climbing ropes, ladders, or
scaffolds; and avoiding concentrated exposure to extreme cold and unprotected heights. The
ALJ noted that the objective medical evidence did not support the degree of symptomatology and
functional limitations alleged by Plaintiff. Further, Plaintiff made unsubstantiated and
inconsistent statements that diminished her credibility. In addition, the ALJ pointed out
Plaintiffs receipt of unemployment benefits into 2013, which indicated that she was capable and
willing to work. (Tr. 17-22)
The ALJ further found that Plaintiff was capable of performing her past relevant work as
a fast food worker and a housekeeper. The ALJ noted that those jobs did not require the
performance of work-related activities precluded by Plaintiffs RFC. Thus, the ALJ concluded
that Plaintiff had not been under a disability from March 1, 2012 through the date of the
decision. (Tr. 22-24)
V. Legal Standards
A claimant for social security disability benefits must demonstrate that he or she suffers
from a physical or mental disability. The Social Security Act defines disability "as the inability
to do 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 12 months." 20 C.F.R. § 404.1505(a).
To determine whether a claimant is disabled, the Commissioner engages in a five step
evaluation process. See 20 C.F.R. § 404.1520(a)(4). Those steps require a claimant to show: (1)
that claimant is not engaged in substantial gainful activity; (2) that she has a severe physical or
mental impairment or combination of impairments which meets the duration requirement; or (3)
she has an impairment which meets or exceeds one of the impairments listed in 20 C.F.R.,
Subpart P, Appendix 1; (4) she is unable to return to her past relevant work; and (5) her
impairments prevent her from doing any other work. Id.
The Court must affirm the decision of the ALJ if it is supported by substantial evidence.
42 U.S.C. § 405(g). "Substantial evidence means less than a preponderance, but sufficient
evidence that a reasonable person would find adequate to support the decision." Hulsey v.
Astrue, 622 F.3d 917, 922 (8th Cir. 2010). "We will not disturb the denial of benefits so long as
the ALJ' s decision falls within the available zone of choice. An ALJ's decision is not outside the
zone of choice simply because we might have reached a different conclusion had we been the
initial finder of fact." Buckner v. Astrue, 646 F.3d 549, 556 (8th Cir. 2011) (citations and internal
quotations omitted). Instead, even if it is possible to draw two different conclusions from the
evidence, the Court must affirm the Commissioner' s decision if it is supported by substantial
evidence. See Youngv. Apfel, 221F.3d1065 , 1068 (8th Cir. 2000).
To determine whether the Commissioner' s final decision is supported by substantial
evidence, the Court must review the administrative record as a whole and consider: (1) the
credibility findings made by the ALJ; (2) the plaintiff's vocational factors; (3) the medical
evidence from treating and consulting physicians; (4) the plaintiff's subjective complaints
regarding exertional and non-exertional activities and impairments; (5) any corroboration by
third parties of the plaintiff's impairments; and (6) the testimony of vocational experts when
required which is based upon a proper hypothetical question that sets forth the plaintiffs
impairment. Johnson v. Chater, 108 F.3d 942, 944 (8th Cir. 1997) (citations and internal
The ALJ may discount a plaintiffs subjective complaints if they are inconsistent with the
evidence as a whole, but the law requires the ALJ to make express credibility determinations and
set forth the inconsistencies in the record. Marciniak v. Shalala, 49 F.3d 1350, 1354 (8th Cir.
1995). It is not enough that the record contain inconsistencies; the ALJ must specifically
demonstrate that she considered all the evidence. Id. at 1354.
When a plaintiff claims that the ALJ failed to properly consider subjective complaints,
the duty of the court is to ascertain whether the ALJ considered all of the evidence relevant to
plaintiffs complaints under the Polaski 1 factors and whether the evidence so contradicts
plaintiffs subjective complaints that the ALJ could discount the testimony as not credible.
Blakeman v. Astrue, 509 F.3d 878, 879 (8th Cir. 2007) (citation omitted). If inconsistencies in
the record and a lack of supporting medical evidence support the ALJ' s decision, the Court will
not reverse the decision simply because some evidence may support the opposite conclusion.
Marciniak, 49 F.3d at 1354.
In her Brief in Support of the Complaint, Plaintiff claims that the ALJ erred in
determining Plaintiffs RFC by failing to account for additional limitations set forth in the
The Eight Circuit Court of Appeals "has long required an ALJ to consider the following
factors when evaluating a claimant's credibility: ' (1) the claimant's daily activities; (2) the
duration, intensity, and frequency of pain; (3) the precipitating and aggravating factors; (4) the
dosage, effectiveness, and side effects of medication; (5) any functional restrictions; (6) the
claimant's work history; and (7) the absence of objective medical evidence to support the
claimant's complaints."' Buckner v. Astrue, 646 F.3d 549, 558 (8th Cir. 2011) (quoting Moore v.
Astrue, 572 F.3d 520, 524 (8th Cir. 2009)) (citing Polaski v. Heckler, 739 F.2d 1320, 1322 (8th
evidence and by failing to order a consultative examination. Further, Plaintiff argues that the
ALJ improperly analyzed Plaintiffs credibility as required by the regulations and applicable case
A. Plaintiff's Credibility
When making credibility determinations with respect to a claimant' s statements, the ALJ
must "consider the entire case record, including the objective medical evidence, the individual' s
own statements about symptoms, statements and other information provided by treating or
examining physicians or psychologists and other persons about the symptoms and how they
affect the individual, and any other relevant evidence in the case record. " SSR 96-7p, 1996 WL
374186, at *1 (Soc. Sec. Admin. July 2, 1996). The ALJ may not discredit the statements solely
because they are unsubstantiated by objective medical evidence, and the ALJ's decision must
give specific reasons for the credibility findings . SSR 96-7p; Wiese v. Astrue, 552 F.3d 728, 733
(8th Cir. 2009) ("an ALJ may not discount a claimant' s subjective complaints solely because the
objective medical evidence does not fully support them."). "If an ALJ explicitly discredits the
claimant' s testimony and gives good reason for doing so, [a court] will normally defer to the
ALJ's credibility determination." Gregg v. Barnhart, 354 F.3d 710, 714 (8th Cir. 2003).
Here, Plaintiff merely asserts that the ALJ did not sufficiently address or consider the
Polaski factors when assessing Plaintiffs credibility. However, contrary to Plaintiffs argument,
the ALJ explicitly cited specific reasons for discounting Plaintiffs credibility. First, the ALJ
noted the objective medical evidence, which demonstrated degenerative disc disease of the
lumbar spine and obesity, did not support Plaintiffs claim of disabling symptoms. (Tr. 18-20)
The objective medical evidence showed that Plaintiff had bulging discs and degenerative
changes. However, Plaintiff displayed only mild to moderate tenderness on examination, as well
as improvement in her level of pain, her gait, and her strength and range of motion resulting from
the use of non-narcotic pain medication, a muscle relaxant, and home exercises. (Tr. 18-20) The
ALJ noted that this conservative treatment, as well as her disinterest in surgery, diminished her
credibility. (Tr. 20-21) The ALJ may rely on a conservative course of treatment and lack of
surgery to discredit Plaintiffs allegations. Black v. Apfel, 143 F.3d 383, 386 (8th Cir. 1998).
Further, where symptoms improve with treatment, the ALJ may find a plaintiffs allegations of
disabling pain not credible. Renstrom v. Astrue, 680 F.3d 1057, 1066 (8th Cir. 2012).
With regard to her alleged depression, the ALJ found that, although Plaintiff briefly used
Trazadone, she failed to attend scheduled psychiatric and counseling appointments, and she did
not require emergent care or psychotropic medications. (Tr. 21) Failure to follow prescribed
treatment is a valid reason for discrediting Plaintiff. Wildman v. Astrue , 596, F.3d 959, 969 (8th
Cir. 2010). The ALJ also noted the inconsistencies between Plaintiffs statements that she was
unable to perform any daily activities and statements to her physicians that she had no difficulty
with activities of daily living including cooking, cleaning, shopping, and driving. (Tr. 21)
Inconsistencies in statements about daily activities can be a reason for discrediting a plaintiff.
Ply v. Massanari, 251 F.3d 777, 779 (8th Cir. 2001); see also Raney v. Barnhart, 396 F.3d 1007,
1010-11 (8th Cir. 2005) (finding inconsistent statements to medical professionals to be a basis
for discounting plaintiffs credibility).
Further, the ALJ noted Plaintiffs poor work history, which was sporadic with low
lifetime earnings. (Tr. 22) A sporadic work record is evidence pointing to the potential lack of
motivation to return to work, and an ALJ is entitled to rely on such evidence to discredit a
plaintiffs credibility. Fredrickson v. Barnhart, 359 F.3d 972, 976 (8th Cir. 2004); Walker v.
Colvin, _ F. Supp. 3d. _ , 2015 WL 4958671 , at* 16 (E.D. Mo. Aug. 19, 2015). Likewise, the
ALJ properly considered the fact that Plaintiff applied for and received unemployment benefits
after she applied for disability benefits. (Tr. 22) "Applying for unemployment benefits
adversely affects credibility, although it is not conclusive, because an unemployment applicant
'must hold [her]self out as available, willing and able to work. "' Smith v. Colvin, 756 F .3d 621 ,
625 (8th Cir. 2014) (quoting Jernigan v. Sullivan, 948 F.2d 1070, 1074 (8th Cir. 1991)).
In short, the Court finds that the ALJ thoroughly and properly evaluated Plaintiffs
credibility, citing valid reasons for discrediting her allegations of disabling pain. Thus, the Court
will defer to the credibility findings of the ALJ and finds that the ALJ's decision is supported by
substantial evidence in the record. Gregg v. Barnhart, 354 F.3d 710, 714 (8th Cir. 2003).
B. Plaintiff's RFC
With regard to Plaintiffs residual functional capacity, "a disability claimant has the
burden to establish [his] RFC." Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004)
(citation omitted). The ALJ determines a claimant' s RFC "'based on all the relevant evidence,
including medical records, observations of treating physicians and others, and [claimant's] own
description of [his] limitations. "' Page v. Astrue, 484 F.3d 1040, 1043 (8th Cir. 2007) (quoting
Anderson v. Shalala, 51 F.3d 777, 779 (8th Cir. 1995)). RFC is defined as the most that a
claimant can still do in a work setting despite that claimant' s limitations. 20 C.F.R. §
Here, Plaintiff contends that the ALJ failed to consider Plaintiffs testimony that her
conditions caused significant limitations, including the need to use a walker, depression, sitting
and walking limitations, the need to rest, daily muscle spasms, and side effects from the muscle
relaxant. Plaintiff further asserts that the ALJ should have ordered a consultative examination to
assess Plaintiffs limitations. Defendant argues that the ALJ properly the entire record, including
Plaintiffs credible subjective complaints, to determine her RFC.
The Court finds that substantial evidence supports the ALJ' s RFC determination and that
further development of the record is not warranted. First, as stated above, the ALJ performed a
proper credibility analysis, including Plaintiffs alleged mental impairment, and discounted those
allegations that were inconsistent with the record as whole. (Tr. 14-17, 21) The ALJ noted that
Plaintiffs allegations that she was unable to perform essentially any daily activities was
inconsistent with her reports to medical professionals denying any difficulties with in activities
of daily living and with the medical records containing no restrictions to such activities. "A
claimant's limitation which is self-imposed rather than a medical necessity is a basis upon which
an ALJ may discredit the claimant's alleged limitation." Denkins v. Astrue, No.
4:11CV394MLM, 2012 WL 274690, at *7 (E.D. Mo. Jan. 31 , 2012).
The ALJ then considered Plaintiffs credible allegations and the objective medical
evidence to determine that Plaintiffs RFC for light work was diminished by limitations to
occasionally stooping, kneeling, crouching, and climbing ramps and stairs; never climbing ropes,
ladders, or scaffolds; and avoidance of concentrated exposure to extreme cold and unprotected
heights. (Tr. 17) The ALJ thoroughly assessed the medical evidence, including physical
limitations contained in the treatment notes. (Tr. 18-22) The ALJ noted that the doctors did not
provide any restrictions and advised Plaintiff to exercise. Such exercise recommendation is
inconsistent with a more restrictive RFC. McFarland v. Colvin, No. No. 2: 14CV0042 TCM,
2015 WL 2383461 , at *21 (E.D. Mo. May 19, 2015); see also Moore v. Astrue, 572 F.3d 520,
524 (8th Cir. 2009) ("A lack of functional restrictions on the claimant' s activities is inconsistent
with a disability claim where, as here, the claimant' s treating physicians are recommending
increased physical exercise).
Further, the ALJ relied upon the treatment records and the objective findings of
limitations to determine Plaintiffs RFC. Physicians noted normal gait, station, and posture, as
well as normal strength, sensation, reflexes, and coordination in the bilateral lower extremities.
Examination also revealed only mild to moderate tenderness in the lumbar region. (Tr. 20)
These essentially normal observations further support the ALJ's RFC determination. Moore, 572
F.3d at 524. While Plaintiff argues that the ALJ failed to obtain an assessment from a physician
that supported the ALJ' s RFC determination, the absence of an explicit reference to "work" in
close proximity to a doctor' s description of the plaintiffs medically evaluated restrictions "does
not make it impossible for the ALJ to ascertain the [plaintiffs] work-related limitations from that
evaluation; such explicit language is unnecessary where the medical evaluation describes the
[plaintiffs] functional limitations ' with sufficient generalized clarity to allow for an
understanding of how those limitation function in a work environment. " ' Wilkerson v. Astrue,
No. 1:10CV00188 AGF, 2012 WL 569942, at *5 (E.D. Mo. Feb. 22, 2012) (quoting Cox v.
Astrue, 495 F.3d 614, 620 n.6 (8th Cir. 2007)).
In short, the evidence demonstrates that Plaintiff has some restrictions in her functioning
and ability to perform work related activities; however, she failed to carry her burden to prove a
more restrictive RFC determination. Andrews v. Colvin, No. 4:13-CV-1033-NAB, 2014 WL
2968815, at *3 (E.D. Mo. July 1, 2014). Thus, the Court finds that " [t]he ALJ thoroughly
discussed the medical records before outlining his RFC determination, which [this Court]
conclude[s] is supported by substantial evidence." Gaston v. Astrue, 276 F. App' x 536, 537 (8th
With regard to Plaintiff's claim that the ALJ failed to properly develop the record and
should have ordered a consultative examination, "[t]he ALJ is required to order medical
examinations and tests only if the medical records presented to him do not give sufficient
medical evidence to determine whether Plaintiff is disabled." McCoy v. Astrue, 648 F.3d 605,
612 (8th Cir. 2011) (citation omitted). Here, the record contained thorough documentation of
Plaintiffs severe impairments, as well as functional restrictions found by physicians. Id.
Therefore, the ALJ did not breach his duty to develop the record because the record contained
sufficient evidence from which to make an informed decision. Ulrich v. Astrue, No. 2: 1OCV89
JCH(LMB), 2011 WL 7401681 , at *13 (E.D. Mo. Dec. 2, 2011). The Court thus finds that
substantial evidence supports the ALJ's RFC determination, and the Commissioner's decision
will be affirmed.
IT IS HEREBY ORDERED that the final decision of the Commissioner denying social
security benefits is AFFIRMED. An appropriate Judgment shall accompany this Memorandum
Dated this 9th day of September, 2015 .
RONNIE L. WHITE
UNITED STATES DISTRICT JUDGE
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?