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Williams v. Berryhill

United States District Court, E.D. Virginia, Norfolk Division

November 15, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Ronald Edward Williams seeks judicial review of the Commissioner of Social Security (''Commissioner")'s denial of his claim for disability insurance benefits ("DIB") and Supplemental Security Income ("SSI"). Specifically, Williams claims that the Administrative Law Judge ("ALJ")'s determination of residual functional capacity ("RFC") failed to account for his need for a walker, and that the ALJ relied on testimony from the vocational expert (" VE") that did not accommodate the same.

         This action was referred to the undersigned United States Magistrate Judge pursuant to provisions of 28 U.S.C. § 636(b)(1)(B) and (C), and Rule 72(b) of the Federal Rules of Civil Procedure.

         For the reasons stated below, this report recommends that the court AFFIRM the final decision of the Commissioner by GRANTING the Commissioner's Motion for Summary Judgment (ECF No. 14) and DENYING Williams' Motion for Summary Judgment (ECF No. 12) .


         On June 28, 2012, Williams filed an application for DIB and SSI. R. at 107-08, 210. He alleged that he was disabled as of February 1, 2009. R. at 210. He alleged his disability was due to sleep apnea, left shoulder injury, diabetes, high blood pressure, and arthritis. R. at 257. The state agency denied his application initially. R. at 147. It did so again upon reconsideration. R. at 158. Williams then requested an administrative hearing from the Social Security Administration. R. at 173-74. An ALJ conducted a hearing on October 14, 2015. R. at 33. Williams was represented by an attorney. R. at 32, 209. At the hearing, Williams amended his claimed disability onset date to June 22, 2012. R. at 44, 243.

         On November 3, 2015, the ALJ denied Williams' claims for DIB and SSI. R. at 26. The ALJ found Williams was not disabled between June 22, 2012, and November 3, 2015. R. at 15, 26. The Appeals Council denied Plaintiff's request for review on November 16, 2016. R. at 1. Williams filed the present action seeking review of the administrative proceedings below on January 18, 2017.


         Williams was born in 1968. See R. at 24. He completed the ninth grade and participated in special education classes. R. at 258. Before stopping work, he was employed as a laborer and a janitor. Id.

         The relevant portions of Williams' medical history are summarized here, as are the portions of the administrative proceedings below that are relevant to his arguments in this court.

         a. History of Medical Treatment and Evaluation.

         Prior to his proposed disability onset date, Williams experienced a number of other impairments, including non-insulin dependent diabetes, hypertension, blurry vision, obesity, degenerative joint disease of the left hip, sleep apnea, and an injury to his left shoulder. R. at 346, 521, 671, 675, 704. After a previous proceeding before one of the Social Security Administration's ALJs on February 12, 2012, Williams was found to have a defined period of disability lasting from February 1, 2009, to March 1, 2010. R. at 15, 83-84. This disability was related to the following impairments: diabetes mellitus, peripheral neuropathy, degenerative joint disease of the left shoulder. R. at 77. He subsequently returned to work. R. at 248. At the 2012 hearing, the ALJ concluded from Williams' return to work that he was no longer disabled at that point, and that Williams' disability benefits be stopped after March 2, 2010. R. at 83.

         In 2011, from March to December, Williams worked as a janitor. R. at 248. From December 2011 to June 2012, he worked as a general laborer. R. at 248. Williams stopped working on June 22, 2012, after reportedly having a heat stroke and being laid off by his employer. R. at 257. The heat stroke he claims led to his termination occurred on June 15, 2012. R. at 468. On June 17, 2012, he sought emergency room treatment for chest pain, pain in his left calf, shortness of breath, left arm numbness, and pain radiating from his left face. Id. The evaluating physicians found his condition "unremarkable" and assigned him to chest pain observation protocols. R. at 466. He was ultimately diagnosed with "acute precordial pain, cardiac unlikely, probably musculoskeletal." R. at 467. He was discharged with a prescription for ibuprofen. R. at 466-67. On February 12, 2013, Williams again sought emergency room treatment for chest pain, and again received an unremarkable evaluation. R. at 444.

         On March 12, 2013, Dr. Chris Bovinet, a consulting physician on behalf of the Agency, examined Williams in connection with his social security disability claim. R. at 368. Williams denied difficulty with personal care and most light housework, though he did claim difficulty with laundry and yardwork. R. at 370. He had no difficulty getting on and off the examination table. R. at 3 71. Regarding Williams' extremities, Dr. Bovinet noted, There is no clubbing, cyanosis or edema. There is no focal atrophy nor contractures noted,

There is bilateral joint line tenderness to palpation to medial and lateral joint spaces anteriorly. There is no instability with varus and valgus stress testing at 0 and 3 0 degrees. Negative anterior and posterior drawer. No. erythema, warmth or effusions noted. There is minimal crepitus noted with active range of motion in the patellofemoral joint space and right greater than left knees.

R. at 372. Additionally, his range of motion was normal in all joints tested. R. at 372. 3755. He had a strong, balanced gait. R. at 372. He had 5 of 5 strength in his lower extremities including hip flexion, hip extension, abduction, knee flexion, and knee extension. R. at 373. Dr. Bovinet also noted Williams exhibited "good dorsiflexion and plantar flexion and great toe extension." Id. His reflexes in his knees and ankles was 2, symmetrical and intact. Id. Williams refused to squat during the examination, saying he could not recover from a squatting position. Id. He also refused to hop, saying he was unable to do so. Id. Dr. Bovinet noted Williams had ''[n]egative straight leg raise bilaterally. No. significant tenderness to palpation in the paravertebral muscles of the cervical or thoracolumbar spine." Id.

         Dr. Bovinet's diagnosis of Williams was that he had

(1) Left upper extremity numbness without any weakness
(2) Obesity
(3) Bilateral knee pain with possible osteoarthritis
(4) Obstructive sleep apnea
(5) Diabetes mellitus
(6) Hypertension which is well controlled


         Dr. Bovinet also assessed Williams' functional capacity. Williams had "some mild limitations" from his left arm numbness and bilateral knee pain. Id. Notwithstanding those limitations, he could still stand six hours out of an eight-hour work day. Id. He could walk for two hours out of an eight-hour work day. Id. He could carry 50 pounds occasionally or 25 pounds frequently. Id. He could lift 100 pounds occasionally or 50 pounds frequently. Id. Dr. Bovinet said Williams "should be able to bend, stoop, crouch, and squat occasionally and limited by his bilateral knee pain [sic] although this is not fully evaluated today as [Williams] refused to do squatting, but otherwise had no limitations during the examination." R. at 374. The doctor concluded by saying, "Claimant does not require nor utilize any assistive device for ambulation whether it be long distances, short distances, or uneven terrain." Id.

         On May 16, 2013, Williams was treated for what he described as "hurting all over." R. at 695. On his musculoskeletal examination, the treating physician described his gait as antalgic and noted he favored his left. R. at 696. His posture was normal. Id. His right hip was painful with all motion, while his left hip was normal. Id. He was tender on the right at the bursa. Id.

         Williams underwent a number of treatments during the spring and summer of 2013 for vision and balance problems. See R. at 646 (floaters in right eye on May 20), 438 (dizziness on May 27), 4 02 (loss of vision in right eye June 20-27) .

         While in the hospital for his vision loss in June 2013, Williams underwent a lumbar puncture[1] to help his doctors evaluate his optic neuritis. See R. at 428. This test resulted in some radicular pain in his lower right leg. See R. at 402. He also underwent an MRI scan, which showed partial lumbarization of the LI vertebral body, mild central canal stenosis at ΒΆ 5-S1, and multilevel degenerative changes. R. at ...

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