United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
Kathleen B. Burke United States Magistrate Judge
Lloyd Fairley, Jr. (“Fairley”) seeks judicial
review of the final decision of Defendant Commissioner of
Social Security (“Commissioner”) denying his
application for Disability Insurance Benefits
(“DIB”) and Supplemental Security Income
(“SSI”). Doc. 1. This Court has jurisdiction
pursuant to 42 U.S.C. § 405(g). This case is before the
undersigned Magistrate Judge pursuant to the consent of the
parties. Doc. 15.
forth more fully below, the Administrative Law Judge
(“ALJ”) failed to explain what he meant when he
included a limitation in his residual functional capacity
assessment that Fairley “must be able to change
position in his seat as needed for comfort” and
testimony from the Vocational Expert does not shed light on
this limitation. Thus, the Court cannot ascertain whether
this limitation is in conflict with the Dictionary of
Occupational Titles and would warrant further investigation
by the ALJ. Accordingly, the decision of the Commissioner is
REVERSED and REMANDED for further proceedings consistent with
filed applications for DIB and SSI on February 6, 2013,
alleging a disability onset date of March 5, 2012. Tr. 12,
182, 212. He alleged disability based on the following: post-
traumatic stress disorder, depression, bipolar disorder,
schizophrenia, diabetes, disc herniation L3-L5, high blood
pressure, supraventricular tachycardia, complex medial
meniscus tear in left knee, and left hip contusion and
sprain. Tr. 228. After denials by the state agency initially
(Tr. 101-102) and on reconsideration (Tr. 129-130), Fairley
requested an administrative hearing. Tr. 156. A hearing was
held before Administrative Law Judge (“ALJ”)
Frederick Andreas on January 29, 2015. Tr. 40-76. In his
April 17, 2015, decision (Tr. 12-35), the ALJ determined that
there are jobs that exist in significant numbers in the
national economy that Fairley can perform, i.e., he is not
disabled. Tr. 34. Fairley requested review of the ALJ's
decision by the Appeals Council (Tr. 7) and, on March 9,
2016, the Appeals Council denied review, making the ALJ's
decision the final decision of the Commissioner. Tr. 1-3.
Personal and Vocational Evidence
was born in 1966 and was 46 years old on the date his
applications were filed. Tr. 34, 212. He graduated from high
school. Tr. 229. He previously worked in a steel mill as a
vacuum operator and at a paper factory as a wrapper. Tr.
69-72. He last worked in 2012. Tr. 48.
Relevant Medical Evidence 
April 2010, Fairley saw chiropractor Brian C. Studer, D.C.,
after a car accident. Tr. 297-304. Fairley complained of
headaches, neck pain, back pain, shoulder pain, and left
wrist pain. Tr. 298. He improved with treatment but continued
to have intermittent muscle spasms/guarding within his
bilateral lumbar region. Tr. 303.
treatment note from March 2011 states that Fairley's type
2 diabetes was under extremely poor control, which, Fairley
admitted, was because of poor dietary restrictions: ingesting
soda pop, a lot of candy, and chocolate. Tr. 328. Treatment
notes in May and July 2011 show that he was not doing
appropriate blood sugar monitoring. Tr. 326, 324.
March 5, 2012, Fairley went to the Mercy Regional Medical
Center after he fell through a grating at work, hitting his
left leg and hip on a steel bar. Tr. 361. X-rays were
unremarkable and Fairley was diagnosed with left hip and knee
strain/contusion and lumbar strain/sciatica. Tr. 362. The
next day, he saw Dr. Studer, who found, among other things,
left-sided trapezius spasms. Tr. 374. Fairley was using a
cane to walk. Tr. 374.
April 2, 2012, Fairley underwent an independent evaluation
with Dr. Paul Martin, M.D., complaining of bilateral knee
pain, bilateral upper extremity numbness and tingling, left
low back and hip pain and spasm, and “some neck
problems.” Tr. 378-379. Upon exam, he had an antalgic
gait to the left and carried a cane. Tr. 379. He had
significantly limited left hip range of motion based on his
reports of pain, but no evidence of soft tissue swelling. Tr.
379. His low back was moderately tender to palpation on the
left side and he had a fairly limited lumbar spine range of
motion due to reported pain, but no evidence of muscle spasm
and a normal lumbar lordosis. Tr. 379. He had low back pain
upon slight dorsiflexion of his ankle and great toe while
supine and increased low back pain with hip range of motion
and head compression. Tr. 379. He had intact motor function
and normal sensation and deep tendon reflexes in his
bilateral lower extremities. Tr. 380. He complained of
significant left knee pain in a fairly diffuse pattern. Tr.
380. Dr. Martin answered all the questions submitted to him
in the form with respect to Fairley's back, hip and knee
impairments; based on these, Dr. Martin opined that Fairley
was unable to return to work without a restriction and had
not reached medical maximum improvement at that time. Tr.
1, 2012, Fairley saw Satish Mahna, M.D., complaining of back
and leg pain as well as intermittent neck pain and
intermittent tingling, numbness and weakness in his left
hand. Tr. 408. He was using a cane in his left hand to
ambulate. Tr. 408. Upon exam, he had tenderness in his left
and posterior trapezial muscle with spasms, no focal trigger
points, and “some” restricted range of motion in
his cervical spine. Tr. 408. His upper extremities were
unremarkable except for complaints of tightness in his
trapezial areas with overhead reaching and a positive Phalen
sign, left greater than right. Tr. 408. His upper extremities
had normal neurological findings: no muscle atrophy or motor
or sensory deficits. Tr. 409. Dr. Mahna diagnosed Fairley
with a sprain/strain in his back and left hip and knee, and
“believe[d]” that, “considering the
mechanics of [Fairley's] injury, ” he suffered a
cervical strain/sprain. Tr. 409. Dr. Mahna recommended MRIs
of Fairley's lumbar spine and left knee as well as
trigger point injections in his lumbar paraspinal muscles and
prescribed Percocet. Tr. 409.
October 4, 2012, Fairley underwent an independent medical
evaluation with Dr. Ira Ungar, M.D. Tr. 410-417. Among his
chief complaints of back, left hip and left knee pain,
Fairley also complained that his hands go numb. Tr. 411. Upon
examination of Fairley's lumbar spine, Dr. Ungar
commented that Fairley made exaggerated complaints of
discomfort at extreme ranges of motion. Tr. 413. Fairley
exhibited exaggerated pain behavior “and 6 out of 7
Wadell signs for somatic amplification are positive
suggesting significant symptom magnification.” Tr. 413.
An examination of his cervical spine showed no atrophy,
spasm, or dissymmetry. Tr. 414. His head posture was normal
and his motion was smoothly coordinated. Tr. 414. He had
minor discomfort upon palpation of his paracervial muscles
but no evidence of “tender or trigger points.”
Tr. 414. Manual muscle testing of his upper extremities
showed no weakness or evidence of atrophy bilaterally. Tr.
414. His grip strength was strong and equal bilaterally and
distal sensation was intact over all dermatomes. Tr. 414. Dr.
Ungar found no evidence of cervical myelopathic deficits by
numbness, weakness or Hoffman's tests. Tr. 414.
Fairley's deep tendon reflexes in his biceps, triceps and
brachioradialis were symmetric bilaterally. Tr. 414. Dr.
Ungar answered all the questions submitted to him in the form
with respect to Fairley's back, hip, knee and neck
impairments; based on these, Dr. Ungar opined that Fairley
was able to return to work without restrictions and had
reached medical maximum improvement at that time. Tr. 416.
December 26, 2012, Fairley saw Dr. Mahna and had tenderness
and spasm in his posterior and left trapezial muscle and
“some” restricted range of motion in his cervical
spine; he carried a cane in his left hand for ambulating; and
had a normal neurological examination of his upper
extremities. Tr. 388.
March 26, 2013, Fairley reported that his pain had gotten
worse, 10/10, and Dr. Mahna prescribed Neurontin. Tr.
529-531. His physical examinations remained unchanged. Tr.
April 16, 2013, Fairley complained to Dr. Mahna of
“pressure type neck pain” without radiation into
his upper extremities and intermittent tingling, numbness and
weakness in both hands, left worse than right. Tr. 532. The
neurological exam findings of his upper extremities were
normal. Tr. 533. Fairley reported that he had stopped taking
Neurontin about two weeks prior because of side effects. Tr.
September 25, 2013, Fairley underwent arthroscopic surgery of
his left knee with a partial medial meniscectomy. Tr. 620. In
a follow-up visit a month later, he had full motion and his
preoperative pain was gone. Tr. 619.
October 8, 2013, Fairley had an EMG study based on his
complaints of numbness in his hands and his history of
diabetes mellitus type 2. Tr. 616. The study showed mild
bilateral median nerve compression neuropathy at the wrists
consistent with a diagnosis of mild bilateral carpal tunnel
syndrome, slightly worse on the left side. Tr. 616. The
reviewer also stated that Fairley's history of diabetes
was resulting in developing changes of early peripheral
neuropathy. Tr. 616.
continued to see Dr. Mahna, who continued to report the same
findings as in previous visits; i.e., neck “essentially
unremarkable, ” with tenderness and spasm in his left
and posterior trapezial muscle and some restriction of range
of motion in his cervical spine; he carried a cane in his
left hand for ambulating; and he had a normal neurological
examination of his upper extremities. Tr. 693, 696, 699, 702,
705, 708. Fairley started back on Neurontin. Tr. 700.
October 10, 2014, Fairley went to the emergency room
complaining of pain in his knees, low back and neck for the
last week. Tr. 599. Upon exam, he had a supple and non-tender
neck with full range of motion. Tr. 599. He had a normal
gait. Tr. 601. He had normal muscle strength and tone, normal
digits, and full range of motion and no tenderness in his
upper extremities. Tr. 601. He had tenderness in his
bilateral lumbar paraspinal muscles. Tr. 601. He was
diagnosed with chronic back pain and diabetic neuropathy, was
given prescriptions (Percocet and Naprosyn), and discharged
home. Tr. 601, 603.
Physical therapist's functional capacity
February 6, 2015, Fairley underwent a functional capacity
evaluation with a physical therapist. Tr. 719-722. His past
medical problems were listed as hypertension, heart problems,
diabetes, and neck, back, hip and knee problems. Tr. 719.
Upon exam, his trunk flexion was 50% of normal, his extension
was 25% of normal, and his bilateral side bend was 50% of
normal. Tr. 719. His upper extremity strength was decreased,
4/5, and his shoulder range of motion was decreased. 720. The
range of motion in his elbows, forearms, wrists and hands was
normal. Tr. 720. His grip and pinch testing was significantly
below normal; the evaluator wrote, “Mr. Fairley did not
demonstrate maximum effort with grip and pinch
testing.” Tr. 720. He displayed poor body mechanics
with the lifting tasks. Tr. 721. The evaluator opined that
Fairley had decreased grip and pinch strength, decreased fine
finger manipulation, and decreased gross motor coordination.
Tr. 722. The evaluator stated that Fairley could perform
sedentary work with ...