United States District Court, S.D. Indiana, Indianapolis Division
TERRY P. WILLIAMS, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
MARK J. DINSMORE, District Judge.
Plaintiff Terry Williams ("Williams") requests judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner") denying his application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("the Act"). See 42 U.S.C. §§ 416(i), 1382c(a)(3). For the reasons set forth below, the Magistrate Judge recommends that the Court REVERSE the decision of the Commissioner and REMAND the matter for further proceedings.
I. Procedural History
Williams filed an application for SSI on May 19, 2011, alleging an onset of disability as of August 9, 1997. Williams' application was denied initially on July 12, 2011 and denied on reconsideration on August 10, 2011. Williams timely requested a hearing, which was held over video before Administrative Law Judge Angela Miranda ("ALJ") on May 10, 2012. The ALJ issued a decision on May 24, 2012 which again denied Williams' application for SSI. The Appeals Council denied Williams' request for review on August 2, 2013, making the ALJ's decision the final decision for purposes of judicial review. Williams timely filed his Complaint with this Court on October 7, 2013.
II. Factual Background and Medical History
Williams, now forty-seven years old, reported in his application that he has a pinched nerve in his neck, a frozen shoulder, and a bullet in his right leg. [R. at 177.] Williams reported taking a myriad of prescriptions and over-the-counter medications to treat his severe pain. [R. at 180, 184.] In subsequent reports submitted in 2011, Williams complained of increased neck and back pain, depression, and reported taking medication to treat muscle spasms. [R. at 188, 190, 197, 199.] Williams also reported that he could not raise things over his head. [R. at 191.]
In 2007, Williams was diagnosed with a frozen shoulder and degenerative joint disease of the neck by Dr. Kevin Gebke. [R. at 280.] From May 2010 until the hearing in May 2012, Williams visited an array of medical practitioners for treatment of his neck and back pain. In May 2010, Williams underwent an MRI of his cervical spine. [R. at 208.] Dr. Zachary Dodd reviewed the MRI and noted that Williams' neck and back pain was precipitated by a motor vehicle accident that occurred in 1997. [R. at 208.] Dr. Dodd assessed Williams with a mild degenerative disc disease in part of the spine with some bulging into the nerve passageways. [ Id. ] Dr. Dodd suggested that Williams' chronic pain precluded surgery as a viable treatment option and instead recommended a selective nerve root block injection. [ Id. ]
In February 2011, Williams began visiting Dr. Ira Means for treatment who diagnosed him with neck pain and a frozen right shoulder. [R. at 249.] In April 2011, Dr. Means additionally diagnosed Williams with hypertension and advised that he visit an orthopedic specialist. [R. at 247.] An x-ray performed in May 2011 revealed a healing deformity of the right humerus, unchanged from an x-ray taken in August 2007. [R. at 209.] An MRI of Williams' cervical spine performed in June 2011 revealed multilevel degenerative joint and disc disease. [R. at 220.] The examiner also noted that part of the cervical spine had an improved appearance. [ Id. ]
On June 25, 2011, consultative examiner Dr. Nauman Salim conducted an evaluation of Williams at the request of the Disability Determination Bureau ("state agency"). [R. at 225-27.] Dr. Salim determined that Williams' range of motion in his right shoulder and neck was significantly limited but noted that "he should be able to feel better after medications and physical therapy." [R. at 227.] Dr. Salim noted that Williams has a normal gait and posture and opined that his disability is "mild." [ Id. ] Dr. Salim also determined that Williams should not lift more than five to ten pounds with his right arm and thirty to forty pounds with his left arm. [ Id. ]
On July 10, 2011, state agency reviewing physician Dr. Jonathon Sands completed a physical residual functioning assessment. Citing Williams' history of right shoulder injury and limited range of motion, Dr. Sands opined that Williams should be restricted from performing any overhead reaching with his right arm. [R. at 230, 232.] Additionally, Dr. Sands suggested that Williams was limited in pushing and pulling with his upper extremities; could occasionally lift or carry up to fifty pounds; frequently lift up to twenty-five pounds; and stand, walk, and sit for a total of about six hours in a workday. [R. at 230.] Dr. Sands suggested no other limitations and indicated that he had reviewed medical source statements and that his assessment was consistent with the objective medical evidence. [R. at 230, 234-35.] Dr. M. Brill affirmed Dr. Sands' assessment in August 2011. [R. at 256.]
Also in July 2011, Williams returned to Dr. Means for a follow up appointment for his neck pain. [R. at 240.] Dr. Means noted that Williams had limited range of motion in his right shoulder and a tender back. [R. at 241.] An MRI exam of Williams' lumbar spine in September 2011 revealed a disc protrusion resulting in moderate narrowing of the spinal canal. [R. at 260.]
In November 2011, Williams was evaluated by an orthopedic specialist. Dr. Bryan McFarland indicated that Williams' motion was "quite stiff, " and, upon examination, concluded that Williams had right arm pain beginning in his cervical spine and right shoulder pain resulting from a humerus fracture healing in a slight varus deformity. [ Id. ]
In December 2011, Williams received a cervical steroid injection and an x-ray of his right shoulder. [R. at 263-65.] The x-ray revealed a stable appearance of the right humeral deformity, stable heterotopic bone growth, and calcified right lung granuloma unchanged from an exam in May 2011. [R. at 265.] Also in December 2011, Williams was evaluated by orthopedic specialist Dr. Ripley Worman. Dr. Worman noted that Williams had "restricted motion" in his right shoulder, limited to about fifty-five degrees of forward flexion abduction. [ Id. ] While Williams was able to move his arm "just beyond the small of his back, " Dr. Worman noted that he had "good external rotation of his shoulder" and diagnosed him with a varus deformity. [ Id. ] A CT exam conducted in January 2012 again confirmed the right shoulder deformity and degenerative joint disease. [R. at 267.]
In March 2012, Williams visited Dr. Mara Jeffrey with complaints of shoulder and neck pain. Dr. Jeffrey noted that Williams had tenderness throughout his right trapezius and shoulder and subjective decreased sensation throughout his right arm. [R. at 274.] Dr. Jeffrey prescribed pain medication and encouraged Williams to ...