United States District Court, N.D. Ohio, Eastern Division
C. NUGENT JUDGE
REPORT AND RECOMMENDATION
Kathleen B. Burke United States Magistrate Judge
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.
reasons explained herein, the undersigned recommends that the
Court AFFIRM the Commissioner's
protectively filed an application for SSI on May 17, 2016,
alleging a disability onset date of August 13,
2015. 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.
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).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.
Personal, educational, and vocational evidence
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.
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 for Williams's somatic
dysfunction and prescribed ibuprofen for her joint pain. Tr.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
a May 20, 2016, appointment with her psychiatrist Therese
Scavelli, M.D., at Coleman Professional Services,
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 ...