United States District Court, W.D. New York
DECISION and ORDER
MICHAEL A. TELESCA, District Judge.
Roshell Rojean Lucius ("Plaintiff" or "Lucius"), proceeding pro se, brings this action pursuant to Title XVI of the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying her application for Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB"). This Court has jurisdiction over the matter pursuant to 42 U.S.C. §§ 405(g), 1383(c). Presently before the Court is Defendant's motion for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure.
II. Procedural History
On October 12, 2009, Plaintiff applied for benefits, alleging disability beginning April 1, 2008, due to fibromyalgia, carpal tunnel syndrome, arthritis, foot pain and bone disease in her legs. T.200-08, 209-12, 244. These applications were denied. T.99, 100, 118-33.3 Plaintiff appeared with counsel, Ida Comerford, Esq., and testified on October 14, 2010, before Administrative Law Judge Michael Devlin ("the ALJ"). T.77-98. On January 14, 2011, the ALJ issued a decision finding Plaintiff not disabled. T.21-37. The Appeals Council denied Plaintiff's request for review on August 21, 2012, making the ALJ's decision the final decision of the Commissioner. T.1-6. Plaintiff then commenced this lawsuit.
III. Summary of the Administrative Record
A. Plaintiff's Medical History
Below, the Court summarizes the medical history pertinent to the severe impairments found by the ALJ: bilateral carpal tunnel syndrome, degenerative disc disease, degenerative joint disease, obesity, and fibromyalgia. T.27. With regard to treatment providers and notes not included in the summary below, the Court refers to, and incorporates herein, Defendant's comprehensive summary of the relevant medical evidence of record set forth in her Memorandum of Law.
Throughout the time-period relevant to her benefits applications, Plaintiff has complained of back pain as well as diffuse muscle pain and joint pain, in varying degrees of severity. Magnetic resonance imaging (MRI) in May 2008 showed mild degenerative changes in her back; prominent degenerative changes with multilevel spinal stenosis and neural foraminal narrowing; and showed reversal of the normal cervical lordosis, which could have been secondary to several factors (arthritic change, muscle strain, or spasm). Plaintiff had a small herniated disc making minimal impression on the ventral margin of the thecal sac at L5-S1 without significant stenosis. MRIs of the cervical spine revealed degenerative changes throughout the cervical spine, with moderate to severe spinal stenosis at C3-C4.
Plaintiffs doctors have diagnosed her with fibromyalgia, for which she takes Lyrica. Plaintiff, who is 5'11/2" tall, weighed 247 pounds in June 2008; and weighed 270 pounds in March 2010. Her doctors have told her that her obesity increases the pain she experiences from these impairments.
In November 2008, Plaintiff began reporting symptoms consistent with carpal tunnel syndrome (e.g., hand numbness, worse in the morning; and difficulty holding things). Plaintiff was treated with wrist braces for four weeks. An electromyography (EMG) showed carpal tunnel syndrome ("CTS"), and Plaintiff had surgery in March 2009. On April 8, 2009, it was noted that Plaintiff was "doing well" post-surgery for her CTS. T.321. In May 2009, Plaintiff reported that she was doing well on increased medication. T.323. She had seen an orthopedist, who had recommended aqua therapy for her pain and joint problems. On July 8, 2009, Plaintiff had an appointment at her health center and again complained of generalized pain for the past three to four years. T.325. According to Plaintiff, nothing relieved her pain. T.325.
She returned to the Strong Pain Clinic on July 15, 2009, and reported experiencing pain that was 8 to 10 on a scale of 1 to 10, with 10 being the most severe. T.431. Plaintiff also had not been sleeping well. Plaintiff was to undergo more water-based physical therapy. T.432.
On August 10, 2009, Plaintiff reported that she had been experiencing shoulder pain for a month, about 4 to 6 on a scale of 1 to 10. T.327. On examination, Plaintiff complained of pain on rotation and palpation of the subacromial bursa, but had full supraspinatus and infraspinatus strength. Plaintiff was referred for corticosteroid injections T.328. On August 21, 2009, Plaintiff received a right shoulder injection. T.355.
An August 22, 2009 x-ray of Plaintiff's right knee showed mild to moderate changes, more so in the patellofemoral compartment. T.347. An MRI of the right knee showed complex degenerative tear of the posterior horn and body of the medial meniscus; intrasubstance degeneration of the lateral meniscus; severe tricompartmental osteoarthritis with small to moderate effusion; and a pericruciate ganglion cyst. T.348.
Plaintiff underwent left CTS release surgery in August 2009. T.449.
On September 10, 2009, Plaintiff reported that her right shoulder pain had improved after the steroid injection, but now the pain had returned. T.353. On examination, Plaintiff had right shoulder impingement syndrome at 70 degrees abduction, with tenderness over the biceps tendon. T.353. On September 22, 2009, Plaintiff was seen at University Pain Management Center. It was noted that Plaintiff had previously missed multiple clinic visits. T.343. The Lyrica prescribed for her fibromyalgia was working fairly well, but did not relieve her body pain completely. T.343. Plaintiff was tender to palpation in the low back and bilateral scapular area. T.343. Plaintiff was to continue Lyrica, but opiates were not indicated. T.343. Plaintiff was officially discharged from the clinic for multiple cancellations and no-shows. T.343.
A September 25, 2009 x-ray of the right shoulder showed mild arthritic changes. T.314. On September 28, 2009, Plaintiff saw Dr. Bridgette Wiefling, who noted that Plaintiff had not followed up with orthopedics for her knee pain, which was holding up her being seen by physical and occupational therapists. Plaintiff reported that she was sleeping "ok" using amitriptiline. She reported that her low back and knee pain limited her activities, and at its worse, was a 10 out of 10 in intensity. On examination, Plaintiff had crepitus (crackling) in the right knee, along with an increase in pain with flexion. There was positive joint line tenderness, but no edema. Dr. Wiefling again referred Plaintiff to orthopedics. T.311-12.
An October 29, 2009 x-ray of the right knee showed degenerative joint disease with mild interval progression since 2008. There was predominantly small to moderate tricompartmental spur formation but no visible substantial joint effusion or opaque intra-articular body. T.313.
Drs. Kenneth DeHaven and Christopher English of Strong Hospital examined Plaintiff's right knee on October 29, 2009. Based on their clinical findings, and review of her October x-ray and August 2009 MRI results, they determined that that Plaintiff's pain was likely due to degenerative changes within the right knee, including osteoarthritis, as well as significant medial meniscus tear. Dr. DeHaven informed Plaintiff that she needed to lower her body weight to reduce the forces through her joint. Plaintiff was referred to sports medicine to evaluate her for a right knee arthroplasty, and was told to obtain standing knee x-rays to evaluate the joint spaces. Plaintiff was to continue with her home physical therapy and work on reducing her weight. T.341-42.
On December 4, 2009, Dr. Warren Hammert of Strong Hospital saw Plaintiff for follow-up of her bilateral CTS releases. Plaintiff complained of mild numbness in all fingers and of pain along the volar side of her left wrist. On examination, Plaintiff had full wrist range of motion and full finger range of motion. Her sensation was intact to light touch and she had good capillary refill. On the right hand side, Plaintiff had a negative carpal tunnel compression test and a negative Tinel's sign at the wrist and elbow. Plaintiff stated that she had a positive Phalen's maneuver in the ring and small fingers, but Dr. Hammert was unable to detect any subluxing of the ulnar nerve over the medial epicondyle. Plaintiff had full range of motion of the wrist and fingers. Dr. Hammert advised Plaintiff to splint her right wrist and elbow, both in extension, while sleeping. He also suggested strengthening and range of motion exercises bilaterally. T.340.
That same day, Plaintiff was evaluated by the hand rehabilitation department and reported pain, at its worse, of 6 out of 10 in intensity. Plaintiff was to undergo rehabilitation and wear removable wrist splints. T.336, 338.
On December 8, 2009, Nurse Practitioner Sophie Dickinson ("Nurse Dickinson") of Jordan Health noted that Plaintiff had joint pain and decreased range of motion in the right knee without erythema or effusion. ...