United States District Court, N.D. Ohio, Eastern Division
JENNIFER J. SELIS-EVANS, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.
REPORT AND RECOMMENDATION
Kathleen B. Burke, United States Magistrate Judge.
Jennifer Selis-Evans (“Selis-Evans”) seeks
judicial review of the final decision of Defendant
Commissioner of Social Security (“Commissioner”)
denying her application for Supplemental Security Income
(“SSI”). Doc. 1. This Court has jurisdiction
pursuant to 42 U.S.C. § 405(g). This matter has been
referred to the undersigned Magistrate Judge for a Report and
Recommendation pursuant to Local Rule 72.2(b)(1).
reasons stated below, the undersigned recommends that the
Commissioner's decision be AFFIRMED.
October 2013, Selis-Evans filed an application for SSI,
alleging a disability onset date of July 24, 2013. Tr. 237.
She alleged disability based on the following: right knee
surgery and reflex sympathetic dystrophy caused by her
surgery. Tr. 260. After denials by the state agency initially
(Tr. 137) and on reconsideration (Tr. 152), Selis-Evans
requested an administrative hearing. Tr. 164. Hearings were
held before an Administrative Law Judge (“ALJ”)
on April 25, 2016, and July 18, 2017. Tr. 67-124. In his
August 3, 2017, decision (Tr. 11-29), the ALJ determined that
there are jobs that exist in the national economy that
Selis-Evans can perform, i.e., she is not disabled. Tr.
28-29. The Appeals Council denied Selis-Evans's request
for review, making the ALJ's decision the final decision
of the Commissioner. Tr. 1-3.
Personal and Vocational Evidence
was born in 1980 and was 33 years old on the date she filed
her application. Tr. 237. She graduated from high school and
completed a few years of college. Tr. 74.
Relevant Medical Evidence
ongoing complaints of right knee pain and instability,
Selis-Evans underwent arthroscopic surgery in July 2013. Tr.
319-320. The surgery was performed by William Sanko, M.D. Tr.
319-320. At her one week follow up, Dr. Sanko stated that
Selis-Evans was doing well but had not been moving her knee
as instructed. Tr. 325. Upon exam, she had some swelling and
limited range of motion. Tr. 325. Dr. Sanko prescribed Norco
to use sparingly, encouraged aggressive physical therapy, and
anticipated that she would be able to return to work in six
to eight weeks. Tr. 325.
September, Dr. Sanko remarked that Selis-Evans had not
bounced back as quickly as she would have liked. Tr. 321. He
commented that her late start with physical therapy and
moving her knee postoperatively led to some problems. Tr.
323. Upon exam, her range of motion had improved to near
normal and she was able to do a straight leg raise. Tr. 321.
However, she reported a burning sensation around her knee
that he was concerned might be early symptoms of Reflex
Sympathetic Dystrophy (RSD). Tr. 321. Dr. Sanko stated that
it was imperative she continue with physical therapy,
prescribed Ultram and Neurontin for pain, and ordered her
kept off work until her next appointment in four weeks. Tr.
next appointment in October 2013, Selis-Evans stated that she
was not doing better, she had stopped therapy, and she
reported a significant burning sensation around her right
knee. Tr. 356. Dr. Sanko described these symptoms as mild to
moderate “RSD type symptoms.” Tr. 356. Upon exam,
she had no redness or warmth of skin, full range of motion,
and scant effusion. Tr. 356. Dr. Sanko assessed a
post-operative RSD problem, recommended continuing physical
therapy, and increased her Neurontin dosage. Tr. 356.
November, Selis-Evans returned to Dr. Sanko's office and
saw a physician assistant. Tr. 354. She reported she had
complied with Dr. Sanko's physical therapy and medication
instructions but had no improvement in her knee pain, which
she described as diffuse and affecting her walking. Tr. 354.
Upon exam, she had tenderness to palpation, reported pain
with range of motion, and had no effusion. Tr. 354. Dr. Sanko
referred her to pain management. Tr. 355.
December 2013, Selis-Evans saw pain management provider
William Hogan, M.D. Tr. 461. Upon exam of her right knee, she
had redness and blotchy skin around her knee, some swelling,
slight warmth, hypersensitivity to touch, significantly
reduced range of motion, and some atrophy of her right thigh
muscle. Tr. 462. Dr. Hogan assessed that Selis-Evans's
pain did appear related to RSD; he increased her gabapentin
and recommended a lumbar nerve block. Tr. 462. In January
2014, Dr. Hogan performed two right lumbar nerve block
injections. Tr. 463-464.
February 2014, Selis-Evans saw a physician's assistant at
Dr. Hogan's office and reported no relief from the nerve
blocks. Tr. 465. Upon exam, her knee was tender, she had
hyperalgesia (increased sensitivity), discolored skin, and a
slightly antalgic, but unaided, gait. Tr. 465. She reported
no new numbness, tingling, or motor weakness. Tr. 465.
Selis-Evans's Neurontin dosage was increased and nerve
root injections were recommended. Tr. 465. She thereafter
received two injections, but at a follow-up appointment with
the physician assistant in March she reported no relief and
her symptoms and examination findings were unchanged. Tr.
469. A different set of nerve blocks were recommended and her
Neurontin was increased. Tr. 469.
April 2014, Selis-Evans underwent an EMG/NCV study on her
right leg that showed normal results. Tr. 358, 368. She
received another nerve block in June from pain management
specialist Gregg Weidner, M.D., which she later reported was
ineffective, stating that the pain had moved to her ankle and
foot. Tr. 397. She reported leg weakness and stiffness. Tr.
October 2014, Selis-Evans visited a pain management center
per Dr. Hogan's referral. Tr. 385-387. She described her
pain as 8/10, constant and stable, with the intensity located
around the knee with some radiation down to her foot. Tr.
385. Upon exam, she had redness around her right knee and an
abnormal gait due to pain, no swelling, normal strength, full
range of motion, and no atrophy. Tr. 387. She was diagnosed
with RSD with a “guarded” prognosis. Tr. 387-388.
Because she reported that medications, injections, nerve
blocks, and a TENS unit had not helped her pain, it was
recommended she return to an aggressive physical therapy
regimen. Tr. 387-388.
January 2015, Selis-Evans saw Dr. Weidner, who recommended
she try spinal cord stimulation. Tr. 401-403. Dr. Weidner
performed a trial implantation of a spinal cord stimulator in
March. Tr. 407. Selis-Evans reported that the stimulator did
not improve her walking or ability to go up and down stairs,
but it reduced her pain by half. Tr. 410, 412. The stimulator
was removed. Tr. 411.
follow-up appointment with Dr. Weidner in April 2015,
Selis-Evans reported continued pain throughout her leg. Tr.
446. Upon exam, she had tenderness over her knee and pain
with range of motion, no swelling, and normal reflexes. Tr.
447. Dr. Weidner encouraged her to continue physical therapy
and range of motion exercises and discussed radiofrequency
ablation, although Selis-Evans was not inclined to undergo
further procedures. Tr. 449. Dr. Weidner prescribed a trial
of Lyrica and released her back to the care of her primary
care physician, stating she could return in six months to
discuss other options. Tr. 449.
2015, Selis-Evans reported to her primary care physician,
Edward Tremoulis, M.D., that she had stopped taking Lyrica
due to reported side effects. Tr. 425.
2016, Selis-Evans went to the emergency department to have
her foot examined after she had stepped on it wrong and
experienced three days of pain that she rated 10/10. Tr. 608.
Upon exam, she had tenderness in her lower leg, foot and
ankle, no swelling or discoloration, and a normal X-ray. Tr.
610-611. She was discharged home with a recommendation to
follow up with her primary care physician. Tr. 612.
2016, Selis-Evans saw Dr. Weidner for a follow-up
appointment. Tr. 624. Upon exam, she had knee tenderness, no
swelling, normal reflexes, pain with knee range of motion,
and full range of motion of her foot. Tr. 626. Dr. Weidner
recommended physical therapy, range of motion exercises,
radiofrequency ablation, and again released her to her
primary care physician for treatment. Tr. 627.
November 2016, Selis-Evans saw pain specialist Tristan
Weaver, M.D., on referral from her primary care physician.
Tr. 683. She reported that she had begun experiencing pain in
her right arm. Tr. 683. Upon exam, her right arm was clammy
compared to her left and she had an antalgic gait. Tr. 685.
Her sensation was intact and she was able to move all her
limbs purposefully. Tr. 685. Dr. Weaver diagnosed her with
RSD of the right arm and leg, but stated he had no further
treatment to offer and instead encouraged her to stay active
and avoid prolonged rest to control her pain. Tr. 686.
January 2017, Selis-Evans saw her primary care physician Dr.
Tremoulis. Tr. 653. Upon exam, she had a normal range of
motion and no tenderness. Tr. 654. Dr. Tremoulis renewed her
prescriptions and recommended a follow up in four months. Tr.
Selis-Evans saw Dr. Weaver for her constant pain in her right
leg, arm and hand; she stated that she needed to follow up
due to her upcoming disability hearing. Tr. 691. Upon exam,
she had intact sensation, no issues moving her arms and legs,
her right arm and leg showed no difference in temperature or
color, and she was ambulatory. Tr. 693. Dr. Weaver assessed a
“questionable diagnosis of [RSD based] on today's
examination, ” explaining that she did not meet enough
of the criteria. Tr. 693. He stated there was no further
intervention he could offer for her reported pain, suggested