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Cody v. Astrue

October 6, 2010

JOSEPH M. CODY, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Michael P. McCUSKEY Chief U.S. District Judge

OPINION

Plaintiff Joseph M. Cody appeals from the denial of his application for Social Security Disability Insurance Benefits (Disability Benefits). 42 U.S.C. §§ 416(I), 423. This appeal is brought pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, the Decision of Defendant Commissioner of Social Security is reversed and remanded.

STATEMENT OF FACTS

Cody was born on January 6, 1956. He completed the twelfth grade. He formerly worked as a printing press operator. He stopped working on December 10, 2003. In August 2007, he tried working a desk job at a collection bureau, but quit after four days because of back pain. Answer to Complaint (d/e 4), attached Certified Transcript of Proceedings Before the Social Security Administration (R.), at 79A, 160.

Cody suffered from osteoarthritis in his knees, degenerative problems in his back, and a left shoulder injury. Dr. Karolyn Senica, M.D., performed a left knee arthroscopy with medial meniscectomy on Cody in December 2002. R. 503. Cody had significant degenerative arthritis in his knee. R. 503.

On July 24, 2003, Cody injured his left shoulder at work. Cody saw Dr. Senica, who referred him for physical therapy. In August 2003, Dr. Senica also injected Hyalgan into Cody's knees to relieve pain from the arthritis. R. 411. Cody started the physical therapy on his shoulder on August 26, 2003. R. 401-06. Cody was ultimately referred to Dr. Rodney Herrin, M.D., for shoulder surgery.

On December 11, 2003, Dr. Herrin performed a left shoulder arthroscopy on Cody. R. 509. Cody went to see Dr. Herrin again on April 12, 2004. At that time, Dr. Herrin recommended that Cody continue physical therapy sessions. R. 504. Cody continued physical therapy sessions through August 2004. R. 282-469.

On April 13, 2004, Cody went to see Dr. Senica for his knees. Cody was six feet tall and weighed 300 pounds. Dr. Senica's treatment notes state that Cody walked with a limp and had moderate joint effusion. She found tenderness along the medial joint line, medial femoral condyle and along the medial patellofemoral articulation. R. 503. X-rays showed nearly bone on bone deformity involving the medial compartment, and also, some patellofemoral arthrosis with osteophyte formation in joint space narrowing as well. Dr Senica diagnosed degenerative arthritis of the left knee, moderately severe. The notes state, "I also discussed with him how important weight loss would be for his knees as well." R. 503.

On May 25, June 1, and June 8, 2004, Dr. Senica administered Hyalgan injections into Cody's left knee to relieve the pain. R. 499-501. Dr. Senica noted that she informed Cody's physical therapist that he should avoid deep squats, kneeling or climbing stairs. Dr. Senica told the therapist that lifting would be all right if Cody was not required to bend over or squat. Dr Senica told the therapist that normal walking was okay. R. 500.

After Cody's June 2004, work hardening physical therapy session, Cody's physical therapists reported that Cody was performing at a "medium physical demand level in terms of lifting floor to tabletop height, however lifting tolerances decrease significantly when approaching shoulder height.

R. 459. The therapist also stated that Cody's "ability to reach to lower levels is compromised . . . due to ongoing treatment of left knee dysfunction." R. 459. The physical therapist also noted that Cody performed the exercises during the physical therapy session with little or no antalgic behavior. R. 457. The June 14-18, 2004, physical therapy summary stated that Cody could walk for one to one and one-half miles at a quick pace. R. 454.

Cody went to see Dr. Senica on August 3, 2004. At that time Cody walked without a significant limp. Cody did not have any significant joint effusion. He still had some tenderness and pain. Dr. Senica told Cody that he was in a difficult situation because he already had arthroscopy and Hyalgan shots and he was too young for knee replacement surgery. Dr. Senica prescribed Bextra, an anti-inflammatory. Dr. Senica also noted, "He really needs to work on weight loss." R. 497.

On August 5, 2004, Cody's physical therapist issued an Occupational Therapy Report. The report stated that Cody weighed 319 pounds. R. 420. The report included a functional capacity evaluation. R. 418. The functional capacity evaluation recommended that Cody could sit for four to six hours in a workday, stand for four to six hours in a workday, walk three to five hours in a workday, occasionally lift 35 pounds to shoulder height and 15 pounds overhead, and occasionally carry 50 pounds. R. 418. On August 12, Dr. Herrin wrote on a prescription pad that the limitations set forth in the August 5, 2004, report were permanent work restrictions for Cody. R. 471.

Cody went to see Dr. Senica on August 19, 2004, after he injured his right knee. Dr. Senica found a small joint effusion and possible tear of the medial meniscus in the right knee. X-rays also showed some mild to moderate joint space narrowing and some patellofemoral arthritis with some small osteophytes and some mild narrowing. R. 494.

On September 24, 2004, Dr. Senica wrote a note listing work restrictions for Cody. Dr. Senica stated that he needed to avoid climbing ladders, kneeling, squatting, running, jumping, and high impact activities. Dr. Senica stated that he needed to limit his use of stairs, should not stand for more than one hour at a time, and should lift no more than twenty-five to thirty pounds. R. 470. She stated that Cody would do best with a desk job. R. 470.

On December 22, 2004, Cody filed his application for Disability Benefits. Cody alleged that he had been disabled since December 10, 2003.

R. 79A.

On January 26, 2005, Cody was examined by agency physician Dr. Vittal V. Chapa, M.D. Cody weighed 334 pounds at the time of the examination. Dr. Chapa found crepitation in both knees, but full range of motion in Cody's hips and knees and no difficulty with ambulation. Cody had decreased range of motion in his left shoulder and full range of motion in his right. Cody had good hand grip bilaterally and could perform both fine and gross motor manipulations with both hands. Dr. Chapa diagnosed status post bilateral shoulder surgery, decreased range of motion of left shoulder, and osteoarthritis in both knees. Dr. Chapa did not have any medical records to review before examining Cody. R. 483-85.

On February 9, 2005, Dr. Towfig Arjmand, M.D., reviewed the medical records and prepared a Residual Functional Assessment of Cody. Dr. Arjmand noted that Cody weighed 334 and had a body mass index (BMI) of 34.1. R. 519. Dr. Arjmand opined that Cody could perform light work with occasional postural limitations and overhead reaching with the left arm. R. 513-15. On June 15, 2005, Dr. Vidya Madala, M.D., concurred with this assessment. R. 521.

On February 22, 2005, Cody went to see Dr. Senica for knee pain. Cody weighed 325 pounds at the time of this examination. Cody walked with a limp. X-rays showed "basically bone-on-bone deformity involving the medial compartments" of both knees. R. 492. His left knee was worse because of osteophyte formation. Cody had patellofemoral arthrosis bilaterally with narrowing and osteophyte formation. Dr. Senica concluded that Cody had severe degenerative arthritis in both knees and moderate to moderately severe patellofemoral arthrosis. R. 492. Dr. Senica prescribed anti-inflammatories, and stated she would try to get insurance approval for more Hyalgan injections, but that if these treatments did not work he would need knee replacement surgery. She also stated, "In addition, he really needs to work on weight loss and this was discussed with him again at length today." R. 493.

On June 7, 2005, Cody saw Dr. Senica again. R. 544-45. Dr. Senica stated in her notes that Cody suffered from severe pain, had extreme difficulty getting out of the chair, could not walk, had pain at night, experienced poor sleep, and had trouble with stairs. She found that he had difficulty getting out of a chair, walked with a limp and had joint effusion. Dr. Senica recommended total knee replacements. She also stated, "We, again, discussed about weight ...


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