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Ingrassia v. Colvin

United States District Court, E.D. New York

March 6, 2017

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          Law Offices of Harry J. Binder and Charles E. Binder, P.C. Attorneys for the Plaintiff By: Charles E. Binder, Esq., Of Counsel

          United States Attorney's Office for the Eastern District of New York Attorneys for the Defendant By: Rukhsanah L. Singh, Assistant United States Attorney


          ARTHUR D. SPATT United States District Judge

         On February 29, 2016, the Plaintiff Karen Ingrassia (the “Plaintiff” or the “claimant”) commenced this civil action pursuant to the Social Security Act, 42 U.S.C. § 405 et seq. (the “Act”), challenging a final determination by the Defendant Acting Commissioner of Social Security Carolyn W. Colvin (the “Commissioner”), that she is ineligible to receive Social Security disability insurance benefits.

         Presently before the Court are the parties' cross motions, pursuant to Federal Rule of Civil Procedure (“Fed. R. Civ. P.” or “Rule”) 12(c) for judgment on the pleadings. For the reasons that follow, the Plaintiff's motion is granted in its entirety and the Commissioner's motion is denied in its entirety.

         I. BACKGROUND

         A. Procedural History

         On February 5, 2013, the Plaintiff filed for Social Security disability benefits. She alleged that she had been disabled since August 10, 2008. The Plaintiff's application was denied, and she requested an administrative hearing.

         On July 15, 2014, Administrative Law Judge Andrew S. Weiss (“ALJ Weiss” or the “ALJ”) conducted an administrative hearing. The Plaintiff was represented by counsel. At the hearing, the Plaintiff amended her alleged onset date of disability to February 2, 2009.

         On August 14, 2014, the ALJ issued a written decision denying the Plaintiff's claim. The Plaintiff requested a review from the Social Security Appeals Council (the “Appeals Council”). On January 6, 2016, the Appeals Council denied her request and the ALJ's decision became the Commissioner's final decision.

         B. The Administrative Record

         1. Relevant Medical Evidence

         a. Before the Relevant Period (Prior to February 2, 2009)

         On August 21, 2008, the Plaintiff underwent arthroscopic surgery of her left knee with reconstruction of the anterior cruciate ligament (the “ACL”) and hamstring autograft and medial meniscal repair. The surgery was conducted by orthopedic surgeon Dr. Jeremy Idjadi (“Dr. Idjadi”). After the operation, the Plaintiff was diagnosed with a left knee ACL tear with a grade 3 sprain; left knee medial meniscus tear; and chondromalacia of multiple compartments, medial and lateral.

         On August 28, 2008, the Plaintiff followed up with Dr. Idjadi. She reported to him that she had gone to the emergency room due to a brief period of redness in her leg. An examination revealed numbness laterally and distally to the tibial incision; a trace amount of warmth; mild to moderate effusion; loss of 3 to 5 degrees from straightening her knee; flexion limited to 45 degrees; pain and guarding with range of motion; and some edema around her ankle. A venous duplex scan was negative for deep vein thrombosis (“DVT”). The Plaintiff stated that she had not yet started physical therapy because she had transportation issues. Dr. Idjadi prescribed physical therapy, Percocet, and OxyContin, and told the Plaintiff not to bear any weight on her left leg.

         On September 4, 2008, the Plaintiff, who arrived to the appointment in a wheelchair, told Dr. Idjadi's physician's assistant (“PA”) that she was experiencing significant discomfort; that she needed home health physical therapy because of the level of her pain; and that she was primarily isolated to the upper floor of her home. The Plaintiff's sutures were removed without significant difficulty. Two-view X-rays of the left knee demonstrated appropriate ACL fixation components. Dr. Idjadi's PA assessed a reasonably good course post left ACL reconstruction and lateral meniscus repair. The PA advised the Plaintiff to remain in a Bledsoe Brace at zero degrees with partial weight bearing on the operative side. He further prescribed Vistaril.

         A patient progress report dated September 30, 2008 notes that the Plaintiff had six total physical therapy sessions as of that date, but only one of those visits occurred after her operation. She had begun physical therapy on July 17, 2008. The Plaintiff was unstable when descending stairs and had a tender knee, with poor control and tone.

         On October 2, 2008, the Plaintiff stated that she had made great progress with physical therapy. The Plaintiff was using a crutch to walk, and her hinged knee brace for “protection.” She said that she only took Percocet at night. Her left leg was neurovascularly unchanged distally.

         She had mild-to-moderate swelling in the ankle extending up to the calf; decreased muscle tone; and weakness graded as 4. Flexion of the knee was 105º to 110º, passively, and extension was about 180º. Dr. Idjadi prescribed a duplex scan to rule out DVT and recommended home exercises and PT. A lower extremity venous duplex scan conducted on October 2, 2008 revealed no evidence of DVT.

         On November 5, 2008, the Plaintiff told Dr. Idjadi's staff that she felt like her improvement had hit a plateau. On examination, the left leg exhibited trace effusion. Dr. Idjadi instructed her on additional home exercises and completed a form for modified duty.

         When the Plaintiff returned for a follow-up on November 26, 2008, she reported that her pain was progressively worsening following aggressive physical therapy. She further stated that she experienced pain when she shopped or ran errands for more than 90 minutes. Physical examination revealed minimal inflammation in and around the knee joint; no joint effusion; point tenderness near the point of surgery; flexion to approximately 120 degrees; some “marked” atrophy compared to the right side; and weakness with knee extension. X-rays of the left knee revealed a well-seated staple in the proximal tibia and a well-seated transfix pin in the distal femur, without evidence of lysis or failure of the components. The Plaintiff was advised to decrease her physical therapy from four days a week to three; and to limit running errands to two to three hours per day. She was prescribed Voltaren and Ultram.

         On December 4, 2008, Dr. Idjadi's physical examination of the Plaintiff revealed that flexion was 5 degrees short of full activity; and a hamstring popliteal angle about 50º, with tightness posteriorly. Dr. Idjadi noted trace effusion again. The Plaintiff's ACL was solid and there no sign of a meniscal problem. Dr. Idjadi prescribed Voltaren gel. The Plaintiff attended physical therapy that day as well.

         On December 23, 2008, the Plaintiff told Dr. Idjadi that she had been fired from her job, but she believed that she had “turned the corner.” On examination, her left leg was neurovascularly intact, with the incisions well healed; she had almost full flexion; she had solid stability and her ligaments were not tender; she had inflammation and moderate tenderness in her knee and hamstring. There was no erythema, warmth, effusion, or pain with movement. She received an injection of Marcaine with epinephrine in her left knee. Dr. Idjadi prescribed Voltaren gel, icing, and physical therapy.

         On January 2, 2009, the Plaintiff saw a PA in Dr. Idjadi's office who gave her a second Marcaine injection. The Plaintiff told the PA that the last injection had caused a decrease in her pain. The PA Noted tenderness in the Plaintiff's hamstrings, and that her range of motion was a well-preserved zero degree of extension to 125 degrees of flexion.

         On January 20, 2009, Plaintiff returned to Dr. Idjadi. She reported that the steroid injection had helped. She further told Dr. Idjadi that she had obtained a new job and believed she was capable of performing all the job's duties. She had no complaints. On examination, she had full strength and range of motion in her left knee.

         b. During the Relevant Period (February 2, 2009 through August 14, 2014)

         On February 2, 2009, a physical therapy report noted that the Plaintiff's range of motion had increased, and that she had met her physical therapy goals.

         When the Plaintiff returned to Dr. Idjadi on February 24, 2009, she told him that her knee had buckled less than a week earlier, and that her pain had returned. A physical examination revealed trace effusion; mild global tenderness in the areas of the joint capsule and lateral joint line; mild opening at 15 degrees; a painful patellofemoral compression test; and mild patellofemoral crepitus. Her ACL was stable. Dr. Idjadi did not know the reason for the setback, but diagnosed her with a mild MCL sprain. He recommended that she wear a hinged knee brace, treat with ice, and take Celebrex.

         A March 11, 2009 MR Arthrogram of the Plaintiff's left knee showed a vertical re-tear of the medial meniscus; a small horizontal tear in the lateral meniscus; and a moderate sized chondral flap in the weight-bearing portion of the medial femoral condyle with small focus of moderately severe cartilage loss in the weight bearing portion of the lateral tibial plateau. The ACL repair was intact.

         On March 13, 2009, the Plaintiff told Dr. Idjadi that she had another episode of buckling, which had preceded the MR Arthrogram. The Plaintiff said that her knee had gotten progressively worse, that it was quite painful, and that the pain was limiting her daily activities and job functions to a great degree. The Plaintiff listed her daily pain as an 8 or 9 out of 10. Exam revealed mild to moderate left knee effusion, “exquisite” medial joint line tenderness, mild medial collateral ligament tenderness and pes region tenderness, and flexion to 120 degrees. Dr. Idjadi recommended further arthroscopic surgery, and instructed the Plaintiff to wear the knee brace and modify her activities. He prescribed Tramadol and Percocet.

         On March 26, 2009, the Plaintiff underwent a second arthroscopic surgery for medial meniscectomy; removal of a loose body; and shaving chondroplasty and debridement. The surgery was performed by Dr. Idjadi.

         A March 30, 2009 venous duplex scan of the Plaintiff's left leg showed no evidence of DVT or superficial thrombophlebitis.

         On April 9, 2009, the Plaintiff followed up with Dr. Idjadi's office. She said that she had started physical therapy, that she was taking oxycodone only at night for pain. Her range of motion was 0º of extension and 115º of flexion. There was tenderness to palpation around the incision sites, mild effusion, and a slight antalgic gait. The Plaintiff was directed to continue physical therapy three times a week, and she was prescribed more oxycodone.

         On April 14, 2009, the Plaintiff reported to Dr. Idjadi that the sharp pain in her knee was worsening. Physical examination revealed mild tenderness along the hamstrings; moderate to severe tenderness along the medial joint line; extension 5 degrees short of full extension; flexion over 130 degrees. Dr. Idjadi administered another steroid injection. There was an increased range of motion following the injection.

         An April 16, 2009 physical therapy report noted that the Plaintiff had tolerance for activity and walking, but had difficulty with endurance and descending stairs. A report from May 5, 2009 noted that the Plaintiff had improved in her tolerance for walking and performing errands.

         On May 6, 2009, the Plaintiff reported that the steroid injection had helped and that she felt she was progressing. Dr. Idjadi noted that the Plaintiff's patella was “somewhat socked in with decreased medial lateral mobility, . . . with inability to bring the tilt to neutral even passively.” (R. at 347).

         On May 21, 2009, the Plaintiff told Dr. Idjadi that she had experienced another buckling episode. She complained that she could not walk for long periods of time. An exam revealed peripatellar tenderness of the distal aspect of the patella and femoral and lateral facets; positive patellofemoral grind test with mild patellofemoral crepitus; medial joint line tenderness; and tightness with deep flexion of the knee. Dr. Idjadi noted that there was no evidence of ongoing meniscal injury, although there was some tenderness. Dr. Idjadi recommended that the Plaintiff receive a second opinion from his partner, Dr. Peter Mandt (“Dr. Mandt”).

         On May 26, 2009, Dr. Mandt examined the Plaintiff. He believed that the Plaintiff's pain was related to some arthrofibrosis, with possible notch impingement. The doctor noted her prognosis was not good because of her body weight. He suggested another steroid injection.

         On June 4, 2009, Dr. Idjadi administered another steroid injection. The Plaintiff's physical examination on that date was unchanged from May 21st, except that Dr. Idjadi emphasized the tenderness in the Plaintiff's knee.

         On June 16, 2009, Ms. Ingrassia stated that the injection helped the sense of “fullness” in her knee, but did not decrease her pain at all. She continued to wear a knee brace and ice her knee, but had an increase in pain following a session of physical therapy. An examination revealed pain with full hyperextension of the knee, anteromedial joint line tenderness adjacent to the patellar tendon and nearby the previous anteromedial incision, and joint effusion. Dr. Idjadi noted that the Plaintiff's pain may have been due to arthrofibrosis and some notch impingement. After a discussion, the Plaintiff intimated that she wanted another arthroscopic surgery. A physical therapy report three days later on June 19, 2009 noted that the Plaintiff felt frustrated with her lack of progress and her inability to return to work.

         A July 14, 2009 x-ray showed degenerative changes in her right knee. Dr. Idjadi assessed possible rheumatologic or systemic joint problems, likely aggravated by overuse and being overweight On August 4, 2009, the Plaintiff reported that she had an independent medical examination performed by Dr. Bradley Billington who mentioned possibly debriding the pes bursitis, and noted decreased range of motion of some 8 degrees of flexion. Dr. Idjadi noted no significant changes from the June 16, 2009 examination, other than moderate tenderness with some soft tissue swelling. Her range of motion was a few degrees of hyperextension.

         The Plaintiff underwent a third arthroscopic surgery on August 10, 2009, which included lysis of adhesions in the knee; chondroplasty of the medial femoral condyle; and an open pes bursectomy/debridement.

         On August 24, 2009, the Plaintiff told a PA at Dr. Idjadi's office that she had some foot swelling and tenderness, but did not go to the emergency room. The Plaintiff was prescribed Percocet.

         On September 15, 2009, the Plaintiff told Dr. Idjadi that her hamstrings were bothering her and she had some numbness. On examination, there was subjective decreased sensation distal to an incision point, but sensation was grossly intact. She had almost full flexion and extension strength. The doctor assessed possible nerve inflammation; prescribed Neurontin; and recommended vitamins.

         On October 2, 2009, the Plaintiff reported that she had an onset of pain the previous night. An examination showed subjectively decreased sensation in her left knee near the incision but it was otherwise grossly intact. Dr. Idjadi recommended a gradual resumption of activities with the physical therapist; a knee brace; icing; and continued medications. He cautioned against deep knee squatting and deep knee bending with any resistance.

         A physical therapy report from October 13, 2009 noted that the Plaintiff walked for ...

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