United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
R. Knepp II United States Magistrate Judge.
Terrence Isaac (“Plaintiff”) filed a Complaint
against the Commissioner of Social Security
(“Commissioner”), seeking judicial review of the
Commissioner’s decision to deny disability insurance
benefits (“DIB”) and supplemental security income
(“SSI”). (Doc. 1). The district court has
jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g).
The parties consented to the undersigned’s exercise of
jurisdiction pursuant to 28 U.S.C. § 636(c) and Civil
Rule 73. (Doc. 12). For the reasons stated below, the
undersigned affirms the decision of the Commissioner.
filed for DIB and SSI in March 2013, alleging a disability
onset date of September 11, 2012. (Tr. 171-89). His claims
were denied initially and upon reconsideration. (Tr. 118-24,
130-41). Plaintiff then requested a hearing before an
administrative law judge (“ALJ”). (Tr. 142).
Plaintiff (represented by counsel) and a vocational expert
(“VE”) testified at a hearing before the ALJ on
February 4, 2015. (Tr. 33-63). On May 20, 2015, the ALJ found
Plaintiff not disabled in a written decision. (Tr. 17-27).
The Appeals Council denied Plaintiff’s request for
review. (Tr. 1-6). Plaintiff then filed the instant action on
June 3, 2016. (Doc. 1).
Background and Testimony
was born in November 1961 (Tr. 64) and had a high school
education and four years of college (Tr. 58). He had past
work as a public works janitor, construction laborer, mail
clerk, and recording clerk. (Tr. 57-58); see also
Tr. 39-43 (Plaintiff’s testimony about his past work).
He lived with his mother and grandmother. (Tr. 48).
testified that in 2012, the “severity of [his] daily
back pain increased tremendously.” (Tr. 43). He
described his problems as “90 percent” back and
“ten percent” shoulder related. (Tr. 43-44). Also
in 2012, he noticed numbness in his legs and pain in the
bottom of his feet upon waking. (Tr. 44). Additionally, he
felt “constant aching” that would radiate to his
hips. Id. His pain level was a “constant
six” out of ten, with good days and bad days. (Tr. 45).
On bad days, he went to the ER to get a “pain injection
of Toradol.” Id. In a good week, he had
“one or two good days”. (Tr. 46). On bad days, he
just laid in his bed, took medication, and did some home
testified he spent 90 percent of his day “basically
laying [sic] in bed with a pillow in between [his]
knees.” (Tr. 44); see also Tr. 48 (explaining
that between 6:00 a.m. and 10:00 p.m. “other than going
down to cooking [sic] breakfast and coming down and getting
dinner, and occasionally going down and checking messages on
the computer, 85 percent of that time is spent in my
bed.”). He did his own laundry, cooked his own
breakfast, and could vacuum for about fifteen minutes. (Tr.
had tried nerve block injections and “another pain
injection procedure” with no relief. (Tr. 44).
He was still undergoing physical therapy, and had just
stopped in November 2014 “based on the number of visits
you’re allowed per calendar.” (Tr. 45). He was
starting again at the time of the hearing. Id. He
testified that in the past, he would “feel a little
better” after leaving physical therapy, but the next
day would be “back to where [he] started.” (Tr.
51-52). Plaintiff also testified he was taking Naproxen,
Flexeril, Diclofenac, and anti-inflammatories. (Tr. 54).
estimated that if he “push[ed] [him]self”, he
could stand for 35 to 40 minutes. (Tr. 49). However, he would
then need to go lay down. Id. He estimated on a good
day, if he “push[ed] [him]self”, he could sit for
an hour to an hour-and-a half at one time, but on a normal
day, it would be more like 30 to 35 minutes before he
“start[ed] feeling some tingling in [his] legs.”
his shoulder, Plaintiff testified that he had a joint
replacement in his right shoulder in 2005 and lost 25 to 30
percent of the range of motion. (Tr. 50). The shoulder still
caused him pain, “[d]epend[ing] on which way [he]
move[s] it, or if [he] catch[es] it.” Id.
to his alleged onset date, Plaintiff underwent a repair of a
torn bicep in 2003 (Tr. 356), a shoulder replacement in 2005
(Tr. 356-57) and had a laminectomy (back surgery) in 2007
(Tr. 680, 843); see also Tr. 680 (listing
“2003 [s]houlder surgery”, “2005 [s]houlder
surgery”, and “2007 [b]ack surgery”).
2012, Plaintiff saw Jerold P. Gurley, M.D., complaining of
increased back, bilateral gluteal, and bilateral proximal
posterior thigh pain. (Tr. 338). Plaintiff reported his
symptoms were increased with activity, and not improved with
rest or activity modification. Id. Dr.
Gurley’s impression was status post lumbar
decompression right L4-5; lumbar spondylosis at ¶ 2-3,
L3-4, L4-5, and L5-S1; recurrent lumbago; and recurrent
bilateral radiculopathy. (Tr. 339). Dr. Gurley found
Plaintiff’s “sensory exam [was] diminished to
light touch in the left L4 distribution” and that his
“[s]traight leg raising [was] positive on the
2012 MRI of Plaintiff’s lumbar spine showed disc space
narrowing at ¶ 2-3, L3-4, and L4-5. (Tr. 319). It also
showed levoscoliosis; degeneration of the discs from L2-3 to
L5-S1; retrolisthesis, disc herniation and bulge; nerve root
impingement; foraminal narrowing; and reactive marrow
changes. Id. When compared to a September 2011
study, “the reactive marrow changes at ¶ 5-S1
ha[d] progressed” but “[o]therwise there [was]
not much interval change in the multilevel disc
returned to Dr. Gurley in June 2012 to review his MRI. (Tr.
337). Dr. Gurley noted Plaintiff’s “surgical
goals ha[d] been met and maintained at the L4-5 level”,
but he had “mechanical back pain symptoms and
functional limitations [that] do correlate with fairly
advance lumbar spondylosis at 4/5 lumbar disc
segments.” Id. Dr. Gurley noted surgery was
not indicated and referred Plaintiff to pain management.
following week, Plaintiff saw Abdallah Kabbara, M.D., for
pain management of his “chronic back pain”. (Tr.
324-25). Plaintiff reported his 2007 laminectomy at ¶
4-L5, which gave him “some pain relief.” (Tr.
324). He reported pain that was ten out of ten, aggravated by
walking, sitting, and lifting. Id. The pain was
localized in his lower back, and radiated toward both hips.
Id. The pain was improved somewhat by medication.
Id. Dr. Kabbara found tenderness on palpation of the
lumbar spine “mildly around the right side of the facet
joint.” (Tr. 324-25). Dr. Kabbara’s impression
was “multilevel spondylosis, lumbar degenerative disk
disease, post laminectomy syndrome and multilevel lumbar disk
displacement and multilevel lumbar spondylolisthesis.”
6, and July 27, 2012, Plaintiff received bilateral steroid
injections at ¶ 4. (Tr. 322-23).
of Plaintiff’s right shoulder in April 2013 showed
“postoperative changes” and “degenerative
changes” including “narrowing of the glenohumeral
joint with associated osteophyte formation” and
“mild widening of the right acromioclavicular
joint.” (Tr. 361).
of Plaintiff’s lumbar spine in April 2013 showed
“[m]ild levoscoliosis, “[m]ild straightening of
the normal lordotic curvature”; and “degenerative
changes”. (Tr. 363). These x-rays showed “disk
space narrowing at the L2-L3, L4-L5 and L5-S1 levels”;
“[anterior osteophytes and lateral osteophytes”;
“[s]mall osteophytes . . . present at ¶ 3-L4 and
L4-5”; [m]ild degenerative changes of the sacroiliac
joints bilaterally”; and “multiple pelvic
calcifications possibly indicating phleboliths.”
2013, Plaintiff saw Daniel Malkamaki, M.D., in the department
of physical medicine and rehabilitation, to address his back
pain. (Tr. 494-99). Plaintiff complained of pain
“localized in the lumbar region” which radiated
to both legs. (Tr. 494). The pain was aggravated by bending,
standing, walking and sitting, and was relieved by
medication, rest, and changing position. (Tr. 494-95). On
examination, Plaintiff had pain on palpation “over the
L/S junction, mostly bilaterally, with mild paraspinal
hypertonicity.” (Tr. 497). His lumbosacral range of
motion was limited to 95 degrees of forward flexion and 25
degrees of extension “with recreation of pain in
flexion.” Id. Dr. Malkamaki’s impression
was “[l]umbar discogenic pain with some early
spondylosis based on the MRI, with clinical evidence of
bilateral LE referral symptoms.” Id. Dr.
Malkamaki ordered “the EPIC injection” and noted
he would consider “transforaminal epidural steroid
injections” in the future. Id. He suggested a
home exercise program, noting “[h]e needs to work on
[his] exercises 5 days a week, BID, diligently, to experience
long term benefit.” Id. Dr. Malkamaki also
noted he would consider formal physical therapy in the
returned to Dr. Malkamaki in September 2013. (Tr. 590-94). He
reported “feeling worse, because he was trying to get
up onto the home exercises, but he was walking a lot at a
festival and got worsening aggravation.” (Tr. 590). He
also reported “other aggravations just with doing
light-ish yard work for his mom”. Id. Dr.
Malkamaki noted similar physical findings to his previous
exam, and maintained the same plan. (Tr. 592). He started
Plaintiff on a “[t]rial of neu[r]ontin, and
visit with a different provider in November 2013, Plaintiff
reported he had tried Neurontin “without much
relief.” (Tr. 610).
March 2014, Plaintiff reported to Dr. Kutalba Tabbaa that he
had low back pain for three years, and noted
“occasional numbness of his leg intermittently
throughout the day. (Tr. 706). He reported he had tried
injections, heat, and ice, with “minimal relief.”
Id. His pain was “worse with
walking/activities”. Id. Plaintiff had a
“[n]ormal neurological exam but for LBP tenderness and
decrease[d] ROM.” Id. Dr. Tabbaa ordered a
lumbar spine x-ray, suggested “[p]ool therapy next
month once his insurance changes; cont[inue] home
exercises”, and scheduled Plaintiff for a medial branch
block. (Tr. 707). A lumbar ...