United States District Court, W.D. Virginia, Roanoke Division
GLEN E. CONRAD, SENIOR UNITED STATES DISTRICT JUDGE
has filed this action challenging the final decision of the
Commissioner of Social Security denying plaintiffs claims for
disability insurance benefits and supplemental security
income benefits under the Social Security Act, as amended, 42
U.S.C. §§ 416(i) and 423, and 42 U.S.C. § 1381
et seq, respectively. Jurisdiction of this court is
pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. §
1383(c)(3). This court's review is limited to a
determination as to whether there is substantial evidence to
support the Commissioner's conclusion that plaintiff
failed to meet the requirements for entitlement to benefits
under the Act. If such substantial evidence exists, the final
decision of the Commissioner must be affirmed. Laws v.
Celebrezze, 368 F.2d 640 (4th Cir. 1966). Stated
briefly, substantial evidence has been defined as such
relevant evidence, considering the record as a whole, as
might be found adequate to support a conclusion by a
reasonable mind. Richardson v. Perales. 402 U.S.
389, 401 (1971).
plaintiff, Charles Ronald Smith, was born on October 13,
1957, and eventually completed his high school education. Mr.
Smith has been employed as a janitor/cleaner, delivery
driver, material handler, and cemetery laborer. He last
worked on a regular and sustained basis in April of 2011.
(Tr. 47, 115). On July 5, 2013, Mr. Smith filed applications
for disability insurance benefits and supplemental security
income benefits. In filing his current claims, Mr. Smith
alleged that he became disabled for all forms of substantial
gainful employment on April 8, 2011, due to pain in his lower
back and left side. (Tr. 236, 250). Mr. Smith now maintains
that he has remained disabled to the present time. With
respect to his application for disability insurance benefits,
the record reveals that Mr. Smith met the insured status
requirements of the Act at all relevant times covered by the
final decision of the Commissioner. See generally,
42 U.S.C. §§416(i) and 423(a).
Smith's applications were denied upon initial
consideration and reconsideration. He then requested and
received a de novo hearing and review before an
Administrative Law Judge. In an opinion dated February 29,
2016, the Law Judge also determined that Mr. Smith is not
disabled. The Law Judge found that Mr. Smith suffers from
several severe impairments, including degenerative disc
disease in the lumbar spine, hypertension, obesity, and
lumbar strain. (Tr. 22). Nevertheless, the Law Judge
determined that Mr. Smith retains the residual functional
capacity to perform a limited range of medium exertional
activity. More specifically, the Law Judge found that
plaintiff is capable of performing medium work, as defined in
20 C.F.R. §§ 404.1567(c) and 416.927(c), except
that he can only "occasionally push or pull, or climb
ladders, ropes and scaffolds, " but can "frequently
climb ramps and stairs, and frequently stoop, kneel, crouch,
and crawl." (Tr. 24). Given such a residual functional
capacity, and after considering testimony from a vocational
expert, the Law Judge determined that Mr. Smith remains
capable of performing his past relevant work as a
janitor/cleaner. In the alternative, the Law Judge found that
if even if Mr. Smith is disabled for past relevant work, he
retains the capacity to perform other work roles existing in
significant number in the national economy. Accordingly, the
Law Judge concluded that Mr. Smith is not disabled, and that
he is not entitled to benefits under either federal program.
See generally 20 C.F.R. §§ 404.1520(f)-(g)
and 416.920(f)-(g). The Law Judge's opinion was adopted
as the final decision of the Commissioner by the Social
Security Administration's Appeals Council. Having
exhausted all available administrative remedies, Mr. Smith
has now appealed to this court.
plaintiff may be disabled for certain forms of employment,
the crucial factual determination is whether plaintiff is
disabled for all forms of substantial gainful employment.
See 42 U.S.C. §§ 423(d)(2) and 1382c(a).
There are four elements of proof which must be considered in
making such an analysis. These elements are summarized as
follows: (1) objective medical facts and clinical findings;
(2) the opinions and conclusions of treating physicians; (3)
subjective evidence of physical manifestations of
impairments, as described through a claimant's testimony;
and (4) the claimant's education, vocational history,
residual skills, and age. Vitek v. Finch. 438 F.2d
1157, 1159-60 (4th Cir. 1971); Underwood v. Ribicoff
298 F.2d 850, 851 (4th Cir. 1962).
review of the record in this case, the court is constrained
to conclude that the Commissioner's final decision is
supported by substantial evidence. The Law Judge's
opinion reflects a thorough evaluation of Mr. Smith's
medical problems and the extent to which they affect his
ability to work. Although Mr. Smith suffers from several
physical impairments, substantial evidence supports the Law
Judge's determination that he retains the residual
functional capacity to perform a limited range of medium
record reveals that Mr. Smith has received intermittent
treatment for pain in his lower back and extremities. On
February 24, 2010, plaintiff presented to the emergency
department of Carilion Roanoke Memorial Hospital with
complaints of pain in his lower back and left leg. (Tr. 300).
He was discharged home and encouraged to follow up with his
primary care physician. (Tr. 303). A spinal x-ray performed
the following year revealed degenerative disc disease at
¶ 3-L4, L4-L5, and L5-S1, facet arthropathy of the mid
and lower lumbar spine, Grade 1 spondylolisthesis, and
diffuse idiopathic skeletal hyperostosis. (Tr. 328). Mr.
Smith returned to the hospital with complaints of back pain
on October 23, 2012. The attending physician prescribed
Lortab, Valium, and Prednisone, and advised him to follow up
with his primary care physician.
Smith was established as a new patient at Carilion Clinic
Family Medicine -Roanoke/Salem on April 25, 2013, at which
time he denied having any back or joint pain. (Tr. 348). He
was diagnosed with hypertension and obesity, and counseled
about losing weight. (Tr. 349-351). Mr. Smith returned with
elevated blood pressure on February 12, 2014, and once again
denied having any pain. (Tr. 365) ("Pt reports pain is 0
out of 10."). During follow-up evaluations on March 17,
2014, July 7, 2014, August 8, 2014, and September 26, 2014,
Mr. Smith's range of motion was normal, and he was
encouraged to exercise five days a week to aid in losing
weight and controlling his hypertension. (Tr. 371, 385, 401,
Smith returned to Carilion Clinic Family Medicine on November
21, 2014, and was examined by Dr. Andrew Walters. At that
time, plaintiff reported experiencing soreness in his
shoulders, feet, and sides. (Tr. 421). During a follow-up
appointment on January 16, 2015, Mr. Smith continued to
complain of generalized soreness. Dr. Walters noted that
plaintiff was a "poor historian" and that it was
"hard to get a good grasp on why he is applying for
disability and what his [symptoms] actually are." (Tr.
months later, Mr. Smith returned to Dr. Walters with
complaints of pain on his left side. Dr. Walters placed him
on a trial of Flexeril and ordered an x-ray of his left hip
to "rule out worsening of his [left] hip
arthritis." (Tr. 439). The x-ray revealed
"[m]oderate left hip joint degenerative changes with
little if any significant change from [the] last exam"
on February 25, 2010. (Tr.451).
Smith was referred to Carilion Clinic Rheumatology, where he
was examined by Dr. Carl Henderson on June 24, 2015. At that
time, plaintiffs range of motion and peripheral pulses were
normal, and the examination revealed no active synovitis or
deformities other than bilateral knee crepitus. Dr. Henderson
diagnosed plaintiff with osteoarthritis and diffuse
idiopathic skeletal hyperostosis. He recommended that Mr.
Smith take Tylenol and nonsteroidal anti-inflammatory drugs
as needed for discomfort. (Tr. 474).
Smith returned to Carilion Clinic Family Medicine on December
17, 2015, when he was seen by Dr. Benjamin Morgan for
complaints of pain in his left shoulder. (Tr. 482). Dr.
Morgan opined that plaintiff was likely experiencing
"muscle strain" and recommended that he take
Ibuprofen. (Tr. 484). During a follow-up appointment on
January 14, 2016, Mr. Smith continued to complain of soreness
in his left shoulder. Dr. Morgan advised him to take Tylenol
every eight hours as needed for pain. (Tr. 496).
administrative hearing, Mr. Smith testified that he
experiences "constant pain, " primarily in his
shoulders and lower back. (Tr. 48-49, 51). Plaintiff also
claimed that his feet swell and hurt, and that he has to
elevate them two or three times every day for approximately
30 minutes. (Tr. 49-52). Mr. Smith further testified that he
experiences a "pinching pain" in his hands, which
leads to numbness and affects his ability to use them. (Tr.
52-53). When questioned by his attorney regarding his ability
to sit or stand, Mr. Smith testified that he can only sit for
about an hour before needing to stand and move, and that he
can only stand for about 20 or 25 minutes before needing to
walk. (Tr. 55). Plaintiff further testified that he needs to
lie down approximately twice a day for 45 minutes. (Tr. 57).
considering all of the evidence of record, the Law Judge
determined that Mr. Smith retains the residual functional
capacity to perform medium work activity that does not
involve more than occasional pushing, pulling, or climbing
ladders, ropes, or scaffolds. In reaching this decision, the
Law Judge reviewed the existing medical records, noting that
the clinical evaluations discussed above include relatively
benign objective findings. The Law Judge also observed that
Mr. Smith's treating physicians have consistently
recommended conservative treatment measures for his
complaints of pain, and that none of them have placed
restrictions on his ability to work. Accordingly, the Law
Judge determined that plaintiff suffers from certain medical