United States District Court, N.D. New York
WILLIS J. CARTER, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.
MEMORANDUM-DECISION AND ORDER
LAWRENCE E. KAHN U.S. DISTRICT JUDGE.
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
Willis J. Carter was born January 1, 1965. Dkt. No. 18
(“Record”) at 34. Carter claims that he became
disabled on April 1, 2014,  as a result of back and wrist
injuries. Id. at 53, 176.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Subjective Description of Pain and Symptoms
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.
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 ...