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Carter v. Berryhill

United States District Court, N.D. New York

June 22, 2017

WILLIS J. CARTER, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.




         [1]This case has proceeded in accordance with General Order 18, which establishes the procedures applicable to appeals from denials of Social Security benefits. Both parties have filed briefs. Dkt. Nos. 24 (“Plaintiff's Brief”), 25 (“Defendant's Brief”). For the following reasons, the decision of the Social Security Administration (“SSA”) is vacated and this case is remanded for further proceedings.


         A. Factual Background

         Plaintiff Willis J. Carter was born January 1, 1965. Dkt. No. 18 (“Record”) at 34. Carter claims that he became disabled on April 1, 2014, [2] as a result of back and wrist injuries. Id. at 53, 176.

         1. Work History

         Carter received his GED in November 1983. Id. at 177. There is no evidence in the record of Carter's activities from November 1983 to February 1997. From February 1997 to January 2007, Carter worked as a counselor in a group home. Id. at 286. From December 2005 to January 2007, Carter appears to have also worked as a bus driver. Id. Further, from January 2007 to December 2008, Carter worked as a bus cleaner. Id. From December 2008 to January 2013, Carter was a commercial driver for the Capital District Transit Authority (“CDTA”) Id. After leaving CDTA, Carter briefly drove for Advantage Transit. Id. at 31.

         Next, Carter worked for Risa Group, driving a medical transport vehicle. Id. at 34. Carter left this job shortly after starting, claiming he could not handle the stress the job put on his back. Id. After leaving this job, Carter briefly worked as a driver for two moving companies. Id. at 35. Carter left both of these jobs because they required him to do heavy lifting. Id. The last time Carter was employed was August 2013. Id. at 36. Carter claims he continued to look for work after August 2013, but could not find work as a driver that did not cause him back pain. Id. at 38. Carter collected unemployment benefits through early 2014. Id. at 52.

         2. Medical History

         In 1991, Carter was injured in a car accident in which he ruptured a disk in his lower back, fractured his coccyx, and broke his right wrist. Id. at 353. As a result, Carter underwent a L4-L5 fusion. Id.

         In March 2011, Dr. Gerald Schynoll examined Carter for back pain that had begun over the previous two or three weeks while he was doing dishes. Id. at 357. Dr. Schynoll concluded that Carter was suffering from musculoskeletal low back pain. Id. He instructed Carter to do back exercises and take over-the-counter pain medicine. Id.

         In July 2012, Dr. Schynoll examined Carter again. Id. at 353. This time, Carter complained of radiating lumbar pain after lifting a wheelchair at work. Id. Carter was out of work for about six months following the injury. Id. On January 23, 2013, he returned to Dr. Schynoll, claiming his back was still bothering him from the July 2012 injury. Id.

         On May 7, 2014, Carter went to the emergency room (“ER”) complaining of sharp back pain radiating to his left buttock with slight numbness in his left leg. Id. at 326. The pain originated from a sneezing and coughing fit Carter had suffered earlier. Id. Upon examination, Dr. Robert Holterman noted muscle spasms, veterbral tenderness, and tenderness in L3-L4 on palpation. Id. at 329. Additionally, the doctor found full range of motion in the extremities with 5/5 bilateral strength. Id. The doctor also noted that Carter had a normal gait. Id.

         On May 11, 2014, Carter returned to the ER complaining of increasing back pain. Id. at 330. Upon examination, Dr. Holterman noted that Carter had minimal deformity in his back, full range of motion in his extremities, and no neurological deficits. Id.

         On June 4, 2014, Dr. Kautilya Puri, serving as a consultative examiner for the SSA, examined Carter. Id. at 335. Dr. Puri made several relevant findings. First, she noted that Carter “appeared to be in no acute distress.” Id. at 336. Dr. Puri did notice that his gait appeared slow and that he used a cane, but observed that his gait was unaffected by the use of his cane. Id. Accordingly, she determined the cane was not necessary. Id. Dr. Puri also noted that Carter needed no help changing for the exam or getting on and off the exam table. Id. When examining Carter's back, Dr. Puri noted that he had mild local tenderness but had full cervical flexion and full rotary movement bilaterally. Id. at 336-37. Additionally, Carter had full range of motion of his shoulders, elbows, and wrists. Id. at 337. Lastly, Dr. Puri noted that Carter's gross and fine motor dexterity was intact with 5/5 grip strength bilaterally. Id. Dr. Puri concluded that Carter had (1) no objective limitations to fine or gross motor activity, his gait, or other activities of daily living, and (2) mild to moderate limitations for squatting, bending, stooping, kneeling, and lifting weights. Id.

         On June 26, 2014, Dr. J. David Abraham examined Carter and found that he had marked restriction of his lumbar spine in flexion and mild back spasms with no neurological deficits. Id. at 340. Dr. Abraham also noted that he thought Carter had a fused L5-S1 with degenerative changes at ¶ 4-L5. Id. Further, Dr. Abraham found that Carter had significant carpometacapal (“CMC”) arthritis in his hand, and he had difficulty doing power grip activities on a repetitive basis. Id. Based on his findings, Dr. Abraham recommended that Carter stay out of work “at this time” and undergo an MRI to determine if there were any further disc problems. Id. Dr. Abraham also referred Carter to Dr. Christopher DeCamp to evaluate Carter's wrist pain. Id.

         On September 22, 2014, Dr. Abraham received the results of Carter's MRI exam, which highlighted varying degrees of disc degeneration from L3-L5. Id. at 342. Additionally, L4-L5 showed evidence of chronic pain. Id. at 342. On October 2, 2014, Dr. Abraham reevaluated Carter and found that he had “significant degenerative changes and pathology above the level of his previous fusion.” Id. at 344. Accordingly, Dr. Abraham concluded that Carter was 100% disabled and unable to return to work “at this time.” Id.

         On October 10, 2014, Dr. Decamp evaluated Carter and found definite pain and crepitus in the CMC joint as well as crepitus and abnormalities in the metacarpophalangeal (“MCP”) joint. Id. at 346. An MRI further outlined a chronic tearing of the ulnar collateral ligament of the left thumb MCP joint as well as moderate to severe CMC arthritis. Id. at 350.

         3. Subjective Description of Pain and Symptoms

         Carter claims that he first suffered back pain as a result of the 1991 surgery. Id. at 283. Carter suffers from a dull throbbing pain in his lower back and hips, which becomes stabbing if he sits for too long. Id. Accordingly, Carter complains that he cannot sit for too long because he needs to get up to prevent stiffness and pain. Id. at 279. He claims the pain is constant and that he is always trying to shift his weight or position to avoid the pain. Id. at 284. He says the pain started to affect his ability to do daily activities in March 2014. Id. at 283. Carter further claims that he has to sit when he showers and puts his pants on. Id. at 275. Further, Carter has to take frequent breaks when he is doing daily activities such as laundry and dishes. Id. at 278. Carter asserts he needs help carrying laundry baskets or heavy items, and that he can walk only one or two blocks before he needs to take a break and must rest for fifteen to twenty minutes before continuing. Id. at 278, 281. Carter uses a cane that he bought from a medical store to help him walk, id., and takes pain medication daily, id. at 284.

         B. Procedural History

         On March 10, 2014, Carter filed an application for disability benefits, alleging disability beginning January 3, 2013. Id. at 13. His claim was initially denied on June 12, 2014. Id. After the denial, Carter requested a hearing. Id. On June 3, 2015, Administrative Law Judge (“ALJ”) Paul Kelly held a video ...

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