United States District Court, S.D. Indiana, Terre Haute Division
KATHLEEN A. CLUESMAN, Plaintiff,
NANCY A. BERRYHILL Acting Commissioner of the Social Security Administration,  Defendant.
ENTRY ON JUDICIAL REVIEW
Kathleen Cluesman requests judicial review of the final
decision of Defendant Nancy A. Berryhill, Acting Commissioner
of the Social Security Administration (the
“Commissioner”), who denied her application for
Disability Insurance Benefits (“DIB”) under Title
II of the Social Security Act, 42 U.S.C. § 423(d).
applied for DIB on April 10, 2013. R. at 16. She first
alleged disability beginning on October 9, 2011, but later
amended the onset date to July 9, 2013. Id. On May
5, 2015, Cluesman, with counsel, presented for a hearing in
front of an Administrative Law Judge (“ALJ”), in
which she testified about her alleged disability. R.at 32-71.
The ALJ denied Cluesman's claim, finding that she was not
disabled at any point from the alleged onset date through the
date of the ALJ's June 1, 2015 decision. R. at 16, 26.
The Appeals Council denied Cluesman's request for review
of the ALJ's decision, which renders it the
Commissioner's final administrative decision for purposes
of judicial review. 20 C.F.R. § 404.981.
RELEVANT MEDICAL EVIDENCE
March 27, 2013, Cluesman saw Dr. Chua, her primary care
doctor, for the first time. R. at 250. Cluesman complained of
headaches and arthritis in both ankles. Id. She also
complained of pain in both hands and feet, as well as carpal
tunnel syndrome in her right hand. Id. She reported
that she was falling asleep while driving. Id. Upon
exam, Cluesman had tenderness in her hands, feet, knees, and
ankles with a positive Phelan's test (a test for carpal
tunnel syndrome) and Tinel's sign (a test for irritated
nerves) on the right, but an otherwise normal neurological
exam. R. at 251. Dr. Chua diagnosed Cluesman with
uncontrolled diabetes, benign hypertension, and ankle and
knee pain. R. at 252. He ordered a blood test. R. at 252-59.
2013, consulting physician Dr. Robert Burkle examined
Cluesman. R. at 268-71. An EKG from that day suggested
impaired left ventricle relaxation, but Cluesman's
ventricle systolic function was normal. R. at 264-65. Upon
exam, Cluesman's ankles were very tender to the touch,
and she had reduced range of motion in several joints and
some reduced strength in her hands, shoulder, hips, ankles,
and knees. R. at 268-70. She also complained that she was
unsteady and her feet hurt when she bent forward eighty
degrees. R. at 270. But she could make a full fist, pick up
small objects without difficulty, had normal reflexes, walked
with a normal gait and no assistive device, walked on her
tiptoes and heels, and stood on one leg. R. at 270-71. She
also had a negative straight-leg-raise test. R. at 271.
2013, state agency reviewing physician Dr. Corcoran opined
that Cluesman could perform sedentary work; never climb
ladders, ropes, or scaffolds; and occasionally perform all
other postural movements. R. at 74-76. The following month,
Dr. Sands reviewed the medical evidence and affirmed the
opinion as written. R. at 87.
12, 2013, Cluesman saw Dr. Chua with complaints of feet,
hand, ankle, and knee pain, and she reported that she was
dropping things with her right hand. R. at 277. She had not
gone to the emergency room or seen any other doctors.
Id. Upon exam, Cluesman had tenderness in her hands,
knees, ankles, and one part of her foot with positive
Tinel's sign and Phalen's tests, but an otherwise
normal exam. R. at 278.
8, 2013, Dr. Chua completed a questionnaire, in which he
opined that Cluesman could continuously lift or carry up to
ten pounds but never lift or carry any more than this weight;
could stand or walk for twenty minutes at a time for a total
of one hour each; could sit for eight hours at one time
without interruption but for six hours total in an eight hour
work day; required a cane to walk; could walk forty feet
without a cane; could never reach overhead or finger; could
occasionally reach otherwise, handle, feel, or push/pull;
could never use foot controls; could never perform any
postural movements; could never work around most
environmental conditions; and could not walk one block at a
reasonable pace on uneven surfaces, travel without a
companion, or sort, handle or use paper files. R. at 303-08.
later, on July 9, 2013, Cluesman saw Dr. Chua with complaints
of pain and burning in both hands, difficulty closing her
hands at times, and pain in her knees, ankles, and feet. R.
at 274. She reported that she was using a cane and always
traveled with her husband, due to a reportedly unsteady gait.
Id. Dr. Chua observed Cluesman had tenderness in her
lower back, hands, knees, and ankles, with limited range of
motion in her ankles. R. at 275. Dr. Chua diagnosed Cluesman
with diabetes with neurology manifestation, benign
hypertension, arthritis of the hand, and ankle, knee, and
foot pain. R. at 276. He ordered multiple x-rays and
prescribed Gabapentin (commonly prescribed for neuropathic
pain) and Celebrex (a non-steroid anti-inflammatory). R. at
August 2013, Cluesman saw Dr. Chua and she was wearing a
brace. R. at 348. Upon exam, she had tenderness and spasms in
her lower back and tenderness in her ankles and feet. R. at
349. Dr. Chua prescribed Tizanidine (a muscle relaxant) in
place of Flexeril. R. at 350.
months later, in November 2013, Cluesman reported that the
Tizanidine helped with the pain. R. at 345. She reported
still having back pain and wondered if a back brace would
help. Id. Upon exam, Cluesman had tenderness in her
lower back and ankles. R. at 346. Dr. Chua prescribed a back
brace. R. at 297-98.
months later, in March 2014, Cluesman reported that she had
arthritis achiness in both feet. R. at 302, 342. She also
complained of lower back pain, right knee pain, and burning
in both hands. R. at 342. Upon exam, she had tenderness in
her lower back, knees, ankles, and feet. R. at 343.
following month, in April 2014, Dr. Chua completed an
Arthritis Medical Source Statement, in which he gave Cluesman
a fair prognosis and identified the following symptoms: knee,
ankle, foot, and hand pain; an ability to sit for about
fifteen minutes before needing to stand or move; an ability
to stand ten minutes at a time; and lower back pain. R. at
210. Dr. Chua characterized Cluesman's pain as severe and
sharp. Id. For objective signs, Dr. Chua noted that
Cluesman had reduced range of motion in her ankles,
tenderness at various points, and reduced grip strength in
her hands. Id. He opined that Cluesman could walk
one block without rest or pain; could sit for fifteen minutes
at a time and stand for ten minutes at a time; with no
indication as to how many hours total in a day Cluesman could
sit or stand; required several unscheduled breaks for fifteen
minutes at a time; needed to elevate her legs, with no
indication as to how high; required a cane, could rarely