United States District Court, N.D. Ohio, Eastern Division
TRACY L. JIROUSEK, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
MEMORANDUM OPINION & ORDER
KATHLEEN B. BURKE, United States Magistrate Judge
Tracy L. Jirousek (“Plaintiff” or
“Jirousek”) seeks judicial review of the final
decision of Defendant Commissioner of Social Security
(“Defendant” or “Commissioner”)
denying her application for social security disability
benefits. 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.
18. As explained more fully below, the Court AFFIRMS the
protectively filed an application for Disability Insurance
Benefits (“DIB”) on November 30,
2012. Tr. 18, 69, 151, 169. Jirousek alleged a
disability onset date of February 1, 2006 (Tr. 18, 151, 169),
which she later amended to November 1, 2012 (Tr. 18, 38-39,
168). Jirousek alleged disability due to neck pain and
stiffness, low back pain, shoulder pain, arm numbness and
tendency to drop things, headaches, depression (low energy,
irritable), insomnia due to pain, impaired concentration,
very slow pace due to pain and stiffness, side effects from
medication, needs sit/stand/walk/recline, and limited
reaching. Tr. 69-70, 95, 103, 180. Jirousek's application
was denied initially (Tr. 95-101) and upon reconsideration by
the state agency (Tr. 103-109). Thereafter, she requested an
administrative hearing. Tr. 110.
February 26, 2015, an administrative hearing was conducted by
Administrative Law Judge Susan Giuffre (“ALJ”).
Tr. 35-68. On April 6, 2015, the ALJ issued her decision. Tr.
15-34. In her decision, the ALJ determined that Jirousek had
not been under a disability within the meaning of the Social
Security Act from November 1, 2012, through March 31, 2013,
her date last insured. Tr. 18, 30. Jirousek requested review
of the ALJ's decision by the Appeals Council. Tr. 14. On
March 22, 2016, the Appeals Council denied Jirousek's
request for review, making the ALJ's decision the final
decision of the Commissioner. Tr. 1-6.
Personal, vocational and educational evidence
was born in 1969. Tr. 151. She completed high school and
obtained a certificate from a medical massage school. Tr.
41-42. However, she never used her medical massage
certificate. Tr. 42. Jirousek last worked full time in 2006
as a bartender/waitress at Henry's Bar. Tr. 42. From 2006
until 2009, Jirousek filled in at Henry's Bar. Tr. 42.
Jirousek lives in a house with her husband and her two minor
children. Tr. 45, 46. At the time of the hearing, her
children were ages nine and five. Tr. 46.
evidence pre-dating amended alleged onset date
in 2005, Jirousek received chiropractic treatment from
Gregory R. Poyle, D.C. Tr. 231-243. Jirousek's complaints
included neck and back pain and tingling in her hands/wrists.
Tr. 234, 237, 238, 241, 242. She continued treatments with
Dr. Poyle through 2007. Tr. 232-243.
October 25, 2007, upon referral of Douglas Potoczak, M.D.,
Jirousek's primary care physician since 2006 (Tr. 592),
Jirousek saw Sanjay Kumar, D.O., of Neurosurgical Services,
Inc., for a consultation regarding her pain (Tr. 392-393).
Jirousek was reporting some neck pain and pain going down the
arm with numbness and tingling into the thumbs since May or
June of 2007. Tr. 392. Jirousek's pain was present with
turning and twisting and sometimes her pain level was a 7/10.
Tr. 392. Jirousek had been taking Vicodin, which helped
minimally. Tr. 392. Jirousek was recently pregnant so she had
stopped taking her medicines except for Tylenol as needed.
Tr. 392. She had tried a prednisone taper but it did not
help. Tr. 392. On physical examination, Dr. Kumar noted that
extension and flexion caused some pain in the neck area;
there was mild pain to palpation over the right mid lower
cervical paraspinal muscles; and spurling maneuver caused
some mild radiating pain down the right arm. Tr. 392. Dr.
Kumar noted that Jirousek described “some paresthesias
in the C6 distribution.” Tr. 392. Dr. Kumar observed
that Jirousek's reflexes were 2 and symmetric; there
were no upper motor neuron signs or symptoms seen; strength
was at least 5/5 in the upper extremities; gait was normal;
and there were no obvious spinal deformities noted. Tr. 392.
Dr. Kumar indicated that a September 27, 2007, MRI showed
generalized disk bulging at ¶ 4-C5, C5-C6 and C6-C7,
greatest at ¶ 6-C7, with no stenosis. Tr. 392. Dr.
Kumar's impression was right-sided neck pain with pain
going down the arm likely secondary to C6 radiculitis with
mild disk bulging. Tr. 393. Because of Jirousek's
pregnancy, treatment options were limited. Tr. 393. Jirousek
indicated she had tried chiropractic manipulations and
traction which had been helping. Tr. 393.
November 2007, approval was obtained from Jirousek's
OB/GYN to proceed with injections. Tr. 391. On December 11,
2007, Jirousek reported that the right C5-C6, C6-C7 facet
injection helped for about a week. Tr. 389. She was still
having some numbness and tingling in her thumb and index
finger and sometimes pain in the parascapular region and
shoulder blade and neck. Tr. 389. Jirousek had experienced a
miscarriage and was taking Vicodin at night. Tr. 389. Nerve
conduction studies were performed and Dr. Kumar concluded
that there appeared to be electrodiagnostic evidence of mild
right-sided carpal tunnel syndrome characterized by sensory
fiber demyelination. Tr. 389. Dr. Kumar recommended carpal
tunnel wrist splints and a cervical epidural injections. Tr.
weeks after receiving the cervical epidural injections, on
December 31, 2007, Jirousek saw Dr. Kumar for follow up
reporting that the injections had helped significantly. Tr.
387. Most of her pain was now in the low back right side. Tr.
387. Her pain was worse with bending and standing and
sometimes it was hard to get out of bed. Tr. 387. She was
taking Vicodin and Tylenol rarely. Tr. 387. On examination,
Dr. Kumar observed some tenderness over the right lumbosacral
junction and SI region. Tr. 387. Flexion bothered Jirousek
more than extension. Tr. 387. Otherwise, she was
neurologically stable. Tr. 387. Dr. Kumar recommended x-rays
of the lumbar spine and SI joints. Tr. 387. Jirousek was
going to continue her home exercise program and see Dr. Kumar
in two weeks for follow up. Tr. 387.
a January 11, 2008, follow up visit with Dr. Kumar, Jirousek
reported that her neck was still feeling pretty good but she
was having low back pain, with her pain worse with lying
down. Tr. 385. The x-rays showed some posterior element
sclerosis in mid distal lumbar spine and arthritic changes at
the bilateral SI joints, right greater than left. Tr. 385.
Jirousek was taking Vicodin and Tylenol only as needed and
she reported that her pain interfered with her activities of
daily living and quality of life. Tr. 385. Dr. Kumar
recommended an MRI since lying down made her symptoms worse.
a January 25, 2008, Dr. Kumar indicated that the MRI showed a
broad base disk bulge at ¶ 4-L5, a small central disk
protrusion at ¶ 5-S1, and bilateral mild facet
arthropathy. Tr. 383. Jirousek's back hurt with extension
but her neck pain was stable. Tr. 383. Jirousek was taking
medicine only as needed. Tr. 383. She was walking
“twice a day 3 miles” which Jirousek felt helped
her. Tr. 383. The plan was for Jirousek to continue her home
exercise program with some flexion oriented exercises. Tr.
383. It was decided that Jirousek would hold off on
injections and Dr. Kumar directed Jirousek to call if she had
any flare ups. Tr. 383.
2, 2008, Jirousek saw Dr. Kumar reporting that her pain was
worse and she could not take it anymore. Tr. 381. She wanted
injections. Tr. 381. Dr. Kumar agreed to schedule L4-L5,
L5-S1 facet joint injections first. Tr. 381. Dr. Kumar
prescribed both Vicodin and Naprosyn. Tr. 381. On May 21,
2008, Jirousek saw Dr. Kumar and reported that her pain was
significantly better following the facet joint injections
performed two weeks prior. Tr. 379. Jirousek indicated that
she felt “awesome[.]” Tr. 379. She did indicate
that sometimes she still had issues with her neck. Tr. 379.
Dr. Kumar was happy with Jirousek's results and indicated
that he would see Jirousek back if she had any flare ups. Tr.
7, 2008, Jirousek returned to see Dr. Kumar reporting that
the pain in her neck had returned with numbness in her arms,
limited range of motion and some spasms. Tr. 377. Dr. Kumar
recommended epidural injections and physical therapy
thereafter. Tr. 377. On July 30, 2008, Jirousek reported 80%
relief from her cervical epidural injections. Tr. 375.
Jirousek inquired about cervical traction. Tr. 375. On
examination, Dr. Kumar observed minimal pain to palpation
over the neck and lower back paraspinal muscles. Tr. 375.
Jirousek's range of motion and strength were functional,
her sensation was intact to light touch, and neurologically
she was stable. Tr. 375. Dr. Kumar recommended comprehensive
outpatient therapy and a cervical traction unit that she
could use at home. Tr. 375.
next saw her primary care physician Dr. Potoczak on February
8, 2010, for follow up of her chronic neck and shoulder pain,
which Jirousek described as slightly worse. Tr. 293. Jirousek
indicated that her shoulder pain had started last summer and
was continuing to bother her but it was not interfering with
daily activities. Tr. 293. Jirousek indicated that she
“[f]elt a pop and some clicking last summer in the pool
with [her] daughter. She threw her up into the air playing
with her.” Tr. 293. On examination, Dr. Potoczak
observed pain and tenderness over the biceps;
“decreased range of motion, flexion, extension,
rotational movement[;]” some pain over supraspinatus;
trapezius muscle and paracervical muscular spasm and pain
with palpation; mild decreased range of motion; flexion and
extension, lateral bending secondary to pain; no parasthesias
in arms; good grip strength; some lumbar discomfort, worse
when on her feet a lot; and negative straight leg raises. Tr.
293. Dr. Potoczak's diagnoses included chronic lumbar
pain; sciatica with intermittent exacerbation; and chronic
shoulder pain, cannot rule out rotator cuff tear. Tr. 293. An
x-ray of Jirousek's right shoulder taken on February 8,
2010, showed mild degenerative changes. Tr. 324. Dr. Potoczak
indicated that the x-ray was negative but noted that an MRI
might be required. Tr. 293. Dr. Potoczak prescribed steroids
for 11 days; recommended heat in the morning and ice at
night; and Vicodin every 6 hours as needed. Tr. 293. An MRI
of the right shoulder taken on March 1, 2010, showed
“No rotator cuff abnormality identified.
Acromioclavicular degenerative changes.” Tr. 322.
following month, on March 31, 2010, Jirousek returned to see
Dr. Kumar almost two years since her last visit with him. Tr.
320, 372. Jirousek complained of right sided low back pain.
Tr. 320. Jirousek indicated that her back pain had flared up
on the right side. Tr. 320. She described her pain as a dull
ache and reported that bending and lifting bothered her. Tr.
320. Jirousek rated her pain as a 4/10. Tr. 320. She had
minimal numbness down her right leg. Tr. 320. She was taking
Vicodin as needed, three or four time per week, and Skelaxin,
Motrin and Tylenol as needed. Tr. 320. Jirousek had started
to jog. Tr. 320. She indicated that her pain affected her
quality of life and her sleep was decreased. Tr. 320.
Jirousek had another child about a year prior. Tr. 320. Dr.
Kumar assessed low back pain with degenerative disk and joint
disease of the lower lumbar spine with facet arthropathy,
symptomatic on the right. Tr. 320. Dr. Kumar noted that
Jirousek had done well with facet joint injections in the
past and recommended L4-L5, L5-S1 facet joint injections. Tr.
320. On April 19, 2010, Jirousek reported to Dr. Kumar's
office that she felt 75% better following her injections. Tr.
September 21, 2010, Jirousek saw Dr. Potoczak with complaints
of intermittent problems with her back and neck. Tr. 287. She
was interested in trying more muscle relaxant and needed a
refill on Vicodin. Tr. 287. Dr. Potoczak observed pain and
tenderness in the paracervical musculature and into the
trapezius but she was improved since before. Tr. 287. Dr.
Potoczak refilled Jirousek's medications with
instructions to follow up in a month or sooner if her
symptoms worsened. Tr. 287.
saw Dr. Potoczak on July 27, 2011, complaining of muscle pain
in her chest, shoulders and arms that had been going on for
about a month. Tr. 284. Dr. Potoczak indicated that the
muscle pain was possibly related to her use of Zocor, which
she had been on for almost a year. Tr. 284. Dr. Potoczak
diagnosed history of hyperlipidemia and chronic neck/back
pain, now with myalgias. Tr. 284. Dr. Potoczak discontinued
the Zocor and recommended follow up in two weeks. Tr. 284.
During an August 12, 2011, follow-up visit with Dr. Potoczak
Jirousek's myalgias had improved slightly. Tr. 283. On
examination, Jirousek's bicep area was not as tender but
she had continued pain in the paracervical musculature and
trapezius bilateral with muscle spasm, achiness in her upper
deltoid and tricep, and some chronic low back pain and
paresthesias in the right buttock area. Tr. 283. Dr. Potoczak
recommended keeping Jirousek off the Zocor and noted that she
was scheduled to see Dr. Kumar for an evaluation of lumbar
cortisone injections. Tr. 283. Dr. Potoczak planned to follow
up with Jirousek in a month and would see if Dr. Kumar felt
that physical therapy was appropriate. Tr. 283.
August 17, 2011, Jirousek saw Dr. Kumar with complaints of
right-sided low back pain and neck pain. Tr. 303, 369.
Jirousek had not seen Dr. Kumar for about 16 months. Tr. 303.
Jirousek reported that her pain had returned over the prior
three months on the right side of her low back. Tr. 303. Her
pain was worse with bending and twisting and the numbness,
tingling, and neck pain had returned on both sides but it was
not as bad as her low back pain. Tr. 303. On examination, Dr.
Kumar observed tenderness on the right mid lower lumbar
paraspinal muscles with positive facet joint provocative
maneuvers; straight leg raising was negative; Jirousek could
heel and toe walk; gait, coordination and balance were
normal; mild tightness in her hamstrings; no pain with hip
rotation; and neck range of motion was functional. Tr. 303.
Dr. Kumar assessed low back pain right sided with facet
arthropathy and history of neck pain. Tr. 303. Dr. Kumar
advised that Jirousek should proceed with right L4-5 and
L5-S1 facet joint injections. Tr. 303. If Jirousek's neck
continued to bother her, Dr. Kumar indicated that Jirousek
may need interventional pain management. Tr. 303. Jirousek
was continuing to do exercises at home and they discussed the
possibility of an inversion table and DRX machine, which
would be more for diskogenic pain. Tr. 303. Jirousek was
going to continue to take Motrin and had enough Vicodin. Tr.
303. On September 6, 2011, Jirousek reported to Dr.
Kumar's office that the injections she had on August 22,
2011, provided 75% relief but she still had some pain and
wanted to know whether she should have another injection. Tr.
368. Dr. Kumar recommended holding off. Tr. 368.
saw Dr. Potoczak on November 8, 2011, for follow up after
having discontinued the Zocor. Tr. 420-421. Jirousek had no
chest pain, focal weakness or shortness of breath. Tr. 420.
Jirousek was interested in restarting Zocor. Tr. 420. Dr.
Potoczak provided a refill for the Zocor. Tr. 422. On
examination, Dr. Potoczak observed multiple trigger points
with deep muscle spasm. Tr. 421. Dr. Potoczak provided
samples of Savella. Tr. 422. During a follow-up visit with
Dr. Potoczak on November 22, 2011, Jirousek reported that
pain was present in her neck, left clavicle, left elbow, left
shoulder, right clavicle, upper right arm, upper left arm,
upper back and right shoulder and she described her pain as
“medium.” Tr. 422. Jirousek reported that
physical therapy was helping with her pain. Tr. 423. Jirousek
was interested in a different muscle relaxer. Tr. 423. She
had no improvement with Savella so Dr. Potoczak discontinued
the medication. Tr. 423. Dr. Potoczak's physical
examination revealed an unremarkable neurologic exam; upper
and lower extremities within normal limits; and full
strength. Tr. 423. Dr. Potoczak diagnosed fibromyalgia and he
prescribed Flexeril to be taken 2 times daily as needed for
muscle spasms. Tr. 423.
November 30, 2011, Jirousek saw a new chiropractor, Dr. Ross
C. Lubrani, DC, for evaluation and treatment of her neck and
lower back pain. Tr. 245-247. Jirousek complained of
“very severe constant sharp neck pain, severe constant
aching low back pain and moderate numbness in both
arms.” Tr. 245. Dr. Lubrani's objective findings
included evidence of muscle spasms, active myofascial trigger
points, and range of motion loss. Tr. 247. Dr. Lubrani
treated Jirousek through at least March 2012. Tr. 245-272.
an April 11, 2012, visit with Dr. Potoczak regarding her
anxiety, Dr. Potoczak noted in his physical examination
findings that Jirousek had a normal range of motion and her
back and neck pain were much better with therapy. Tr. 424. On
May 8, 2012, Jirousek returned to see Dr. Kumar with
complaints of bilateral shoulder pain that had been bothering
her for the prior 6 months. Tr. 366. She also reported neck
pain but her shoulders were really bad. Tr. 366. Both sides
bothered her with lifting her arms and sleeping at night. Tr.
366. She had a hard time reaching behind her back. Tr. 366.
Jirousek was using Vicodin sparingly and tried Motrin. Tr.
366. Dr. Kumar diagnosed bilateral shoulder pain with rotator
cuff tendonitis and bursitis. Tr. 366. Dr. Kumar started
Jirousek on Mobic; ordered x-rays of both shoulders; and
scheduled bilateral shoulder subacromial injections. Tr. 366.
During a visit at Dr. Kumar's office on May 30, 2012,
Jirousek reported significant relief following bilateral
shoulder subacromial injections earlier that month. Tr. 363.
She had more relief while awake but was still having bad pain
at night. Tr. 363. She was using Mobic and Tylenol, which
seemed to help her perform her daily activities. Tr. 363.
Because Jirousek was continuing to have significant
discomfort in the evening, the nurse indicated that an MRI of
the left shoulder would be taken to rule out any rotator cuff
involvement. Tr. 363.
her left shoulder MRI (Tr. 354, 415-416), on June 27, 2012,
Jirousek saw David Zanotti, M.D., of the Center for
Orthopedics, for an evaluation of her shoulder pain (Tr.
337-338, 347). Jirousek reported that her right shoulder was
worse than her left. Tr. 337. On examination, Dr. Zanotti
observed that Jirousek had full overhead motion of both
shoulders; very limited neck flexion and extension with pain
radiating down both paracervical regions; significant pain in
the biceps groove on both sides; 5/5 abduction and
supraspinatus strength with mild pain during stressing; pain
with impingement maneuvers on both sides; and subscapularis
stretching caused significant discomfort on both sides. Tr.
337. Jirousek denied any numbness or tingling during the
visit but reported having radiating pain down her arms at
times. Tr. 337. Dr. Zanotti indicated that x-rays of both
shoulders showed minimal degenerative changes of the
glenohumeral joint with the alignment maintained and an MRI
of the left shoulder showed subluxated biceps tendon with
some cuff tendinitis. Tr. 337, 354, 415-416. Dr. Zanotti
assessed right greater than left shoulder biceps tendinitis
with left sided bicipital subluxation and bilateral
impingement and a history of cervical radiculopathy. Tr. 338.
An MRI of the right shoulder was ordered and Dr. Zanotti
administered an injection of Celestone and Lidocaine in the
left bicipital groove. Tr. 338.
2, 2012, MRI of the right shoulder showed distal
supraspinatus and infraspinatus with partial undersurface
tearing of the distal anterior fibers of the supraspinatus
without full-thickness tear; moderate AC joint osteoarthrosis
with inferior projecting osteophyte from the distal clavicle
causing mass effect on the myotendinous junction of the
supraspinatus; and mild subacromial and subcoracoid bursitis.
Tr. 351, 417.
saw a physician assistant at Dr. Zanotti's office on July
23, 2012. Tr. 345. The assessment was right shoulder
impingement, right shoulder bicipital tendinitis, and
improved left shoulder bicipital tendinitis. Tr. 345.
Jirousek received an injection of Celestone and Lidocaine
into the right subacromial space and was referred her to
physical therapy for her neck and shoulder. Tr. 345. On
August 1, 2012, Jirousek received an initial physical therapy
evaluation at Total Joint Rehab. Tr. 339-340.
September 2012, Jirousek saw a physician assistant at Dr.
Zanotti's office for two different visits. Tr. 342, 344.
Jirousek continued to report pain in both shoulders as well
as in her neck with stiffness in her neck. Tr. 342, 344.
Jirousek reported some relief from an earlier injection in
her left bicipital groove and past cortisone injections. Tr.
342, 344. Dr. Zanotti ordered a cervical MRI, which was taken
on September 19, 2012, and showed degenerative and arthritic
changes in the cervical spine; multilevel discogenic
degenerative disease and a few bulging disks in the cervical
spine but no evidence of a frank herniated nucleus pulposus;
a few narrowed neural foramina but no spinal canal stenosis
in the cervical spine; and unremarkable cervical cord with no
cord compression at the c-spine. Tr. 348-349, 418-419.
September 26, 2012, examination at Dr. Zanotti's office
showed that Jirousek had “full overhead motion with the
ability to get her hand behind her back lacking two-levels
bilaterally.” Tr. 342. She exhibited pain on
impingement maneuvers and significant bicipital groove pain
on the right with less on the right. Tr. 342. She had a
positive Spurling's maneuver. Tr. 342. She reported no
numbness or tingling in her hands. Tr. 342. Jirousek received
an injection in her left shoulder, both subacromially and
bicipitally, and a cortisone injection in the right bicipital
groove. Tr. 342. Jirousek was provided a prescription for
Mobic, since it had provided some relief in the past. Tr.
342. It was recommended that Jirousek be seen on an as needed
basis if she had further concerns or questions regarding her
shoulder or neck. Tr. 342.
October 24, 2012, Jirousek was seen again at Dr.
Zanotti's office. Tr. 329-330. Jirousek reported
increasing pain in her left shoulder along the outside of her
arm. Tr. 329. The physical examination showed full overhead
motion with ability to get her hand behind her head and
behind her back. Tr. 329. There was pain with internal
rotation and pain on stressing in abduction as well as cross
body stressing. Tr. 329. Jirousek exhibited 5/5 abduction and
supraspinatus strength. Tr. 329. Upon Jirousek's request,
an injection of Celestone and Lidocaine was administered into
the left subacromial space. Tr. 330. Jirousek would follow up
with Dr. Zanotti on an as needed basis. Tr. 330. She planned
to schedule an appointment with Dr. Kumar regarding her neck
pain. Tr. 330.
evidence post-dating amended alleged onset date
saw Dr. Kumar on November 13, 2012. Tr. 361. She reported
that the left side of her neck had flared up quite a bit from
last seeing Dr. Kumar six months prior. Tr. 361. Jirousek
indicated she sometimes had pain down the arm and numbness in
her hands and arms when using them. Tr. 361. She was also
having right-sided low back pain. Tr. 361. On examination,
Dr. Kumar's observations included tenderness in the left
mid-lower cervical paraspinal muscles with positive facet
joint provocative maneuvers; strength was functional in the
upper extremities; some pain with shoulder strength testing
on the left; tenderness in the right lower lumbar paraspinal
muscles with positive facet joint provocative maneuvers; some
tenderness in the lumbrosacral junction; strength was
functional for ambulation; and gait, coordination and balance
were normal. Tr. 361. Dr. Kumar diagnosed left-sided back
pain with cervical spondylosis, degenerative disk disease;
numbness and tingling in the hands and arms; right-sided low
back pain with facet arthropathy; chronic pain; and left
shoulder pain with rotator cuff syndrome. Tr. 361. Dr. Kumar
ordered physical therapy for the low back; x-rays of the
lumbar and cervical spine; and facet joint injections in the
cervical and lumbar regions. Tr. 361. Dr. Kumar also ordered
EMG testing of the upper extremities. Tr. 361.
November 28, 2012, Jirousek underwent EMG testing of the
upper extremities to evaluate for carpal tunnel syndrome. Tr.
449. The testing showed “electrodiagnostic evidence of
mild bilateral median mononeuropathies at the wrist or carpal
tunnel syndrome characterized primarily by sensory fiber
demyelination, left worse than right.” Tr. 449.
Jirousek was wearing wrist splints. Tr. 449.
December 6, 2012, Jirousek received facet joint lumbar
injections. Tr. 451-453. On December 12, 2012, Jirousek
reported to Dr. Kumar's office that the injections had
taken the edge off and she was doing about 70-80% better at
the time. Tr. 364. There is a handwritten note on the
December 12, 2012, office note that states, “When pain
comes back we will do RF [radiofrequency].” Tr. 364.
February 2013, Jirousek saw Dr. Potoczak with complaints of
back pain. Tr. 430-434. Jirousek reported a gradual worsening
of her back pain, which she described as burning with a
severity level of 7/10. Tr. 431. On examination, Dr. Potoczak
observed decreased range of motion, tenderness and spasm in
the cervical back. Tr. 433. There was normal range of motion
in the neck but pain and spasm in the neck and trapezius
muscle. Tr. 433. Dr. Potoczak prescribed some medication but
no other orders were placed. Tr. 434.
evidence post-dating date last insured
April 24, 2013, Jirousek called Dr. Kumar's office to
report that she was having pain again and her injections for
right side lumbar had worn off. Tr. 454. Per Dr. Kumar's
prior instructions, she was calling about right side lumbar
radiofrequency. Tr. 454. On May 2, 2013, radiofrequency
ablation was performed at the right L3, L4, and L5 area. Tr.
455-457. Also, on May 2, 2013, knee x-rays were taken, which
were normal. Tr. 443-444. Also, in May 2013, Dr. Kumar
administered a right shoulder subacromial injection due to
right shoulder pain. Tr. 458. Dr. Kumar held off on
administering an injection in the left knee. Tr. 458.
returned to see Dr. Potoczak on June 25, 2013, with reports
of new pains - - bilateral shoulder pain, bilateral knee
pain, and bilateral hip pain for about two months. Tr.
434-438. She was receiving moderate relief through the use of
Flexeril, Mobic, Vicodin, Tylenol and Motrin. Tr. 434. On
examination, Dr. Potoczak observed normal range of motion in
the neck but decreased range of motion and tenderness in the
right shoulder; decreased range of motion, pain and spasm in
the lumbar back; and tenderness in the left forearm. Tr. 437.
Dr. Potoczak recommended that Jirousek try physical therapy
and Lyrica. Tr. 437. Also, Dr. Potoczak indicated that
Jirousek needed to have an MRI performed and a rheumatologist
consult. Tr. 437.
Dr. Potoczak's referral, on July 2, 2013, Jirousek saw
Vagesh M. Hampole, M.D., for possible fibromyalgia. Tr.
572-574. Dr. Hampole's examination findings included no
swelling of any of the joints of upper and lower extremities;
tender areas present over back, across shoulders and upper
and lower extremities; no weakness; pain with range of motion
in neck rotation, bilateral shoulder abduction, bilateral
elbow flexion and extension, bilateral hip internal rotation
and external rotation; motor and sensory function, reflexes,
gait and coordination all intact. Tr. 573. Dr. Hampole
assessed fibromyalgia and prescribed Flexeril and directed
Jirousek to continue taking Lyrica as she had been. Tr. 574.
Dr. Hampole ordered lab work, including an arthritis panel.
Tr. 574. Jirousek's lab work showed a positive
anti-nuclear antibodies (ANA) test at 1:80
titers. Tr. 577. Dr. Hampole reviewed the lab work
with Jirousek on July 23, 2013, and continued the diagnosis
of fibromyalgia but added cervical radiculitis. Tr. 579. Dr.
Hampole started Jirousek on Trazadone and stopped the
Flexeril. Tr. 579. Lyrica, Mobic, and Vicodin were continued.
Tr. 579. Jirousek was going to follow up with Dr. Kumar
regarding the cervical radiculitis. Tr. 579. Jirousek
continued to see Dr. Hampole from September 2013 through
April 2014. Tr. 582-587. Dr. Hampole's examination
results were generally the same throughout with some changes
to medications made during Dr. Hampole's treatment of
Jirousek. Tr. 585.
24, 2013, Jirousek saw Dr. Kumar with complaints of shoulder
and neck pain. Tr. 461. She was having numbness down her
right arm. Tr. 461. Jirousek indicated that the numbness was
driving her crazy at times and affecting her quality of life.
Tr. 461. She was frustrated with the pain. Tr. 461. On
examination, Spurling's maneuver was mildly positive and
there was positive impingement signs in the right shoulder.
Tr. 461. Strength was 5/5 in the upper extremities. Tr. 461.
Extension and rotation were limited in the neck and forward
flexion past 100 degrees caused some shoulder pain. Tr. 461.
Gait, coordination and balance were normal. Tr. 461. Dr.
Kumar assessed right sided cervical spondylosis with
radiculitis, most likely at ¶ 6; rotator cuff
dysfunction right shoulder; chronic pain; and history of
lumbar pathology. Tr. 461. Dr. Kumar recommended an MRI of
the right shoulder and a cervical epidural. Tr. 461. An
August 3, 2013, MRI of the right shoulder showed no
significant change since the July 2, 2012, MRI. Tr. 439-440.
Jirousek received a cervical epidural injection at the C7-T1
level on July 25, 2013. Tr. 463-465. During an August 8,
2013, appointment for medial branch blocks at the C4, C5, and
C6 levels for right-sided neck pain radiating down the
shoulder, Jirousek reported no improvement from the cervical
epidural injections she had received two week earlier. Tr.
466-468. She also reported that when she saw a surgeon there
was no indication for surgical intervention. Tr. 466. On
August 15, 2013, Jirousek reported about 30% relief of her
right shoulder and arm pain from the C4, C5, and C6 medial
branch blocks but she was continuing to have pain from the
neck down to her index finger along the C6 dermatome. Tr.
469. Thus, a C6 right nerve block was administered. Tr.
September 6, 2013, Jirousek saw Dr. Kumar reporting continued
pain and only minimal relief from the C6 nerve block. Tr.
472. The medial branch blocks and epidural were not helpful.
Tr. 472. Jirousek relayed to Dr. Kumar that she was seeing
Dr. Hampole who was prescribing Lyrica for possible
fibromyalgia. Tr. 472. Dr. Kumar recommended an EMG of the
upper extremities, noting that a cervical spine MRI might be
required depending on the results of the EMG. Tr. 472. He
also recommended a “small work LSO brace to help reduce
pain in the lumbar spine and restrict mobility of the trunk
and to help support the spinal muscles.” Tr. 472.
testing was performed on September 13, 2013. Tr. 474. The
results of the testing showed “electrodiagnostic
evidence of mild to moderate bilateral median
mononeuropathies at the wrist or carpal tunnel syndrome
characterized primarily by demyelination with some chronic
changes. There is also a hint of axonal irritation on the
right at ¶ 6 but no active denervation.” Tr. 474.
Dr. Kumar recommended a right-sided carpal tunnel injection.
Tr. 474. If that did not work, Dr. Kumar indicated that an
MRI of the cervical spine may be needed. Tr. 474. On
September 18, 2013, Jirousek received a right carpal tunnel
injection. Tr. 476-477.
an October 18, 2013, follow-up visit with Dr. Kumar, Jirousek
reported that the carpal tunnel injection did not help much.
Tr. 478. She was still having pain in the neck going down the
right arm. Tr. 478. Also, Jirousek indicated she was favoring
her right leg but her low back was hurting more on the right
side. Tr. 478. Physical examination findings, included a
positive Spurling maneuver on the right; numbness in the C6
distribution on the Right; tenderness in the right lower
lumbar paraspinal muscles with positive facet joint
provocative maneuvers; gait was antalgic favoring the right
lower extremity; balance was fair; coordination was normal;
and there was a decreased range of motion with right sided
rotation and side bending of the cervical spine. Tr. 478. Dr.
Kumar recommended radiofrequency ablation on the right at
¶ 3-4-5 and a cervical spine MRI. Tr. 478.
ablation was performed on November 4, 2013, on the right at
¶ 3, L4, and L5. Tr. 480-482. A November 8, 2013,
cervical spine MRI showed “Mild cervical spondylosis,
with canal narrowing with mild canal narrowing at ¶ 5-6
and C6-7. Right foraminal narrowing at ¶ 3-4. No
significant change from MRI scans dated September 19,
2012.” Tr. 441.
early January 2014, Jirousek called seeking an appointment
with Dr. Kumar, indicating she was having severe pain in her
right shoulder and she was interested in an injection. Tr.
485. She saw Dr. Kumar on January 14, 2014. Tr. 486. Dr.
Kumar noted that Jirousek was at the visit for right sided
neck pain and posterior shoulder pain and she wanted a
shoulder injection. Tr. 486. However, on examination,
Jirousek did not have any pain with the shoulder with
internal or external rotation or abduction and flexion so no
shoulder injection was administered. Tr. 486. She did have
significant spasms in the right parascapular region and
trapezius region; her neck range of motion was impaired
significantly and there was tenderness in the right mid lower
cervical paraspinal muscles. Tr. 486. Turning and twisting
bothered her. Tr. 486. She was taking two Norco at a time at
5 mg strength, which helped a little, and she was taking
Flexeril and Motrin. Tr. 486. Dr. Kumar increased the Norco
strength to 10 mg, twice a day, as needed, and recommended
C4-5, C5-6, and C6-7 cervical facet joint injections to calm
down her pain. Tr. 486. The facet joint injections were
performed on January 15, 2014. Tr. 488-490.
saw Caryn DeLisio, CNP, with Dr. Kumar's office on May
21, 2014, for follow up. Tr. 491. Nurse DeLisio noted that
Jirousek had done very well with radiofrequency ablation in
the past, as well as with cervical facet joint injections.
Tr. 491. Accordingly, radiofrequency ablation on the right at
levels L3-4 and 5 was set up and, after that, cervical facet
joint injections would be performed on the right at ¶
4-5, C5-6 and C6-7. Tr. 491, 493-495, 496-498. Also, a TENS
unit was ordered. Tr. 491. Jirousek reported point tenderness
on the right elbow so an x-ray of the right elbow was ordered
to rule out other issues. Tr. 491.
Dr. Kumar's referral, on June 25, 2014, Jirousek saw
Robert Perhala, M.D., for a consultation for possible lupus.
Tr. 515-519. Jirousek reported neck stiffness and pain for
about 6-7 years and low back and hip pain for about 4-5
years. Tr. 515. She reported 2-3 hours of morning stiffness,
mostly in the spinal area. Tr. 515. Jirousek reported that
she walked regularly for exercise. Tr. 516. On examination,
Dr. Perhala observed that Jirousek walked with a slightly
antalgic gait; there was moderate tenderness of the cervical
paraspinal area bilaterally, right lumbar paraspinal area
down into the right SI joint area; tenderness in the
shoulders bilaterally; synovial thickening and tenderness of
the right elbow; tenderness in right finger joints;
tenderness in the knees; and full range of motion in
shoulders, elbows, wrists, hips, knees, ankles. Tr. 517. Dr.
Perhala found no tenderpoints of fibromyalgia present but
noted 8 tender joints and 1 swollen joint. Tr. 517.
Jirousek's upper and lower extremity strength was 5/5
bilaterally and her reflexes in her upper and lower
extremities were normal bilaterally. Tr. 518. Dr. Perhala
reviewed radiology reports, noting that Jirousek's left
knee x-ray was normal; an x-ray of her knees bilaterally was
normal; a cervical spine MRI showed “DDD with mild
stenosis, ” and a right shoulder MRI showed “AC
arthrosis and RC tendonosis.” Tr. 518. Dr. Perhala
assessed unspecified polyarthropathy inflammatory;
unspecified backache; cervicalgia; and “shoulder region
affections other not elsewhere class.” Tr. 518. Dr.
Perhala indicated that he felt strongly that Jirousek's
arthritis was “inflammatory in basis, that she should
be on DMARD therapy” and he was “going to
initiate sulfasalazine . . . a high risk medication requiring
lab monitoring consistently.” Tr. 519. Lab work showed
an ANA titer of 1:160. Tr. 522.
2014, Jirousek saw Dr. Kumar. Tr. 499. She had some relief
from the radiofrequency ablation and facet joint injections.
Tr. 499. She was continuing to use Norco 10 mg at night. Tr.
499. Jirousek was seeing Dr. Perhala for more rheumatologic
workup. Tr. 499. She was having pain in her knees, back and
neck with spasms. Tr. 499. Activity bothered Jirousek. Tr.
499. She had no new numbness or weakness. Tr. 499. Dr. Kumar
continued Jirousek on Norco 10 mg and directed Jirousek to
call if she needed a right SI joint injection. Tr. 499. On
August 11, 2014, Jirousek called Dr. Kumar requesting the SI
injection and, on August 18, 2014, Dr. Kumar administered the
injection. Tr. 502-504.
saw Dr. Perhala on August 18, 2014, for follow up of her
inflammatory arthritis. Tr. 523-526. Jirousek reported being
more fatigued but her inflammatory arthritis was under
“fair control.” Tr. 523. She reported a
“degree of stiffness and pain in the hands, wrists,
shoulders, knees and feet more on the right side. Most other
joints [were] stable.” Tr. 523. Norco, prescribed
through her other doctors, was providing her relief for
breakthrough pain. Tr. 523. On examination, Dr. Perhala
observed 13 tender joints and 1 swollen joint but no
tenderpoints of fibromyalgia and full range of motion. Tr.
525. Because of the possibility that Jirousek's
medication was causing her fatigue, Dr. Perhala changed
Jirousek from Sulfasalazine to Plaquenil. Tr. 526, 529.
saw Dr. Perhala on October 20, 2014, for follow up. Tr.
529-532. Jirousek's inflammatory arthritis had been under
“fair control” since the last visit. Tr. 529.
Plaquenil therapy was providing minimal control of
Jirousek's arthritis. Tr. 529. As he had in the prior
visit, Dr. Perhala observed 13 tender joints and 1 swollen
joint. Tr. 531. There was full range of motion. Tr. 530-531.
Dr. Perhala stopped Plaquenil since the effects were minimal
and started Jirousek on Methotrexate. Tr. 532.
October 23, 2014, Jirousek saw Dr. Kumar for follow up. Tr.
506. She indicated that she had been diagnosed with
rheumatoid arthritis and was taking Methotroxate. Tr. 506.
She reported being in miserable pain and understood she could
not have another radiofrequency procedure until December. Tr.
506. Norco helped some but she sometimes needed to take two
in a day. Tr. 506. Dr. Kumar's physical examination
revealed that Jirousek ambulated in a flexed spine position
favoring the left leg; she was very tender in the right
mid-low back with positive facet joint provocative maneuvers;
straight leg raising was negative for radicular pain; there
was quite a bit of muscle hypertonicity appreciated; balance
was fair; coordination was normal; neck pain was worse on
extremes; there was mild tightness in hamstrings; there was
generalized stiffness. Tr. 506. Dr. Kumar's diagnoses
were right sided mid-low back pain with facet arthropathy; SI
joint dysfunction; cervical spondylosis; degenerative disk
disease; rheumatoid arthritis; and chronic pain. Tr. 506.
Until the radiofrequency ablation procedure could be
performed, Dr. Kumar recommended right L3-4, L4-5, L5-S1
facet joint injections. Tr. 506. Also, Dr. Kumar planned to
get lumbar flexion/extension x-rays. Tr. 506. Dr. Kumar also
increased Jirousek's Norco. Tr. 506. X-rays of the lumbar
spine were taken on October 23, 2014, which showed
“[m]ild mid and distal lumbar posterior element
arthritis, no change with flexion and extension.” Tr.
445. Facet joint injections were performed on October 27,
2014. Tr. 508-509.
November 21, 2014, Jirousek saw Dr. Kumar and reported that
the facet joint injections had helped her a lot and were
continuing to help her but they were wearing off. Tr. 510.
She indicated that the Methotrexate and Motrin helped. Tr.
510. She did not need to take as much Norco because of the
facet joint injections. Tr. 510. Activity bothered her and
her pain was affecting her quality of life. Tr. 510. Dr.
Kumar recommended radiofrequency ablation after December 2,
2014. Tr. 510. There was some tenderness in the right mid low
back with positive facet joint provocative maneuvers but her
straight leg raising was negative and she could heal walk ...