United States District Court, W.D. Virginia, Roanoke Division
PAMELA WYATT JONES, as Mother and Next Friend of Bryan Roberson, an infant, and Scott Roberson, an infant, successors in interest to Barry T. Roberson, deceased, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
ROBERT S. BALLOU, Magistrate Judge.
Plaintiff Barry T. Roberson ("Roberson") filed this action challenging the final decision of the Commissioner of Social Security, ("Commissioner"), finding him not disabled and therefore ineligible for disability insurance benefits ("DIB") under the Social Security Act ("Act"). 42 U.S.C. §§ 401-433. Specifically, Roberson alleges that the Administrative Law Judge ("ALJ") erred by failing to properly weigh the opinions of the treating and consulting physicians. I agree that the ALJ improperly discredited the opinions of Roberson's treating and consultative physicians. As such, I RECOMMEND GRANTING IN PART Roberson's Motion for Summary Judgment (Dkt. No. 13), DENYING the Commissioner's Motion for Summary Judgment. (Dkt. No. 18), and reversing and remanding this case pursuant to sentence four of 42 U.S.C. § 405(g) for further administrative proceedings consistent with this report and recommendation.
STANDARD OF REVIEW
This court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that Roberson failed to demonstrate that he 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).
Roberson filed for DIB on April 1, 2009, claiming that his disability began on February 26, 2009. R. 149. The state agency denied his application at the initial and reconsideration levels of administrative review. R. 60-69, 70-79. On May 6, 2011, ALJ Geraldine H. Page held a hearing to consider Roberson's disability claim. R. 30-59. Roberson was represented by an attorney at the hearing, which included testimony from Roberson and vocational expert AnnMarie E. Cash. R. 30-59.
On June 21, 2011, the ALJ entered her decision analyzing Roberson's claim under the familiar five-step process,  and denying Roberson's claim for benefits. R. 15-29. The ALJ found that Roberson suffered from the severe impairments of degenerative joint disease/osteoarthritis of the left knee, status-post surgery left knee arthroscopy, history of cellulitis, and obesity. R. 20. The ALJ found that these impairments, either individually or in combination, did not meet or medically equal a listed impairment. R. 22. The ALJ further found that Roberson retained the residual functional capacity ("RFC") to perform a range of light work, with the qualification that he could lift and carry up to ten pounds frequently and twenty pounds occasionally; that he could sit, stand and/or walk for up to six hours in an eight hour work day; that he could never crawl; that he was limited in pushing/pulling with his left lower extremity to the lift/carry amount; that he could occasionally balance, stoop, kneel, crouch and climb ramps and stairs; and that he should avoid working around hazards, including unprotected heights, vibrating surfaces, hazardous machinery, or climb ladders, ropes, or scaffolds. R. 22. The ALJ determined that Roberson could return to his past relevant work as a machine operator (R. 28), and he could also work at jobs that exist in significant numbers in the national economy, such as dishwasher, office machine operator, and folding machine operator. R. 29. Thus, the ALJ concluded that he was not disabled. R. 29. On December 31, 2012, the Appeals Council denied Roberson's request for review (R. 1-4), and this appeal followed.
Roberson argues that the ALJ erred by giving little weight to the functional restrictions suggested by his treating physician, William M. Skewes, M.D., and consultative physician Robert Stephenson, M.D.,  and by failing to provide sufficient rationale for rejecting their opinions. Specifically, on May 6, 2011, Dr. Skewes found that Roberson could walk/stand no more than two hours a day with frequent breaks, that his pain would interfere with his concentration, and that his impairments would cause significant absenteeism from work. Dr. Stephenson gave the opinion on May 11, 2011 that Roberson could walk/stand for two hours a day, would need frequent position changes and could perform only limited positional activities such as crouching, kneeling, squatting, etc. R. 346-47, 436-41. Roberson also argues that the ALJ erred by finding his complaints of low back pain and right knee pain to be non-severe impairments. Having reviewed the record, I find that the ALJ improperly discounted the opinions of Drs. Skewes and Stephenson, and did not sufficiently explain her rationale with regard to the weight she gave the medical opinion evidence.
The focus of this appeal is on the functional limitations caused by Roberson's left knee impairments. Roberson was born in February 1968 and has a high school diploma. R. 35-36. He injured his left knee in 1998, and subsequently underwent arthroscopic surgeries, in 1998 and 2002. R. 284, 330, 333-34. Over the next seven years, Roberson continued to have bilateral knee pain, left greater than right. R. 386, 353-54, 406-07. His doctors prescribed pain medication, and in June 2006, Roberson reported that medication controlled his symptoms so that he could maintain a functional state. R. 351. Roberson was working as a machine operator at that time, which was medium exertion, semi-skilled work. R. 52, 163.
On April 27, 2008, Roberson presented to the emergency room complaining of swelling in his legs. R. 236-42. The emergency room physician diagnosed Roberson with cellulitis, and instructed him to elevate his legs and consider wearing support hose to reduce the swelling. R. 236. A few weeks later, Roberson saw his longtime treating family physician, Dr. Skewes, complaining of low back and left knee pain. R. 273-74. Dr. Skewes ordered an MRI of Roberson's left knee which revealed generalized degenerative arthritic changes involving the medial and lateral compartments and patellofemoral joint. R 228. An MRI of Roberson's lumbar spine showed a mild broad based disc protrusion at L4-L5 and L5-S1 that was probably not clinically significant. R. 229.
Dr. Skewes referred Roberson to Brent Johnson, M.D., an orthopedic specialist, to evaluate his complaints of increasing knee pain. R. 230-31. On September 11, 2008, Roberson visited Dr. Johnson, and reported that his job required working on his feet on concrete ten to twelve hours a day. R. 230. He wore a knee brace to prevent buckling, and reported swelling and increased pain in his left knee by the end of each day. R. 230. On examination, Dr. Johnson noted that Roberson had good range of motion of both hips, normal looking valgus alignment of both knees with standing, and pes planus bilaterally. R. 230. He had good quad activation, but patellofemoral crepitus bilaterally, and pain with patella compression on the left. R. 230-31. Roberson reported some lateral facet tenderness on the left, and lateral joint line tenderness. R. 231. He had full knee extension bilaterally, and flexion of 110 degrees on the left and 125 degrees on the right. R. 231.
Dr. Johnson reviewed the MRI of Roberson's left knee, and found "relatively significant degenerative changes involving all three joints, " with some lateral patellar subluxation and evidence of "osteochondral almost fracture in the posterior sort of central aspect of the lateral femoral condyle." R. 231. Dr. Johnson diagnosed Roberson with left knee osteoarthritis. He noted that Roberson had diffuse degenerative changes in his knee, a "significant problem for a 40-year-old." R. 231. Dr. Johnson found no obvious surgical lesion, and recommended weight reduction, bracing, and occupational change or modification so that Roberson was not chronically standing on his feet on concrete. R. 231.
Five months later in February 2009, Roberson was laid off from his job and began collecting unemployment. R. 36-37. Roberson testified that prior to losing his job he had difficulty performing his job duties, and missed four to five days of work per month. R. 47. Roberson returned to Dr. Skewes on June 11, 2009, September 10, 2009, January 5, 2010, and July 5, 2010 with left knee pain complaints. R. 265-66, 277. Dr. Skewes's office notes for those visits are largely illegible.
On June 16, 2009, state agency physician Joseph Duckwall, M.D., reviewed Roberson's records and concluded that he was capable of lifting 25 pounds occasionally and 50 pounds frequently; sitting, standing and/or walking six hours in an eight hour workday; and occasionally performing postural changes such as climbing ramps/stairs, balancing, stooping, kneeling, crouching and crawling. R. 64-65. Dr. Duckwall found that Roberson should never climb ladders, ropes or scaffolds, and should avoid concentrated exposure to hazards. R. 64-65. On November ...