United States District Court, N.D. Ohio, Eastern Division
TAMMY H. HOWELL, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
Christopher A. Boyko
REPORT AND RECOMMENDATION
R. KNEPP, II UNITED STATES MAGISTRATE JUDGE
Tammy Howell (“Plaintiff”) filed a Complaint
against the Commissioner of Social Security
(“Commissioner”) seeking judicial review of the
Commissioner's decision to deny supplemental security
income (“SSI”). (Doc. 1). The district court has
jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g).
This matter has been referred to the undersigned for
preparation of a report and recommendation pursuant to Local
Rule 72.2. (Non-document entry dated February 16, 2017).
Following review, and for the reasons stated below, the
undersigned recommends the decision of the Commissioner be
reversed and remanded for further proceedings.
filed for SSI in June 2014, alleging a disability onset date
of January 1, 2013. (Tr. 149). Her claims were denied
initially and upon reconsideration. (Tr. 80, 96). Plaintiff
then requested a hearing before an administrative law judge
(“ALJ”). (Tr. 112). Plaintiff (represented by
counsel), and a vocational expert (“VE”)
testified at a hearing before the ALJ on July 28, 2016. (Tr.
40-64). On August 12, 2016, the ALJ found Plaintiff not
disabled in a written decision. (Tr. 21-34). The Appeals
Council denied Plaintiff's request for review, making the
hearing decision the final decision of the Commissioner. (Tr.
1-4); see 20 C.F.R. §§ 416.1455, 416.1481.
Plaintiff timely filed the instant action on February 15,
2017. (Doc. 1).
Background and Testimony
was born in June 1967, and was 49 years old at the time of
the ALJ hearing. See Tr. 44, 149. Plaintiff had an
eighth-grade education in special education classes, and a
GED. See Tr. 45, 52. Plaintiff was divorced, and
lived with a friend, but did not pay rent. (Tr. 45).
Plaintiff testified she had last worked doing assembly work
in 2005. (Tr. 46-47).
described why she felt she was disabled:
At this time it's my neck, my shoulder and my back with
all the pain that I have throughout the day, and all the
breaks that I take throughout the day when I'm doing
something. I don't believe I could do a job. And then
with my mental problems I'm afraid that I might have an
anger outburst and hurt someone.
(Tr. 48). For treatment, Plaintiff took pain medicine for her
back, and went to physical therapy for her neck and shoulder.
Id. She anticipated an MRI after physical therapy
also testified to problems with her left knee. (Tr. 52). She
got migraine headaches at least once per week. Id.
When the migraines occurred, she took medicine and laid down,
and was “usually out for two days”. Id.
Plaintiff also had COPD. (Tr. 54-55).
testified that for her mental health treatment, she took
Valium and Ativan, saw a counselor once per week, and saw a
psychiatrist once or twice per month. (Tr. 49). She thought
these measures were helping. Id. She had been in
counseling for two years to address anger and depression.
estimated she could stand in one place for ten minutes before
having to move due to “sharp pains in [her] lower back
that run up to the middle of [her] back.” (Tr. 49).
At that point, she would have to “[e]ither shift or sit
down.” Id. She would have to sit for twenty
minutes before standing back up. Id. Walking was
“[a]bout the same” as standing. Id.
Plaintiff used a cane sometimes, when her back was
“really, really hurting or [her] sciatic nerve [pain
was] really bad.” (Tr. 49-50). Plaintiff estimated she
could sit for half an hour, but would have pain during that
time. (Tr. 50). She could lift “[n]o more than five
pounds”, and could lift a gallon of milk with her left
hand. Id. Plaintiff also testified to difficulty
bending, kneeling, crouching, as well as reaching overhead or
out in front of her with her right arm. (Tr. 51). She had
trouble with grip in her right hand. Id. Plaintiff
testified as to how she got through her days:
I stand for a little while, I can stand for about 10, 15
minutes, then I sit down or shift my weight to this side. I
don't stand a lot permanent on my feet. When I'm
sitting I can only sit for 20 minutes then my back starts
hurting so I get up and walk around a little bit to relieve
that. Still I have pain.
(Tr. 53). She spent the most time in the recliner.
roommate did most of the household work, but she testified
she folded clothes, loaded the dishwasher, and cleaned her
bathroom. Id. Plaintiff also shopped for groceries,
and went to doctor appointments. (Tr. 54).
2014, Plaintiff went to the emergency room with right back
and arm pain. (Tr. 249). On examination, Plaintiff had
decreased range of motion, pain and spasm in her cervical
spine, and tenderness around her right scapula. (Tr. 250).
She was assessed with musculoskeletal pain, and discharged
with prescription medication. (Tr. 252).
then saw Sherry Adkins, M.D., at Family Health Center for a
follow-up visit. (Tr. 272-74). She requested a rheumatology
referral, wanted to change her anxiety medication, and wanted
a cane due to knee pain. (Tr. 272). She reported back, neck,
and knee pain. Id. On examination, Dr. Adkins found
some tenderness in Plaintiff's right arm. (Tr. 273). She
assessed Plaintiff with uncontrolled anxiety, discussed
medication options, and referred her to a psychiatrist.
Id. She also assessed bilateral knee pain, which she
found most consistent with bursitis, and referred Plaintiff
for an orthopedic consultation. (Tr. 273-74).
2014, Plaintiff saw Eric Koperda, M.D., at Family Health
Center. (Tr. 275). Her physical examination was normal. (Tr.
276). Plaintiff reported she was unable to reach a
psychiatrist, and Dr. Koperda repeated the referral.
Id. Dr. Koperda also assessed bilateral pedal edema,
which Plaintiff reported was worse at the end of the day.
Id. He noted he would “oblige pt with cardiac
workup” due to family history of coronary artery
echocardiogram performed later that month showed: 1) the left
ventricular systolic function was in the lower limit of
normal to mildly reduced; 2) the right ventricular cavity
size was mildly enlarged; 3) the right atrial cavity size was
mildly dilated; 4) mild mitral regurgitation; and 5) mild to
moderate tricuspid regurgitation. (Tr. 290). A bone density
scan showed osteoporosis in Plaintiff's lumbar spine.
2014, Plaintiff saw Rodel Cacas, M.D. at Wilmington
Physicians Group, LLC, to establish care. (Tr. 333). She
reported depression, anxiety, COPD, osteoporosis, sciatica,
and PTSD. Id. Plaintiff reported arthralgias/joint
pain, and joint stiffness, but no muscle aches or weakness.
(Tr. 335). On examination, Dr. Cacas noted normal muscle
strength and tone, no tenderness, and full range of motion.
(Tr. 336). Her psychiatric examination was normal.
Id. Dr. Cacas assessed, inter alia, PTSD,
an inflamed sacroiliac joint, and carpal tunnel syndrome.
returned to Dr. Cacas in August 2014 for a sacroiliac joint
injection. (Tr. 329-32).
visit to a urologist in September 2014, Plaintiff denied back
pain, joint pain or swelling, or neck pain, but was noted to
have osteopenia. (Tr. 347). Her physical and psychiatric
examinations were normal. (Tr. 348).
October 2014, Plaintiff returned to Dr. Cacas with neck,
shoulder, and back pain. (Tr. 324-28). She reported the pain
had been worsening for a few week, and that it had waxed and
waned for years. (Tr. 326). She reported Advil did not help,
and the sacroiliac injection “did not help much”.
Id. Her muscle tone, strength, and range of motion
were normal, but she had tenderness in seventeen out of
eighteen fibromyalgia points. (Tr. 327). Dr. Cacas assessed
“[p]rimary fibromyalgia syndrome”, and started
Plaintiff on trial medication. Id. Her psychiatric
examination was normal. Id.
that month, Plaintiff returned to Dr. Cacas for follow-up.
(Tr. 319-23). She reported pain through her shoulders, lower
back, and buttock, and that she was “[h]aving a
flare” and “having difficulties getting
around.” (Tr. 321). Dr. Cacas again assessed primary
fibromyalgia syndrome, noting the same seventeen out of
eighteen positive points. (Tr. 322). He noted Plaintiff did
not tolerate previously prescribed medication, and started
Plaintiff on a trial of Tylenol 3. Id. Her
psychiatric examination was again normal. Id.
returned to Dr. Cacas again at the end of October 2014. (Tr.
315-18). Dr. Cacas again noted Plaintiff reported
arthralgias/joint pain, but no muscle aches or weakness, (Tr.
317). She also reported anxiety and emotional lability but no
emotional problems/concerns or depression. Id. On
examination, Dr. Cacas found tenderness and limited range of
motion. Id. Her mental status was anxious and
depressed. (Tr. 318). Dr. Cacas again assessed primary
fibromyalgia syndrome, and noted he would “fill
December 2014, Plaintiff had MRIs of her right elbow and left
knee. (Tr. 461-62). In her elbow, she had a tendon tear; in
her knee, she had an oblique undersurface tear of the medial
meniscus posterior horn-body junction and adjacent posterior
body segment, small areas of low-grade articular cartilage
loss, and small knee joint effusion. Id. That same
month, Plaintiff saw Andrea Manhart, D.O., about migraines.
(Tr. 483-88). Her examination (mental and physical) was
essentially normal. (Tr. 487). She was assessed with
migraines and prescribed medication. (Tr. 487-88). A
follow-up brain MRI showed no acute abnormality. (Tr. 460).
March 2015, Plaintiff returned to Dr. Manhart regarding her
headaches. (Tr. 479-83). Dr. Manhart assessed migraines, neck
pain, and muscle tension; she prescribed medication. (Tr.
April 2015, Plaintiff saw Dr. Cacas “to fill out
disability paperwork.” (Tr. 523). Plaintiff again
reported arthralgias and joint pain, but no muscle aches,
weakness, or joint stiffness. Id. On examination,
Dr. Cacas noted Plaintiff had normal tone and strength, but
“tenderness” in her joints, bones and muscles.
(Tr. 524). Dr. Cacas continued to assess, inter
alia, primary fibromyalgia syndrome. Id.
returned to Dr. Cacas in May 2015. (Tr. 514-19). Plaintiff
reported arthralgias and joint pain, but no muscle aches,
weakness, or joint stiffness. (Tr. 518). She had normal
muscle tone, and strength, but some tenderness. Id.
Dr. Cacas assessed lateral epicondylitis (“tennis
elbow”). Id. Later that month, Plaintiff
underwent surgery on her elbow. (Tr. 455-56).
2015, Plaintiff saw a physician's assistant at Wilmington
Physicians Group regarding her elbow. (Tr. 421). Notes
indicate an appropriate range of motion and normal sensation.
(Tr. 424). Plaintiff reported still having some pain, but
that she felt better than prior to the surgery. (Tr. 425).
2015, Plaintiff underwent multiple sessions of chiropractic
care with Randall Fick, D.C., D.A.B.C.O. (Tr. 350-51). She
complained of pain and stiffness in her neck, back, and
shoulder. (Tr. 350). Dr. Fick found reduced range of motion
in the lumbar and thoracic spines, as well as myospasm in the
mid thoracic multifidus and the suboccipitals. Id.
again saw a physician's assistant at Wilmington
Physician's Group about her elbow. (Tr. 415-20).
Plaintiff had appropriate range of motion and normal
sensation, Tr. 418, but reported increased pain, Tr. 420. The
physician's assistant found it “somewhat
concerning” that she still had swelling, and performed
a corticosteroid injection to address the swelling.
returned to Dr. Cacas in July 2015, reporting right elbow and
shoulder pain. (Tr. 511-13). Plaintiff reported severe pain
right after the steroid injection, and that it was not
improving. (Tr. 511). On examination, Plaintiff had some
musculoskeletal tenderness. (Tr. 512). Dr. Cacas assessed
cubital tunnel syndrome, status post surgery and
corticosteroid shot, and prescribed medication pending
orthopedic follow-up. Id.
August 2015, Plaintiff returned to Dr. Cacas with right
shoulder pain. (Tr. 501-07). She reported reaching movements
were the worst, and that she was “[h]aving a hard time
in general as it is very aching [sic]”. (Tr. 505). On
musculoskeletal examination, Dr. Cacas noted full range of
motion, but with tenderness. Id. He ordered x-rays
of Plaintiff's shoulder and neck. (Tr. 506). The shoulder
x-ray was normal. (Tr. 454).
February 2016, Plaintiff returned to Dr. Cacas regarding neck
and back pain. (Tr. 496-500). On examination, Dr. Cacas noted
full range of motion and tenderness. (Tr. 499). Dr. Cacas
assessed, inter alia, fibromyositis/fibromyalgia and
neck pain. (Tr. 499-90). A follow-up x-ray of Plaintiff's
neck showed degenerative changes at ¶ 5-6 and C6-7, as
well as loss of the normal cervical lordosis. (Tr. 453).
2016 bone density analysis showed “[o]steoporosis but
values are essentially stable as compared to prior
exams.” (Tr. 452). Later that month, Plaintiff
underwent an abdominal and pelvic CT scan due to abdominal
pain. (Tr. 447). It showed no pancreatic edema, a 2
centimeter low density mass of the left adrenal, and
low-density mass lesions of bilateral kidneys, most likely
representing cysts. Id. Her appendix looked normal,
and she had left colon diverticulosis without acute phlegmon.
returned to Dr. Cacas for follow-up in April 2016. (Tr.
490-94). Plaintiff reported musculoskeletal symptoms in her
neck, shoulders, elbow, knee, foot, ankle, and lower back.
(Tr. 493). She again reported arthralgias and joint pain, but
no muscle aches or weakness, and no joint stiffness. (Tr.
494). On musculoskeletal examination, Dr. Cacas noted