United States District Court, D. New Jersey
WILLIAM C. KIMBLE, JR., Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
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
B. SIMANDLE, U.S. DISTRICT JUDGE.
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.
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
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
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.)
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.)
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.)
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.)
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.)
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.)
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.
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.)
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.)
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.
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.)
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.
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.)
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.
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.)
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.)
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.)
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.)
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 ...