Williams v. Commissioner of Social Security Administration

          DONALD C. NUGENT JUDGE

          REPORT AND RECOMMENDATION

          Kathleen B. Burke United States Magistrate Judge

         Plaintiff Jasmine Marie Williams (“Plaintiff” or “Williams”) 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.

         For the reasons explained herein, the undersigned recommends that the Court AFFIRM the Commissioner's decision.

         I. Procedural History

         Williams protectively filed^[1] an application for SSI on May 17, 2016, alleging a disability onset date of August 13, 2015.^[2] Tr. 15, 82-83, 97, 196-204, 208-213, 226. She alleged disability due to hip dysplasia, anxiety, depression, and a learning disability. Tr. 82, 116, 123, 229. After initial denial by the state agency (Tr. 116-122) and denial upon reconsideration (Tr. 123-127), Williams requested a hearing (Tr. 131-133). A hearing was held before the Administrative Law Judge (“ALJ”) on May 3, 2018. Tr. 31-63.

         In her June 21, 2018, decision (Tr. 12-30), the ALJ determined that Williams had not been under a disability since May 17, 2016, the date the application was filed (Tr. 16, 26).^[3]Williams requested review of the ALJ's decision by the Appeals Council. Tr. 192-193, 292-296. On January 23, 2019, the Appeals Council denied Williams's request for review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-6.

         II. Evidence

         A. Personal, educational, and vocational evidence

         Williams was born in 1993. Tr. 25, 38, 208. At the time of the hearing, Williams was living in an apartment with her sister and niece. Tr. 38-39. Williams graduated from high school. Tr. 41. Williams was in special classes since the first grade because of learning disabilities. Tr. 41. Williams had no past relevant work. Tr. 42.

         B. Medical evidence^[4]

         1. Treatment history

         Williams received treatment for her hip pain through various providers at Summa Health System. On March 25, 2015, Williams saw Elizabeth Archinal, M.D., with complaints of left-sided hip pain that she had been having for a few months. Tr. 487-488. She reported having pain every day. Tr. 487. Williams's pain was worse with walking, especially for long periods or with stairs. Tr. 487. Williams denied numbness or tingling but indicated that sometimes she felt like her leg was going to give out. Tr. 487. Dr. Archinal assessed joint pain. Tr. 487. She also assessed somatic dysfunction in the pelvic/hip region, sacral region, lower extremity, and lumbar region. Tr. 487. Dr. Archinal applied OMT^[5] for Williams's somatic dysfunction and prescribed ibuprofen for her joint pain. Tr. 488.

         Williams saw Dr. Archinal on April 13, 2015, for follow up regarding her left hip pain. Tr. 485-486. Williams reported some ankle numbness and swelling and indicated her whole leg was numb for about two hours. Tr. 485. A heating pad helped with the swelling. Tr. 485. Ibuprofen was helping with her pain and the OMT had helped but only for the day that it was applied. Tr. 485. On examination, Williams exhibited exaggerated lumbar lordosis; she had normal range of motion in her extremities but she was unable to raise her leg above 45 degrees due to hamstring tightness; and her pulses in her extremities were 2 bilaterally. Tr. 485. Dr. Archinal noted uncertain etiology of pain. Tr. 486. She felt Williams could benefit from more regular OMT but Williams declined. Tr. 486. Dr. Archinal advised Williams to start taking acetaminophen for pain; ordered x-rays of Williams's hip and spine; and referred Williams for physical therapy, noting that there should be an emphasis on stretching and strengthening. Tr. 485-486.

         During a June 2, 2015, visit with Dr. Archinal, Williams complained of continued pain in her left hip that was radiating into her lower back. Tr. 483-484. Williams was not working. Tr. 483. She reported spending the day riding around on buses, shopping, etc. and watching her 5-year-old cousin but she did not lift him. Tr. 483. Williams was doing some exercises that she had been shown. Tr. 483. OMT was helpful but only temporarily. Tr. 483. Williams had not gone to physical therapy. Tr. 483. She indicated that the referral had not been received when she called. Tr. 483. Williams was taking acetaminophen and ibuprofen. Tr. 483. Dr. Archinal assessed “spasm of muscle” and started Williams on cyclobenzaprine. Tr. 483. Dr. Archinal noted that Williams's hips and back were markedly tight and Williams was very anxious. Tr. 484. Williams had been seeing psychiatry and attending counseling. Tr. 483. Dr. Archinal encouraged Williams to schedule physical therapy and OMT and to continue taking acetaminophen and ibuprofen, performing home stretches and applying heat. Tr. 484.

         On June 25, 2015, Williams saw Katherine Carmichael, D.O., for OMT. Tr. 477-480. Williams reported that her left hip and low back pain was relieved with warm showers, ibuprofen, Tylenol, Flexeril and worsened by walking too much. Tr. 477. Williams had been attending physical therapy and relayed that she thought it was helping. Tr. 477. Williams was also doing home exercises. Tr. 477. Dr. Carmichael noted that x-rays taken of Williams's left hip and lumbar spine in April 2015 were normal. Tr. 477. Williams reported some numbness but no weakness. Tr. 477. Overall, Williams indicated her pain had stayed about the same. Tr. 477. On physical examination, Dr. Carmichael observed decreased range of motion in Williams's hips and lumbar back. Tr. 478. There was also tenderness in Williams's lumbar back. Tr. 478. Williams's straight leg raise was negative but she had hamstring tightness bilaterally. Tr. 478. Williams had equal strength and sensation bilaterally. Tr. 478. Dr. Carmichael indicated that she felt that Williams's musculoskeletal pain was likely muscular spasm versus possible trochanteric bursitis versus superficial pinched nerve versus other underlying inflammatory or rheumatologic condition. Tr. 478-479. Dr. Carmichael recommended that Williams continue with physical therapy, OMT, home exercises, and ibuprofen and Tylenol as needed for pain. Tr. 479. If Williams's pain failed to improve, Dr. Carmichael indicated that Williams could consider a trochanteric injection. Tr. 479. Williams noted she has had “shaking” all her life when she tries to relax. Tr. 479. Dr. Carmichael observed mild shaking during OMT and she recommended that Williams seek further evaluation regarding the issue. Tr. 479.

         Williams saw Dr. Archinal on July 8, 2015. Tr. 473-476. Williams relayed that her hip pain seemed to be slowly improving with exercises but was taking longer than expected. Tr. 473. Williams's tremors were worse with exercise and her knee/leg would shake at times when at rest. Tr. 473. Dr. Archinal noted that Williams's physical therapist had communicated with her regarding Williams's progress. Tr. 473. Williams was participating well in physical therapy and performing home exercises for about a month but she had made little progress. Tr. 473. Williams was fatiguing easily with exercise; she had tightness in her hip flexors and hamstrings; she had difficulty maintaining an upright posture during exercise; and at times she had labored speech and would lose her train of thought. Tr. 473. Williams's physical therapist was questioning an uninvestigated etiology, e.g., a neurological problem. Tr. 473. On physical examination, Williams exhibited no edema or tenderness; her reflexes were normal; her muscle tone was normal; and her coordination was normal. Tr. 474. Williams's speech was quiet and hesitant but not slurred or delayed - she gave an overall impression of withdrawn anxiety. Tr. 475. Dr. Archinal's assessment included left hip pain and depression. Tr. 475. Dr. Archinal indicated that Williams's hip pain was likely related to chronic muscle tension, noting that Williams also had tremors and intermittent syncope but Dr. Archinal did not think things pointed to any particular neurological or rheumatological disorder. Tr. 475. Dr. Archinal indicated that, [i]n the absence of any concerning physical exam findings, we will continue with home exercises and OMT, and attempt to improve mental health status.” Tr. 475.

         Williams saw Kyle Yoder, D.O., on July 15, 2015. Tr. 469-471. Physical examination showed normal range of motion and strength in the hips bilaterally and normal range of motion and no tenderness in the lumbar back. Tr. 469-470. OMT examination findings were: overall poor posture; decreased pelvic rotation to the right; anterior right innominate; inflare right innominate; left lumbar paraspinal muscle hypertonicity; and decreased range of motion with right leg abduction. Tr. 470. Neurologically, Williams was alert; she had normal sensation and strength; and her gait was normal. Tr. 470. Dr. Yoder assessed left hip pain, somatic dysfunction of lower extremity, somatic dysfunction of pelvic region, and somatic dysfunction of lumbar region. Tr. 470. Dr. Yoder recommended that Williams follow up with her primary care physician and continue OMT as long as it was providing relief. Tr. 470.

         On August 3, 2015, Williams sought treatment at the emergency room for acute on chronic left hip pain. Tr. 336-347. Williams denied any new trauma since she started having her hip pain about seven months prior but relayed that her pain had become progressively worse since the day before. Tr. 336. Williams was requesting “readjust[ment] [of] her hip[.]” Tr. 336. Williams denied any paresthesia, weakness or loss of function of her left lower extremity and stated that her pain was localized to the left lateral aspect of her hip with no associated radiation. Tr. 336. On physical examination, no spinal tenderness was observed in the back. Tr. 336. There was mild tenderness to palpation of the lateral aspect of the left lower extremity with no associated deformity, abrasion or contusion and strength was 5/5. Tr. 336. Williams received a shot of Toradol. Tr. 337. Since no new trauma was reported and the last x-rays were within normal limits no new imaging was ordered. Tr. 337. The attending physician recommended that Williams follow up with her primary care physician and physical therapist. Tr. 337.

         On August 12, 2015, Williams saw Brittany Jergovich, D.O., for OMT. Tr. 464-465. Williams relayed that she had pain in her left hip, low back, and along the outside of her left upper leg. Tr. 464. Williams's pain was worse with walking, climbing stairs, and walking on uneven ground. Tr. 464. A heating pad and Tylenol and ibuprofen helped with the pain. Tr. 464. During physical therapy, Williams had been told that one leg was shorter than the other - she had an insert for her shoe but indicated that it made the pain worse. Tr. 464. Dr. Jergovich observed that the lumbosacral spine area revealed no local tenderness or mass; there was full and painless lumbosacral range of motion; straight leg raise was negative at 90 degrees on both sides; reflexes, motor strength, and sensation were normal, including heel and toe gait; peripheral pulses were palpable; and hip and knees had full range of motion without pain. Tr. 465. Dr. Jergovich's structural exam showed increased tension of the quadratus lumborum on the left in the lumbar area; “left upslip” of the hip; and increased tension of the iliotibial band and biceps femoris restriction of the left lower extremity. Tr. 465. Dr. Jergovich assessed iliotibial band syndrome and she showed Williams stretches that should be done at home twice each day. Tr. 465. Dr. Jergovich also advised Williams to ice the area twice each day. Tr. 465. Following her OMT treatment, Williams noted improved range of motion. Tr. 465.

         Williams saw Janice Camino, M.D., on September 10, 2015, for complaints of lower back pain and left hip pain. Tr. 450-452. Williams indicated that her low back symptoms were improving especially with Flexeril and ibuprofen. Tr. 450. Williams had completed physical therapy but indicated she was discharged because she was unable to handle the pain associated with therapy. Tr. 450. She was continuing to perform exercises as shown to her. Tr. 450-451. Williams's hip pain was stable at that time. Tr. 451. Williams noted that she usually lifts her nephews and nieces who weigh more than 20 pounds without bending her knees. Tr. 451. She indicated that her hip and knee pain was worse after lifting them. Tr. 451. Dr. Camino's musculoskeletal examination revealed tenderness to palpation in the bilateral paralumbar region and left hip joint; there was no edema on the joints; there was some decreased range of motion; scoliosis was absent; and there was mild lordosis. Tr. 451. The neurological examination revealed a negative straight leg raise; slight eversion in gait; heel walk and toe walk were normal; motor function was normal; sensory function was normal; and reflexes were intact and symmetrical bilaterally. Tr. 451. Dr. Camino indicated that the clinical picture was most consistent with a diagnosis of lumbosacral strain. Tr. 451. Dr. Camino discussed proper lifting/bending techniques and stretching exercises. Tr. 451. Dr. Camino recommended water therapy since regular therapy did not work due to pain. Tr. 451-452.

         Williams saw Dr. Camino on December 10, 2015, regarding her left lower back and left hip pain. Tr. 432-434. She described her pain as aching, burning, and tingling in nature with radiation into her leg. Tr. 432. Williams's pain was “constant, typically moderate in intensity, and [was] exacerbated by flexion, extension, sitting, standing, lying down, climbing stairs and inactivity.” Tr. 432. Associated symptoms included paresthesias and numbness of her left leg. Tr. 432. Dr. Camino's musculoskeletal examination revealed normal range of motion; Williams was tender to palpation on the left ASIS; she had 5/5 strength in the lower extremities; negative straight leg test; there was no groin pain; and no crepitus in the hip. Tr. 433. Dr. Camino observed that one leg was noticeably shorter. Tr. 433. Dr. Camino assessed pain of both hip joints and indicated that Williams's pain was likely musculoskeletal with the cause likely due to asymmetry between her legs that caused Williams to bear more weight on her right leg. Tr. 434. Dr. Camino recommended re-evaluation after Williams did home exercises for hip pain and possibly shoe inserts or other mechanical compensation for the congenital deficit of the left leg. Tr. 434.

         A month later, on January 6, 2016, Williams saw Stanley Hunter, M.D., in sports medicine regarding her left hip pain. Tr. 425-430. Williams reported that the pain started a year earlier. Tr. 426. Her pain radiated down her leg at times and was sharp in nature. Tr. 426. Williams's pain was reportedly better with hot compresses. Tr. 426. She denied weakness or numbness. Tr. 426. Her pain was worse with walking and started within one minute of walking. Tr. 426. She indicated that her hip “locks up.” Tr. 426. Williams was no longer in physical therapy. Tr. 426. She had done physical therapy in the past with partial improvement. Tr. 426. Dr. Hunter reviewed the April 2015 x-rays and performed a physical examination. Tr. 426. He assessed arthralgia of the left hip, noting a highly antalgic gait. Tr. 429. He indicated that Williams's neurological examination overall was reassuring. Tr. 429. Dr. Hunter suspected that a substantial part of Williams's pain was from postural factors affecting her muscles. Tr. 429. While he did not observe it on examination, “hip locking [and] catching suggest[ed] mechanical etiology in hip joint.” Tr. 429. Also, Dr. Hunter indicated that “[r]eproduction of pain with isolated femoral internal [and] external rotation suggest[ed] intraarticular source[].” Tr. 429. Dr. Hunter recommended physical therapy and repeat x-rays. Tr. 429. Dr. Hunter also discussed possible injections, NSAIDs, and postural realignment. Tr. 429.

         Williams saw Dr. Hunter and Nilesh Shah, M.D., on January 14, 2016. Tr. 367-371. Dr. Hunter reviewed hip x-rays taken on January 14, 2016. Tr. 370. The x-rays showed no fracture or dislocation; no significant degenerative changes or arthropathy; there was mild bilateral flattening of the femoral heads; there was notable asymmetry of the pelvis; and the left hip was about 1.9 cm higher than the right. Tr. 370. Dr. Hunter felt that Williams's left hip joint was likely causing her pain because the most pronounced exam maneuver was left hip range of motion, particularly internal/external rotation. Tr. 371. Dr. Hunter recommended a left hip injection. Tr. 371.

         On February 3, 2016, Dr. Shah administered an injection in Williams's left hip. Tr. 362-365. Following the injection, Williams reported much improvement in her pain but still felt like something was catching in her hip. Tr. 365. Dr. Shah indicated that, if Williams's pain did not improve within two weeks, an MRI might be warranted to look for cause of mechanical symptoms. Tr. 365. Williams returned to see Dr. Shah on February 18, 2019. Tr. 358-361. She reported minimal benefit from the injection. Tr. 358. She had also tried physical therapy and NSAIDs without benefit. Tr. 358. Williams was continuing to have pain with ambulation and catching of her left hip joint. Tr. 358. On physical examination, Dr. Shah observed an antalgic gait. Tr. 360. Dr. Shah recommended an MRI. Tr. 361.

         Williams saw Dr. Shah on March 14, 2016, for follow up regarding the MRI results. Tr. 352-356. The impression from the left hip MRI, taken on March 8, 2016, was “[m]ildly shallow dysplastic left acetabulum along with internal rotation or anteversion of the left femoral neck[;]” “[i]ntermediate grade partial-thickness tear along the ligamentum teres origin with some morphologic irregularity[, ] . . . rais[ing] concern for possible ligamentum impingement along the acetabulum[;]” “[t]race signal irregularity seen along the anterior labrum peripherally thought to likely represent artifact [and] [a] tiny tear in this region is not entirely excluded but felt a less likely consideration[;]” and “mild tendinopathy gluteus medius.” Tr. 355-356. Dr. Shah's assessment was left hip impingement syndrome and hip pain, chronic, left. Tr. 356. Dr. Shah recommended that Williams see Javon Laskovski, M.D., at the Crystal Clinic, Inc., for an opinion regarding surgical intervention. Tr. 356.

         On March 29, 2016, Williams saw Dr. Laskovski for an evaluation of her left hip pain. Tr. 511-513. Dr. Laskovski concluded that Williams had a labral tear, ligamentum tear with possible impingement and a patulous hip capsule. Tr. 513. Dr. Laskovski discussed options with Williams and Williams indicated she would like to try therapy again prior to discussing surgery. Tr. 513.

         Williams's first physical therapy session at the Crystal Clinic occurred on April 13, 2015. Tr. 507-508. During that visit, Williams relayed that her injury was a year old. Tr. 508. Williams relayed that she had injured herself jumping off a step at her house and her primary concern was her left hip pain and weakness. Tr. 508. She relayed that she had decreased range of motion and strength; difficulty with ambulation; and increased pain with functional activities. Tr. 508. The physical therapist observed that Williams ambulated with an antalgic limp and chose not to use an assistive device. Tr. 508. Williams favored her right lower extremity. Tr. 508. The therapist concluded that Williams's symptoms were consistent with her diagnosis and he recommended therapy to reduce her impairments and functional limitations from her condition. Tr. 507.

         On April 27, 2016, Williams saw Dr. Laskovski for follow up regarding her left hip pain. Tr. 503-506. Williams relayed that her pain was worse since her last visit. Tr. 506. She described her pain as sharp, aching, dull and throbbing. Tr. 506. Williams reported that she had been doing a lot of walking. Tr. 506. She had not fallen within the prior six months. Tr. 506. Williams had been treating with physical therapy but she was getting worse with physical therapy. Tr. 504, 506. She was having more trouble walking and trying to perform her activities of daily living. Tr. 504. After discussing all options, Williams indicated she wanted to proceed with surgery. Tr. 504.

         On June 21, 2016, after attending five physical therapy sessions, Williams was discharged from physical therapy because she had not attended physical therapy since April 26, 2016. Tr. 569.

         During a May 20, 2016, appointment with her psychiatrist Therese Scavelli, M.D., at Coleman Professional Services, ^[6] Williams relayed that she was scheduled for hip surgery in June 2016. Tr. 514. Williams indicated she would need help from her family following her surgery but was concerned that her family would not be there to help her. Tr. 514. Nurse practitioner Laura Hare indicated in a ...