United States District Court, W.D. Virginia, Roanoke Division
REPORT AND RECOMMENDATION
ROBERT S. BALLOU, Magistrate Judge.
Plaintiff Loura Mechelle Dalton ("Dalton") filed this action challenging the final decision of the Commissioner of Social Security ("Commissioner") finding her not disabled and therefore ineligible for disability insurance benefits ("DIB") under the Social Security Act ("Act"). 42 U.S.C. §§ 401-433. Specifically, Dalton alleges that the Administrative Law Judge ("ALJ") erred by not giving her treating physician's opinion controlling weight, improperly discrediting her own testimony, and failing to obtain the testimony of a vocational expert. I conclude that substantial evidence supports the ALJ's decision on all grounds. As such, I RECOMMEND DENYING Dalton's Motion for Summary Judgment (Dkt. No. 11), and GRANTING the Commissioner's Motion for Summary Judgment. Dkt. No. 15.
STANDARD OF REVIEW
This Court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that Dalton failed to demonstrate that she was disabled under the Act. Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001). "Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal citations omitted). The final decision of the Commissioner will be affirmed where substantial evidence supports the decision. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).
BACKGROUND AND CLAIM HISTORY
Dalton was born on June 24, 1964 (Administrative Record, hereinafter "R." at 19), and is considered a younger person under the Act as of her alleged onset date. 20 C.F.R. § 404.1563. Dalton is insured through December 31, 2005 (R. 49) and therefore must show that her disability began before the end of her insurance period and existed for twelve continuous months to receive DIB. 42 U.S.C. § 423(a)(1)(A), (c)(1)(B), (d)(1)(A); 20 C.F.R. §§ 404.101(a), 404.131(a). Dalton has a high school education (R. 37) and has worked as seamstress, account executive, and office manager. R. 176. Dalton did not complete a function report regarding her daily activities during the relevant period. R. 18.
Dalton protectively filed for DIB on July 30, 2009, claiming that her disability began on August 4, 2004. R. 49, 150. The state agency denied her application at the initial and reconsideration levels of administrative review. R. 49-65. On October 17, 2011, ALJ Thomas W. Erwin held a hearing to consider Dalton's disability claim. R. 24-47. Dalton was represented by an attorney at the hearing, which included testimony from Dalton. R. 24-47.
On November 2, 2011, the ALJ entered his decision analyzing Dalton's claim under the familiar five-step process and denying Dalton's claim for benefits. R. 9-20. The ALJ found that Dalton suffered from the severe impairments of left ankle post-traumatic arthritis and status-post right ankle injury. R. 14. The ALJ found that these impairments, either individually or in combination, did not meet or medically equal a listed impairment. R. 15. The ALJ further found that Dalton retained the residual functional capacity ("RFC") to perform the full range of sedentary work. R. 15. The ALJ determined that Dalton could not return to her past relevant work (R. 19), but that Dalton could work at jobs that exist in significant numbers in the national economy. R. 19. Thus, the ALJ concluded that she was not disabled. R. 20. On February 19, 2013, the Appeals Council denied Dalton's request for review (R. 1-6), and this appeal followed.
Dalton argues that the ALJ's decision denying benefits is not supported by substantial evidence for three interrelated reasons in connection to Dalton's ankle impairments. First, Dalton alleges that the ALJ should have given more weight to the opinion of her treating physician, James Chandler, M.D., regarding the debilitating nature of Dalton's ankle injuries. Dalton next contends that the ALJ erred by discrediting her own testimony about the severity of her ankle pain. Finally, Dalton argues that the ALJ erred by failing to obtain the testimony of a vocational expert to establish that she was capable of performing work available in the national economy.
Dalton alleges that the ALJ erred by failing to give more weight to the opinion of Dalton's orthopedic surgeon, James Chandler, M.D., with respect to the functional limitation caused by Dalton's ankle injuries. Dalton saw Dr. Chandler as early as October 1999 and performed multiple surgeries on Dalton's left ankle, all prior to the relevant period. Dr. Chandler completed a functional capacity assessment at the request of Dalton's attorney on June 1, 2010. Dr. Chandler indicated that Dalton had limitations that would preclude her from working at the sedentary level, and that the limitations related back to the relevant period, e.g. prior to December 31, 2005, Dalton's date last insured. The ALJ found that the restrictive limitations found by Dr. Chandler were not supported by the medical record, specifically noting that post-operative x-rays of Dalton's left ankle showed a solid fusion, records showed full motor strength, Dalton reported less pain, and that she went several months without follow-up. R. 18. For these reasons, the ALJ gave Dr. Chandler's opinion limited weight. I find that substantial evidence supports this evaluation of Dr. Chandler's opinion.
The social security regulations require that an ALJ give the opinion of a treating physician source controlling weight, if he finds the opinion "well-supported by medically acceptable clinical and laboratory diagnostic techniques" and "not inconsistent with the other substantial evidence in [the] case record." 20 C.F.R. § 404.1527(c)(2). The ALJ must give "good reasons" for not affording controlling weight to a treating physician's opinion. 20 C.F.R. § 416.927(c)(2); Saul v. Astrue, 2011 WL 1229781, at *2 (S.D. W.Va. March 28, 2011). Further, if the ALJ determines that a treating physician's medical opinion is not deserving of controlling weight, the following factors must be considered to determine the appropriate weight to which the opinion is entitled: (1) the length of treatment and frequency of examination; (2) the nature and extent of the treatment relationship; (3) the opinion's support by medical evidence; (4) the opinion's consistency with the record as a whole; and (5) the treating physician's specialization. 20 C.F.R. § 416.927(c)(2)-(5). "None of these factors may be omitted or disregarded by the ALJ in weighing the value of a treating physician's opinion." Ricks v. Comm'r, 2010 WL 6621693, at *10 (E.D. Va. Dec. 29, 2010) (citations omitted).
Dalton broke both of her ankles in a motor vehicle accident in 1986, the left worse than the right. R. 288. Dalton has since had numerous surgeries on her left ankle, including multiple arthroscopies (R. 215-18, 288), an anterior osteophyte resection in 1999 (R. 219-21), and most recently an arthrodesis fusion performed by Dr. Chandler in 2002 (R. 206-08). Follow-up x-rays from less than two weeks after Dalton's 2002 ankle fusion showed good position of the hardware and fusion site. R. 273. X-rays from approximately six weeks out showed the hardware was in excellent position, although there were early signs of callus formation at the fusion site. R. 272. Twelve weeks post-fusion Dalton reported to Dr. Chandler that she still had pain, but that it was better than it was pre-operation, and that she could feel her toes where she was unable to feel them prior to the surgery. R. 270. X-rays also showed an early union in her left ankle. Five months post-fusion in January 2003 Dalton reported some discomfort in the ankle, but again reported having "much less pain than she had preoperatively." R. ...