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Kance v. Commissioner of Social Security

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

June 6, 2019



          Thomas M. Parker, United States Magistrate Judge

         I. Introduction

         Plaintiff, Michael Kance, seeks judicial review of the final decision of the Commissioner of Social Security, denying his applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act. This matter is before me pursuant to 42 U.S.C. § 405(g) and the parties consented to my jurisdiction under 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73. ECF Doc. 12. Because the Administrative Law Judge (“ALJ”) failed to apply proper legal standards in evaluating the medical opinions, the Commissioner's final decision denying Kance's application for DIB and SSI must be VACATED and the matter REMANDED for further proceedings consistent with this memorandum of opinion and order.

         II. Procedural History

         On December 24, 2015, Kance applied for DIB and SSI. (Tr. 216, 220).[1] Kance alleged that he became disabled on December 30, 2014 (Tr. 216, 220) due to Dupuytren's contracture, depression, anxiety, nervousness and hives. (Tr. 97). The Social Security Administration denied Kance's applications initially and upon reconsideration. (Tr. 146, 149, 157, 164). Kance requested an administrative hearing. (Tr. 69). ALJ Scott R. Canfield heard Kance's case on November 7, 2017, and denied the claim in a February 20, 2018, decision. (Tr. 14-29). On June 20, 2018, the Appeals Council denied further review, rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-5). On August 16, 2018, Kance filed a complaint to seek judicial review of the Commissioner's decision. ECF Doc. 1.

         III. Evidence

         A. Relevant Medical Evidence

         As noted above, Kance claimed disability due to several conditions. (Tr. 97). However, he has limited his appeal to the ALJ's analysis of his Dupuytren's contractures of the hands and the related symptoms, restrictions and limitations in the use of his hands. ECF Doc. 14 at 5. For this reason, the court summarizes only the evidence related to the challenged issues.

         In 2014, Kance's treating physician, Dr. Carl A. Robson, referred him for an assessment of the pain and contractures in his hands. (Tr. 348). The assessment showed that Kance had bilateral contractures with decreased pinch and grip strength. (Tr. 350).

         On August 27, 2015, Kance was diagnosed with palmer fibromatosis/Dupuytren's contracture, which had progressed since his appointment a year earlier. (Tr. 348). Examination showed contractures of the ring and small fingers to 80 degrees at the metacarpophalangeal (MP) joint and 60 degrees at the proximal interphalangeal (PIP) joint, with palpable cords, notable tenderness about the cord to the small finger, and decreased pinch and grip strength. Surgery was scheduled to treat Kance's condition. (Tr. 348).

         On October 9, 2015, Kance underwent left arm partial palmer fasciectomy with excision of digital extension ring and small fingers. (Tr. 342). His post-surgical diagnosis was left-hand palmar fibromatosis with digital extensions ring and small fingers. (Tr. 342).

         Following his surgery, Kance attended physical therapy. (Tr. 325-340). At his initial evaluation, he was fitted for splints and was instructed on their use. (Tr. 339). On November 10, 2015, Kance reported that he did not have pain unless pushing and then it was 4/10. (Tr. 332). On December 1, 2015, Kance reported 2/10 pain in his small finger. He stated that he was trying to use his hand as much as he could. He reported moving furniture, taking out trash and raking. (Tr. 317, 321). The therapist noted gradual gains in Kance's range of motion in his left hand with the exception of his small finger PIP joint. (Tr. 318). However, at his sixth appointment on December 8, 2015, Kance continued to lack range of motion in his hand and he had decreased grip strength. (Tr. 326).

         On January 27, 2016, Kance saw Dr. Robson, who noted that Kance still had very poor function and a weak grip, with the right hand worse than the left. He was unable to hold tools or perform any manual labor. (Tr. 355).

         In January 2016, Kance's sister assisted him in filling out a function report. (Tr. 262-269). Kance reported struggling with grip strength and stiffness in his hands. He reported that he did not cook; his sister cooked for him. He didn't do any household chores except washing the dishes sometimes. (Tr. 264).

         Kance saw Dr. Robson on May 18, 2016. (Tr. 359) Kance's left-hand grip strength was 2/5 with contractures moderately reducing his left-hand range of motion. (Tr. 360-361). His right-hand grip strength was 3/5 with contractures moderately reducing the range of motion in his right-hand fingers. (Tr. 361). Dr. Robson noted that due to “weakness of grip strength and dexterity” Kance was “totally unable to do any carpentry or any other work requiring hand grip and dexterity due to Dupuytren's contractures.” (Tr. 359).

         Kance saw Dr. Robson at his office on August 18, 2016. (Tr. 387). Dr. Robson noted, “hands - left surg scars, contraction 5th, Range of motion: mild pain w/motion, poor grip, Right: 4th tendon contracture, range of motion: mild pain with grip, poor grip…grip strength left, cannot register any change, right hand = 14mm change, :me: about 180 mm grip bilateral for comparison.” (Tr. 388). Dr. Robson also noted that “with no significant grip strength either hand, he is absolutely disabled for any type of manual labor, total and permanent.” He referred Kance back to the hand clinic to see if injections might help. (Tr. 389). Dr. Robson's treatment notes on September 15th restated his opinion that Kance was totally disabled. (Tr. 391, 393).

         On March 28, 2017, Dr. Robson noted that Kance's strength was 1-2/5 in the left with weak grip and contractures and 2-3/5 in the right; he was unable to extend or make a fist. The left side was similar with poor strength and grasp. (Tr. 425).

         B. Relevant Opinion Evidence

         1.Treating Physician - Carl A. Robson, M.D.

         Dr. Robson completed the first of two medical source statements on May 18, 2016. (Tr. 381-382). Dr. Robson opined that Kance's ability to lift/carry, stand/walk, and sit were not affected by his impairment. (Tr. 381). He opined that Kance could rarely climb or perform fine and gross manipulation. (Tr. 381-382). He opined that Kance should not be exposed to heights or moving machinery due to his unsafe gripping. He reported that Kance experienced moderate pain that would interfere with his concentration but would not take him off task or cause absenteeism. At the bottom of the questionnaire, Dr. Robson wrote that Kance “had experience as carpenter - now totally disabled for this work. Has no other skills or training- cannot use hands for any occupation due to poor grip and dexterity.” (Tr. 382).

         On August 18, 2016, after examining Kance, Dr. Robson wrote a note stating, “In my opinion he is totally, permanently disabled for any type of labor with his hands, including dishwashing. His grip strength is virtually zero (measured). I don't think the state doc measured this.” (Tr. 394).

         On October 18, 2017, Dr. Robson completed his second medical source statement. (Tr. 428-429). Dr. Robson opined that Kance's ability to lift and carry was limited by his impairment and that he was limited to lifting 10-15 pounds occasionally and “none” frequently due to his palmar fasciitis and Dupuytren's contractures in both hands. He opined that Kance could never climb and could only occasionally balance, crouch, kneel and crawl. (Tr. 428). He opined that Kance's abilities to reach and pull were limited due to his poor grip and that he was unable to perform fine or gross manipulation. He noted that Kance's pain was minor and that it did not interfere with his concentration; would not take him off task; or cause absenteeism. (Tr. 429).

         2.Consultative Examiner - Robin Benis, M.D.

         On February 8, 2016, Robin Benis, M.D. examined Kance and completed a report. (Tr. 363-367). Dr. Benis reported that Kance had contractures in both hands, decreased ability to flex all his fingers, especially the 4th and 5th fingers on both hands. (Tr. 365). He had decreased range of motion in the bilateral PIP and DIP joints and decreased grip strength and fine motor manipulation in both hands. (Tr. 365, 370). Dr. Benis opined that Kance had marked limitations using both hands due to Dupuytren's contractures. He was unable to hold objects for a long period of time, had difficulty writing and difficulty with fine motor manipulation of both hands. Dr. Benis opined that Kance's prognosis was fair. (Tr. 366).

         3.State Agency Physicians

         On February 22, 2016, state agency physician, Anne Prosperi, D.O., reviewed Kance's records and opined that he could perform light work; (Tr. 108) that he was able to occasionally lift and/or carry up to 20 pounds; and frequently lift and/or carry up to 10 pounds. (Tr. 105) She further opined that he was limited to occasional handling and fingering with both hands. (Tr. 109).

         Elizabeth Das, M.D., reviewed Kance's records on July 3, 2016 and agreed with the functional limitations ...

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