United States District Court, N.D. Ohio, Western Division
Rita G. Baus, Plaintiff,
Acting Commissioner of Social Security, Defendant.
G. Carr Sr. U.S. District Judge.
a Social Security case in which the plaintiff, Rita G. Baus,
appeals the Commissioner's decision denying her
application for disability insurance benefits (DIB).
administrative law judge (ALJ) found Baus was not under a
disability. As a result, the ALJ denied plaintiff's
is the Magistrate Judge's Report and Recommendation
(R&R), which recommends affirming the ALJ's decision
denying benefits. (Doc. 17).
objects to the R&R and asks that I overrule the R&R
and reverse the Commissioner's decision. (Doc. 18).
following reasons, I adopt in full the R&R, and I affirm
the ALJ's decision.
began a treatment relationship with Dr. James Wysor, M.D., in
1986 for recurrent lower back pain.
September, 1995, plaintiff returned to Dr. Wysor, again
complaining of low back pain. A physical examination revealed
bilateral tenderness at the lumbar sacral junction, negative
straight leg raising test, and symmetric knee and ankle
reflexes. In June, 2006, plaintiff went back to Dr. Wysor
with similar complaints, and a physical examination showed
lumbar tenderness, diminished reflexes, and a negative
straight leg raising test.
April, 2009, plaintiff was in a car accident, and as a
result, she went to the emergency room, complaining of neck
pain and nausea. Despite some knee discomfort and shoulder
tenderness, plaintiff showed normal deep tendon reflexes,
sensation, and range of motion in all extremeties. A chest
x-ray showed endplate spurring in plaintiff's spine, and
a cervical spine x-ray showed multilevel disc space narrowing
and endplate spurs.
days after the accident, plaintiff went to Dr. Wysor, where
an examination revealed satisfactory neck range of motion.
Plaintiff participated in physical therapy for neck, left
arm, low back, and right leg pain, demonstrating good
potential for rehabilitation.
July, 2009, Dr. Wysor referred plaintiff to Dr. Dale Braun,
M.D., -a neurosurgeon. At a September, 2009 appointment with
Dr. Braun, the results of plaintiff's neurological
examination were normal. A physical examination showed
plaintiff had a full range of motion and no tenderness in her
neck. Dr. Braun diagnosed plaintiff with cervicalgia and
cervical spondylosis without myelopathy and recommended an
October, 2009, plaintiff followed up with Dr. Wysor. At that
appointment, plaintiff complained of neck and knee pain. An
examination showed joint line tenderness without instability
or effusion and no erythema, warmth, or residual ecchymosis.
After the appointment, Dr. Wysor referred plaintiff to an
orthopedic surgeon-Dr. Michael Felter, M.D., -to treat her
right knee pain.
Felter made the following notes after evaluating plaintiff:
Examination of the right knee shows no significant redness,
warmth, swelling or effusion. There is no sign of ecchymosis.
There is pain to palpation with patellar compression but no
crepitation. She has full flexion, full extension. Quad and
patellar tendon function are intact. There is no significant
medial instability. Lachman test is somewhat limited
secondary to guarding. McMurray's test causes slight
medial and lateral discomfort.
February, 2010, plaintiff went back to Dr. Felter. Despite
intermittent knee pain and Dr. Felter's recommendation,
plaintiff postponed right knee surgery. Instead, plaintiff
received a right knee injection. With respect to
plaintiff's left knee, Dr. Felter noted that she recently
heard or felt a “pop.” On March 8, 2010, Dr.
Felter performed right knee arthroscopic surgery for a torn
medial meniscus. After surgery, plaintiff expressed she felt
improvement in her right knee but still experienced pain
caused by activity. In April, 2010, based on her unusually
slow recovery, Dr. Felter advised plaintiff to lose weight
and also gave her another right knee injection.
August, 2010, Dr. Felter examined plaintiff's knees and
diagnosed degenerative joint disease, right knee pain, and
progressive arthritis. As a result, Dr. Felter administered a
series of five right knee injections. At the end of that
month, plaintiff's complaints of continuing right knee
pain continued. An examination revealed the following:
Examination of the right knee reveals neutral alignment.
Slight effusion is noted. Mild medial joint line tenderness.
Full active and passive range of motion is noted. The patella
tracks well. Good quad strength. Normal stability in all
directions. The skin is intact and clear over the knee. There
is no tenderness to palpation in the calf. There is no
redness, increased warmth, or pain on passive stretch of
calf. Pulses are intact.
(Id. at 382).
on this examination, Dr. Felter concluded that plaintiff
suffered pre-existing asymptomatic arthritis in her right
knee, aggravated by the April, 2009 car accident.
February, 2011, plaintiff sought treatment from Dr. Braun for
neck pain. A bone scan and x-ray showed no significant
pathology. Dr. Braun recommended further treatment with
after another appointment with Dr. Felter, plaintiff elected
to pursue additional injection therapy, as opposed to
undergoing a total knee arthroplasty.
February, 2011 to May, 2011, plaintiff participated in
physical therapy. Despite improved right knee extension
throughout the course of treatment, plaintiff was
dissatisfied and cancelled her remaining physical therapy
June, 2011, plaintiff fell, further injuring her right knee.
A physical examination of both knees showed slight effusion,
mild joint tenderness, full active and passive range of
motion, and normal stability in all directions. Plaintiff
received another round of injections, and Dr. Felter told her
that, eventually, she would need to consider another surgery.
January, 2012, plaintiff started another round of knee
injections-this time in her left knee. That same month, a
physical examination performed by Dr. Felter showed normal
right knee results and slight effusion and mild tenderness in
plaintiff's left knee.
December, 2012, however, plaintiff told Dr. Felter she was
experiencing fairly severe pain in both knees. Because her
pain was worse in the left knee, Dr. Felter administered a
left knee injection.
January, 2013, plaintiff again complained of mid-back pain
and muscle spasms. At that time, Dr. Marsha D. Cooper, M.D.,
performed a consultative examination at the state
agency's request. In addition, two state agency
physicians-Drs. Leanne M. Bertani, M.D., and Elizabeth Das,
M.D., -provided opinions.
following month, plaintiff complained of severe right knee
pain. As a result, Dr. Felter performed a series of
injections based on plaintiff's previous success with
this treatment plan.
March, 2013, thoracic x-rays revealed mild to moderate
spondylosis in plaintiff's mid to lower thoracic region.
Not long after the x-rays, plaintiff stated she had
experienced body aches generally since the time of her April,
2009 car accident, and those aches worsened when she remained
in the same position for more than an hour, especially while
standing. Dr. Wysor diagnosed cervical/thoracic spondylosis
and recommended physical therapy.
2013, Dr. Felter administered yet another series of
injections in plaintiff's left knee. After the fifth
injection, plaintiff reported improvement.
one year later, in March, 2014, plaintiff returned to Dr.
Wysor, complaining of back pain. Similarly, in May, 2014,
plaintiff told Dr. Wysor she had experienced back and hip
pain for the last two weeks.
between April, 2014 and June, 2014, Dr. Felter administered
another series of right knee injections, after which
plaintiff reported improvement.