Miles v. Commissioner of Social Security Administration

Filing 17

Memorandum Opinion and Order. The undersigned affirms the ALJ's decision. Substantial evidence supports the finding of the ALJ that Plaintiff has the residulal functional capacity (RFC) to perform her past relevant work as a dietary aid/dishwasher, and therefore is not disabled. Hence, she is not entitled to DIB and SIS. Signed by Magistrate Judge George J. Limbert on 5/14/2012. Related document 1 . (H,LA)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
EASTERN DIVISION

DAMIKO MILES,
Plaintiff,
v.
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

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CASE NO.:

5:11CV864

MAGISTRATE JUDGE
GEORGE J. LIMBERT
MEMORANDUM OPINION & ORDER

Plaintiff requests judicial review of the final decision of the Commissioner of Social Security
denying Damiko Miles Disability Insurance Benefits (DIB) and Supplemental Security Income
Benefits (SSI). The Plaintiff asserts that the Administrative Law Judge (ALJ) erred in her April
9, 2012 decision in finding that Plaintiff was not disabled because she could perform her past
relevant work (Tr. 13-22). The Court finds that substantial evidence supports the ALJ’s decision for
the following reasons:

I.

PROCEDURAL HISTORY
Plaintiff, Damiko Miles filed her application for DIB and SSI on January 28, 2008, alleging

she became disabled on July 1, 1987, but later amended her onset date to January 1, 2008 (Tr. 123124).

Plaintiff’s application was denied initially and on reconsideration (Tr. 164-170, 172-177).

Plaintiff requested a hearing before an ALJ, and on March 2, 2012, a hearing was held where
Plaintiff appeared with counsel and testified before an ALJ (Tr. 294-367).

Ted Massey, a

vocational expert also testified. (Tr. 121-165).
On April 9, 2010, the ALJ issued her decision, finding Plaintiff not to be disabled (Tr. 1122). Plaintiff requested a review before the Appeals Council, and the Appeals Council denied
Plaintiff’s request for review (Tr. 1- 4). Therefore, Plaintiff has requested judicial review of the
Commissioner’s final decision pursuant to 42 U.S.C. Section 405(g) and 42 U.S.C. 1383(c).

II.

STATEMENTS OF FACTS
Plaintiff, who was 43 years old on the date of the ALJ’s decision, is a “younger person” under

the regulations (Tr. 127). Plaintiff has a high school education in addition to six months of training
at the American School of Technology to become a medical office assistant, but did not graduate
(Tr. 127).

III.

She also has past relevant work experience as a dietary aid/dishwasher (Tr. 129).

SUMMARY OF MEDICAL EVIDENCE
Plaintiff is only contesting the ALJ’s findings with regard to her physical impairments,

particularly her alleged carpal tunnel syndrome and degenerative disc disease.
On December 20, 2006, Plaintiff went to the emergency room after falling on her knees while
trying to catch the bus (Tr. 440). X-rays of plaintiff’s knees showed no fracture or dislocation and
mild tricompartmental osteoarthritis (Tr. 444-45). Plaintiff was discharged with crutches, Ace
Bandages, and prescriptions for Naprosyn and Vicodin (Tr. 441).
On January 4, 2007, Plaintiff was examined by Kurt Stemple, M.D., an orthopedist (Tr. 412).
On physical examination of Plaintiff’s knees, Dr. Stemple noted no swelling or effusion, good range
of motion and stability, and diffuse anterior tenderness and crepitus (Tr. 412). Dr. Stemple examined
Plaintiff’s x-rays, noting evidence of degenerative joint disease with osteophytic spurring (Tr. 412).
He administered cortisone injections to Plaintiff’s knees for short term pain control, and
recommended that Plaintiff lose weight (Tr. 413).
On April 1, 2007, Plaintiff went to the emergency room with complaints of a flare-up of her
knee and low back pain (Tr. 438). Plaintiff was diagnosed with polyarthralgia and discharged with
a prescription for Vicodin (Tr. 438-39).
X-rays of Plaintiff’s lumbosacral spine, on November 28, 2007, showed mild degenerative
changes (Tr. 443).
Plaintiff sought no additional treatment for knee pain until January 2009, when she sought
treatment from Vimal B. Patel, M.D., her family doctor (Tr. 406). A physical examination of
Plaintiff’s knees was normal except for some slight crepitus (Tr. 406). Dr. Patel diagnosed morbid
obesity and bilateral knee pain, prescribed Ultram, and educated Plaintiff with regard to diet and
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exercise (Tr. 406).
On March 16, 2009, Plaintiff sought treatment from Dr. Patel for carpal tunnel pain (Tr. 426).
Dr. Patel reported that Plaintiff had positive Tinel’s and Phalen’s tests of the right wrist with
numbness over the median nerve distribution (Tr. 426) He diagnosed carpal tunnel syndrome,
advised Plaintiff to take an NSAID for five days, gave her a wrist splint to use at night, and
educated her to cut down on repetitive motions and do hand stretching exercises (Tr. 426). On
March 26, 2009, Plaintiff continued to complain of carpal tunnel pain, and Dr. Patel advised her to
avoid repetitive motions with her wrists and gave her a prescription for a cock-up night -time wrist
splint (Tr. 425).
On April 8, 2009, Plaintiff went to the emergency room with complaints of numbness and
tingling in her right hand and back pain (Tr. 455). Plaintiff was diagnosed with carpal tunnel
syndrome and released (Tr. 458).
On May 26, 2009, Plaintiff went to the emergency room complaining of chronic back pain
(Tr. 556). On physical examination Plaintiff had no tenderness of the cervical, thoracic, or lumbar
spine (Tr. 556). Plaintiff’s extremities had full range of motion, a straight leg raising test was
negative, and she was able to ambulate without difficulty (Tr. 556). Plaintiff was diagnosed with
chronic back pain and discharged with a prescription for Motrin 800 mg. (Tr. 556).
On June 23, 2009, Plaintiff sought treatment from Dr. Patel for complaints of chronic back
pain and bilateral knee pain (Tr. 507). Dr. Patel advised Plaintiff that she needed to modify her diet
and start exercising more (Tr. 507). Dr. Patel noted that x-rays of Plaintiff’s back showed only mild
degenerative disc disease (Tr. 409, 507). On physical examination, Plaintiff’s knees had slight
crepitus and no joint laxity, and a straight leg raising test was negative (Tr. 507). Plaintiff had some
point tenderness over the lower lumbar region (Tr. 507). Dr. Patel advised Plaintiff to keep a food
diary and take Motrin a couple of times per week (Tr. 507).
On September 3, 2009, Plaintiff saw Dr. Patel with complaints of back pain and bilateral
knee pain (Tr. 599). A musculoskeletal examination was negative for any scoliosis or kyphosis and
Plaintiff’s spinal ranges of motion were intact with positive point tenderness in the lumbar region
(Tr. 599). A straight leg raising test was negative and Plaintiff’s strength was fully intact in her
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upper and lower extremities (Tr. 599). Plaintiff’s knees were positive for crepitus, but had intact
range motion and were negative for any swelling or tenderness (Tr. 599).
On August 11, 2009, Plaintiff went to the emergency room with complaints of pain in her
right knee, right hip, and low back (Tr. 646). Plaintiff was diagnosed with back, hip, and knee pain
and released with prescriptions for an anti-inflammatory medication and Vicodin (Tr. 646).
On September 13, 2009, Seyed Shahmedi, M.D., completed a Medical Source Statement (Tr.
518). Dr. Shahmedi opined that Plaintiff could lift and carry fifteen pounds occasionally, and ten
pounds frequently; stand and walk for two hours in an eight-hour day, and thirty minutes without
interruption; occasionally balance, reach, handle, and feel; and never climb, stoop, crouch, kneel,
crawl, push, pull, or perform fine manipulations (Tr. 518-19). Dr. Shahmedi reported that Plaintiff
had been prescribed a cane and a breathing machine (Tr. 519). He opined that migraines, leg pain,
back pain, numbness and tingling in her legs, and hand cramps, would interfere with Plaintiff’s
ability to perform full time work (Tr. 519).

IV. SUMMARY OF TESTIMONY
At this hearing of this matter, Plaintiff indicated that she could not work due to her reduced
memory, food addiction, pain in her knees and back, broken veins, and numbness and tingling in her
legs. The Plaintiff indicated that her abilities to sit, stand and walk were very limited by her
experience of increased joint pain and stiffness.
The Plaintiff reported that she remains able to attend to her own personal needs, prepare
meals, care for her daughter, perform household tasks such as cleaning, laundry and ironing, use
public transportation and sometimes drive, shop and attend meetings of Alcoholic Anonymous,
Overeaters Anonymous and attend church regularly. (Tr. 115-159).
Ted S. Magg, a vocational expert reviewed Plaintiff’s file and listened to her testimony at
the hearing. He testified that a dietary aide/dishwasher is generally an unskilled light exertion
occupation and it is sometimes medium and semi-skilled. (Tr. 115-159).

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V.

STEPS TO EVALUATE ENTITLEMENT TO SOCIAL SECURITY BENEFITS
An ALJ must proceed through the required sequential steps for evaluating entitlement to

DIB and SSI. These steps are:
1.

An individual who is working and engaging in substantial gainful activity
will not be found to be “disabled” regardless of medical findings (20 C.F.R.
§§ 404.1520(b) and 416.920(b) (1992));

2.

An individual who does not have a “severe impairment” will not be found to
be “disabled” (20 C.F.R. §§ 404.1520(c) and 416.920(c) (1992));

3.

If an individual is not working and is suffering from a severe impairment
which meets the duration requirement, see 20 C.F.R. § 404.1509 and
416.909 (1992), and which meets or is equivalent to a listed impairment in
20 C.F.R. Pt. 404, Subpt. P, App. 1, a finding of disabled will be made
without consideration of vocational factors (20 C.F.R. §§ 404.1520(d) and
416.920(d) (1992));

4.

If an individual is capable of performing the kind of work he or she has done
in the past, a finding of “not disabled” must be made (20 C.F.R. §§
404.1520(e) and 416.920(e) (1992));

5.

If an individual's impairment is so severe as to preclude the performance of
the kind of work he or she has done in the past, other factors including age,
education, past work experience and residual functional capacity must be
considered to determine if other work can be performed (20 C.F.R. §§
404.1520(f) and 416.920(f) (1992)).

Hogg v. Sullivan, 987 F.2d 328, 332 (6th Cir. 1992). The claimant has the burden to go forward with
the evidence in the first four steps and the Commissioner has the burden in the fifth step to show that
alternate jobs in the economy are available to the claimant, considering her age, education, past work
experience and residual functional capacity. See, Moon v. Sullivan, 923 F.2d 1175, 1181 (6th Cir.
1990).

VI.

STANDARD OF REVIEW
Under the Social Security Act, the ALJ weighs the evidence, resolves any conflicts, and

makes a determination of disability. This Court’s review of such a determination is limited in scope
by Section 205 of the Act, which states that the “findings of the Commissioner of Social Security
as to any fact, if supported by substantial evidence, shall be conclusive.” 42 U.S.C. Section 405(g).
Therefore, this Court’s scope of review is limited to determining whether substantial evidence
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supports the Commissioner’s findings and whether the Commissioner applied the correct legal
standards. See, Abbott v. Sullivan, 905 F.2d 918, 922 (6th Cir. 1990). The Court cannot reverse the
decision of an ALJ, even if substantial evidence exists in the record that would have supported an
opposite conclusion, so long as substantial evidence supports the ALJ’s conclusion. Walters v.
Commissioner of Soc. Sec., 127 F.3d 525, 528 (6th Cir.1997). Substantial evidence is more than a
scintilla of evidence, but less than a preponderance. See, Richardson v. Perales, 402 U.S. 389, 401
(1971). It is evidence that a reasonable mind would accept as adequate to support the challenged
conclusion. See, Id.; Walters, 127 F.3d at 532. Substantiality is based upon the record taken as a
whole. See, Houston v. Sec’y of Health & Human Servs., 736 F.2d 365 (6th Cir. 1984).

VII.

ANALYSIS
Issues:
I.

Whether the ALJ erred when she found that Plaintiff’s impairments of carpal tunnel
syndrome and lumbar degenerative disk disease were not severe

II.

Whether the ALJ failed to properly evaluate the opinion of Plaintiff’s treating
physician

The ALJ found that Plaintiff had “severe” degenerative joint disease of the bilateral knees
that did not meet or equal the criteria of any of the listed impairments (Tr. 13-15, Findings 3-4).
The ALJ also determined that Plaintiff’s carpal tunnel syndrome and mild degenerative disc disease
were non-severe impairments (Tr. 14-15). The ALJ found that Plaintiff had the physical residual
functional capacity (RFC) to perform a full range of light work (Tr. 17, Finding 5). The ALJ found
that Plaintiff was not disabled because she could perform her past relevant work as a dietary aide
and she actually performed it (Tr. 21, Finding 6).
Substantial evidence supports the ALJ’s finding that Plaintiff’s carpal tunnel syndrome and
degenerative disc disease were non-severe impairments.

An impairment or combination of

impairments is not severe if it does not significantly limit a claimant’s physical or mental ability to
do basic work activities.

20 C.F.R. Sections 404.1521(a), 416.921(a). Basic work activities are

defined in the regulations as the abilities or aptitudes necessary to do most jobs.
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20 C.F.R.

Sections 404.1521(b), 416.921(b). Examples of these abilities include physical functions such as
walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling.

Id.

An

impairment or combination of impairments is not severe when medical evidence establishes only a
slight abnormality or a combination of slight abnormalities which would have no more than a
minimal effect on an individual’s ability to perform basic work activities. Social Security Ruling
(SSR) 85.28.
In this case the ALJ found Plaintiff’s carpal tunnel syndrome to be a non-severe impairment
because her physicians had never recommended that she undergo definitive diagnostic testing for
this condition, such as an EMG study, or that she explore any surgical options such as carpal tunnel
decompression surgery (Tr. 14). At most, Dr. Patel gave Plaintiff a wrist splint to use at night and
educated her to cut down on repetitive motions and do hand stretching exercises (Tr. 426). In light
of the lack of objective medical studies to support Plaintiff’s diagnosis of carpal tunnel syndrome
and the conservative measures used to treat her complaints, the ALJ correctly concluded that this
condition would not significantly limit plaintiff’s ability to perform basic work activities and,
therefore, was non-severe.
With regard to Plaintiff’s degenerative disc disease, the ALJ explained that she determined
it to be non-severe because objective medical studies, such as x-rays in November of 2007,
supported no more than mild degenerative changes (Tr. 14, 443, 507). In addition,, tenderness to
palpation was the only clinical sign of any back impairment noted by Plaintiff’s treating physicians
(Tr. 15, 507, 599). Plaintiff’s physicians consistently reported that straight leg raising tests were
negative and she had no difficulty with ambulation (Tr. 507, 556, 599). Based upon the clinical
evidence and the lack of evidence that Plaintiff’s mild degenerative disc disease caused limitations
that would significantly interfere with her ability to perform basic work activities, the ALJ correctly
found that this impairment was non-severe (Tr. 15).
The Court finds that substantial evidence supports the ALJ’s conclusion that Dr. Shahmedi’s
opinion was entitled to little weight (Tr. 19). The opinion of a treating physician as to the nature and
severity of an impairment is only entitled to controlling weight if it is well supported by medically
acceptable clinical and laboratory diagnostic techniques, and is not inconsistent with the other
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substantial evidence in the case. 20 C.F.R. Sections 404.1527(d), 416.927(d).
In this case, the ALJ explained that she gave little weight to Dr. Shahmedi’s Medical Source
Statement because Dr. Shahmedi did not cite any clinical or diagnostic findings in support of the
physical limitations that he espoused (Tr. 19, 518-19). Since Dr. Shahmedi’s opinions of extreme
limitations appeared to be based solely on Plaintiff’s subjective complaints, the ALJ correctly gave
them little weight (Tr. 19). See, 20 C.F.R. Section 416.927(d)(3) (providing that a medical sources’s
opinions must be based on objective clinical or laboratory findings).
In contrast to Dr. Shahmedi’s opinion of extreme physical limitations, the evidence supported
the ALJ’s conclusion that she was capable of performing light work. Plaintiff has never required
more than conservative measures to treat her degenerative joint disease, and she sought only sporadic
medical treatment (Tr. 18-19). The clinical signs noted by her treating physicians were limited to
crepitus with no swelling, effusion, or decreased range of motion (Tr. 19, 412). Plaintiff’s physicians
reported that she had no difficulty with ambulation (Tr. 556). Despite her impairments, Plaintiff was
able to engage in a range of activities of daily living including preparing meals, caring for her
daughter, performing household tasks (cleaning, laundry, ironing), using public transportation, and
attending Alcoholics Anonymous, Overeater’s Anonymous, and church services on a regular basis
(Tr. 21, 274-78). These limited clinical findings and fairly normal activities of daily living
supported the ALJ’s RFC assessment.

VIII. CONCLUSION
Based upon a review of the record and law, the undersigned affirms the ALJ’s decision.
Substantial evidence supports the finding of the ALJ that Plaintiff has the residual functional
capacity (RFC) to perform her past relevant work as a dietary aid/dishwasher, and therefore is not
disabled. Hence, she is not entitled to DIB and SSI.
DATE: May 15, 2012

/s/George J. Limbert
GEORGE J. LIMBERT
UNITED STATES MAGISTRATE JUDGE

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