United States District Court, W.D. Virginia, Roanoke Division
ANGELA M. YOUNG, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
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, Angela M. Young, was born on March 14, 1969, and
eventually completed her high school education. Ms. Young has
been employed as a cashier, office clerk, assistant
manager/dispatcher, and receptionist. She last worked on a
regular and sustained basis in December of 2010, when her and
her husband's company went out of business. (Tr. 61). On
November 7, 2012, Ms. Young filed applications for disability
insurance benefits and supplemental security income benefits.
In filing her current claims, Ms. Young alleged that she
became disabled for all forms of substantial gainful
employment on June 1, 2012, due to depression, anxiety,
fibromyalgia, diverticulosis, and fatigue. (Tr. 331, 365).
Ms. Young now maintains that she has remained disabled to the
present time. With respect to her application for disability
insurance benefits, the record reveals that Ms. Young met the
insured status requirements of the Act through the fourth
quarter of 2015, but not thereafter. See generally,
42 U.S.C. §§ 416(i) and 423(a). Consequently,
plaintiff is entitled to a period of disability and
disability insurance benefits only if she has established
that she became disabled for all forms of substantial gainful
employment on or before December 31, 2015.
Young's applications were denied upon initial
consideration and reconsideration. She then requested and
received a de novo hearing and review before an
Administrative Law Judge. In an opinion dated May 4, 2016,
the Law Judge also determined, after applying the five-step
sequential evaluation process, that Ms. Young is not
disabled. See 20 C.F.R. §§ 404.1520 and
416.920. The Law Judge found that Ms. Young suffers
from several severe impairments, including major depressive
disorder with melancholic features, anxiety disorder, alcohol
dependence, dysthymic disorder, fibromyalgia, thoracolumbar
strain, and lumbago, but that none of the conditions satisfy
the requirements of a listed impairment. (Tr. 22.) The Law
Judge then assessed Ms. Young's residual functional
capacity as follows:
After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform light exertion work with
lifting and carrying 20 pounds occasionally and 10 pounds
frequently, standing and walking six hours of an eight-hour
workday and sitting six hours of an eight-hour workday. She
can never climb ladders, ropes, and scaffolds or crawl and
can occasionally climb ramps and stairs, kneel, crouch, and
stoop/bend. The claimant is [to] avoid more than occasional
exposure to vibration and all exposure to hazards. She can
only perform simple, easy to learn, job instructions
consistent with unskilled work, with no more than occasional
interaction with the public and coworkers.
(Tr. 26). Given such a residual functional capacity, and
after considering testimony from a vocational expert, the Law
Judge determined that Ms. Young is unable to perform any of
her past relevant work. (Tr. 30). However, the Law Judge
found that Ms. Young retains sufficient functional capacity
to perform other work roles existing in significant number in
the national economy. (Tr. 30-31). Accordingly, the Law Judge
concluded that Ms. Young is not disabled, and that she is not
entitled to benefits under either federal program. See
generally 20 C.F.R. §§ 404.1520(g) and
416.920(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, Ms. Young 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 Ms. Young's
medical problems and the extent to which they affect her
ability to work. Although Ms. Young suffers from a
combination of physical and emotional impairments,
substantial evidence supports the Law Judge's
determination that she retains the residual functional
capacity to perform a limited range of light work.
first to the plaintiffs physical impairments, the record
reveals that Ms. Young has a history of musculoskeletal
complaints. In September of 2012, her primary care physician,
Dr. Bonnie Culkin, prescribed Tramadol for back pain. (Tr.
439). Ms. Young continued to complain of muscle pain in May
of 2013. (Tr. 545). Dr. Culkin diagnosed Ms. Young with
unspecified myalgia and myositis for which she again
prescribed Tramadol. (Tr. 547). During a subsequent
"well woman exam" on October 28, 2013, Ms. Young
continued to complain of back pain but exhibited normal range
of motion in her head and neck, as well as in her upper and
lower extremities. (Tr. 539-40). Her muscle strength, gait,
coordination, and deep tendon reflexes were also normal. (Tr.
540). On June 26, 2014, Ms. Young presented with back pain
and exhibited tenderness along the lumbar spine. (Tr.
584-85). However, her straight leg raise test was normal, her
deep tendon reflexes were intact, and she exhibited normal
motor strength. (Tr. 585). Dr. Culkin added a diagnosis of
lumbago and prescribed Soma as needed for muscle spasms. (Tr.
586). That same month, Ms. Young presented to an urgent care
facility with complaints of back pain. (Tr. 596). Ms. Young
reported that she had injured her lower back while lifting
one of her grandchildren. Although Ms. Young appeared to be
"uncomfortable, " her physical examination revealed
"no spinal tenderness, " normal motor strength, and
"normoactive" reflexes. (Tr. 598). The examining
physician diagnosed her with lumbrosacral radiculitis and
prescribed Norco as needed for pain. (Tr. 598).
administrative hearing held on January 14, 2016, Ms. Young
testified that she experiences radiating pain in her legs and
sides. (Tr. 79-80). She estimated that she can sit for
approximately thirty to forty-five minutes before needing to
stand and move, and that she can only stand for approximately
five to ten minutes before "everything hurts" and
she becomes "lightheaded." (Tr. 88-89). Plaintiff
further testified that she takes a nap once a day, and that
the naps last between two and three hours. (Tr. 89). Although
plaintiff acknowledged that she occasionally watches her
three young grandchildren for several hours at a time, she
testified that she usually naps as soon as they leave and
that "everything hurts" for several days
thereafter. (Tr. 86, 87, 90).
considering all of the evidence of record, the Law Judge
determined that Ms. Young's physical impairments are not
so severe as to prevent performance of lighter forms of work
activity. In making this determination, the Law Judge found
that Ms. Young's allegations of disabling physical
limitations are not entirely credible. The Law Judge noted
that the plaintiffs treatment records do not support her
allegations regarding the need for daily naps, and that the
clinical evaluations discussed above include relatively
benign objective findings. The Law Judge emphasized that
while the medical records reflect consistent complaints of
pain, particularly in the plaintiffs back, the findings on
examination were generally limited to tenderness and did not
reveal signs of more severe abnormalities or defects, such as
reduced range of motion, sensory or motor deficits, or
positive straight leg raise. (Tr. 28). Accordingly, the Law
Judge concluded that while plaintiff has work-related
limitations resulting from her musculoskeletal impairments,
the clinical findings and other evidence in the record do not
fully support the plaintiffs statements concerning the
intensity and persistence of the symptoms she claims to
Judge also declined to accept Dr. Culkin's opinion
regarding plaintiffs ability to work. In July of 2015, Dr.
Culkin completed a medical source statement of the plaintiffs
physical ability to perform work-related activities that is
inconsistent with the Law Judge's assessment of plaintiff
s physical residual functional capacity. In particular, Dr.
Culkin opined that Ms. Young can occasionally lift no more
than ten pounds, stand and/or walk for less than two hours in
an eight-hour workday, and engage in only limited reaching,
pushing, and pulling. (Tr. 590-91).
review of the record, the court believes that the Law Judge
reasonably afforded little weight to Dr. Culkin's
assessment. While the Law Judge recognized Dr. Culkin as a
"long time treating source, " he noted that Dr.
Culkin is not a specialist in the areas of the plaintiffs
impairments, and that she did not identify any objective
studies or findings that would support her opinions regarding
the plaintiffs functional limitations. (Tr. 29). The Law
Judge also emphasized that Dr. Culkin's opinions were
inconsistent with those offered by two state agency
physicians, as well as the opinion of Dr. William Humphries,
who performed a consultative physical evaluation on July 19,
2013. Based on his own clinical findings, which were
essentially normal, Dr. Humphries opined that plaintiff can
stand and walk up to six hours in an eight-hour day, and lift
up to fifty pounds occasionally and twenty pounds
frequently. (Tr. 534). Both of the state agency
physicians concurred with Dr. Humphries' assessment,
emphasizing that Ms. Young's medical records simply do
not include objective documentation of serious
musculoskeletal problems. (Tr. 115, 116, 143, 144).
reviewed the record in its entirety, which is notably devoid
of significant physical findings and clinical signs, the
court concludes that substantial evidence supports the Law
Judge's decision to not give controlling weight to Dr.
Culkin's opinion. Although the opinions of a treating
source are generally. entitled to greater weight under the
administrative regulations applicable to plaintiffs claims,
see 20 C.F.R. §§ 404.1527(c)(2) and 416.927(c)(2),
the court believes that, in the instant case, the Law Judge
properly determined to give greater weight to other medical
evidence, including the reports from Dr. Humphries and the
state agency physicians. All three physicians observed that
the medical record simply does not include objective
documentation of serious musculoskeletal problems, and that
there is no indication that the plaintiffs fibromyalgia could
be expected to render her disabled for all work-related
activity. In short, ...