GOODEN v. COMMISSIONER OF SOCIAL SECURITY

Filing 13

OPINION. Signed by Judge Kevin McNulty on 8/6/2015. (nr, )

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW JERSEY
MARY GOODEN,
Civ. No. 2:14-cv-5378 (KM)

Plaintiff,
V.

OPINION

COMMISSIONER OF SOCIAL SECURITY,
Defendant.

Mary Gooden’s application for Social Security disability benefits was
denied by the Social Security Administration. Gooden has appealed to this
Court. She argues that the AU

did not properly consider her description of her

symptoms, and that substantial evidence did not support the AU’s findings.
Because I find that there was substantial evidence to support the AU’s
decision, I will deny Gooden’s appeal.

1
Background

1

Citations to the record will be abbreviated as follows:

“Decision” Decision of Administrative Law Judge Richard West, dated February 21,
2013, Dkt. No. 6-2.
“ER Record Aug 2010” The University Hospital, Emergency Department Record dated
August 28, 2010, Dkt. No. 6-7, Exh. 1OF, 275-76.
“ER Record Feb 2011” Saint Michael’s Medical Center Emergency Record dated
February 24, 2011, Dkt. No. 6-7, Exh. 3F, 225-35.
“Fernando Report,” Essex Diagnostic Group, Report of Justin Fernando, MD, Dkt.
No. 6-7, Exh. 7F, 262-267.
“Hrg.” Transcript, Hearing before Administrative Law Judge Richard West, dated
January 15, 2013, Dkt. No. 6-2, 22-53.
“Mot.” Plaintiffs Memorandum of Law, Dkt. No. 9.
“PT Evaluation” Physical Therapy Evaluation dated January 18, 2012, Dkt No. 6-7,
Exh. 11F,277-80.
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Mary Gooden was 58 years old on the alleged disability onset date of
April 30, 2009. (Hrg., 6) Gooden alleges that she is unable to work because of
several conditions: hypertension, osteoarthritis, and osteoporosis. She
experiences pain in her hands, shoulders, knees, hips, and back. Before the
alleged disability onset date, Gooden worked cleaning airplanes, assembling
paper inserts for advertising, as a security guard, and as a machine operator
assembling fingernail clippers. (Hrg., 9-13) After the onset date, she worked for
for approximately one year supervising children at a daycare center. (Hrg., 8-9)
Gooden applied for disability benefits in April of 2011.

The AU’s decision
To determine whether Feeley met the criteria to be considered disabled,
the AU

followed the familiar five-step process outlined at 20 C.F.R.

404.1520(a). Under that framework, an AU first asks whether the claimant is
presently engaged in substantial gainful activity. 20 C.F.R.
Step 2, an AU

§ 404.1520(b). At

asks whether the claimant has a medically determinable

impairment, or a combination of impairments, that is “severe.” 20 C.F.R.

§ 404.1520(c). At Step 3, the AU asks whether the claimant’s impairments are
so severe as to meet or medically equal the criteria for an impairment listed in
20 C.F.R. Part 404, Subpart P, Appendix 1. See 20 C.F.R.

§ 404.1520(d). The

AU will then assess the claimant’s residual functional capacity (“RFC”). 20
C.F.R.

§ 404.1520(e). In layman’s terms, this means that the AU will

determine what is the most the claimant can do despite the limitations that
have been established. 20 C.F.R.

§ 404.1545(a)(1). At Step 4, the ALT

determines whether, given that RFC, the claimant can still perform past
relevant work. 20 C.F.R.

§ 404.1520(a)(4)(iv). Finally, at Step 5 the ALT will

determine whether the claimant can perform another kind of work that exists
in the national economy. 20 C.F.R.

§ 404.1520 (a)(4)(v).

Essentially the AU determined that although Gooden had three severe
impairments, she retained the residual functional capacity to perform light
work, and to return to her previous job as a security guard. (Decision, 4-6)
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At Step 1, the AU determined that Gooden had not engaged in
substantial gainful activity since the alleged disability onset date. (Decision, 3)
The

AU

noted that Gooden had worked at a day care center during the alleged

disability period. This work, however, did not rise to the level of substantial
gainful activity. (Decision, 3)
At Step 2, the AU determined that Gooden had three severe
impairments: osteoarthritis, osteoporosis, and hypertension. (Decision, 3-4) He
found that Gooden’s shoulder issues did not qualify as a severe impairment.
(Decision, 4)
At Step 3, the AU found that Gooden’s impairments, alone or in
combination, did not meet or medically equal the severity of one of the listed
impairments in 20 CFR Part 404, Subpart P, Appendix 1.
The AU then assessed Gooden’s residual functional capacity. He found
that Gooden could perform “light work.” Light work, as defined in the
regulations, involves infrequent carrying of heavy objects or frequent carrying
of lighter objects, and may require a “good deal” of walking or standing.
(Decision, 4, citing 20 C.F.R. § 404.1567(b)).
At Step 4, the AU determined that based on her residual functional
capacity, Gooden could return to her previous job as a “desk security guard.”
(Decision, 6) That job involved signing delivery trucks in and out of a facility.
(Hrg., 12) Because the AU determined that Gooden could return to her
previous work, the AU did not proceed to Step 5.
Discussion

I find that the AU’s decision was supported by substantial evidence. For
each category of impairment that Gooden claimed, there is evidence in the
record indicating that the impairment is not sufficiently severe to warrant a
finding of disability.

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Hips, Arms, Hands, Knees, Shoulder

The ALJ found that Gooden’s feelings of weakness and pain in her
hands, arms, hips, knees, and shoulder did not rise to the level of severity
required to qualify for disability benefits. He likewise found that these
conditions left Gooden with the residual functional capacity to perform light
work. I find that those decisions were supported by substantial evidence.
The regulations that define disability explain what conditions a claimant
must establish to qualify for benefits. The regulations address a “major
dysfunction of a joint” such as a “hip, knee, or ankle” or “shoulder, elbow, or
wrist-hand” at 20 CFR Part 404, Subpart P, Appendix 1 § 1.02. For all of these
impairments, the dysfunction must be “[c]haracterized by gross anatomical
deformity” and “chronic joint pain and stiffness.” Id. There must be “signs of
limitation of motion or other abnormal motion of the affected joints” and
findings of “joint space narrowing, bony destruction, or ankyloses of the
affected joint.” Id. There is no evidence in the record that Gooden’s
impairments rise to this level.
Shoulder, Wrist/Hand, Arms

If the impairment involves the shoulder, elbow, or wrist/hand, it must
result in an “inability to perform fine and gross movements effectively.” 20 CFR
Part 404, Subpart P, Appendix 1 § 1.02(A). This means that the claimant has
experienced an “extreme loss of function of both upper extremities,” resulting
in an “inability to independently initiate, sustain, or complete activities.” 20
CFR Part 404, Subpart P, Appendix 1 § 1 .00(B)(2)(c) Examples of an inability to
perform fine and gross movements include “the inability to prepare a simple
meal and feed oneself, the inability to take care of personal hygiene, the
inability to sort and handle papers or files, and the inability to place files in a
file cabinet or above waist level.” Id.
Gooden was indeed diagnosed with “early osteoarthritic changes in the
fingers of both hands.” (Fernando Report, 2) And Gooden was instructed to
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wear a shoulder immobilizer in December of 2012, though it is not clear for
how long she used the device. (Dkt. No. 6-7, Exh. 9F, 2) But “Laboratory
evidence showed only mild degenerative changes of the right hand.” (Decision,
5) Dr. Fernando, a state agency physician, reported in 2011 that her hand and
finger dexterity was “5/5,” that her pinch strength was also “5/5.” He also
reported that the “[s]houlders, elbows, forearms, wrists, and fingers all
show[edj full range of motion.” (Fernando Report, 2) In the hands, Dr.
Fernando found “no evidence of any muscle atrophy or sensory abnormality.”
Id. At an occupational therapy inpatient evaluation in 2012, Gooden reported

that although she did so slowly, she could fasten buttons, snaps, zippers, and
laces, and could open jars. (PT Evaluation, 1, 3) And at her hearing before the
AL

Gooden testified that although most of the time one of her children cooks

for her, she is able to prepare a simple meal, such as a sandwich. (Hrg., 25-26)
There is, then, no evidence of the kind of inability to perform daily activities
that is required for a finding of disability. I therefore find that the AU’s
conclusions with respect to these impairments were supported by substantial
evidence.
Hip, Knee

If the claimant’s impairment comes from the hip or knee it must result in
an “inability to ambulate effectively.” 20 CFR Part 404, Subpart P, Appendix 1

§ 1.02(A) To ambulate effectively, the claimant must be able to sustain “a
reasonable walking pace over a sufficient distance to be able to carry out
activities of daily living.” 20 CFR Part 404, Subpart P, Appendix 1

§ 1 .00(B)(2)(b) Ineffective ambulation includes characteristics like the
inability to walk without the use of a walker, two crutches or two
canes, the inability to walk a block at a reasonable pace on rough
or uneven surfaces, the inability to use standard public
transportation, the inability to carry out routine ambulatory
activities such as shopping and banking, and the inability to climb
a few steps at a reasonable pace with the use of a single hand rail.

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Id.
Dr. Fernando diagnosed Gooden with possible osteoarthritis in the knee,
though he surmised that Gooden’s knee issues were more likely explained by a
meniscus tear. (Fernando Report, 2) Nonetheless, there is substantial evidence
to support the AU’s conclusion that Gooden’s impairments, alone or in
combination, did not rise to the level of severity the regulations require. To
begin with, it appears that Gooden could ambulate effectively. A 2011 report
from Dr. Fernando reported that Gooden’s gait was normal, and that she did
not use an assistive device. Id. Indeed, Dr. Fernando reported that Gooden
could walk at a reasonable pace. (Fernando report, 6) At her hearing before the
AL

Gooden indicated that she can walk about two blocks before she needs to

stop to rest. (Hrg., 22) Gooden did report having fallen because her knee “gave
out” (Id.), but she also reported using only one cane, rather than the two that
the regulations suggest indicate an inability to ambulate. See 20 CFR Part 404,
Subpart P, Appendix 1

§ 1.O0(B)(2)(b).

Second, Gooden’s range of motion in her hips and knees appeared
normal. Dr. Fernando found that the hips, knees, and ankles all showed full
range of motion. (Fernando Report, 2) Emergency room records from 2010
indicate a full range of motion in the lower extremities. (ER Record Aug 2010,
2) At a physical therapy evaluation in 2012, Gooden was observed to have right
knee flexion strength of 3+ / 5, right hip strength at 4/5, and full strength with
all other extremities. (PT Evaluation, 1) I therefore find that the AU was
supported by substantial evidence in concluding that Gooden’s hip and knee
problems did not rise to the level of severity required for a finding of disability.
Other impairments
Back
The regulations address disorders of the spine at 20 CFR Part 404,
Subpart P, Appendix 1

§ 1.04. To render a person disabled, the disorder must

result in compromise of a nerve root or the spinal cord with either: (1) evidence
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of nerve root compression, limitation of motion of the spine, motor loss
accompanied by sensory reflex loss, and (for the lower back) positive straightleg raising test; (2) spinal arachnoiditis, confirmed by appropriate medical
evidence; or (3) lumbar spinal stenosis, manifesting in chronic pain and
weakness, and resulting in an inability to ambulate effectively. 20 CFR Part
404, Subpart P, Appendix 1 § 1.04(A)-(C).
Gooden reported experiencing pain in her lower back. The AU had
substantial evidence, though, that Gooden’s back problems did not rise to the
level of disability.
Dr. Fernando did indeed diagnose Gooden as having pain in her lower
back. (Fernando Report, 2) Dr. Fernando noted that Gooden’s back pain could
be cause by arthritic changes in the back, but he noted that there was “no
distinct evidence of any degenerative disk disease or disk herniation in the
back or in the cervical spine.” Id. at 3.
Examinations of Gooden’s back indicate that it retained sufficient range
of motion. Records from a visit to Saint Michael’s Medical Center in February
2011 indicate that Gooden’s back was normal. (ER Record Feb 2011, 3) The
records also indicate that Gooden’s upper extremities and lower extremities
were normal. Id. At a physical therapy evaluation in 2012, Gooden was
observed to have “functional range of motion of the spine,” with soreness and
pulling, and some spinal tenderness. Dr. Fernando reported in 2011 that
Gooden’s cervical spine and lumbar spine both showed full range of motion.
(Fernando Report, 2) He noted only “some tenderness” at the “very end of the
lumbosacral spine. And tenderness over the right sacroiliac joint.” Id. Further,
as discussed supra, the record does not support a finding that Gooden was
unable to ambulate effectively.
I therefore find that the AU’s determination that Gooden’s back
problems did not render her disabled was supported by substantial evidence.

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Pain

With respect to all of Gooden’s physical disorders, she argues that the
AU did not properly take into account her descriptions of the pain her

conditions cause her. (Mot., 12) It is difficult, of course, for anyone other than
the person experiencing pain to gauge its severity. Nonetheless, the regulations
call upon the Social Security Administration to do so, and they enumerate
relevant considerations. To find that pain or other symptoms affect an
individual’s ability to work, “medical signs or laboratory findings must show
the existence of a medically determinable impairment(s) that could reasonably
be expected to produce the pain or other symptoms.” 20 CFR Part 404, Subpart
P, Appendix 1 § 1 .00(B)(2)(d) A claimant’s statements about the pain she
experiences do not compel a finding of disability; “there must be medical signs
and laboratory findings which show that [the claimanti ha[s] a medical
impairment(s) which could reasonably be expected to produce the pain or other
symptoms alleged.” 20 C.F.R. § 404.1529(a) I find that the medical evidence
cited above provided a sufficient basis for the AU to conclude that the pain
Gooden experienced did not rise to the level of rendering her unable to work.
Hypertension

Gooden was also diagnosed with hypertension. The regulations explain
that when hypertension causes disability, it generally does so by affecting other
body systems. 20 CFR Part 404, Subpart P, Appendix 1 § 4.00(H)(1). For
example, high blood pressure can have a disabling impact on the heart, brain,
kidneys, or eyes. Id. Gooden does not point to any evidence that her
hypertension has had a severe impact on another body system. Nor has any
doctor characterized her hypertension as severe. I therefore find that the AU’s
conclusion that Gooden’s hypertension was consistent with an ability to
perform light work was supported by substantial evidence.

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Shortness of breath/Mental impairments
Before this Court, Gooden argues that the AU did not give sufficient
weight to her own reports of certain symptoms and limitations. (Mot., 7.-li) For
instance, Gooden argues that the AU did not consider her complaints of pain,
limitation of motion and function, shortness of breath, and mental
impairments including panic attacks, paranoia, and insomnia. Id. at 8.
With respect to shortness of breath or panic attacks, the only medical
evidence of such a condition Gooden submitted was a letter from a doctor
addressed “To Whom it May Concern.” The letter diagnosed Gooden as having
“difficulty breathing” and “Panic attacks.” (Dkt. No. 6-7, Exh. 4F, 2) The letter
goes on to recommend that Gooden be “replaced on a lower level floor or a
lower level home.” Id. The regulations provide that evidence of respiratory
disorders “must be provided in sufficient detail to permit an independent
reviewer to evaluate the severity of the impairment.” 20 CFR Part 404, Subpart
P, Appendix 1 § 3.00(A) The one-paragraph physician’s letter that Gooden has
provided does not provide such detail. Counsel’s characterization of Gooden’s
condition as “shortness of breath” likewise does not provide enough detail to
justify a finding of disability.
To the extent that Gooden is claiming a mental disorder and related
physical manifestations (such as panic attacks, paranoia, and insomnia) there
is likewise insufficient evidence to warrant a finding of disability. In support,
Gooden offers the same one-paragraph physician’s letter. (Dkt. No. 6-7, Exh.
4F, 2) Gooden also testified at her hearing before the AU that she suffers from
claustrophobia. Her condition, she explained, makes her fearful when she is in
small spaces like elevators, or when she is in close proximity to groups of
people. (Hrg., 18-19) The regulations, though, require a greater degree of
disruption for a mental disorder to result in a finding of disability.
The regulations do recognize that paranoia can render a person unable to
work. 20 CFR Part 404, Subpart P, Appendix 1 § 12.03. For instance, a
medically documented history of schizophrenia or other psychotic disorder of at
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least two years’ duration will result in a finding of disability. 20 CFR Part 404,
Subpart P, Appendix 1 § 12.03(C). Failing that, for paranoia to rise to the level
of disability the claimant must suffer from one or more of the following:
persistent hallucinations, catatonic or other grossly disorganized behavior,
incoherence (resulting in blunt, flat, or inappropriate affect), or emotional
withdrawal and/or isolation. Id. at § 12.03(A). In addition, the claimant’s
condition must cause at least two of the following: marked restriction in
activities of daily living; marked difficulties in social functioning; marked
difficulties in maintaining concentration, persistence, or pace; or repeated
episodes of decompensation. Id. at § 12.03(C) Gooden has not testified or
provided medical evidence suggesting that her paranoia has risen to this level.
The regulations also recognize that a claimant can be rendered unable to
work by an anxiety disorder. 20 CFR Part 404, Subpart P, Appendix 1 § 12.06.
But again Gooden has not alleged symptoms that would meet the regulatory
criteria for a finding of disability. The regulations require medically
documented findings of at least one of the following: Generalized persistent
anxiety (characterized by motor tension, autonomic hyperactivity, apprehensive
expectation, or vigilance and scanning), persistent irrational fear of a particular
situation resulting in a compelling desire to avoid the dreaded situation,
“recurrent severe panic attacks manifested by a sudden unpredictable onset of
intense apprehension, fear, terror, and sense of impending doom occurring on
the average of at least once a week,” recurrent obsessions or compulsions, or
recurrent intrusive recollections of a traumatic experience. Gooden has not
even alleged that her symptoms approach that level of severity.

10

Past relevant work
Gooden points to a state agency physician’s statement that Gooden had
no past relevant work. However, in considering Gooden’s residual functional
capacity, the AU

found that she could perform past relevant work as a

security guard. (Mot., 12-13)
The state agency physician’s statement is not an expert diagnosis; it
seems to be more than an errant statement. The statement appears
immediately after that physician’s listing of four prior jobs (as a daycare
employee, custodian, security guard, and factory worker). (Dkt. No. 6-3, Exh.
6A, 5) In any case, I find the residual functional capacity finding to be
supported by other substantial medical and factual evidence in the record, as
discussed above. I therefore do not agree that this discrepancy is a basis for
remand.

Conclusion
Gooden’s appeal will be denied. A separate order will issue.

August 6, 2015
Newark, New Jersey

Kevin McNulty
United States District Jud

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