United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OF OPINION AND ORDER
M. Parker United States Magistrate Judge
Darren Sistrunk, seeks judicial review of the final decision
of the Commissioner of Social Security denying his
applications for supplemental security income and disability
insurance benefits under Titles II and XVI of the Social
Security Act (“Act”). The parties have consented
to my jurisdiction. ECF Doc. 11.
statements found in the ALJ's decision and the record
evidence support a finding that Sistrunk failed to prove he
met Listing 1.04, the ALJ's Step Three findings must be
affirmed. However, because the ALJ did not state good reasons
for rejecting the treating physician's opinion, the final
decision of the Commissioner must be VACATED and the claim
must be REMANDED for further proceedings.
November 29, 2011, Sistrunk applied for disability insurance
benefits and supplemental security income, alleging
disability beginning February 1, 2007. (Tr. 399-404, 406-411)
The claims were denied initially and on reconsideration. (Tr.
218- 229, 230-241, 242- 255, 257-270) Sistrunk requested a
hearing on October 19, 2012. (Tr. 312) Administrative Law
Judge (“ALJ”) Susan G. Giuffre heard the case on
June 12, 2013 (Tr. 181-216) and found Sistrunk was not
disabled. (Tr. 271-283) After Sistrunk's request for
review (Tr. 377), the Appeals Council vacated the ALJ's
2013 decision on February 9, 2015, and remanded the matter to
ALJ Giuffre to conduct further proceedings. (Tr. 287-291)
the remand order, ALJ Giuffre held a second hearing on May
27, 2015 (Tr. 150-179) and issued a second unfavorable
decision on July 1, 2015. (Tr. 8-21) The Appeals Council
denied further review, rendering the ALJ's decision
final. (Tr. 1-4) Sistrunk instituted this action to challenge
the Commissioner's final decision.
Personal, Educational and Vocational Evidence
was born on December 18, 1961 and was 53 years old when the
ALJ issued her 2015 decision. (Tr. 399) He completed high
school and attended vocational school to become an
electronics technician, but dropped out because the
coursework was too difficult for him. (Tr. 185) For many
years, he worked for the Zircoa Company in several different
production jobs as well as cleaning and maintenance. (Tr.
186-187) He had not worked since his alleged 2007 onset date.
He lived with his mother and helped care for her until she
died in 2011. (Tr. 204-206)
Sioson, M.D., examined Sistrunk on January 23, 2012 at the
request of the State Disability Determination Service
(“DDS”). (Tr. 501-507) An x-ray ordered by Dr.
Sioson showed degenerative changes consisting of severe disc
space narrowing and endplate osteophyte formation at the L4-5
level and hypertrophic facet changes at the L4-5 and L5-S1
levels. (Tr. 501)
established care with Erron Bell, D.O. on May 15, 2012.
Sistrunk reported he'd had back pain for four years. Dr.
Bell reviewed Sistrunk's x-rays from January. (Tr. 512)
Dr. Bell noted reduced range of motion in Sistrunk's
back. Sistrunk's extremities were normal; his muscle
strength was intact; and his spine range of motion was
normal. After diagnostic testing, Dr. Bell diagnosed elevated
blood pressure and prescribed medication. He also referred
Sistrunk to pain management. (Tr. 514) Sistrunk followed-up
with Dr. Bell on May 31, 2012. He had been feeling well since
his last appointment and his blood pressure was normal. (Tr.
31, 2012, Sistrunk established care with Zachary Allred, D.O.
at the pain management department of Metro Health Medical
Center. (Tr. 524) Sistrunk described his pain as sharp and
stabbing; as having lasted for the past year; and as being
alleviated by rest and stretching. (Tr. 524) He told Dr.
Allred that he had been fired from his job several years ago
for drug abuse issues. He said he was trying to get
disability benefits but would also be happy if his back pain
improved and he could return to work. (Tr. 525) Sistrunk said
that he could ambulate and perform daily activities without
devices. Dr. Allred found Sistrunk's pelvis to be
asymmetric, elevated to the right side. Sistrunk had mild
tenderness to palpation in the left lumbosacral muscles.
Allred did not observe any spasms or trigger points and
straight leg raise testing was negative. (Tr. 526) Dr. Allred
diagnosed low back pain secondary to facet arthropathy. He
told Sistrunk that physical therapy and a home exercise
program were the key for his back rehabilitation. Sistrunk
was hesitant to pay the five dollar copay for physical
therapy. He also seemed hesitant to do the home exercise
program but accepted it. Dr. Allred told Sistrunk that he
would not qualify for disability because he had not undergone
any treatment or rehabilitation for his low back pain. (Tr.
went to the emergency room at South Pointe Hospital on
November 12, 2012. (Tr. 569) He reported pain down his right
leg and buttock and down the posterior thigh. He said that
the pain had started five to seven days earlier. He said he
had no back pain. He had normal range of motion, strength and
reflexes. (Tr. 570) Straight leg raising was negative. (Tr.
571) He was diagnosed with sciatica of the right side. (Tr.
began pool-based physical therapy on December 18, 2012. He
complained of constant low back pain which radiated down the
right lower extremity to the toes, with left-sided low back
and knee pain. (Tr. 607) On December 20, 2012, the therapist
noted that Sistrunk had elevated blood pressure and sent him
to the emergency room. (Tr. 593) Sistrunk was discharged from
physical therapy on March 13, 2013 because he had not
achieved his treatment goals. (Tr. 608)
December 20, 2012, Sistrunk went to the hospital with
elevated blood pressure. He also reported blurry vision and
back pain but said these were chronic and no worse than
usual. (Tr. 575) Sistrunk had normal strength and no sensory
deficits. (Tr. 577) He was instructed to follow up with his
primary care physician. (Tr. 577)
January 2, 2013, Sistrunk met with Nathan Tracey, D.O., to
follow-up on his high blood pressure. (Tr. 578) Sistrunk also
reported chronic back pain. He had normal range of motion,
gait, coordination, and muscle tone. (Tr. 579-580) Dr. Tracey
prescribed medication for Sistrunk's high blood pressure
and recommended diet and regular aerobic exercise. (Tr. 580)
Sistrunk followed-up with Dr. Tracey on January 25, 2013. He
said his diet was healthy but he was not exercising due to
back pain. (Tr. 582) Sistrunk had normal muscle tone and
gait. Dr. Tracey continued his medications and recommended
regular aerobic exercise. (Tr. 584)
February 19, 2013, Sistrunk went to the emergency room at
South Pointe Hospital complaining of low back pain. He was
diagnosed with lumbosacral neuritis. (Tr. 591)
March 27, 2013, Sistrunk started treating with Euglok Yap,
M.D. Dr. Yap administered a lumbar epidural steroid
injection. (Tr. 617) He administered a second injection on
April 17, 2013. (Tr. 58)
April 1, 2013, Sistrunk saw William Welches, D.O. for pain
management. Sistrunk reported low back pain travelling down
his left leg. (Tr. 622) He reported poor sleep habits and two
hours of uninterrupted sleep each night. (Tr. 622) Sistrunk
told Dr. Welches that osteopathic manipulative therapy
(“OMT”) had not helped his pain. He rated his low
back pain as ranging from 5 to 8/10 with numbness and
tingling into his legs. (Tr. 623) Dr. Welch performed OMT on
April 1, 2013 but indicated that further OMT treatments were
unwarranted because of lack of progress. He recommended that
Sistrunk should further investigate epidural injections,
which had provided temporary relief. (Tr. 625)
met with Dr. Tracey on April 10, 2013 for hypertension and
back problems. (Tr. 587) Dr. Tracey noted that Sistrunk was
treating with pain management and had received multiple
shots. (Tr. 587) Sistrunk complained of spasms or cramps in
his leg. (Tr. 587-588) He had normal coordination, gait, and
muscle tone. Dr. Tracey noted that Sistrunk was depressed -
he felt like his back wouldn't heal or stop hurting. (Tr.
saw Dr. Tracey on July 11, 2014. He complained that his lower
back pain was worse than the prior year. The pain radiated
down his left leg and he was having difficulty sleeping. He
also complained of leg weakness and decreased sensation in
his leg. Physical therapy and injections had provided minimal
relief. Sistrunk had 3/5 strength in his left hip flexor, 3/5
strength in his left knee and 4/5 strength in his left foot.
He had 5/5 strength in his right lower extremity. He had
decreased sensation to palpation at the lateral aspect of the
lower leg, but normal muscle tone. (Tr. 628) Sistrunk
requested pain medication. (Tr. 627) Dr. Tracey diagnosed
spondylolisthesis of the lumbar region, lumbar degenerative
disc disease and hypertension. He prescribed pain medication
and recommended that Sistrunk lose weight. (Tr. 629) In a
follow up visit on July 25, 2014, Sistrunk told Dr. Tracey
his back pain was the same. He had normal muscle tone, gait
and range of motion. He had reduced strength in his hips.
(Tr. 636) Dr. Tracey ordered an MRI of Sistrunk's lumbar
spine. (Tr. 637)
started treating with Patrick Shaughnessy, M.D., at South
Pointe Physical Medicine Clinic on August 13, 2014. Sistrunk
reported that he'd had a sports injury in 1980 but his
back pain became worse five years ago. He told Dr.
Shaughnessy that he spent ten hours a day reclining. (Tr.
642) Physical examination showed decreased strength in the
left lower extremity from -4 to 4 out of 5 at the hip and
knee. Dr. Shaughnessy also noted a loss of sensation on the
left in an S1 distribution. Straight leg raising test was
positive on the left. (Tr. 644) Dr. Shaughnessy prescribed
pain medication and recommend daily walking and weight loss.
He thought that Sistrunk was a “candidate for
SSI” and that surgery might be an option. (Tr. 645)
lumbar MRI on August 19, 2014 showed a grade I
anterolisthesis of L4-5 and a grade I retrolisthesis of
L5-S1. There were mild superior and inferior endplate
compression deformities of all lumbar vertebrae and a remote
bilateral L4 pars defect. At ¶ 3-4, there was
moderate-to-severe canal stenosis due to hypertrophic facet
changes as well as developmental shortening. The L4-5
interspace was noted to be severely narrowed with
degenerative endplate changes and a left-sided disc bulge.
The MRI revealed “suspected impingement” of the
L4 nerve root. At ¶ 5-S1, there was severe disc space
narrowing with disc bulge to the right, and endplate
degenerative changes with minimal encroachment on the ventral
thecal sac, but with moderate right and mild left foraminal
narrowing. (Tr. 697)
saw Virginia Factor, D.O. on August 19, 2014 in the Family
Practice Department at the Cleveland Clinic. Dr. Factor
checked Sistrunk's hypertension and completed paperwork
for an RTA paratransit pass so Sistrunk would have direct
transportation; walking to the bus stop aggravated his pain.
followed up with Dr. Shaughnessy on September 3, 2014.
Sistrunk complained of pain radiating down both legs. His
pain was worse than his last visit and rated as 6/10.
Sistrunk reported that his legs would occasionally “go
weak.” (Tr. 652-653) Dr. Shaughnessy noted bilateral
decreased ankle jerk reflexes. Straight leg raising was
negative for radicular pain but caused back and hip pain.
Sistrunk had limited range of motion in his back due to pain,
but full range of motion in his extremities and 4/5 strength
in his hips. His gait was abnormal; he leaned forward and he
would not heel or toe walk or perform tandem gait.
Romberg's sign was equivocal. (Tr. 653) Dr. Shaughnessy
diagnosed spondylolisthesis, spondylolysis and radiculopathy.
He noted that Sistrunk's symptoms were consistent with
his physical exam and MRI findings. He recommended a
conservative approach and that Sistrunk pursue disability. He
also recommended that Sistrunk be evaluated for possible
surgery but noted that he would be reluctant to pursue
surgery in the absence of progression of muscle weakness. Dr.
Shaughnessy opined that it was extremely unlikely that
Sistrunk's condition would improve; he expected it to
stay the same or slowly deteriorate. (Tr. 654) Dr.
Shaughnessy recommended that Sistrunk walk as much as he was
able and that he limit his lifting to no more than 10 pounds,
with no bending to lift. (Tr. 655)
September 12, 2014, Sistrunk followed up with Dr. Tracey for
his high blood pressure. (Tr. 656) He had adjusted his diet
and decreased his portion sizes. He was in pain management
for his back pain. He told Dr. Tracey that he was not
planning to pursue surgery until the pain management was no
longer dealing with his pain. He had tenderness in his back
on palpation. (Tr. 657)
followed up with Dr. Shaughnessy on October 1, 2014. He said
that his back pain had not changed since the prior visit.
Sistrunk reported that he had walked ½ to ¾
mile several times. It was painful and he rested at bus stops
along the way. (Tr. 664) Straight leg raising was negative.
Sistrunk had full range of motion in his extremities. His
lower back was painful to palpation. (Tr. 665) Dr.
Shaughnessy noted that Sistrunk “appears
disabled.” (Tr. 666) He diagnosed right L5 neuritis and
recommended that he continue his medication and walking
routine. (Tr. 666-667)
told Dr. Tracey that his back was really bothering him on
October 13, 2014. The pain had started when he woke up that
morning. (Tr. 668) Sistrunk had normal muscle tone. Dr.