Riley v. Commissioner of Social Security

Filing 13

MEMORANDUM OPINION (Order to follow as separate docket entry) re 1 Complaint filed by Eric Riley. Signed by Chief MJ Daryl F. Bloom on January 6, 2025. (kjn)

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
ERIC RILEY,
Plaintiff,
v.
CAROLYN COLVIN, Acting
Commissioner of Social Security,1
Defendant.

: Civil No. 1:24-CV-187
:
:
:
:
: (Chief Magistrate Judge Bloom)
:
:
:
:

MEMORANDUM OPINION
I.

Introduction
On June 18, 2021, Eric Riley filed an application for disability and

disability insurance benefits under Title II of the Social Security Act. A
hearing was held before an Administrative Law Judge (“ALJ”), who
found that Riley was not disabled from his alleged onset date, January
30, 2021, to February 13, 2023, the date the ALJ issued his decision.
Riley now appeals this decision, arguing that the decision is not
supported by substantial evidence. After a review of the record, we

1 Carolyn Colvin became the Acting Commissioner of the Social Security

Administration on November 30, 2024. Pursuant to Rule 25(d) of the
Federal Rules of Civil Procedure and 42 U.S.C. § 405(g), Carolyn Colvin
is substituted for Martin O’Malley as the defendant in this suit.

conclude that the ALJ’s decision is not supported by substantial evidence.
Therefore, we will remand this matter for further consideration by the
Commissioner.
II.

Statement of Facts and of the Case
On June 18, 2021, Riley applied for disability and disability

insurance benefits, alleging disability due to left knee torn meniscus,
high blood pressure, obesity, herniated discs, leg pain, irritable bowel
syndrome, kidney stones, anxiety, difficulty sleeping, and difficulty
walking and standing. (Tr. 57). Riley was 50 years old on his alleged
onset date of disability, had at least a high school education, and had past
work as an oil delivery truck driver. (Tr. 27, 57).
The medical records underlying Riley’s appeal revealed that Riley
suffered a left knee injury, ultimately found to be a meniscus tear, while
at work in January of 2021. (Tr. 572). Riley saw his treating physician,
Dr. Brad Conner, D.O., several weeks after the incident, at which time
Dr. Conner noted that Riley had been given a steroid injection and formal
physical therapy that helped. (Id.). A physical examination at this time
revealed grossly intact sensation, minimal knee effusion, and 5/5
2

strength. (Tr. 573-74). Dr. Conner opined that Riley could return to work
“full duty without restrictions” and recommended he wear a knee brace
at work. (Tr. 574). However, roughly one month later, Riley returned to
Dr. Conner complaining that his pain was worse than before. (Tr. 564). A
physical examination showed grossly intact sensation, 5/5 strength, and
minimal knee effusion, but Riley exhibited an antalgic gait. (Tr. 566). He
was referred to a new physical therapist. (Id.).
Riley began treating with Waynesboro Physical Therapy in
February of 2021 with physical therapist Derek Kling. (Tr. 387). At a
February 19 appointment, Riley reported that his knee was “sore” and
his symptoms were unchanged. (Tr. 390). PT Kling noted that Riley
tolerated his therapy well without an increase in his symptoms. (Id.). At
a follow up visit a few days later, PT Kling noted that Riley continued to
have an antalgic gait but was able to progress to some strengthening
without an increase in pain. (Tr. 391). In March, Riley reported some
increased pain after he was jerked while walking his dog. (Tr. 395). After
several visits, PT Kling wrote to Dr. Conner explaining that Riley had
improved strength and nearly full range of motion and recommended
3

that he continue physical therapy. (Tr. 398). Ultimately, Riley underwent
knee surgery with Dr. Conner in March. (Tr. 594).
At a follow up appointment for suture removal in April, it was noted
that Riley was to attend physical therapy post-surgery, and that he would
be off work for a minimum of eight weeks. (Tr. 600). A physical
examination at this time revealed a mild antalgic gait, decreased
sensation, no significant effusion, and 4/5 strength, and it was noted that
Riley was using a crutch to assist him in walking. (Id.). At his initial
physical therapy visit, Riley noted that he was feeling good after surgery
but started to have worsening pain. (Tr. 404). Riley reported some
improvement in his pain at his next visit, although he complained of
difficulty with walking and performing activities of daily living. (Tr. 407).
It was noted that Riley had an antalgic gait pattern due to stiffness, but
his range of motion was progressing as expected. (Tr. 408). At a visit on
April 26, Riley reported increased pain after therapy, which required him
to take pain medications and use a walking stick. (Tr. 412). At this visit,
PT Kling noted that Riley’s range of motion was progressing, and his
extension was nearing normal limits. (Id.).
4

In May, Riley reported continued soreness, and PT Kling noted that
he “continues to display an antalgic gait pattern and is sufficiently
challenged by his current program.” (Tr. 420). Treatment notes from May
10 indicate that Riley felt he had improved about 50 percent since
starting physical therapy, but that he continued to have pain with stairs,
walking on uneven ground, and at random times. (Tr. 421). At this visit,
PT Kling noted that Riley had met certain short-term goals, was
progressing toward long term goals, but that strength, stability, and
functional limitations remained. (Tr. 422).
Riley continued with therapy, during which it was noted that he
experienced some increased pain after reports of doing yardwork and
household chores, and he ultimately discontinued physical therapy in
July in favor of receiving gel shots. (Tr. 425-33). He also continued to
treat with Dr. Conner during this time, and Dr. Conner’s treatment notes
consistently revealed an antalgic gait and mild to moderate knee
effusion, as well as grossly intact sensation and 5/5 strength. (Tr. 467,
474, 482). Treatment notes from Dr. Conner in July indicated that while
Riley had some progress with physical therapy, his progress had
5

plateaued. (Tr. 458). Riley reported increased pain if he is on uneven
ground or walking downhill, and that he used a walking stick. (Tr. 45859). He further reported moderate effusion in his knee with increased
activities. (Tr. 458). A physical examination revealed an antalgic gait,
moderate knee effusion, grossly intact sensation, and 5/5 strength. (Tr.
461). Dr. Conner recommended permanent lifting restrictions of no more
than 10 pounds, as well as seated or sedentary jobs with limited
ambulation. (Id.). He provided Riley with a lubrication injection at this
visit. (Tr. 461-62).
In October of 2021, Riley underwent an independent medical
evaluation with Dr. Kevin Anbari, M.D. (Tr. 683-88). Dr. Anbari’s
physical examination noted that Riley brought a cane to the examination
but was able to walk without it with slight antalgia, and he had mild
knee effusion and 5/5 knee strength. (Tr. 684-85). Dr. Anbari opined that
Riley’s pain and functional limitations were likely due to osteoarthritis
of the left knee, and that Riley had recovered from his left knee injury.
(Tr. 687-88).

6

Riley subsequently underwent an internal medicine examination
with Dr. Ahmed Kneifati, M.D., in November. (Tr. 690-99). Dr. Kneifati
noted that Riley did not use an assistive device during the examination.
(Tr. 690). Riley reported his activities of daily living to include cleaning
twice per week, personal care daily, watching television, and social
media. (Tr. 691). On examination, his gait was widened with short steps;
he was able to stand and walk on his toes but was unsteady; his squat
was limited to 45 percent; and he was able to rise from the chair without
difficulty. (Tr. 692). Riley exhibited no effusion and 5/5 strength in his
lower extremities. (Id.). Dr. Kneifati opined that Riley could lift and carry
up to 20 pounds occasionally; could sit for 5 hours, stand for 3 hours, and
walk for 2 hours in an 8-hour workday; did not require a cane to
ambulate; and could perform occasional postural movements except he
could never climb stairs, ramps, ladders, or scaffolds. (Tr. 694-97).
In April of 2022, Riley underwent an examination with Nurse
Practitioner Christine Fahr. (Tr. 732-36). Riley reported that he used a
cane but did not bring it with him to the examination. (Tr. 733). He
reported that he did not need help at home, that he cooked and cleaned
7

daily and shopped once per week, and that he performs personal care
daily. (Tr. 733-34). A physical examination revealed an antalgic gait, that
he was able to do 25 percent of a full squat due to knee pain, that he could
walk on his heels and toes with pain, and he had a normal stance. (Tr.
734). His lower extremity strength was 4/5, and he had no effusion or
sensory deficits. (Tr. 735). NP Fahr opined that Riley could occasionally
lift and carry up to 20 pounds; could sit for 8 hours, stand for 7 hours,
and walk for 6 hours in an 8-hour workday; he did not need a cane to
ambulate; and he could perform occasional postural movements except
he could never crawl or climb ramps, stairs, ladders, or scaffolds. (Tr. 73843).
During the alleged period of disability, Riley also treated with a
counselor for an adjustment disorder and post-traumatic stress disorder.
(Tr. 831-964). These treatment notes documented Riley’s complaints of
knee pain throughout the relevant period, as well as his activities of daily
living, which included camping, taking RV trips with his wife, visiting

8

flea markets and breweries, and being the best man in his brother’s
wedding. (Id.).2
In January of 2023, PT Kling filled out a medical source statement
regarding Riley’s ability to do work related activities. (Tr. 827-28). PT
Kling opined that Riley could sit for six hours and stand and walk for two
hours in an 8-hour workday, would need to take breaks every 20 minutes,
could occasionally lift, and carry up to 20 pounds, ad would need
unscheduled breaks and walking breaks. (Id.). He further opined that
Riley’s pain would occasionally affect his focus and concentration, and
that he would be absent one day per month. (Tr. 828).
It was against the backdrop of this evidence that the ALJ conducted
a hearing on January 31, 2023, during which Riley and a Vocational
Expert testified. (Tr. 34-56). Following the hearing, on February 13,
2023, the ALJ issued a decision denying Riley’s application for benefits.
(Tr. 12-33). At Step 1 of the of the sequential analysis that governs Social

2 We limit our discussion of the plaintiff’s mental health treatment notes

to document his continued complaints of knee pain and activities of daily
living, as the plaintiff’s appeal is based solely on the ALJ’s treatment of
his physical impairments.
9

Security cases, the ALJ concluded that Riley did not engage in
substantial gainful activity between January 31, 2021—the alleged onset
date of disability—and the date the decision was issued. (Tr. 17). At Step
2, the ALJ found that Riley suffered from the following severe
impairments: degenerative joint disease of the left knee and obesity. (Tr.
18). At Step 3, the ALJ concluded that none of Riley’s severe impairments
met or equaled the severity of a listed impairment under the
Commissioner’s regulations. (Tr. 20).
Between Steps 3 and 4, the ALJ concluded that Riley:
[H]a[d] the residual functional capacity to perform light work
as defined in 20 CFR 404.1567(b) and he can occasionally
balance, stoop, kneel, crouch, and climb ramps and stairs; and
never crawl or climb ladders, ropes, or scaffolds. He can have
no concentrated exposure to extreme cold, vibration,
unprotected heights, or moving machinery parts.
(Tr. 20).
In reaching this RFC determination, the ALJ considered the
objective medical record detailed above, the medical opinion evidence,
and Riley’s reported symptoms. (Tr. 20-26). With respect to the medical
opinion evidence, the ALJ found persuasive the opinions of the state
agency consulting sources, Dr. Bilynsky and Dr. Smith. (Tr. 22). Dr.
10

Bilynsky opined in December of 2021 that Riley could perform a range of
light work with occasional postural movements, except he could never
climb ladders, ropes, and scaffolds and had certain environmental
limitations. (Tr. 61-62). In May of 2022, on reconsideration, Dr. Smith
opined that Riley could perform light work with occasional postural
movements, except that he could never crawl or climb ladders, ropes, and
scaffolds and had certain environmental limitations. (Tr. 73-74). Dr.
Smith further noted that Riley should be allowed a cane “as needed to
offload pain.” (Tr. 74). The ALJ found that these opinions were supported
by the longitudinal treatment notes showing intact sensation, full
strength, capillary refill in less than three seconds, and no edema, and
were consistent with Riley’s activities of daily living. (Tr. 22-23).
The ALJ found the opinions of Dr. Kneifati and NP Fahr partially
persuasive. (Tr. 23). The ALJ reasoned that these opinions were
consistent with and supported by the treatment notes insofar as they
limited Riley to a range of light work. (Id.). However, the ALJ noted that
the remainder of these opinions overstated Riley’s limitations and were
inconsistent with his activities of daily living. (Id.).
11

Finally, the ALJ found the opinions of Dr. Conner and PT Kling
unpersuasive. (Tr. 23-24). Regarding Dr. Conner’s opinion that Riley was
permanently limited to lifting no more than ten pounds, the ALJ found
that this statement was inconsistent with treatment notes showing no
acute distress, intact sensation, full strength, capillary refill in less than
three seconds, and no erythema. (Tr. 23). He also reasoned that these
limitations were inconsistent with Riley’s activities of daily living. (Tr.
23-24). With respect to PT Kling’s medical source statement, the ALJ
characterized this statement as a checklist with minimal explanation,
and further found that this opinion was not supported by PT Kling’s own
treatment notes or the plaintiff’s activities of daily living. (Tr. 24).
The ALJ also considered Riley’s symptoms, but ultimately found
that the statements concerning the intensity, persistence, and limiting
effects of his impairments were not entirely consistent with the medical
evidence. (Tr. 20-22). In making this determination, the ALJ considered
Riley’s testimony from administrative hearing. Riley testified that his
knee pain disrupted his sleep, and that his obesity prevented him from
getting around. (Tr. 40-42). He reported that his left knee was worse since
12

his surgery, and that he sometimes used a cane to get around, although
it was not prescribed by a physician. (Tr. 44-46). He testified that he could
do light housework, but that he cannot be on his feet very long. (Tr. 47,
49).
The ALJ found Riley’ statements to be inconsistent with the
objective clinical findings and his reported activities of daily living. (Tr.
21-22). In doing so, the ALJ focused heavily on Riley’s activities of daily
living, noting that he took camping and other trips, visited flea markets
and breweries, and rode an e-bike, and that he was able to take care of
his personal needs, operate a riding lawn mower, shop in stores, and
grocery shop. (Id.). The ALJ also focused on examination findings in the
record, including the early 2021 physical therapy notes from PT Kling,
as well as the November 2021 and April 2022 consultative examination
findings that showed full strength, no effusion, negative straight leg raise
testing, and no sensory deficits. (Tr. 21).
Having made these findings, at Step 4 the ALJ found that Riley
could not perform his past work but found at Step 5 that Riley could
perform jobs in the national economy, such as a laminated machine
13

offbearer, a laundry folder, and a photocopy machine operator. (Tr. 2728). Accordingly, the ALJ found that Riley had not met the stringent
standard prescribed for disability benefits and denied his claim. (Tr. 28).
This appeal followed. On appeal, Riley argues that the ALJ erred
in his consideration of the opinion evidence and failed to include adequate
physical limitations in the RFC. After consideration, we conclude that
the ALJ’s opinion is not supported by substantial evidence. Accordingly,
we will remand this matter to the Commissioner for further
consideration.
III.

Discussion

A. Substantial Evidence Review – the Role of This Court
This Court’s review of the Commissioner’s decision to deny benefits
is limited to the question of whether the findings of the final
decisionmaker are supported by substantial evidence in the record. See
42 U.S.C. §405(g); Johnson v. Comm’r of Soc. Sec., 529 F.3d 198, 200 (3d
Cir. 2008); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa. 2012).
Substantial evidence means less than a preponderance of the evidence
but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401
14

(1971). Substantial evidence “does not mean a large or considerable
amount of evidence, but rather such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.”

Pierce v.

Underwood, 487 U.S. 552, 565 (1988).
A single piece of evidence is not substantial evidence if the ALJ
“ignores, or fails to resolve, a conflict created by countervailing evidence.”

Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993) (quoting Kent v.
Schweiker, 710 F.2d 110, 114 (3d Cir. 1983)) (internal quotations
omitted).

However, where there has been an adequately developed

factual record, substantial evidence may be “something less than the
weight of the evidence, and the possibility of drawing two inconsistent
conclusions from the evidence does not prevent [the ALJ’s decision] from
being supported by substantial evidence.”

Consolo v. Fed. Maritime

Comm’n, 383 U.S. 607, 620 (1966). The court must “scrutinize the record
as a whole” to determine if the decision is supported by substantial
evidence. Leslie v. Barnhart, 304 F. Supp.2d 623, 627 (M.D. Pa. 2003).
The Supreme Court has explained the limited scope of our review,
noting that “[substantial evidence] means—and means only—‘such
15

relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.’” Biestek, 139 S. Ct. at 1154 (quoting Consolidated

Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). Under this standard, we
must look to the existing administrative record to determine if there is
“‘sufficient evidence’ to support the agency’s factual determinations.” Id.
Thus, the question before us is not whether Riley is disabled, but rather
whether the Commissioner’s finding that he or she is not disabled is
supported by substantial evidence and was based upon a correct
application of the law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014
WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) (“[I]t has been held that an
ALJ’s errors of law denote a lack of substantial evidence”) (alterations
omitted); Burton v. Schweiker, 512 F. Supp. 913, 914 (W.D. Pa. 1981)
(“The Secretary’s determination as to the status of a claim requires the
correct application of the law to the facts”); see also Wright v. Sullivan,
900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal
matters is plenary); Ficca, 901 F. Supp. 2d at 536 (“[T]he court has
plenary review of all legal issues . . . .”).

16

When conducting this review, “we must not substitute our own
judgment for that of the fact finder.” Zirnsak v. Colvin, 777 F.3d 607, 611
(3d Cir. 2014) (citing Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir.
2005)).

Thus, we cannot reweigh the evidence.

Instead, we must

determine whether there is substantial evidence to support the ALJ’s
findings. In doing so, we must also determine whether the ALJ’s decision
meets the burden of articulation necessary to enable judicial review; that
is, the ALJ must articulate the reasons for his decision. Burnett v.

Comm’r of Soc. Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000). This does
not require the ALJ to use “magic” words, but rather the ALJ must
discuss the evidence and explain the reasoning behind his or her decision
with more than just conclusory statements. See Diaz v. Comm’r of Soc.

Sec., 577 F.3d 500, 504 (3d Cir. 2009) (citations omitted). Ultimately, the
ALJ’s decision must be accompanied by “a clear and satisfactory
explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700,
704 (3d Cir. 1981).

17

B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ
To receive disability benefits under the Social Security Act, a
claimant must show that he or she 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
12 months.” 42 U.S.C. §423(d)(1)(A); 42 U.S.C. §1382c(a)(3)(A); see also
20 C.F.R. §§404.1505(a), 416.905(a). This requires a claimant to show a
severe physical or mental impairment that precludes him or her from
engaging in previous work or “any other substantial gainful work which
exists in the national economy.”

42 U.S.C. §423(d)(2)(A); 42 U.S.C.

§1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits
under Title II of the Social Security Act, a claimant must show that he or
she is under retirement age, contributed to the insurance program, and
became disabled prior to the date on which he or she was last insured.
42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
In making this determination, the ALJ follows a five-step
evaluation.

20 C.F.R. §§404.1520(a), 416.920(a).
18

The ALJ must

sequentially determine whether Riley: (1) is engaged in substantial
gainful activity; (2) has a severe impairment; (3) has a severe impairment
that meets or equals a listed impairment; (4) is able to do his or her past
relevant work; and (5) is able to do any other work, considering his or her
age, education, work experience and residual functional capacity (“RFC”).
20 C.F.R. §§404.1520(a)(4), 416.920(a)(4).
Between Steps 3 and 4, the ALJ must also determine Riley’ residual
functional capacity (RFC). RFC is defined as “that which an individual is
still able to do despite the limitations caused by his or her
impairment(s).” Burnett, 220 F.3d at 121 (citations omitted); see also 20
C.F.R. § 404.1545(a)(1).

In making this assessment, the ALJ must

consider all Riley’ medically determinable impairments, including any
non-severe impairments identified by the ALJ at step two of the analysis.
20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).

Our review of the ALJ’s

determination

is

of

the

plaintiff’s

RFC

deferential,

and

that

determination will not be set aside if it is supported by substantial
evidence. Burns v. Barnhart, 312 F.3d 113, 129 (3d Cir. 2002).

19

Riley bears the burden at Steps 1 through 4 to show a medically
determinable impairment that prevents him from engaging in any past
relevant work. Mason, 994 F.2d at 1064. If met, the burden then shifts
to the Commissioner to show at Step 5 that there are jobs in significant
numbers in the national economy that Riley can perform consistent with
Riley’ RFC, age, education, and work experience.

20 C.F.R.

§§404.1512(f), 416.912(f); Mason, 994 F.2d at 1064.
With respect to the RFC determination, courts have followed
different paths when considering the impact of medical opinion evidence
on this determination. While some courts emphasize the necessity of
medical opinion evidence to craft a claimant’s RFC, see Biller v. Acting

Comm’r of Soc. Sec., 962 F. Supp. 2d 761, 778–79 (W.D. Pa. 2013), other
courts have taken the approach that “[t]here is no legal requirement that
a physician have made the particular findings that an ALJ adopts in the
course of determining an RFC.” Titterington v. Barnhart, 174 F. App’x
6, 11 (3d Cir. 2006).

Additionally, in cases that involve no credible

medical opinion evidence, courts have held that “the proposition that an
ALJ must always base his RFC on a medical opinion from a physician is
20

misguided.” Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D. Pa.
2015).
Given these differing approaches, we must evaluate the factual
context underlying an ALJ’s decision.

Cases that emphasize the

importance of medical opinion support for an RFC assessment typically
arise in the factual setting where well-supported medical sources have
found limitations to support a disability claim, but an ALJ has rejected
the medical opinion based upon an assessment of other evidence. Biller,
962 F. Supp. 2d at 778–79. These cases simply restate the notion that
medical opinions are entitled to careful consideration when making a
disability determination. On the other hand, when no medical opinion
supports a disability finding or when an ALJ relies upon other evidence
to fashion an RFC, courts have routinely sustained the ALJ’s exercise of
independent judgment based upon all the facts and evidence.

See

Titterington, 174 F. App’x 6; Cummings, 129 F. Supp. 3d at 214–15.
Ultimately, it is our task to determine, considering the entire record,
whether the RFC determination is supported by substantial evidence.

Burns, 312 F.3d 113.
21

C. The ALJ’s Decision is Not Supported by Substantial Evidence.
As we have noted, the ALJ’s decision must be accompanied by “a
clear and satisfactory explication of the basis on which it rests,” Cotter,
642 F.2d at 704, and the ALJ must “indicate in his decision which
evidence he has rejected and which he is relying on as the basis for his
finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F. 3d 429, 433 (3d Cir.
1999).

After

consideration,

we

conclude

that

the

ALJ’s

RFC

determination is not supported by an adequate explanation.
Here, Riley contends that the ALJ erred in finding the opinions of
Dr. Conner and PT Kling unpersuasive. He asserts that the ALJ did not
consider the abnormal examination findings from these providers and
instead focused heavily on other findings as well as Riley’s activities of
daily living. Indeed, the ALJ consistently refers to examination findings
showing “the claimant is in no acute distress with full strength, intact
sensation, capillary refill in less than three seconds, and no edema.” (Tr.
21-24). The ALJ also focused heavily on Riley’s activities of daily living,
including his ability to perform personal care, care for pets, make simple
meals, and drive. (Id.). However, the decision contains no discussion
22

whatsoever of any of the abnormal examination findings in the record,
such as treatment notes from Dr. Conner and PT Kling, as well as the
internal medicine examinations, showing at times that Riley had mild to
moderate effusion and an antalgic gait. (See Tr. 391, 404, 407-08, 420,
461, 474, 482, 566, 573-74, 600, 684-85, 692, 734).
While the ALJ was not required to accept the limitations as set
forth in Dr. Conner’s and PT Kling’s opinions, in our view, the decision
fails to adequately explain how the limitations set forth by these
providers were inconsistent with their treatment records, specifically
those records that contained abnormal examination findings. As we have
explained, the ALJ must “indicate in his decision which evidence he has
rejected and which he is relying on as the basis for his finding.”

Schaudeck, 181 F. 3d at 433. Here, the ALJ did not discuss the abnormal
examination findings from these treatment providers or those contained
in the internal medicine examinations, and further, failed to articulate
his reasons for rejecting these findings. Given that the ALJ failed to even
mention the abnormal examination findings in the record, we cannot
conclude that his assessment of these medical opinions is supported by
23

substantial evidence. See e.g., Altland v. Kijakazi, 2023 WL 3163222, at
*11 (M.D. Pa. April 28, 2023) (Carlson, M.J.); O’Dell v. Saul, 2020 WL
6203098, at *7-8 (M.D. Pa. Oct. 22, 2020) (Arbuckle, M.J.).
Accordingly, a remand is required for further consideration of these
issues. While we reach this conclusion, we note that nothing in this
Memorandum Opinion should be deemed as expressing a judgment on
the ultimate outcome of this matter. Rather, that task is left to the ALJ
on remand.
IV.

Conclusion
For the foregoing reasons, the decision of the Commissioner will be

REMANDED for further consideration.
An appropriate order follows.

s/ Daryl F. Bloom

Daryl F. Bloom
Chief United States Magistrate Judge

Date: January 6, 2025

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