United States District Court, N.D. Indiana, Fort Wayne Division
OPINION AND ORDER
ANDREW P. RODOVICH, Magistrate Judge.
This matter is before the court on petition for judicial review of the decision of the Commissioner filed by the plaintiff, Alan Joe Royal, on May 2, 2014. For the following reasons, the decision of the Commissioner is REMANDED.
The plaintiff, Alan Joe Royal, filed an application for Disability Insurance Benefits on March 2, 2011 and Supplemental Security Income on March 8, 2011, alleging a disability onset date of December 9, 2010. (Tr. 162, 169). The Disability Determination Bureau denied Royal's application on April 28, 2011, and again upon reconsideration on July 26, 2011. (Tr. 104, 115). Royal subsequently filed a timely request for a hearing on October 14, 2011. (Tr. 21). A hearing was held on September 17, 2012, before Administrative Law Judge (ALJ) William D. Pierson, and the ALJ issued an unfavorable decision on November 1, 2012. (Tr. 21, 33). Vocational Expert (VE) Joseph Thompson and Jessica Royal, Royal's wife, testified at the hearing. (Tr. 21). The Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner. (Tr. 13-15).
At step one of the five step sequential analysis for determining whether an individual is disabled, the ALJ found that Royal had not engaged in substantial gainful activity since December 9, 2010, his alleged onset date. (Tr. 23). At step two, the ALJ determined that Royal had the following severe impairments: minimal spur/disc complex at C2-3, lumbar degenerative disc disease, and mild right carpal tunnel syndrome. (Tr. 24). Also at step two, the ALJ stated that Royal had a more recent diagnosis of fibromyalgia. (Tr. 24). At step three, the ALJ concluded that Royal did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. (Tr. 25).
The ALJ then assessed Royal's residual functional capacity as follows:
[T]he claimant is limited to lifting, carrying, pushing and pulling 10 pounds frequently and occasionally throughout the workday. He is able to stand and/or walk for a total of 2 hours and sit for a total of 6 hours in an eight-hour period. He can frequently handle and finger with his dominant hand and upper extremity and can constantly handle and finger with his non-dominant hand and upper extremity. He must alternate between sitting and standing every 45 minutes while remaining on task.
(Tr. 25). The ALJ explained that in considering Royal's symptoms he followed a two-step process. (Tr. 25). First, he determined whether there was an underlying medically determinable physical or mental impairment that was shown by a medically acceptable clinical or laboratory diagnostic technique that reasonably could be expected to produce Royal's pain or other symptoms. (Tr. 25). Then, he evaluated the intensity, persistence, and limiting effects of the symptoms to determine the extent to which they limited Royal's functioning. (Tr. 26).
In August 2009, Royal underwent a L5-S1 discectomy with left S1 nerve root decompression. (Tr. 26). The surgeon, Dr. Hoffman, stated that Royal was able to resume normal activities within four weeks. (Tr. 26). The ALJ found it appeared that Royal returned to substantial gainful work activity in 2010, but Royal alleged disability beginning December 9, 2010. (Tr. 26).
The ALJ concluded that the record supported the finding that Royal had severe back and neck problems and right carpal tunnel syndrome. (Tr. 26). A late 2010 MRI of his lumbar spine revealed a recurrent disc extrusion at L5-S1 that abutted the left S1 nerve root, a stable disc protrusion at L4-5 that mildly deformed the thecal margin, and degenerative disc disease at L4-5 and L5-S1. (Tr. 26). Additionally, a late 2010 MRI of his cervical spine discovered that Royal had a disc/spur complex at C2-3. (Tr. 26). In June 2012, an electrodiagnostic study indicated a chronic bilateral L5 and S1 radiculopathy, and a September 2012 electrodiagnostic study found that Royal had right-sided carpal tunnel syndrome. (Tr. 26). The ALJ also found that Royal suffered from obesity and had a body mass index of 32.6. (Tr. 26).
For treatment, Royal received chiropractic treatment, physical therapy, hot baths, icing his neck, caudal, and epidural steroid injections. (Tr. 26). Additionally, he took the following medications: Cyclobenzaprine, Cymbalta, Chlorzoxazone, Gabapentin, Vicodin, Meloxicam, Naproxen, Tramadol, Morphine, Ibuprofen, and Oxycodone-Acetaminophen. (Tr. 26). Royal alleged that cold and activity worsened his pain but that lying down helped. (Tr. 26). Furthermore, he claimed he spent four days per month solely alternating between lying in bed and taking hot baths. (Tr. 26). The ALJ concluded that Royal sought the above treatment but that the record did not support such limiting symptoms that required Royal to lie in bed and take hot baths four days per month. (Tr. 26).
Royal alleged a constant grinding pain in his middle and lower back and that he had difficulty standing and walking due to weakness, fatigue, numbness, burning pain, and leg spasms. (Tr. 26). Additionally, he claimed he used a cane, had difficulty bending and sleeping, was limited to sitting for thirty minutes and standing for twenty-five minutes, and could not pick up a gallon of milk. (Tr. 26). His wife alleged that Royal could not do anything and that he constantly adjusted his position. (Tr. 26).
The ALJ concluded that the objective medical evidence did not support the degree of limitations alleged by Royal and his wife. (Tr. 26). The record demonstrated that Royal received a second lumbar spine surgery in February 2011, but that Dr. Shugart's medical records indicated that Royal said his back and legs were not too bad. (Tr. 26-27). Additionally, Royal's main complaint involved his neck and arms, although he reported some leg numbness. (Tr. 27). He exhibited a 5/5 in strength and intact reflexes and exhibited a non-antalgic gait, negative heeltoe walking, and negative straight-leg-raising. (Tr. 27). Furthermore, Dr. Shugart gave Royal no restrictions. (Tr. 27). The ALJ found the above facts and objective medical evidence inconsistent with Royal's claim of disabling function limitations due to lumbar degenerative disc disease. (Tr. 27).
The ALJ also found that Royal did not aggressively and frequently seek or receive ongoing treatment for low back and leg symptoms in 2011, which the ALJ found supported his credibility finding. (Tr. 27). The ALJ noted that Dr. T. Miller's medical records from June and August 2012 did not demonstrate any abnormal findings for Royal's lumbar spine, that March 2011 arthritis panels were negative, and May 2012 ANA, RA, and SED rate screenings reflected no significant abnormalities for Royal's back and lower extremities. (Tr. 27).
In June 2012, Royal reported that Cymbalta helped his symptoms and that the burning sensations in his legs had resolved. (Tr. 27). Additionally, the objective medical evidence indicated that Royal could transition from seated to standing positions and could get on and off exam tables independently and without difficulty. (Tr. 27). Royal exhibited positive reflexes and full lower extremity strength at 5/5, despite an absent left ankle reflex. (Tr. 27). The ALJ also noted that a May 2012 examination revealed negative straight leg raises, 5/5 strength, a nonantalgic gait, and a normal heel and toe walk. (Tr. 27). The ALJ concluded that the above objective medical findings did not support Royal's claim that a more restrictive RFC was necessary due to back and lower extremity weakness. (Tr. 27).
The ALJ found Royal incredible because he reported to Dr. Shugart that his back and legs "are not too bad" on May 25, 2011, but then he told Nurse V. Bradley in May 2012 that the second surgery did not improve his pain. (Tr. 27). In June 2012, Royal reported back and leg pain at only "1-2/10" and he exhibited 100% of general active and passive ranges of motion in his spine, arms, and legs and 75% of lumbar active flexion. (Tr. 27). He also exhibited strength of 4/5 and 5/5 for his leg and buttock muscles. (Tr. 27). Although he had a decreased left S1 achilles reflex, Royal demonstrated a normal gait and balance. (Tr. 27). However, Royal had a slight tenderness over the lumbar paraspinals and physical therapy was recommended. (Tr. 27). The ALJ determined that the above medical evidence supported his RFC assessment. (Tr. 27).
The ALJ stated that Royal used a cane despite no treating physician prescribing one. (Tr. 28). Furthermore, the ALJ found the record unclear whether a cane, even if prescribed, would be needed for balance or walking on difficult terrain. (Tr. 28). The ALJ concluded that Royal appeared comfortable at the hearing, remaining seated did not appear to strain him, and he could move his hands to speak without needing them for support. (Tr. 28). Royal alleged his legs were burning and shaking, but the ALJ did not notice much change in Royal's demeanor or stance. (Tr. 28).
Royal alleged severe neck pain that made it difficult to hold his head up or even lift a remote. (Tr. 28). He also stated he could not turn his neck at times, his arms and hands became stiff and tired, he experienced numbness in his hands and arms, and he had difficulty holding his arms on a steering wheel. (Tr. 28). Dr. Miller's notes indicated complaints of paresthesia in Royal's upper extremities in May 2011, and magnetic resonance imaging revealed some degenerative disc disease. (Tr. 28). ...