United States District Court, E.D. Virginia, Richmond Division
REPORT AND RECOMMENDATION
DAVID J. NOVAK, Magistrate Judge.
Lisa Beck Stanley ("Plaintiff) is 52 years old and previously worked as a cashier, a customer service manager and a grocery store manager. On November 29, 2010, Plaintiff applied for Social Security Disability Benefits ("DIB") stemming from degenerative disc disease, bone spurs and arthritis with an alleged onset date of October 27, 2009. Plaintiffs application was denied both initially and upon reconsideration. On May 3, 2012, Plaintiff appeared and testified before an Administrative Law Judge ("ALJ"). On May 29, 2012, the ALJ issued a written decision denying Plaintiffs claims. On August 22, 2013, the Appeals Council denied Plaintiffs request for review, rendering the ALJ's decision the final decision of the Commissioner of Social Security.
Plaintiff now appeals the ALJ's decision in this Court pursuant to 42 U.S.C. § 405(g), arguing that the ALJ erred in assessing Plaintiffs credibility and incorrectly determined Plaintiffs residual functional capacity ("RFC"). The parties have submitted cross-motions for summary judgment, which are now ripe for review. Having reviewed the parties' submissions and the entire record in this case, the court is now prepared to issue a report and recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). For the reasons that follow, the Court recommends that Plaintiffs Motion for Summary Judgment (ECF No. 8) be DENIED; that Defendant's Motion for Summary Judgment (ECF No. 10) be GRANTED; and that the final decision of the Commissioner be AFFIRMED.
Because Plaintiff alleges that the ALJ erred in her assessment of Plaintiffs RFC by concluding that Plaintiff could perform light work, and that the ALJ incorrectly determined Plaintiffs credibility, Plaintiffs education and work history, medical history, function reports, state agency physician assessments, testimony and the vocational expert's ("VE") testimony are summarized below.
A. Education and Work History
Plaintiff was 47 years old when she applied for DIB. (R. at 157.) Plaintiff graduated from high school. (R. at 36.) She worked at a grocery store from 1995 to 2009. (R. at 191.) Plaintiff stopped working on October 22, 2009. (R. at 38.)
Within the grocery store Plaintiff worked as a cashier/checker, a customer service manager, a manager and finally as a stock clerk. (R. at 52.) Most recently, Plaintiff worked as a store manager for Food Lion. (R. at 37.)
B. Medical Records
On November 4, 2009, Plaintiff sought treatment from David Antonio, M.D., reporting a spontaneous onset of right low back pain radiating into her right lower extremity. (R. at 335.) Plaintiff complained of experiencing lower back pain for the past week. (R. at 335.) Plaintiff had a restricted range of motion ("ROM") of the lumbar spine in all directions. (R. at 335.) She had some back pain, but no referred leg pain. (R. at 335.) A neurological evaluation of Plaintiffs lower extremities showed no abnormalities in motor sensation or reflexes. (R. at 335.) She had no significant spinal deformity or muscle spasms. (R. at 335.) X-rays of her lumbar spine showed increased lumbar lordosis and 50 percent disc space narrowing at L-5. (R. at 335.) Dr. Antonio diagnosed Plaintiff with lumbar spondylitis and sciatica, and prescribed Lortab and Aleve. (R. at 335.)
Plaintiff attended a follow-up appointment on November 11, 2009, and showed 30 percent improvement, but she still had significant pain on her right side. (R. at 334.) Dr. Antonio noted that Plaintiff walked with a somewhat antalgic gait, but she remained neurologically grossly intact. (R. at 334.) Dr. Antonio prescribed Percocet to Plaintiff, which was to be taken "judiciously." (R. at 334.) Dr. Antonio also restricted Plaintiff from work and instructed her to avoid lifting and bending for the following two weeks. (R. at 334.) Plaintiff returned on November 20, 2009, complaining of a severe increase in "sciatic type right leg pain." (R. at 333.) Dr. Antonio diagnosed her as having Lumbar HNP with right radiculopathy and recommended that Plaintiff receive an MRI as soon as possible. (R. at 333.)
On December 2, 2009, Ronald Washburn, M.D. performed a CT scan on Plaintiff and noted that she had mild degenerative spondylosis at L5-S1 and that Plaintiff may have had an extruded disc. (R. at 286.) He also noted that the rest of the scan was unremarkable. (R. at 286.) On December 7, 2009, Dr. Antonio reported that Plaintiffs CT scan revealed multilevel moderate degenerative changes, and he diagnosed her as having severe right sciatica. (R. at 332.) Dr. Antonio referred Plaintiff for an assessment of her candidacy for pain management epidural steroid injection ("ESI"). (R. at 332.)
On January 6, 2010, Plaintiff presented to Barbara Perona, M.D., complaining of low back pain, but denying any significant pain. (R. at 278.) Upon examination, Dr. Perona noted that Plaintiff walked with an antalgic gait, but that she had no tenderness to palpation of her paraspinous processes, except over the bony tip and that she had full motor strength in her lower extremities. (R. at 278.) Plaintiff was reluctant to proceed with an ESI and wanted time to think about it from home. (R. at 278.) Dr. Perona noted that no evidence of myelopathy existed. (R. at 278.)
On January 13, 2010, Plaintiff returned to Dr. Antonio complaining of "fairly significant right sciatica, " and an onset of left sciatica. (R. at 331.) Dr. Antonio noted that pain medications Lortab and Darvocet failed to provide Plaintiff with relief, so he prescribed Percocet. (R. at 331.) A physical exam revealed that Plaintiffs reflexes were "symmetrically hyporeflexic" and that she had some back pain, but that her neurology was grossly intact. (R. at 331.)
On January 20, 2010, Plaintiff underwent an ESI procedure. (R. at 273.) On February 2, 2010, Dr. Antonio noted that this ESI procedure provided relief for eight or nine days, after which the pain began to recur. (R. at 330.) Plaintiff rated her sciatica pain as an eight out often. (R. at 330.) Dr. Antonio opined that Plaintiff was a good candidate for repeat ESI and that any treatment that could avoid surgery was "certainly worth trying." (R. at 330.) On February 17, 2010, Dr. Perona made similar findings to those of Dr. Antonio. (R. at 280.)
On February 17, 2010, Plaintiff underwent a second ESI procedure. (R. at 280-81.) That same day, Dr. Perona recommended that Plaintiff consider a third ESI procedure. (R. at 281.) On February 26, 2010, Dr. Antonio noted that Plaintiff showed "very minimal improvement" after a second ESI procedure. (R. at 329.) Dr. Antonio opined that Plaintiff would likely need surgery, but that she needed a myelogram to "further elucidate the pathology." (R. at 329.)
On March 31, 2010, Dr. Washburn performed a second CT scan on Plaintiff and found that no evidence of an extradural or intradural mass displacing nerve roots or compression of the nerve roots existed. (R. at 283.) Otherwise, the scan appeared unremarkable. (R. at 283.) Dr. Washburn also performed a myelogram on Plaintiff and observed no intradural or extradural filling defectsand no displacement of the thecal sac. (R. at 285.) Overall, the lumbar myelogram was normal. (R. at 285.)
On April 9, 2010, Dr. Antonio noted that activity aggravated Plaintiffs pain and he referred Plaintiff to a neurologist. (R. at 328.) On May 19, 2010, Dr. Antonio opined that it would be an "excellent idea" to wean Plaintiff off narcotics altogether. (R. at 327.) Dr. Antonio thenprescribed a combination of two Ibuprofen, two Tylenol and one Ultram three to four times a day to Plaintiff. (R. at 327.) Dr. Antonio also recommended that Plaintiff "walk around as much as comfortable, " but noted that Plaintiff could not sustain a "full-fledged back rehab program." (R. at 327.) Dr. Antonio restricted Plaintiff from working for six more weeks. (R. at 327.)
On June 30, 2010, Plaintiff returned to Dr. Antonio, complaining of "fairly significant lower back pain" that radiated down her right leg to her knee. (R. at 326.) He noted that Plaintiff had been experiencing the symptoms for about one year and that neither Elavil nor Chlorazine provided Plaintiff any relief. (R. at 326.) Dr. Antonio recommended that Plaintiff see a pain manager. (R. at 326.)
On September 27, 2010, Meenakshi Bindal, M.D. examined Plaintiff. (R. at 366-69.) He noted that Plaintiff had full range of motion, no tenderness and no deformities in her upper or lower extremities. (R. at 368.) He also noted that she walked with a slight antalgic gait, could walk on her heels and tiptoes with pain, and had near full muscle strength, intact sensation and normal reflexes. (R. at 368.) Dr. Bindal recommended an ESI, but Plaintiff preferred to wait. (R. at 369.)
On October 13, 2010, Plaintiff returned to Dr. Antonio, after receiving two ESI procedures from Dr. Bindal, and showed twenty percent improvement with her leg and back pain. (R. at 325.) Dr. Antonio also noted that physical therapy helped Plaintiff. (R. at 315, 325.) Dr. Antonio recommended a third ESI procedure and ordered Plaintiff to continue using Neurotin. (R. at 325.) On October 27, 2010, Dr. Antonio noted that Plaintiff presented new symptoms of acute pain on her left buttock, "radiating anterior thigh burning and numbness." (R. at 324.) A physical exam revealed that Plaintiff was neurologically intact with no abnormality in her motor sensation or reflexes and no significant swelling or tenderness of her lumbar spine. (R. at 324.) Dr. Antonio noted that Percocet and Lortab no longer provided relief and recommended switching Plaintiff from Flexeril to Skelaxin. (R. at 324.) Dr. Antonio also suggested that Plaintiff proceed with a third ESI when she returned from her vacation to Maine. (R. at 324.)
On November 17, 2010, Dr. Antonio noted that Plaintiff only sparingly took Percocet, but she continued to use Neurotin. (R. at 323.) He further reported that Plaintiff had been doing "fairly well" until she had an onset of sciatica, but that she appeared "reasonably well" during this appointment. (R. at 323.) On December 9, 2010, Dr. Bindal reported that Plaintiffs pain was overall 40-50 percent better and that Plaintiff had not suffered from severe pain in the past month. (R. at 375.) On December 29, 2010, Dr. Antonio noted that Plaintiff walked without "any obvious limp, " and that her lumbar spine was about 50 percent restricted in all directions. (R. at 456.) He ordered Plaintiff to "very sternly" take Percocet, and suggested that Plaintiff continue to see him on an as-needed basis. (R. at 456.)
On February 14, 2011, Dr. Antonio stated that Plaintiff was tender and had restricted ROM of her spine. (R. at 455.) On February 28, 2011, Dr. Antonio completed a disability form for Plaintiff and indicated that Plaintiff could not work at all, because she could not stand or sit and she could not lift on either an occasional or frequent basis. (R. at 400.) Dr. Antonio reported that Plaintiff could never move or manipulate her body. (R. at 400.) He also indicated that Plaintiff could never tolerate exposure to cold, dust or noise. (R. at 400.) Finally, Dr. Antonio reported that Plaintiff suffered from "extreme" pain. (R. at 400.)
On March 18, 2011, Benjamin Contreras, M.D. examined Plaintiff and noted that her laboratory results showed no evidence of extradural or intradural mass displacing nerve roots and no compression on the nerve roots. (R. at 450.) Dr. Contreras discussed alternative treatment plans with Plaintiff for her low back pain, lumbar degenerative disc disease and lumbar facet arthropathy, which included neurosurgical intervention. (R. at 450.) Plaintiff, however, preferred to continue with conservative management. (R. at 450.) Dr. Contreras also assessed Plaintiff with an opioid dependence. (R. at 450.) On April 21, 2011, Dr. Contreras noted that Plaintiff did not wish to undergo interventional pain procedures. (R. at 448.)
On May 2, 2011, Dr. Antonio noted that Plaintiff still experienced "fairly significant problems" with persistent midline lower back pain that went down her right side to the knee. (R. at 453.) His examination of Plaintiff revealed that her lumbar spine was significantly restricted in all directions by 50 percent, that she had generalized weakness in both of her legs and that she walked with a slight antalgic gait, but that she had no obvious muscle atrophy, no leg pain and no obvious abnormality in motor sensation or reflexes. (R. at 453.) Dr. Antonio further ...