United States District Court, N.D. Ohio, Eastern Division
REPORT AND RECOMMENDATION OF MAGISTRATE
J. LIMBERT, UNITED STATES MAGISTRATE JUDGE.
Curtis Leflouria (“Plaintiff”) requests judicial
review of the final decision of the Commissioner of Social
Security Administration (“Defendant”) denying his
application for Disability Insurance Benefits
(“DIB”). ECF Dkt. #1. In his brief on the merits,
filed on May 25, 2017, Plaintiff asserts that the
administrative law judge (“ALJ”): (1) issued a
decision that is not supported by substantial evidence; and
(2) failed to call a medical expert to testify or order a
consultative examination. ECF Dkt. #15. Defendant filed a
response brief on July 25, 2017. ECF Dkt. #18. Plaintiff
filed a reply brief on July 31, 2017. ECF Dkt. #19.
following reasons, the undersigned RECOMMENDS that the Court
AFFIRM the ALJ's decision and dismiss Plaintiff's
case in its entirety with prejudice.
March 24, 2014, Plaintiff protectively filed an application
for DIB. ECF Dkt. #12 (“Tr.”) at
The application was denied and Plaintiff requested a hearing.
Id. at 82, 86. The hearing was held on September 16,
2015. Id. at 32. On October 6, 2015, the ALJ issued
a decision denying Plaintiff's claim. Id. at 15.
Subsequently the Appeals Council denied Plaintiff's
request for review. Id. at 3. Accordingly, the
October 6, 2015, decision issued by the ALJ stands as the
filed the instant suit seeking review of the ALJ's
October 6, 2015, decision on January 23, 2017. ECF Dkt. #1.
On May 25, 2017, Plaintiff filed a brief on the merits. ECF
Dkt. #15. Defendant filed a response brief on July 25, 2017.
ECF Dkt. #18. Plaintiff filed a reply brief on July 31, 2017.
ECF Dkt. #19.
RELEVANT MEDICAL AND TESTIMONIAL EVIDENCE
April 25, 2005, Plaintiff was diagnosed with polysubstance
dependency in remission and indicated that he was celebrating
three years of sobriety from drugs and alcohol on this date.
Tr. at 1130. In May 2005, Plaintiff was treated for his
Hepatitis C and it was noted that his liver function remained
stable. Id. at 1127. On July 6, 2005, it was noted
that Plaintiff had a history of ulcerative colitis and that
he reported he had been sober for four years. Id. at
August 2005, Plaintiff reported increasing pain in his hips.
Tr. at 1120. X-rays taken in September 2005 showed minimal
arthritic change and evidence of osteoporosis. Id.
at 508. A bone density study also performed in September 2005
showed no signs of osteoporosis. Id. at 507-508.
Plaintiff received treatment for sore hips on October 11,
2005. Id. at 610. On examination, Plaintiff
displayed good hip range of motion with mild soreness, good
curvature and range of motion of his spine, and a normal
October 19, 2006, Plaintiff sought treatment for a sore right
hip after he slipped on some wires on the floor at work and
landed on his right hip. Tr. at 231. Plaintiff stated that he
also landed on his right wrist, but that his wrist and hand
were not bothersome. Id. On examination, Plaintiff
exhibited tenderness and swelling in his right hip, pain on
rotation, and some pain on flexion of the hip. Id.
X-rays of Plaintiff's right hip showed a
“tiny” osteophyte that could have been “the
earliest findings in degenerative hip disease.”
Id. at 232. On August 23, 2006, Plaintiff reported
“level 10" pain at times in his right hip.
Id. at 230. On examination, Plaintiff had positive
straight leg raises on his right and was assessed as having a
right hip contusion with radiculopathy. Id.
was hospitalized for substance abuse treatment from March 30,
2007 through May 9, 2007. Tr. at 256, 259. During this time,
Plaintiff reported that he was suicidal, and that he had lost
everything and was thinking about hanging himself.
Id. at 260. In June 2007, it was noted that
Plaintiff's cocaine, alcohol, and marijuana dependence
were in remission. ID. at 284.
of Plaintiff's hips taken on August 9, 2007 were normal,
and x-rays of his right ankle showed calcaneal enthesopathy.
Id. at 312, 505-506. Additional x-rays showed
arthritic changes in the left acromioclavicular
(“AC”) joint. Id. at 312. The following
day, Plaintiff sought treatment for left shoulder pain and
reported a rotator cuff flare when he was lifting weights at
a gym. Id. at 265. Plaintiff displayed a smooth,
steady gait, localized left shoulder pain, full range of
motion of the cervical spine, and normal hand strength.
Id. at 265-66. Additionally, Plaintiff was able to
raise his arm over his head with some discomfort.
Id. at 266. That same day, Plaintiff had an
appointment regarding his Hepatitis C and denied any
abdominal pain, nausea, or vomiting. Id. at 812. In
September 2007, Plaintiff displayed nearly full range of
motion in his left shoulder and normal strength. Id.
at 590. X-rays showed degenerative disc disease in the AC
joint. Id. Plaintiff received an injection in his
shoulder. Id. at 803.
February 8, 2008, Plaintiff again complained of left shoulder
pain. Tr. at 788. X-rays of the shoulder showed minimal
degenerative changes in the AC joint. Id. at
501-502. That same day, Plaintiff sought treatment for blood
in his stool due to ulcerative colitis. Id. at 791.
On February 29, 2008, Plaintiff exhibited normal shoulder
range of motion, normal strength, and no AC tenderness, and
received another injection in his left shoulder. Id.
at 782-83. Further, Plaintiff stated that he was able to
perform his activities of daily living, but experienced some
pain. Id. at 579. Plaintiff also reported that he
was still passing blood at times, but his symptoms had
improved, and denied any urinary or bowel problems.
Id. at 776.
March 3, 2008, Plaintiff reported that he was enrolled in
school and was working towards a nursing degree. Tr. at 783.
Plaintiff stated that he was maintaining A grades in nearly
all of his classes, with a B in a single course. Id.
Additionally, Plaintiff indicated that he was brainstorming
recreational activities for his church and wanted to contact
Veterans Affairs (“VA”) regarding fishing trips.
2008, Plaintiff complained of bilateral sacroiliac joint pain
with intermittent buttock pain with no known injury. Tr. at
501. X-rays showed normal sacroiliac joints. Id.
Additional x-rays of Plaintiff's lumbar spine showed
multilevel degenerative disc disease. Id. at 500. It
was noted that a small caliber bullet was “probably in
the far left flank.” Id. In July 2008, it was
reported that Plaintiff was following through with his
substance abuse groups and taking classes to help improve his
life. Id. at 750.
reported back pain in May 2009 and was prescribed medication.
Tr. at 735-36. On June 10, 2009, Plaintiff reported pain in
his left heel and was assessed as having bursitis, abnormal
gait, and plantarflexed metatarsals. Id. at 566-67.
Later that month, Plaintiff complained of stiffness in his
back in the mornings, but indicated that it resolved by the
afternoon. Id. at 569. It was also noted that
Plaintiff was seen previously for shoulder problems, which
had been resolved. Id. at 726. Plaintiff had pain
and tenderness in his right sacroiliac joint with full
flexion of the lumbar spine, mild scoliosis, full straight
leg raise tests, normal lower extremity strength, normal
sensation, and minimal leg discrepancy. Id. at 569,
726. Based on this diagnosis, Plaintiff was given materials
for a home exercise program. Id.
August 2009, Plaintiff was issued orthotics that supported
the arch in a subtailor joint neutral position and raised the
heel. Tr. at 561-62. Plaintiff also received another
injection in his left shoulder for the pain. Id. at
718-19. On October 27, 2009, Plaintiff underwent an
examination of his spine in connection to VA disability
benefits. Id. at 707. On examination,
Plaintiff's pelvis was tilted to the right and he
displayed an antalgic gait. Id. at 709-10. Plaintiff
had muscle spasms in his back and lower extremity weakness in
his left leg, but full motor strength in his extremities
other than slightly reduced left hip and knee flexion.
Id. at 711-12. It was stated that Plaintiff had leg
length discrepancy and degenerative disc disease in his back,
and that his back condition was secondary to his hip injury.
Id. at 636, 717.
February 2010, Plaintiff complained of continued pain in his
lower back, left leg, and left hip, and was prescribed
medications. Tr. at 699. Plaintiff stated that he experienced
left shoulder pain in March 2010 and received another
injection. Id. at 693-94. On April 5, 2010, a CT of
Plaintiff's lumbar spine showed moderate multilevel
degenerative disc disease. Id. at 498-99. In July
2010, Plaintiff participated in physical therapy for lower
back pain and displayed normal lower extremity strength,
normal straight leg raise testing, and a posture that shifted
to the left. Id. at 541-42. A home exercise plan was
developed and Plaintiff was seen for additional physical
therapy sessions through July 2010 and August 2010, which he
tolerated well. Id. at 542-43, 663-74. Plaintiff