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Bobbie W. v. Berryhill

United States District Court, S.D. Indiana, Terre Haute Division

August 21, 2018

BOBBIE W., Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner for Operations, Social Security Administration, Defendant.



         Plaintiff Bobbie W.[1] requests judicial review of the denial by the Commissioner of the Social Security Administration (“Commissioner”) of her application for Social Security Disability Insurance (“DIB”) under Title II of the Social Security Act (“the Act”). See 42 U.S.C. §§ 423(d), 405(g). For the reasons set forth below, this Court hereby REVERSES the ALJ's decision denying the Plaintiff benefits and REMANDS this matter for further consideration.

         I. Background

         A. Procedural History

         On February 27, 2014, Bobbie W. filed for disability insurance benefits under Title II of the Act, alleging her disability began on October 15, 2013. The claims were denied initially and upon reconsideration. The Plaintiff then filed a written request for a hearing on August 11, 2014, which was granted.

         On April 28, 2016, Administrative Law Judge William Sampson conducted the hearing, where Bobbie and a vocational expert testified. On August 12, 2016, the ALJ issued an unfavorable decision finding that the Plaintiff was not disabled as defined in the Act. The Appeals Council denied Bobbie's request for review of this decision on July 26, 2017, making the ALJ's decision final. The Plaintiff now seeks judicial review of the Commissioner's decision. See 42 U.S.C. § 1383(c)(3).

         B. Factual Background

         Bobbie was born on June 13, 1963, and was 50 years old at the time of the alleged onset date in 2013. [Dkt. 10-5 at 2 (R. 203).] She completed four or more years of college [Dkt. 10-6 at 7 (R. 225).]. The Plaintiff last engaged in substantial gainful activity in 2014 when she worked as a Safety Facilitator at Zachary Industrial [Dkt. 10-5 at 13 (R. 214).] She has past relevant work history as a job coordinator and distribution clerk. [Dkt. 10-6 at 7 (R. 225).]

         C. Medical History

         On June 13, 2012, Bobbie presented to the Veterans Administration Hospital in Indianapolis for various imaging studies due to widespread joint pain. [Dkt. 10-8 at 34-39 (R. 434-440).] An x-ray of the lumbar spine revealed degenerative disc and facet disease, while an x-ray of the right hand revealed degenerative joint disease. [Id.].

         Bobbie returned to the Indianapolis Veterans Administration Hospital (“VA”)on July 25, 2013 for a follow-up on her psoriatic arthritis[2]. [Dkt. 10-8 at 16 (R. 417).] It was noted that her back pain had been treated for several years with steroid injections to the sacroiliac joint. [Id.] She was diagnosed with psoriatic arthritis, sacroiliac joint disorder[3], fibromyalgia[4], and peripheral neuropathy[5]. [Id. at 418]. It was suggested that Bobbie continue with steroid joint injections due to her previous positive responses. [Id.].

         On October 19, 2013, Bobbie returned to her rheumatologist, Dr. Labib Ayoub, for bilateral sacroiliac joint injections. [Dkt. 10-7 at 95-6 (R. 393-94).] Her sacroiliac joint disorder was appreciated to be mechanical, because her imaging studies did not show sacroiliitis[6]. [Id.]

         Bobbie presented to Dr. Ami Rice on April 2, 2014 for a physical consultative exam at the request of the Disability Determination Bureau. [Dkt. 10-8 at 56-60 (R. 357-361).] She reported hip and back pain, for which she had been receiving steroid injections every six months, knee pain, and numbness in her feet with a pins and needles sensation. [Id.] It was noted that Bobbie had tried physical therapy and water therapy, with good result, but had resorted to using a cane for stability. [Id.] Bobbie reported that she could sit for 30-45 minutes, stand for 3-4 minutes at a time, lift up to 10 pounds, and drive a car for up to 45 minutes. [Id.]

         During the examination with Dr. Rice, Bobbie's gait was slow and antalgic while using a cane. [Id.] She had psoriatic plaques across her body, could not oppose the thumb to the fourth and fifth digits on her right hand, and had limited range of motion in her shoulder and left hip. [Id.] Dr. Rice diagnosed Bobbie with psoriatic arthritis, fibromyalgia, neuropathy, gastroesophageal reflux disease, obesity, and a sinus infection. [Id.]

         On April 10, 2014, Bobbie returned to the Indianapolis VA for follow-ups with dermatology and rheumatology. [Dkt. 10-9 at 40-45 (R. 554-59).] Dermatologist Jennifer Croix noted larger, well demarcated psoriasis plaques throughout Bobbie's body, for which phototherapy and continued medication were recommended. [Id.] Dr. Ayoub with rheumatology noted a positive Faber test[7], along with hand and ankle swelling. [Id.] Bobbie was diagnosed with psoriasis with a worsening skin rash, psoriatic arthritis, sacroiliac joint disorder, and fibromyalgia. [Id.] She received bilateral sacroiliac joint steroid injections. [Id.]

         Bobbie presented to psychologist Richard Casserly, Psy.D, HSPP, LCAC on June 3, 2014 for a psychological consultative examination at the request of the Disability Determination Bureau. [Dkt. 10-9 at 3-6 (R. 517-20).] She reported that because she could no longer work due to pain, she had experienced a great deal of anxiety and stress. [Id.] Dr. Casserly diagnosed Bobbie with adjustment disorder with anxiety and panic-like symptoms, “which may develop at some time to a more serious anxiety disorder.” [Id.]

         On July 10, 2014, Bobbie returned to Dr. Ayoub with the rheumatology department at the Indianapolis VA. [Dkt. 10-10 at 43-48 (R. 615-20).] The exam showed decreased sensation over the left thumb, a positive Phalen's test[8] on the left side, and bony enlargement of multiple fingers and wrist joints. [Id.] She was diagnosed with psoriasis with a worsening skin rash, psoriatic arthritis, sacroiliac joint disorder, fibromyalgia, and likely bilateral carpal tunnel syndrome. [Id.] She was advised to continue receiving sacroiliac joint steroid injections every six months and referred to occupational therapy for wrist splints. [Id.]

         Bobbie reported to Melissa Sloop for an occupational therapy consult on July 28, 2014, where she reported numbness, occasional tingling, and dropping items with both of her hands, along with a history of bilateral hand arthritis. [Dkt. 10-10 19-21 (R. 591-93).] Sloop provided education on carpal tunnel syndrome and fitted Bobbie with wrist orthoses. [Id.] On November 20, 2014, Bobbie underwent an electromyography (EMG)[9] test due to her complaints of right arm paresthesias. [Dkt. 10-16 at 19 (R. 1073).] The test revealed right median neuropathy of the wrist (carpal tunnel syndrome). [Id.]

         On December 9, 2014, Bobbie returned to Dr. Thomas Webster for chronic pain management. [Dkt. 10-16 at 9-14 (R. 1063-68).] She had complaints of joint pain in her right shoulder, right hand, and bilateral hips and knees, along with tingling and burning sensations in both feet. [Id.] Due to painful left lumbar radiculopathy with a positive left-sided straight leg raising test, she was scheduled for an MRI of the lumbar spine. [Id.] She was also referred to Physical Medicine & Rehabilitation (“PM&R”) for a course of physical therapy for her knee and back pain. [Id.]

         On December 15, 2014, Bobbie followed up with Dr. Webster for her left knee pain. [Dkt. 10-15 77-81 (R. 1037-41).] She described hearing a popping sound in her knee, with associated pain and swelling; furthermore, she had been using a cane to walk. [Id.] She was referred for x-rays and a CT scan to rule out a tibial plateau fracture. [Id.] The x-rays showed a moderate sized suprapatellar joint effusion and a Baker's cyst, while the MRI showed a lateral meniscus tear. [Dkt. 10-13 at 29-30 (R. 790-91).] Bobbie also underwent an MRI of the lumbar spine on December 15, 2014, which revealed a disc bulge at ¶ 2-L3 with mild facet arthropathy; disc bulges at ¶ 32-L4 and L4-L5 with mild central canal stenosis; and facet arthropathy and moderate bilateral foraminal stenosis at ¶ 5-S1. [Dkt. 10-13 at 32-33 (R. 793-94).]

         On January 27, 2015, Bobbie presented to Sullivan County Community Hospital for her final physical therapy visit. [Dkt. 3-12 at 10 (R. 727-33).] She had completed eight (8) physical therapy sessions, but still experienced pain in the 4 to 8 range on a 0 to 10 scale in her left knee, and in the 4 to 10 range on a 0 to 10 scale in her lower back. [Id.] Bobbie filled out a report of her condition post-physical therapy, wherein she noted that she could not squat, bend, stoop, kneel, walk long distances, walk outdoors, climb stairs, hop, jump, run, push, or pull. [Id.]

         Dr. Ayoub evaluated Bobbie in follow-up on February 3, 2015. [Dkt. 10-15 at 47-49 (R. 1007-09).] It was noted that she had several psoriatic plaques, bony enlargements of multiple fingers, and leg and ankle swelling. [Id.] She received a left knee steroid injection and was referred to a physical therapist for a cane evaluation. [Id.] That same day, Physical Therapist Lora Pangallo evaluated Bobbie's use of a cane and demonstrated the proper use of a standard cane for ambulation, walking up and down stairs, and navigating curbs. [Dkt. 10-15 at 46 (R. 1006).] On March 16, 2015, the Plaintiff emailed Dr. Webster, informing him that her knee continued to swell, that her back pain had been worsening, and that the home exercises were not effective at relieving her symptoms. [Dkt. 10-15 at 9 (R. 969).]

         On April 28, 2015, Bobbie returned to Dr. Ayoub for a follow-up on her psoriatic arthritis and fibromyalgia. [Dkt. 10-14 at 68-70 (R. 934-36).] Her psoriasis had greatly improved since starting Stelara in February 2015, but she had experienced no improvement in her chronic low back pain. [Id.] She received a left knee steroid injection and bilateral steroid injections in her sacroiliac joint. [Id.]

         Bobbie presented to the Emergency Department at the Indianapolis VA on May 14, 2015, complaining of left hip and buttock pain. [Dkt. 10-14 at 57-59 (R. 923-25).] She walked with a mild degree of limping to the left leg, even with the aid of a cane, and was diagnosed with a left hip sprain. [Id.]

         On October 1, 2015, Dr. Ayoub evaluated Bobbie in follow-up of her psoriatic arthritis and fibromyalgia. [Dkt. 10-17 at 68-70 (R. 1155-57).] Her skin rash had almost entirely cleared up, but there was no improvement in her chronic low back pain. [Id.] Her last sacroiliac joint steroid injection provided relief for only about two months and she further reported new pain and swelling in the knuckles of her right hand. [Id.] She was given bilateral steroid injections in her sacroiliac joint and was recommended for a possible right carpal tunnel steroid injection if her symptoms continued to worsen. [Id.] Bobbie returned to the Dermatology clinic on October 7, 2015 for an injection of Stelara. [Dkt. 10-17 at 59 (R. 1146).]

         On October 13, 2015, the Plaintiff spoke with Dr. Ayoub's office and informed them that she continued to have swelling in her hands and knuckles due to synovitis. [Dkt. 10-17 at 56 (R. 1143).] She was prescribed a higher dose of azathioprine. [Id.] Bobbie returned to Dr. Ayoub on December 1, 2015 for follow-up on her psoriasis, psoriatic arthritis, and fibromyalgia. [Dkt. 10-17 at 33-36 (R. 1120-23).] Since starting Stelara, her rash had cleared, but she continued to have persistent arthralgias and low back pain. [Id.] She further reported a marked decrease in hand joint pain and swelling, mainly in the right hand, and a decrease in low back pain from a 10 to a 7 on the 0 to 10 scale. [Id.]

         On December 21, 2015, Bobbie returned to Dr. Ayoub for complaints of persistent nausea, abdominal discomfort, diarrhea, chills, night sweats, and fever. [Dkt. 10-17 at 22 (R. 1109).] These symptoms occurred after the increase in azathioprine and had improved after she stopped taking the medication; Dr. Ayoub advised Bobbie to stop taking azathioprine. [Id.] On January 12, 2016, Bobbie returned to the Dermatology department for follow-up of her chronic psoriasis. [Dkt. 10-18 at 31-32 (R. 1210-11). She reported no new flare-ups or psoriasis plaques, but that ...

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