United States District Court, N.D. New York
MEMORANDUM-DECISION & ORDER
LAWRENCE E. KAHN, District Judge.
This case has proceeded in accordance with General Order 18, which sets forth the procedures to be followed in appealing a denial of Social Security benefits. Both parties have filed briefs. Dkt. Nos. 11 ("Plaintiff's Brief"); 12 ("Defendant's Brief"). For the following reasons, the judgment of the Social Security Administration ("SSA") is affirmed.
A. Plaintiff's Medical Records
On July 5, 2007, the alleged onset date of Plaintiff David Bell's ("Plaintiff") disability, Plaintiff fell off a ladder at work, resulting in injury to his right knee. Dkt. No. 9 ("Record") at 32. On July 8, 2007, Plaintiff was treated at the Massena Memorial Hospital Emergency Room for pain and swelling associated with his right knee. R. at 155-62. Plaintiff was given an x-ray, which revealed a small joint effusion in his right knee, and prescribed over-the-counter pain medication. R. at 160, 162. Upon discharge, Plaintiff was referred to Dr. Roger Sullivan for a follow-up appointment. R. at 162. Dr. Sullivan ordered an MRI of Plaintiff's right knee on July 11, 2007, which revealed a large joint effusion and lateral subluxation of the patella with areas of high-signal seen in the distal aspect of the patella tendon compatible with sprain and partial tear. R. at 163.
Plaintiff sought treatment for his right knee with Dr. Bedros Bakirtzian on August 7, 2007. R. at 168. Dr. Bakirtzian performed arthroscopic surgery on Plaintiff's right knee on August 13, 2007, for retrieval of a loose body and partial lateral meniscectomy. R. at 165-66. Upon Plaintiff's readmission to the hospital for a second surgery, Dr. Bakirtzian noted that Plaintiff complained of right knee pain but had full range of motion. R. at 176. Dr. Bakirtzian performed a second arthroscopic surgery on Plaintiff's right knee on January 30, 2008, for a resection of the medial plica as well as multiple synovial biopsies. R. at 174-75. Dr. Bakirtzian noted that Plaintiff had pain in his lower back in addition to limited range of motion in his right knee. R. at 198, 200. Dr. Bakirtzian prescribed medication and physical therapy, and concluded that Plaintiff could return to work by the end of August 2007. R. at 200-01. On December 17, 2008, Dr. Bakirtzian diagnosed Plaintiff with arthritis. R. at 198. On March 13, 2009, Dr. Bakirtzian concluded that Plaintiff had a partial, 50% disability due to weakness of muscle, but also noted that Plaintiff had full range of motion in his knee. R. at 193, 195. Later, on September 1, 2009, Dr. Bakirtzian again assessed Plaintiff at a 50% impairment due to pain in his right knee, but noted that Plaintiff did have symmetrical flexion and extension in both knees. R. at 191. In the same assessment, Dr. Bakirtzian also noted that Plaintiff was looking for work. Id.
As required by his Workers' Compensation claim, Plaintiff underwent multiple Independent Medical Examinations ("IME"), which were performed by Dr. George Mina. R. at 184-88, 204-05. In his June 2, 2008, IME, Dr. Mina diagnosed Plaintiff with status post arthroscopic partial lateral meniscectomy, partial synovectomy, and right knee with residual non-specific synovitis. R. at 185. Dr. Mina concluded that Plaintiff's range of motion was "good, " that Plaintiff had a moderate disability (50% partial/temporary), and that Plaintiff could return to work with the restriction of avoiding lifting more than twenty pounds and squatting. Id . At Plaintiff's second IME on December 18, 2008, Dr. Mina concluded that Plaintiff had reached maximum medical treatment and could return to work with the restriction of avoiding excessive squatting and kneeling, and lifting more than thirty to forty pounds only occasionally. R. at 188. Dr. Mina further concluded that Plaintiff had a "mild, partial" disability. Id . After Plaintiff's third IME on September 29, 2009, Dr. Mina again concluded that Plaintiff could return to work with the limitation of avoiding lifting more than twenty pounds and squatting, and that Plaintiff's disability was "partial mild." R. at 205. Dr. Mina also noted that Plaintiff displayed "hardly any positive objective findings" in his right knee. Id.
Between September 2, 2009, and December 7, 2009, Plaintiff received chiropractic treatment from Dr. Robert Klein. R. at 216-30. The Record only contains two documented instances of Plaintiff receiving chiropractic treatment, specifically on September 9, 2009, and December 7, 2009. R. at 226, 229. In those two reports, Dr. Klein opined that Plaintiff was limited to lifting, carrying, pushing, and pulling ten pounds occasionally and five pounds frequently, and could only stand or walk less than two hours in a workday. R. at 219-20. Plaintiff testified at his hearing that he received chiropractic treatment from Dr. Klein twice a week for a year. R. at 34.
On October 27, 2009, Plaintiff was examined by Dr. David Welch as part of an SSA examination. R. at 206. Dr. Welch determined that Plaintiff's range of motion of his neck and upper extremities was normal, although "diffusely uncomfortable." R. at 206-07. Dr. Welch also noted that Plaintiff's back had "a long kyphotic curve with a loss of normal lumbar lordosis" and that Plaintiff was unable to lie prone and could only achieve a partially upright position. R. at 207. However, Dr. Welch noted that Plaintiff's straight leg raising was sixty degrees for both legs with only slight limitation. Id . Plaintiff only had a loss of ten degrees of internal rotation and five degrees of external rotation in his right hip, while his left hip was normal. Id . Plaintiff had full extension to at least 120 degrees of flexion in both knees with no evidence of instability. Id . Dr. Welch ordered an x-ray of Plaintiff's knee which revealed no evidence of fracture, joint effusion, degenerative changes, or osteochondral defects. R. at 208.
On January 21, 2010, the state agency physician Dr. D. White reviewed Plaintiff's medical records and concluded that Plaintiff was able to perform light work, including lifting twenty pounds and standing, walking, and sitting six hours out of an eight hour workday, with a restriction on crawling, kneeling, climbing scaffolds, ropes, ladders, and anything more than occasional crouching. R. at 231-32.
On April 14, 2011, Dr. Sullivan diagnosed Plaintiff with lumbago and cervicalgia, prescribed Vicodin, and ordered an MRI. R. at 256, 258. Medicaid did not permit Plaintiff to receive the ordered MRI. R. at 256. On June 28, 2011, Plaintiff followed up with Dr. Sullivan with a complaint of left elbow pain for which he was prescribed Prednisone, but otherwise had no complaints or issues. R. at 256. From an MRI taken on July 12, 2011, Dr. Sullivan diagnosed Plaintiff with spondylosis deformans and disc disease at several layers causing neural foraminal stenosis and nerve root displacement. R. at 278-79. Dr. Sullivan referred Plaintiff to specialist Dr. Monsey at the Spine Institute of New England, who concluded that Plaintiff displayed signs of mild degenerative changes, but no evidence of significant neurological impingement, radicuopathy, or myelopathy. R. at 281.
Between April 20, 2011, and June 28, 2011, Plaintiff attended thirteen physical therapy sessions at the Massena Memorial Hospital for treatment of his lumbago and cervicalgia. R. at 258-277. The physical therapy and rehabilitation had limited results for Plaintiff. Id.
On January 21, 2010, Plaintiff underwent a physical residual functional capacity ("RFC") assessment performed by SSA Single Decision Maker M. Mayer. R. at 234-46. Mayer concluded that Plaintiff could occasionally lift twenty pounds, frequently lift ten pounds, stand and/or walk about six hours out of an eight hour workday, sit about six hours out of an eight hour workday, and push or pull an unlimited amount. R. at 234. Mayer further concluded that Plaintiff could only occasionally climb ramps and stairs, balance, stoop, or crouch, and that Plaintiff could never climb ladders, ropes, scaffolds, kneel, or crawl. R. at 234-35.
B. Procedural History
On September 16, 2009, Plaintiff protectively filed an application for disability insurance benefits, alleging disability resulting from lower back pain, cervical degenerative disc disease with spondylosis and facet arthropathy, and right knee pain, with an onset date of July 5, 2007. R. at 97; Pl.'s Br. at 1. When the SSA denied Plaintiff's application on January 25, 2010, Plaintiff made a timely request for a hearing before an Administrative Law Judge ("ALJ") on March 5, 2010. R. at 49-51, 54. On August 3, 2011, ...