United States District Court, W.D. Virginia, Lynchburg Division
REPORT AND RECOMMENDATION
S. Ballou, United States Magistrate Judge.
Verna Boggs (“Boggs”) filed this action
challenging the final decision of the Commissioner of Social
Security (“Commissioner”) determining that she
was not disabled and therefore not eligible for supplemental
security income (“SSI”), and disability insurance
benefits (“DIB”) under the Social Security Act
(“Act”). 42 U.S.C. §§ 401-433,
1381-1383f. Specifically, Boggs alleges that the ALJ erred by
failing to give the opinion of her treating physician proper
weight and failing to properly evaluate her credibility. I
conclude that the ALJ failed to adequately explain the
reasoning for the weights assigned to the physician opinions
in the record. Consequently, I RECOMMEND GRANTING in
part Boggs' Motion for Summary Judgment (Dkt.
No. 12), DENYING the Commissioner's
Motion for Summary Judgment (Dkt. No. 15), and
REVERSING and REMANDING
this matter for further administrative consideration
consistent with this opinion.
court limits its review to a determination of whether
substantial evidence supports the Commissioner's
conclusion that Boggs failed to demonstrate that she 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).
is appropriate if the ALJ's analysis is so deficient that
it “frustrate[s] meaningful review.” Mascio
v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (noting
that “remand is necessary” because the court is
“left to guess [at] how the ALJ arrived at his
conclusions”); see also Monroe v. Colvin, 826
F.3d 176, 189 (4th Cir. 2016) (emphasizing that the ALJ must
“build an accurate and logical bridge from the evidence
to his conclusion” and holding that remand was
appropriate when the ALJ failed to make “specific
findings” about whether the claimant's limitations
would cause him to experience his claimed symptoms during
work and if so, how often) (citation omitted). In
Mascio and Monroe, the court remanded
because the ALJ failed to adequately explain how he arrived
at conclusions regarding the claimant's RFC.
Mascio, 780 F.3d at 636, Monroe, 826 F.3d.
at 189. Similarly, I find that remand is appropriate here
because the ALJ's opinion leaves the court to guess at
how he reached his conclusions regarding the weight given to
Boggs' treating physician.
filed applications for SSI, DIB and disabled widow's
benefits in October 2012, claiming that her disability began
on November 22, 2009. R. 211-26. The Commissioner denied
Boggs' applications at the initial and reconsideration
levels of administrative review. R. 80, 114. ALJ Brian P.
Kilbane held an administrative hearing on May 19, 2015, to
consider Boggs' disability claim. R. 36-51. Boggs was
represented by an attorney at the hearing, which included
testimony from Boggs and vocational expert Arthur Brown.
26, 2015, the ALJ entered his decision analyzing Boggs'
claim under the familiar five-step process,  and denying
Boggs' claim for disability. R. 12-30. The ALJ found that
Boggs suffered from the severe impairments of fracture of the
lower extremity, osteoarthrosis and allied disorders. R. 15.
The ALJ determined that Boggs' severe impairments did not
meet or medically equal a listed impairment, and that she
retained the RFC to perform medium work, except occasional
left lower extremity operation of foot controls and
pushing/pulling; frequent balancing and occasional climbing
of ladders, ropes and scaffolds. R. 16. The ALJ determined
that Boggs is capable of performing her past relevant work as
a cashier and painter, and thus is not disabled. R. 28. Boggs
appealed the ALJ's decision and the Appeals Council
denied her request for review on July 22, 2016. R. 1-4. This
asserts that the ALJ failed to properly evaluate and explain
the weight given to the opinion of her treating orthopedic
surgeon, Robert Adelaar, M.D. Boggs has a history of ankle
injury and arthritis. Specifically, Boggs fractured her left
ankle and underwent four surgeries between December 2009 and
June 2012: an open reduction and internal fixation of
unstable fracture (December 20, 2009, R. 325); ankle hardware
removal (June 30, 2010, R. 334); surgical repair; (Spring
2011, R. 883); and subtalar fusion with proximal tibial bone
grafting (June 26, 2012, R. 379.)
April 2011, after her third ankle surgery, Boggs visited M.
Truitt Cooper, M.D., and complained of pain, weakness and
swelling in her left ankle. R. 312. Boggs reported
occasionally using an ASO brace, and that the pain was worse
with activity and better with rest. Upon exam, Dr. Cooper
noted that Boggs had a slight antalgic gait on the left, her
incisions were well-healed, she had mild swelling, and she
had tenderness and reduced range of motion. Her motor
strength was intact and she had no instability. Dr. Cooper
reviewed x-rays which revealed mild osteopenia, some minimal
degenerative changes and anatomic alignment of the distal
fibula. Dr. Cooper stated, “I had a long talk with
Verna. She has been dealing with this since her surgery. She
has had three surgeries on the ankle and I am not sure that
there is much can be done to resolve her pain fully. I would
recommend compression stocking as needed for swelling as well
as continued exercise as much as possible, taking
anti-inflammatories as needed.” Id. On April
22, 2011, Boggs returned to Dr. Cooper and reported severe
constant pain around her left ankle and tingling at the end
of her toes. R. 313. She also reported that she had not been
wearing any type of boot or participating in exercises. Upon
exam, Boggs had antalgic gait on the left, minimal swelling,
well-healed incision, positive Tinel's over her peroneal
nerve, intact sensation and pedal pulses. Boggs' ankle
range of motion was 5 degrees of dorsiflexion and 35 degrees
of plantar flexion. Dr. Cooper recommended compression
stocking during the day and an ASO brace when active, and
explained the importance of working on physical therapy
exercises. He also injected her ankle joint. Id.
continued to complain of left ankle pain, and an MRI taken on
October 26, 2011, revealed the need for a fusion of her
joint. R. 344-45, 383-84. Boggs initially visited Dr. Adelaar
on November 14, 2011, with a swollen left ankle with no
subtalar motion, tenderness “everywhere” and
diminished sensation over the dorsum of her foot. R. 346-47.
Dr. Adelaar diagnosed left ankle arthritis, possible subtalar
coalition, and performed a subtalar injection. Id.
Boggs returned to Dr. Adelaar in January, March, and May of
2012, with continued complaints of persistent left ankle pain
and swelling. R. 348-49, 358-63. Upon examination, her ankle
was tender with mild to moderate swelling, reduced range of
motion, intact sensations and pulses and no discoloration.
Id. Boggs reported that walking on unlevel ground
tended to exacerbate her foot pain. She was given pain
medication and injections to her subtalar joint. Id.
26, 2012, Dr. Adelaar performed a left subtalar fusion and
tibial bone graft for Boggs' left subtalar arthritis. R.
375-380. On July 9, 2012, Boggs reported that her pain was
well controlled with medication and she had been non-weight
bearing on her left lower extremity post-surgery. R. 364-65.
She was doing well post-operatively. Id.
followed up with Dr. Adelaar in August 2012, and reported
doing well without significant pain. She had mild swelling
and was given a Cam boot to bear weight as tolerated. R.
366-69. In September 2012, Boggs complained of pain in her
ankle joint and heel and reported wearing the Cam boot but
still using crutches. R. 370-71. Upon exam, Boggs had intact
sensation, ability to flex and extend, dorsiflex and plantar
flex. She was prescribed Tramadol and referred to physical
therapy. She was also advised to wear regular shoes and bear
weight as tolerated. Id. Boggs returned in December
2012, and reported that “everything is going well with
physical therapy.” R. 391. She noted achy pain from
swelling if she stands or walks for long periods of time. The
swelling goes down if she elevates her leg and compression
socks help. X-rays showed midfoot osteoarthritis status post
subtalar fusion and some posttraumatic deformity of the
posterior and lateral malleolus. Upon exam, Boggs was able to
flex and extend her toes and had good dorsiflexions and
plantar flexion of the foot with good strength. Dr. Adelaar