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Buggs v. Berryhill

United States District Court, N.D. Indiana, South Bend Division

August 29, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Christopher Buggs was hospitalized in May 2013 for swelling in his lower legs, ankles, and feet, and in January 2014, he began experiencing right foot drop of an uncertain etiology. He applied for social security disability benefits, claiming that he was no longer able to work, but the Commissioner denied his application. Buggs filed this action seeking review of that decision. For the following reasons, the Court reverses and remands this action for further proceedings.


         Since May 2013, Buggs has continuously sought medical treatment (in relevant part) for right lower extremity problems, including leg edema, ankle arthritis, and foot drop. He takes hydrocodone to help with unbearable pain, but because he doesn't like taking pain pills he regularly suffers from moderate pain. He has tried steroid injections and uses an ankle foot orthosis and cane to ambulate.

         The only consultative examination of record occurred on August 4, 2014 (Tr. 412-17). At that time, Dr. Ibekie observed that Buggs walked with a “slightly bending posture using a cane.” Upon examination, Buggs presented with limited range of motion, decreased strength, and abnormal sensation to his right ankle and foot. Dr. Ibekie reported that:

[Buggs] has an ataxic gait using a cane. He is able to stoop and squat with difficulty. He is unable to walk heel to toe and tandemly. He is able to get on and off the examination table with difficulty and did not require any assistance. He is able to stand from a sitting position with difficulty.

         Dr. Ibekie opined that Buggs suffered from a history of right foot drop since 2013 with a limited range of motion and a history of pain and paresthesia in the right lower extremity.

         Thereafter, the reviewing state agents opined that Buggs was capable of performing sedentary work (Tr. 176-92, 194-210).

         In January 2015, an EMG confirmed that Buggs had nerve damage in his right lower extremity (Tr. 449-53). Specifically, the EMG revealed “subtle denervation changes” in the “anterior tibialis muscle[, ] consistent with history of recent foot drop; however, there is no evidence for ongoing or active peroneal nerve entrapment at the fibular head or for sciatic nerve dysfunction.” Nor was there any electrical evidence for lumbosacral radiculopathy. Buggs was able to heel and toe walk on that date, but he was limited by pain and mild swelling. There was a mild Tinel's sign at the fibular head. It was believed that Buggs had suffered some peroneal or distal sciatic nerve injury several months prior and he was referred to a podiatrist.

         In September 2015, Buggs sought treatment with a podiatrist, Dr. Michael C. Lyons, who diagnosed Buggs with right foot drop and ankle arthritis (Tr. 492). Dr. Lyons continued to document Buggs' problems with pain, swelling, and reduced strength in his right foot. As late as August 2016, Dr. Lyons noted that Buggs had not had any improvement in his pain, range of motion, and muscle strength (Tr. 465). Dr. Lyons recommended a second opinion from a neurologist and discussed the possibility of Buggs being placed on disability “given his lack of improvement, lack of function, and overall limitations.”

         Despite this evidence, the ALJ found that Buggs' severe impairments of right ankle arthritis and right foot drop did not render Buggs disabled because he was still able to perform sedentary work, subject to a number of physical limitations including the need to use a cane “for prolonged ambulation.” Based on testimony from a vocational expert, the ALJ concluded that a person with that residual functional capacity would still be able to perform work as a call out operator, addresser, tube operator, eyeglass frames polisher, surveillance system monitor, charge account clerk, and telephone order clerk. The VE testified that consistent with the Dictionary of Occupational Titles, these jobs existed in significant numbers. Given the VE's testimony, the ALJ found that Buggs was not disabled and denied his claim. The Appeals Council denied review, so Buggs filed this action, asking that the Commissioner's decision be reversed and remanded for further proceedings.


         Because the Appeals Council denied review, the Court evaluates the ALJ's decision as the final word of the Commissioner of Social Security. Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). This Court will affirm the Commissioner's findings of fact and denial of disability benefits if they are supported by substantial evidence. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). Substantial evidence consists of “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). This evidence must be “more than a scintilla but may be less than a preponderance.” Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). Thus, even if “reasonable minds could differ” about the disability status of the claimant, the Court must affirm the Commissioner's decision as long as it is adequately supported. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).

         It is the duty of the ALJ to weigh the evidence, resolve material conflicts, make independent findings of fact, and dispose of the case accordingly. Perales, 402 U.S. at 399-400. In this substantial-evidence determination, the Court considers the entire administrative record but does not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute the Court's own judgment for that of the Commissioner. Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). Nevertheless, the Court conducts a “critical review of the evidence” before affirming the Commissioner's decision. Id. An ALJ must evaluate both the evidence favoring the claimant as well as the evidence favoring the claim's rejection and may not ignore an entire line of evidence that is contrary to his or her findings. Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir. 2001). Consequently, an ALJ's decision cannot stand if it lacks evidentiary support or an adequate discussion of the ...

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