United States District Court, E.D. Virginia, Richmond Division
REPORT AND RECOMMENDATION
DAVID J. NOVAK, Magistrate Judge.
Darlene Marrow ("Plaintiff") is 50 years old and previously worked as a packer. On March 25, 2010, Plaintiff applied for Social Security Disability Benefits ("DIB") and Supplemental Security Income ("SSI"), stemming from fibromyalgia, arthritis, chronic pain, hypertension, back problems, high cholesterol and plantar fasciitis with an alleged onset date of April 10, 2008. Plaintiff's application was denied both initially and upon reconsideration. During a video hearing on April 4, 2011, Plaintiff testified before an Administrative Law Judge ("ALJ"). On April 28, 2011, the AU issued a written decision denying Plaintiff's claims. On July 26, 2013, the Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision the final decision of the Commissioner.
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 Plaintiff's credibility, failed to afford the Plaintiff's treating physician's opinion controlling weight and incorrectly found that Plaintiff could perform jobs existing in significant numbers in the national economy. 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 Plaintiff's Motion for Summary Judgment (ECF No. 16) be DENIED; that Plaintiff's Motion to Remand (EFC. No. 17) be DENIED; that Defendant's Motion for Summary Judgment (ECF No. 19) be GRANTED; and that the final decision of the Commissioner be AFFIRMED.
Because Plaintiff argues that the ALJ incorrectly determined Plaintiff's credibility, failed to afford the opinion of Plaintiff's treating physician controlling weight and erred in determining that Plaintiff could perform jobs existing in significant numbers in the national economy, Plaintiff's education and work history, medical history, function reports, state agency physicians' opinions, Plaintiff's testimony and vocational expert ("VE") testimony are summarized below.
A. Education and Work History
Plaintiff was 47 years old when she applied for DIB and SSI. (R. at 20, 35.) Plaintiff graduated from high school. (R. at 35-365, 468.) Plaintiff never a held driver's license and she previously worked as a packer. (R. at 36, 295.)
B. Medical Records
1. Boydton Medical Center
On January 5, 2009, Plaintiff saw Rachel I. Huot, M.D. at Boydton Medical Center, complaining of pain in both of her shoulders, extending all the way down her left side. (R. at 944.) A physical examination revealed tightness in Plaintiff's trapezius muscles as well as tenderness and decreased range of motion in her spine; however, Plaintiff had no clubbing or edema in her extremities. (R. at 945.) Dr. Huot diagnosed Plaintiff with high cholesterol, essential hypertension and vitamin D deficiency. (R. at 945.)
On February 5, 2009, Plaintiff returned with complaints of depression and "always hurting somewhere." (R. at 946.) Dr. Huot diagnosed Plaintiff with depression and prescribed medication for hypercholesterolemia, fibromyalgia, hypertension and depression. (R. at 947.) On March 22, 2010, Plaintiff complained of problems with her right foot, left ankle, left knee and left hip. (R. at 1030.) The report indicated that Plaintiff did not take her antidepression medication, because it reacted poorly with her other medications. (R. at 1030.) Dr. Huot diagnosed Plaintiff with "pain in limb" and restless leg syndrome. (R. at 1031.)
On May 14, 2010, Plaintiff complained of pain in the right side of her jaw and of a new knot on her right foot. (R. at 1056.) Dr. Huot diagnosed Plaintiff with varicose veins, fibromyalgia, allergic rhinitis and neuralgia/neuritis. (R. at 1058.) Dr. Huot referred Plaintiff to a vascular clinic for varicose veins and a neurological consultation. (R. at 1058.) Plaintiff attended a follow-up visit on September 20, 2010, for her neck pain and nodules in her legs and feet. (R. at 1092.) Dr. Huot noted that Plaintiff's depression was under control even though Plaintiff was not on antidepressants. (R. at 1092).
On October 28, 2010, Plaintiff returned, complaining of menstrual problems and neck pain. (R. at 1088.) Dr. Huot ultimately diagnosed Plaintiff with menorrhagia and GERD for which she was prescribed medications. (R. at 1090.) Plaintiff's last recorded visit at the Boydton Medical Center was on March 22, 2011. (R. at 1139.) At that time, Plaintiff complained of problems with her left knee, both of her shoulders and pain in her left eye. (R. at 1139.) Dr. Huot diagnosed Plaintiff with conjunctivitis and fibromyalgia for which she was prescribed medication. (R. at 1139.)
2. Halifax Regional Hospital
On September 20, 2008, Plaintiff went to the Emergency Room at Halifax Regional Hospital, complaining of pain in the top of her head that radiated down the left side of her face and into her left ear. (R. at 852.) During Plaintiff's evaluation, Plaintiff was alert and oriented, and she was not experiencing problems other than head pain. (R. at 853). Plaintiff walked normally and had no extremity tenderness. (R. at 854.) The primary diagnosis was a headache. (R. at 855.)
On October 31, 2008, Plaintiff underwent an MRI of her brain. (R. at 851.) The MRI showed no signs of acute or recent infraction; however, it showed a few FLAIR signal hyperintensities in the frontal lobe and a small arachnoid cyst. (R. at 851.) Overall, the assessment revealed no abnormal enhancement. (R. at 851.)
On September 15, 2010, Plaintiff went to the emergency room for neck pain and knots on the side of her neck. (R. at 1116-17.) John W. Steffe, M.D. diagnosed Plaintiff with cervical strain and insect bites. (R. at 1118.) Dr. Steffe noted that Plaintiff was alert and oriented to person, place and time. (R. at 1118.) Dr. Steffe also noted some spinal tenderness. (R. at 1118.) Dr. Steffe prescribed Doxycycline, Fexoril and Vicodin and discharged her on the same day. (R. at 1119.)
3. VCU Health Systems
On March 27, 2008, Christopher Wise, M.D. completed a Fibromyalgia RFC Assessment in which he found that Plaintiff could sit and stand/walk for about two hours during an eight-hour work day. (R. at 733.) Dr. Wise opined that Plaintiff could rarely lift up to ten pounds, twist, stoop or bend. (R. at 733-35.) Dr. Wise also opined that Plaintiff could never crouch, climb ladders or stairs and that Plaintiff experienced significant limitations in her ability to do repetitive reaching, handling or fingering. (R. at 735.) Overall, Dr. Wise found that Plaintiff could not perform even low stress jobs and that Plaintiff would likely miss two days of work per month. (R. at 733, 735.)
On April 22, 2008, Plaintiff visited Dr. Wise at the VCU Rheumatology Clinic. (R. at 910.) Dr. Wise's report indicated that he had not seen Plaintiff since September 2007 and that no major changes had occurred in the interim, as Plaintiff still experienced pain. (R. at 910.) Plaintiff told Dr. Wise that her physical therapy helped some. (R. at 910.)
On June 11, 2008, Plaintiff saw Jonathan Isaacs, M.D. at the VCU Orthopedic Specialty Clinic. (R. at 996.) Dr. Isaacs' reported that he had treated Plaintiff for several years and that she "present[ed] with inconsistent complaints." (R. at 996.) Dr. Isaacs also noted that he could not interpret Plaintiff's provocative signs, because "they [were] everywhere." (R. at 996.) Dr. Isaac noted that Plaintiff was first diagnosed with carpal tunnel, but Plaintiff canceled the surgery that would have fixed it. (R. at 996.) Plaintiff then returned with complaints suggestive of radiculopathy, but an MRI showed no signs of it. (R. at 996.) Plaintiff gave vague, diffuse pain complaints, but a nerve study showed only carpal tunnel and no problems with the nerve. (R. at 996.) Dr. Isaacs generally noted that Plaintiff presented a difficult situation, because she would appear for treatment, "get worked up, and then disappear for one and one-half years at a time." (R. at 996.) Dr. Isaacs further reported that Plaintiff's "complaints [were] always vague and difficult to interpret." (R. at 996.) Lastly, Dr. Isaacs reported that Plaintiff's exam that day was "all over the place." (R. at 996.)
On July 2, 2008, Plaintiff returned to Dr. Isaacs. (R. at 993.) Dr. Isaacs reiterated his observation that Plaintiff was "very inconsistent and ha[d] disappeared for long periods of time." (R. at 993.) Dr. Isaacs stated that he was "not really sure where all [Plaintiff's] discomfort [was] coming from" and opined that Plaintiff could have fibromyalgia. (R. at 993.) On December 30, 2008, Plaintiff returned to Dr. Wise, complaining of pain "all over" and headaches. (R. at 909.) In his report, Dr. Wise questioned Plaintiff's diagnosis, noting "?Fibromyalgia? From outside doc." (R. at 909.) Dr. Wise also noted an MRI from 2006 that showed Plaintiff had c-spine pathology. (R. at 909.) Dr. Wise refilled Plaintiff's medication and set up a three-month followup. (R. at 909.)
On February 19, 2009, Jonathan W. Berkenstein, M.D. treated Plaintiff for her chronic headaches at the VCU Department of Neurology. (R. at 955.) Plaintiff had normal evaluation results, and Dr. Berkenstein diagnosed Plaintiff with migraine variants for which a trial of medications was prescribed. (R. at 956.)
On March 29, 2009, Plaintiff returned to the VCU Rheumatology Clinic for a follow-up with Dr. Wise. (R. at 908.) Plaintiff complained of chronic pain of an unknown cause and constant aching. (R. at 908.) Dr. Wise also noted in his report that Plaintiff used a cane and had reduced range of motion in her shoulders. (R. at 908.) Dr. Wise adjusted Plaintiff's medications and scheduled a follow-up in four months. (R. at 908.) On June 1, 2009, Plaintiff returned to
Dr. Isaacs, complaining of pain in her left knee, hip and lower back. (R. at 990). Dr. Isaacs diagnosed Plaintiff with IT band syndrome, prescribed Celebrex and directed Plaintiff to resume her physical therapy exercises and to follow-up in three months. (R. at 990-91.)
On July 21, 2009, Plaintiff had a follow-up at the VCU Rheumatology Clinic with Lenore Buckley, M.D., complaining of chronic aches in her shoulders. (R. at 903.) Plaintiff's shoulder pain would improve within about fifteen minutes of her getting up. (R. at 903.) Plaintiff had tenderness in her shoulder, neck, thoracic spine and left leg, but she also exhibited good range of motion and no synovitis. (R. at 903.) Dr. Buckley suggested that Plaintiff continue her medications and attend an orthopedic consultation. (R. at 903.)
That same day, at MCV Hospitals, Plaintiff had an x-ray performed of her left knee, which showed mild, medial joint space narrowing with esteophyte formation in the medial tibial spine, a small patellar enthesophyte, no fracture or joint effusion and no interval change since May 11, 2005. (R. at 1020.) On April 21, 2010, Plaintiff returned to the VCU Department of Orthopedic Surgery, complaining of pain in both feet that hurt "mostly first thing in the morning, " but that "never really got that much better during the day." (R. at 1007.) Plaintiff was diagnosed with right foot plantar fasciitis and left chronic ankle pain or ankle sprain. (R. at 1008.) Plaintiff was directed to resume physical therapy. (R. at 1008.) An MRI of Plaintiff's right foot showed mild, bilateral firs and metatarsal phalangeal joint osteoarthritis. (R. at 1018.)
4. Cox Rehabilitation Center
Plaintiff first attended physical therapy from February 13, 2008, through March 11, 2008, and underwent a second round of physical therapy from April 8, 2008, to April 29, 2008. (R. at 767-74, 777-90.) Plaintiff's complaints included pain in her knees, shoulders, back and neck. (R. 764-74.) Plaintiff initially seemed to feel "looser" from the therapy, but her therapists noted that Plaintiff did not experience any significant decrease in her pain. (R. at 764-74.) Plaintiff's therapist discharged her to home exercises on April 29, 2008, because she had not met any of her therapy goals. (R. at 764-74.)
Plaintiff's third round of physical therapy began on June 12, 2009, and ended July 14, 2009. (R. at 754-65.) During the course of this round of therapy, Plaintiff complained of pain in her lower back, hip and knee. (R. at 754-65.) Plaintiff further complained of trouble sleeping due to pain in her left leg. (R. at 755.) Plaintiff indicated that her pain decreased after treatment. (R. at 755.) When discharged, Plaintiff used a cane and her therapist noted that Plaintiff did not meet any of her treatment goals. (R. at 756.)
Plaintiff returned to physical therapy for a single visit on July 22, 2009, complaining of pains. (R. at 752.) Plaintiff measured her pain between a four and a six on a scale of one to ten. (R. at 752.) Plaintiff was discharged, because she had reached optimal benefit that could be achieved through therapy. (R. at 752.)
Plaintiff began a fourth round of physical therapy on April 29, 2010, which lasted until June 3, 2010. (R. at 1063-75.) Plaintiff's complaints included tenderness and pain in her ankles, heel, feet, toes and "all over." (R. at 1063-75.) On May 6, 2010, therapists noted that Plaintiff's "hypersensitivity [made] therapy difficult." (R. at 1067.) On May 18, 2010, however, the therapist noted that Plaintiff "progressed through exercises well." (R. at 1070.) On ...