Kimble v. Commissioner of Social Security

          Steven Hordis, Esq. Attorney for Plaintiff William Kimble, Jr.

          Heather Benderson, Esq. Special Assistant U.S. Attorney Social Security Administration Office of the General Counsel, Region III Attorney for Defendant Commissioner of Social Security

          OPINION

          JEROME B. SIMANDLE, U.S. DISTRICT JUDGE.

         I. INTRODUCTION

         This matter comes before the Court pursuant to 42 U.S.C. § 405(g) for review of the final decision of the Commissioner of the Social Security Administration denying Plaintiff William Kimble's applications for disability benefits and supplemental security benefits under Title II and Title XVI of the Social Security Act, 42 U.S.C. § 401, et seq. Plaintiff, who suffers from status-post left shoulder rotator cuff surgery, status-post right shoulder rotator cuff surgery, an intellectual/learning disability, hearing loss and degenerative disc disease of the lumbar spine was denied benefits for the period beginning December 27, 2011, the alleged onset date of disability, to January 7, 2016, the date on which the Administrative Law Judge (“ALJ”) issued a written decision.

         In the pending appeal, Plaintiff argues that the ALJ's decision must be reversed and remanded on four grounds. Plaintiff contends that the ALJ erred in (1) determining at step three that Plaintiff did not meet Listing 12.05C; (2) finding that Plaintiff lacked sufficient credibility; (3) failing to accord proper weight to the Third Party Function Report of Plaintiff's wife; and (4) according “great weight” to the consultative report of Dr. William Dennis Coffey. For the reasons stated below, this Court finds that substantial evidence supports the ALJ's determinations, and will affirm the ALJ's decision denying Plaintiff disability benefits and supplemental security benefits.

         II. BACKGROUND

         A. Procedural History

         Plaintiff William Kimble filed an application for disability insurance benefits on April 23, 2013. (R. at 140.) Plaintiff also filed an application for supplemental security benefits on July 30, 2013. (R. at 141.) In both applications, Plaintiff alleged an onset of disability as of December 27, 2011. (R at 141-42.) On November 12, 2013, the Social Security Administration (“SSA”) denied these claims, and upon reconsideration on April 15, 2014. (R. at 20.) A hearing was held on December 1, 2015 before ALJ Karen Shelton, at which Plaintiff appeared with counsel and testified. (Id.) On January 7, 2016 the ALJ issued a written decision finding that Plaintiff was not disabled (R. at 32.) On May 20, 2016, the Appeals Council denied Plaintiff's request for a review, and Plaintiff timely filed the instant action. (R. at 1-7.)

         B. Medical History

         The following are facts relevant to the present motion. Plaintiff was 44 years old as of the date of the ALJ Decision. Plaintiff graduated from high school and obtained vocational training as a cook at the Burlington County Special Services. Plaintiff had work experience as a cook, a gas attendant, a housekeeper, and a factory operations worker. (R. at 58-59.)

         1. Physical Impairments

         Plaintiff filed a claim for disability insurance benefits and supplemental security benefits, alleging that he suffered from disability due to status-post left shoulder rotator cuff surgery, status-post right shoulder rotator cuff surgery, an intellectual/learning disability, hearing loss and degenerative disc disease of the lumbar spine (R. at 43.)

         Plaintiff's medical records commence with a December 2011 report that indicates that Plaintiff's family physician, Dr. Kennedy Ganti, ordered that an ADX 2105 - Spine Lumbosacral procedure be performed on Plaintiff. (R. at 351.) The resulting report indicated a finding of degenerative disc disease at L5-S1 of the lumbar spine. (Id.) The report also indicated that Plaintiff's intervertebral disc space levels were maintained in height; that his facet joints were intact; and, that there was no destructive osseous pathology. (R. at 352.) In November 2012, Plaintiff underwent a physical examination, performed by Dr. Ronald Bagner (R. at 361.) Dr. Bagner noted that Plaintiff claimed that he sustained injury to his lower back in December of 2011 while working as a machine operator. Plaintiff complained of difficulty bending, which caused the pain to radiate up to the mid-back. (Id.) Plaintiff stated that he had an MRI in January of 2012, but had not seen a physician or received medicine for back pain since then. (Id.) Plaintiff also informed Dr. Bagner that he fractured both clavicles years prior. (Id.)

         Throughout the Physical Examination, Dr. Bagner observed that Plaintiff ambulated without difficulty, got on and off the examining table without difficulty, and dressed and undressed without assistance. (Id.) Moreover, Plaintiff did not display any discomfort while in the seated position throughout the examination. (Id.) Dr. Bagner noted that Plaintiff's upper extremities, including his shoulders, elbows, forearms, wrists, and fingers showed a normal range of movement. (Id.) With regard to Plaintiff's back, Dr. Bagner observed that Plaintiff possessed 0-90 degrees of flexion, yet Plaintiff experienced pain on movement of the lower back. (Id.) Dr. Bagner's overall impression was that Plaintiff suffered from a Lumbosacral strain. (R. at 365.)

         In November 2012, Plaintiff underwent a LS Spine Film, conducted by Dr. Samuel Wilchfort. (R. at 366). Dr. Wilchfort recorded that the LS Spine Film indicated normal “alignment, vertebral heights, ” but also showed moderate narrowing of L5-S1 of the lumbar spine. (Id.) No other abnormalities were noted. (Id.)

         In April 2013, Plaintiff was examined by Dr. Asha Vijayakumar for a complaint of “dislocating arm and torn ligaments.” (R. at 367.) Plaintiff informed Dr. Vijayakumar that he had experienced recurrent shoulder dislocation since being the victim of a mugging at age 18. (Id.) Plaintiff informed the doctor that the shoulder pain interfered with his sleep and his activity. (Id.) Dr. Vijayakumar noted that Plaintiff experienced shoulder joint pain that gradually worsened as Plaintiff attempted to raise his shoulders. (Id.) Dr. Vijayakumar ordered that Plaintiff follow up in one month, to consult with an Orthopedic Surgeon, to wear a sling as needed and to take Motrin for pain. (R. at 368.)

         Plaintiff's follow-up appointment took place on May 24, 2013. (R. at 369.) Dr. Wayne Shaw performed the examination on this date. (Id.) Dr. Shaw noted that Plaintiff was not able to visit an orthopedist because his appointment was rescheduled. (Id.) Plaintiff also reported that he had a broken arm at that time, which was in a sling. (Id.) Dr. Shaw ordered that Plaintiff follow up in two months, to consult an Orthopedic Surgeon, and to take Tramadol for pain. (Id.)

         In August 2013, Plaintiff's left shoulder was examined by Dr. Sean McMillan of Lourdes Medical Associates Professional Orthopaedics. (R. at 391.) Examination of the left shoulder revealed that Plaintiff had range of motion from 0 to 140 degrees overhead, which is about 10 degrees shy of the contralateral side. (R. at 391.) Dr. McMillan noted that Plaintiff experienced pain when making such motion. Plaintiff's internal rotation was to his chest wall, and external rotation was about 25 degrees. (Id.) Abduction was from 0 to 80 degrees. Plaintiff had negative sulcus sign, and experienced pain with Jobe relocation testing. (Id.) Dr. McMillan noted that Plaintiff had a 4/5 rotator cuff strength. (Id.) Lastly, Dr. McMillan noted that Plaintiff had negative impingement and positive bicipital groove pain. (Id.) Dr. McMillan's assessment was not certain that Plaintiff was experiencing “true dislocation.” (Id.) An MRI of Plaintiff's left shoulder was prescribed in order to make this determination. (Id.)

         In September 2013, following the MRI, Dr. Mc Millan informed Plaintiff that he had a left shoulder ALPSA lesion, as well as a SLAP tear and sub-acromial impingement. (Id.) After discussing the pros and cons of surgery with Dr. McMillan, Plaintiff was scheduled for surgery to repair his left shoulder. (R. at 390.) On September 23, 2013, Dr. Ronald Bagner performed his second examination of Plaintiff. (R. at 372.) Dr. Bagner, again, noted Plaintiff's claim of dislocation of the left shoulder and the pain caused by movement of the left shoulder. (Id.) However, Dr. Bagner noted that Plaintiff was scheduled for surgery to repair the left shoulder in four days from the date of the examination. (Id.) Plaintiff's left shoulder showed 0-70 degrees forward elevation, 0-70 degrees of abduction, 0-50 degrees internal rotation and normal external rotation. (Id.) Plaintiff's right shoulder showed a normal range of motion. (Id.) Notably, Dr. Bagner, again, noted that Plaintiff was able to ambulate, get on and off the examining table, and get dressed and undressed without any assistance or difficulty. (R. at 373.)

         Plaintiff was also examined by Dr. Stephen Toder on September 23, 2013. (R. at 376.) Dr. Toder opined that Plaintiff's left shoulder was intact, that there existed no fracture or dislocation, and that there was minimal degenerative change. (Id.)

         In September 2013, Dr. McMillan performed a surgical arthroscopy of Plaintiff's left shoulder, which consisted of a SLAP repair and a biceps tenodesis. Thereafter, in October 2013, Plaintiff returned to Lourdes Medical Associates Professional Orthopaedics for a post-surgery follow-up appointment. Dr. Danielle Thorn examined Plaintiff's left shoulder and noted bruising and swelling that was consistent with the surgery. (R. at 387.) Dr. Thorn also noted that Plaintiff was to begin physical therapy. (Id.)

         In November 2013, Plaintiff told Dr. McMillan that he believed that he re-tore his biceps tendon while changing a flat tire for his wife. (R. at 385.) Dr. McMillan noted that Plaintiff had a “biceps tendon, which [was] sunken down somewhat distally.” (Id.) Dr. McMillan believed that this may have indicated a rupture versus incompetence due to healing. (Id.) Although Dr. McMillan was not certain as to whether Plaintiff's bicep was torn, he informed that it was an acceptable form of treatment modality and insisted that Plaintiff continue treatment. (Id.) Plaintiff was given a corticosteroid injection for pain. (R. 386.)

         In December 2013, Plaintiff was again examined by Dr. Thorn for status post left shoulder athroscopic SLAP repair, bicep tendesis and subacromial decompression. (R. at 383.) Plaintiff continued to complain of pain when performing overhead activity, but his range of motion had improved. (Id.) Dr. Thorn suggested that Plaintiff continue physical therapy. (Id.)

         On December 18, 2013, an Appeal Disability Report was filed on Plaintiff's behalf by his sister, Cynthia Vassey. (R. at 306-311.) The report indicated that the Plaintiff could barely lift his left arm, as he reportedly “slipped on black ice and injured [his] arm even worse.” (Id. at 306.) Additionally, the report indicated that Plaintiff's right arm was worsening as well. (Id.) The approximate date of the Plaintiff's changed conditions was listed for September 2013. (Id.)

         From October 2013 to January 2014, Plaintiff attended physical therapy for his left shoulder for three days per week for a total of 25 sessions. (R. at 393-406.)

         In January 2014, Plaintiff informed Dr. McMillan that, on January 2, 2014, he had a slip and fall and landed on his left shoulder. (R. at 429.) The apparent discrepancy in dates of his falling accident are unexplained, namely, September 2013, according to his sister's ADR (R. at 306.), supra, and his statement to Dr. McMillan that he fell on January 2, 2014 (R, at 429.). Additionally, Plaintiff informed Dr. McMillan that he believed that his right shoulder had “popped on him, ” stating that his right shoulder had become extremely painful following the January 2, 2014 slip and fall. (Id.) However, an MRI performed on the day of the slip and fall revealed no evidence of acute fracture or dislocation. (R. at 492.) During the physical examination of Plaintiff, Dr. McMillan noted that Plaintiff possessed a range of motion of the right shoulder of 0 to 130 degrees, with the left shoulder's range of motion at 0 to 110 degrees. (Id.) Dr. McMillan also noted that Plaintiff had tenderness to palpation at both shoulders and some periscapular atrophy on the right shoulder. (Id.) Ultimately, Dr. McMillan gave Plaintiff corticosteroid injections in both shoulders for pain and decided that Plaintiff was to suspend physical therapy for two weeks. (R. at 430.)

         On January 29, 2014, Plaintiff's wife filed an additional Adult Function Report on his behalf. (R. at 312-19.) The report indicated that, due to the worsening of his shoulders, Plaintiff required assistance with dressing and grooming himself. (Id.) The report also indicated that Plaintiff could no longer perform yard or housework. (Id.) Plaintiff's wife also reported, however, that he pursued hobbies and interest including hunting and fishing. (R. at 315.)

         In February 2014, Plaintiff informed Dr. McMillan that he believed that his shoulder “popped out” the week prior. (R. at 427.) During the examination, Dr. McMillan noted that Plaintiff possessed a range of motion of the left shoulder of 0 to 140 degrees and about 110 degrees with abduction. (Id.) Plaintiff's right shoulder demonstrated a range of motion from 0 to 140 degrees with discomfort. (Id.) Dr. McMillan also noted that Plaintiff's right shoulder had some dimpling about the posterior, which Dr. McMillan believed to indicate posterior rotator cuff atrophy. (Id.) Plaintiff was provided a card for Rainbow Rehab Physical Therapy in order for him to continue working on his range of motion. (R. at 428.)

         In March 2014, Plaintiff complained that pain in both of his shoulders rendered him unable to return to work and unable to complete simple house tasks, such as taking out the trash. (R. at 475.) Nevertheless, Plaintiff reported that his right shoulder was beginning to feel better. (Id.) The physical examination of Plaintiff indicated a range of motion of the left shoulder from 0 to 150 degrees overhead and abduction at 0 to 120 degrees. (Id.) The right shoulder remained at 0 to 140 degrees with discomfort and abduction at 0 to 120 degrees. (Id.) Again, Dr. McMillan noted that he did not believe that there was any true evidence of apprehension or instability within the right shoulder. (Id.) With regard to the left shoulder, Dr. McMillan noted that the repairs that were done had healed. (Id.) To address Plaintiff's complaint of weakness of his left shoulder, Dr. McMillan set forth ...