United States District Court, W.D. Virginia, Charlottesville Division
MYRA S. JOHNSON, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.
Joel C. Hoppe United States Magistrate Judge
Plaintiff Myra S. Johnson asks this Court to review the Commissioner of Social Security’s (“Commissioner”) final decision denying her application for disability insurance benefits (“DIB”) and disabled widow’s benefits (“DWB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401–34. The case is before me by the parties’ consent under 28 U.S.C. § 636(c)(1). ECF No. 14. Having considered the administrative record, the parties’ briefs, and the applicable law, I find that substantial evidence supports the Commissioner’s decision that Johnson is not disabled.
I. Standard of Review
The Social Security Act authorizes this Court to review the Commissioner’s final decision that a person is not entitled to disability benefits. See 42 U.S.C. § 405(g); Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court’s role, however, is limited-it may not “reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment” for that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, the Court asks only whether the Administrative Law Judge (“ALJ”) applied the correct legal standards and whether substantial evidence supports the ALJ’s factual findings. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011).
“Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). It is “more than a mere scintilla” of evidence, id., but not necessarily “a large or considerable amount of evidence, ” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes into account the entire record, and not just the evidence cited by the ALJ. See Universal Camera Corp. v. NLRB, 340 U.S. 474, 487–89 (1951); Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984). Ultimately, this Court must affirm the ALJ’s factual findings if “conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled.” Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996)). However, “[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law.” Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
A person is “disabled” if he or she is unable to engage in “any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A); 20 C.F.R. § 404.1505(a). Social Security ALJs follow a five-step process to determine whether an applicant is disabled. The ALJ asks, in sequence, whether the applicant (1) is working; (2) has a severe impairment; (3) has an impairment that meets or equals an impairment listed in the Act’s regulations; (4) can return to his or her past relevant work based on his or her residual functional capacity; and, if not (5) whether he or she can perform other work See 20 C.F.R. § 404.1520(a)(4); Heckler v. Campbell, 461 U.S. 458, 460–62 (1983). The applicant bears the burden of proof at steps one through four. Hancock, 667 F.3d at 472. At step five, the burden shifts to the agency to prove that the applicant is not disabled. See id.
II. Procedural History
Johnson protectively filed an application for DIB on July 27, 2011, Administrative Record (“R.”) 222–23, and protectively filed an application for DWB on August 8, 2011, R. 224–27. She was 51 years old at the time. R. 222. Johnson alleged a period of disability beginning on November 11, 2009-the day after an ALJ rejected her previous application for benefits. R. 243–44. She claimed her disability was caused by fibromyalgia, depression, anxiety, high blood pressure, degenerative joint disease, osteoarthritis, and anti-nuclear antibodies. R. 248. Disability Determination Services (“DDS”), the state agency, denied her claim at the initial and reconsideration stages. R. 104–31, 134–63.
On July 15, 2013, Johnson appeared with counsel at an administrative hearing before ALJ Mark O’Hara. R. 35–77. ALJ O’Hara denied her claim in a written decision issued on October 8, 2013. R. 14–34. He identified Johnson’s date last insured as March 31, 2012,  and found that Johnson met the non-disability requirements for DWB through that date. R. 16–17. He then observed that since her alleged onset date, Johnson had worked part-time as a housekeeper and as a nanny, but found that these did not amount to substantial gainful activity. R. 17. He determined that Johnson had severe impairments of obesity, lumbosacral spine spondylosis, and fibromyalgia syndrome, R. 17–19, but that these impairments, alone and in combination, did not meet or medically equal the severity of a listed impairment, R. 19–20.
The ALJ next found that Johnson had the residual functional capacity (“RFC”) to perform light work with some postural limitations. R. 20–32. Based on this RFC finding and the testimony of a vocational expert (“VE”), the ALJ determined that Johnson could perform her past relevant work as a nanny and a teacher’s aide, or, alternatively, could perform other work existing in the national economy, including non-USPS mail clerk, counter rental clerk, and parking lot attendant. R. 32–34. Therefore, the ALJ concluded that Johnson was not disabled. R. 34. The Appeals Council received additional evidence into the record, R. 5, but ultimately declined Johnson’s request for review, R. 2–4. This appeal followed.
A. Relevant Medical Records
The administrative record contains medical records spanning the period from October 2006, R. 356–63, through May 2013, R. 996. The record prior to the alleged onset date of November 11, 2009, indicates that Johnson suffered from periodic, generalized aching and pain associated with her fibromyalgia. Johnson complained of pain in her neck, shoulders, arms, hips, thighs, knees, and shins. R. 335, 338, 372, 374, 382, 463–64, 466, 472–75, 478, 494, 527, 536, 539, 544. Johnson also reported fatigue caused by her fibromyalgia, R. 476, though the record suggests the fatigue may have been caused by medication she took for hypertension, see R. 494– 96, 542, 544.
Johnson’s subjective descriptions of her fibromyalgia symptoms varied. She told Michael Harper, M.D., of the University of Virginia Health System’s (“UVAHS”) Family Medicine Clinic, that her fibromyalgia was day to day, with some aching on most days, but fewer symptoms on others. R. 474, 478. On occasion, Johnson complained of intense pain that prevented her from functioning. R. 335, 374, 463, 474. Physical examination findings during some of those visits and others, however, documented that her fibromyalgia caused generally mild to moderate signs, or was otherwise under control and clinically stable. R. 374, 382, 411, 527, 542, 544. She typically had full range of motion in her neck and both upper and lower extremities. R. 372, 411, 464, 466, 530–31, 544. She did on occasion experience pain upon range of motion in her hips and neck, R. 372, and upon range of motion and adduction above 90 degrees in her shoulders, R. 374, 466, 474. She sometimes exhibited tenderness to palpation at multiple points, including in her left upper extremity, around her chest, and along her back. R. 374, 464, 466, 543.
In August 2008, Johnson was diagnosed with plantar fasciitis in both feet (though more severe in her right foot) after reporting pain that rendered her nearly unable to walk. Dr. Harper recommended exercise and provided her with written material regarding her condition. R. 476. She later reported feeling better after undergoing physical therapy. R. 533. In August 2009, Johnson reported pain in her left foot and ankle resulting from a fall. She could bear weight and ambulate on the affected foot, but complained that this aggravated her pain. Her foot and ankle were tender to palpation but had full range of motion. She was diagnosed with arthritis of the left ankle joint. R. 529–32.
The first medical record following Johnson’s alleged onset date is from a November 13, 2009, visit with Donald L. Kimpel, M.D., at the UVAHS Rheumatology Clinic. In addition to generalized aching from her fibromyalgia, Johnson complained of pain in her lower back and over her left hip. She stated that she walked twice per week and attended physical therapy. Dr. Kimpel offered an injection, which Johnson declined, for left hip pain. R. 738–39.
On November 30, 2009, Johnson reported to Dr. Harper with complaints of worsening pain in her shoulders, neck muscles, hips, and upper thighs. She also indicated some generalized weakness. Physical examination revealed tenderness on paracervical and levator scapulae, rhomboid muscle area, trapezius muscle superior portion, and anterior and lateral thighs bilaterally. Johnson had full range of motion in her neck and shoulders, but had pain on shoulder adduction from 60–90 degrees all the way over her head. Examination of her hips revealed pain on all versions, with some limitation of internal and external rotation. Examination of her knees was within normal limits. Dr. Harper observed that Johnson was teary as she discussed her symptoms. He noted that she was taking Paxil only on an intermittent basis, with no explanation as to why she was not taking it regularly. Dr. Harper expressed concern about the possibility of polymyalgia rheumatica. He increased Johnson’s dosage of Paxil with instructions to take it daily, and he also prescribed a daily dosage of prednisone for her pain. R. 560–61.
Johnson reported back to Dr. Harper on December 28, 2009. She told him that she was taking Paxil regularly and that she had noticed a dramatic improvement in her pain after starting prednisone. Examination revealed only some musculoskeletal discomfort consistent with Johnson’s fibromyalgia. Her gait and cerebellar functions were normal, with no muscle tenderness noted. Dr. Harper concluded that Johnson’s fibromyalgia was clinically stable. R. 604–05.
On February 8, 2010, Johnson reported to Eric Carson, M.D., at the University of Virginia’s McCue Center Clinic. Johnson complained of mild discomfort and pain related to her plantar fasciitis. Examination revealed tenderness over the plantar aspect of her foot and full range of motion. R. 705–06. X-rays of her left hip taken that same day revealed no acute fracture or dislocation, and no significant hip joint space narrowing or osteophyte formation. R. 636. Johnson underwent a hip injection on February 12. R. 633–35. When she reported back to Dr. Carson on March 16, he observed that she had responded extremely well to this procedure. She also told Dr. Carson that she was doing reasonably well and continued to work on light duty restrictions. R. 600. Johnson visited Dr. Carson again on June 15, 2010. She stated that her foot felt reasonably well, but she also complained of localized discomfort over her IT band. Dr. Carson found X-rays of her hip to be unremarkable. He ordered another injection of Johnson’s hip and did not recommend therapy, but noted that therapy would be the next step if the injection did not improve Johnson’s pain. R. 676–77.
On July 19, 2010, Johnson went back to Dr. Harper for a follow-up visit. She had little to report other than her left hip pain, which had been diagnosed as a proximal iliotibial band syndrome. The injection she received had provided some relief, but did not totally alleviate her discomfort. She also complained of generalized myalgias, and Dr. Harper found her blood pressure to be at the upper limits of normal. Johnson stated that she was not taking Naprosyn because she did not believe that it helped much, but instead wanted to try a new anti-inflammatory. She told Dr. Harper that she continued to do some housekeeping work with her housecleaning business, but did not do very much at the time. She also claimed that she feels worse for several days if she “overdoes it.” Dr. Harper noted that Johnson’s pain was located in her neck, shoulders, and left hip extending down the lateral side of her thigh. Johnson was able to walk and function, and her activities of daily living were without restriction. Physical exam revealed full range of motion in her neck, upper extremities, and knees. Johnson also had full range of motion of both hips, but with some limitation of external rotation. She had a negative straight leg raise test and tenderness to the trapezius, levator scapulae, paracervical muscles, and superior portion of the left IT band. Dr. Harper prescribed Voltaren and also recommended glucosamine because medical personnel from orthopedics thought she had a degenerative joint disease component to her discomfort. R. 555–56.
Johnson had another visit with Dr. Carson on August 23, 2010. She stated that a hip injection she received helped her significantly, but she still had some soreness in that region. Upon examination, she had a positive Ober test and point tenderness. Dr. Carson prescribed physical therapy and stretching exercises for her hip. R. 593–94. Johnson followed up with Dr. Carson on October 7, 2010. She stated that her ankle felt well, but that her hip pain was worsening. She described the pain as radiating into the leg and thigh, and she complained of weakness, but no numbness or tingling. Johnson had full range of motion in her hip and tenderness over the greater trochanter, with slight pain upon flexion and extension of the hip and lower back. Dr. Carson found Johnson’s pain to be consistent with hip osteoarthritis and trochanteric bursitis. R. 592.
On November 4, 2010, Johnson presented to the UVAHS Emergency Department with an acute headache and associated dizziness, blurred vision, and lightheadedness. Johnson’s blood pressure was also higher than normal. Physical examination was negative for leg pain above baseline. Johnson’s strength was 5/5 in all extremities, and her gait was steady and at a normal pace. She was discharged in stable condition after her symptoms resolved. R. 586–90. Johnson followed up on November 10 with Catherine Casey, M.D., at UVAHS. Johnson explained that she had discontinued some of her blood pressure medications because of adverse side effects. Review of symptoms was positive for anxiety and left hip pain. R. 591.
Johnson visited Dr. Carson again on November 18 to follow up regarding her left hip IT band syndrome and osteoarthritis. Johnson stated that a hip injection had helped her significantly, but some soreness remained. She also complained of pain originating in her lower back and radiating to the left leg. She had a positive Ober test and point tenderness. She was tender in the greater trochanteric region and had pain with flexion of her spine. Dr. Carson provided her with a physical therapy home exercise program and stretching exercises. R. 585–86. At a follow-up visit on January 6, 2011, Johnson told Dr. Carson that her pain had slightly improved since her last visit, with worse pain in her groin than in her back, buttock, and lateral thigh. Upon examination, Johnson had negative Ober and FABER tests, but a positive straight leg raise test and increased pain with hip external and internal rotation. Dr. Carson scheduled Johnson for a fluoro-guided corticosteroid injection of the left hip to delineate whether her hip or her back was the primary source of her pain. He also recommended that Johnson continue with low-impact aerobic exercise. R. 584–85.
Johnson received the injection on January 20, R. 626–30, and followed up with Dr. Carson on March 3. Dr. Carson noted that a radiograph showed moderate bilateral hip osteoarthritis. Otherwise, his report was essentially identical to that of Johnson’s previous visit. R. 583–84. On March 10, 2011, Johnson reported to Dr. Casey with complaints of congestion and a headache. Review of symptoms revealed joint pain. R. 582–83. Johnson returned to Dr. Carson on April 14, 2011. She reported that her ankle was doing well, but stated that she had worsening pain in her hip that radiated into her leg and thigh. She complained of weakness, but not of numbness or tingling. Johnson had full range of motion in her left hip, with tenderness over the greater trochanter and slight pain on flexion and extension of the hip and lower back. Dr. Carson’s record of this visit also indicates that Johnson was to return to light duty work in mid-May. R. 581–82.
On May 27, 2011, Johnson visited James Browne, M.D., at UVAHS. Johnson told Dr. Browne that her symptoms had improved significantly after receiving an intraarticular injection in her hip and that her pain had improved overall since it began the previous year. She stated that she was very active and walked five miles per day. She still had pain located in her groin and the lateral aspect of her hip that radiated down her leg. Physical exam revealed no swelling, redness, or inflammation in the area of her left hip. She had full range of motion with painful internal rotation, painless knee motion, and negative straight leg raise test. Johnson was nontender over the sacroiliac joint, lumbar spine, and greater trochanter. X-rays revealed coxa profunda with good joint preservation and very minimal ...