United States District Court, N.D. New York
Josephine Gottesman Dennis Kenny Law Counsel for Plaintiff
L. Kershner Social Security Administration Office of Regional
General Counsel - Region II Counsel for Defendant
MEMORANDUM-DECISION AND ORDER
NORMAN A. MORDUE, SENIOR UNITED STATES DISTRICT COURT JUDGE.
Brett P. filed this action under 42 U.S.C. § 405(g) and
1383(c)(3), challenging the denial of his application for
Social Security Disability (“SSD”) insurance
benefits. (Dkt. No. 1). The parties' briefs are presently
before the Court. (Dkt. Nos. 11, 18). After carefully
reviewing the administrative record, (Dkt. No. 8), and
considering the parties' arguments, the Court reverses
the denial decision and remands for further proceedings
consistent with this Order.
applied for disability benefits in May 2015, alleging that he
had been disabled since August 1, 2013. (R. 11). Plaintiff
claims he is disabled due to Stickler syndrome, hearing loss,
irritable bowel syndrome, and depression. (R. 507). The
Social Security Administration (“SSA”) denied
Plaintiff's application on August 20, 2015. (R. 364-79).
Plaintiff appealed that determination and requested a hearing
before an Administrative Law Judge (“ALJ”). (R.
394-95). The hearing was held on August 2, 2017 before ALJ
Asad M. Ba-Yunus. (R. 274-355). At this hearing, Plaintiff
appeared and testified, as did a Vocational Expert
(“VE”). (Id.). On October 20, 2017, the
ALJ issued a decision finding that Plaintiff was not
disabled. (R. 11-21). Plaintiff's subsequent request for
review by the Appeals Council was denied on October 2, 2018.
(R. 1-7). Plaintiff then commenced this action on November
30, 2018. (Dkt. No. 1).
Plaintiff's Background and Testimony
was born in 1983. (R. 19). He graduated from high school and
went on to study piano and psychology in college. (R. 19,
309-10). Plaintiff attended graduate school for a year and a
half where he studied vocational rehabilitation. (R. 1319).
Plaintiff was unable to complete the program due to his
medical conditions. (R. 294-95).
testified that in 2007-2008 he started to get tendinopathies
all over his body, including his hands, which made using a
computer difficult. (R. 299-301). Plaintiff testified that he
also started experiencing pain in his neck, arms, and groin.
(R. 301-02). Plaintiff became frustrated when his
doctors were unable to diagnose his condition. (R. 301).
Plaintiff testified that he would start jobs but then would
be forced to quit or be fired as a result of the pain caused
while performing his job duties. (R. 304). He stated that he
became “horribly depressed because I couldn't
figure out what was wrong with me.” (R. 310). Plaintiff
was ultimately diagnosed with a connective tissue disorder
associated with Stickler syndrome. (R. 309).
treat his chronic pain, Plaintiff received prolotherapy
injections to stimulate his connective tissue and strengthen
his joints. (R. 311). These injections allowed him to
continue his education and attend graduate school for a brief
time. (R. 292, 311). While he was interning during his
graduate studies, Plaintiff's tendinopathies worsened and
affected his hands, shoulders, and the back of his neck. (R.
312-13). Plaintiff testified that his pain symptoms, along
with fatigue and exhaustion, forced him to quit the
internship and withdraw from doing anything because he was
immobile and he was afraid of hurting himself.
(Id.). He continued with the prolotherapy injections
and was prescribed Fentanyl and Hydrocodone, but his
condition continued to worsen. (R. 316). Plaintiff testified
that he has tried various pain medicines but has been unable
to achieve relief. (Id.)
asserts that his nervous system was impaired causing
“brain zaps, ” shortness of breath, sweating with
the smallest amount of heat, nausea, increased sensitivity to
light and sound. (R. 316-17). Plaintiff reported the he
underwent a surgical procedure that further worsened his
condition. (R. 318). He testified that after his surgery he
suffered from an increasing number of flare-ups and his
relationship with his parents deteriorated due to his growing
dependence on them. (R. 321-22). Plaintiff claims that his
parents “had [him] committed” to Albany Medical
Center. (R. 318-19).
stated that when he was released from Albany Medical Center,
he went to live in a motel. (R. 322). Plaintiff testified
that he continues to have chronic pain and that he has
difficulty focusing when people speak to him. (R. 322-23). He
estimated he would have to stop to rest after walking sixty
to seventy yards. (R. 324). Plaintiff stated that repetitive
use of his hands continues to cause pain. (Id.). He
stated that he can only drive short distances in a car. (R.
325). Plaintiff said he must set aside twelve hours each day
to sleep because he cannot sleep for extended periods of time
and wakes up “exhausted, feeling like [you] just ran a
marathon when [you] just had 10 hours of sleep.”
(Id.). Plaintiff asserts that his prescribed
medication has resulted in weight gain, dizziness, and memory
problems. (R. 325-26).
reported that he lived with his parents for some time, but
recently moved into an apartment. (R. 288). Plaintiff stated
that his parents prepare most of his meals because repetitive
motions such as chopping and stirring cause him pain. (R.
526). Plaintiff stated that he has no problems with personal
care. (R. 524). He said he can “only lift light
items” and must “limit standing because of
sciatic pain.” (R. 529). He reported that
“sitting too long can cause sciatica” and that he
“can climb stairs but not frequently.”
(Id.). Plaintiff stated that he spends his days
reading, watching television, and listening to music. (R.
527). Plaintiff uses hearing aids, contact lenses, and hand
splints. (R. 530). He reported that he has no problems
getting along with others and noted that stress or changes in
schedule can cause him difficulty completing tasks. (R.
Medical Evidence of Disability
disability claim stems from complaints of widespread joint
pain, mobility issues, chronic and severe neck pain, muscle
spasms, constant fatigue, sensorineural hearing loss,
irritable bowel syndrome, spine problems, and leg and foot
issues. (Dkt. No. 11, p. 13). He also reports suffering from
anxiety, depression, agitation, impaired attention span,
sleep problems, and suicidal ideation. (Id.).
Plaintiff claims that he has struggled with these conditions
since 2008 and has received treatment from a number of
began receiving treatment for ear and hearing problems in
2008, which led to multiple surgeries for tympanostomy
between 2011 and 2015. (See generally R. 747-887).
Plaintiff has worn hearing aids since 2008. (R. 749). In
2013, test results showed chronic bilateral sensorineural
hearing loss that was “moderate to severe” in the
right ear and “mild to moderately severe” in the
left ear. (R. 846).
Dr. Mikhail Strut
November 2013, Plaintiff presented to Dr. Mikhail Strut for
treatment of his chronic pain symptoms. (R. 918-20).
Plaintiff reported that he had generalized pain throughout
his body for many years and had previously been treated with
prolotherapy by another doctor. (R. 918). Plaintiff reported
that his current pain was a six on a ten-point scale but
noted that it typically ranged anywhere between a five and a
ten. (Id.). Dr. Strut diagnosed Plaintiff with:
chronic cervical spine pain; cervical ligamentous
dysfunction; cervical muscle spasm; cervical enthesopathy;
cranio-cervical headaches; lumbar enthesopathy; lumbar muscle
spasms; sacroiliitis; and chronic lumbar pain. (R. 919). Over
the next several years, Dr. Strut treated Plaintiff's
pain symptoms with prolotherapy injections throughout his
body. (See generally R. 889-928). Dr. Strut's
treatment records frequently note Plaintiff's depressed
mood and flat affect. (See e.g., R. 899, 912, 921).
Dr. Howard Philip Levy
April 2015, Plaintiff was seen by Dr. Howard Philip Levy at
Johns Hopkins Medical Center for a genetic evaluation for
Ehlers Danlos syndrome and Stickler syndrome. (R. 930- 35).
Dr. Levy diagnosed Plaintiff with Stickler syndrome based on
“[h]is personal and family history of sensorineural
hearing loss and high myopia, combined with his flat facial
profile, very high/narrow palate, submucous cleft palate, and
aches [and] pains . . . .” (R. 933). With regard to
Plaintiff's pain symptoms, Dr. Levy wrote that
“pain is a common problem in Stickler syndrome, ”
and noted that “there is no simple solution.”
(Id.). Dr. Levy then listed a number of
recommendations that Plaintiff should follow, including: (1)
avoidance of high-impact activity and resistance exercise;
(2) improvement of joint stability by increasing muscle tone
through low resistance exercise like walking, swimming, and
yoga; (3) recognizing and not exceeding current physical
limitations by minimizing resistance and avoiding excess
repetition; and (4) attending physical therapy. (R. 934). Dr.
Levy also diagnosed Plaintiff with asthma and congenital
bilateral sensorineural hearing loss. (Id.).
Dr. Manish Saha
2015, Plaintiff presented to Dr. Manish Saha complaining of
continued joint pain. (R. 1687-91). Dr. Saha noted that
Plaintiff was in graduate school but had recently taken
medical leave due to difficulties with pain and an inability
to stay on top of his schoolwork. (R. 1689). Dr. Saha
confirmed Plaintiff's Stickler syndrome diagnosis and
also diagnosed Plaintiff with depression. (R. 1689-90).
Plaintiff saw Dr. Saha again in June and July of 2015 for
treatment of his pain symptoms. (R. 1678-86). Dr. Saha noted
that “there is no treatment for [Stickler syndrome]
other than ongoing therapy and managing symptoms.” (R.
1681). Dr. Saha prescribed a Fentanyl patch and a neck brace
to help with Plaintiff's neck pain. (R. 1685).
continued to see Dr. Saha through March 2017 for his
pain-related symptoms. (R. 1911-61). The medical records show
that Plaintiff consistently complained of generalized pain
symptoms and that he continued to experience fatigue and
difficulty sleeping. (See e.g., R. 1911, 1914,
1931-32). Dr. Saha saw Plaintiff for a preoperative visit on
March 13, 2017. (R. 1959-61). Plaintiff underwent surgery for
a spinal fusion surgery on March 28, 2017. (R. 1973-41).
After the operation, Plaintiff continued to complain of the
same symptoms he had prior to the surgery. (R. 1983-84).
Doctors determined that Plaintiff might also benefit from
additional surgery to fuse other areas of his spine.
Dr. Ernest Enzien
2016, Plaintiff was seen by Dr. Ernest Enzien for his primary
care. (R. 1764- 67). Dr. Enzien reported that Plaintiff
suffered from Stickler syndrome, depression and anxiety and
noted that his prognosis was “guarded.” (R.
1764). Plaintiff suffered from pain in all of his joints that
worsened for no apparent reason. (Id.). Plaintiff
reported that his pain was generally a six or seven on a
ten-point scale. (Id.). Dr. Enzien noted that
Plaintiff's condition would be expected to last more than
twelve months and that Plaintiff's depression and anxiety
were affecting his physical condition. (Id.). Dr.
Enzien noted that Plaintiff suffered from muscle weakness and
chronic pain and fatigue. (R. 1765). He also determined that
Plaintiff had “significant limitations” with
reaching, handling, and fingering. (R. 1766). Dr. Enzien also
found Plaintiff's condition would cause him to be
off-task for at least 25 percent of the ...