United States District Court, W.D. New York
W. PAYSON United States Magistrate Judge
Nicole Cecelia Mitchell (“Mitchell”) brings this
action pursuant to Section 205(g) of the Social Security Act
(the “Act”), 42 U.S.C. § 405(g), seeking
judicial review of a final decision of the Commissioner of
Social Security (the “Commissioner”) denying her
applications for Supplemental Security Income and Disability
Insurance Benefits (“SSI/DIB”). Pursuant to 28
U.S.C. § 636(c), the parties have consented to the
disposition of this case by a United States magistrate judge.
(Docket # 7).
before the Court are the parties' motions for judgment on
the pleadings pursuant to Rule 12(c) of the Federal Rules of
Civil Procedure. (Docket ## 16, 18). For the reasons set
forth below, this Court finds that the decision of the
Commissioner is supported by substantial evidence in the
record and complies with applicable legal standards.
Accordingly, the Commissioner's motion for judgment on
the pleadings is granted, and Mitchell's motion for
judgment on the pleadings is denied.
protectively filed for SSI/DIB on November 6, 2012, alleging
disability beginning on December 29, 2011, as a result of a
left knee injury, anxiety, depression, high blood pressure,
and a left shoulder injury. (Tr. 213, 218). On December 27,
2012, the Social Security Administration denied both of
Mitchell's claims for benefits, finding that she was not
disabled. (Tr. 84-85). Mitchell requested and was
granted a hearing before Administrative Law Judge Michael W.
Devlin (the “ALJ”). (Tr. 125-26, 136-40). The ALJ
conducted a hearing on April 30, 2014. (Tr. 40-63). Mitchell
was represented at the hearing by her attorney, Mark J.
Palmiere, Esq. (Tr. 40, 123). In a decision dated July 3,
2014, the ALJ found that Mitchell was not disabled and was
not entitled to benefits. (Tr. 15-39).
October 21, 2015, the Appeals Council denied Mitchell's
request for review of the ALJ's decision. (Tr. 1-5).
Mitchell commenced this action on December 8, 2015, seeking
review of the Commissioner's decision. (Docket # 1).
Relevant Medical Evidence
Brown Square Center
notes indicate that Mitchell received primary care treatment
from Terri Michele Ragin (“Ragin”), PA, and
Colleen T. Fogarty (“Fogarty”), MD, at Brown
Square Center. In June 2009, Fogarty ordered images of
Mitchell's right and left knee due to ongoing pain. (Tr.
475-77). The images demonstrated medial compartment
osteophytic spurring in the left knee and early degenerative
changes in the medial compartment with tiny spurring in the
right knee. (Id.).
an appointment with Ragin on January 28, 2010, Mitchell
indicated that Zolpidem, prescribed to manage her depression
and anxiety, was not effective, and she requested a trial of
Ambien CR. (Tr. 303-05). Ragin agreed to prescribe Ambien,
but noted that a depression and anxiety screen would be
conducted during the next visit. (Id.).
14, 2010, Mitchell met with Ragin, who assessed several
conditions, including diabetes mellitus, hypertension, and
hyperlipidemia. (Tr. 300-02). During the appointment,
Mitchell complained of ongoing knee pain and anxiety.
(Id.). She indicated that her left knee was
sometimes swollen and that her pain was worse with activity
and standing. (Id.). She reported having been
treated by an orthopedist the previous year, who had
recommended physical therapy and a knee brace.
(Id.). She requested a referral to a sports medicine
specialist. (Id.). Regarding her anxiety, Mitchell
described feeling stressed and worried. (Id.). She
reportedly did not find the Ambien effective and had tried
Paxil in the past without relief. (Id.). She
reported previous relief using Xanax. (Id.). She
requested a referral for mental health treatment.
noted tenderness to palpation in the lateral anterior joint
of the left knee and crepitus, although range of motion was
intact. (Id.). She noted that imaging from the
previous year had demonstrated mild degenerative changes.
(Id.). She assessed osteoarthritis and instructed
Mitchell to continue taking Naprosyn and Ultraset.
(Id.). She also referred Mitchell to a sports
medicine specialist for evaluation of the knee pain.
(Id.). With respect to Mitchell's anxiety, Ragin
discontinued Ambien and prescribed Zolpidem and a short
course of Xanax. (Id.). She referred Mitchell to a
mental health provider. (Id.).
returned on October 20, 2010, for an appointment with Ragin.
(Tr. 292-94). Mitchell complained of increasing depression,
frustration, and stress. (Id.). She reported
experiencing periods of panic characterized by shortness of
breath and chest pressure. (Id.). Although Mitchell
had begun treatment at Unity, she reported that she would not
be able to see a psychiatrist for approximately two months.
(Id.). She cried during the appointment and appeared
agitated. (Id.). Ragin prescribed Xanax and Zoloft.
January 18, 2011, Mitchell returned for an appointment with
Ragin. (Tr. 285-87). Mitchell complained of sleep disturbance
and an anxious mood. (Id.). She reported that she
had missed some appointments with her counselor and had not
yet been evaluated by a psychiatrist. (Id.).
According to Mitchell, her therapist had recommended group
therapy, but Mitchell was not inclined to participate.
(Id.). Ragin refilled Mitchell's prescription
for Xanax and Zoloft and advised her to remain compliant with
the treatment plan recommended by her mental health provider.
an appointment with Fogarty on May 19, 2011, Mitchell
reported abusing prescription medication, including Percocet
and Ambien, due to back pain. (Tr. 273-75). Mitchell
indicated that she had attempted mental health treatment,
which was not helpful because group therapy had been
recommended. (Id.). Mitchell returned the following
week for a follow-up appointment with Fogarty. (Tr. 271-72).
During the appointment, she presented as irritable and
impatient. (Id.). Mitchell was advised to follow up
regarding her anxiety in approximately one month.
notes dated October 7, 2011, indicate that an intern from
Unity Mental Health contacted Fogarty's office to express
concern regarding Mitchell's increased anxiety attacks
and depression. (Tr. 268-69). The intern noted that Mitchell
would not be evaluated by a psychiatrist until the end of
November and would need medication in the meantime.
(Id.). During an appointment that day with Fogarty,
Mitchell reported feeling tired and agitated and that Paxil
was not alleviating her symptoms. (Id.). Mitchell
indicated that she was not aware that she was supposed to
have increased her dosage and stated that she stopped taking
the medication. (Id.). She reported feeling sad,
agitated, irritable, and tired, and that she was no longer
taking any mental health medication. (Id.). Fogarty
discontinued Zoloft, instructed Mitchell to continue taking
Paxil, and prescribed Xanax as needed. (Id.).
returned for an appointment with Ragin on October 19, 2011.
(Tr. 352-53). She complained of severe left knee pain and
reported that she had visited a walk-in clinic over the
weekend due to the pain. (Id.). According to
Mitchell, images were taken, but she was not informed of the
results. (Id.). Additionally, she was given a
prescription for Naproxen. (Id.). She complained
that her knee felt as though it was “cracking”
and frequently gave out. (Id.). According to
Mitchell, she walked a lot for her job, which exacerbated her
pain. (Id.). She reported that she had previously
participated in physical therapy and had not seen her
orthopedist in approximately one year. (Id.).
examination, Ragin noted mild swelling, crepitus, and
clicking in the left knee. (Id.). She noted that
Mitchell walked with a limp, but was able to bear weight.
(Id.). She reviewed the images taken over the
weekend and noted that they demonstrated mild arthritis.
(Id.). She recommended that Mitchell use a knee
brace and continue to take Naprosyn and Tramadol.
(Id.). She referred Mitchell for an MRI to assess
for soft tissue damage and to an orthopedist. (Id.).
returned for an appointment with Fogarty on October 26, 2011.
(Tr. 350-51). Mitchell continued to suffer from left knee
pain and requested a refill for Xanax. (Id.).
Fogarty noted that the knee brace that had been prescribed
was not covered by Mitchell's insurance and that Mitchell
continued to work, despite the fact that Ragin had written a
note to excuse her from work. (Id.). Upon
examination of the knee, Fogarty noted mild inflammation,
full range of motion with pain, mild crepitus, and tenderness
to palpation. (Id.). She recommended that Mitchell
continue to take Naprosyn and Tramadol while she awaited an
MRI and an orthopedic evaluation. (Id.).
November 10, 2011, Mitchell attended an appointment with
Ragin to review her MRI results. (Tr. 348-49). Mitchell
reported that she was scheduled to see an orthopedist at the
end of the month. (Id.). She indicated that despite
her continued use of medication, she was still in significant
pain. (Id.). The MRI of her left knee demonstrated a
tear of the anterior horn of the lateral meniscus and a tear
of the inner margin of body of medial meniscus.
(Id.). It also revealed abnormal signal intensity
involving the anterior cruciate ligament due to either
degeneration or a sprain, osteoarthritis, moderate size
effusion, and a small Baker's cyst. (Id.). Ragin
assessed a torn meniscus and indicated that Mitchell might
need surgery to correct it. (Id.). Mitchell
indicated that the standing and walking requirements of her
job exacerbated her pain. (Id.). Ragin advised her
to contact her human resources department to determine
whether she was eligible for leave. (Id.). Ragin
prescribed Amitriptyline to manage pain and ameliorate
anxiety and sleep issues. (Id.).
attended another appointment with Fogarty on January 12,
2012. (Tr. 346-47). During the appointment she complained of
ongoing knee pain, reported that she had been scheduled for
knee surgery, and requested pain medication and that Fogarty
complete a disability form. (Id.). Fogarty advised
her that she would need to consult with her orthopedist who
was providing post-operative care. (Id.).
14, 2012, Mitchell returned for an appointment with Ragin.
(Tr. 342-43). She reported that she had had surgery on her
left knee in February 2012 and had participated in physical
therapy for a time. (Id.). Her orthopedist had
scheduled another MRI and had indicated that she might need
another surgery. (Id.). She also reported an
upcoming appointment at the pain clinic. (Id.).
According to Mitchell, her knee pain was worse at the end of
the day, despite taking Naprosyn, Ibuprofen, and Tramadol.
(Id.). Upon examination, Ragin noted mild swelling
and painful range of motion. (Id.). Ragin prescribed
Vicodin as needed for severe pain and advised her to follow
up with her orthopedist. (Id.).
conducted on June 18, 2012, revealed a mucoid degeneration of
the ACL, post-operative changes with no definite re-tear,
tricompartmental mild chondral wear, a small joint effusion,
and a small neck of a Baker's cyst. (Tr. 378-79). On June
28, 2012, Mitchell attended an appointment with Fogarty. (Tr.
340-41). She complained of right knee pain, perhaps as a
result of her inability to bear weight on her left knee.
(Id.). She also reported that she was not working
and was experiencing increased stress. (Id.).
February 6, 2013, Mitchell attended an appointment with
Ragin. (Tr. 334-35). Ragin assessed Mitchell's depression
as moderate. (Id.). She also reported ongoing pain
in her left knee. (Id.). By letter dated February
12, 2013, Ragin declined to complete a medical questionnaire
in connection with Mitchell's claim for benefits, instead
requesting that Mitchell “have an independent medical
examination to determine the degree of disability.”
of Rochester Orthopaedics
October 29, 2009, Mitchell attended an appointment with Dr.
DeHaven (“DeHaven”) with the Orthopaedics
Department of the University of Rochester Medical Center
complaining of ongoing knee pain for the previous six months.
(Tr. 478-79). Mitchell reported pain and cracking that had
increased in intensity over the previous two months, which
was aggravated by weight bearing and activity.
(Id.). She reported that she had attempted physical
therapy and NSAIDs for the previous eight weeks without
examination, DeHaven noted moderate effusions bilaterally on
Mitchell's knees with decreased range of motion.
(Id.). Mitchell demonstrated palpable pain on the
medial joint lines and some mild pain on the lateral joint
line, with greater pain on the right side. (Id.).
Mitchell also complained of patellar crepitus, pain with
patellar movement, and lateral patellar subluxation.
(Id.). The Lacman, posterior drawer and
circumduction tests were all negative, and her sensation was
recommended against corticosteroid injections given
Mitchell's relatively young age and recent x-rays that
did not reveal significant osteoarthritis. (Id.).
DeHaven recommended that she continue to take Naproxen and
return in one week for imaging. (Id.). Imaging
conducted on November 6, 2009, demonstrated no significant
changes in the right knee and a small central osteophyte on
the left knee, without joint effusion or substantial joint
space narrowing. (Tr. 480).
November 17, 2011, Mitchell attended an appointment with
Gregg Nicandri (“Nicandri”), MD, and Lindsey
Caldwell, a medical resident. (Tr. 397-98). Mitchell
complained of ongoing left knee pain that had worsened since
she had been treated in 2009. (Id.). Mitchell
reported difficulty ambulating and was concerned about her
ability to return to work. (Id.). She requested a
further evaluation following an MRI ordered by her primary
care physician. (Id.). Mitchell reported some
swelling and occasional popping and locking in her knee.
examination, Mitchell was able to ambulate without
assistance, and her lower right extremity demonstrated full
range of motion with minimal tenderness. (Id.).
Mitchell's left knee had moderate effusion with pain on
patellar grind and palpation of the medial and lateral
aspects of the patella. (Id.). Mitchell demonstrated
pain and crepitus on range of motion of her left knee,
although she did demonstrate full range of motion.
(Id.). Her MRI revealed diffuse degenerative changes
throughout the knee, including the lateral meniscus, the ACL
and the chondromalacia of the patella, and joint effusion.
(Id.). A cortisone injection was administered at
that time, along with a prescription for physical therapy.
returned for an appointment with Nicandri and another medical
resident on December 29, 2011. (Tr. 399-400). Mitchell
reported that the injection had provided relief for
approximately two weeks and that physical therapy was not
alleviating her pain. (Id.). She wanted to discuss
surgical options. (Id.). A physical examination
revealed an obvious effusion of the left knee and, although
she retained range of motion, her gait was hindered by a
limp. (Id.). Nicandri recommended arthroscopic left
knee surgery to address the lateral meniscus and the patellar
cartilage. (Id.). He prescribed Vicodin to manage
Mitchell's pain until surgery. (Id.).
performed surgery on Mitchell's left knee on February 13,
2012. (Tr. 401-03). Following surgery, Nicandri recommended
that Mitchell remain non-weight bearing for approximately six
weeks and start a rehabilitation program to increase her
range of motion. (Id.).
February 15, 2012, Mitchell attended an unscheduled
appointment with Nicandri because her surgical site was
bleeding. (Tr. 404). Upon examination, Nicandri noted that
her surgical incision was well-healed with no active
bleeding. (Id.). He assessed appropriate
post-surgical discharge and instructed her to continue with
post-operative exercises and to begin physical therapy as
returned on February 22, 2012, for her scheduled
post-operative appointment. (Tr. 405). She complained of pain
and, upon examination, demonstrated full extension and
flexion to 95 degrees. (Id.). She was instructed to
continue physical therapy to improve her range of motion and
to follow up in approximately one month. (Id.).
March 15, 2012, Mitchell returned for a follow-up appointment
with Nicandri. (Tr. 406-07). Mitchell complained of continued
pain, although she demonstrated “excellent range of
motion, ” with full extension and flexion to 130
degrees. (Id.). Mitchell reported that she continued
to maintain her non-weight bearing status, although she
admitted to placing weight on her left leg occasionally at
home. (Id.). Nicandri noted significant tenderness
to palpation, although Mitchell was neurovascularly intact.
(Id.). Nicandri recommended that she continue to
avoid bearing weight on her left leg for two more weeks and
continue her range of motion exercises. (Id.). He
also prescribed a brace and advised her to follow up in two
to three weeks. (Id.).
two weeks later, Mitchell returned for an appointment with
Nicandri. (Tr. 410-11). Despite instructions to remain
non-weight bearing, Mitchell reported she had not been
compliant. (Id.). Mitchell continued to suffer
significant pain and was still taking narcotic pain
medication. (Id.). Upon examination, Nicandri noted
a knee effusion and tenderness to palpation with good range
of motion. (Id.). He noted that she had been
compliant with physical therapy and offered a cortisone
injection to relieve the pain and inflammation in her knee.
(Id.). The injection was administered without
complication, and Nicandri advised Mitchell to continue using
the knee brace. (Id.).
dated October 12, 2012, indicated that Mitchell's next
appointment with Nicandri was rescheduled for January 31,
2013, so that her progress could be better evaluated after
treatment at the URMC Sawgrass Pain Clinic. (Tr. 564). On
January 3, 2013, Wenjing Zeng authored a note on behalf of
Nicandri. (Tr. 393). The note indicated that Mitchell would
be undergoing a series of injections and would be unable to
work for at least five weeks, after which she would be
reevaluated. (Id.). On January 31, 2013, Nicandri
apparently completed a form indicating that Mitchell was not
able to return to work, had not yet reached maximum
improvement, and would be reevaluated on April 18, 2013. (Tr.
September 12, 2013, Mitchell attended an appointment with
Taylor Buckley (“Buckley”), MD. (Tr. 412). During
the appointment, Mitchell reported that she had been
attending appointments at the pain management clinic, but was
frustrated by the clinic's willingness to prescribe
opioid medications. (Id.). She also reported
continued physical therapy with minimal progress.
(Id.). Buckley noted that Mitchell previously had
surgery on her knee, as well as corticosteroid and Hyalgan
injections. (Id.). Upon examination, Buckley noted
tenderness to palpation, and pain and crepitus with range of
motion. (Id.). Buckley did not recommend any new
intervention, but instructed Mitchell to continue with pain
management treatment and physical therapy. (Id.).
Sawgrass Pain Treatment Center
19, 2012, Mitchell attended an appointment with Joel L. Kent
(“Kent”), MD, at the Sawgrass Pain Treatment
Center. (Tr. 252-54). Mitchell reported that she had
undergone a left knee arthroscopy in February 2012 and that
her pain had been worsening since then. (Id.).
According to Mitchell, she experienced pain while resting,
which was aggravated by activity, including climbing stairs,
bending, and adjusting positions during sleep.
(Id.). Mitchell reported that she could alleviate
her pain by lying down, taking medications, or applying heat
or a TENS unit. (Id.). She described her pain as
sharp, with numbness and tingling sensations. (Id.).
She reported swelling, redness, and clicking of the left knee
with increased activity. (Id.). ...