United States District Court, N.D. Ohio, Western Division
JEFFREY J. HELMICK, JUDGE
REPORT & RECOMMENDATION
M. PARKER, UNITED STATES MAGISTRATE JUDGE
Crystal Autumn Bell seeks judicial review of the final
decision of the Commissioner of Social Security denying her
applications for supplemental security income
(“SSI”) under Title XIV of the Social Security
Act. This matter is before me pursuant to 42 U.S.C.
§§ 405(g), 1383(c)(3), and Local Rule 72.2(b).
Because the Administrative Law Judge (“ALJ”)
failed to apply proper legal standards in evaluating
Bell's subjective symptom complaints, I recommend that
the Commissioner's final decision denying Bell's
application for SSI be VACATED and that Bell's case be
REMANDED for further consideration.
January 15, 2014, Bell protectively applied for SSI. (Tr. 20,
228-44). Bell alleged that she became disabled on
December 3, 2013, due to reflex sympathetic dystrophy
syndrome (“RSDS”) in her left leg, anxiety, chronic
back pain, mental problems, depression, and thyroid issues.
(Tr. 120, 230). The Social Security Administration denied
Bell's application initially and upon reconsideration.
(Tr. 120-54). Bell requested an administrative hearing. (Tr.
172). ALJ Terry Banks heard Bell's case on July 12, 2017,
and denied the claim in an October 31, 2017, decision. (Tr.
17-89). On May 14, 2018, the Appeals Council denied further
review, rendering the ALJ's decision the final decision
of the Commissioner. (Tr. 1-7). On July 13, 2018, Bell filed
a complaint to seek judicial review of the Commissioner's
decision. ECF Doc. 1.
Personal, Educational and Vocational Evidence
was born on November 19, 1979, and she was 34 years old on
the alleged onset date. (Tr. 238). Bell had a tenth-grade
education, and she did not have any vocational training or
relevant transferrable skills. (Tr. 31, 58). Bell had
previous work as a shipping and receiving clerk, but she was
unable to perform any of her past work. (Tr. 30-31, 86).
Relevant Medical Evidence
October 13, 2011, Bell saw James Weiss, MD, for a medication
refill. Dr. Weiss noted that that she had chronic pain,
intermittent swelling, and purple discoloration in her left
foot after she dropped a wood pallet on her left leg a month
before her visit. (Tr. 388). She reported that her treatment
had improved her pain and functional status and that she did
not have any adverse side effects from Vicodin. (Tr. 388).
October 19, 2011, Bell told Corey Russell, DPM, that she had
continued pain in her left foot after she dropped a wood
pallet on her left leg and Achilles tendon. (Tr. 381). She
noted that she was using gabapentin for her pain and that she
was receiving pain management for RSDS. (Tr. 381). Dr.
Russell recommended that Bell perform range of motion
exercises and receive physical therapy two to three times per
week. (Tr. 381). He also gave Bell a walker and recommended
that she follow up with pain management. (Tr. 381).
January 9, 2012, Bell told William James, MD, that she had
chronic pain in her left foot, with intermittent swelling and
purple discoloration. (Tr. 378). She said that, although she
had some trouble with other medications, Vicodin effectively
controlled her pain without side effects. (Tr. 378). Dr.
James continued Bell's treatment through medication but
also referred her to be evaluated for spinal cord stimulator
(“SCS”) therapy. (Tr. 379).
October 22, 2013, Bell saw James Otting, MD, at the
Comprehensive Center for Pain Management (“CCPM”)
for treatment of lumbar pain and numbness in her leg. (Tr.
561). Dr. Otting noted that Bell had stimulation in all areas
of pain after an SCS revision, but she had new pain in her
left buttock after falling and burning pain in her SCS
generator site. (Tr. 561). Bell complained that she had pain
in her left calf and foot. (Tr. 561). Bell also stated that
an injection on January 6, 2012 improved her functioning,
that her SCS reduced her pain by 50%, and that Vicodin was
effective in controlling her pain without side effects. (Tr.
562). Bell continued seeing Dr. Otting for regular pain
management sessions from October 2013 through March 2017.
(Tr. 374, 402, 503-05, 509-11, 514-16, 537-58, 695-96,
705-07, 710-11, 728-30, 759-60, 768-70, 938-95, 1000-01). At
her pain management sessions, Bell regularly rated her lumbar
pain between 8 and 7 on a 10-point scale, indicated that her
SCS and opioid medications helped her pain without side
effects, and said that she was more active and could perform
home exercises. (Tr. 374, 402, 503-05, 509-11, 514-16,
537-58, 695-96, 705-07, 710-11, 728-30, 759-60, 768-70,
938-95, 1000-01). Bell regularly reported joint and muscle
pain, especially in her left calf and ankles. (Tr. 516, 544,
550, 554, 707, 711, 962, 970, 976-77). On December 13, 2013,
Dr. Otting performed an SCS revision, and on January 14,
2014, he said that Bell's “SCS reprogramming . . .
was able to greatly improve symptoms.” (Tr. 374, 402,
556). Bell reported that she had numbness, weakness, and
tingling in her leg, but no swelling on March 17, 2015, July
14, 2016, September 13, 2016, and November 15, 2016; however,
she reported leg/ankle swelling, discoloration, and coldness
on May 12, 2015, July 14, 2015, January 11, 2016, March 8,
2016, and May 10, 2016. (Tr. 505, 511, 696, 730, 995, 983,
989). Over the course of Bell's treatment, Dr. Otting
gave her several lumbar sympathetic block injections, which
Bell tolerated well and said reduced her pain by up to 75%.
(Tr. 538, 544, 550, 564, 566, 568, 570, 572, 574, 696, 706,
965-66, 976-78, 980-81, 994, 1000-01). Diagnostic imaging on
September 17, 2015, and November 13, 2015, showed only mild
degenerative changes in Bell's spine and that her spinal
condition was otherwise normal. (Tr. 759-60, 768, 770). In
January through March 2017 - after Bell injured her ankle -
Dr. Otting noted that Bell had swollen ankles, joint and
muscle pain, numbness, and tingling. (Tr. 941, 948, 955).
Nevertheless, she was able to move all her extremities well
and could walk with an immobilizing boot on her right leg.
(Tr. 942, 948, 956).
April 11, 2014, Bell told Raja Hanif, MD, that she
“fe[lt] well with no complaints” and that her
medication was effective. (Tr. 361, 397). On examination, Dr.
Hanif noted that Bell had no swelling, no tenderness, and no
deformities. (Tr. 398).
October 13, 2014, Bell went to the triage unit at Bay Park
Hospital for treatment of a cough. (Tr. 775). Bell said that
she had aching pain all over her body, but examination
indicated that her neck, back, lower extremities, range of
motion, gait, and neurological function were all normal. (Tr.
776-77). Bell returned to Bay Park Hospital with the same
complaints (a cough and “intermittent” pain) on
September 18, 2015, but examination again revealed that her
neck, back, range of motion, gait, and neurological function
were normal. (Tr. 762-64).
October 21, 2014, December 31, 2014, and January 20, 2015,
Bell saw Bryant Ittiara, DO, at CCPM for pain management.
(Tr. 519-33). Bell told Dr. Ittiara that she had aching back
pain and “burning” or “throbbing”
pain in her left calf and foot. (Tr. 525, 531). She also said
that she had numbness, tingling, and weakness in her left
leg, but did not report any swelling. (Tr. 521-22, 528, 533).
Bell told Dr. Ittiara that her medication and other treatment
helped her pain without side effects, and that she was able
to be more active and perform home exercises. (Tr. 519-20,
September 2015, Bell had three physical therapy sessions at
CCPM. (Tr. 716, 718, 721). Records from those sessions
indicate that Bell tolerated therapy well, understood her
home exercise plan, and was “slowly progressing”
toward her treatment goals. (Tr. 716, 718, 721). On October
6, 2015, Bell had a physical therapy session at Bay Park
Hospital, where she told Trent Gardner, PT, that she had
“good and bad days” with her pain. (Tr. 1003).
Gardner noted that although Bell's pain and range of
motion improved during her physical therapy sessions, she
would return the following day with little or no improvement.
November 16, 2015, Bell saw Jennifer Delaney, CNP, for
treatment of her RSDS. (Tr. 591). Nurse Delaney noted that
Bell had joint pain but did not have any joint redness,
swelling, or muscle atrophy. (Tr. 592). Bell saw Nurse
Delaney for five medication management appointments from
February 23, 2016, through June 15, 2017. (Tr. 1122-38). Bell
regularly reported having back and joint pain, but
examination did not indicate any joint swelling or muscle
atrophy. (Tr. 1122, 1129, 1132-33, 1136-37). In addition to
refilling Bell's medication, Nurse Delaney instructed
Bell to maintain a healthy diet and exercise regularly. (Tr.
1123, 1127, 1130, 1134, 1138). On February 9, 2017, Nurse
Delaney noted that Bell had injured her back in December
2016, but it was healing with treatment. (Tr. 1126).
October 20, 2016, Bell told Connie Nolina, RN, that she had
chronic back pain following a car accident and that she
wanted to make sure her SCS unit was not damaged. (Tr.
737-38). During her visit, diagnostic imaging showed no
evidence of compression fracture, malalignment of the spine,
or acute bony pathology, but there was reduced disc space in
the L5 S1 region. (Tr. 745). On examination, Nurse Nolina
noted that Bell's lower extremity strength, range of
motion, and sensation were normal. (Tr. 739-40). Upon
discharge, Nurse Nolina noted that Bell ambulated without
assistance and drove herself. (Tr. 740).
November 2, 2016, Bell saw Dr. Russell for treatment of an
ingrown toenail and pain and swelling in her left ankle. (Tr.
794). Dr. Russell noted that Bell was in pain management for
RSDS. (Tr. 794). On examination, Bell had full muscle
strength and her muscle mass, muscle tone, and range of
motion were within normal limits. (Tr. 794). Dr. Russell
debrided the ingrown toenail and gave Bell an ankle brace.
December 16, 2016, Bell told Gregory Georgiadis, MD, that she
injured her right ankle after slipping on ice on December 14,
2016. (Tr. 841, 1019); see also (Tr. 855). Dr.
Georgiadis noted that Bell had gone to Bay Park hospital, but
they did not properly reduce her ankle fracture and sent her
home in a posterior short leg splint. (Tr. 841, 1019). Dr.
Georgiadis noted that Bell did not complain of any pain in
her upper or lower extremities other than her right ankle
pain. (Tr. 841, 1019). Dr. Georgiadis admitted Bell for ankle
surgery. (Tr. 844, 1023). On December 17, 2016, Dr.
Georgiadis noted that Bell did not have any edema or other
issues in her left leg. (Tr. 848). Dr. Georgiadis estimated
that, after surgery on her right ankle, Bell would be
non-weight-bearing for up to three months. (Tr. 849, 1033).
After surgery, Bell was admitted to a rehabilitation facility
for physical therapy. (Tr. 1037). She was discharged to home
care on December 19, 2016. (Tr. 1046). At a follow-up on
January 3, 2017, Dr. Georgiadis noted that Bell was doing
well and did not note any issues with Bell's left leg.
(Tr. 1048). On January 24, 2017, Dr. Georgiadis noted that
Bell had mild swelling in her left leg, but her sensation was
intact, she was doing well, and she was able to increase her
weight-bearing. (Tr. 1051). On March 7, 2017, Dr. Georgiadis
noted that Bell was partially weight- bearing, used a walker
and boot to ambulate, and could tolerate her ankle pain. (Tr.
1054). Bell's left ankle was “unremarkable.”
(Tr. 1054). On May 2, 2017, Dr. Georgiadis removed Bell's
boot and noted “minimal swelling” in her ankle.
(Tr. 1058). He instructed Bell to wean off her boot and
crutches and did not recommend use of any other ambulatory
aids. (Tr. 1059). He continued Bell's pain medication and
recommended outpatient physical therapy; however, Bell stated
she was “not interested” in physical therapy.
Relevant Opinion Evidence
Treating Physician-Corey Russell, DPM
April 14, 2017, Dr. Russell completed a “residual
functional capacity assessment form” based on his
experience treating Bell from June 2010 through November
2016. (Tr. 925-29). Dr. Russell noted that Bell was diagnosed
with RSDS, an unstable ankle, and an ingrown toenail. (Tr.
925). He indicated that Bell's condition improved with
treatment, and she had no restrictions related to hazard
exposure, operating machinery, or driving. (Tr. 926, 928).
Dr. Russell indicated that Bell did not need to have her legs
elevated when she sat for prolonged periods and that she
would not need “periods of recumbency during the work
day as a result of [her] impairments.” (Tr. 927).
Treating Physician-Gregory Georgiadis, MD
7, 2017, Dr. Georgiadis completed a “residual
functional capacity assessment form” based on his
experience treating Bell. (Tr. 1013-17). Dr. Georgiadis noted
that he treated Bell after she sustained a right ankle
fracture in December 2016, that x-rays showed that she was
stable after his operation, that Bell was “slowly
improving from ankle surgery, ” and that her prognosis
was “good.” (Tr. 1013-14). Dr. Georgiadis
indicated that Bell could sit for up to two hours at a time
and up to eight hours during an eight-hour workday; stand for
two hours at a time and up to two hours during an eight-hour
workday; and walk for one hour at a time and up to one hour
during an eight-hour workday. (Tr. 1014). He said that Bell
would need a sit/stand option and would “need to
elevate her right lower extremity on an as needed basis . . .
for pain and swelling.” (Tr. 1014-15). He estimated
that, if needed, Bell would raise her right leg for 20% of
the workday. (Tr. 1015). Dr. Georgiadis opined that Bell was
able to perform full-time, sedentary work. (Tr. 1014). She
could occasionally lift up to 20 pounds and occasionally
carry up to 10 pounds. (Tr. 1015). He said that Bell could
not use her feet for repetitive movement such as pushing or
pulling leg controls, and she could not squat, crawl, or
climb. (Tr. 1016). Bell could occasionally bend and reach
with both legs. (Tr. 1016). Bell had mild restrictions to
moving machinery, exposures to extreme temperatures, and
driving, and she had a moderate restriction to unprotected
heights. (Tr. 1016).
Treating Nurse-Jennifer Delaney, CNP
5, 2017, Nurse Delaney completed a “residual functional
capacity assessment form” based on her experience
treating Bell. (Tr. 1140-44). Nurse Delaney indicated that
Bell could sit for one hour at a time and up to four hours
during an eight-hour day, but she could not stand or walk at
all. (Tr. 1141). Nurse Delaney indicated that if engaged in
sedentary work, Bell would need to keep her legs elevated at
waist level or higher for 50% of the day. (Tr. 1142). She
said that Bell could never use her feet for repetitive
movement; never squat, crawl, or climb; occasionally bend;
and frequently reach with both legs. (Tr. 1143).
Consultative Examiner-Sushil Sethi, MD
August 13, 2015, Sushil Sethi, MD, examined Bell on referral
from the Division of Disability Determination. (Tr. 577-83).
Bell told Dr. Sethi that she had back and left leg pain
“off and on, ” but she denied any paralysis,
weakness, or loss of control in any part of her body. (Tr.
577). On examination, Dr. Sethi noted that Bell did not have
any edema, cyanosis, or clubbing in her lower extremities.
(Tr. 578). Bell did not use any ambulatory aids, and her gait
was normal. (Tr. 578). Diagnostic imaging revealed mild
osteoarthritis and a slight decrease in intervertebral space,
but her spine was otherwise normal. (Tr. 579). Based on his
examination, Dr. Sethi determined that Bell had chronic back
pain and mild osteoarthritis. (Tr. 579). He determined that
Bell had a normal ability to sit, stand, walk, lift, carry,
and handle objects; she could carry 30-50 ...