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Rodarmer v. Berryhill

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

December 18, 2017

HAROLD L. RODARMER, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          JAMES S. GWIN JUDGE

          REPORT AND RECOMMENDATION

          JONATHAN D. GREENBERG UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Harold L. Rodarmer (“Plaintiff” or “Rodarmer”), challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying his applications for a Period of Disability (“POD”) and Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 416(i), 423 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to an automatic referral under Local Rule 72.2(b) for a Report and Recommendation. For the reasons set forth below, the Magistrate Judge recommends that the Commissioner's final decision be AFFIRMED.

         I. PROCEDURAL HISTORY

         In October 2013, Rodarmer filed applications for POD and DIB, alleging a disability onset date of July 23, 2012 (later amended to October 14, 2013), and claiming he was disabled due to ankylosing spondylitis, bilateral sacroiliitis, phlebitis, arthritis, and depression. (Transcript (“Tr.”) 40, 180, 200.) The applications were denied initially and upon reconsideration, and Rodarmer requested a hearing before an administrative law judge (“ALJ”). (Tr. 133, 142, 149.)

         On October 28, 2015, an ALJ held a hearing, during which Rodarmer, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 30.) On December 7, 2015, the ALJ issued a written decision finding Rodarmer was not disabled. (Tr. 12-25.) The ALJ's decision became final on January 11, 2017, when the Appeals Council declined further review. (Tr. 1.)

         On March 7, 2017, Rodarmer filed his Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 12 & 13.) Rodarmer asserts the following assignments of error:

(1) The ALJ erred when he failed to account for Rodarmer's need for a cane in the RFC.
(2) The ALJ did not properly weigh the opinion of Dr. Ignat, a treating physician. (Doc. No. 12.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Rodarmer was born in December 1966 and was 47 years-old at the time of his administrative hearing, making him a “younger” person under social security regulations. (Tr. Tr. 23.) See 20 C.F.R. §§ 404.1563(c). He has a limited education and is able to communicate in English. (Tr. 23) He has past relevant work as a maintenance worker, assistant property manager, and an inside sales and ordering worker. (Id.)

         B. Medical Evidence

         As Rodarmer's grounds for relief relate solely to his physical impairments, the Court's recitation of the medical evidence will be limited to those impairments, with a particular emphasis on Rodarmer's use of a cane and his treatment with Dr. Ignat.[2]

         On April 25, 2011, Rodarmer underwent a consultative examination with Robert A. Blaine, M.D., in connection with a prior application for disability.[3] (Tr. 256.) During this examination, he did not use an assistive device to ambulate. (Tr. 257.) Rodarmer had a slightly decreased range of motion in his cervical spine and shoulders, and complained of back pain when he elevated his arms. (Id.) He had a full range of motion in his elbows, wrists, knees, and ankles, but decreased range of motion in his hips and thoracolumbar spine. (Id.) Straight leg raises produced back pain. (Tr. 258.) Rodarmer's grip strength was full, and he had full strength in his upper and lower extremities. (Id.) He had a normal gait, station, and heel and toe walk. (Id.) He was able to squat halfway to the floor without assistance. (Id.)

         Following this examination, Dr. Blaine filled out a "Medical Source Statement of Ability To Do Work-Related Activities (Physical)." He made the following findings regarding Rodarmer:

• He could occasionally lift and carry up to 20 pounds.
• He could sit, stand, and walk for 30 minutes at one time. He could sit for 8 hours total in an 8-hour workday, stand for one hour in an 8-hour workday, and walk for one hour in an 8-hour workday.
• He did not require the use of a cane to ambulate.
• He could occasionally reach, including overhead. He could occasionally handle, finger, feel, push, and pull.
• He could occasionally work at unprotected heights, near moving mechanical parts, operate a motor vehicle, and work in humidity, wetness, extreme cold, and extreme heat. He could frequently work near dusts, odors, fumes, pulmonary irritants, and vibrations.
• He could not walk a block at a reasonable pace on rough or uneven surfaces, but he could ambulate without using a wheelchair, walker, or two canes or crutches.

(Tr. 259-264.)

         On February 12, 2013, Rodarmer first visited Allied Health & Chiropractic, a chiropractor practice with Ty Dahodwala, D.C. and James Alberty, D.C. (Tr. 349, 350, 361.) He reported neck pain and stiffness. (Id.) On examination, he had a normal gait. (Tr. 361) Rodarmer then visited this practice on four more occasions in 2013[4]. (Tr. 360). During his last visit of record, on March 5, 2013, he indicated his neck was improving overall, but it still felt tight and achey. (Id.)

         On February 28, 2013, Rodarmer began to treat with Gheorghe Ignat, M.D., a rheumatologist. (Tr. 307.) Rodarmer indicated he had ankylosing spondylitis for the past 20 years. (Id.) He reported lower back and neck pain, along with stiffness and pain in his hips. (Id.) On examination, Rodarmer's hips were tender, with a decreased range of motion. (Id.) His shoulders exhibited crepitus with a normal range of motion. (Id.) His cervical spine was tender, with a normal range of motion, while his lumbar spine had a decreased range of motion. (Id.) Rodarmer had tenderness in his sacroiliac joint, but his muscle strength was normal. (Id.) Dr. Ignat renewed Rodarmer's prescriptions for Prednisone, Meloxicam, and Hydrocodone. (Id.)

         Rodarmer returned to Dr. Ignat's office on March 26, 2013. He reported his medications were helping “partially.” (Tr. 306.) Dr. Ignat then sought insurance approval for Simponi, a different medication. (Id.) Rodarmer began to take Simponi for his symptoms. (Tr. 305.) He followed up with Dr. Ignat on August 22, 2013. He indicated “in general he has improved since starting Simponi” but he was having some swelling in his right elbow. (Id.) Dr. Ignat prescribed steroids for his right elbow symptoms and renewed the Simponi and Meloxicam. (Id.)

         On September 10, 2013, Rodarmer first saw Jeffrey Owen Galvin, M.D., a primary care physician. (Tr. 310.) His complaints were mild generalized fatigue, memory loss, and right-sided olecranon bursitis. (Id.) He reported daily pain from his ankylosing spondylitis, and requested his cholesterol levels be checked. (Id.) On examination, Rodarmer had a mild amount of soft tissue swelling over the right elbow. (Tr. 312.) Dr. Galvin ordered labwork and provided Rodarmer with an ace bandage for his elbow. (Tr. 313.)

         Rodarmer returned to Dr. Ignat on October 23, 2013. He was still having pain along his entire spine, and he indicated his Meloxicam did not always help. (Tr. 304.) On examination, he was tender in the SI joints, with a decreased range of motion in his lumbar spine. (Id.) His muscle strength was normal. (Id.) Dr. Ignat assessed Rodarmer as having “ankylosing spondylitis, mainly spine involvement, still active, improved on Simponi.” (Id.)

         On January 22, 2014, Rodarmer reported decreased pain to Dr. Ignat, but Dr. Ignat noted he “still has pain in his whole spine, peripheral joints, intermittently.” (Tr. 303.) On examination, his hips and lumbar spine were tender with a decreased range of motion. (Id.) His shoulders were tender with a normal range of motion. (Id.) His sacroiliac joints were tender, but he had normal muscle strength. (Id.) Dr. Ignat renewed Rodarmer's Simponi prescription, and prescribed Prednisone. (Id.)

         Rodarmer returned to Dr. Galvin on February 4, 2014. He indicated he recently had been experiencing dyspnea with exertion. (Tr. 325.) He also reported worsening pain in his back and rib cage for the past six months. (Id.) He relayed this pain intensified the weekend prior, and he contemplated visiting the emergency room. However, the pain then subsided spontaneously. (Id.) Rodarmer appeared normal on physical examination. (Tr. 327.) Dr. Galvin indicated Rodarmer likely had a gallstone attack. (Id.)

         On February 28, 2014, Rodarmer had a consultation with rheumatologist Qingping Yao, M.D., for his shortness of breath. (Tr. 333.) He indicated 20% improvement of his ankylosing spondylitis symptoms with Simponi. (Id.) He reported he was able to perform normal, basic daily activities without limitation. (Id.) Rodarmer did not have an unsteady gait and was not using a cane. (Tr. 334.) He had no swelling in his joints, but his chest expansion was limited. (Id.)

         Dr. Yao indicated Rodarmer's shortness of breath was likely due to his limited chest expansion, and ordered diagnostic testing. (Id.) Pulmonary function testing was normal, and a chest x-ray was negative for acute cardiopulmonary process. (Tr. 341, 346.) An x-ray of Rodarmer's sacroiliac joints revealed sclerosis, with probable mild ankylosis on the right side. (Tr. 337.)

         On July 15, 2014, Rodarmer visited John Krebs, M.D., an orthopedist, for bilateral hand pain and numbness. (Tr. 421.) He reported his hand symptoms had been present for “quite sometime, ” but had worsened after using a sander in May 2014. (Id.) Dr. Krebs noted a past EMG did confirm bilateral carpal tunnel syndrome. (Id.) Rodarmer had positive Tinel's and Phalen's signs bilaterally. (Id.) Rodarmer then underwent a right carpal tunnel release on August 20, 2014 and a left carpal tunnel release on November 12, 2014. (Tr. 424, 426.)

         Rodarmer returned to Dr. Ignat on August 22, 2014. Dr. Ignat renewed the Simponi prescription, and Rodarmer indicated he had decreased pain. (Tr. 381.) However, on October 20, 2014, Rodarmer reported severe pain in his lumbar spine, which was radiating into his buttocks. (Tr. 380.) On examination, Rodarmer had normal muscle strength, but decreased range of motion in his hips and lumbar spine, with tenderness in his spine and sacroiliac joints. (Id.) Dr. Ignat administered a Toradol injection and renewed Rodarmer's medications. (Id.)

         That same day, Dr. Ignat filled out a form entitled “Physical Residual Function Capacity Medical Source Statement.” (Tr. 410.) While he reported treating Rodarmer since January 2013, he also indicated Rodarmer's “impairments, symptoms, and limitations” had been present since 2011. (Id.) Dr. Ignat provided the following limitations for Rodarmer:

• He could occasionally lift up to 15 pounds, but never lift 20 pounds or more.
• He could walk one city block or more without rest or pain, but could not walk one block or more on rough or uneven ground.
• He could not climb steps without the use of a handrail at a reasonable pace, and he had problems with balance while ambulating.
• He had problems with stooping, crouching, and bending.
• He would need to lie down/recline for 30 minutes before needing to sit up, stand up, or walk around. He would need to lie down/recline for about 3 hours out of an 8-hour workday.
• He could sit for less than one hour in an 8-hour workday. He could stand and walk for less than one hour in an 8-hour workday.
• He would need to take unscheduled breaks every 30-60 minutes. During these breaks, he would need to lie down or sit quietly, and rest for 30 minutes before returning to work.
• He would not need to elevate his legs with prolonged sitting. He would need an assistive device with prolonged ambulation.
• He could use his hands 100% of the day for grasping, turning, and twisting objects. He could perform fine manipulation for 80% of the workday, and reach, including overhead, for 50% of the workday.
• He could not push and pull arm or leg controls from a sitting position for 6 or more hours during an 8-hour workday.
• He could not climb stairs, ladders, scaffolds, ropes, or ramps.
• His pain would frequently interfere with his attention and concentration. His “experience of stress” would occasionally interfere with his attention and concentration.
• He would be off-task more than 30% of the workday, be absent from work more than 5 days a month, and 5 days a month he would be unable to complete an 8hour workday.
• Compared to an average worker, he could efficiently perform a job on a sustained basis 50% or less of the time.
• He is “unable to obtain and retain work in a competitive work environment, 8 hours per day, 5 days per week for a continuous period of six months or more.

(Tr. 410 -413.)

         Rodarmer returned to Dr. Ignat's office on January 15, 2015. Dr. Ignat prescribed a course of steroids because Rodarmer reported increased pain. (Tr. 379.)

         On January 20, 2015, Rodarmer returned to his chiropractor[5] for cervical spine pain. (Tr. 358.) Rodarmer attributed it to an awkward sleeping position. (Id.) The chiropractor performed spinal and tissue manipulation to the cervical area. (Id.) Rodarmer returned to his chiropractor on January 23, 2015, reporting improvement with treatment. (Tr. 357.) On examination, he exhibited mild spasms with palpitation. (Id.)

         On January 26, 2015, Rodarmer visited Dr. Ignat. He reported increased pain in his spine and shoulders, along with chest tightness. (Tr. 378.) He also indicated improvement since his last visit, with “only mild” lumbar spine pain radiating into the buttocks. (Id.) Dr. Ignat continued to prescribe Simponi. (Id.)

         Rodarmer visited his chiropractor six more times over January and February 2015. (Tr. 351-356.) He reported continued cervical spine pain, attributing it to various activities, including using a snow plow, illness, and painting. (Tr. 355, 354, 353.) On March 3, 2015, Rodarmer's cervical spine was “mildly sore.” (Tr. 352.) His chiropractor noted Rodarmer had “improvements with cane.” (Id.)

         On March 12, 2015, Rodarmer established with Munketh Salem, DPM, a podiatrist. (Tr. 368.) He reported pain in the ball of his right foot, after slipping on a flight of stairs. (Id.) Rodarmer indicated this pain increased with ambulation, and rated the pain as 5/10. (Id.) On examination, the muscle strength in his foot and ankle was 5/5. (Tr. 369.) Rodarmer was unable to dorsiflex the ankle beyond a neutral position with his knee extended. (Id.) Dr. Salem noted no edema, but there was pain with palpation to the right foot. (Id.) An x-ray of Rodarmer's right foot revealed no acute pathology or fracture, but he did have moderate degenerative joint disease throughout the foot. (Id.) Dr. Salem noted Rodarmer's “current pain is very minimal” and due to a hammertoe deformity and capsulitis in the joints at the ball of the foot. (Tr. 370.) Dr. Salem prescribed Rodarmer a course of steroids. (Id.)

         Rodarmer returned to Dr. Salem on April 22, 2015. (Tr. 364.) He had continued pain in his right foot, which was intermittent in nature. (Id.) Dr. Salem taped and splinted Rodarmer's toes, prescribed steroids, and recommended custom orthotics. (Tr. 366.)

         Rodarmer visited Dr. Ignat on April 20, 2015. Dr. Ignat noted Rodarmer's condition was “still active, not controlled on medications.” (Tr. 376.) On examination, Rodarmer's hips were tender with decreased range of motion and his shoulders exhibited crepitus, but with a normal range of motion. (Id.) His cervical spine range of motion was normal, but his lumbar range of motion was decreased. (Id.) He had severe tenderness in his ...


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