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Simmons v. Saul

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

January 6, 2020

CHARLES SIMMONS, Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security, Defendant.

          MEMORANDUM OF OPINION AND ORDER

          JONATHAN D. GREENBERG UNITED STATES MAGISTRATE JUDGE.

         Plaintiff, Charles Simmons (“Plaintiff” or “Simmons”), challenges the final decision of Defendant, Andrew Saul, [1] Commissioner of Social Security (“Commissioner”), denying his applications for a Period of Disability (“POD”), Disability Insurance Benefits (“DIB”), and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(I), 423, and 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and the consent of the parties, pursuant to 28 U.S.C. § 636(c)(2). For the reasons set forth below, the Commissioner's final decision is AFFIRMED in part, and VACATED AND REMANDED in part for further consideration consistent with this opinion.

         I. PROCEDURAL HISTORY

         In October 2014, Simmons filed an application for POD, DIB, and SSI alleging a disability onset date of January 2, 2011, and claiming he was disabled. (Transcript (“Tr.”) at 178-185.) The applications were denied initially and upon reconsideration, and Simmons requested a hearing before an administrative law judge (“ALJ”). (Id. at 145-46.)

         On July 18, 2018, an ALJ held a hearing, during which Simmons, represented by counsel, and an impartial vocational expert (“VE”) testified. (Id.) At the hearing, Simmons amended the alleged onset date of disability to October 4, 2016. (Id.) On October 11, 2018, the ALJ issued a written decision finding Plaintiff was not disabled. (Id. at 16-26.) The ALJ's decision became final on March 5, 2019, when the Appeals Council declined further review. (Tr. 1.)

         On April 4, 2019, Simmons filed his Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 13, 15, 16.) Simmons asserts the following assignment of error:

(1) Whether the ALJ violated the treating physician rule when he discounted the evidentiary weight assigned to the medical opinion of Simmons' treating physician, Dr. Park.

(Doc. No. 13 at 8.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Simmons was born in March 1977 and was 39 years old at his amended alleged onset date of disability, making him a “younger” person under Social Security regulations. (Tr. 24.) See 20 C.F.R. §§ 404.1563 & 416.963. He received a GED in 2012, and is able to communicate in English. (Id.) He has past relevant work as a construction laborer and stock clerk. (Id.)

         B. Relevant Medical Evidence - Physical Impairments[2]

         In January 2011, Simmons hurt his back, fractured his clavicle, fractured his hips, and dislocated his left hip in a car accident. (Tr. 282.) Surgery was required to reconstruct his left hip joint. (Id.) Following the accident, he was hospitalized for three days and then had approximately two weeks of care in an inpatient rehabilitation facility. (Id. at 277, 304.)

         His recovery was complicated by traumatic left sciatic neuropathy, which was treated with Lyrica. (Id. at 266.) An electro diagnostic study from February 2011 showed severe damage to the left peroneal nerve and mild left tibial nerve palsy. (Id.) The hip fracture caused a left foot drop, which was treated with a brace Simmons wore at night. (Id. at 267.)

         By October 2012, Simmons continued to have a “slight limp.” (Id. at 533.) He reported severe pain in his hip, back, and knee, caused by standing too long while working in a kitchen. (Id.) His treating doctor, Dr. Haas, opined that Simmons had neuropathy resulting from the car accident. (Id. at 560.) An x-ray of his knee taken in September 2012 showed “mild narrowing of the medial knee compartment, ” but “no acute abnormality.” (Id. at 549.)

         Simmons sought treatment for his hip and back pain from the Cleveland Clinic in October 2016. (Id. at 961.) Dr. Franklin Price ordered new x-rays, which showed post-surgical changes in his left hip, but noted the “hardware appears grossly intact” and Simmons' joints were maintained, with the exception of a “small ossification along the inferior hip joint space.” (Id.) The x-ray of his back showed normal vertebral body heights and spacing, but “tiny marginal osteophytes at multiple thoracic and lumbar levels.” (Id. at 965.) Dr. Price prescribed ibuprofen and gabapentin for pain, and baclofen and meloxicam to treat inflammation. (Id. at 994.)

         Simmons also sought treatment for migraine headaches from University Hospitals (“UH”) in October 2016. (Id. at 971-72.) He reported to Dr. Hoon Park that sitting hurt his back, but he could not walk long distances due to pain, and his shoulder and back pain were worse when he moved. (Id.) The physical exam showed “Examination of gait: Normal” and cranial nerves intact. (Id. at 973.) Dr. Park prescribed the anti-hypertensive Verapamil. (Id. at 1071.)

         Simmons returned to Dr. Price in November 2016 for a follow-up visit, reporting pain in his wrist. (Id. at 986.) An x-ray of his wrist showed no significant findings. (Id. at 989.) He returned again in December 2016 complaining of left hip pain. (Id. at 995.) Dr. Price prescribed Ben-gay ointment. (Id. at 996.)

         Simmons returned to Dr. Park in January 2017, reporting pain in the left side of his lower back when he moved his hip, and pain if he walked more than 100 yards. (Id. at 1013.) He also reported that he continued to get migraines frequently, and his medication was making him drowsy. (Id.) Again, the physical exam showed “Examination of gait: Normal” and cranial nerves intact. (Id. at 1015.) Dr. Park referred him for physical therapy to treat his back and hip pain. (Id. at 1015.)

         Simmons began physical therapy at UH in February 2017. (Id. at 1058.) His evaluation noted that the left side of his pelvis was elevated, his gait was antalgic, with his body mechanics shifting right to protect his left side. (Id. at 1065.) The physical therapist noted gait deviations, abnormal posture, and pelvic asymmetry, as well as functional limitations affecting sitting, standing, walking, reaching, lifting, squatting, sleeping, and activities of daily living. (Id. at 1066.)

         After receiving therapy twice a week during February, Simmons was re-evaluated by the UH physical therapists at the beginning of March 2017. (Id. at 1137.) They recommended he continue therapy twice weekly for four more weeks, because his goals were only partially met, and although he had “mild gains” in range of movement, he continued to show significant asymmetry. (Id.) His physical therapist recommended a home TENS unit, since he responded well to a trial at physical therapy. (Id. at 1131.)

         On March 6, 2017, Dr. Park completed a medical source statement for Simmons. (Id. at 1181-82.) He opined that Simmons experienced “severe” pain due to his hip and shoulder conditions and cluster migraine headaches that would interfere with his concentration, take him off task, and cause absenteeism. (Id.) He further opined that Simmons had the following functional limitations:

• lift 5 pounds occasionally and 2 pounds frequently;
• stand and walk for a total of half an hour in an 8-hour workday;
• sit for a total of one hour in an 8-hour workday;
• rarely climb, stoop, crouch, kneel, crawl, or push/pull;
• occasionally balance and reach;
• need to elevate his legs 45 degrees at will;
• require an average of 7 hours of additional rest breaks per 8-hour day.

(Id.)

         In April 2017, Simmons received a TENS unit to help with his back pain. (Id. at 1125.)

         In May 2017, Simmons was again re-evaluated by the UH physical therapy department. (Id. at 1120.) They recommended he continue physical therapy weekly for the next 8 weeks. He still had not received a brace that was ordered, and the assessor noted he continued to have an antalgic gait, with his body mechanics shifted to the right. (Id. at 1121.)

         In June 2017, his physical therapist noted that Simmons “significantly compensated for [his] foot drop and hip hike/circumduction, [increasing] strain on his left hip. (Id. at 1117.)

         Simmons was discharged from physical therapy in July 2017, after 23 treatment sessions. (Id. at 1113.)

         In July 2017, Simmons saw Dr. Park again. (Id. at 1180.) Dr. Park noted that Simmons was wearing his brace all day for left leg stability, and had an “abnormal gait” and “limping.” (Id.) However, the physical exam showed “Examination of gait: Normal” and cranial nerves intact. (Id. at 1083.)

         In September 2017, Simmons saw Dr. Park again. (Id. at 1175.) Again, the physical exam showed “Examination of gait: Normal” and cranial nerves intact. (Id. at 1078.)

         In December 2017, Simmons saw Dr. Park again. (Id. at 1199.) Again, the physical exam showed “Examination of gait: Normal” and cranial nerves intact. (Id. at 1202.)

         In March 2018, Simmons saw Dr. Park again. (Id. at 1194.) Dr. Park noted that Simmons was “getting bruises from [his] ankle brace” and “limpimng [sic].” (Id.) Again, the physical exam showed “Examination of gait: Normal” and cranial nerves intact. (Id. at 1097.)

         In June 2018, Simmons saw Dr. Park again. (Id. at 1228.) Dr. Park noted that Simmons was “limping, ankle is the same.” (Id.) Again, the physical exam showed “Examination of gait: Normal” and cranial nerves intact. (Id. at 1078.)

         C. State Agency Reports - Physical Impairments

         In January 2017, state agency reviewing physician Leigh Thomas, M.D., opined that Simmons had the following functional limitations:

• occasionally lift and/or carry 20 pounds, and frequently lift and/or carry 10 pounds;
• stand and/or walk, and sit about 6 hours in an 8-hour workday;
• unlimited pushing and pulling;
• occasionally climb ramps or stairs, stoop, kneel, crouch, and crawl; and
• never climb ladders/ropes/scaffold.

(Tr. 74-76.)

         In April 2017, state agency reviewing physician Leon Hughes, M.D., concurred with the opinion of Dr. Thomas. (Id. at 85-87.)

         D. ...


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