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Ridge v. Berryhill

United States District Court, E.D. New York

March 30, 2018

Mark J. Ridge, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          JOSEPH F. BIANCO, DISTRICT JUDGE

         Plaintiff Mark Ridge (“plaintiff”) commenced this action pursuant to 42 U.S.C. § 405(g) of the Social Security Act on February 3, 2017, challenging the final decision of the Acting Commissioner of Social Security (the “Commissioner” or the “government”) denying plaintiff's application for Social Security disability benefits on December 12, 2016. An Administrative Law Judge (“ALJ”) determined that plaintiff had the residual functional capacity to perform light work, as defined in 20 C.F.R. § 404.1567(b), with certain limitations. The ALJ found that there were a significant number of jobs in the national economy that plaintiff could perform despite these limitations, and, therefore, that plaintiff was not disabled. The Appeals Council denied plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner.

         Plaintiff now moves for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). The Commissioner opposes the motion and cross-moves for judgment on the pleadings. For the reasons set forth below, the Court denies plaintiff's motion for judgment on the pleadings, denies the Commissioner's cross-motion for judgment on the pleadings, and remands the case to the Administrative Law Judge (“ALJ”) for further proceedings consistent with this Memorandum and Order.

         I. Factual Background

         The following summary of the relevant facts is based upon the administrative record (“AR”) developed by the ALJ. (ECF No. 7.) A more exhaustive recitation is contained in the parties' submissions to the Court and is not repeated herein.

         A. Personal and Work History

         Plaintiff was born on December 31, 1967, and is currently 50 years old. (AR at 164.) Plaintiff is divorced and has three teenage children who live with their mother. (AR at 41.) Plaintiff lives with his parents. (AR at 43.) He completed one or two years of college. (AR at 168, 214.)

         Prior to becoming unable to work, plaintiff worked as a correction officer for the Nassau County Sheriff's Department from August 1995 through January 2013. (AR at 214.) Plaintiff was injured at work on January 6, 2011, when an inmate fell on him while he was attempting to stop a fight. (AR at 368.) The incident resulted in injuries to plaintiff's hip, shoulder, and back (AR at 279, 368), and plaintiff received Workers' Compensation as a result of this injury from January 2011 to February 2012 (AR at 133, 136, 139). Plaintiff returned to work “in a light duty capacity” from February 2012 through January 2013, when he retired on disability pension. (AR at 44-45, 399.) At plaintiff's hearing before the ALJ in this case, he testified that he sustained injuries to his neck “from numerous inmate altercations, assaults . . . throughout [his career], ” and that his neck pain got worse after a motor vehicle accident in 2014. (AR at 45.)

         Plaintiff claimed that his disability onset date was July 4, 2012. (AR at 129.) At his hearing before the ALJ, he claimed that he was disabled because he was “limited to a less-than sedentary occupational life.” (AR at 36-37.) In a function report dated June 5, 2013, plaintiff reported that he did not need help taking care of his personal needs and grooming, could fix light meals, although he used to cook more “before [his] conditions began, ” and was able to do some light cleaning in the house. (AR at 221-22.) He stated that he needed help with all chores, and could no longer do outdoor chores. (AR at 222.) Plaintiff reported that he went outside daily, drove a car, and shopped for personal items and groceries about once a week. (AR at 222-23.) He stated, however, that he could not go to the gym, lift weights, or ride a bike. (AR at 223.) He reported that he was limited in what he could lift, and could only stand, walk, and sit for short periods of time.[1] (AR at 224-25.) Section C, discussing plaintiff's testimony at his hearing before the ALJ, includes additional information about plaintiff's personal and work history, injuries, and symptoms.

         B. Relevant Medical History

         As plaintiff summarizes, he has been diagnosed with lumbar herniations, bulging discs, stenosis, lumbar spondylosis, lumbar and cervical radiculopathy, facet arthritis, thoracic or lumbosacral neuritis or radiculitis, shoulder tendinitis, hypertension, and anxiety. (AR at 266, 269, 275-76, 280, 291, 295, 310, 314, 318, 322, 332, 388, 418, 463, 476.)

         1. Medical Evidence Before the July 4, 2012 Alleged Onset Date

         On January 6, 2011, plaintiff went to the Winthrop University Hospital emergency room with complaints of left shoulder, left hip, and left lower back pain after falling at work while trying to stop an inmate fight. (AR at 337-40, 368.) The emergency room doctor noted paresthesia in the legs and injuries to the shoulder, hip, and back with radiculopathy. (AR at 338.) Plaintiff was treated with a Medrol Dose Pack and referred for an orthopedic consultation. (Id.)

         On January 11, 2011, plaintiff visited Charles Ruotolo, M.D. (“Dr. Ruotolo”), at Total Orthopaedics & Sports Medicine (“Total Orthopaedics”). (AR at 368.) Plaintiff reported pain with lifting or strenuous activity after an injury at work. (Id.) Dr. Ruotolo noted that plaintiff reported a pain level of six out of ten in his left hip, left shoulder, and lower back radiating into his leg; had numbness/tingling down the posterior and lateral left thigh to the knee; and was tender to palpation of the left hip. (Id.) Plaintiff also reported that his left shoulder soreness was mild and had “pretty much resolved.” (Id.) Plaintiff was not working at the time, but intended to return to work when medically cleared. (Id.) An examination of plaintiff's hips showed normal gait; range of motion of 0 to 140 degrees in flexion and extension, 0 to 40 internal rotation, 0 to 45 external rotation, 0 to 60 abduction, and 0 to 30 adduction; normal motor strength; and intact sensation and reflexes. (AR at 369.) Dr. Ruotolo noted that plaintiff had no observable difficulties standing, walking, sitting, or arising from a seated position. (Id.) Dr. Ruotolo prescribed Naprosyn for pain and noted that plaintiff was to have a magnetic resonance imaging (“MRI”) scan of his lumbar spine, and referred him to Karen Avanesov, D.O. (“Dr. Avanesov”), for an evaluation of his spine. (AR at 370.) Dr. Ruotolo found that plaintiff was “temporarily totally disabled” pending MRI results. (Id.)

         Plaintiff's January 19, 2011 MRI showed: L3-L4 disc bulging with no more than mild bilateral neural foraminal stenosis; five millimeter “retrolisthesis of L4 on L5, ” L4-L5 disc bulging and central to left paracentral disc herniation resulting] in moderate bilateral neural foraminal stenosis without spinal canal compromise, and a small L4-L5 annular tear; and grade I anterolisthesis of L5 on S1 with bilateral chronic-appearing L5 spondylolysis, associated L5-S1 disc pseudo bulging and facet arthropathy resulting in mild right and moderate left-sided neural foraminal stenosis. (AR at 332.)

         On January 24, 2011, plaintiff returned to Total Orthopaedics and met with Dr. Avanesov, who reviewed his MRI results. (AR at 365.) Dr. Avanesov examined plaintiff and found plaintiff had normal gait and posture; spasms in the lower lumbar paraspinal muscles and tenderness to palpation, with more pain to palpation on the left side; range of motion of the back of 40 degrees in forward flexion, 20 in extension, 20 in left side bending or rotation, and 30 in right side bending or rotation; straight leg raise to 20 degrees on the left and negative on the right; full muscle strength and tone; normal neurological sensory testing, although plaintiff had deep dull pain and paresthesia in the left buttock and posterior thigh; and deep tendon reflexes of 2/2 on both sides. (AR at 365-67.) Plaintiff rated the level of pain in his left leg a five out of ten. (AR at 365.) He reported that his symptoms were exacerbated by bending and sleeping. (Id.) Dr. Avanesov diagnosed plaintiff with spinal instability at L 4-5 and L5-S1, left lumbar radiculopathy, and degenerative disc disease at L 4-5 and L5-S1. (AR at 366.) He found plaintiff was “temporarily totally disabled, ” prescribed Vicodin and Valium, and referred plaintiff for four weeks of physical therapy three to five times per week. (AR at 367.)

         On February 21, 2012, plaintiff saw Dr. Avanesov again and reported left leg pain, which was aggravated by sitting and sleeping, and which plaintiff said nothing, including physical therapy, alleviated. (AR at 362.) Plaintiff reported that his pain had increased to a level of seven out of ten. (Id.) Dr. Avanesov found spasms in the bilateral lumbar paraspinal muscles and left sciatic region; tenderness to palpation at the lumbar spine, especially around facet joints of the lower lumbar segment; impaired lumbar range of motion, with flexion to 40 degrees, extension to 20 degrees, and lateral bending and rotation to 30 bilaterally; and positive straight leg raise on the left at 20 degrees. (AR at 362-63.) He diagnosed plaintiff with L4-5 and L5-S1 left foraminal stenosis; L4-5 and L5-S1 facet hypertrophy; L4-5 and L5-S1 grade retrolisthesis; L5-S1 grade spondylolisthesis; L5 spondylosis; and L4-5 and L5-S1 degenerative disease. (AR at 363-64.) Dr. Avanesov recommended continuing with “conservative care” and another six weeks of physical therapy, prescribed Norco, and referred plaintiff for pain management and electromyography and nerve conduction velocity (“EMG/NCV”) studies of the lower extremities. (AR at 364.)

         On March 3, 2011, plaintiff saw Luis Alejo, M.D. (“Dr. Alejo”), at Total Orthopaedics. (AR at 357.) Dr. Alejo reviewed plaintiffs EMG/NCV results and found that the study was consistent with lumbar radiculopathy with greater involvement at the L4/5 level. (AR at 359.) He noted “persistent and radiating low back pain down [plaintiffs] left lower extremity associated with numbness and pain and spasms in the lower back as well as the lower extremity.” (AR at 268.)

         On March 4, 2011, plaintiff saw police surgeon Louis Lombardi, M.D. (“Dr. Lombardi”). (AR at 318.) Plaintiff complained of back pain radiating to the left buttock and lower extremity. (AR at 318.) Dr. Lombardi reviewed plaintiffs MRI and examined plaintiff, and found para lumbar tenderness with spasm; flexion to 60 degrees; positive facet load test; and dysesthesias in the left buttock and posterior thigh/leg. (AR at 318.) Dr. Lombardi diagnosed plaintiff with herniated discs at ¶ 4-5 and C5-6, facet arthritis, and chronic neck pain, and concluded that plaintiff was “unable to perform restricted assignment.” (Id.) The doctor recommended that plaintiff return in two weeks “to determine possible return to restricted assignment.” (Id.)

         On March 21, 2011, Dr. Avanesov examined plaintiff and found that his “physical examination [was] unchanged.” (AR at 355.) He noted continued complaints of lower back pain radiating to the left buttock and down his leg to his foot. (Id.) Plaintiff reported that his symptoms were aggravated by sitting, standing, and sleeping, and complained of some paresthesia and numbness in the left lower extremity. (Id.) Dr. Avanesov found that plaintiff had antalgic gait during the stance phase, positive straight leg raise on the left at 20 degrees, and full motor strength (neurovascular intact). (Id.) Dr. Avanesov recommended that plaintiff see a pain management specialist for lumbar epidural steroid injections, “since his pain is uncontrollable.” (Id.) He recommended that, if the injections failed to resolve plaintiff's pain, he schedule lumbar decompression and possible fusion. (AR at 356.)

         Plaintiff saw pain management physician Timothy D. Groth, M.D. (“Dr. Groth”), on March 30, 2011. (AR at 279.) Plaintiff reported pain from sitting for too long, standing, and sleeping, but stated that he had no problem walking. (Id.) Climbing stairs, coughing, and sneezing also aggravated plaintiff's pain. (Id.) Plaintiff reported that the lower back pain radiated down his lower left extremity, with a burning, aching, and tingling sensation. (Id.) He rated his pain a three to six out of ten, and reported that it interfered with sleeping, sports, housework, and exercise. (Id.) Dr. Groth reviewed plaintiff's MRI, and examined plaintiff and found lumbar spine flexion of 80 degrees and extension to 5 degrees, no significant spinal tenderness, positive left-sided straight leg raise, and that plaintiff was unable to toe walk on the left. (AR at 280.) Dr. Groth noted that his impression was lumbar radiculopathy. (Id.) From April 2011 to July 2011, Dr. Groth administered a series of injections. (AR at 274.) On August 23, 2011, Dr. Groth completed a Workers' Compensation Board form indicating that plaintiff had 100 percent temporary impairment. (AR at 290-91.)

         On August 24, 2011, orthopedic surgeon Stuart Kandel, M.D. (“Dr. Kandel”), performed an orthopedic evaluation at the request of the Workers' Compensation Board. (AR at 308-311.) Dr. Kandel noted that plaintiff complained of lower back pain radiating to his left buttock and left lower extremity. (AR at 309.) Plaintiff informed Dr. Kandel that he had not worked since his injury on January 6, 2011, and was applying for retirement. (Id.) Dr. Kandel examined plaintiff and found range of motion in the lumbar spine of 60 degrees in flexion, 20 degrees in extension, and 40 degrees right and left lateral flexion; no muscle spasm; normal sensation; no gross muscle weakness; 2 reflexes; and negative straight leg raise bilaterally. (Id.) Dr. Kandel reviewed plaintiff's medical records, including his MRI and records from Drs. Groth and Avanesov. (AR at 309-10.) Dr. Kandel diagnosed plaintiff with a lumbosacral sprain superimposed on degenerative disease of the lumbar spine with radiculopathy. (AR at 310.) He found that plaintiff had a “moderate partial disability which should be considered to be permanent in nature.” (Id.) Dr. Kandel found that plaintiff was capable of performing full-time work that did not require repeated bending or lifting of materials weighing more than ten to fifteen pounds. (Id.) Additionally, he noted that plaintiff was not capable of returning to his usual job and, specifically, that he was not capable of having direct prisoner contact. (Id.)

         Plaintiff saw Dr. Avanesov five times, approximately once a month, from March through September 2011. (AR at 341-56.) On June 29, 2011, Dr. Avanesov noted increased pain, that lumbar range of motion remained limited, and positive straight leg raise on the left at 30 degrees. (AR at 351-52.) He noted that plaintiff was due for his third epidural injection and prescribed Valium. (AR at 352.) On August 15, 2011, Dr. Avanesov found plaintiff's condition unchanged as to his lumbar, neck, and left leg pain, and continued to find limited range of motion and point tenderness to palpation in the lower lumbar spine, despite the injection the prior month. (AR at 348-49.) On September 19, 2011, Dr. Avanesov again found plaintiff's condition unchanged as to his pain, tenderness to palpation, and limited range of motion. (AR at 344.) At both the August and September 2011 visits, Dr. Avanesov offered plaintiff lumbar decompression and stabilization surgery, but noted that plaintiff wanted to continue with conservative care. (AR at 344, 349.)

         On September 29, 2011, Dr. Avanesov completed a Workers' Compensation report based on his September 19, 2011 examination, in which he diagnosed plaintiff with lumbago, thoracic or lumbosacral neuritis or radiculitis, and congenital spondylolisthesis, and reported that plaintiff had 100 percent temporary impairment. (AR at 341-42.)

         At a visit with Dr. Alejo on October 19, 2011, plaintiff reported that he was “very limited with respect to bending, lifting and walking” due to his pain. (AR at 422.) Dr. Alejo noted persistent lumbar tightness and that trigger points were present, very tight and guarded range of motion, and antalgic gait. (Id.) Dr. Alejo recommended a chiropractic consultation, and noted that plaintiff agreed to have one. (Id.) He also recorded that plaintiff was “100% disabled from work.” (Id.)

         Plaintiff saw Dr. Alejo again on December 7, 2011 and reported that he did not attend chiropractic care because his insurance company was not going to approve it. (AR at 423.) At this visit and a December 28, 2011 visit, Dr. Alejo adjusted plaintiff's pain medications. (AR at 423-24). At the December 7, 2011 visit, [2] Dr. Alejo “attempt[ed] to wean [plaintiff] off the Neurontin.” (AR at 423.) Then, on finding at the December 28, 2011 visit that plaintiff “was not able to tolerate the weaning without increasing his symptoms, ” Dr. Alejo put plaintiff back on his regular Neurontin dose. (AR at 424.) Dr. Alejo also referred plaintiff for a second opinion on pain management. (Id.) He noted in Workers' Compensation reports based on these examinations that plaintiff was “temporarily totally disabled, ” and diagnosed thoracic or lumbosacral neuritis or radiculitis. (AR at 382-83, 385-86.)

         On January 5, 2012, plaintiff visited Aristide Burducea, D.O. (“Dr. Burducea”), from Orthopedics Spine & Sports, who noted “decreased forward flexion, extension and lateral flexion” of the lumbar spine and positive straight leg raise on the left. (AR at 394-95.) Dr. Burducea diagnosed lumbar radiculopathy, degenerative disc disease, and facet arthropathy, and ordered an L5 and S1 transforaminal steroid injection. (AR at 394.) Dr. Burducea noted in a Workers' Compensation report based on this examination that plaintiff had 100 percent temporary impairment. (AR at 391-92.)

         On February 1, 2012, Dr. Alejo found that plaintiff had “significant discogenic findings with respect to his lumbar spine MRI inclusive of L3-L4 bulging disks, retrolisthesis of L4 and L5 with herniation as well as at ¶ 4-L5.” (AR at 425.) He also found an annular tear at ¶ 4-5, a disc bulge at ¶ 5-S1, tightness in the lumbar spine, trigger points, limited range of motion, and antalgic gait. (Id.) Dr. Alejo referred plaintiff for physical therapy, recommended another trial of epidural steroid injections, and noted that his opinion was that plaintiff was “100% disabled from his specific occupation.” (Id.)

         On February 17, 2012, impartial medical expert Gerald Greenberg, M.D. (“Dr. Greenberg”), completed a medical interrogatory regarding plaintiff's condition. (AR at 396.) Dr. Greenberg found that plaintiff's impairments did not meet an impairment in the “Listing of Impairments, ” and that plaintiff should be capable of sedentary work “within less than one year” of his January 2011 injury. (AR at 396-98.)

         On March 26, 2012, Dr. Avanesov wrote a “narrative report on [plaintiff].” (AR 399-401.) Dr. Avanesov noted that plaintiff returned to light duty work in February 2012. (AR at 399.) He also noted that plaintiff continued to complain of pain in his lower back and left leg that “ha[d] been constant ever since the injury and not improved despite extensive therapy, ” and which he rated a pain level of seven out of ten. (AR at 399-400.) Based on his physical examination that day, Dr. Avanesov found that plaintiff had significantly reduced lumbar range of motion, full muscle strength in his lower extremities, normal reflexes, numbness and paresthesia, no sensation to light touch and pinprick in his left L5 and S1 dermatomal distribution, and positive straight leg raise on the left at 30 degrees. (AR at 400.) He diagnosed plaintiff with left lumbar radiculopathy at L4-5 and L5-S1, mechanical lower back pain secondary to L4-5 retrolisthesis and L5-S1 spondylolisthesis, disc herniations, L5 spondylosis, degenerative disc disease involving the lower lumbar spine, facet hypertrophy at L 4-5 and L5-S1, and left L4-5 and L5-S1 neural foraminal stenosis. (Id.)

         Dr. Avanesov stated in this report that plaintiff was unable to continue working as a correction officer in his facility. (AR at 401.) He noted that plaintiff's functional restrictions for dynamic abilities, such as lifting, carrying, pushing, and pulling, should be reduced to a minimum, and that plaintiff needed to avoid climbing, bending, stooping, kneeling, and reaching. (Id.) He also found that plaintiff was limited to walking, sitting, and standing approximately one hour at a time with a prolonged rest in between. (Id.) He noted that plaintiff should be restricted to light activities requiring him to exert no more than twenty pounds of force occasionally and not more than ten pounds frequently. (Id.) He also indicated that plaintiff “sustained total moderate disability and will require surgical intervention in the future in order to treat his problem.” (Id.)

         Plaintiff saw Dr. Alejo on April 17, 2012 and May 29, 2012, and continued to complain of lower back pain. (AR at 426-27.) On April 17, 2012, plaintiff informed Dr. Alejo that his insurance company “is no longer approving any physical therapy.” (AR at 426.) An independent medical examiner physician from the insurance company had cleared plaintiff “to perform light duty only.” (Id.) Plaintiff told Dr. Alejo that this work bothered his back because there was no room to stretch. (Id.) He also told Dr. Alejo that he was afraid of attempting surgery. (Id.) Dr. Alejo's assessment was that “[a]t this point in time, [plaintiff] has failed conservative treatment.” (Id.) He noted, however, that plaintiff did not want another set of epidural injections, and was “afraid of the surgical procedure.” (Id.) Dr. Alejo again indicated that plaintiff was “100% disabled from performing his occupation as a corrections officer.” (Id.) Dr. Alejo completed another report for Workers' Compensation based on this visit, noting the same diagnoses as in past reports-thoracic or lumbosacral neuritis or radiculitis-and that plaintiff was temporarily totally disabled. (AR at 405.)

         On May 29, 2012, Dr. Alejo noted the same diagnoses as he had previously based on plaintiff's MRI, and summarized that plaintiff's three epidurals were not helpful, and that physical therapy helped, but only on a very temporary basis (and, regardless, plaintiff's insurance would no longer cover physical therapy). (AR at 404.) Dr. Alejo diagnosed plaintiff with chronic low back pain with radiculopathy and spasms secondary to disc herniation, as well as multilevel disc bulges, and noted that plaintiff was “100% disabled from performing his occupation.” (Id.) He also noted again that plaintiff had “failed conservative treatment” and was “deferring surgery at this time. He was scared of the procedure, I do understand.” (Id.)

         2. Medical Evidence After the July 4, 2012 Alleged Onset Date

         On June 4, 2012, [3] plaintiff went to the Winthrop University Hospital emergency room after injuring his right shoulder, and experiencing neck spasms. (AR at 411-17.) On June 5, 2012, Dr. Alejo wrote a note stating that, due to this injury, plaintiff was under his “active care” for a right shoulder rotator cuff injury and that, due to this injury, he was “totally disabled and unable to work until further notice.” (AR at 417.)

         Plaintiff had a right shoulder MRI taken on June 27, 2012. (AR at 418.) The MRI showed hypertrophic change of the acromioclavicular joint, prominent tendinosis of the supraspinatus tendon and focal bursal surface tear at the insertion, subchondral cystic degenerative change of the humeral head, and a small cyst in the adjacent soft tissue. (Id.)

         On July 6, 2012, plaintiff saw Robert Lippe, M.D. (“Dr. Lippe”), at Orlin & Cohen Orthopedic Associates.[4] (AR at 419.) Plaintiff reported that he injured his right shoulder at work during an altercation on June 4, 2012, when he was on restricted duty supervising inmates. (Id.) Dr. Lippe noted that plaintiff had no prior shoulder issues, and that the shoulder pain did not affect plaintiff's ability to sleep. (Id.) He also noted that plaintiff had therapy and an MRI and “now feels he's ready to return to work.” (Id.)

         Plaintiff had multiple visits with Dr. Alejo for his lower back pain from July 19, 2012 through August 15, 2013. (AR at 428-38, 492.) On July 19, 2012, plaintiff reported that his “episodes of pain ha[d] not improved[, ] in fact they are increasing, ” as were his spasms. (AR at 428.) Dr. Alejo stated, as before, that plaintiff was “100% disabled from his occupation.” (Id.) In describing his work, plaintiff stated that “they ha[d] him pushing buttons on the job at this time.” (Id.) This report does not discuss plaintiff's right shoulder condition. (Id.)

         On December 12, 2012, Dr. Alejo noted “[c]hronic persistent low back pain and radiculopathy for multilevel discogenic sources.” (AR at 431.) He also reported that plaintiff learned physical therapy exercises that he could perform at home to try to improve his range of motion, but could not lift any weights and was instructed to find a facility with an indoor pool where he could perform aerobic exercises without weight-bearing stress on his lower back. (Id.)

         On March 5, 2013, plaintiff reported to Dr. Alejo that he had retired. (AR at 433.) He informed Dr. Alejo that his pain “ha[d] not been getting worse, especially since he is now retired.” (Id.) Dr. Alejo still found plaintiff's lumbar spine to be stiff and range of motion limited. (Id.) On May 22, 2013, Dr. Alejo noted that plaintiff “still has persistent intermittent low back pain, ” as well as trigger points and limited range of motion. (AR at 438.)

         On August 15, 2013, plaintiff reported that he could not be active and was gaining weight in his retirement because of his back pain. (AR at 492.) Plaintiff still did not want surgery; Dr. Alejo noted that he was scared of the procedure. (Id.) Dr. Alejo recommended epidural injections for plaintiff's “acute severe pain” and weight watchers for weight loss. (Id.)

         On August 28, 2013, plaintiff saw Chaim Shtock, D.O. (“Dr. Shtock”), for a consultative orthopedic examination for the Social Security Administration Division of Disability Determination. (AR at 439-46.) Dr. Shtock does not discuss reviewing any of plaintiff's other medical records. (AR at 439-42.) Plaintiff complained of lower back pain ranging from five to nine out of ten. (AR at 439.) Plaintiff stated that his lower back pain radiated down his left leg with numbness and tingling; was aggravated by prolonged sitting, standing, and bending over; and was relieved by rest, refraining from aggravating activities, and over-the-counter anti-inflammatory medication. (Id.) Plaintiff also complained of tightness and stiffness in his neck that he typically experienced once a week, and which was aggravated by turning his neck. (Id.) Dr. Shtock noted that plaintiff's activities of daily living included that he was “independent” in cooking, light cleaning, laundry, shopping, showering, dressing, and grooming. (AR at 440.) Plaintiff reported that he watched television, listened to the radio, read books, went to doctor's appointments, and visited friends. (Id.)

         Dr. Shtock examined plaintiff at this visit and found that plaintiff appeared to be in no acute distress, had normal gait, walked on his heels and toes without difficulty, needed no help changing for the examination or getting on and off the examination table, and could rise from a chair without difficulty. (Id.) Plaintiff could not, however, squat beyond 40 percent. (Id.) Dr. Shtock found that plaintiff had intact hand and finger dexterity, and 5/5 right and 4 left grip strength. (AR at 441.) He found that plaintiff's cervical spine showed flexion to 40 degrees, extension to 30 degrees, side bending to 30 degrees bilaterally, and rotation to 55 degrees bilaterally, and plaintiff had no tenderness, paracervical pain, or spasm. (Id.) Dr. Shtock found that plaintiff had full range of motion in his upper extremities, full strength, no sensory abnormalities, and physiologic and equal reflexes. (Id.) He found that plaintiff's thoracic and lumbar spine showed flexion to 60 degrees, extension to 10 degrees, and lateral flexion and rotary movements to 20 or 25 degrees bilaterally. (Id.) Plaintiff reported left lumbar paraspinal tenderness, but had no spasm. (Id.) Straight leg raising was positive at 35 degrees bilaterally in the sitting position. (Id.) In plaintiff's lower extremities, Dr. Shtock found plaintiff had 4 muscle strength in the proximal and distal muscles bilaterally with no muscle atrophy or sensory abnormality, deep tendon reflexes in his left knee of 1, decreased sensation to light touch over the left leg and lateral aspect of the left foot, and no joint effusion, inflammation, or instability. (Id.) A cervical spine x-ray showed straightening. (Id.)

         Dr. Shtock noted in his “medical source statement” that plaintiff had moderate limitations for heavy lifting, squatting, crouching, frequent stair climbing, walking long distances, and frequent bending. (AR at 442.) Plaintiff had mild to moderate limitations for sitting and standing for long periods. (Id.) He had no limitations for performing overhead activities with both arms or for fine and gross motor ...


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