United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
R. Knepp II United States Magistrate Judge.
Carmella Caterina Gardner (“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”). (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 in accordance with 28 U.S.C. §
636(c) and Civil Rule 73 (Doc. 14). For the reasons stated
below, the undersigned reverses the Commissioner's
decision and remands for further proceedings consistent with
filed for DIB in January 2013, alleging a disability onset
date of June 1, 2009. (Tr. 224-25). Her claims were denied
initially and upon reconsideration. (Tr. 136-42). Plaintiff
then requested a hearing before an administrative law judge
(“ALJ”). (Tr. 143). Plaintiff (represented by
counsel), and a vocational expert (“VE”)
testified at a hearing before the ALJ on February 11, 2015.
(Tr. 68-107). On March 24, 2015, the ALJ found Plaintiff
not disabled in a written decision. (Tr. 38-46). The Appeals
Council denied Plaintiff's request for review, making the
hearing decision the final decision of the Commissioner. (Tr.
1-7); 20 C.F.R. §§ 404.955, 404.981. Plaintiff
filed the instant action on July 21, 2016. (Doc. 1).
Background, Statements, and Testimony
was born in February 1950 and was 59 years old at her alleged
onset date. (Tr. 59). At the time of the hearing, Plaintiff
lived alone, Tr. 76, in a two-story house, “but [her]
living [was] on the first floor only”, Tr. 77-78. She
did not go upstairs because it was “too much of a
chore” and she had “fallen down those stairs too
many times.” (Tr. 78). Plaintiff testified that after
her hip replacement, she had “no balance anymore”
and had “to hold onto something.” (Tr. 85). Last
time she climbed the stairs in her house, when coming back
down “it seemed like [she] went numb on one side and
[she] ended up just rolling down the stairs.” (Tr. 86).
husband and son accompanied her to the hearing. (Tr. 78).
Plaintiff saw her son approximately every other day, and her
daughter once per week. (Tr. 79). Plaintiff testified her
adult children helped with “the heavy stuff” like
mopping and vacuuming. (Tr. 77). She was able to do her own
laundry, wash dishes, and prepare simple meals for herself,
primarily in the microwave. Id. Plaintiff testified
she could do her own grocery shopping “and [her] kids
pick[ed] up a lot of things for [her]” because if she
walked around the grocery store, she could not “even
get [her] groceries back into the house right away.”
was able to drive, but did not drive long distances. (Tr.
78). She liked to read, and watch television, but did not use
a computer. (Tr. 80). Her pain would sometimes interfere with
her reading: “if I sit there too long either one side
gets stiff or I just need to un-stiff myself and change
positions or put the book down and try to get up and move a
little bit.” (Tr. 99). Plaintiff had friends with whom
she tried to get together every couple of months for lunch or
a visit. (Tr. 80). She would, however, frequently cancel
outings, and her friends would come to her house instead.
testified that on a typical day, she would sleep a lot (due
to her medications and poor night sleep). (Tr. 81). She
testified to difficulty sleeping at night, and would nap
during the day to make up lost sleep. Id.; Tr.
96-97. Typically, she estimated, she would sleep for two to
three hours during the day. (Tr. 97).
testified she left her prior job as a realtor because
“[i]t became too physical, too demanding and [she] just
couldn't keep appointments that [she] had set because
[she] was starting to feel really bad and it got in the way
of losing [her] clients or having to give them to somebody
and then it was just the patience it takes to deal with
someone making a large purchase.” (Tr. 83). When she
first left the work, “it was tiredness” and
“aches and pains” that made her leave. (Tr. 84).
Before she stopped working, Plaintiff would nap after work.
testified that she tried not to take any pain medication, but
did use a muscle relaxer approximately once per month. (Tr.
93). She dealt with her pain by stretching, laying down, and
avoiding activities that caused her pain. Id.
estimated she could stand for 20 to 30 minutes before needing
to sit down. (Tr. 93-94). Standing was worse on harder
surfaces. (Tr. 94). Plaintiff also estimated she could sit
for 30 to 45 minutes “depending on what [she was]
sitting on.” (Tr. 95). Plaintiff generally sat in a
recliner so she could elevate her legs. (Tr. 96); see
also Tr. 99-100 (“Well I don't sit on the
couch, I may lie on the couch but I'm always in my
recliner.”). Standing was “harder” than
sitting. (Tr. 99).
February 2013, Plaintiff completed a symptom report
describing her symptoms as including pain, fatigue, agility,
stamina, sleep problems, and stiffness. (Tr. 259). She
reported the symptoms were “always there” but got
worse when she walked, sat, slept, did daily tasks, or
cleaned. Id. She indicated her pain and fatigue were
nine out of ten on a good day, and ten out of ten on a bad
day. (Tr. 260). She reported she had zero good days in a
week; rather, she had all bad days. Id. Plaintiff
also reported she could not bend, stoop, or walk for any
length of time. (Tr. 261). Rest and warm or hot showers
helped her pain. Id. She reported she was not taking
any medication for her symptoms. Id.
disability report dated April 2013, Plaintiff reported
difficulty getting in and out of bed. (Tr. 278). She also
reported her son helped her to shower, and she had dropped
hot food when she tried to cook. Id. She reported
“[n]eck and knee pain” and that she “ha[d]
to be on anti-depressants (because of [her] depression [she
was] unable to work)”. Id.
December 2008 MRI of Plaintiff's cervical spine showed
degenerative changes at the C4/5 and C5/6 levels. (Tr. 424).
February 2009, Plaintiff saw Shreeniwas Lele, M.D., with neck
pain, going down her arm. (Tr. 386). Dr. Lele noted, among
other things, “[n]eck pain, with radiculopathy”,
referred her “for possible neck operation”, and
suggested she try physical therapy. Id.
taken of Plaintiff's right knee in July 2010 due to
“[t]rauma” showed “[s]mall spurring . . .
at the insertion of the quadriceps tendon, but no joint
effusion, fracture, or dislocation. (Tr. 419). An X-ray of
Plaintiff's left hip the same day showed “advanced
osteoarthritis” which was “stable from [the]
prior study [in June 2010].” (Tr. 420).
days later, also in July 2010, Plaintiff reported to the
emergency room after a fall in which she fractured her hip.
(Tr. 311, 314-16). She was admitted to the hospital for five
days, during which time she underwent a “[c]losed
reduction, cannulated hip screw fixation, right hip.”
(Tr. 314). Subsequent x-rays in September and October 2010
showed a stable radiographic appearance of orthopedic screws
without evidence of hardware failure. (Tr. 415-16).
April 2011, Plaintiff returned to Dr. Lele complaining of
fatigue as well as “excruciating neck pain, going into
arm and legs.” (Tr. 377). On examination, Dr. Lele
found diffuse tenderness in Plaintiff's neck, as well as
pain along the right arm. Id. She also noted
“some arthritis and pain” in the right arm and
leg, but normal sensory and motor functioning. Id.
Dr. Lele assessed neck pain, radiculopathy and arthritis,
prescribed Vimovo, and noted she would monitor Plaintiff.
August 2011, Plaintiff returned to Dr. Lele, who noted
“[o]verall, she is feeling well.” (Tr. 376). Her
arthritis was “[s]omewhat . . . bothering her.”
Id. She also reported her “[a]nxiety and
stress” were “okay”. Id. On
examination, Dr. Lele noted “[m]inimal swelling and
tenderness present”. Id. She assessed
osteoarthritis and advised Plaintiff to continue her current
September 2014 (three years later), Plaintiff returned to Dr.
Lele with pain behind her right knee, with redness and
swelling. (Tr. 453). She reported pain that was seven out of
ten. Id. Plaintiff also reported feeling fatigued
and weak. Id. On examination, Dr. Lele noted a red,
inflamed area on Plaintiff's right thigh, which she