The opinion of the court was delivered by: Scheindlin, District Judge.
Plaintiff, Richard Cleveland, brings this action under Section
205(g) of the Social Security Act (the "Act"), as amended,
42 U.S.C. § 405(g), to review a final determination of the
Commissioner of Social Security (the "Commissioner") denying
plaintiff's application for Supplemental Security Income ("SSI")
benefits based upon disability. For the reasons set forth below,
the decision of the Commissioner is reversed and the case is
remanded to the Administrative Law Judge for further proceedings
consistent with this Opinion.
Plaintiff filed applications for SSI benefits and for
disability insurance benefits on March 15, 1996 due to back pain
and hypertension. Tr.*fn1 at 2. His claims were denied
initially, Tr. at 58, and upon reconsideration, Tr. at 71. He
then requested a hearing to review his claims, Tr. at 82, which
was held on March 6, 1997 before Administrative Law Judge ("ALJ")
James B. Reap. Tr. at 29. Attorney Robert Bellone represented
plaintiff at this hearing. Id. The ALJ considered plaintiff's
case de novo and, on May 1, 1997, found that plaintiff was not
disabled and not eligible for SSI or disability insurance
benefits.*fn2 Tr. at 24-25. This decision became the final
decision of the Commissioner when the Appeals Council denied
plaintiff's request for review on February 25, 1999. Tr. at
Plaintiff's complaint, seeking review of the Commissioner's
decision, was filed on April 29, 1999. The Commissioner now moves
for judgment on the pleadings, pursuant to Federal Rule of Civil
Procedure 12(c), seeking affirmance of his decision. Plaintiff
has cross-moved for reversal of the Commissioner's decision and
payment of benefits as requested in his application.
II. Plaintiff's Personal History
Plaintiff is a 54-year-old man who lives alone in a
fourth-floor apartment in an elevator-equipped building. Tr. at
33. At the hearing before the ALJ, plaintiff testified that he
injured his back in an on-thejob
accident on February 2, 1987.*fn3 Plaintiff, who has completed
high school and two and a half years of college, alleges that he
has been unable to work since December 18, 1989 because of a back
disability.*fn4 Tr. at 84. In describing his back pain,
plaintiff stated that it felt like "molten lead . . . and make a
dagger out of it, and stick it in you." Tr. at 40. Plaintiff
reported that he has periods of weeks or "a couple of months"
where his back does not cause him pain but that he will also have
periods of a "week or two" where his back prevents him from doing
"what a normal person does." Tr. at 30-31. He also stated that
the pain is sometimes constant. Tr. at 41.
Plaintiff testified that he cooks, does light cleaning, takes
out his trash and does his laundry. Tr. at 44-45. He also
stated that he does his own shopping, but that he cannot lift
objects weighing more than 20 pounds for fear of dropping them.
Tr. at 49-50. Plaintiff is able to take walks, drive an
automobile, and ride public buses, but if he walks too much his
back starts to bother him. Tr. at 44-46. His most comfortable
position is sitting in a straight-backed chair. Tr. at 51.
Doctors have prescribed Motrin and Flexeril for pain and
plaintiff "periodically" attends physical therapy. Tr. at 41.
Plaintiff stated that his pain is something he has learned to
live with and that when his back is causing him pain he usually
"just lays at home." Tr. at 43.
III. Summary of the Medical Evidence
A. Treating Physician's Findings
Plaintiff was treated periodically by Dr. Robert D. Small from
1985 to 1997. Tr. at 101-11. He was initially treated for a
left shoulder injury in May of 1985, Tr. at 112, but suffered a
left hamstring injury in February of 1987. Tr. at 109. From May
14, 1987 to February 18, 1988, plaintiff sought treatment for
pain and numbness in his left leg, back pain, and occasional pain
and numbness in his left hand. Tr. at 105-08. Dr. Small ordered
a magnetic resonance imaging test ("MRI") and an electromyograph
("EMG") of plaintiff's lumbosacral spine on May 14, 1987. Tr.
at 108, 214. During appointments in August and September of 1987,
plaintiff continued to report severe pain in his left leg, but
stated that he had some relief of his back pain. Tr. at 106-07.
On December 22, 1987, the results of the MRI and the EMG came
back "normal." Tr. at 106. Plaintiff, however, reported
continued back pain, severe at times, and numbness in his leg.
Id. Dr. Small informed him that there was no further treatment
available. Id. Plaintiff made another appointment to see Dr.
Small on February 18, 1988. Tr. at 105. He reported mild back
pain radiating down his left leg and occasionally his right leg.
Id. Dr. Small informed plaintiff that since his symptoms were
subjective and that no physiological cause of his pain could be
demonstrated, there was nothing he could do. Id. He advised
plaintiff to seek help from a neurologist or an alternative
physician. Id. Dr. Small concluded that plaintiff was partially
disabled due to subjective feelings of pain. Tr. at 104.
Plaintiff returned to Dr. Small approximately four years later
on March 26, 1996, on referral from his attorney because he was
applying for SSI benefits. Tr. at 175. He reported constant
lower back pain radiating from the left buttock. Id. Dr. Small
determined that plaintiff was asymptomatic after performing a
physical examination. Id. On July 22, 1996, plaintiff sought
treatment from Dr. Small for pain and stiffness in his left leg
and back radiating down both thighs. Tr. at 175. Dr. Small
found that plaintiff's straight leg raising was positive at 80
degrees and that there was some paravertebral muscle spasm, but
that the deep tendon reflexes remained intact. Id.
Plaintiff's final appointment with Dr. Small was on February
24, 1997. Tr. at 173. Plaintiff made the appointment so that
Dr. Small would complete the paperwork for his disability claim.
Id. Dr. Small examined plaintiff and found that he was able to
sit and stand but had tenderness over the left sciatic notch.
Id. Dr. Small concluded, in a nine-line statement, that
plaintiff is "disabled" with "consistent left sciatic pain" but
that the etiology of the pain could not be identified. Id. Dr.
Small determined that plaintiff should return to him on a "prn
basis." Id. Dr. Small also completed a Workers' Compensation
form indicating that plaintiff is "totally disabled" and that it