United States District Court, N.D. Ohio, Eastern Division
REPORT AND RECOMMENDATION
A. Ruiz, United States Magistrate Judge
Sandra Ward (hereinafter “Plaintiff”), challenges
the final decision of Defendant Nancy A. Berryhill, Acting
Commissioner of Social Security (hereinafter
“Commissioner”), denying her applications for a
Period of Disability (“POD”) and Disability
Insurance Benefits (“DIB”) under Titles 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.
January 30, 2014, Plaintiff filed her applications for POD
and DIB, alleging a disability onset date of September 2,
2010. (Transcript (“Tr.”) 183-186). The
application was denied initially and upon reconsideration,
and Plaintiff requested a hearing before an Administrative
Law Judge (“ALJ”). (Tr. 136-139, 142-152).
Plaintiff participated in the hearing on February 9, 2016,
was represented by counsel, and testified. (Tr. 38-94). A
vocational expert (“VE”) also participated and
testified. Id. On March 15, 2016, the ALJ found
Plaintiff not disabled. (Tr. 32). On February 28, 2017, the
Appeals Council declined to review the ALJ's decision,
and the ALJ's decision became the Commissioner's
final decision. (Tr. 1-3). On March 30, 2017, Plaintiff filed
a complaint challenging the Commissioner's final
decision. (R. 1). The parties have completed briefing in this
case. (R. 14-1 & 16).
asserts the following assignments of error: (1) the ALJ erred
by finding no severe impairment of the bilateral knees, and
(2) the ALJ erred by finding Plaintiff did not meet Listing
1.02(A). (R. 14-1).
Personal and Vocational Evidence
was born in November of 1967 and was 42-years-old on her
alleged onset date. (Tr. 183). She had a high school
education. (Tr. 212). She had past relevant work as an
assembler, daycare worker, and cleaner/housekeeper. (Tr. 31,
Relevant Medical Evidence
Treatment Records Before Date Last Insured
disability paperwork, Plaintiff identified her physical and
mental conditions that limited her ability to work as (1)
herniated disc L4 & 5, (2) right hand problems, (3)
sciatic left leg, and (4) major depressive disorder. (Tr.
September 8, 2010, Plaintiff was seen by Shu Huang, M.D.,
after spraining her right wrist due to a fall at work. (Tr.
308-309). On physical examination, Plaintiff's
“[m]uscle stretch reflexes are 2 and symmetric at
bilateral patellae, [A]chilles. Muscle strength is 5/5
bilaterally in hip flexion, knee extension, ankle DF/PF, EHL.
Able to stand on heels and toes.” (Tr. 308). Dr. Huang
noted that Plaintiff had symptoms “that are much more
than one expect from a simple fall. I spent long time asking
her to work on regular activity and not to limit her daily
activity.” (Tr. 309).
October 13, 2010, chiropractor Matthew Rivers noted
“DTR of the lower extremity revealed a 2 out of 4
rating bilaterally for the Patella and a 1 out of 4 rating
bilaterally for the Achilles, ” motor strength of the
right knee for flexion and extension was 5/5, and left knee
motor strength was 4/5. (Tr. 289). Plaintiff was also noted
to have difficulty with heel and toe walking. Id.
Supine straight leg raise was negative on the right and
positive at 15 degrees on the left. Id.
December 18, 2010, Plaintiff underwent an occupational
medicine consultation to evaluate Plaintiff's workers
compensation claims related to her fall. (Tr. 723-727). On
exam, Plaintiff had normal motor strength and reflexes in her
lower extremities, and a negative straight leg raise test.
(Tr. 725). The examiner noted multiple Waddell's signs,
which demonstrate “a bnormal illness
behavior.” (Tr. 725).
March 23, 2011, chiropractor Rivers indicated in a letter
that Plaintiff was experiencing swelling in her right wrist.
(Tr. 622-624). Plaintiff's “[m]otor strength
testing of the lower extremity was rated a 4 out of 5 on the
left for knee flexion and extension and a 5 out of 5 on the
right for knee flexion and extension. The patient was unable
to perform heel walking and toe walking at this time because
she is wearing a walking boot due to an injury she sustained
to her right foot.” (Tr. 623).
September 15, 2011, chiropractor Rivers observed Plaintiff
walking with a limp. (Tr. 529).
February 28, 2012, Mark Allen, M.D., noted
“[a]ggravation with straight leg raising. Reflexes are
symmetrical within normal limits, however, there may be some
sensory changes in the left leg more th[a]n the right
…” (Tr. 445-446).
March 18, 2012, chiropractor Anthony J. Simone observed that
Plaintiff had a positive straight leg raise test at 42
degrees on the right and 44 degrees on the left. (Tr. 442).
March 21, 2013, Sherif Salama, M.D., examined Plaintiff. (Tr.
1233-1237). With respect to Plaintiff's knees, Dr. Salama
noted range of motion was within normal limits for flexion
and extension, muscle strength and tone were within normal
limits, and no spasticity or at rophy were observed. (Tr.
24, 2013, Plaintiff was seen by occupational therapist Kathy
Stroh regarding complaints of right hand pain and constant
shaking in the right hand. (Tr. 826-827). The therapist
stated that Plaintiff's hand was not shaking until she
related that specific symptom to her, and that her hand did
not shake when writing or performing the 9-hole peg test.
3, 2013, Dr. Salama noted that Plaintiff was walking with an
assistive device. (Tr. 1209).
4, 2013, Mark R. Grubb, M.D., noted Plaintiff was using a
cane and had an antalgic gait. (Tr. 743).
2, 2013, Dr. Grubb noted Plaintiff walked with a
“slightly antalgic” gait. (Tr. 742).
16, 2013, Dr. Grubb saw Plaintiff who related a great deal of
back and leg pain. (Tr. 741). She was noted to have a normal
August 22, 2013, Dr. Grubb noted that Plaintiff was
“doing much better, ” that physical therapy was
helping, ” and that her “gait is improved.”
(Tr. 740). Dr. Grubb recommended a further increase in her
activity levels. Id.
October 17, 2013, Dr. Grubb noted that Plaintiff had a
slightly antalgic gait, but was not using a cane. (Tr. 739).
Her straight leg raise test was negative. Id.
November 12, 2013, Plaintiff was seen by Michael Gomez, M.D.,
as a new patient with complaints of right knee pain that had
been chronic for the past year. (Tr. 803). She wanted to
establish physical therapy, reported no falls thus far, and
denied significant numbness or weakness. Id. Her
pain was controlled with Neurontin. Id. On
examination, her right knee had “no varus/valgus
laxity, neg Ant drawers, 5/5 strength flex/ext. No sensory
deficits.” (Tr. 806). In addition, neurologically she
was “[i]ntact and symmetric, ” had a normal gait,
normal reflexes, gr ossly intact sensation, and no motor
deficits. (Tr. 806).
November 21, 2013, Plaintiff complained of pain radiating
down her right leg all the way top her foot. (Tr. 738). Dr.
Grubb noted that Plaintiff stood with good posture, had a
slightly antalgic gait, and was able to heel and toe walk.
Id. Straight leg raise test was negative
December 2, 2013, an MRI of Plaintiff's lumbar spine
yielded a normal result. (Tr. 737, 746).
December 19, 2013, Plaintiff reported worsening leg pain to
Dr. Grubb. (Tr. 737). On physical examination, he noted that
Plaintiff “stands up readily from her chair, ”
“has normal gait, ” and “is able to heel
and toe walk.” Id. He recommended pain
January 13, 2014, nurse practitioner Elise Leone noted that
Plaintiff was using a cane, that her range of motion in her
right knee was pain free but her left knee had “active
painful range of motion.” She had limited knee strength
bilaterally. (Tr. 765-766).
January 30, 2014, Plaintiff stated she fell in her driveway
injuring her right knee two weeks earlier. (Tr. 783-784). On
examination, Plaintiff's right knee was tender and unable
to bear weight, while her left knee was normal. (Tr. 784).
She was diagnosed with a knee contusion. Id.
January 30, 2014, imaging of Plaintiff's right knee
revealed “no evidence for acute traumatic injury,
” “no acute fracture or dislocation, ” the
knee joint space was maintained, and there was no joint