United States District Court, N.D. Ohio, Eastern Division
REPORT & RECOMMENDATION
M. Parker, United States Magistrate Judge
Tracee Stinedurf, seeks judicial review of the final decision
of the Commissioner of Social Security, denying her
application for supplemental security income benefits
(“SSI”) under Title XVI of the Social Security
Act. This matter is before me pursuant to 42 U.S.C. §
405(g) and Local Rule 72.2(b). Because the Administrative Law
Judge (“ALJ”) failed to apply proper legal
standards in evaluating a treating-source opinion, I
recommend that the Commissioner's final decision denying
Stinedurf's application for SSI be VACATED and that
Stinedurf's case be REMANDED for further consideration.
November 23, 2015, Stinedurf protectively filed her
application for SSI. (Tr. 452).Stinedurf alleged that she became
disabled on April 1, 1996, due to reflex sympathetic
dystrophy syndrome (“RSD”), herniated disc,
cervical radiculopathy and depression. (Tr. 452, 468). She
later submitted an amended onset date of November 23, 2015.
(Tr. 47). The Social Security Administration denied
Stinedurf's application initially and upon
reconsideration. (Tr. 385, 393). Stinedurf requested an
administrative hearing. (Tr. 397). ALJ Gregory M. Beatty
heard Stinedurf's case on May 17, 2018, and denied the
claim in a June 20, 2018, decision. (Tr. 13-25). On January
25, 2019, the Appeals Council denied further review,
rendering the ALJ's decision the final decision of the
Commissioner. (Tr. 1-3). On March 5, 2019, Stinedurf filed a
complaint to seek judicial review of the Commissioner's
decision. ECF Doc. 1.
Relevant Medical Evidence
has been diagnosed with several conditions including lumbar
discogenic disease, cervical radiculopathy, RSD, migraine
headaches, anxiety, central sleep apnea and severe pain. She
uses an implanted Medtronic infusion pump for pain
medication. (Tr. 547).
January 19, 2009, an MRI of Stinedurf's lumbar spine
showed minimal discogenic lumbar disease. (Tr. 532). A
polysomnography in September 2009 showed obstructive and
central sleep apnea with central apnea being far more severe.
(Tr. 529). A titration study in October 2009 showed that
Bi-Pap was largely ineffective at improving the central apnea
(a small decrease from 275 apneas to 191 apneas occurred on
titration; REM sleep was not achieved.) (Tr. 530). On
September 21, 2011, an electromyelogram study of
Stinedurf's upper right extremity was normal. (Tr. 537).
8, 2015, Stinedurf's pain pump was removed and replaced
in a surgical resection, with extensive scar tissue. (Tr.
944). Following the surgery, Stinedurf reported increased
problems with her RSD. On June 10, 2015, Stinedurf reported
an increase in pain and limitation to her lower extremities
and new pain problems in her upper left extremity. (Tr.
669-671). On examination she was very sensitive to light
touch over her legs and left arm; she had decreased strength
in her legs and left upper extremity (decreased grip
strength); she had muscle spasms in her lumbar spine;
positive facet loading testing; and decreased range of motion
in all planes. Mentally, she had a restricted affect; she was
irritable and tearful. (Tr. 670-671). Positive findings such
as muscle spasms, weakness, decreased sensation, decreased
range of motion and hypersensitivity in her legs and left arm
continued. (Tr. 678, 682, 687). Examination findings also
showed swelling in her legs, discoloration and weakness of
her left upper extremity, abnormal coordination, and sensory
deficits in her lower extremities and left upper extremity.
end of 2015 and beginning of 2016, Stinedurf underwent a
series of left stellate ganglion blocks to her left lower
extremity. (Tr. 714, 722, 728). In February 2016, she went to
the emergency room after falling on some steps. Examination
showed decreased range of motion, tenderness to palpation,
spasm and neurological hypersensitivity. (Tr. 782- 283). A CT
scan of her cervical spine showed mild reversal of the
cervical lordosis. (Tr. 888).
March 2, 2016, Stinedurf reported neck pain. She had some
extremity weakness and sensory deficit, although she
displayed symmetrical strength. She continued taking
medications for her conditions. (Tr. 850). Notes from March
7, 2016 show that Stinedurf may have misplaced a
prescription; she reported having short-term memory problems.
(Tr. 953). Stinedurf's pain management physician, Dr.
Tracy Neuendorf's, examinations in July and August 2016
showed tenderness to palpation, spasm, reduced range of
motion with pain, positive straight leg raise testing
bilaterally, positive Faber's testing and positive
Facet's testing. (Tr. 830, 833).
x-ray of Stinedurf's right knee on September 9, 2016
showed mild medial compartment arthrosis and small joint
effusion. During a pain management appointment with Dr.
Neuendorf on November 6, 2016, Stinedurf complained of
bilateral lower extremity pain and left arm discoloration.
(Tr. 956). She had tenderness, significant muscle spasms and
reduced range of motion in all three planes of her
spine. She was able to ambulate without an
assistive device. She had unusual spasm, numbness and
tingling of her legs and arms. (Tr. 958).
February 8, 2018, Stinedurf complained of ongoing low back
pain radiating down her legs. She reported that her pain was
aggravated with activity and controlled with her current pain
medication and pain pump. (Tr. 979). Examination of her back
showed tenderness, palpable spasms and decreased motion in
her back with positive hyperreflexia. (Tr. 980). She
displayed normal motor strength and a non-antalgic gait. (Tr.
980). Stinedurf declined physical and aquatic therapy
referrals and continued her medication regimen. (Tr. 981).
March 12, 2018, at another pain management appointment for
refill of her pain pump, Stinedurf reported ongoing low back
pain. She described the pain as radiating from her back down
her legs to her feet and in her left arm, with numbness and
tingling. (Tr. 975). Examination showed cervical spine muscle
spasms, multiple trigger points and texture, asymmetry,
altered range of motion and tenderness changes. She also had
tenderness in her trapezius and paraspinal muscles, limited
neck range of motion due to pain, RSD spread to left arm with
positive Spurling sign in the left arm, bilateral paraspinal
muscle spasm, decreased range of motion in the back, positive
RSD in the lower limbs, positive hyperreflexia,
osteoarthritis of the right knee, and positive lumbar facet
loading bilaterally. (Tr. 977-978).
Relevant Opinion Evidence
Treating Source Opinion-Tracy Neuendorf, D.O.
August 23, 2017, Dr. Neuendorf completed a medical source
statement. (Tr. 965-966). He opined that Stinedurf was unable
to lift more than 10 pounds; could stand and walk no more
than an hour a day; could sit no more than two hours a day
(Tr. 966); would rarely be able to reach, push/pull and
perform gross manipulation; and would occasionally be able to
perform fine manipulation. He opined that Stinedurf's
pain was likely to cause absenteeism and off-task behaviors.
He opined that she would require six hours of breaks beyond
those normally allowed in a typical work environment. Dr.
Neuendorf stated that his opinions were based on physical
exam. He also opined that Stinedurf would be unable to engage
in any meaningful employment. (Tr. 967).
State Agency Consulting Examiner, Jennifer Haaga,
April 19, 2016, consulting psychologist, Jennifer Haaga,
examined Stinedurf at the request of the state agency. (Tr.
772-779). Dr. Haaga diagnosed persistent depressive disorder,
late onset with anxious distress with intermittent major
depressive disorder. (Tr. 777). Dr. Haaga reported that
Stinedurf would be limited to performing simple routine
tasks; would likely need reminders and assistance
(particularly when learning new jobs); would have some
difficulty with attention and concentration, with her
symptoms of anxiety and depression likely causing
difficulties in this area or exacerbating those difficulties
that she already had. She would likely also have increased
symptoms if faced with pressure in a work situation
particularly if she felt she was not able to complete tasks.
(Tr. 778). Dr. Haaga also noted that Stinedurf was tearful,
shifted in her chair at times and appeared uncomfortable.
State Agency Reviewing Physicians
January 29, 2016, state agency reviewing physician, Stephen
Sutherland, M.D., reviewed Stinedurf's records. He opined
that Stinedurf could perform light work, but she could never
climb ladders, ropes, or scaffolds; she could frequently
stoop, kneel, crouch, crawl, and climb ramps or stairs; and
she must avoid concentrated exposure to temperature changes,
vibration and hazards. (Tr. 362-363).
April 28, 2016, a state agency psychologist, Judith
Schwartzman, Psy.D., reviewed Stinedurf's records and
opined that she was limited to simple, routine tasks without
strict time or production standards, in a non-public
environment where interactions with others were brief and
superficial. She opined that supervisors must offer
constructive criticism in a relatively static environment
with advance notice and gradual implementation of major
changes. (Tr. 363-365).
state agency reviewing physician, Mehr Siddiqui, M.D.,
reviewed Stinedurf's records on September 7, 2016. She
generally agreed that Stinedurf was limited to light work
with the same postural limitations as Dr. Sutherland.
However, she opined that Stinedurf could only stand and/or
walk for four hours and must be able to alternate positions
every thirty minutes due to her RSD. (Tr. 378). Dr. Siddiqui