United States District Court, N.D. New York
MEMORANDUM-DECISION AND ORDER
Lawrence E. Kahn U.S. District Judge.
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. 14 ("Plaintiffs Brief), 17
("Defendant's Brief), 20 ("Reply"). For
the following reasons, the decision of the Social Security
Administration ("SSA") is vacated and this case is
remanded for further proceedings.
The Disability Allegations and Medical History
Tanya Dodson was thirty-two years old on January 1, 2013, her
alleged disability onset date. Dkt. No. 8
("Record") at 64. She is married with two children,
and has a ninth grade education. Id. at 34-35, 42.
Dodson's most recent employment, as a certified nursing
assistant, ended on January 31, 2001. Id. at 42-43.
As early as August 2011, and before her alleged onset date,
Dodson received treatment from rheumatologist Dr. David
Griger, who noted minimal signs of osteoarthritis from pain
and tenderness in her joints. Pl.'s Br. at 2. Dodson saw
rheumatologist Dr. Donald Raddatz on November 22, 2011; he
noted that her past diagnoses included joint pain and
fibromyalgia and suggested that her widespread pain was
consistent with fibromyalgia. R. at 220-22. Dodson also
received treatment for migraines before her alleged onset
date from both her general practitioner, Dr. Ashly Joseph,
and her neurologist, Dr. Lore Garten. Pl.'s Br. at 3. On
November 16, 2012, Dr. Garten noted that medications
prescribed for Dodson's migraines were initially helpful
but losing efficacy and that Dodson did not wish to increase
her dosage because of potential weight gain. Id.
appeal primarily concerns Dodson's physical impairments.
Administrative Law Judge ("ALJ") Arthur Patane
found that Dodson's severe impairments included
fibromyalgia, mild degenerative changes in the cervical and
lumbar spine, and obesity. R. at 19. ALJ Patane concluded
that Dodson's migraines, asthma, and other ailments were
not severe and that her osteoarthritis was "nonmedically
determinable." Id. The Court now turns to the
record relating to Dodson's physical impairments after
her alleged onset date.
January 8, 2013, Dr. Joseph noted that Dodson suffered from
daily headaches and migraines, had a small pituitary lesion
found in a recent MRI, and experienced pain in her lower back
and legs. Id. at 309. Dodson was taking Depakote,
Maxalt, Verapamil, and Naproxen for headaches, as well as
Mobic and Gabapentin for back pain, but she had declined
injection therapy for her headaches as suggested by Dr.
Garten because she was afraid of needles. Id. Dr.
Joseph found Dodson positive for headaches, back, and
abdominal pain, and negative for joint swelling and gait
problems. Id. She also found tenderness and pain in
Dodson's back and assessed her with dyspepsia (from
chronic nonsteroidal anti-inflammatory drugs
("NSAID") use), lower back pain, and chronic daily
headaches. Id. at 310-11. Dr. Joseph altered
Dodson's medications to combat her headaches and
dyspepsia. Id. at 311. On February 6, 2013, Dr.
Garten noted Dodson was experiencing "severe and
sharp" pain on the left side of her neck and weakness in
her upper extremities. Id. at 210. Dr. Garten also
found Dodson had normal motor strength, coordination, and
gait that day but concluded that Dodson had "probable
movement disorder" that had been present for several
years, and that her pain had been increasing in her neck and
head. Id. A previous MRI showed straightening of the
lordosis, which could be consistent with disc disease, but
the brain MRI did not extend far enough to evaluate her full
April 13, 2013, Dr. Joseph pointed to Dodson's MRI, which
showed "degenerative changes of the cervical spine,
" "mild bilateral neuroforaminal stenosis, "
and worsening back pain. Id. at 312. Dr. Joseph also
found that Dodson's headaches were no longer daily,
though she continued to get headaches, have neck pain, and
experience numbness in her upper extremities. Id.
Dr. Joseph thus continued prescribing Gabapentin and
Hydrocodone. Id. She stated that Dodson was taken
off NSAIDs after listing her continuing dyspeptic and reflux
issues. Id. at 315. Dr. Joseph also referred Dodson
to a physical therapist for degnerative joint disease.
Garten noted on April 19, 2013, that Dodson had degenerative
disc disease as revealed by her MRIs and that she had neck,
back, and extremity pain, including "myalgias,
arthralgia, and hip pain, " which medications had not
abated. Id. at 202. She noted that Dodson had normal
gait, coordination, and motor strength, and was awake, alert,
and oriented that day. Id. Dr. Garten also stated
that Dodson "has had difficulty in using preventive
medications [for her migraines] because they quickly seem to
become less effective." Id.
April 23, 2013, Dr. Garten wrote a letter concluding that
Dodson was "permanently disabled from working."
Id. at 242. Dr. Garten stated that Dodson had been a
patient since 2010, and that she had a history of medical
problems, including Von Willebrand disease, chronic
migraines, neck and back pain stemming from degenerative disc
disease, and polyarthralgias. Id. Dr. Garten noted
that Dodson had taken many different medications for her
migraines which had been unsuccessful due to tachphylaxis.
Id. Dr. Garten also found that Dodson's neck and
back pain as well as her migraines had only become worse over
April 25, 2013, Dodson saw a physical therapist on referral
from Dr. Joseph. Id. at 247. The physical therapist
noted that Dodson's subjective assessment was a six out
often with constant pain, while her objective assessment
indicated "maximal restriction of all movements."
Id. After some decrease in pain over the course of
seven visits with the physical therapist, Dodson reported a
fall during her visit on May 27, 2013. Id. at 248.
There had been no change in her maximal restriction diagnosis
and she still had pain in her lumbar and cervical paraspinal
13, 2013, Dodson was seen by endocrinologist Dr. Pascale
Raymond, who noted that she had "persistent dyspeptic
symptoms" and had struggled to lose weight after the
birth of her two children. Id. at 332. Dr. Pascale
also stated that Dodson took "chronic narcotics and
NSAIDS for back pain, " and he noted the MRI findings
discussed above pertaining to Dodson's degenerative
spinal changes as well as her lingering problems with
headaches and back and neck pain. Id.
19, 2013, Dodson saw Dr. Garten, who noted that trials of
preventive medicine for headaches, neck, and back pain were
all unsuccessful. 11 at 336. Dr. Garten stated that Dodson
had "musculoskeletal headaches and these are very likely
triggering some of the migraines, " and noted some
improvement when Dodson wore a transcutaneous electrical
nerve stimulation ("TENS") unit. Id. at
Dr. Garten also stated that Dodson now found it difficult to
do her household and gardening tasks as she was "unable
to sit, stand, walk or even lie down for prolonged stretches
of time." Id. at 336. She further noted that
Dodson was, "limited in her ability to lift or carry
even light amounts." Id.
31, 2013, Dodson saw Dr. Emily Desantis on referral from Dr.
Garten for her chronic neck pain and migraines. Id.
at 258. Dr. Desantis noted that Dodson's Oswestry
Disability Index was sixty-four out of one hundred and that
she experienced sharp, radiating pain in her head.
Id. Analysis of an MRI of her spine from February
2013 reportedly showed a slight flattening of her cervical
lordosis, and Dr. Desantis noted Dodson had tenderness in
portions of her cervical paraspinal and upper pariscapular
muscles as well as full but painful cervical range of motion.
Id. at 259. Dr. Desantis noted Dodson's manual
muscle testing was a five out of five in her major and minor
muscle groups but that her proximal arm testing caused
discomfort. Id. Dodson was recommended for injection
therapy, which she received on August 5, 2013. Id.
at 260-61. After receiving six trigger point injections,
Id. at 260, Dodson had a follow-up on September 4,
2013, where her Oswestry Index did not change, and Dodson
stated that her TENS unit no longer reduced her headache
symptoms at all, leading instead to nausea, Id. at
262. Dodson also stated that her pain increased after the
injections, with stabbing neck pain, low back pain exceeding
a ten out often scale, and painful cervical range of motion.
Id. Dr. Desantis noted Dodson still suffered from
migraines, chronic neck pain, and occipital headaches, which
were "most suspicious for myofascial etiology with
postular and muscular imbalances." Id. Dr.
Desantis also stated that Dodson was already taking an
increased dose of Gabapentin and that there was little else
she could do for Dodson, so she recommended acupuncture.
September 18, 2013, Dr. Joseph stated that Dodson had chronic
myofascial pain and degenerative joint disease of the lumbar
and cervical spines, and that she exhibited tenderness in the
paraspinal region. Id. at 317. In her review of
symptoms, Dr. Joseph also noted that Dodson was positive for
neck pain, abdominal pain, and myalgias all over with use and
exertion. Id. at 316. Also on September 18, 2013,
Dr. Garten ordered an MRI of Dodson's cervical spine, and
all findings were normal except at ¶ 4-C5 and C5-C6,
where there was minimal leftward foraminal compromise.
Id. at 380-81. Dr. Garten's notes also include
results from an MRI of the lumbar spine revealing a
"broad-based disk bulge with flattening along the
anterior aspect of the thecal sac . . . [and] mild bilateral
neural foraminal compromise" at ¶ 4-L5, as well as
a small disc bulge at ¶ 5-S1. Id. at 378. Dr.
Garten concluded that there was mild bilateral neural
foraminal compromise and mild degenerative joint disease.
Id. at 378-79.
October 22, 2013, Dr. Joseph found Dodson had new and
persistent right shoulder pain and noted a decreased range of
motion in all directions but no tenderness, swelling, or
other signs of musculoskeletal problems in the shoulder.
Id. at 319. Dr. Joseph assessed the shoulder pain as
a potential sprain or tendinitis. Id. at 320. On
October 28, 2013, Dodson returned to see Dr. Griger, who
noted that she had "diffuse tenderness to palpation in a
characteristic fibromyalgic distribution." Id.
at 348. After views were taken of the right shoulder and no
abnormalities were found, Dr. Griger concluded that
Dodson's pain was connected to her fibromyalgia.
Id. at 348-49. On October 28, 2013, Dodson saw a
physical therapist, Michael Quinn, on a referral from Dr.
Joseph and in light of her Social Security Disability
application. Id. at 350. Quinn noted that Dodson got
only three to four hours of sleep a night because of her
pain, did housework only with her daughter's help, that
"all motions [were] self-limited, " and that even
when lifting small weights she had increased pain.
Id. at 351-52. Quinn concluded that there was
"little objective evidence to support work limitations,
" but that her ongoing medical and mental health
conditions needed to be considered. Id. at 353.
November 7, 2013, Dodson returned to see Dr. Garten because
her headaches had not abated. Id. Dr. Garten noted
that Dodson was having difficulty doing basic tasks at home
and experienced increased pain as the Gabapentin was losing
efficacy. Id. Dr. Garten also stated that Dodson had
crepitus in her joints along with paraesthesias in her arms,
which was aggravated with movement. Id. Dr. Garten
also noted weaknesses in all four extremities and that Dodson
was limited in standing, walking, and sitting for prolonged
periods due to her neck and back pain. Id. In her
diagnosis, Dr. Garten advised Dodson to gradually taper off
Depakote for migraines since it was ineffective, and she
advised an increase of Gabapentin and Verapamil as well as a
trial of Midrin and Maxalt for migraines. Id. at
354. Dr. Garten also completed a physical capacities
evaluation form that day where she opined that Dodson was
unable to sit, stand, or walk for over thirty minutes in an
eight-hour day and that she could only occasionally lift or
carry less than ten pounds. LI at 250. Dr. Garten also wrote
that Dodson "has severe migraines and should not be
exposed to conditions such as heat, dust, noise, cold, odors
etc., " and that Dodson's back, neck, and joint pain
affected her ability to do any physical work and that she had
"confusion" associated with her migraines and
fibromyalgia, which further limited her work ability.
Id. at 251.
November 11, 2013, Dodson saw Dr. Karl Siebuhr on a referral
from Dr. Joseph for her right shoulder pain. Id. at
274. Dr. Siebuhr noted that Dodson refused to complete some
of the range of motion tests, telling him she would end up
"on the floor" if she did them. Id. at
278. He noted Dodson had a full range of spinal motion and
pain in the strength tests, and he recommended an MRI and a
"conservative treatment plan" for her right
shoulder pain. Id. Dr. Siebuhr also noted that
Dodson was still on multiple medications, including Tramadol,
Effexor, Gabapentin, Indomethacin, and Midrin, and that she
was using a TENS unit and hot and cold packs. Id. at
274-75. He also stated that she did not have numbness,
weakness, or tingling in her hand or fingers, Id. at
275, but he did find her positive for shortness of breath and
noted her asthma symptoms were stable, Id. at 278.
On November 25, 2013, Dodson saw Dr. Stephanie Oceguera on
referral from Dr. Joseph for a hiatal hernia. Id. at
284. Dr. Oceguera found Dodson positive for back and joint