Baldwin v. Commissioner of Social Security Administration
ORDER affirming the decision of the Commissioner. Signed by Magistrate Judge Paige J. Gossett on 04/24/2017. (bshr, )
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF SOUTH CAROLINA
Melissa B. Baldwin,
Nancy A. Berryhill, Acting Commissioner )
of Social Security,1
C/A No. 0:16-363-PJG
This social security matter is before the court pursuant to Local Civil Rule 83.VII.02 (D.S.C.)
and 28 U.S.C. § 636(c) for final adjudication, with the consent of the parties, of the plaintiff’s
petition for judicial review. The plaintiff, Melissa B. Baldwin, brought this action pursuant to 42
U.S.C. §§ 405(g) and 1383(c)(3) to obtain judicial review of a final decision of the defendant, Acting
Commissioner of Social Security (“Commissioner”), denying her claims for Disability Insurance
Benefits (“DIB”). Having carefully considered the parties’ submissions and the applicable law, the
court concludes that the Commissioner’s decision should be affirmed.
SOCIAL SECURITY DISABILITY GENERALLY
Under 42 U.S.C. § 423(d)(1)(A) and (d)(5), as well as pursuant to the regulations formulated
by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an
“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); see also
Pursuant to Federal Rule of Civil Procedure 25(d), Nancy A. Berryhill is substituted as the
named defendant because she became the Acting Commissioner of Social Security on January 23,
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Blalock v. Richardson, 483 F.2d 773 (4th Cir. 1973). The regulations require the Administrative
Law Judge (“ALJ”) to consider, in sequence:
whether the claimant is engaged in substantial gainful activity;
whether the claimant has a “severe” impairment;
whether the claimant has an impairment that meets or equals the requirements of an
impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (“the Listings”), and
is thus presumptively disabled;
whether the claimant can perform her past relevant work; and
whether the claimant’s impairments prevent her from doing any other kind of work.
20 C.F.R. § 404.1520(a)(4).2 If the ALJ can make a determination that a claimant is or is not
disabled at any point in this process, review does not proceed to the next step. Id.
Under this analysis, a claimant has the initial burden of showing that she is unable to return
to her past relevant work because of her impairments. Once the claimant establishes a prima facie
case of disability, the burden shifts to the Commissioner. To satisfy this burden, the Commissioner
must establish that the claimant has the residual functional capacity, considering the claimant’s age,
education, work experience, and impairments, to perform alternative jobs that exist in the national
economy. 42 U.S.C. § 423(d)(2)(A); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir.
1983); Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); Wilson v. Califano, 617 F.2d 1050,
1053 (4th Cir. 1980). The Commissioner may carry this burden by obtaining testimony from a
vocational expert. Grant v. Schweiker, 699 F.2d 189, 192 (4th Cir. 1983).
The court observes that effective August 24, 2012, ALJs may engage in an expedited
process which permits the ALJs to bypass the fourth step of the sequential process under certain
circumstances. 20 C.F.R. § 404.1520(h).
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In October 2012, Baldwin applied for DIB, alleging disability beginning December 15, 2006.
Baldwin’s application was denied initially and upon reconsideration, and she requested a hearing
before an ALJ. A hearing was held on August 7, 2014, at which Baldwin appeared and testified, and
was represented by Leeds Barroll, IV, Esquire. After hearing testimony from a vocational expert,
the ALJ issued a decision on November 4, 2014 finding that Baldwin was not disabled. (Tr. 12-20.)
Baldwin was born in 1958 and was forty-seven years old on her disability onset date. (Tr.
20.) She has a high school education and past relevant work experience as an administrative
assistant supervisor. (Tr. 155.) Baldwin alleged disability due to spinal, lower back, and neck
injuries; scoliosis; fibromyalgia; a herniated disc; and teeth chattering. (Tr. 154.)
In applying the five-step sequential process, the ALJ found that Baldwin had not engaged in
substantial gainful activity from her alleged onset date of December 15, 2006 through her date last
insured of December 31, 2011. The ALJ also determined that, through the date last insured,
Baldwin’s degenerative disc disease was a severe impairment. However, the ALJ found that,
through the date last insured, Baldwin did not have an impairment or combination of impairments
that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404,
Subpart P, Appendix 1 (the “Listings”). The ALJ further found that, through the date last insured,
Baldwin retained the residual functional capacity to
perform light work as defined in 20 CFR 404.1567(b). However, claimant could
never climb ladders, ropes, and scaffolds, only occasionally climb ramps, climb
stairs, stoop, kneel, crouch, perform overhead reaching, crawl, and balance, and only
frequently reach, handle, and finger. Claimant needed to avoid concentrated
exposure [to] vibration and avoid all exposure to hazards and unprotected heights.
(Tr. 15.) The ALJ found that, through the date last insured, Baldwin was capable of performing past
relevant work as an administrative assistant supervisor, and that this work did not require the
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performance of work-related activities precluded by Baldwin’s residual functional capacity.
Therefore, the ALJ found that Baldwin was not disabled from the alleged onset date of December
15, 2006 through the date last insured of December 31, 2011.
The Appeals Council denied Baldwin’s request for review on January 20, 2016, making the
decision of the ALJ the final action of the Commissioner. (Tr. 1-5.) This action followed.
STANDARD OF REVIEW
Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner’s denial of benefits.
However, this review is limited to considering whether the Commissioner’s findings “are supported
by substantial evidence and were reached through application of the correct legal standard.” Craig
v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); see also 42 U.S.C. § 405(g); Coffman v. Bowen, 829
F.2d 514, 517 (4th Cir. 1987). Thus, the court may review only whether the Commissioner’s
decision is supported by substantial evidence and whether the correct law was applied. See Myers
v. Califano, 611 F.2d 980, 982 (4th Cir. 1980). “Substantial evidence” means “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more
than a mere scintilla of evidence but may be somewhat less than a preponderance.” Craig, 76 F.3d
at 589. In reviewing the evidence, the court may not “undertake to re-weigh conflicting evidence,
make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Id.
Accordingly, even if the court disagrees with the Commissioner’s decision, the court must uphold
it if it is supported by substantial evidence. Blalock, 483 F.2d at 775.
Baldwin raises the following issues for this judicial review:
The ALJ erred in failing to honor the Treating Physician Rule[;]
The ALJ erred in finding that myofascial pain is a non-severe impairment[;]
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The ALJ erred in failing to evaluate symptoms properly pursuant to the twopart test of Craig v. Chater and SSR 96-7p[;]
The ALJ violated the legal standard for evaluating RFC[.]
(Pl.’s Br., ECF No. 9.)
Although Baldwin raises several issues for this judicial review, the court, like the
Commissioner, addresses these issues in order of the sequential process. Further, for the reasons that
follow, the court finds that Baldwin has failed to demonstrate that the ALJ’s decision is unsupported
by substantial evidence or controlled by an error of law.
Severity of Impairments
Step Two of the sequential evaluation requires the ALJ to “consider the medical severity of
[a claimant’s] impairment(s).” 20 C.F.R. § 404.1520(a)(4)(ii).3 The claimant bears the burden at
this step to show that he has a severe impairment. See Bowen v. Yuckert, 482 U.S. 137, 146 n.5
(1987). A severe impairment is one that “significantly limits [a claimant’s] physical or mental ability
to do basic work activities.” 20 C.F.R. § 404.1520(c). “Basic work activities” means “the abilities
and aptitudes necessary to do most jobs.” Examples of these include:
Physical functions such as walking, standing, sitting, lifting, pushing, pulling,
reaching, carrying, or handling;
Capacities for seeing, hearing, and speaking;
Understanding, carrying out, and remembering simple instructions;
Use of judgment;
The court notes that numerous social security regulations and social security rulings (SSRs)
have changed effective March 27, 2017. However, these changes specifically state that they are
applicable to claims filed on or after March 27, 2017. See, e.g., 20 C.F.R. §§ 404.1513, 404.1527.
Because the instant claim was filed in 2012, all references in the instant Report and
Recommendation are to the prior versions of the regulations which were in effect at the time
Baldwin’s application for benefits was filed unless otherwise specified.
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Responding appropriately to supervision, co-workers and usual work
Dealing with changes in a routine work setting.
20 C.F.R. § 404.1521(b). “[A]n impairment can be considered as not severe only if it is a slight
abnormality which has such a minimal effect on the individual that it would not be expected to
interfere with the individual’s ability to work, irrespective of age, education, or work experience.”
Evans v. Heckler, 734 F.2d 1012, 1014 (4th Cir. 1984) (emphasis in original) (internal quotation
At Step Two, the ALJ found that Baldwin’s degenerative disc disease was a severe
impairment, but that Baldwin’s other impairments, including her allegations of myofascial pain
syndrome, were nonsevere. (Tr. 14-15.) With regard to Baldwin’s alleged myofascial pain, the ALJ
specifically stated as follows:
Claimant also testified she has been diagnosed with fibromyalgia and myofascial pain
syndrome. However, the record reveals no objective medical evidence from an
“acceptable medical source” prior to the date last insured demonstrating the presence
of these conditions. Medical evidence prior to the date last insured does reveal any
definitive diagnosis of fibromyalgia or myofascial pain syndrome. Thus, I conclude
that fibromyalgia and myofascial pain syndrome were not medically determinable
impairments (SSRs 96-4p and 06-03p).
(Tr. 15.) Baldwin challenges this finding, pointing to evidence demonstrating that Baldwin “has had
chronic, continuous cervical, thoracic, and even lumbar pain radiating to all extremities since 2005:
this would appear to embrace myofascial pain.” (Pl.’s Br. at 11, ECF No. 9 at 11.) Baldwin argues
that the ALJ erred in failing to explain the difference between the pain documented, further arguing
that she “suffers myofascial pain because of her degenerative disc disease.” (Id. at 12.)
However, as argued by the Commissioner, Baldwin’s general arguments do not reveal any
errors in the ALJ’s finding.
In fact, Baldwin has not directed the court to any evidence
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demonstrating that Baldwin was diagnosed with myofascial pain syndrome or to findings of the
requisite trigger points associated with this impairment. Thus, remand is not warranted on this basis.
Baldwin also argues that the ALJ erred in evaluating the opinion evidence from Dr. Frank
Martin, her treating physician, and Keith Didyoung, Dr. Martin’s physician’s assistant. The law
applicable to Baldwin’s application provides that regardless of the source, the Commissioner will
evaluate every medical opinion received. 20 C.F.R. § 404.1527(c). Typically, the Social Security
Administration accords greater weight to the opinion of treating medical sources because treating
physicians are best able to provide “a detailed, longitudinal picture” of a claimant’s alleged
disability. See 20 C.F.R. § 404.1527(c)(2). However, “the rule does not require that the testimony
be given controlling weight.” Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992) (per curiam).
Rather, a treating physician’s opinion is evaluated and weighed “pursuant to the following nonexclusive list: (1) whether the physician has examined the applicant, (2) the treatment relationship
between the physician and the applicant, (3) the supportability of the physician’s opinion, (4) the
consistency of the opinion with the record, and (5) whether the physician is a specialist.” Johnson
v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005) (citing 20 C.F.R. § 404.1527). Any other factors that
may support or contradict the opinion should also be considered. 20 C.F.R. § 404.1527(c)(6). In
the face of “persuasive contrary evidence,” the ALJ has the discretion to accord less than controlling
weight to such an opinion. Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001). Further, “if a
physician’s opinion is not supported by clinical evidence or if it is inconsistent with other substantial
evidence, it should be accorded significantly less weight.” Id. (quoting Craig, 76 F.3d at 590).
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Additionally, SSR 96-2p provides that a finding that
a treating source medical opinion is not well-supported by medically acceptable
clinical and laboratory diagnostic techniques or is inconsistent with the other
substantial evidence in the case record means only that the opinion is not entitled to
“controlling weight,” not that the opinion should be rejected. Treating source
medical opinions are still entitled to deference and must be weighed using all of the
factors provided in 20 CFR 404.1527 and 416.927. In many cases, a treating source’s
medical opinion will be entitled to the greatest weight and should be adopted, even
if it does not meet the test for controlling weight.
SSR 96-2p, 1996 WL 374188, at *5. This Ruling also requires that an ALJ’s decision “contain
specific reasons for the weight given to the treating source’s medical opinion, supported by the
evidence in the case record, and must be sufficiently specific to make clear to any subsequent
reviewers the weight the adjudicator gave to the treating source’s medical opinion and the reasons
for that weight.” Id.
Moreover, ALJs are instructed to apply the above factors—including the length and nature
of the source’s treatment relationship with the claimant, the supportability of the opinion, the
opinion’s consistency with the other evidence in the record, whether the source is a specialist, and
any other factors that may support or contradict the opinion—to all medical opinions, including those
from consultative examiners and medical sources who are not acceptable medical sources, such as
physician’s assistants.4 20 C.F.R. § 404.1527(c), (f); cf. 20 C.F.R. § 404.1502 (a)(8) (including
licensed physician’s assistants as acceptable medical sources for impairments within their licensed
scope of practice “only with respect to claims filed . . . on or after March 27, 2017”). Importantly,
more weight is generally given to the opinions of an examining source than a non-examining one.
In evaluating opinions from other sources, not every factor may apply. See 20 C.F.R.
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Id. Additionally, more weight is generally given to opinions of treating sources than non-treating
sources, such as consultative examiners. Id.
In this case, the ALJ evaluated the opinions from both of these sources, finding as follows:
In March 2006, Keith Didyoung, PA-C, reported claimant was “permanently
disabled” due to injuries suffered in a 2005 car accident, and “need[ed] to be out of
work until further reduction of pain is attained” (Exhibit 12F).
I give Mr. Didyoung’s opinions light weight. Whether or not an individual is
“disabled” within the meaning of the Social Security Act is an issue reserved to the
Commissioner (SSR 96-5p), and Mr. Didyoung did not describe any specific
work-related limitations. Also, Mr. Didyoung’s opinions are inconsistent with one
another because, though Mr. Didyoung stated claimant was “permanently disabled,”
he also said claimant only needed to “be out of work until further reduction of pain
[was] attained.” Moreover, Mr. Didyoung’s opinions are inconsistent with Dr.
Rambo’s opinions, as well as evidence described above showing that diagnostic
testing revealed only mild abnormalities at worst, physical exams were mostly
unremarkable, and claimant sought almost no treatment in 2008. Further, though Mr.
Didyoung apparently based his opinions to a substantial degree on claimant’s
reported radiculopathy, nerve conduction studies in 2006 actually showed no
radiculopathy (Exhibit 3F/9).
J. Frank Martin, MD, completed a statement concerning claimant in March 2013.
Therein, Dr. Martin reported claimant had lost strength and sensation in her
extremities. Dr. Martin also reported claimant “ha[d] been unable to maintain any
substantial gainful activity on a reliable, consistent basis” since 2005. Dr. Martin
also stated claimant was “unable to sit or stay in one position for any length of time,”
The record also contains a second statement from Dr. Martin, where Dr. Martin
reported [claimant] “ha[d] lost strength and sensation in [her] upper and lower
extremities and [was] unable to hold any gainful employment” (Exhibit 35F).
I give Dr. Martin’s opinions light weight. Whether or not an individual is “disabled”
within the meaning of the Social Security Act is an issue reserved to the
Commissioner, and treating source opinions thereon are not entitled to special
significance (SSR 96-5p). Also, contrary to Dr. Martin’s report that claimant had lost
strength and sensation in her extremities, exams cited above generally showed
normal strength and sensation, and nerve conduction studies in 2006 revealed no
radiculopathy or neuropathy. In addition, Dr. Martin’s opinions are inconsistent with
evidence described above showing diagnostic testing revealed only mild
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abnormalities at worst, physical exams were mostly unremarkable, and claimant
sought almost no treatment in 2008.
(Tr. 18-19) (fourth alteration added).
In challenging the ALJ’s evaluation of the opinion evidence, Baldwin argues that the ALJ
failed to note that Dr. Martin’s opinion contained a “detailed discussion of pain.” (Pl.’s Br. at 5,
ECF No. 9 at 5.) Baldwin also argues that the opinions are supported by objective findings. For
example, Baldwin argues treatment notes document muscle spasms, and points to treatment notes
from an orthopedist in 2006 indicating that a shot administered to Baldwin’s shoulder did not help;
that the cervical MRI showing “persistent foraminal stenosis in C3-4 and C6-7 areas on the left”
could account for Baldwin’s left arm symptoms; that Baldwin was still experiencing pain and could
not do her work because prolonged sitting caused pain; and that Baldwin was prescribed Neurontin.
(Id. at 5-6.) Baldwin challenges the ALJ’s reliance on Dr. Rambo’s 2006 opinion, arguing that this
opinion “would not refute disability in 2011.” (Id. at 6.) Finally, Baldwin points to treatment notes
in 2011 documenting muscle spasms, diagnosing back and neck pain, and indicating that Baldwin
was taking medications such as Prednisone, Xanax, Demerol, Lyrica, Lexapro, and Prozac. Baldwin
also argues that the opinions are well-supported by medically acceptable techniques, and appears to
argue that the Commissioner cannot point to persuasive contrary evidence to refute these opinions.
Upon thorough review of the ALJ’s decision and the record, the court concludes that the ALJ
applied the relevant factors in evaluating the opinion evidence, and finds that Baldwin has failed to
demonstrate that the ALJ’s evaluation of these opinions is unsupported by substantial evidence or
based on an incorrect application of the law. See 20 C.F.R. § 404.1527(c); Mastro, 270 F.3d at 178
(stating that “if a physician’s opinion is not supported by clinical evidence or if it is inconsistent with
other substantial evidence, it should be accorded significantly less weight”) (internal quotation marks
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and citation omitted); Dunn v. Colvin, 607 F. App’x 264, 267 (4th Cir. 2015) (“An ALJ’s
determination as to the weight to be assigned to a medical opinion generally will not be disturbed
absent some indication that the ALJ has dredged up ‘specious inconsistencies,’ . . . or has failed to
give a sufficient reason for the weight afforded a particular opinion[.]”) (internal citations omitted).
The decision reflects that the ALJ weighed these opinions and reasonably found that the medical
findings and observations in the record did not support all of them.5 Although Baldwin may be able
to point to select medical records that arguably support the opinions, she has failed to demonstrate
that the ALJ’s conclusions regarding them are unsupported by substantial evidence. In fact, it is
clear that the ALJ, as part of his duties in weighing the evidence, properly relied on medical records,
treatment notes, examination findings, and evidence in evaluating the opinions. See Craig, 76 F.3d
at 589 (stating that the court may not “undertake to re-weigh conflicting evidence, make credibility
determinations, or substitute [its] judgment for that of the [Commissioner]”); Hays v. Sullivan, 907
F.2d 1453, 1456 (4th Cir. 1990) (holding that it is the ALJ’s responsibility, not the court’s, to
determine the weight of evidence and resolve conflicts of evidence).
Thus, the court finds that Baldwin has not shown that the ALJ’s decision with regard to the
opinion evidence, was unsupported by substantial evidence or reached through application of an
incorrect legal standard.
Moreover, the court notes that to the extent any source opined that Baldwin is disabled or
unable to work, such an opinion is reserved to the Commissioner and not entitled to special
significance. See 20 C.F.R. § 404.1527(d) (explaining that the issue of whether a claimant is
disabled or unable to work is reserved to the Commissioner, and opinions by medical sources on that
point are not entitled to special significance).
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Baldwin also challenges the ALJ’s evaluation of her subjective complaints of pain. With
regard to subjective complaints, the United States Court of Appeals for the Fourth Circuit has stated
that “the determination of whether a person is disabled by pain or other symptoms is a two-step
process.” Craig, 76 F.3d at 594. The first step requires there to “be objective medical evidence
showing the existence of a medical impairment(s) which results from anatomical, physiological, or
psychological abnormalities and which could reasonably be expected to produce the pain or other
symptoms alleged.” Id. (internal quotation omitted). During the second step, the ALJ must
expressly consider “the intensity and persistence of the claimant’s [symptom] and the extent to which
it affects [his] ability to work.” Id. In making these determinations, the ALJ’s decision “must
contain specific reasons for the finding on credibility, supported by the evidence in the case record,
and must be sufficiently specific to make clear to the individual and to any subsequent reviewers the
weight the adjudicator gave to the individual’s statements and the reasons for that weight.” SSR
96-7p, 1996 WL 374186, at *4.6 “[A]llegations concerning the intensity and persistence of pain or
other symptoms may not be disregarded solely because they are not substantiated by objective
Effective March 28, 2016, SSR 96-7p was superseded by SSR 16-3p, 2016 WL 1119029.
See 2016 WL 1237954 (correcting the effective date of SSR 16-3p to read March 28, 2016).
Because this application was adjudicated prior to the effective date of SSR 16-3p, the court analyzes
Baldwin’s allegations under SSR 96-7p. See Best v. Berryhill, No. 0:15-cv-02990-DCN, 2017 WL
835350, at *4 n.3 (Mar. 3, 2017) (applying SSR 96-7p under the same circumstances). Regardless,
the court observes that SSR 16-3p discontinues use of the term “credibility,” but “the methodology
required by both SSR 16-3p and SSR 96-7, are quite similar. Under either, the ALJ is required to
consider [the claimant’s] report of his own symptoms against the backdrop of the entire case record.”
Id. (alteration in original) (quoting Sullivan v. Colvin, Civil Action No. 7:15-cv-504, 2017 WL
473925, at *3 (W.D. Va. Feb. 3, 2017)); see also Keaton v. Colvin, No. 3:15CV588, 2017 WL
875477, at *6 (E.D. Va. Mar. 3, 2017) (“Effective as of March 28, 2016, SSR 16-3p superseded SSR
96-7p. SSR 16-3p effectively removes the use of the term “credibility” but does not alter the
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medical evidence.” Id. (emphasis added). “This is not to say, however, that objective medical
evidence and other objective evidence are not crucial to evaluating the intensity and persistence of
a claimant’s pain and the extent to which it impairs [his] ability to work.” Craig, 76 F.3d at 595.
A claimant’s subjective complaints “need not be accepted to the extent they are inconsistent with the
available evidence, including objective evidence of the underlying impairment, and the extent to
which that impairment can reasonably be expected to cause the [symptoms] the claimant alleges he
suffers.” Id. The social security regulations inform claimants that in evaluating subjective
complaints, the Commissioner will consider the following relevant factors:
Your daily activities;
The location, duration, frequency, and intensity of your pain or other
Precipitating and aggravating factors;
The type, dosage, effectiveness, and side effects of any medication you take
or have taken to alleviate your pain or other symptoms;
Treatment, other than medication, you receive or have received for relief of
your pain or other symptoms;
Any measures you use or have used to relieve your pain or other symptoms
(e.g., lying flat on your back, standing for 15 to 20 minutes every hour,
sleeping on a board, etc.); and
Other factors concerning your functional limitations and restrictions due to
pain or other symptoms.
20 C.F.R. § 404.1529(c)(3).
In this case, the ALJ summarized Baldwin’s allegations as follows:
Claimant appeared before me on August 7, 2014 and gave testimony. Therein,
claimant stated she experiences back pain, chatters or grinds her teeth due to pain,
experiences “a lot of nerve pain,” experiences neck and arm pain, and has been
diagnosed with fibromyalgia or myofascial pain syndrome. Claimant also stated that,
in 2010 and 2011, she laid down most of the day, experienced extremity numbness
and weakness, experienced some grogginess due to medication, could not [lift] over
10 pounds, could only stand 5-10 minutes at a time, could only sit about 20 minutes
at a time, had difficulty raising the arms, and had a hard time writing or opening jars.
Claimant additionally stated she has a history of headaches or migraines lasting for
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several hours to several days, has received physical therapy, and has problems
The ALJ found that “other than [Baldwin’s] alleged demyelinating disease, fibromyalgia,
teeth problems, and myofascial pain syndrome, [her] medically determinable impairments could
reasonably be expected to cause the alleged symptoms,” but that her statements concerning the
intensity, persistence, and limiting effects of the alleged symptoms were not entirely credible based
on the record in this case. (Tr. 16.) In support of this finding, the ALJ found that the medical
evidence partially supported Baldwin’s allegations. Specifically, the ALJ observed as follows:
MRI of claimant’s cervical spine in 2005 showed degenerative disc disease with
some foraminal protrusion (Exhibit 1F), and claimant underwent disc decompression
at C6-7 in October 2005 (Exhibit 11F/1). In addition, MRIs of claimant’s lumbar
spine in 2005 and 2009 revealed degenerative changes (Exhibits 2F and 27F).
Moreover, exam in January 2006 showed some pain with hip, neck, shoulder, and hip
motion (Exhibit 4F/10), records from 2006 report a history of epidural steroid
injections and complaints of extremity numbness or pain (See, for example, Exhibit
4F/10), and records show claimant was prescribed a number of pain medications such
as Lortab (Exhibit 17F). Moreover, claimant received physical therapy for neck and
back pain in 2009 and 2011 (Exhibits 5F, 20F, 22F, and 26F), and exam in April
2010 showed some low back tenderness (Exhibit 24F/2).
(Id.) The ALJ found that this evidence partially supported Baldwin’s allegations that “she
experienced neck, back, and extremity symptoms with problems lifting, using her hands, and
bending,” and, therefore, the ALJ limited Baldwin to “light work exertionally with substantial
postural and manipulative limitations.” (Id.) The ALJ continued, restricting Baldwin’s exposure
to vibrations based on her documented pain and to hazards and unprotected heights based on her pain
and medication usage.
However, the ALJ found that other evidence indicated that Baldwin’s “impairments were not
highly limiting and would not preclude the performance of activities within the restrictions set forth
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in my residual functional capacity finding.” (Tr. 17.) Specifically, the ALJ first found that
“diagnostic testing did not show a great deal of abnormalities, suggesting claimant’s spinal
impairments were not highly limiting.” (Id.) The ALJ summarized medical reports indicating MRIs
in 2005 and 2009 showed mild abnormalities with one doctor reporting the 2009 lumbar spine MRI
“showed only mild abnormalities with possible ‘minimal contact with the right L4 nerve root.’
(Exhibit 27F/3-4).” The ALJ observed that one doctor reported a 2005 lumbar spine MRI “ ‘did not
show anything to explain the numbness in [claimant’s] legs’ (Exhibit 27F/3-4)” and another doctor
reported that a 2006 nerve conduction study was “ ‘normal’ with no evidence of radiculopathy or
neuropathy (Exhibit 3F/9).” (Id.) The ALJ also noted that spinal MRIs from early 2014, “well after
the date last insured,” “were also largely unremarkable with only mild to moderate abnormalities
(Exhibit 33F/13 and 21).” (Id.) Second, the ALJ found that “physical exams of record were mostly
unremarkable, showing that claimant had a great deal of functional ability.” (Id.) The ALJ
summarized medical records from January 2006 through 2012, indicating findings such as mild pain,
normal reflexes, normal range of motion and no tenderness in the neck, normal gait, and normal
extremity strength. The ALJ also acknowledged and summarized records after Baldwin’s date last
insured, finding that “recent unremarkable exams also contradict claimant’s allegations of ongoing,
debilitating pain that causes her to he mostly bed ridden.” (Id.) Third, the ALJ found that “though
claimant alleges disabling symptoms since December 2006, the record reveals almost no medical
treatment in 2008,” finding “[s]uch a large treatment gap would not be expected of someone
experiencing highly limiting symptoms,” and that “[s]imilarly, the record reveals no emergent
treatment as might be expected of someone with persistent, highly limiting pain.” (Tr. 18.) Thus,
the ALJ found
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though claimant testified she could only sit, stand, and walk for short periods, could
only lift 10 pounds, and could not raise her arms, such limitations are not supported
by the objective medical evidence described above. In particular, exams generally
showed normal strength, no exam revealed any muscle atrophy, cervical spine MRIs
did not show substantial abnormalities, exams largely showed normal gait, claimant
sought almost no medical treatment in 2008, and nerve conduction studies revealed
no radiculopathy (Exhibit 3F/9).
The ALJ also considered the opinion evidence. This evidence included the opinions of Dr.
Martin and Mr. Didyoung, which are discussed in detail above, as well as (1) a February 2006
opinion from Dr. Rambo that he “ ‘really c[ould not] keep [claimant] out of work’ given the mild
abnormalities shown on MRIs and unremarkable exams (Exhibit 3F/6)”; (2) a January 2006
temporary restriction from a source at The Moore Orthopedic Clinic reporting “claimant was ‘to
remain out of work’ until her next appointment in February 2006 (Exhibit 4F/14)”; and (3) the state
agency consultants’ conclusions that “there was insufficient evidence by which to evaluate the
severity of claimant’s impairments as of the date last insured (Exhibits 1A and 3A).” (Tr. 18-19)
(alterations in original). In sum, the ALJ found Baldwin “has a history of lumbar and cervical spine
abnormalities with some reported back, neck, and extremity pain. However, MRIs of the lumbar and
cervical spine prior to the date last insured showed largely mild abnormalities, nerve conduction
studies in 2006 were normal, physical exams were largely unremarkable, and the record reveals
almost no medical treatment in 2008.” (Tr. 19-20.)
Page 16 of 20
Baldwin attempts to challenge some of the reasons offered by the ALJ, arguing the record
and the opinion evidence support Baldwin’s subjective complaints.7 Further, Baldwin appears to
argue that she may rely solely on her subjective reports to support Step Two of the process and that
the ALJ erred by only considering medical evidence in the second step. Baldwin also challenges the
ALJ’s reliance on her failure to seek treatment in 2008, arguing that she sought treatment both before
and after 2008, which is all prior to her date last insured. Finally, Baldwin argues that the ALJ failed
to sufficiently explain his evaluation of Baldwin’s subjective complaints and appears to challenge
the ALJ’s consideration of the side effects from her medications.
As an initial matter, with regard to Baldwin’s argument that once she satisfied the first step
of the two-step process in evaluating allegations of disabling pain or other symptoms, she was
entitled to rely exclusively on subjective evidence to prove the intensity, persistence, and severity
of the symptoms and that the ALJ erred by considering only the medical evidence, the court
disagrees. In Hines v. Barnhart, 453 F.3d 559 (4th Cir. 2006), the Fourth Circuit stated: “Having
met his threshold obligation of showing by objective medical evidence a condition reasonably likely
to cause the pain claimed, [the claimant] was entitled to rely exclusively on subjective evidence to
prove the second part of the test, i.e., that his pain [was] so continuous and/or severe that it
prevent[ed] him from working a full eight-hour day,” 453 F.3d at 565; however, the Hines Court
acknowledged that “[o]bjective medical evidence of pain, its intensity or degree (i.e., manifestations
of the functional effects of pain such as deteriorating nerve or muscle tissue, muscle spasm, or
To the extent that Baldwin’s allegation of error hinges on her allegation that the ALJ erred
in failing to properly consider her myofascial pain syndrome and erred in evaluating the opinion
evidence, for the reasons discussed above, Baldwin has failed to demonstrate any error by the ALJ.
Similarly, to the extent that Baldwin is challenging the ALJ’s analysis at Step One of the process,
the court finds that Baldwin has failed to demonstrate that it was insufficient.
Page 17 of 20
sensory or motor disruption), if available, should be obtained and considered.” Id. at 564 (quoting
SSR 90-1p). Moreover, the Hines Court noted that
[w]hile objective evidence is not mandatory at the second step of the test, “[t]his is
not to say, however, that objective medical evidence and other objective evidence are
not crucial to evaluating the intensity and persistence of a claimant’s pain and the
extent to which it impairs her ability to work. They most certainly are. Although a
claimant’s allegations about her pain may not be discredited solely because they are
not substantiated by objective evidence of the pain itself or its severity, they need not
be accepted to the extent they are inconsistent with the available evidence, including
objective evidence of the underlying impairment, and the extent to which that
impairment can reasonably be expected to cause the pain the claimant alleges she
Id. at 565 n.3 (quoting Craig v. Chater, 76 F.3d 585, 595 (4th Cir. 1996)). Baldwin has failed to
demonstrate that the ALJ erred in applying this law.8
Moreover, upon careful consideration of Baldwin’s remaining arguments and the record in
this matter, the court finds that Baldwin has failed to demonstrate that the ALJ’s evaluation of
Baldwin’s subjective complaints is unsupported by substantial evidence or controlled by an error of
law. See Craig, 76 F.3d at 589 (defining “substantial evidence” as “such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere
scintilla of evidence but may be somewhat less than a preponderance” and stating that the court may
not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its]
judgment for that of the [Commissioner]”); Blalock, 483 F.2d at 775 (indicating that regardless of
whether the court agrees or disagrees with the Commissioner’s decision, the court must uphold it if
it is supported by substantial evidence). Baldwin has failed to demonstrate that the ALJ failed to
properly apply the relevant factors in evaluating her subjective complaints. See 20 C.F.R.
Moreover, the court observes that the ALJ found there was objective evidence only as to
some of the alleged symptoms.
Page 18 of 20
§ 404.1529(c)(3). Further, while Baldwin may point to selective medical evidence in the record in
support of her argument, such evidence does not render the ALJ’s decision unsupported. Even
accepting Baldwin’s arguments as true, the court finds that her arguments do not render the ALJ’s
decision unsupported in light of all the reasons offered by the ALJ. Thus, as stated above, the court
may not substitute its judgment for the Commissioner’s and finds that the ALJ’s conclusions are
within the bounds of the substantial evidence standard. See Craig, 76 F.3d at 595 (stating that a
claimant’s subjective complaints of pain itself or its severity “need not be accepted to the extent they
are inconsistent with the available evidence, including objective evidence of the underlying
impairment, and the extent to which that impairment can reasonably be expected to cause the
[symptoms] the claimant alleges she suffers”); see also Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir.
1993) (per curiam) (finding that the ALJ may properly consider inconsistencies between a plaintiff’s
testimony and the other evidence of record in evaluating the credibility of the plaintiff’s subjective
Residual Functional Capacity
Finally, Baldwin argues that the ALJ failed to sufficiently explain the residual functional
capacity as required by SSR 96-8p and failed to engage in a function-by-function assessment of
Baldwin’s capacities as required by SSR 96-9p. A claimant’s residual functional capacity is “the
most [a claimant] can still do despite [her] limitations” and is determined by assessing all of the
relevant evidence in the case record. 20 C.F.R. § 404.1545(a)(1). In assessing residual functional
capacity, an ALJ should scrutinize “all of the relevant medical and other evidence.” 20 C.F.R.
§ 404.1545(a)(3). Social Security Ruling 96-8p further requires an ALJ to reference the evidence
supporting his conclusions with respect to a claimant’s residual functional capacity.
Page 19 of 20
Much of Baldwin’s argument hinges on her subjective complaints which were discounted
by the ALJ, and for the reasons discussed above, Baldwin has failed to demonstrate any reversible
error by the ALJ in evaluating her subjective complaints. Moreover, review of the ALJ’s opinion
as a whole reflects that he sufficiently explained Baldwin’s residual functional capacity assessment
and the basis for the limitations and restrictions included. Similarly, the court finds unavailing
Baldwin’s argument that the ALJ erred in failing to perform a function-by-function analysis in
determining Baldwin’s RFC. Cf. Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (holding that
“remand may be appropriate . . . where an ALJ fails to assess a claimant’s capacity to perform
relevant functions, despite contradictory evidence in the record, or where other inadequacies in the
ALJ’s analysis frustrate meaningful review”) (quoting Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir.
2013)) (alterations in original). Baldwin has failed to point to contradictory evidence in the record
or other inadequacies in the ALJ’s analysis that frustrate meaningful review such that remand would
For the foregoing reasons, the court finds that Baldwin has not shown that the
Commissioner’s decision was unsupported by substantial evidence or reached through application
of an incorrect legal standard. See Craig, 76 F.3d at 589; see also 42 U.S.C. § 405(g); Coffman, 829
F.2d at 517. Therefore, it is hereby
ORDERED that the Commissioner’s decision is affirmed.
IT IS SO ORDERED.
April 24, 2017
Columbia, South Carolina
Paige J. Gossett
UNITED STATES MAGISTRATE JUDGE
Page 20 of 20
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