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Middleton v. Commissioner of Social Security

United States District Court, District of Columbia

March 13, 2018




         Charletha B. Middleton (“plaintiff”) challenges the decision of the Acting Commissioner of Social Security (“SSA”) to deny her application for period of disability and disability insurance benefits (“DIB”) under Title II of the Social Security Act, see 42 U.S.C. §§ 401-33. This matter is before the Court on plaintiff's Motion for Judgment of Reversal and the SSA's Motion for Judgment of Affirmance. For the reasons discussed below, the Court denies the former and grants the latter.

         I. BACKGROUND

         A. Procedural History

         Plaintiff submitted an application for DIB on January 11, 2013. (A.R. 168-74.)[1] At that time, she was 36 years of age. (A.R. 70.) According to plaintiff, she became disabled on May 3, 2012, (A.R.168), because of the condition of her neck, shoulder, arm, hand and leg, and the resulting pain she experiences, (A.R. 204). SSA denied her application on March 29, 2013. (A.R. 93-96). Plaintiff sought reconsideration of the decision, (A.R. 97), without success, as the SSA found “that the previous determination . . . was proper under the law, ” (A.R. 98). On August 5, 2013, plaintiff requested, (A.R. 107-08), and SSA scheduled, (A.R. 133-37), a hearing before an administrative law judge (“ALJ”). The hearing took place on May 13, 2015. Plaintiff, who then was represented by counsel, testified at the hearing, as did an impartial vocational expert. (A.R. 40-69). The record remained open for 14 days after the hearing in order that plaintiff submit updated treatment records; plaintiff filed none. (A.R. 22).

         The ALJ issued his decision on June 25, 2015 that plaintiff is not disabled and, therefore, is not entitled to period of disability or disability insurance benefits. (A.R. 33). On July 5, 2015, plaintiff sought review of the ALJ's decision. (A.R. 14-15). The Appeals Council denied the request on July 16, 2016. (A.R. 1-6).

         B. Medical Records

         According to plaintiff, she has “endured [her] condition since 2005.” (Mot. for J. of Reversal at 1; A.R. 360). She reported that she has severe pain in her back, neck, right arm and right hand. (A.R. 212). Plaintiff underwent magnetic resonance imaging (“MRI”) of the right shoulder in May 2012. (A.R. 441). The test revealed “[m]ild AC joint arthropathy, ” but “no significant tear of the rotator cuff or labrum, ” (A.R. 441), and was “[o]therwise [a] negative study.” (A.R. 441; see A.R. 260). X-rays of plaintiff's cervical spine in May 2012 showed “[m]ild degenerative spondylosis and foraminal stenosis.” (A.R. 440). An MRI of plaintiff's cervical spine in June 2012 showed “[d]egenerative disk spondylitic change with multilevel neural foraminal encroachment, ” but “no spinal stenosis or cord compression.” (A.R. 369; see A.R. 258).

         In July and August 2012, plaintiff attended four sessions with a physical therapist. (A.R. 265). Eight sessions had been scheduled, yet plaintiff discharged herself and chose not to return after a fourth visit. (A.R. 264).

         Plaintiff presented to Avery Healthcare Associates, PC, on January 30, 2013, complaining of neck, shoulder and back discomfort, and requested a referral for consultation with an orthopedic specialist. (A.R. 360). On March 13, 2013, Dr. Elliott Aleskow conducted a disability evaluation. (A.R. 306-14). Plaintiff complained of “pain radiat[ing] to the middle of her back and both shoulders, ” and stated she had not sustained a neck injury at any time. (A.R. 306). She required no assistive device; she could sit and stand 15-30 minutes; she could walk 4-5 blocks; she could travel without difficulty. (A.R. 306). In addition, plaintiff “was able to walk on heels and toes, squat rise from a squatting position and tandem walk without difficulty.” (A.R. 307). The strength of her hand grip was normal bilaterally, and she “was able to do fine-motor skills without significant difficulty.” (A.R. 307). According to Dr. Aleskow, plaintiff “had full range of motion of all extremities with the exception of the cervical spine region, ” and aside from this limited range of motion, plaintiff “appear[ed] to be stable medically” and without “any obvious neurological deficit[.]” (A.R. 307).

         Plaintiff consulted with Dr. Damon Robinson, a pain management specialist, (A.R. 50), on June 7, 2013, complaining of “continuous, throbbing, aching, shooting and severe” pain that had begun seven years previously and gradually progressed. (A.R. 436). After conducting a physical examination, Dr. Robinson's “primary diagnosis [was] cervical radiculopathy secondary cervical disc displacement.” (A.R. 437). Dr. Robinson conducted cervical examinations on July 5, 2013 (A.R. 433-34), July 26, 2013 (A.R. 430-31), September 25, 2013 (A.R. 421-22), October 25, 2013 (A.R. 418-19), November 11, 2013 (A.R. 415-16), November 27, 2013 (A.R. 411-12), May 5, 2014 (A.R. 404-05), September 9, 2014 (A.R. 401), October 7, 2014 (A.R. 397), November 21, 2014 (A.R. 392), and March 17, 2015 (A.R. 371). He reported nearly identical negative results from these examinations. Dr. Robinson conducted lumbar examinations on September 13, 2013 (A.R. 427), March 12, 2014 (A.R. 408-09), November 21, 2014 (A.R. 393), and March 17, 2015 (A.R. 371), and one thoracic examination on November 21, 2014, with negative results. (A.R. 393).

         Dr. Robinson referred plaintiff to physical therapy on November 27, 2013. (A.R. 321). Plaintiff was considered “an excellent candidate for physical therapy intervention to decrease the pain in the arm and in the neck, teach proper posture and body mechanics, and overall therapeutic exercises to promote muscle strength and restore over all function.” (A.R. 324). On February 19, 2014, plaintiff reported that her “pain condition [was] unchanged, ” (A.R. 342), and significant improvement with her range of motion and strength in her neck and shoulder, (A.R. 344). Her last appointment was February 25, 2014. (A.R. 348).

         Plaintiff had an MRI of her cervical spine on November 7, 2015, (A.R. 10), which revealed “[m]ultilevel degenerative changes with severe left and moderate right neural foraminal narrowing at ¶ 4-C5, moderate to severe right and moderate left neural foraminal narrowing at ¶ 5-C6, and moderate left neural foraminal narrowing at ¶ 6-C7, ” (A.R. 11).

         On April 6, 2016, plaintiff underwent an MRI of her lumbar spine, which revealed:

Specific disc disease is as follows:
L4-L5: There is a mild diffuse disc bulge and a moderate-sized central annular fissure. There is no significant spinal canal or neural foraminal narrowing.
L5-S1: There is a mild diffuse disc bulge and a moderate-sized central annular fissure that contacts the descending S1 nerve roots.
There is mild bilateral facet arthropathy resulting in mild bilateral neural foraminal narrowing. There is no significant spinal canal narrowing.
The remainder of the vertebral levels are unremarkable with no evidence of significant spinal canal or neural foraminal narrowing.
Mild diffuse disc bulges and moderate central annular fissures at ΒΆ 4-L5 and L5-S1 with abutment of the descending ...

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