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WOODFORD v. APFEL

May 1, 2000

GERTRUDE WOODFORD, PLAINTIFF,
V.
KENNETH S. APFEL, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Robert L. Carter, District Judge.

OPINION

Claimant, Gertrude Woodford ("Woodford"), brings this action pursuant to 42 U.S.C. § 405(g) to challenge the final determination of defendant, the Commissioner of Social Security ("Commissioner"), denying her Supplemental Security Income Disability benefits ("SSDI"). Both parties move under Rule 12(c), F.R. Civ. P., for judgment on the pleadings.

I. BACKGROUND

A. Procedural History

Woodford applied for disability benefits on October 27, 1993, alleging that she was disabled since May 7, 1993, due to residual injuries stemming from a fractured left ankle. (Tr. at 32).*fn1 Woodford's claim was denied on the initial and reconsideration levels. (Id.). Woodford appealed the reconsideration denial, and requested a hearing with an Administrative Law Judge ("ALJ"). (Id.). ALJ David Nisnewitz heard Woodford's case on October 24, 1995. (Tr. at 54-83). In a decision, dated January 24, 1996, the ALJ found that Woodford had the residual functional capacity to perform her prior job as a bookkeeper and other kinds of sedentary work,*fn2 and therefore she was not disabled under the SSDI guidelines, and was not entitled to benefits. (Tr. at 33, 36). On March 8, 1996, Woodford requested that the Appeals Council review the ALJ's decision. (Tr. at 28). The Appeals Council denied her request, making the ALJ's decision final. (Tr. at 2-4). Woodford then filed the instant claim under 42 U.S.C. § 405(g), requesting review of the ALJ's and the Appeals Council's decisions.

B. Administrative Hearing Facts

Woodford is a 59 year old woman, with two years of college education. (Tr. at 66-70). From the date she immigrated to the United States in 1962, until the date of her injury, May 7, 1993, Woodford was steadily employed as a bookkeeper. (Tr. at 65-78). Woodford's bookkeeping jobs primarily required her to record financial information while sitting at a desk, and occasionally to walk around the office in order to retrieve financial information. (Tr. at 67-70).

On May 7, 1993, Woodford fell into a roadside drainage ditch outside her daughter's Westchester County home and fractured her left ankle. (Tr. at 60-61). She was taken to Northern Westchester County Hospital and a surgeon, Dr. Mark Altman, diagnosed her as having suffered an "open, Grade II, bi-malleolar equivalent left ankle fracture." (Tr. at 128). Dr. Altman performed an "open reduction and internal fixation to the [left] fibula:" he installed a metal plate and six screws in the ankle to increase ankle stability during the healing process. (Tr. at 128-29, 152). He also sutured Woodford's deltoid ligament in two places. (Tr. at 129). Woodford was in the hospital for three days, and convalesced with her daughter in Westchester County for three months. (Tr. at 62). During this period, Dr. Altman prescribed antibiotics and pain medication. (Tr. at 63-64, 133).

1. Treating Physician's Reports

Woodford ultimately moved back into her Elmhurst, New York apartment and, on January 24, 1994, sought treatment from an osteopath, Dr. William J. Kulak, M.D., who thereafter served as her treating physician. (Tr. at 35, 64).

In his initial report, dated March 21, 1994, Dr. Kulak indicated that Woodford complained of intermittent pain in her ankle and knees while flexing and while walking. (Tr. at 150). He also noted that she walked with a slow gait. (Id.). Dr. Kulak diagnosed Woodford as having a series of ankle injuries, including: an ankle fracture, and inflammation of the soft tissues, ligaments and tendons in the left ankle.*fn3 (Tr. at 152). He determined that Woodford's injuries constituted a partial disability that limited the use of her left ankle and foot.*fn4 (Tr. at 153).

Dr. Kulak also indicated that a long term prognosis for Woodford could not be developed at such an early stage in her treatment; however, he predicted that there was a strong probability that she would suffer long term injury, including: permanent loss of ankle flexibility, recurring pain symptoms, and ankle inflammation. (Tr. at 152-53). He noted that it was unclear when Woodford would be able to resume work or recreational activities. (Tr. at 153). For the initial treatment period, he prescribed stretching exercises, anti-inflammatory drugs, and recommended the use of a cane. (Tr. at 151, 153).

Dr. Kulak's follow-up report, dated April 4, 1995, summarized medical examinations conducted on August 22, November 7, and December 19, 1994, and April 3, 1995. (Tr. at 144-48). Dr. Kulak indicated that, at the four examinations, Woodford complained about various kinds of left ankle pain, specifically: pain which radiated to her calf, and caused twitching and tightness in her calf muscles when walking, (Tr. at 144); pain which caused a "tired" feeling in her right lower extremity and back, and intense "sleepy" sensations in her left foot, (Tr. at 145); and calf and left ankle cramps that caused her to lose her balance and fall. (Id.). Consistent with these symptoms, Dr. Kulak noted that Woodford was still experiencing pain on "heel to heel" and "toe to toe" walking. (Tr. at 146).

At each of the four examinations, Dr. Kulak conducted flexibility tests on Woodford's ankles. He determined that Woodford's range of motion in her left ankle was increasing, but that flexing, rotation and palpitation of the left ankle still produced pain. (Tr. at 145). X-rays he ordered in November, 1994, confirmed that Woodford's ankle fracture had healed, but that scar tissue, calcification or bone fragments had accumulated around ligaments at the injury site. (Id.). Dr. Kulak noted that these deposits could be expected to cause secondary symptoms such as pain and inflammation. (Tr. at 146). Additionally, he indicated that scar tissue was causing decreased sensation in part of Woodford's ankle. (Id.). At all of the examinations, Dr. Kulak prescribed the same course of ...


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