United States District Court, W.D. Virginia, Danville Division
REPORT AND RECOMMENDATION
C. Hoppe United States Magistrate Judge
Kent Reynolds asks this Court to review the Commissioner of
Social Security's (“Commissioner”) final
decision denying his application for disability insurance
benefits (“DIB”) under Title II of the Social
Security Act (the “Act”), 42 U.S.C. §§
401-434. The case is before me by referral under 28 U.S.C.
§ 636(b)(1)(B). ECF No. 13. Having considered the
administrative record, the parties' briefs, and the
applicable law, I find that the Commissioner's decision
is supported by substantial evidence. Therefore, I recommend
that the Court DENY Reynolds's motion for summary
judgment, ECF No. 14, GRANT the Commissioner's motion for
summary judgment, ECF No. 16, and AFFIRM the
Commissioner's final decision.
Standard of Review
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).
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).
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 Heckler v. Campbell, 461 U.S. 458, 460-62
(1983); 20 C.F.R. § 404.1520(a)(4). 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.
applied for DIB on June 19, 2012, alleging disability caused
by arthritis, cervical stenosis, and sensory loss in the left
arm. Administrative Record (“R.”) 58, ECF No. 10.
At the time of his alleged onset date of July 13, 2011,
Reynolds was forty-six years old. Id. Disability
Determination Services (“DDS”), the state agency,
denied his claims at the initial, R. 58-66, and
reconsideration stages, R. 69-79. On May 1, 2014, Reynolds
appeared with counsel at an administrative hearing before ALJ
Marc Mates. R. 40-57. Reynolds testified about his past work,
medical conditions, and the limiting effect these conditions
had on his daily activities. See R. 42-51. A
vocational expert (“VE”) also testified at this
hearing regarding the nature of Reynolds's past work and
his ability to perform other jobs in the national and local
economies. See R. 51-56.
Mates denied Reynolds's claim in a written decision
issued on June 25, 2014. R. 20- 33. ALJ Mates found that
Reynolds had severe impairments of degenerative disc disease,
left arm difficulty, hypertension, and diabetes mellitus, but
that these impairments did not meet or medically equal the
severity of a listed impairment. R. 22-23. As to
Reynolds's residual functional capacity
(“RFC”), the ALJ found that he could perform
sedentary work,  but must avoid concentrated exposure to
heights and more than occasional use of the non-dominant
(i.e., left) hand for overhead reaching and gross and fine
manipulation. R. 23-32. Relying on the RFC and the testimony
of the VE, the ALJ found that Reynolds could not perform his
past relevant work, but could perform jobs existing in the
national and local economies, including surveillance system
monitor and call-out operator. R. 32-33. Therefore, ALJ Mates
determined that Reynolds was not disabled. R. 33. The Appeals
Council denied Reynolds's request for review, R. 1-3, and
this appeal followed.
Relevant Medical Evidence
March 23, 2006, X-rays of Reynolds's cervical spine
revealed degenerative disc disease of the mid and lower
cervical spine with disc space and bony neural foraminal
narrowing at ¶ 4-C5, C5-C6, and C6-C7, and bony neural
foraminal narrowing at ¶ 3-C4. R. 337. An MRI from April
4, 2006, also showed a large protrusion at ¶ 4-C5, a
prominent bulge at ¶ 5-C6, and a disc osteophyte complex
at ¶ 6-C7, all of which impressed the thecal sac. R.
335. The bulge at ¶ 5-C6 also caused significant
impression on the spinal cord. Id.
14, 2011, a day after his alleged onset date, Reynolds
visited one of his primary care physicians, John Hoffman,
M.D., because his neck had been bothering him at work. R.
264. A physical exam showed a slight decrease in the range of
motion in the neck and negative straight leg raise test.
Id. Dr. Hoffman ordered imaging of the cervical
spine to further assess the situation. Id. Radiology
reports and an MRI, compared to Reynolds's 2006 MRI,
showed interval progression of the disc disease, increased
signal intensity with the cervical cord at ¶ 4, C5, C6,
and development of gliosis of the cervical cord. R. 275, 276.
August 18, Reynolds saw John Jane, M.D., Ph.D., for a
neurological consultation. R. 233-34. Dr. Jane reviewed the
imaging, confirmed Reynolds had C4-C5, C5-C6, and C6-C7
disease on the left, and ordered a CT myelogram and
electromyography (“EMG”) studies. R. 234. The
studies revealed electrophysiological evidence of left
chronic C7 radiculopathy with ongoing denervation, but no
compelling evidence of polyneuropathy, R. 233, and
significant neural foraminal stenosis and herniated nucleus
pulposus at ¶ 6-C7, R. 223.
October 3, Reynolds presented to University of Virginia
(“UVA”) Hospital East with a primary diagnosis of
cervical stenosis. R. 223. His left arm was observed to be
noticeably weak, particularly in the triceps and grip
strength. Id. Based on his past medical history and
his present symptoms, Reynolds was deemed a reasonable
operative candidate, and Dr. Jane proceeded with a left C6-C7
foraminotomy and a left C6-C7 posterior diskectomy. R. 224.
Dr. Jane subsequently referred Reynolds to physical therapy
as part of his recovery. R. 456. Reynolds saw Christine
Black, PT, DPT, roughly twice a week from October 13 through
November 10. R. 428-51. PT Black discharged Reynolds on
November 23, however, having failed to get in touch with him
after several attempts. R. 422-25. She noted that Reynolds
had denied experiencing improvement in symptoms and
complained of increased pain. R. 425. She opined that
extended therapy may be necessary to treat his severe
November 18, Reynolds returned to UVA and saw Thomas Szabo,
PA. R. 226. PA Szabo noted that Reynolds had not done as well
as expected following the surgery. R. 227. A physical exam
revealed loss of fine touch sensation in the thumb, index,
and middle fingers of both hands and in the left lateral
forearm and triceps. Id. Reynolds had normal
strength in both legs; findings of 5/5 for all motor tests in
the right arm; 3 grip strength, 4 wrist flexion, 5/5
wrist extension, 5/5 biceps, 4 triceps, and 5/5 deltoid in
the left arm; normal tandem gait; no Romberg's sign; and
negative Lhermitte's sign and Spurling's test.
Id. PA Szabo gave Reynolds a note to be off work
until January 2, 2012, ordered a follow-up CT myelogram of
the cervical spine, and started him on Neurontin.
Id. The myelogram demonstrated that in spite of
interval improvement, there still existed persistent moderate
neuroforaminal narrowing at ¶ 6-C7 with resolution of
the spinal canal stenosis, persistent moderate central canal
stenosis at ¶ 4-C5 with mass effect on the spinal cord,
and severe left-sided and moderate-to-severe right-sided
neuroforaminal narrowing at ¶ 5-C6. R. 243.
continued to see a variety of medical providers in 2012. On
January 11, 2012, he visited Dr. Jane, who indicated that
although all the muscle groups in Reynolds's left side
were weak, Dr. Jane felt it was effort dependent. R. 223.
Neurological exam showed that Reynolds had a normal affect,
full strength, and intact sensation to light touch and
showed no active denervation. Id. Dr. Jane added:
I just don't know what further we can do from a surgical
point of view. He has had physical therapy and injections
without relief. . . . I don't think I am going to be able
to come up with a plan that will relieve his pain, the
significance of which is not clear to me.
January 13, Reynolds saw Dr. Hoffman, who found decreased
range of motion in the neck, decreased grip strength on the
left, and light touch sensation a little decreased over the
thenor side as opposed to the ulnar. R. 261. Dr. Hoffman
assessed cervical radiculopathy and hypertension.
Id. Dr. Hoffman referred Reynolds to Neurology
Associates of Lynchburg, Inc., where he saw Peter Konieczny,
M.D., on February 3. R. 252. Dr. Konieczny performed a
physical exam, which showed decreased muscle bulk in the left
triceps, biceps, deltoid, and brachioradialis, but no
evidence of fasciculations; weakness in the left biceps at 4
MRC, left triceps at 4, left finger and wrist extensors at
4-, and left deltoid at 4/5 MRC; full strength and normal
muscle tone in the bilateral lower extremities; and decreased
sensation to pin, vibration, and temperature in the left
forehand and arm. R. 253. Dr. Konieczny explained that
because of Reynolds's left hand weakness, he could not
presently grasp or manipulate objects, and that his problems
likely stemmed from a chronic history of cervical
radiculopathy and the resultant neuropathic damage.
Id. He did note, however, that it was unlikely that
further cervical surgery would help Reynolds. Id. On
March 5, Dr. Konieczny reaffirmed his view that Reynolds was
not a surgical candidate, and he increased Reynolds's
Neurontin dose. R. 251.
saw Dr. Hoffman again on March 29, this time complaining of
trouble with his lower back and hips. R. 256. A physical exam
revealed negative straight leg raise test, and Dr. Hoffman
observed that Reynolds ambulated without too much difficulty
and had fair range of motion in the lumbar spine, but still
used his left arm sparingly. Id. Dr. Hoffman
assessed low back pain, hip pain, and cervical stenosis,
prescribed Tramadol, and ordered X-rays of the low back and
hips. Id. The X-rays of the lumbar spine revealed
fairly advanced facet degenerative changes at ¶ 5-S1
with approximately 7-8 mm of anterolisthesis of L5 on S1 and
similar findings to a lesser degree at ¶ 4-L5. R. 274.
The X-rays of the hips showed nearly normal findings, with
only minimal degenerative narrowing bilaterally. Id.
On April 5, Reynolds visited Dr. Konieczny, who noted a
history of degenerative disc disease and osteoarthritis. R.
250. Dr. Konieczny explained that tripling the Neurontin
dosage had provided only minimal-to-moderate pain relief.
Id. He also indicated that he discussed further
treatment options, including possibly a referral to a pain
center, but that Reynolds wished to pursue more conservative
options such as physical therapy first, which Dr. Konieczny
thought were “perfectly appropriate at this
began seeing PT Black again for physical therapy on April 12.
R. 413. On examination, Reynolds demonstrated limited active
range of motion of the lumbar spine, positive midline Slump
Test, positive Neurotension Test on the right and left, and
positive straight leg raise test on the right and left. R.
414. PT Black recommended physical therapy three times per
week for twenty-four total visits, R. 415, which Reynolds
attended until mid-July, R. 345. During these visits, PT
Black assessed general improvement overall. See,
e.g., R. 390 (decreased pain and progression without
exacerbation on May 14), 380 (improved hip external rotation,
flexion mobility, and range of motion as well as lumbar
paraspinals on May 29), 378 (overall improvement in mobility
on May 30), 366 (demonstrates improved range of motion and
ability to ambulate three times the distance he had been
walking without a break on June 13), 360 (improvements on
straight leg raise test on June 20), 356 (improvement in
subjective reports as well as great improvement in muscle
mobility on June 27), 347-48 (note indicating slow progress
towards goals on July 16).
saw Dr. Hoffman again on May 11, and Dr. Hoffman observed
that Reynolds walked with a little bit of a limp on the left
side and seemed to move his left arm okay. R. 255. He also
noted that a straight leg raise test was negative.
Id. Dr. Hoffman assessed cervical stenosis, low back
pain, diabetes, and hypertension. Id. On May 15, Dr.
Jane completed a musculoskeletal questionnaire regarding his
treatment of Reynolds. R. 277-80. Dr. Jane diagnosed cervical
stenosis and identified Reynolds's symptoms as including
neck pain and pressure, numbness and weakness in the left
arm, and tightness and numbness in the right hand. R. 277.
Dr. Jane acknowledged that sensory loss and muscle weakness
constituted positive objective signs of Reynolds's pain,
R. 278, but further opined that no clinical findings or
laboratory and test results provided an explanation for his
symptoms, R. 277. Reynolds returned to Dr. Hoffman on July 26
and relayed that physical therapy had not been effective and
that his neck and arm continued to hurt. R. 559. Dr. Hoffman
noted that on examination, Reynolds walked stiffly, was well
muscled, and had positive straight leg raise test near ninety
degrees. R. 560.
August 13, Reynolds visited the Orthopaedic Center of Central
Viginia and treated with Kamal Chantal, PA-C. R. 459-63. PA-C
Chantal diagnosed spondylolisthesis, low back pain, lumbar
spondylosis without myelopathy, and sciatica. R. 459. On
examination, Reynolds walked with a normal, non-antalgic
gait; was negative for Patrick's Faber test; experienced
back pain with straight leg raise test on the right, but was
negative on the left; was moderately restricted in flexion,
extension, and lateral bending; and had no pain with hip
motion. R. 459-60. PA-C Chantal also ordered an MRI of the
lumbar spine, which showed a dominant finding of grade 2
spondylolisthesis of L5 on S1 secondary to bilateral pars
defects of L5 with pseudodisc of listhesis severely narrowing
the neural foramen and effacing the exiting L5 nerve roots
bilaterally. R. 465. The MRI also showed mild-to-moderate
foraminal narrowing at ¶ 4-L5, subtle retrolisthesis of
L3 and L4, and abutment of the L4 nerve roots. Id.
During a follow-up visit on August 29 to obtain the results
of his MRI, PA-C Chantal scheduled Reynolds for a bilateral
L5-S1 nerve root block (“NRB”), R. 466, which
Joyce Huerta, M.D., administered on September 19, R. 474. On
October 16, PA-C Chantal and Reynolds discussed further
treatment options, including medications, more injections,
physical therapy, and surgery. R. 491. Reynolds returned to
his orthopedist's office on December 21, claiming that
the pain in his lower back, which had been on the left side
prior to the NRB, was now greater on the right. R. 495. Jesse
Stem, M.D., who had been ...