Crocker v. Colvin

Filing 24

MEMORANDUM OPINION re: Cross-motions for summary judgment. Signed by Magistrate Judge John F. Anderson on 04/21/16. (pmil, )

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF VIRGINIA
Alexandria Division
SHIRLEY L. CROCKER,

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Plaintiff,

v.

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)
)

CAROLYN W. COLVIN,
Acting Commissioner,
Social Security Administration,
Defendant.

Civil Action No. 1:15cv1215 (JFA)

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)
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)

MEMORANDUM OPINION
This matter is before the court on cross-motions for summary judgment. Plaintiff seeks
judicial review of the final decision of Carolyn W. Colvin, Acting Commissioner of the Social
Security Administration ("Commissioner"), denying plaintiffs claim for Disability Insurance
Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the
Social Security Act. See 42 U.S.C. §§ 423, 1382. The Commissioner's final decision is based
on a finding by the Administrative Law Judge ("ALJ'') and Appeals Council for the Office of
Disability Adjudication and Review ("Appeals Council") that claimant was not disabled as
defined by the Social Security Act and applicable regulations. 1
On January 28, 2016, plaintiff filed a motion for summary judgment (Docket no. 14) and
memorandum in support (Docket no. 15). Thereafter, the Commissioner submitted a crossmotion for summary judgment (Docket no. 16), memorandum in support (Docket no. 17), and

1

The Administrative Record ("AR") in this case has been filed under seal, pursuant to Local Civil Rules 5
and 7(C). (Docket no. I 0). In accordance with those rules, this opinion excludes any personal identifiers such as
plaintiff's social security number and date of birth (except for the year of birth), and the discussion ofplaintifrs
medical information is limited to the extent necessary to analyze the case.

1

memorandum in opposition (Docket no. 18). The two briefs submitted on behalf of the
Commissioner are identical. (Docket nos. 17, 18). Plaintiff submitted her reply brief on March
11, 2016. (Docket no. 22). For the reasons set forth below, plaintiffs motion for summary
judgment (Docket no. 14) will be denied; the Commissioner's cross-motion for summary
judgment (Docket no. 16) will be granted; and the Commissioner's final decision will be
affirmed.

I. PROCEDURAL BACKGROUND
Plaintiff applied for DIB and SSI on February 13, 2012 and February 28, 2012,
respectively, with an alleged onset date of November 17, 2009. (AR 78-79, 180-92). The
Social Security Administration denied plaintiffs claims initially (AR 57-79, 114-35) and on
reconsideration (AR 80-109, 138-51 ). After receiving the notices of denial, plaintiff requested a
hearing before an ALJ. 2 (AR 152-53). The Office of Disability Adjudication and Review
acknowledged receipt of plaintiffs request (AR 154-58) and scheduled the matter for a hearing
on April 21, 2014.
On April 21, 2014, ALJ Timothy Wing held a telephonic hearing in Wilkes Barre,
Pennsylvania. (AR 28). Plaintiff appeared telephonically with her representative Megan
Dawson. 3 (Id). On June 9, 2014, the ALJ issued a decision denying plaintiffs claims for
disability under the Social Security Act. (AR 10-22). In reaching this decision, the ALJ
2

On February 14, 2012, plaintiff signed a form entitled "Appointment of Representative," authorizing Brad
Myler to act on her behalf with respect to her asserted claims. (AR 113). On February 27, 2012, plaintiff signed
another fonn entitled "Appointment of Representative," authorizing Thomas Klint to act on plaintifrs behalf with
respect to her asserted claims. (AR 111 ). Both fonns appear to authorize the respective representative to be
plaintifrs primary representative. Plaintifrs initial request for reconsideration, dated June 12, 2012, indicated that
she was represented by Brad Myler. (AR 136-37). Thereafter, plaintiff filed a "Request for Hearing by
Administrative Law Judge" on November 8, 2012, indicating that she was represented by Thomas Klint. (AR 15253). On February 13, 2014, plaintiff signed a fonn entitled "Appointment of Representative," authorizing Howard
Olinsky to act on plaintifrs behalf with respect to her asserted claims. (AR 269). This form represented that Brad
Myler continued to be plaintiffs main representative. (Id).
3
On April 4, 2014, plaintiff signed another form entitled "Appointment of Representative," authorizing
Megan Dawson to act on her behalf. (AR 179). On this form, plaintiff indicated that Brad Myler was her main
representative. (Id).

2

concluded that plaintiff was not disabled under either Title II (sections 216(i) and 223(d)) or
Title XVI (section 1614(a)(3)(A)) of the Social Security Act.
On July 9, 2014, plaintiff filed a request for review with the Appeals Council. (AR 8-9).
On July 28, 2014, the Appeals Council granted plaintiff's request for more time to provide
additional information or argument. (AR 6-7). On August 18, 2014, plaintiff provided a brief
on her behalf to the Appeals Council, objecting on a number of grounds to the ALJ's decision.
(AR 264-68). On July 23, 2015, the Appeals Council denied plaintiffs request for review. (AR
1-5). As a result, the decision rendered by the ALJ became the final decision of the
Commissioner. See 20 C.F.R. §§ 404.981, 416.1481.
On September 23, 2015, plaintiff filed a complaint in the U.S. District Court for the
Eastern District of Virginia, seeking judicial review pursuant to 42 U.S.C. § 405(g). (Docket no.
I). Thereafter, the parties agreed to refer this matter to the undersigned magistrate judge for
resolution. (Docket no. 23). This case is now before the court on cross-motions for summary
judgment. (Docket nos. 14, 16).

II. STANDARD OF REVIEW
Under the Social Security Act, the court's review of the Commissioner's final decision is
limited to determining whether the decision was supported by substantial evidence in the record
and whether the correct legal standard was applied in evaluating the evidence. See 42 U.S.C. §
405(g); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). Substantial evidence means
"such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."

Hays, 907 F.2d at 1456 (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). While the
standard is high, where the ALJ's determination is not supported by substantial evidence on the

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record, or where the ALJ has made an error of law, the district court must reverse the decision.

See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
In determining whether the Commissioner's decision is supported by substantial
evidence, the court must examine the record as a whole, but may not "undertake to re-weigh the
conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the
Secretary." Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (alteration in original) (citing

Craig v. Chafer, 76 F.3d 585, 589 (4th Cir. 1996)). The Commissioner's findings as to any fact,
if the findings are supported by substantial evidence, are conclusive and must be affirmed. See

Perales, 402 U.S. at 390. Moreover, the Commissioner is charged with evaluating the medical
evidence and assessing symptoms, signs, and medical findings to determine the functional
capacity of the claimant. See Hays, 907 F.2d at 1456-57. Overall, if the Commissioner's
resolution of conflicts in the evidence is supported by substantial evidence, the district court
must affirm the decision. See Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966).

III. FACTUAL BACKGROUND
A.

Plaintiffs Age, Education, and Employment History

Plaintiff was born in 1962 and was fifty-one years old at the time of the ALJ's decision.
(AR 20, 22, 180). Plaintiff left school in 1976, having completed the eighth grade (AR 217), her
highest level of schooling (AR 36). Plaintiff reports that she did not complete any additional
training or specialized schooling. (AR 217). Plaintiff identifies working as a feeder on a pig
farm from the summer of 1995 through the winter of 1996, from 1998 through 1999, and again
from March 2005 through January 2006. (AR 205, 257). Subsequently, plaintiff identifies
working in a warehouse as a packager from September 2006 through December 2006, September
2007 through January 2008, September 2008 through January 2009, and September 2009

4

through November 2009. 4 (AR 205, 258). Plaintiff's last day of employment was November 6,
2009. (AR 257).
Plaintiff currently resides in Virginia with her husband and grandson. (AR 37).

B.

Summary of Plaintiffs Medical History 5

Plaintiff's submitted medical records contain treatment notes beginning in 2009. (AR
456). On February 9, 2009, plaintiff presented at the Horizon Health Services, Waverly Medical
Center ("Waverly Medical Center") for a refill of her blood pressure medication. (Id). Plaintiff
indicated that she was doing well and had no complaints of shortness of breath, chest pain,
dizziness, or headaches. Plaintiff stated that she was taking her medications as prescribed, but
continued to have some arthritic pain in her hands and knees. (Id.). Treatment notes indicate
that plaintiff had a history of rheumatoid arthritis and was having some stiffness and pain. (Id).
Further, plaintiff indicated that she was concerned about her right thumb because it was very
swollen and painful. (Id). Plaintiff stated that naproxen works well for her arthritis, but that the
medication can upset her stomach. (Id). Finally, plaintiff indicated that her blood pressure
medication did not cause her to experience any side effects. (Id.). Valeri L. Jaskowski, N.P.
("Nurse Jaskowski") examined plaintiff and indicated that her right thumb was very swollen on
the first and second joint, was warm to the touch, red, tender, and had limited range-of-motion
due to pain and swelling. (AR 457). Nurse Jaskowski assessed the plaintiff with benign
hypertension and rheumatoid arthritis and recommended that plaintiff continue amlodipine and
4

The AR contains differing dates for when plaintiff was employed as a feeder and packager. The
Disability Report identifies that plaintiff was employed as a feeder from January 1997 through January 1998 and as
a packager from January 2000 through November 2009. (AR 217). However, plaintiff also identifies that she
worked as a feeder from March 2005 through January 2006 and as a packager from September 2007 through
January 2008, September 2008 through January 2009, and September 2009 through November 2009. (AR 205).
The dates contained in this opinion appear to be the most consistent dates identified by plaintiff.
5
The AR contains approximately 470 pages of medical records from various sources relating to plaintiff's
medical treatments. This summary provides un overview ofplaintltrs medical treatments and cundiliuns relevant to
her claims and is not intended to be an exhaustive list of each and every medical treatment.

5

captopril for her hypertension and that she continue taking Tylenol and Ultram, stop naproxen,
and start prednisone to treat her rheumatoid arthritis. (Id). Nurse Jaskowski recommended that
plaintiff follow up in four months with George C. Coleman, MD ("Dr. Coleman") for routine
follow-up regarding her hypertension. (Id).
On November 6, 2009, plaintiff sought treatment at Sentara Obici Hospital ("Sentara
Obici") in Suffolk, Virginia for significant rectal bleeding and was transferred and admitted to
Sentara Norfolk General Hospital ("Sentara Norfolk") in Norfolk, Virginia. (AR 546). Plaintiff
underwent a bleeding scan upon arrival, which showed a source of the bleeding in her right
colon. (AR 556). The bleeding appeared to resolve itself. (Id). However, on plaintiffs third
into fourth day at Sentara Norfolk, she developed further rectal bleeding. (Id.). After additional
testing, an embolization angiography was performed, after which, plaintiffs bleeding appeared
to again resolve. (Id.). Plaintiff was discharged on November 13, 2009 with no activity
restrictions and with directions to follow up with her primary-care provider. 6 (AR 558).
Plaintiff next followed up with Dr. Coleman at Waverly Medical Center on January 6,
2010. (AR 459). Plaintiff represented to Dr. Coleman that she was not taking her prescribed
medications because she had none, but did indicate that she was exercising one to three times per
week. (Id.). Dr. Coleman assessed that the plaintiff was continuing to suffer from hypertensive
disease and had an acute respiratory infection at multiple sites. (Id). Dr. Coleman prescribed a
treatment regime of Lisinopril for plaintiffs hypertension and medication for plaintiffs
respiratory infection. (AR 459-60). Treatment notes also indicate an order to stop taking
captopril, prednisone, Ultram, Tylenol, and amlodipine, and finally, to follow up in four months.
(AR 460). Following additional testing, Dr. Coleman indicated that plaintiffs lipid panel was

6
Plaintiff claims that she became unable to work due to her disabling condition on November 17, 2009.
(AR 180, 184).

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okay and indicated that plaintiff should adhere to a heart-healthy diet and be as physically active
as she could be, that plaintiffs blood count showed no anemia, and that plaintiffs blood
chemistry was okay. (AR 462-63).
A little over six months later, plaintiff followed up with Dr. Coleman at Waverly Medical
Center on July 20, 2010. (AR 461). Plaintiff reported that she was taking her medicationsLisinopril and cough and cold medications-as prescribed and reported that she checks her blood
pressure at home once per day. (Id.). Plaintiff also reported that she was engaging in exercise
and physical activity five times per week. (Id.). Dr. Coleman assessed plaintiff with
hypertensive disease, gastrointestinal vessel anomaly ("GV A"), and menopausal and
postmenopausal disorder ("MPD"), and indicated that plaintiff should continue Lisinopril for her
hypertension and ordered lab work to assess plaintiffs OVA and MPD. (AR 463). Dr. Coleman
also indicated that plaintiff should stop taking the cough and cold medications and that plaintiff
would be next due for a routine follow-up visit in January 2011. (Id).
Plaintiff appeared at her follow-up appointment with Dr. Coleman on January 21, 2011.
(AR 468). Plaintiff reported that she was doing well and that she exercised at home using a
stationary bike and treadmill, but that she did not do so regularly. (Id). Treatment notes further
indicate that plaintiff reported no problems with her knees or back. (Id.). Plaintiff reported that
she continued to take Lisinopril for hypertension. (Id). A physical examination indicated that
plaintiff experienced some pain when her hip was moved into a flexion position, but none when
the hip joint was rotated-the range of motion was full. (AR 469). Plaintiff also did not report
any pain upon examination of her knees. (Id.). Dr. Coleman assessed plaintiff as having
hypertension and benign neoplasm large bowel, and treatment notes indicate that Lisinopril was
to be refilled and a basic metabolic panel, cholestech lipid, and cholestech ALT/AST labs were

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run. (AR 470). Also listed under "treatment" was information regarding exercising at a training
heart rate of 65-75% of plaintiff's maximum heart rate. (Id). Plaintiff was advised to return in
May 2011 for a routine follow-up appointment.
Plaintiff next followed up with Waverly Medical Center for hypertension on July 8, 2011.
(AR 4 72). Plaintiff reported that she was doing very well and was going to a gym, which
seemed to help with stress and controlling her hypertension. (Id.). Plaintiff complained,
however, of a very heavy menstrual cycle, which left her with significantly decreased energy
upon occurrence. (Id). Plaintiff also indicated that she was taking Lisinopril and a
multivitamin. (Id.). Dr. Coleman described plaintiff as well-appearing. (AR 473). Dr. Coleman
assessed plaintiff as continuing to suffer from hypertension and refilled her Lisinopril
prescription and also ordered a metabolic panel. (AR 474). Plaintiff and Dr. Coleman also
discussed the issues concerning her menstrual cycle, and Dr. Coleman indicated that they should
be evaluated. To that end, plaintiff indicated she preferred to have her follow-up with Sussex
Health Department and would make an appointment. (Id). Plaintiff was again advised to return
in six months for a follow-up appointment.
Plaintiff next presented at the Waverly Medical Center on October 24, 2011 for pain in
her right foot. {AR 475). Plaintiff indicated that when she was playing with children in July
2011, she stepped in a hole and twisted her ankle. (Id.). Lois Brown, N.P. ("Nurse Brown")
examined plaintiff and advised that she should start taking Naprosyn for her ankle pain, have
varying labs drawn, and have an x-ray taken of her right foot. (AR 476). An x-ray of plaintiffs
right foot was negative for fracture or dislocation and showed minimal hallux valgus of the great
toe and degenerative plantar calcaneal spurring, but was otherwise normal. (AR 645).

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On November 13, 2011, plaintiff presented at Sentara Norfolk Emergency Department
with rectal bleeding and was admitted that day. (AR 570). Plaintiff underwent a colonoscopy,
which found pancolonic diverticulosis with an active bleed in the ascending colon. (AR 571).
Plaintiff reported that she had no prior instances of rectal bleeding between her prior 2009
hospital admittance and this occasion. (AR 594). Plaintiff was treated with an epinephrine
injection and two clips. (AR 571 ). Plaintiff also began to experience heavy menstrual bleeding
during her hospital admission, and as a result, her hemoglobin and hematocrit levels were
monitored. (Id.). Plaintiff indicated that she was short of breath and had experienced shortness
of breath upon exertion over the past two years. (Id.). Plaintiff was transfused three units of
packed red-blood cells, which improved her hemoglobin and hematocrit levels and overall
symptoms. (Id.). Electrocardiogram and echocardiogram tests were benign. (Id). On
November 18, 2011, plaintiff was discharged following normal bowel movements and the
absence of any bleeding or symptomatic anemia. (Id.). Plaintiff was advised about a high-fiber
diet and a healthy lifestyle and was told to follow up with Dr. Coleman in two weeks. (Id.).
Plaintiff was not put on any activity restrictions upon discharge (AR 573), but was advised to
start taking omeprazole, along with continued use of Tylenol and Lisinopril {AR 628).
Plaintiff presented at Waverly Medical Center on December 8, 2011 for a follow-up visit.
(AR 4 78). Nurse Brown examined plaintiff. Plaintiff stated that she felt fine, but that she tires
quickly and always feels tired. (Id.). Nurse Brown indicated that plaintiff had no dyspnea on
exertion and no shortness of breath. (Id.). Plaintiff identified that she was taking a multivitamin,
Lisinopril, omeprazole, and Tylenol arthritis. (Id). Nurse Brown assessed plaintiff as suffering
from anemia due to acute blood loss, gastrointestinal vessel anomaly, hypertensive disease, and
menometrorrhagia. (AR 479). Nurse Brown's plan to treat these ailments included plaintiff

9

starting ferrous sulfate tablets and vitamin C and continuing to take a multivitamin to treat
plaintiffs anemia, continue omeprazole to treat plaintiffs gastrointestinal vessel anomaly,
continue Lisinopril to treat plaintiffs hypertensive disease, and a referral to a gynecologist to
treat plaintiffs menometrorrhagia. (Id). Plaintiff was to follow up in one week, which she did
on December 15, 2011. (AR 481). On that date, plaintiff again indicated that she was feeling
very fatigued and that her menstrual cycle came on when she was stressed and ceased when she
rested. (Id.). Nurse Brown assessed plaintiff as again suffering from anemia due to acute blood
loss, and ordered that she continue taking ferrous sulfate tablets, Vitamin C, and a multivitamin
with folic acid. (AR 482). Nurse Brown indicated that plaintiff should continue taking
Lisinopril and follow up in four weeks. (Id).
On January 23, 2012, plaintiff presented at Waverly Medical Center for her four-week
follow-up. (AR 483). She reported that she was a little off balance and that after sitting for a
while, she is unsteady on her feet upon standing. (Id.). Plaintiff indicated that these symptoms
had been present since she left the hospital in November 2011. Again, a review of plaintiffs
symptoms revealed no dyspnea on exertion and no shortness of breath. (Id.). Nurse Brown
assessed plaintiff as continuing to suffer from anemia due to acute blood loss and hypertensive
disease and ordered that a complete blood count ("CBC") with differential be performed on
plaintiff. (AR 484). Plaintiff was to follow up in two months.
Two months later, on March 19, 2012, plaintiff presented at Waverly Medical Center for
her follow-up. (AR 485). Plaintiff indicated that she was experiencing numbness and tingling in
her left hand, had been having shortness of breath and palpitations on and off since 2009, and
finally, had been under a lot of stress over the last month. (Id). A physical examination by
Nurse Brown identified that plaintiff had a full range of motion without pain in her back and

IO

spine. (AR 486). Plaintiff also had a full range of motion throughout her upper- and lowerextremity joints. (Id). Plaintiffs gait was also normal. (Id.). Nurse Brown assessed that
plaintiff had anemia due to acute blood loss, hypertensive disease, tingling in extremities,
palpitations, edema, and anxiety. (Id.). Nurse Brown ordered various blood-work labs, as well
as a referral to neurology for the numbness in plaintiffs left side. (AR 486-87). Plaintiff was
also referred to counseling services for anxiety and ordered to return for a follow-up in two
months. (AR 487).
Also on March 19, 2012, Nurse Brown completed a "residual functional capacity
questionnaire. " 7 (AR 270). In this questionnaire, Nurse Brown identified that plaintiff suffered
from palpitations, numbness, tingling, and edema. (Id.). Nurse Brown opined, inter alia, that
plaintiff could walk less than one city block without rest or significant pain; could sit for 60
minutes at a time; could stand/walk for 15 minutes at a time; could sit for eight hours a day; and
stand/walk for four hours a day. (Id.). Nurse Brown also opined that plaintiff could occasionally
lift and carry less than 10 pounds, but never 20 pounds. (AR 271). She also identified that
plaintiff could use her right hand, right-hand fingers, and right arm for 100% of an eight-hour
workday for grasping, turning, and twisting objects; fine manipulation; and reaching,
respectively. She identified, however, that plaintiff could only use her left hand, left-hand
fingers, and left arm for 10% of the time during an eight-hour workday for the same categories of
function. (Id). Also, Nurse Brown concluded that plaintiff was likely to be absent from work
more than four times per month as a result of her impairments. (Id). Plaintiff was also
identified as needing a psychological evaluation. (Id.).

7

All the medical records from Waverly Medical Center preceding this visit identified plaintiff's occupation
as a homemaker and contained no restrictions on her daily activity.

11

On March 22, 2012, plaintiff sought treatment at Central Virginia Health Services
("CVHS") after being referred for psychological services. (AR 275). Plaintiffs Lisinopril was
increased to 20 mg per day and she was given a prescription for Celexa for depression, as well as
trazodone for insomnia. (275-76). A physical examination showed that plaintiff had a full range
of motion in her back and a straight-leg raise was negative. (AR 275).
On March 29, 2012, plaintiff presented at VCU Medical Center ("VCU") in Richmond,
Virginia for menometrorrhagia. (AR 311 ). An endometrial biopsy was performed (AR 299) and
was negative for endometrial cancer (AR 297). Plaintiff was started on Provera for the first ten
days of the month and blood work was also ordered. (AR 311). A physical exam showed a
normal range of motion and strength in plaintiffs musculoskeletal system. (Id.). Plaintiff
followed-up with VCU on April 19, 2012 and reported that she was doing well, with much
improvement and minimal bleeding. (AR 294, 297).
On May 3, 2012, plaintiff presented for follow-up treatment at CVHS for hypertension
and depression. (AR 272). Plaintiff indicated that she had been compliant in taking her
medications and that she had no chest pain, shortness of breath, or dizziness. (Id.). Plaintiff also
reported that she had no numbness or tingling of lower extremities. (Id). Plaintiff also stated
that the joint pain she experiences in the morning in her hands and knees had gotten worse and
indicated that when she rests, the pain resolves, but exacerbates with activities throughout the
day. (Id.). Plaintiff finally reported that she takes Tylenol arthritis, but had not currently found
any and that her insomnia had improved. (Id.). A physical examination indicated that plaintiff
had a full range of motion in her back and in her knees, with no edema. (Id). Plaintiff also had
a full range of motion in her wrists, which were nontender on palpation. (Id.). Treatment notes
indicate that plaintiff's hypertension was stable with her current medication and that she was to

12

monitor the amount of salt in her diet and exercise as tolerated. (Id). Plaintiff was also to
continue her current medication for insomnia and was given a trial of diclofenac for her joint
pain. (Id.). Finally, plaintiff identified that her depression was much improved, and treatment
notes indicate that she was to continue with her current medications. (AR 273).
On May 18, 2012, plaintiff presented at VCU for her annual exam. (AR 288). She
represented that she was doing well and that her bleeding had greatly improved. (AR 285, 288).
Treatment notes indicate that plaintiff's hypertension was controlled with Lisinopril, her diabetes
was controlled with diet, her gastro-esophageal reflux was controlled with omeprazole, and her
diverticulosis was stable. (AR 288).
On May 30, 2012, plaintiff followed up with Nurse Brown at Waverly Medical Center.
(AR 488). Nurse Brown's progress notes indicate that plaintiff complained of right-hand pain
that had been present for one week. (Id.). Plaintiff stated that for three days, she could not close
her hand and that the pain radiates up her right arm to her head. She also indicated that she used
an arm brace to help with the discomfort and had been taking Tylenol arthritis and diclofenac,
which helped somewhat with the pain. (Id). Nurse Brown's physical examination showed that
plaintiff had a limited range of motion with pain on left lateral bending and flexion and the right
side of her back was tender to palpation. (489). Nurse Brown assessed plaintiff with neck pain
and numbness and tingling in her right hand and indicated that plaintiff should begin taking
Flexeril and undergo an x-ray of her spine and back. (Id.).
The following day, May 31, 2012, plaintiff underwent an x-ray of her spine. (AR 315,
539). The x-ray showed "no malalignment" and "[n)o fracture." (AR 315, 539). The x-ray
report further identified that "[t)here are prominent partially bridging anterior osteophytes at C5C-6" and "mild disc narrowing at C5-C6." (AR 315, 539). Also, the report stated that "[t)he

13

neural forarnina are patent," "[f]acetjoints are maintained," and "[t]he odontoid is normal." (AR
315, 539). The overall impression showed "[c ]ervical spondylosis with mild disc narrowing at
C5-C6." (AR 315, 539).
Dr. Coleman's progress notes indicate that plaintiff next followed up at Waverly Medical
Center on June 8, 2012 for her hypertension and anemia. (AR 491). Plaintiff indicated that she
was taking her medications as prescribed. Dr. Coleman's physical examination does not appear
to note any abnormal findings; Dr. Coleman noted that plaintiff was well-appearing. (AR 493).
Dr. Coleman assessed plaintiff as continuing to have hypertensive disease, anemia due to acute
blood loss, gastrointestinal vessel anomaly, and anxiety associated with depression. (Id.).
Plaintiff was instructed to continue taking 20 mg of hydrochlorothiazide-lisinopril, omeprazole,
trazadone, diclofenac enteric, medroxyprogesterone, cyclobenzaprine, and additional blood work
was ordered. (493-94). Plaintiff was further instructed to stop taking Flexeril and the lower
dose of Lisinopril. (Id.).
Plaintiff next sought treatment from Waverly Medical Center on June 28, 2012. (AR
495). Nurse Brown's treatment notes indicate that plaintiff presented for right-hand pain that
had been present since May 2012 and indicated that pain radiates from her finger tips to her right
shoulder, back of neck. (Id). Plaintiff further indicated that neck exercises help, but the pain
returns. Nurse Brown assessed plaintiff as having arm pain, weakness of muscles, gait
abnormality, spondylosis, and numbness and tingling of her right arm. (AR 496). Nurse Brown
instructed that diagnostic imaging, consisting of an EMO, electromyogram, and nerve
conduction study, be conducted for plaintiff's weakness of muscles. Nurse Brown further
instructed plaintiff to begin using a cane as directed and have a CT scan conducted of her head,
with and without contrast. (Id.).

14

A CT scan was performed on June 29, 2012 by Southside Regional Medical Center
("SRMC"). (AR 321, 540). The report indicates that "axial images from the skull base to the
vertex were obtained prior to and following intravenous contrast administration." The
impression notes that there was a "[s]ubtle area of low density in the left parietal lobe deep to the
gray matter. This could be artefactual. Possibility of old ischemia cannot be excluded. A mass
is felt to be less likely. Recommend follow[-]up as clinically warranted." (AR 321, 540-41).
Plaintiff next presented at Waverly Medical Center on July 9, 2012 for right-arm pain and
numbness. (AR 498). Plaintiff identified that she had some paresthesia on the right side of her
face, but that it had resolved. (Id). She also identified that she had chronic intermittent
weakness in her legs. (Id). Dr. Coleman assessed that plaintiff should have an MRI done of her
brain, with and without contrast, to assess the right-sided muscle weakness. (AR 500). Dr.
Coleman also indicated, after conducting a Phalen's sign test that was positive, that findings
suggested that plaintiff had carpal tunnel syndrome, but this was uncertain. (Id). He further
instructed plaintiff to start taking aspirin, as well as continuing her other medications. (Id).
On July 10, 2012, plaintiff underwent a nerve-conduction study at SRMS. (AR 319,
529-30, 534--35). The report indicated that plaintiffs study was "normal." (AR 319, 529-30).
On July 19, 2012, plaintiff also underwent an MRI. (AR 322, 528, 533). The report
noted that it was a "normal exam" and identified plaintiff as suffering from chronic pansinusitis.
(AR 322, 528, 533).
On August 1, 2012, plaintiff was seen by Dr. Pavani Guntur ("Dr. Guntur") at VCU
Health System, Neurology ("VCU Neurology") in Richmond, Virginia. (AR 429-32). Dr.
Guntur reviewed plaintiffs MRI and nerve-conduction study. (AR 432). Dr. Guntur assessed
plaintiff as having "peripheral neuropathy ... in the setting of longstanding [diabetes mellitus]

15

with diet control" and indicated that an EMO of plaintiff's lower extremities would be beneficial.
(Id). Dr. Guntur's attending physician, Dr. James Bennett, assessed that plaintiff "likely has

non-painful diabetic neuropathy" and agreed with the ordering of an EMG. (AR 428).
On August 10, 2012, plaintiff was seen by Dr. Sari Eapen ("Dr. Eapen"), at the request of
the Virginia Department of Rehabilitative Services, for a complete medical evaluation "due to
rheumatoid arthritis, carpal tunnel [syndrome], diabetes[,] and hypertension." (AR 324). A
physical examination revealed, inter a/ia, that plaintiff had "[f]ull range of motion of the cervical
spine, both shoulders, elbows[,] and wrists. Grip strength 4/5 on right, 515 on left side. Tinel
sign negative at right wrist for median nerve. Phalen['s] sign negative on right." (AR 326). The
examination also indicated that plaintiff had "[n]o apparent hand muscle wasting. She is able to
make almost a complete fist." (AR 326). Additionally, Dr. Eapen found:
Examination of the lumbosacral spine and lower extremities, full range of motion
of the lumbosacral spine. Able to bend forward and touch the toes. Full range of
motion in both hips, knees and ankles. Straight leg raising negative in both lower
extremities. Muscle extensor and flexors are active and symmetrical in both
upper and lower extremities. Coordination is intact finger-to-nose and heel-toknee bilaterally. She was able to take a few steps on toes and on heels. Tandem
walking is normal. She is able to stand on each leg.
Peripheral joint evaluation without any evidence of active joint
inflammation.
(Id). Dr. Eapen's impressions were generalized arthralgia, right-hand pain and paresthesias, and

hypertension. (Id.). After performing this evaluation, Dr. Eapen concluded that plaintiff"should
be able to sit, stand[,] and walk without limitations. She should be able to do occasional
kneeling and crouching. She should be able to bend, lift[,] and carry objects weighing 15 pounds
frequently, 25 pounds occasionally. She should be able to do reaching, handling, feeling,
grasping[,] and fingering without limitations." (AR 327).

16

On August 12, 2012, plaintiff presented at the Sentara Obici Emergency Department with
intermittent lower, left-sided abdominal cramps. (AR 338). Plaintiff indicated that she was not
experiencing any nausea, vomiting, fevers, chills, or sweats. (AR 335). Plaintiff underwent CT
scans of her abdomen and pelvis on August 12 and 14, 2012, which identified that she was
suffering from diverticulitis with micro-perforation. (AR 342-43, 345-46). Plaintiff was
advised to discontinue taking diclofenac. (AR 335). Hospital records indicate that plaintiff had
gradual improvement, but with continuing discomfort. (Id.). She was discharged on August 16,
2012 with a full liquid diet, Avelox, and Flagyl and was advised to follow up with Dr. Matthew
McBee at Sentara Obici for a follow-up CT scan. (AR 333-35). Treatment notes indicate that
plaintiff followed-up with Dr. McBee on August 20, 2012, who assessed that plaintiff had
diverticulitis of the colon, but provided no additional details. (AR 330).
On September 7, 2012, plaintiff presented at the Waverly Medical Center for a follow-up
appointment with Dr. Coleman. (AR 502). Plaintiff indicated that she had completed her
antibiotics and that she had changed her diet radically, primarily eating fruits and vegetables in
puree form as compared to animal fat and fried foods. (Id). Plaintiff indicated that she was not
having any abdominal pain. (Id.). Plaintiff also advised that she was scheduled for surgery at
Sentara Norfolk for a segmental colon resection on September 25, 2012. (Id.). Dr. Coleman's
treatment notes also indicate that plaintiff complained of trigger-finger problems affecting her
fourth and fifth fingers of her right hand, but that plaintiff believed this issue to be a low priority
considering her current situation. (Id). Dr. Coleman assessed plaintiff as suffering from
diverticulitis of the large intestine, hypertensive disease, and anxiety associated with depression.
(AR 504). Plaintiff was advised to continue her medications for hypertension (aspirin and

17

hydrochlorothiazide-lisinopril) and anxiety (citalopram and trazodone) and also continue taking
omeprazole, but was instructed to discontinue all others. (Id).
Plaintiff again presented at the Sentara Norfolk Emergency Department on the morning
of September 11, 2012 with complaints of abdominal pain. (AR 352-53). Plaintiffs abdomen
was soft and tender to palpation. (AR 364). During the afternoon of September 11, 2012,
plaintiff indicated that she had no further complaints of abdominal pain. (AR 363). Plaintiffs
abdominal CT scan was negative for any acute process, and plaintiff experienced no tenderness
during a physical exam of her abdomen. (AR 354). Plaintiff was discharged that same day with
no pain being experienced. (Id). The following day, September 12, 2012, plaintiff followed-up
with Nurse Brown at Waverly Medical Center. (AR 508). Plaintiff indicated that she was to
undergo a left colectomy on September 25, 2012. (Id). Nurse Brown advised plaintiff to follow
up with her planned surgery and follow up as necessary. (AR 509).
On October 6, 2012, plaintiff presented at the Sentara Norfolk Emergency Department
with left-flank and lower-left quadrant pain. (AR 380). Plaintiff complained that the left flank
paid was intermittent and had been present for the prior three days. (Id). A physical
examination indicated that plaintiffs abdomen was tender to palpation. (AR 379). Plaintiff also
underwent a CT scan of her abdomen. After experiencing no pain later in the evening, plaintiff
was discharged. (AR 378). Treatment notes indicate that plaintiff was to have surgery the
upcoming week for diverticulitis. (AR 380).
On November 29, 2012, plaintiff underwent an additional EMG study. (AR 408). Dr.
Binod Wagle indicated that it was "a normal electrophysiologic study of bilateral lower
extremities with no evidence of a large fiber neuropathy. However, a small fiber neuropathy

18

cannot be excluded." (AR 414). The report indicated that "[c]linical correlation is advised."
(Id).

On December 13, 2012, plaintiff again presented at Waverly Medical Center. (AR 511).
Nurse Brown's treatment notes indicate that plaintiff was following-up on her "lower
hemicolectomy [with] mobilization of the splenic flexure and primary end-to-end anastomosis at
the level of the rectum" which occurred at Sentara Norfolk two months earlier on October 11,
2012. 8 (AR 511). Plaintiff indicated that she was experiencing lower left-side back pain that
radiates to her left hip that she only feels during activity. Plaintiff indicated that she had been
taking muscle relaxers and pain medications, which help but wear off. (Id). Nurse Brown
started plaintiff on prednisone and directed that she have an x-ray completed of her spine and
lumbosacral, in addition to plaintiff continuing on her other medications for back pack,
hypertension, anxiety, and reflux. (AR 512). On that same day, plaintiff underwent an x-ray of
her back at SRMC. (AR 527, 532). The "[f]ive views of the lumbar spine" indicated "(t]here is
normal alignment of the lumbar vertebral column. There is no lumbar vertebral body
compression deformity. There is no degenerative change of significance." (AR 527, 532).
On January 9, 2013, plaintiff followed up with VCU Neurology. (AR 404-07). Dr.
Alicia M. Zukas ("Dr. Zukas") indicated that plaintiff had clinical signs of peripheral neuropathy
in the setting of her diabetes mellitus. (AR 407). Dr. Zukas prescribed plaintiff gabapentin for
nerve pain. (Id).
On January 10, 2013, plaintiff presented at Waverly Medical Center with complaints of
recurrent low-back pain. (AR 514). Plaintiff indicated that all her pain began after her surgery.
Nurse Brown's treatment notes indicate that plaintiff was instructed to start naproxen tablets, and
was referred to rehabilitation for her back. (AR 515).
8

The AR does not appear to contain treatment notes detailing plaintiff's surgery on October 11, 2012.

19

Plaintiff began physical therapy on January 29, 2013 with Colonial Orthopedics in
Colonial Heights, Virginia. (AR 451-53). Plaintiff identified that she was beginning physical
therapy because of the pain in her back. (AR 451). An initial physical examination by Dr. Jay
Pavan ("Dr. Pavan") noted that plaintiffs lumbar spine had no spinal deformity and there was no
paraspinal spasm. (AR 452). Dr. Pavan indicated that there was tenderness in the lower-lumbar
level, which showed a flexion of the spine up to 60 degrees with pain and an extension past 10
degrees producing pain. (Id.). Plaintiffs toe walking and heel walking were normal and her gait
and station were normal. (Id.). Lumbar spine x-rays performed on January 29, 2013 showed
"diffuse lumbar facet [degenerative joint disease]" and mild lumbar spondylosis, with vertebral
body heights and disc spaces appearing intact. (Id.). Dr. Pavan and the plaintiff considered
activity modification, physical therapy, further imaging studies, medications, injections, and
surgery and, from those, selected a treatment plan that included the plaintiff beginning
meloxicam and physical therapy and stopping naproxen. (Id.).
On March 29, 2013, plaintiff presented at Waverly Medical Center for an evaluation for
disability. (AR 519-21). Dr. Coleman's examination of plaintiff identified that she was
"[o]bese, appears to be in some discomfort," but was in no distress. (AR 521). A
musculoskeletal exam revealed
pain with range of motion of both shoulders, however range of motion is full.
There is tenderness with palpation of the wrists bilaterally, no warmth or synovial
thickening. Wrists and hands are normal to inspection. Phalen's sign is positive
bilaterally at the wrists. Lower extremities reveal pain with flexion of the hip and
knee bilaterally but full range of motion. Normal strength in all extremities.
(Id). After he identified that plaintiff presented for a disability examination, Dr. Coleman then

noted,
Because of her general deconditioning, diffuse chronic pain, [and] carpal tunnel
syndrome[,] she is currently not able to perform his [sic] usual duties at her job.
20

She did not provide me with a job description on paper but this is based on her
verbal description of assignments and of her functional status.

(Id).
On April 25, 2013, plaintiff underwent an MRI of her lower spine without contrast. (AR
731). The study's conclusion was: "Degenerative facetjoint disease L4-L5 and LS-Sl. No disc
herniation or significant central or foraminal stenosis." (Id.).
Plaintiff telephoned Dr. Coleman on May 12, 2013 for "chart review for form
completion." (AR 523). The AR does not appear to contain any form completed by Dr.
Coleman after plaintiffs follow-up telephone call.
On July 31, 2013, plaintiff presented at VCU Neurology for a follow-up visit for
numbness and tingling in her right side. (AR 679). Plaintiff was assessed with clinical signs of
peripheral neuropathy in the setting of longstanding diabetes mellitus with diet control. (AR
700). Based on a normal EMG of plaintiffs lower extremities that showed no evidence of
neuropathy, a recent workup of cord imaging that showed only mild arthritis, and that plaintiffs
symptoms had been stable for years, Dr. Robert M. Baldwin ("Dr. Baldwin") advised plaintiff to
return to the clinic in six months. (AR 701). Dr. Robert J. Delorenzo's ("Dr. Delorenzo")
treatment notes also indicate that a repeat MRI of plaintiffs head in a year was advised. (Id).
Plaintiff attended a physical therapy session with Colonial Orthopedics in November
2013. (AR 724-25). A physical exam on that date identified that plaintiff's lower extremity
strength was normal and her gait was stable. Plaintiff declined facet injections and was to
continue to use her TENS unit, which was helping. (AR 725). She was also advised to continue
her home exercise program. (Id.).
Next, plaintiff followed up with VCU Neurology on February 5, 2014. (AR 649-65).
Plaintiff complained at that visit that the numbness/tingling in her left upper and lower
21

extremities was slowly worsening. (AR 661 ). Treatment notes indicate that plaintiff was
experiencing frequent imbalance and falls. (AR 664). Dr. Baldwin advised that plaintiff should
increase her prescription for gabapentin, be evaluated for physical therapy, and have an MRI of
her cervical spine. (Id.). Drs. Baldwin and Delorenzo assessed that plaintiff had clinical signs of
"peripheral neuropathy [of her lower- and upper-extremities] in the setting of longstanding
diabetes mellitus with diet control." (Id). Treatment notes indicate that an "EMG of [plaintiffs
lower extremities] shows no evidence of neuropathy" and a "[r]ecent workup of cord imaging
showed only mild arthritis." (Id.). Dr. Delorenzo also indicated that plaintiff had "chronic [leftupper extremities and lower-left extremity] sensory changes for over 20 years. No major
changes .... " (Id.).
Nurse Brown completed a "residual functional capacity questionnaire" on February 24,
2014. Nurse Brown identified that plaintiff suffered from neuropathic pain, lumbar and sacral
spondylosis, and arthritis. (AR 703). She furthered identified that plaintiff could only sit for 5
minutes at a time and stand/walk for IO minutes at one time. (Id). Nurse Brown also indicated
that plaintiff could frequently lift and carry less than 10 pounds, but never lift and carry 10
pounds or more. (AR 704). In this questionnaire, she also identified that plaintiff could not use
her right hand, right-hand fingers, and right arm for any percentage of an eight-hour workday,
but could use her left hand, left-hand fingers, and left arm for 25%, 50%, and 50% of an eighthour workday for grasping, turning, and twisting objects; fine manipulation; and reaching,
respectively. (Id).
Plaintiff also underwent physical therapy sessions at Colonial Orthopedics from February
2014 through March 2014 (AR 714-23). On March 13, 2014, plaintiff identified that "[i]t's a lot
better. I can close my hand now. No pain at rest." (AR 716). On that date, plaintiffs left-hand

22

grip was 16 kilograms and her right-hand grip was 9 kilograms. (Id). On March 20, 2014,
plaintiff indicated that "[i]t's doing well. No pain at rest." (AR 715). Treatment notes also
indicated that plaintiff's grip in her right hand was 14 kilograms. (Id.).
On March 21, 2014, plaintiff underwent a stress test due to chest pain. (AR 711). The
stress ECG, perfusion status, attenuation, and LV function were normal. (AR 712). Next, on
March 26, 2014, plaintiff underwent an MRI of her cervical spine without contrast. {AR 707).
The exam findings indicate that plaintiffs vertebral body heights and alignment were within
normal limits, disc spaces were normal in height, and the spinal cord had normal signal
characteristics. The impression of the study was borderline canal stenosis CS-6 and small central
disc protrusion C3-4. (Id.).
On March 27, 2014, her last session at Colonial Orthopedics, plaintiff reported that "[i]t's
all good. No pain at rest." (AR 714). At that time, treatment notes indicate that plaintiff had
completed 4 out of 5 of her therapeutic goals and was ready to be discharged from physical
therapy. (Id.). Plaintiffs right-hand grip was again 14 kilograms. (Id.).

C.

The ALJ's Decision on June 9, 2014

Under 42 U.S.C. §§ 423(d)(5) and 1382c(a)(3)(H)(i), the individual claiming entitlement
to disability benefits has the burden of proving a disability. See Blalock v. Richardson, 483 F.2d
773, 774 (4th Cir. 1972). The Social Security Regulations set forth a five-step sequential
evaluation for the adjudication of disability claims. It is this process the court examines on
appeal to determine whether the correct legal standards were applied and whether the final
decision is supported by substantial evidence. Specifically, the Commissioner must consider
whether a claimant: (I) is currently engaged in substantial gainful employment; (2) has a severe
impairment; (3) has an impairment that meets or equals any of the impairments listed in

23

Appendix 1, Subpart P ofthe regulations that are considered per se disabling; (4) has the ability
to perform her past relevant work; and (5) if unable to return to past relevant work, whether
claimant can perfonn other work that exists in significant numbers in the national economy. See
20 C.F.R. §§ 404.1520 (DIB); 416.920 (SSI). The regulations promulgated by the Social
Security Administration also provide that all relevant evidence will be considered in determining
whether a claimant has a disability. See 20 C.F.R. §§ 404.1520(a)(3), 416.920(a)(3). Lastly,
when considering a claim for DIB, the Commissioner must determine whether the insured status
requirements of sections 216(i) and 223 of the Social Security Act are met. See 42 U.S.C. §§
416(i), 423.
Here, the ALJ made the following findings of fact: (1) plaintiff meets the insured status
requirements of the Social Security Act through March 31, 2011; (2) the record does not
establish that plaintiff engaged in substantial gainful activity since November 17, 2009, the
alleged onset date; (3) plaintiff has the following severe impairments: obesity, lumbar spinal
disorder, and inflammatory arthritis; (4) plaintiff does not have an impairment or combination of
impairments that meets or medically equals the severity of one of the listed impairments in 20
C.F.R. § 404, Subpart P, Appendix 1; (5) plaintiff has the residual functional capacity to perform
light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b) assuming certain postural,
manipulative, and environmental limitations9 ; (6) plaintiff is capable of performing past relevant
work as a packager, which is classified as medium duty unskilled work, but which was
performed at the light exertional level, and this work does not require the performance of workrelated activities precluded by the plaintiffs residual functional capacity, or alternatively,
considering plaintiffs age, education, work experience, and residual functional capacity, plaintiff
9

Those limitations include "no more than occasional postural maneuvers, such as balancing, stooping,
kneeling, crouching and climbing on ramps and stairs," and no "climbing on ladders or crawling" or "exposure to
dangerous machinery and unprotected heights." (AR 16).

24

is capable of making a successful adjustment to other work that exists in significant numbers in
the national economy; and (7) plaintiff has not been under a disability, as defined in the Social
Security Act, from November 17, 2009 through the date of the ALJ's decision. (AR 15-22).

IV. ANALYSIS
A.

Overview

On September 23, 2015, plaintiff filed a complaint in the U.S. District Court for the
Eastern District of Virginia seeking review pursuant to 42 U.S.C. § 405(g). (Docket no. 1).
Plaintiff's motion for summary judgment argues that four errors were committed by the
ALJ. (Docket no. 15). The first relates to the ALJ's residual functional capacity assessment
prior to step four of the sequential evaluation process. See 20 C.F.R. §§ 404.1520(e),
416.920(e). Plaintiff argues the ALJ erred in determining that plaintiff was capable of
performing light work by first failing to evaluate a purported medical opinion of plaintiffs
treating physician, Dr. Coleman. (Docket no. 15 at 11-13). Specifically, plaintiff claims the
ALJ's decision does not include "an evaluation of Dr. Coleman's opinion of limitations," in
which Dr. Coleman writes on March 29, 2013:
Because of her general deconditioning, diffuse chronic pain, [and] carpal tunnel
syndrome[,] she is currently not able to perform his [sic] usual duties at her job.
She did not provide me with a job description on paper[,] but this is based on her
verbal description of her assignments and her functional status.
(AR 521). Plaintiff claims that Dr. Coleman's March 29, 2013 notation constitutes a medical
opinion, and thus, the ALJ erred in not evaluating it. (Docket no. 15 at 11 ). Plaintiff next argues
the ALJ erred in determining that plaintiff was capable of performing light work by failing to
give proper weight to Nurse Brown's March 2012 and February 2014 opinions of limitation.
Here, plaintiff claims that the ALJ erred in placing no weight on Nurse Brown's March 2012
opinion on account of the ALJ' s uncertainty on who authored the opinion, when the record
25

evidence demonstrates Nurse Brown wrote the assessment. (Docket no. 15 at 14). Plaintiff also
claims the ALJ erred in placing no weight on Nurse Brown's March 2012 and February 2014
evaluations because the ALJ failed to provide any analysis for his decision. (Id.). Finally,
plaintiff also argues the ALJ' s residual functional capacity determination was in error because
the ALJ failed to account for plaintiff's limitations that result from her prescribed cane use.
(Docket no. 15at17-18).
Plaintifrs second claimed error is that the ALJ's failure to include carpal tunnel
syndrome as a severe impairment at step two of the sequential evaluation process was in error.
(Docket no. 15 at 18); see generally 20 C.F.R. §§ 404.1520(a)(l)(4)(ii) (second sequential step
description), 416.920(a)(4)(ii) (same). Specifically, plaintiff argues that the "ALJ determined
that [plaintiff's] severe impairments included only obesity, lumbar spinal disorder, and
inflammatory arthritis," but failed to find plaintiffs carpal tunnel syndrome to be severe despite
medical evidence suggesting its severity. (Docket no. 15 at 18). Plaintiff also argues that the
ALJ's failure to include any limitations concerning carpal tunnel syndrome in her residual
functional capacity was error. (Docket no. 15 at 19 n.5).
The third claimed error relates to the ALJ's determination that plaintiffs statements
concerning the intensity, persistence, and limiting effects of her symptoms were not entirely
credible. (Docket no. 15 at 19). Plaintiff claims that the ALJ failed to properly articulate
specific and adequate reasons for discrediting plaintiff's statements.
The fourth and final error relates to the ALJ's conclusions at the fourth and fifth steps of
the sequential evaluation process-finding that plaintiff is capable of performing her past
relevant work as a packager performed at the light exertional level and alternatively, that there
are other jobs existing in the national economy that she is able to perform. (Docket no. 15 at 21;

26

AR 20). Prior to making this determination, the ALJ considered plaintifrs residual functional
capacity and the physical and mental demands ofplaintifrs prior work as a packager. (AR 20).
Based on this comparison, the ALJ found that plaintiff would be able to perform her past work as
a packager and was not disabled as a result. Alternatively, the ALJ considered plaintifrs
residual functional capacity and the vocational factors of age, education, and work experience as
required by 20 C.F.R. §§ 404.1560(c), 416.960(c). The ALJ also considered the testimony of a
vocational expert who determined that plaintiff would be able to perform several unskilled, light
duty occupations, including: box inspector, ticketer, and produce weigher. (AR 21, 54). Based
on this testimony, the ALJ found that plaintiff was capable of making a successful adjustment to
other work that exists in significant numbers in the national economy. (Id). Generally, plaintiff
argues that the ALJ's errors at steps two and three in the sequential process, described above,
caused the ALJ's conclusions at step four and alternatively, step five, to be in error. (Id.).
Based on the foregoing, plaintiff argues the decision rendered by the ALJ-and
subsequently adopted as the final decision of the Commissioner-is not supported by substantial
evidence and was the product of legal error. The Commissioner rebuts this assertion, claiming
first that the ALJ correctly determined at step two of the sequential process that plaintiff suffered
certain "severe" impairments and any purported error in failing to consider additional
impairments was harmless. (Docket no. 17 at 11 ). The Commissioner next argues that
substantial evidence exists to support the ALJ's determination of plaintifrs residual functional
capacity, as the ALJ properly considered plaintifrs carpal tunnel syndrome, her use of a cane,
properly considered Nurse Brown's questionnaire and Dr. Coleman's purported opinion, and
properly analyzed the plaintifrs credibility. (Docket no. 17 at 12-22). Finally, the
Commissioner argues that the ALJ asked the vocational expert a hypothetical question that

27

properly reflected plaintifrs residual functional capacity as determined by the ALJ, and because
this residual functional capacity is supported by substantial evidence, the ALJ committed no
error at steps four and five. (Docket no. 17 at 22).
Plaintiff seeks reversal of the ALJ's decision on June 9, 2014, which subsequently
became the final decision of the Commissioner after the Appeals Council affirmed Judge Wing's
ruling on July 23, 2015 (AR 1-5), and a remand of the matter for further administrative
proceedings. The Commissioner requests that the final decision be affirmed. As previously
stated, judicial review under these circumstances is limited to considering whether the ALJ' s
findings are supported by substantial evidence and whether the applicable regulations were
correctly applied in reaching a decision. See Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir.
2002). The court will address plaintiffs arguments in the order presented.

B.

The ALJ's Determination of Plaintiff's Residual Functional Capacity Is
Supported by Substantial Evidence and Was Determined in Accordance with
Applicable Law

Plaintiff argues that the ALJ' s determination of her residual functional capacity ("RFC")
is not supported by substantial evidence for three reasons. First, plaintiff argues the ALJ erred
when he failed to consider Dr. Coleman's March 29, 2013 statements as a medical source
opinion. Second, plaintiff argues the ALJ erred in giving Nurse Brown's questionnaires "no
weight" without providing an adequate basis for doing so. Third, plaintiff argues the ALJ erred
when he failed to account for plaintiffs limitations that result from her prescribed cane use.
1.

The ALJ Did Not Err in Failing to Specifically Address the March 29,
2013 Statement by Dr. Coleman

The plaintiffs first contention is that the ALJ erred when he failed to consider an opinion
of plaintiffs treating physician. On March 29, 2013, plaintiff visited the Waverly Medical
Center to "have disability forms filled out." (AR 519). Plaintiff brought with her a "disability
28

form" and indicated that she "[p]reviously worked in production packing boxes for shipment."
(Id). Treatment notes indicate that plaintiff stated that "she is no longer able to do this kind of

work because of [an] inability to stand long or sitting long because ofleg and back pain as well
as bilateral hand and wrist pain [and] weakness." (Id). Plaintiff also reported "having
difficulties with cognition [and] completing tasks." She indicated that "[h]er back pain is at
times stabbing, other times burning throughout the low back and left thigh" and that "the back
pain began after her hemicolectomy in October" 2012. (Id.). Finally, plaintiff indicated that she
had "tried physical therapy [and a] TENS unit helps but [she] does not have one for home use."
(Id.). Dr. Coleman, who plaintiff had seen over a number of prior visits (see AR 459, 461, 468,

473, 493), then conducted a physical examination of plaintiff. (AR 521). Dr. Coleman's
physical examination indicated that plaintiff was "[o]bese [and] appears to be in some
discomfort" but was not in "distress." (Id). Dr. Coleman noted that plaintiff was "able to
transfer independently from chair to exam table" and a musculoskeletal exam revealed
pain with range of motion of both shoulders, however range of motion is full.
There is tenderness with palpation of the wrists bilaterally, no warmth or synovial
thickening. Wrists and hands are normal to inspection. Phalen's sign is positive
bilaterally at the wrists. Lower extremities reveal pain with flexion of the hip and
knee bilaterally but full range of motion. Normal strength in all extremities.
(Id.). Dr. Coleman listed 7 assessments after his physical examination: (1) Encounter for

disability examination; (2) neuropathic pain; (3) hypertensive disease; (4) diverticulitis of the
large intestine; (5) Type II diabetes mellitus; (6) carpal tunnel syndrome; and (7) back pain.
(Id.). Dr. Coleman then noted under the heading "Treatment" and subheading "l. Encounter for

disability examination":
Because of her general deconditioning, diffuse chronic pain, [and] carpal tunnel
syndrome[,] she is currently not able to perform his [sic] usual duties at her job.
She did not provide me with a job description on paper but this is based on her
verbal description of assignments and of her functional status.
29

(Id.). The ALJ did not expressly consider or note plaintiff's March 29, 2013 examination by Dr.

Coleman nor Dr. Coleman's statement contained in his treatment notes from that date.
Plaintiff argues the failure to consider this statement constitutes error because Dr.
Coleman's statement was a medical opinion. (Docket no. 15 at 11; Docket no. 22). The
Commissioner argues that Dr. Coleman's statement was not a medical opinion, but instead a
recitation of plaintiff's own analysis of her functionality that was devoid of any identification of
any specific functions that Dr. Coleman believed plaintiff to be unable to perform. (Docket no.
17 at 19). To the extent such a record was Dr. Coleman's own opinion, the Commissioner
argues that any failure to expressly consider it was harmless error. (Docket no. 17 at 20).
The regulations "draw a distinction between a physician's medical opinion and his legal
conclusions." Morgan v. Barnhart, 142 F. App'x 716, 721 (4th Cir. 2005). "Medical opinions
are statements from physicians ... that reflect judgments about the nature and severity of[a
claimant's] impairment(s), including ... symptoms, diagnosis and prognosis, what [a claimant]
can still do despite impairment(s), and [a claimant's] physical or mental restrictions." 20 C.F.R.

§ 404. l 527(a)(2). "Legal conclusions, on the other hand, are opinions on issues reserved to the
ALJ, such as 'statements[s] by a medical source that [the claimant is] 'disabled' or 'unable to
work."" Morgan, 142 F. App'x at 721-22 (alterations in original) (quoting 20 C.F.R. §
404.1527(e)(l)). An ALJ must give a treating physician's medical opinions special weight in
certain circumstances. Craig v. Chafer, 76 F.3d 585, 590 (4th Cir. 1996) (holding that a treating
physician's medical opinion must be given controlling weight only when it "is well supported by
medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with
the other substantial evidence" in the record (quoting 20 C.F.R. § 404.1527(d)(2))). An ALJ is
not, however, obligated to give a treating physician's legal conclusions any heightened
30

evidentiary value. Morgan, 142 F. App'x at 722 (citing 20 C.F.R. § 404.1527(e)(3)).
Nevertheless, the ALJ must not simply ignore a treating physician's legal conclusions, but
instead "must evaluate all the evidence in the case record to determine the extent to which the
[treating physician's legal conclusion] is supported by the record." SSR 96-5p, 1996 WL
374183, at *3 (July 2, 1996). To the extent a treating physician's legal conclusion contributes
very little to the record, an ALJ's failure to discuss the opinion is harmless error. Winder v.

Astrue, No. 1:1l-CV-956,2012 WL 4461284, at *5 (E.D. Va. Sept. 24, 2012).
Plaintiff's contention that Dr. Coleman's statement constitutes an "opinion of limitations"
and a "medical opinion" is baseless. Dr. Coleman's statement 10 merely expressed an opinion on
plaintiff's ability to return to her previous work in packaging, and as such, is a legal opinion. See

Morgan, 142 F. App'x at 722 ("[A]n opinion that [a claimant] cannot complete the duties of her
previous job is merely a legal conclusion on an issue reserved for the ALJ at the fourth step of
the sequential evaluation process.") (citing 20 C.F.R. § 404.1520(a)(4)(iv)). That Dr. Coleman
"tied his determination to Plaintiffs impairments" does not transform his legal opinion into a
medical one, as plaintiff suggests. (See Docket no. 22 at 2). Instead, it merely provides the basis
upon which Dr. Coleman rendered his legal opinion. Accordingly, as a legal conclusion, Dr.
Coleman's opinion is not deserving of any special weight, but instead "is persuasive only if
supported elsewhere in the record." Winder, 2012 WL 4461284, at *5.

10

The Commissioner's argument that Dr. Coleman's statement was merely a reflection of plaintiff's
statements to him and not his own opinion is unpersuasive. In fact, the Commissioner has omitted and replaced a
word in Dr. Coleman's treatment notes when arguing that Dr. Coleman's statement is a mere recitation ofplaintifrs
conclusions, and in doing so, changes the meaning of Dr. Coleman's statement. The Commissioner identified that
Dr. Coleman wrote that "[b]ecause of her general deconditioning, diffuse chronic pain, [and] carpal tunnel syndrome
she [was] currently not able to perform his [sic] usual duties at her job." (Docket no. 17 at 19) (alterations in
original). However, Dr. Coleman's statement actually provides, "Because of her general deconditioning, diffuse
chronic pain, carpal tunnel syndrome she is currently not able to perform his usual duties at her job." (AR 521)
{emphasis added). The omission of"is" and its replacement with "was" makes Dr. Coleman's statement appear to
be merely descriptive of plaintiff's ability to perform her previous work in 2009, instead of her ability to perform her
previous work on March 29, 2013 during Dr. Coleman's assessment.

31

While Dr. Coleman was plaintiffs treating physician and had examined plaintiff for a
number of years prior to March 29, 2013, see 20 C.F.R. § 404.1527(c)(l)-(2) (describing how an
examining relationship and treatment relationship of a physician are considered in the weight to
be given an opinion), other factors weigh against assigning great credibility to Dr. Coleman's
March 29, 2013 statement. First, Dr. Coleman explicitly indicates that his statement was based
in part on plaintiff's description of her functional status. (AR 521). Moreover, Dr. Coleman's
statement was also based on plaintiffs "verbal description of assignments" at her previous
occupation and Dr. Coleman was not provided a job description of plaintiffs previous work as a
packager. (Id.). Such bases provide Dr. Coleman's opinion with very little credibility. See 20
C.F.R. § 404.1527(c)(3) ("The more a medical source presents relevant evidence to support an
opinion, ... the more weight [the ALJ] will give that opinion."). Furthermore, Dr. Coleman did
not explain how his physical examination of plaintiff that day or how plaintiffs lab or exam
findings from other days-that, for example, discounted a finding of carpal tunnel syndrome
(AR 529)-corroborate his prediction that plaintiff could not perform the usual duties at her job.

See 20 C.F.R. § 404.l527(c)(4) ("Generally, the more consistent an opinion is with the record as
a whole, the more weight [the ALJ] will give that opinion"). Dr. Coleman also failed to indicate
why the impairments he listed prevent plaintiff from performing the usual duties at her previous
position. See 20 C.F.R. § 404.1527(c)(3) ("The better an explanation a source provides for an
opinion, the more weight [the ALJ] will give that opinion."). For these reasons, the credibility of
Dr. Coleman's legal opinion is low.
Moreover, the impairments listed by Dr. Coleman-"general deconditioning, diffuse
chronic pain, and carpal tunnel syndrome"-were all discussed by the ALJ, with the ALJ finding
plaintiffs obesity, lumbar spinal disorder, and inflammatory arthritis all to be severe

32

impainnents (AR 15) and plaintiff's exam results suggesting a lack of carpal tunnel syndrome

(See infra Part IV.C). Consequently, Dr. Coleman's March 29, 2013 statement offered very little
contribution to the record in this matter regarding the impainnents he listed. See Winder, 2012
WL 4461284, at *5 (holding harmless an ALJ's lack of discussion ofa legal opinion that offered
"very limited contribution to the record'').
For the foregoing reasons, the court finds that the failure of the ALJ to consider Dr.
Coleman's March 29, 2013 statement was harmless.
2.

The ALJ Properly Considered the Residual Functional Capacity
Assessments of Nurse Brown

Plaintiff next asserts that the ALJ erred in giving no weight to two opinions of Nurse
Brown. (Docket no. 15 at 13). An ALJ must explicitly indicate the weight given to all
considered evidence. Gordon v. Schweiker, 725 F.2d 231, 235-36 (4th Cir. 1984). "An ALJ
must also note whether a claimant's primary care medical source is an 'acceptable medical
source' for the purpose of detennining Social Security Disability and give weight to that source
accordingly." Fallon v. Colvin, No. 2:12-CV-423, 2013 WL 5423845, at *9 (E.D. Va. Sept. 26,
2013). Acceptable medical sources include both licensed physicians and osteopathic doctors. 20
C.F.R. §§ 404.1513(a)(l), 416.913(a)(l). A nurse practitioner, however, is considered an "other
source," and thus is not an acceptable medical source. 20 C.F.R. §§ 404.1513(d)(l),
416.913(d)(l). This is significant because only an acceptable medical source can be a "treating
source," whose medical opinions can receive controlling weight by an ALJ. 20 C.F.R. §§
404.1527(d), 416.927(d)(2). The regulations provide that the ALJ may also use evidence from
"other sources" such as nurse practitioners. 20 C.F.R. §§ 404.1513(d), 416.913(d). Thus, the
ALJ is not required to use evidence from an "other source." However, SSR 06-03p states that
the Social Security Administration considers all relevant evidence in disability detenninations,
33

including opinion evidence from "other sources." SSR 06-03p, 2006 WL 2329939, at *4 (Aug.
9, 2006). Thus, to the extent an ALJ evaluates an opinion from a nurse practitioner, the weight
given to such sources "will vary according to the particular facts of the case, the source of the
opinion," the source's qualifications, and additional factors, including how long the source has
known the claimant, how frequently the source has seen the claimant, how consistent the opinion
is with other evidence, the extent to which the source presents relevant evidence to support their
opinion, and how well the source explains the opinion. Id An ALJ may assign "no weight" to
an opinion so long as the ALJ articulates "specific and legitimate reasons" for rejecting the
opinion. See Bishop v. Comm 'r ofSoc. Sec., 583 F. App'x 65, 67 (4th Cir. 2014) (per curiam)
(unpublished) (discussing the rejection of a treating physician's medical opinion).
Plaintiff contends that the ALJ's allocation of"no weight" to Nurse Brown's March 2012
and February 2014 assessments was improper. First, plaintiff argues that the ALJ improperly
discounted Nurse Brown's March 2012 opinion because the ALJ was unsure of the source of the
opinion. Plaintiff cites the ALJ's statement that the ALJ was unclear "if this opinion was
prepared by a doctor or other acceptable medical source." (AR 19). However, in the next
paragraph, the ALJ also noted that Nurse Brown "appears to be the person who prepared the
March 2012 questionnaire" and the ALJ's opinion makes clear he proceeded on such an
assumption. (See id.) ("[I]n the most recent [questionnaire of February 2014], she reduced
claimant's physical exertional capacity to a range of sedentary work and continued to opine that
her symptoms would cause her to miss work more than four times per month."). Thus, despite
noting uncertainty regarding the author of the March 2012 questionnaire, it is clear the ALJ
found Nurse Brown to be the author. For this reason, plaintiffs argument that the ALJ

34

improperly discounted the March 2012 questionnaire because of uncertainty regarding its author
is without merit.
Next, the plaintiff argues that the ALJ "improperly discounted [the questionnaires) for an
alleged lack of objective findings to support the opinions and because NP Brown is a nurse
practitioner." (Docket no 15 at 14). The ALJ properly gave Nurse Brown's residual functional
capacity questionnaires no weight. First, the ALJ noted that the questionnaires were inconsistent
with each other and provided no "objective findings or basis" for the inconsistency. (AR 19);
see 20 C.F.R. § 404.1527(c)(3) ("The more a medical source presents relevant evidence to
support an opinion, ... the more weight [the ALJ] will give that opinion."). Specifically, the
ALJ noted that the questionnaires came to inconsistent conclusions regarding plaintiffs residual
functional capacity without providing findings or clinical evidence to support such a change.
(AR 19). As described by the ALJ, the March 2012 report found that the plaintiff was capable of
performing a range of light level exertional work, while the February 2014 report reduced
plaintiff's capacity to a range of sedentary work. (Id.). In fact, the March 2012 questionnaire
reported that plaintiff could use her right hand, right-hand fingers, and right ann for 100% of an
eight-hour workday for grasping, turning, and twisting objects; fine manipulation; and reaching,
respectively. (AR 271). The March 2012 report also indicated that plaintiffs left hand, lefthand fingers, and left ann were 10% for each category. (Id). Then, in February 2014, Nurse
Brown opined that plaintiffs right hand, right-hand fingers, and right ann were 0% for each
category, while plaintiffs left hand, left-hand fingers, and left ann were now 25%, 50%, and
50%, respectively. (AR 704). As the ALJ concluded, Nurse Brown did not identify any
objective basis or evidence for the change in functional status in the February 2014 questionnaire
and the inconsistency with her earlier questionnaire. (AR 19); see Craig, 76 F.3d at 590 (4th Cir.

35

1996) ("[l]f a physician's opinion ... is inconsistent with other substantial evidence, it should be
accorded significantly less weight."); SSR 96-2p, 1996 WL 374188, at *2 (July 2, 1996)
(discussing that lower weight may be given when a medical source opinion is inconsistent with
other substantial evidence in the case record).
The ALJ also identified that Nurse Brown did not provide any evidence or clinical
findings to support her conclusions in March 2012 and February 2014, namely that plaintiffs
symptoms would cause her to miss work more than four times per month. {AR 19, 271, 704);

see 20 C.F.R. § 404.1527(c)(3). Furthermore, the ALJ noted that such conclusions were
inconsistent with the totality of the evidence. (AR 19); see Craig, 76 F.3d at 590 (4th Cir. 1996).
For example, the ALJ noted that in August 2012, Dr. Eapen's examination found that plaintiffs
grip strength was 4/5 in her right hand and 515 in her left hand and that she was able to make
almost a complete fist. {AR 19, 326). Additionally, the ALJ noted that in July 2013, plaintiff
underwent an EMO secondary to complaints of peripheral neuropathy. (AR 18-19, 700). The
ALJ noted that this study revealed that a "workup of cord imaging showed only mild arthritis"
and identified that plaintiffs symptoms had been "stable for years." (AR 19, 700). Furthermore,
the evidence cited by the ALJ showed that in July 2011, plaintiff was working out at a local
fitness center and felt her energy level had improved. (AR 18, 472). The ALJ also discussed
that plaintiff described her pain in March 2014 as "all good'' and that she had "[n]o pain at rest."
(AR 19, 20, 714). Thus, substantial evidence supports the ALJ's conclusion that Nurse Brown's
opinions are at odds with the totality of the evidence.
In sum, the ALJ cited specific and legitimate reasons for assigning no weight to Nurse
Brown's questionnaires, namely inconsistency with each other and the totality of the evidence
without explanation or clinical findings presented as support. As these reasons are supported by

36

substantial evidence in the record, the ALJ did not err in assigning Nurse Brown's opinions no
weight.
3.

The ALJ Properly Evaluated Plaintiffs Use of a Cane in Detennining
Plaintiffs Residual Functional Capacity

Finally, plaintiff challenges the ALJ's conclusion that the evidence did not show that
plaintiffs arthritis in her knees and lower extremities was so severe as to mandate the use of a
cane for ambulation, which in turn, did not require that plaintiffs use of a cane be considered in
her residual functional capacity. (Docket no. 15 at 17). Instead, plaintiff claims that substantial
evidence required the ALJ to consider how plaintiffs use of a cane would affect her residual
functional capacity. (Docket no. 15 at 18). Plaintiff also contends that the ALJ erred when
finding that a cane was not mandated by prescription. (Docket no. 15 at 17).
Social Security Ruling ("SSR") 96-9p provides guidance regarding the necessary
showing for an ALJ to reach the conclusion that a claimant's hand-held device, such as a cane, is
"medically required" where an individual is capable of less than a full range of sedentary work.
SSR 96-9p, 1996 WL 374185, at *7 (July 2, 1996). SSR 96-9p requires the ALJ to consider the
impact of "medically required" hand-held assistive devices and indicates:
To find that a hand-held assistive device is medically required, there must be
medical documentation establishing the need for a hand-held assistive device to
aid in walking or standing, and describing the circumstances for which it is
needed (i.e., whether all the time, periodically, or only in certain situations;
distance and terrain; and any other relevant information).

Id. (emphasis added). Courts in the Fourth Circuit have held that even where a claimant is
prescribed a cane, substantial evidence may support a conclusion that the cane is not medically
necessary, and as such, an ALJ's decision not to consider the impact of a claimant's cane use on
her residual functional capacity is not error. See, e.g., Morgan v. Comm 'r, Soc. Sec., No. 13-CV2088-JKB, 2014 WL 1764922, at *1 (D. Md. Apr. 30, 2014) (finding claimant's use of a cane
37

was not medically necessary where "treating physician not[ed] normal gait during examination,"
"x-ray show[ed] moderate degenerative changes in the left hip with some joint space loss and
spurring" and an "examination demonstrate[ ed] no pain on rolling test of hip[,)" and thus
claimant was capable of light work with limitations); Wimbush v. Astrue, 4:10-CV-00036, 2011
WL 1743153, at *2-3 (W.D.Va. May 6, 2011) (plaintiff prescribed a cane, but did not show it
was medically necessary where doctors observed that her gait was normal and exams indicated
she was "functionally better than ... her self-perception[,)" and thus was capable of light work).
In this case, while Nurse Brown prescribed for plaintiffs use of a cane for "99 months"
"as directed" in June 2012, Nurse Brown did not describe the circumstances for which the cane
is needed. (AR 496). In prescribing the use of a cane, Nurse Brown only noted that plaintiff had
"right arm pain[,] numbness getting worse[,] had develped [sic] weakness in [right-upper
extremities] and unsteady gait." (AR 495). The plaintiff testified before the ALJ that she "uses a
cane to ambulate and she contended that she can't walk without it." {AR 17, 46).
The ALJ found "no such indications in the record" that plaintiff could not walk without
a cane. (AR 17). The ALJ also indicated that "the evidence does not reveal that [plaintiffs]
arthritis is so severe in her knees and lower extremities that it mandates the use of a cane for
ambulation." (AR 20). The ALJ cited Drs. Delorenzo and Baldwin's February 5, 2014 notation
of plaintiffs "antalgic appearing gait secondary to arthritic knee pain." (AR 20, 663). The ALJ
also noted that a January 29, 2013 assessment provided that plaintiffs "[t]oe walking and heel
walking" were normal and that plaintiffs "[g]ait and station" were normal. {AR 18, 452). The
ALJ also noted plaintiffs physical therapy records, in which Dr. Paven identified that plaintiffs
"[g]ait is stable" and her "[l)ower extremity strength is normal" on May 7, 2013, July 25, 2013,
November 19, 2013, and February 13, 2014. (AR 730, 727, 725, 723). Her physical therapy

38

notes also indicate that plaintiff attended a physical therapy session on March 13, 2013 without
her cane. (AR 441 ). Dr. Eapen' s evaluation on August 10, 2012, considered by the ALJ (AR
19), also found that plaintiffs "gait appears stable without any assistive devices" and plaintiff
"exhibits good mobility." (AR 326). Finally, the ALJ noted plaintiffs July 2013 EMG testing,
which found that a "workup of cord imaging showed only mild arthritis" and identified that
plaintiffs symptoms had been "stable for years." (AR 19, 700).
For these reasons, despite the ALJ's error in not identifying that cane use was prescribed
by plaintiffs nurse practitioner in June 2012, any such error was harmless as the evidence is
insufficient to show that the plaintiffs cane use was medically necessary. Accordingly, the
ALJ's decision not to consider the impact of plaintiffs cane use on her residual functional
capacity has substantial evidentiary support.

C.

The ALJ's Determination of the Medical Severity of Plaintiff's Impairments
at Step Two in the Sequential Evaluation Process Is Supported by
Substantial Evidence

Plaintiff contends that the ALJ's determination at step two of the sequential evaluation
process was in error. (Docket no. 15 at 18). Specifically, plaintiff notes that the ALJ determined
that plaintiffs severe impairments only included obesity, lumbar spinal disorder, and
inflammatory arthritis. (AR 15). Plaintiff contends that the ALJ's conclusion that plaintiff did
not suffer from carpal tunnel syndrome as a severe impairment was in error, as plaintiffs
"treating providers specifically opined that carpal tunnel syndrome would cause" plaintiff to
have work-related limitations. (Docket no. 15 at 18-19). Plaintiff also contends that in addition
to failing to include carpal tunnel syndrome as a severe impairment, the ALJ "did not include
limitations from [carpal tunnel syndrome] in the RFC determination[,] which is also an erroneous
finding." (Docket no. 15 at 19 n.5).

39

A severe impairment is one that "significantly limits an individual's physical or mental
abilities to do basic work activities." SSR 96-3p, 1996 WL 374181, at *I (July 2, 1996). In
tum, "[a]n impairment is not severe if it does not significantly limit [the claimant's] physical or
mental ability to do basic work activities." 20 C.F.R. §§ 404.1521, 416.921. If a claimant has no
severe impairment, the disability evaluation process ends. 20 C.F.R. §§ 404.1520(c), 416.920(c).
However, if the claimant is found to have a severe impairment, the evaluation process continues
on to step three. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The province of a reviewing court
here is not to reconcile inconsistencies in the medical evidence nor substitute its judgment for
that of the Commissioner if her decision is supported by substantial evidence. See Hays v.

Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).
At step two in this action, the ALJ found plaintiffs obesity, lumbar spinal disorder, and
inflammatory arthritis to be severe impairments under 20 C.F.R. §§ 404.1520(a)(4)(ii),
416.920(a)(4)(ii). (AR 15). The ALJ did not find that plaintiffs severe impairments included
carpal tunnel syndrome. (Id.). At step three, the ALJ considered plaintiffs complaints on
February 9, 2009 of arthritic pain and stiffness in her hands. (AR 17, 456). The ALJ considered
that plaintiff reported that Naproxen worked well for her arthritis, but upset her stomach. (Id.).
Plaintiffs follow-up appointment in January 2010, in which plaintiffs physical-examination
findings were within normal limits and plaintiffs doctor discontinued the medications prescribed
to treat her arthritis (AR 459-60), was also considered by the ALJ (AR 18). The ALJ also noted
that during a July 8, 2011 medical appointment, plaintiff indicated that she was working out at a
local fitness center and found the activity helped alleviate stress in her life. (AR 18, 472-73).
The ALJ also considered an August 10, 2012 evaluation in which plaintiff was evaluated
by Dr. Eapen for carpal tunnel syndrome, among other ailments. {AR 19, 324). The ALJ

40

discussed that Dr. Eapen's assessment noted that plaintiffs grip strength was 415 on the right and

515 on the left. (AR 19, 326). The ALJ also considered that Dr. Eapen conducted two tests for
carpal tunnel syndrome during the assessment-Tine} sign and Phalen's sign-that were both
negative. (AR 19, 326). Dr. Eapen's findings that plaintiff had "[n]o apparent hand muscle
wasting" and that she was "able to make almost a complete fist" were also discussed by the ALJ
at step three. (AR 19, 326). Additionally, a peripheral joint evaluation did not find any evidence
of active joint inflammation, which the ALJ also discussed. (AR 19, 326). Furthermore, the
ALJ considered Dr. Eapen's discussion of plaintiffs electrodiagnostic studies in July 2012 to
"rule out carpal tunnel syndrome" in light of plaintiffs complaints of"pain with paresthesias in
the right hand" and use of a brace for carpal tunnel syndrome. (AR 19, 324). Dr. Eapen noted
that the "electrodiagnostic studies" were negative for carpal tunnel syndrome. (AR 324; see also
AR 319, 529-30).
Finally, the ALJ considered plaintiffs physical-therapy treatment notes. (AR 19-20).
The ALJ considered that at plaintiffs most recent physical therapy session on March 27, 2014,
plaintiff reported, "[i]t's all good" and she had "[n)o pain at rest." (AR 20, 714). The ALJ also
discussed that on that date, plaintiff had met 4 out of 5 of her therapeutic goals and was
discharged from care. (AR 20, 714). The record indicates that the 4 goals met were: (1) plaintiff
"will demonstrate at least a 75% improvement in functional activities by discharge or within 3
months"; (2) plaintiff "will improve wrist E/F by 25% without pain in < 3 weeks in response to
splinting/HEP"; (3) plaintiff"will tolerate upgrade to wrist eccentrics to improve grip to> 8kgs
without pain in 6 weeks"; and (4) plaintiff "will improve finger TAM of ring/little to > 185
degrees to hold onto utensils for cutting food." (AR 714). This final discharge treatment note, as

41

noted by the ALJ, also does not contain any work limitations and only advised plaintiff to "wear
splint at night and perform exercises for 1 week and then disregard." (Id.).
Based on the foregoing, the court finds that substantial evidence supports the ALJ' s
conclusion that plaintiff did not suffer from carpal tunnel syndrome as a severe impairment. The
court also finds that the ALJ's lack of analysis of carpal tunnel syndrome in plaintiffs residual
functional capacity is also supported by substantial evidence.

D.

The ALJ Properly Evaluated Plaintiffs Credibility

Plaintiff next argues that the ALJ erred in finding her statements concerning the intensity,
persistence, and limited effects of her alleged symptoms to be not entirely credible. (Docket no.
15 at 19). Specifically, plaintiff alleges that the ALJ failed to properly assess the effect of her
use of a cane; her attempts at obtaining relief through ice packs, heating pads, physical therapy,
pool therapy, a back brace, and a TENS unit; her use of a handicapped plate on her vehicle; and
the persistence with which she sought treatment for pain. (Docket no. 15 at 20). The
Commissioner maintains that substantial evidence supports the ALJ's credibility analysis,
arguing that the ALJ fully considered plaintiff's testimony regarding her symptoms and the
limited effects of those symptoms before rending his decision. (Docket no. 17 at 20--22). Based
on the reasons set forth below, the court finds that the ALJ properly considered plaintiffs
complaints along with the other findings and opinions in the administrative record.
When evaluating the intensity and persistence of a claimant's symptoms and the effect of
those symptoms on a claimant's ability to engage in gainful activity, the ALJ may consider a
claimant's treatment, other than medication; a claimant's daily activities; prior work record; and
a claimant's own statements about his or her symptoms. See 20 C.F.R. §§ 404.1529, 416.929;

see also Johnson v. Barnhart, 434 F.3d 650, 657-58 (4th Cir. 2005). This court must give great

42

deference to the ALJ's credibility determinations. See Eldeco, Inc. v. NLRB, 132 F.3d 1007,
1011 (4th Cir. 1997). The Fourth Circuit has determined that "[w]hen factual findings rest upon
credibility determinations, they should be accepted by the reviewing court absent 'exceptional
circumstances.'" Id (quoting NLRB v. Air Prods. & Chems., Inc., 717 F.2d 141, 145 (4th Cir.
1983)). Therefore, this court is bound to accept the ALJ's credibility determinations unless they
are "unreasonable, contradict[] other findings of fact, or [are] 'based on an inadequate reason or
no reason at all.'" Id (quoting NLRB v. McCullough Envtl. Servs., Inc., 5 F.3d 923, 928 (5th
Cir. 1993)).
After careful consideration of the evidence, the ALJ found that while the plaintiffs
medically determinable impairments could reasonably be expected to cause the alleged
symptoms, the plaintiffs "statements concerning the intensity, persistence and limiting effects of
these symptoms are not entirely credible for the reasons explained in this decision." (AR 17). In
arriving at this conclusion, the ALJ did not find that plaintiff did not experience any pain or
limitations related to her spinal condition or arthritis; instead, the ALJ accounted for plaintiffs
existing severe impairments and found that plaintiff was capable of performing a range of light
work as defined in 20 C.F.R. §§ 404.1567(b), 416.967(b) 11 with limitations to accommodate the
pain and restrictions she experiences secondary to her spinal condition and arthritis. (AR 20).
The ALJ described those limitations as follows:

11

Those sections provide:
Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of
objects weighing up to I 0 pounds. Even though the weight lifted may be very little, a job is in this
category when it requires a good deal of walking or standing, or when it involves sitting most of
the time with some pushing and pulling of arm or leg controls. To be considered capable of
performing a full or wide range of light work, you must have the ability to do substantially all of
these activities. If someone can do light work, we determine that he or she can also do sedentary
work, unless there are additional limiting factors such as loss of tine dexterity or inability to sit for
long periods of time.
20 C.F.R. §§ 404.1567(b), 4 l6.967(b).

43

[Plaintiff] is limited to occupations that require no more than occasional postural
maneuvers, such as balancing, stooping, kneeling, crouching and climbing on
ramps and stairs. She must avoid occupations that require climbing on ladders or
crawling. She is limited to occupations which do not require exposure to
dangerous machinery and unprotected heights.
(AR20).
In assessing plaintiffs statements regarding the intensity, persistence, and limiting effects
of her symptoms, the ALJ first considered and identified discrepancies between plaintiffs
testimony regarding the pain in her hands with her physical-therapy treatment reports. (AR 1920). The ALJ discussed that while plaintiff testified that she can lift and carry about 1 to 2
pounds and was told by her physical therapists not to strain it (AR 17), she identified in her most
recent physical therapy session, when asked about her pain, that "[i]t's all good" and that she had
"[n]o pain at rest." (AR 20, 714). As previously discussed, the ALJ also noted that plaintiff had
met 415 of her therapeutic goals and was discharged from physical therapy on March 27, 2014.
(AR 20, 714). Indeed, one of those therapeutic goals was that plaintiff "will tolerate upgrade to
wrist eccentrics to improve grip'' to greater than 8 kilograms without pain. (AR 714).
The ALJ also discussed Dr. Eapen's findings that plaintiffs grip was 4/5 in her right
hand and 5/5 in her left hand. (AR 19, 326). Additionally, as the court has already discussed,
the ALJ considered plaintiffs testimony regarding her use of a cane and found that a cane was
not medically necessary. In his findings, the ALJ cited Drs. Delorenzo and Baldwin's February

5, 2014 notation of plaintiffs "antalgic appearing gait secondary to arthritic knee pain." (AR 20,
663). The ALJ also discussed plaintiffs January 29, 2013 assessment, which noted that her
"[t]oe walking and heel walking" were normal and that plaintiffs "[g]ait and station" were
normal. (AR 18, 452). Additionally, the ALJ discussed plaintiffs physical therapy records, in

44

which Dr. Paven identified that plaintiffs "[g]ait is stable" and her "[l]ower extremity strength is
normal" on numerous occasions in 2013 and in February 2014. (AR 20, 730, 727, 725, 723).
Finally, while plaintiff argues that the ALJ failed to consider her "attempts at obtaining
relief through ice packs, heating pads, physical therapy, pool therapy, a back brace, and a TENS
unit" and the "sheer persistence with which she sought treatment for pain," the ALJ considered
these complaints. Indeed, the ALJ considered that a July 2013 EMG of plaintiffs lower
extremities showed "no evidence of neuropathy" and a "workup of cord imaging showed only
mild arthritis." (AR 19, 700). The ALJ also discussed that the same assessment found plaintifrs
symptoms had been "stable for years." (AR 19, 700). Additionally, the ALJ considered that on
July 8, 2011, the plaintiff noted that she was working out at a local fitness center and her energy
level had improved. (AR 18, 472).
For the foregoing reasons, the record in this case fails to show any "exceptional
circumstances" that would lead the court to disturb the ALJ's credibility determination.
Accordingly, because the ALJ's credibility determination is supported by substantial evidence,
the plaintiffs argument that the ALJ erred in failing to give more credit to plaintiffs statements
is without merit.

E.

The ALJ's Determination That Plaintiff's Residual Functional Capacity
Permits Her to Perform Past Relevant Work as a Packager or Alternatively,
Jobs That Exist in Significant Numbers in the National Economy, Is
Supported by Substantial Evidence

Plaintiff contends that because the ALJ improperly evaluated her complaints of carpal
tunnel syndrome, her residual functional capacity, her credibility, and the opinions of her treating
physician and nurse practitioner, the ALJ's subsequent determination that plaintiffs residual
functional capacity permits her to perform past relevant work as a packager, or alternatively,
other jobs that exist in significant numbers in the national economy, is without substantial
45

evidence. (Docket no. 15 at 21). The Commissioner asserts that the ALJ's hypothetical question
to the vocational expert regarding the ability of an individual with plaintiffs residual functional
capacity to perform past relevant work or other jobs that exist in significant numbers in the
national economy adequately reflected a residual functional capacity for which the ALJ had
substantial evidence. (Docket no. 17 at 22). Accordingly, the Commissioner argues that the
ALJ's determinations at steps four and five are supported by substantial evidence. (Id.).
Upon determination of a claimant's residual functional capacity at step three in the
sequential process, the ALJ must next determine whether the claimant is capable of returning to
past relevant work-step four in the adjudication of disability claims. See 20 C.F.R. §§
404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the ALJ finds in the affirmative in step four, the ALJ
will conclude that the claimant is not disabled. Id. However, if the ALJ finds that the claimant is
not capable of returning to past relevant work, review will then proceed to step five. See Hunter

v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992). At step five of the adjudication, the ALJ must
determine whether the individual is capable of adjustment to other work. 20 C.F.R §§
404.1520(a)(4)(v), 416.920{a)(4)(v). Ifa claimant's residual functional capacity limits her
ability to perform the full range of work at a particular level, the ALJ must determine in this step
whether there is work available in the national economy that the particular claimant can perform
given her individual limitations. See Walker v. Bower, 889 F.2d 47, 49-50 (4th Cir. 1989). This
determination can be aided by a vocational expert who has been made aware of all the evidence
in the record and to whom hypothetical questions are posed that "fairly set out all of [a)
claimant's impairments." Id. at 50. "A hypothetical question is unimpeachable if it 'adequately
reflect[s]' a residual functional capacity for which the ALJ had sufficient evidence." Fisher v.

46

Barnhart, 181 F. App'x 359, 364 (4th Cir. 2006) (per curiam) (unpublished) (citing Johnson v.
Barnhart, 434 F.3d 650, 659 (4th Cir. 2005)).
Here, at step three in the sequential process, the ALJ determined that the plaintiff had the
residual functional capacity to
perform a range of light work as defined in 20 CFR [§§] 404.1567(b) and
416.967(b)[ 12]. She is limited to occupations that require no more than occasional
postural maneuvers, such as balancing, stooping, kneeling, crouching and
climbing on ramps and stairs. She must avoid occupations that require climbing
on ladders or crawling. She is limited to occupations, which do not require
exposure to dangerous machinery and unprotected heights.
(AR 16). Based upon this residual functional capacity, the ALJ next considered whether the
plaintiff was capable of performing past relevant work as a packager, which is classified as
medium unskilled work, but which plaintiff performed at the light exertional level-as identified
by Patricia Jillary, a vocational expert who provided testimony to the ALJ to aid in his analysis. 13
(AR 20, 52). The ALJ asked the vocational expert to "assume a hypothetical individual with the
same age, education[,] and work experience as the claimant" who would be limited to a range of
light work and "[w]ould be limited to occupations requiring no more than occasional posturals[,]
such as balancing, stooping, kneeling, crouching as well as climbing on ramps and stairs but
must avoid occupations that would require climbing on ladders" and "exposure to dangerous
machinery and unprotected heights." (AR 53). Based on this hypothetical, the ALJ asked the
vocational expert whether such a person could perform any of the claimant's past relevant work.

12

See supra note 11 (definition oflight work in 20 C.F.R. §§ 404.1567(b). 416.967(b)).
The vocational expert identified that in plaintiff's previous position as a hand packager, plaintiff"was
required to type in work orders, then pack them in boxes, and that consisted of packing small products such as
peanuts and prizes at a desk." (AR 52). The vocational expert indicated that this previous job "would be classified
as a hand packer - packager and it was performed at the light duty exertional level based upon the information
contained in the work history report of lifting of 20 pounds [and] standing for two hours." (Id). Plaintiff does not
dispute the characterization that she performed her prior work as a hand packager at the light exertional level.
13

47

(Id). The vocational expert indicated that such a claimant could perform past work as a hand
packager 14 as performed at the light-duty level. (Id).
As an alternative finding, the ALJ proceeded to step five and considered whether, when
considering the plaintiffs age, education, work experience, and residual functional capacity, jobs
that the plaintiff can perform exist in significant numbers in the national economy. The ALJ
relied upon the same hypothetical person as described above. (AR 53). The ALJ asked the
vocational expert whether such a hypothetical individual would be able to perform other work.

(Id). The vocational expert indicated that such an individual would be able to perform the work
ofrepresentative unskilled, light positions such as: box inspector, U.S. Dep't of Labor,

Dictionary of Occupational Titles,§ 762.687-014 (4th ed. 1991); ticketer, Id. § 229.587-018; and
produce weigher, Id § 299.587-010. 15 The vocational expert testified that each of the
representative occupations would be available in significant numbers in the national economy
and plaintiffs regional economy. (AR 54). After considering the other evidence in the record
and the vocational expert's testimony, the ALJ concluded, in the alternative to his step four
finding, that the plaintiff was capable of making a successful adjustment to other work that exists
in significant numbers in the national economy. (AR 21).
First, plaintiff does not dispute that the hypothetical question posed by the ALJ
adequately reflected the plaintiffs residual functional capacity, as determined by the ALJ in step

14

See Packager, Hand, U.S. Dep't of Labor, Dictionary of Occupational Titles, § 920.587-018 (4th ed.

1991 ).
15
The vocational expert identified "sample [Dictionary of Occupational Titles]" in her testimony by job
code, but did not precisely identify the name of each occupational title. (AR 54). The ALJ incorrectly identifies
these sample occupational titles as "sorter," "stock clerk," and "weigher," respectively, in his opinion. (AR 21).
However, in his opinion, the ALJ cited the same Dictionary of Occupational Titles job codes as provided in the
vocational expert's testimony. (AR 21, 54). Plaintiff does not raise this specific error and the court declines to
address it. However, the court does note that the Fourth Circuit has cited with approval dictum from the Third
Circuit that noted that an ALJ's erroneous citation to the Dictionary of Occupational Titles is not per se reversible
error. See Fisher v. Barnhart, 18 l F. App'x 359, 367 (4th Cir. 2006) (per curiam) (unpublished) (citing with
approval Burns v. Barnhart, 312 F.3d 113 (3d Cir. 2002)).

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three. On this issue, the court agrees with the Commissioner that the hypothetical posed by the
ALJ accurately reflected the ALJ's assessment of plaintiff's residual functional capacity.
(Docket no. 17 at 22). Plaintiff also does not dispute that her past relevant work as a hand
packager, as performed, and the representative unskilled, light positions identified by the
vocational expert do not exceed her residual functional capacity, as determined by the ALJ.
Thus, plaintiffs argument that the ALJ' s hypothetical question to the vocational expert was
incomplete relies upon plaintiffs argument that the ALJ erred at steps two and three.
Specifically, that the ALJ erred in evaluating her complaints of carpal tunnel syndrome,
determining her residual functional capacity, evaluating her credibility, and weighing and
evaluating the opinions of her treating physician and nurse practitioner. (Docket no. 15 at 21).
As the court has concluded, however, the ALJ's determination of the medical severity of
plaintiffs impairments at step two, his determination of plaintiff's residual functional capacity at
step three, and his evaluation of plaintiffs credibility are all supported by substantial evidence
and were properly determined by the ALJ in accordance with applicable law. The court also
concluded that the failure to discuss the legal opinion rendered by plaintiffs treating physician
was harmless error. Thus, because the ALJ's determination of plaintiffs residual functional
capacity is supported by substantial evidence and the hypothetical posed accurately reflected this
residual functional capacity, the ALJ's determination that plaintiff could perform her past
relevant work as a hand packager, which was performed at the light exertional level and did not
exceed plaintiffs residual functional capacity, is supported by substantial evidence. Next,
alternatively, because the hypothetical question posed to the vocational expert accurately
reflected a residual functional capacity for which the ALJ had substantial evidence and was
properly determined in accordance with applicable law, the ALJ did not err at step five. Thus,

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the ALJ's determinations at step four and alternatively, at step five, of the sequential evaluation
process are supported by substantial evidence and were decided in accordance with applicable
law.

V. CONCLUSION
Based on the foregoing, the Commissioner's final decision rendered on June 9, 2014denying benefits for the period ofNovember 17, 2009 through June 9, 2014-is supported by
substantial evidence. The court also finds that proper legal standards were applied when
evaluating the evidence and determining the credibility of various medical sources. Accordingly,
plaintiffs motion for summary judgment (Docket no. 14) is denied; the Commissioner's motion
for summary judgment (Docket no. 16) is granted; and the final decision of the Commissioner is
affirmed.

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Entered this 21st day of April, 2016.

_ _ ___ /s/ _ _ _ _ _ __
John F. Anderson
United States Magistrate Judge

John F. Anderson
United States Magistrate Judge
Alexandria, Virginia

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