Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Issac v. Commissioner of Social Security

United States District Court, N.D. Ohio, Eastern Division

August 28, 2017

TERRENCE ISSAC, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          MEMORANDUM OPINION AND ORDER

          James R. Knepp II United States Magistrate Judge.

         Introduction

         Plaintiff 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.

         Procedural Background

         Plaintiff 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).

         Factual Background[1]

         Personal Background and Testimony

         Plaintiff 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).

         Plaintiff 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 exercises. Id.

         He 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. 47-48).

         Plaintiff 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).

         Plaintiff 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.” Id.

         Regarding 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.

         Medical Evidence

         Treatment Evidence

         Prior 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”).

         In May 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 right”. Id.

         A June 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 disease.” Id.

         Plaintiff 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. Id.

         The 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.” (Tr. 325).

         On July 6, and July 27, 2012, Plaintiff received bilateral steroid injections at ¶ 4. (Tr. 322-23).

         X-rays 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).

         X-rays 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.” Id.

         In July 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 future. Id.

         Plaintiff 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 voltaren.” Id.

         At a visit with a different provider in November 2013, Plaintiff reported he had tried Neurontin “without much relief.” (Tr. 610).

         In 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 ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.