United States District Court, N.D. Ohio, Eastern Division
R. ADAMS, JUDGE.
REPORT AND RECOMMENDATION OF MAGISTRATE
J. LIMBERT, UNITED STATES MAGISTRATE JUDGE.
Ruth Janice Jones (“Plaintiff”) requests judicial
review of the final decision of the Commissioner of Social
Security Administration (“Defendant”) denying her
application for Disability Insurance Benefits
(“DIB”). ECF Dkt. #1. In her brief on the merits,
Plaintiff asserts that the administrative law judge
(“ALJ”) failed to: (1) properly evaluate the
opinions of her treating sources; (2) properly evaluate her
credibility; and (3) meet the burden at Step Five of the
Steps for Evaluating the Entitlement to Disability Benefits.
ECF Dkt. #13. For the following reasons, the undersigned
recommends that the Court REVERSE the decision of the ALJ and
REMAND Plaintiff's case to the ALJ for reevaluation and
analysis of Dr. Schnell's opinion.
FACTUAL AND PROCEDURAL HISTORY
protectively filed an application for DIB on February 17,
2016 alleging disability beginning September 29, 2015 due to
a shattered left wrist, broken pelvic bone, generalized
anxiety disorder, recurrent depression, and degenerative disc
disease (“DDD”) in her neck and spine. ECF Dkt.
#11 (“Tr.”) at 235-236, 263. The Social
Security Administration (“SSA”) denied her
application initially and upon reconsideration. Id.
at 171-187. Plaintiff requested a hearing before an ALJ, and
the ALJ held a hearing on November 8, 2017, where Plaintiff
was represented by counsel and testified. Id. at 81,
188. A vocational expert (“VE”) also testified.
1, 2018, the ALJ issued a decision denying Plaintiff's
application for DIB. Tr. at 16-26. Plaintiff requested that
the Appeals Council review of the ALJ's decision and the
Appeals Council denied her request for review on September
24, 2018. Id. at 1-4.
November 19, 2018, Plaintiff filed the instant suit seeking
review of the ALJ's decision. ECF Dkt. #1. She filed a
merits brief on March 13, 2019 and Defendant filed a merits
brief on May 29, 2019. ECF Dkt. #s 13, 17. Plaintiff filed a
reply brief on June 11, 2019. ECF Dkt. #18.
RELEVANT MEDICAL AND TESTIMONIAL EVIDENCE
dated May 14, 2015 from Dr. Hanna, a neurologist, show that
Plaintiff presented for chronic neck pain for the last twenty
years. Tr. at 981. Upon examination, Dr. Hanna found normal
motor strength, sensation and a normal gait, but abnormal
reflexes. Id. at 984. He diagnosed Plaintiff with
cervical spondylosis and decided to treat her conservatively
with medications and exercises. Id. He indicated
that Plaintiff should not perform manual work above her
shoulders in order to avoid prolonged cervical extension.
September 27, 2015, Plaintiff presented to the emergency room
after she had tripped over her cat and fell, injuring her
left wrist and pelvis. Tr. at 421, 473. There was a
consultation with Dr. Sechler as Plaintiff had an abnormal
EKG, but it ended up being a baseline artifact that was
misread by the computer. Id. at 422, 475. The
consultation note indicated that Plaintiff reported never
having cardiac issues and being very active as she played
golf and basketball, and she mowed her own yard. Id.
Physical examination revealed an obvious deformity in
Plaintiff's left wrist and tenderness to palpation of her
left hip. Id. at 473. X-rays showed a left wrist
radius ulnar fracture with radial displacement of the distal
fracture fragment and displaced ulnar styloid fracture, and a
mildly displaced comminuted left iliac bone and acetabular
fracture and mildly displaced angulated fracture of the left
inferior pubic ramus. Id. at 474, 502, 507, 509,
667. A brain CT scan showed no abnormality, and a neck CT
scan showed mild posterior disc osteophytes and bilateral
facet arthropathy at ¶ 2-C3, C3-C4, C4-C5, C5-C6, and
C6-C7, with mild to moderate left neural foraminal
encroachment at ¶ 2-C3, moderate to severe right neural
foraminal and mild to moderate left neural foraminal
narrowing at ¶ 3-C4, mild canal stenosis and mild to
moderate bilateral neural foraminal encroachment at ¶
4-C5, moderate to severe canal and bilateral neural foraminal
stenosis at ¶ 5-C6, and severe canal and bilateral
neural foraminal encroachment at ¶ 6-C7. Id. at
Schnell, an orthopedic surgeon, examined Plaintiff on
September 28, 2015 and recommended an open reduction and
internal fixation for her left wrist, to which she agreed.
Tr. at 478. Plaintiff underwent a left distal radius open
reduction and internal fixation on September 28, 2015.
Id. at 479, 673. Plaintiff was discharged from the
hospital on September 30, 2015. Id. at 482.
Schnell's October 9, 2015 treatment notes show that
Plaintiff followed up for her left wrist and hip and she
reported that her pain level was 6 out of 10 and he was not
bearing weight on either extremity. Tr. at 648. Dr. Schnell
noted that x-rays showed satisfactory alignment of the
fracture and hardware and no significant displacement of the
acetabular fracture of the left hip. Id. Dr. Schnell
reminded Plaintiff of the severity of her wrist injury and
how unstable it was with marked articular comminution.
Id. He stressed to her that she was not to bear
weight for at least 6 weeks and he put her in a long arm
fiberglass cast. Id. He also told her not to bear
weight on her left lower extremity. Id.
October 23, 2015, Plaintiff followed up with Dr. Schnell and
he noted no obvious deformity and that her wound was healing.
Tr. at 585, 647. X-rays showed that there was some interval
subsidence of the posterior articular surface of the distal
radius with questionable penetration of the screws.
Id. X-rays of the pelvis showed no evidence of any
significant displacement of the fracture. Id. Dr.
Schnell told Plaintiff that there was some subsidence of the
articular surface dorsally and she would likely benefit from
elevation articular surface of dorsal plating. Id.
He also indicated that he wanted to consult with colleagues
concerning her wrist x-rays. Id.
October 27, 2015, Plaintiff followed up with Dr. Schnell
after he reviewed her x-rays with colleagues and they agreed
with him about re-reducing the fracture and plating the
dorsal radius, which would require removing the pins from the
volar side also. Tr. at 587, 649. He discussed the surgery
with Plaintiff. Id.
October 30, 2015, Plaintiff underwent a revision of open
reduction and internal fixation of a left distal radial
fracture with failure of fixation. Tr. at 423. He noted that
Plaintiff underwent an open reduction and internal fixation
with a volar locking plate on September 27, 2015, but at her
one-month follow up, she showed a loss of fixation with
dorsal collapse of the articular surface. Id. Dr.
Schnell noted that they discussed a revision surgery and the
risks associated with it, and Plaintiff wished to proceed
with surgery, which was performed on October 30, 2015.
Id. The procedure went well and there were no
complications. Id. at 426.
Schnell's November 6, 2015 treatment note indicates that
Plaintiff followed up with him and said her pain was
well-controlled, but she was upset that a home health aide
told her that she could bear weight on the left side,
although she was using a cane due to her hip and groin pain.
Tr. at 588, 646, 658. X-rays of the left wrist showed
satisfactory alignment of the fracture and hardware.
Id. Dr. Schnell advised Plaintiff of the seriousness
of her wrist injury and he explained that she was likely
going to have significant posttraumatic arthrosis in the
future. Id. at 588.
November 13, 2015, Plaintiff followed up with Dr. Schnell for
her left wrist and she reported that her pain was improving,
but she was still having volar radial wrist pain. Tr. at 584,
645. He removed her sutures and placed her in a short arm
fiberglass cast. Id. November 30, 2015 treatment
notes indicate that Dr. Schnell reviewed x-rays with
Plaintiff which showed that despite the buttressing of the
dorsal articular surface, she had further collapse.
Id. at 589, 645. He told her that there were not many
good options and they discussed putting an external fixator
on, although Plaintiff did not seem interested and he
indicated that even with the external fixator, he could not
guarantee that the outcome would be significantly better.
Id. He put her wrist back in a cast. Id.
Schnell's December 11, 2015 treatment note shows that
Plaintiff presented with complaints of moderate pain in her
left wrist and chronic aching in her pelvic area and lower
back, especially after prolonged walking. Tr. at 589, 650.
X-rays showed no significant interval changes in the overall
alignment of her wrist fracture and some collapse of the
dorsal articular surface with dorsal translation of the
lunate. Id. He put her in a wrist splint and limited
her range of motion in the wrist with no weight-bearing, as
further collapse could occur with weight-bearing.
notes from January 7, 2016 show that Plaintiff presented to
Dr. Stecyk for medication refills and complaints of sinus
problems and left leg swelling. Tr. at 613. Physical
examination showed left lower extremity edema, but normal
range of motion and strength. Id. at 615-616. He
diagnosed Plaintiff with acute sinusitis, insomnia, and
statis edema of the left lower extremity. Id. at
616. He ordered an ultrasound of Plaintiff's left lower
extremity. Id. The duplex scan was negative for
acute deep vein thrombosis. Id. at 628.
8, 2016 treatment notes from Dr. Schnell show that Plaintiff
followed up for her wrist pain. Tr. at 603. She reported that
she still had significant pain in the wrist, but the pain in
her pelvis was improving. Id. X-rays of the wrist
showed intraarticular penetration of the distal locking
screws. Id. Dr. Schnell informed Plaintiff that the
hardware would need to come out of her wrist because of
irritation of the tendons from the volar plate. Id.
He advised Plaintiff that she would likely have chronic pain
and may ultimately need a fusion. Id.
January 28, 2016, Plaintiff presented to the emergency room
with neck pain. Tr. at 400. She explained that she was
reaching up into a cabinet with her right hand and her neck
popped and she felt some left arm pain and paresthesias.
Id. Physical examination showed that Plaintiff was
in no apparent distress, except for a supple neck with
cervical paraspinal pain with palpation, and normal
extremities with no edema. Id. at 401. Plaintiff was
diagnosed with acute cervical sprain and cervical radiculitis
and given injections of Toradol and Norflex. Id. A
cervical x-ray showed Grade 1 retrolisthesis at ¶ 5-C6
and C6-C7 and severe disc space narrowing at those points
anterior endplate osteophytes. Id. at 403, 634. The
impression was cervical spondylosis and Plaintiff was given
medications, told to ice the area, and discharged with a
cervical collar. Id. at 402.
February 1, 2016, Plaintiff presented to Dr. Schnell and
reported that her neck was feeling better, but she had
crepitation with flexion/extension of her fingers and pain
and swelling of the left long finger. Tr. at 651. Dr. Schnell
noted swelling along the incision of the left hand with some
crepitation volarly with flexion/extension of the fingers.
Id. X-rays showed the previously noted collapse of
the articular surface with intraarticular penetration.
Id. Dr. Schnell talked with Plaintiff about the
x-ray and informed her that she was getting significant
tendon irritation and he recommended taking the plates out of
her wrist to prevent further tendon injury. Id. He
also told Plaintiff that she may require further surgery at a
later date. Id.
4, 2016 treatment notes from Dr. Stecyk indicate that
Plaintiff presented to him for medication refills. Tr. at
609. Review of Plaintiff's symptoms indicated that she
complained of anxiety and neck pain, and x-rays showed
degenerative joint disease. Id. He also noted that
Plaintiff saw Dr. Schnell for her left wrist fracture.
Id. Dr. Stecyk noted no masses or swelling in
Plaintiff's neck, no back pain or myalgias, no difficulty
walking or limb weakness, no numbness or tingling, and no
anxiety or depression. Id. at 609-610. Physical
examination showed tenderness in the neck, left wrist
tenderness and swelling, normal range of motion and muscle
strength, intact judgment and insight, and normal mood and
affect. Id. at 611. He diagnosed anxiety, insomnia,
left arm fracture, and neck pain. Id. at 611-612. He
added a medication, renewed her other medications, and
referred her for physical therapy for neck pain. Id.
February 24, 2016, Plaintiff underwent surgery by Dr. Schnell
to remove symptomatic hardware from her left wrist. Tr. at
364, 597, 670. The operative report outlined Plaintiff's
original injury in September of 2015 and her subsequent open
reduction and internal fixation and allograft bone
grafting. Id. The report also noted that after the
first procedure, Plaintiff underwent a second procedure on
October 30, 2015 with revision for placement of the volar
hardware and a dorsal plate. Id. Dr. Schnell further
noted that the articular surface collapsed again despite the
two procedures and Plaintiff developed crepitation along the
volar aspect of the wrist with finger flexion and extension.
Id. The decision was then made to remove the plates
with this third procedure. Id. The hardware was
removed and Plaintiff tolerated the third procedure well.
Id. at 365.
notes from Dr. Schnell indicate that on February 26, 2016,
Plaintiff reported that her pain was tolerable and she no
longer had the crepitus with flexion/extension of her
fingers. Tr. at 583. Dr. Schnell noted that Plaintiff had
minimal bleeding and well-approximated incisions, and
Plaintiff could flex/extend her fingers with no evidence of
March 3, 2016, Plaintiff presented to Dr. Stecyk for her neck
pain and he found no masses and no swelling in the neck, and
he found that Plaintiff had no difficulty walking, no limb
weakness, no numbness, and no tingling. Tr. at 605-606. He
noted left wrist and neck tenderness, but normal muscle
strength and range of motion. Id. at 607. He found
that her judgment and insight were intact, and her mood and
affect were normal, with no anxiety or depression.
Id. at 606-607. He diagnosed Plaintiff with anxiety,
depression, left arm fracture, and neck pain. Id. at
608. He renewed her psychiatric medications and prescribed
Oxycodone for her pain. Id. at 607.
4, 2016 notes from Dr. Schnell show that Plaintiff was doing
well after surgery and he removed Plaintiff's suture and
put her in a temporary volar splint. Tr. at 655.
April 4, 2016, Dr. Schnell wrote a “To Whom This May
Concern” letter indicating that Plaintiff had fallen
down a staircase on September 27, 2015 and suffered a
significant left wrist fracture and fractures to her superior
and inferior pubic rami. Tr. at 702. He described her wrist
surgeries and concluded that, “[d]ue to the severity of
her original injury and multiple surgeries, the patient's
progress has been slow. She has been unable to work during
this recovery.” Id.
8, 2016 treatment notes from Dr. Schnell indicate that
Plaintiff presented with more wrist pain and a red raised
area over her left wrist incision. Tr. at 652. Dr. Schnell
noted the small raised area over the wrist and a small vicryl
suture working its way through the skin. Id. He
diagnosed a small vicryl stitch abscess and removed it.
Id. at 652. Plaintiff followed up on April 15, 2016
and reported that the pain was better, but she had pain along
the ulnar aspect of the wrist that radiated proximally.
Id. at 653. Dr. Schnell's examination showed
that there was no swelling over the wrist, but Plaintiff was
very tender along the volar aspect of the wrist. Id.
He also noted that Plaintiff was able to fully flex and
extend the fingers and thumb, but her wrist range of motion
was limited due to discomfort. Id. He prescribed
anti-inflammatories for pain. Id.
20, 2016, Dr. Schnell's treatment notes show that
Plaintiff presented for right wrist pain and numbness and
tingling. Tr. at 654, 720. Examination showed that she was
able to fully flex and extend her fingers and thumb, but she
had a positive Tinel's and Phalen's at the wrist.
Id. Dr. Schnell believed that Plaintiff was
developing carpal tunnel syndrome (“CTS”), and he
ordered an EMG of Plaintiff's left wrist. Id.
Schnell wrote another “To Whom It May Concern”
letter on June 2, 2016 indicating that Plaintiff fell down a
staircase on September 27, 2015 and sustained a left wrist
fracture and fractures to her superior and inferior pubic
rami. Tr. at 700. He noted that she underwent a left wrist
open education and internal fixation on September 28, 2015
and upon failure of the fixation surgery, she underwent
revision surgery on October 30, 2015 and she was immobilized
for an extended period of time. Id. He further noted
that Plaintiff participated in physical therapy and then
hardware irritation developed and Plaintiff underwent a third
surgery on February 24, 2016 to remove the plates on the
volar and dorsal aspects of her wrist. Id. Dr.
Schnell continued that Plaintiff was having intermittent
pain, numbness and tingling along the ulnar part of her wrist
and she appeared to be developing CTS. Id. Dr.
Schnell concluded that Plaintiff's progress had been
“very slow” and she had not been able to work
during her recovery “[d]ue to the severity of her
original surgery, having multiple surgeries and her ongoing
2016 treatment notes show that Dr. Schnell discussed the EMG
results with Plaintiff which showed very subtle evidence of
irritation of the left ulnar sensory branches to the fifth
finger and no evidence of cervical radiculopathy.
Id. at 654, 660, 709, 720. He told her to finish the
medication that he prescribed to reduce the swelling and then
take Aleve as once the swelling decreased, the ulnar nerve
irritation should as well. Id. He also had her wear
a wrist splint when she was active. Id.
29, 2016 treatment notes from Dr. Schnell indicate that
Plaintiff presented complaining of significant left wrist
pain, with numbness and shooting pain along the dorsoulnar
aspect of her wrist and fingers. Tr. at 719. He gave her a
corticosteroid injection and ordered a bone density scan and