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Selis-Evans v Commissioner of Social Security Administration

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

August 2, 2019

JENNIFER J. SELIS-EVANS, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          JACK ZOUHARY, JUDGE.

          REPORT AND RECOMMENDATION

          Kathleen B. Burke, United States Magistrate Judge.

         Plaintiff 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).

         For the reasons stated below, the undersigned recommends that the Commissioner's decision be AFFIRMED.

         I. Procedural History

         In 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.

         II. Evidence

         A. Personal and Vocational Evidence

         Selis-Evans 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.

         B. Relevant Medical Evidence[1]

         After 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.

         In 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. 321.

         At her 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.

         In 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.

         In 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.

         In 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.

         In 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. 397.

         In 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.

         In 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.

         At a 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.

         In June 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.

         In May 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.

         In June 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.

         In 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.

         In 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. 654-655.

         In May, 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 changing ...


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