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Sandra M. Cabrera v. Michael J. Astrue

April 20, 2011


The opinion of the court was delivered by: Magistrate Judge Sheila Finnegan


Plaintiff Sandra M. Cabrera seeks to overturn the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. 42 U.S.C. §§ 416, 423(d). The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and have now filed cross-motions for summary judgment. After careful review of the record, the Court now denies Plaintiff's motion and grants the Commissioner's motion.


Plaintiff applied for DIB on March 8, 2007, alleging that she became disabled on January 5, 2005 from carpal tunnel syndrome, arthritis, and swelling in the joints and hands. (R. 139, 159.) The Social Security Administration ("SSA") denied the application initially on April 26, 2007, and again on reconsideration on August 1, 2007. (R. 72-73, 78-82, 88-91.) Pursuant to Plaintiff's timely request, Administrative Law Judge ("ALJ") Mona Ahmed held an administrative hearing on March 18, 2009. The ALJ heard testimony from Plaintiff, who appeared with counsel, and from vocational expert ("VE") Frank M. Mendrick.

A little more than four months later, on July 27, 2009, the ALJ found that Plaintiff is capable of performing a significant number of unskilled sedentary jobs available in the national economy and, thus, is not disabled. (R. 16-25.) The Appeals Council denied Plaintiff's request for review on May 24, 2010, and Plaintiff now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner. (R. 1-3.)

Plaintiff challenges that decision on the grounds that the ALJ made flawed assessments regarding her residual functional capacity and her credibility, and relied on improper VE testimony. As explained below, the Court finds substantial evidence to support the ALJ's conclusions, including that Plaintiff is capable of frequent handling and fingering, her complaints of pain lack overall consistency and are not fully credible, and there are a significant number of jobs available that she can perform.


Plaintiff was born on July 18, 1965, and was 44 years old at the time of the ALJ's decision. (R. 154). She has a high school education and lives with her husband and two children. (R. 33, 166). Plaintiff worked for nearly 13 years as a general manager of a first aid supply company for school nurses, but her position was eliminated on November 30, 2004. (R. 157, 183). She did not work after that date, and claims that she became disabled shortly thereafter on January 5, 2005.

A. Medical History

1. Carpal and Cubital Tunnel Syndrome

Plaintiff first complained of pain and numbness in both hands and wrists when she saw her family physician, Dr. Robert Winiecki, on January 5, 2005.*fn1 (R. 598). Dr. Winiecki referred Plaintiff to Dr. Christopher R. Glock of M&M Orthopaedics, Ltd., who examined her on February 4, 2005 and diagnosed "[r]ight-sided double crush syndrome with costoclavicular and carpal tunnel syndrome, as well as cubital tunnel on the right," "periclinical left wrist carpal tunnel syndrome," and "bilateral thumb trigger digits." (R. 258-60). Dr. Glock recommended Aleve, wrist braces and physical therapy. (R. 260-61). On February 25, 2005, Dr. Glock administered a steroid injection to help alleviate Plaintiff's pain, and instructed her to return in four weeks. He indicated that her "work status remains full, although she is currently not at work." (R. 258).

Plaintiff next saw Dr. Glock on March 25, 2005. She reported good relief from the injection and said that she was "happy" with the 20% to 30% improvement she felt. (R. 255-57). At a follow-up visit on April 22, 2005, Plaintiff decided to proceed with a right carpal tunnel release in the hopes of achieving more permanent relief. (R. 253-55). Dr. Glock performed the procedure on May 10, 2005, and six days later on May 16, 2005, Plaintiff was healing well and "very happy with how [the procedure] is working so far." (R. 252, 279-80). Plaintiff remained on "off work" status until June 20, 2005 when she returned to "full" work status pending a left carpal tunnel release. (R. 250-51).

On July 7, 2005, Dr. Glock performed surgery on Plaintiff's left wrist. (R. 277-78). A few days later, on July 11, 2005, she was doing "very well" but still had some numbness and tingling in the middle, ring and small fingers of her left hand. (R. 247-48). Dr. Glock's colleague, Dr. Andrew Kim, removed Plaintiff's stitches on July 20, 2005, and on August 22, 2005, Dr. Glock released her to return to regular work activities. Plaintiff was still experiencing symptoms in her middle, ring and small fingers, however, and Dr. Glock stated that she "may very well require surgical treatment for the right cubital tunnel." (R. 245, 247).

Dr. Glock relocated his practice after that time so Plaintiff started seeing Dr. Brian A. Murphy of M&M Orthopaedics on August 31, 2005. Dr. Murphy diagnosed right cubital tunnel syndrome and recommended surgical intervention. (R. 244-45). Plaintiff underwent right subcutaneous ulnar nerve transposition on September 13, 2005. (R. 275-76). At a follow-up visit with Dr. Murphy on September 26, 2005, Plaintiff was "doing quite well," and reported that the "numbness and tingling in her fingers have almost resolved completely."

(R. 242-43). On October 24, 2005, Dr. Murphy indicated that with respect to Plaintiff's right hand, he "would be happy to allow her to return to work." She still exhibited symptoms in her left hand, however, and Dr. Murphy instructed her to return in four to six weeks for further assessment. (R. 241-42).

By December 2005, Plaintiff was still experiencing left hand numbness and tingling, and a December 16, 2005 nerve conduction study was "suggestive of very early minimal ulnar compressive mononeuropathy on the left." (R. 269-70). Dr. Murphy concluded that Plaintiff would benefit from a left subcutaneous ulnar nerve transposition to address her left cubital tunnel syndrome. (R. 240). Dr. Murphy performed the surgery on January 12, 2006, and on February 24, 2006, Plaintiff reported only occasional pain when she engaged in significant lifting, and stated that the numbness and tingling had resolved completely. Dr. Murphy released Plaintiff to "her full duties at work" at that time. (R. 238, 273-74).

On April 4, 2006, Dr. Jeffrey E. Coe examined Plaintiff in connection with a workers' compensation claim she had filed based on "[r]epetitive trauma to both hands." (R. 128, 597-605). Plaintiff exhibited normal range of motion in her elbows, normal range of motion in her wrists except for a five degree loss of radial and ulnar deviation on the left side, negative Tinel's and Phalen's signs*fn2 at the right wrist, negative Phalen's sign and equivocal Tinel's sign at the left wrist with only localized tingling, grossly intact sensation with associated tingling dysesthesia*fn3 on the flexor surface of the left first through fifth fingers, grossly intact peripheral pulses of the upper extremities, and left hand tingling and pain with grip strength testing. (R. 602-04). Five months later, on September 26, 2006, Plaintiff settled her workers' compensation claim. The settlement order indicated that Plaintiff was "temporarily totally disabled from 5/10/05-6/20/05; 7/11/05-8/19/05; 9/13/05-2/26/06." (R. 128-29).

2. Treatment for Elbow, Back and Neck Pain (Dr. Karlsson)

On October 26, 2006, Plaintiff had a lumbar spine radiograph that showed multilevel degenerative changes, most pronounced at the L5-S1 level. (R. 505). Plaintiff sought treatment again shortly thereafter on November 16, 2006 due to upper and lower back pain. (R. 237-38). Dr. Troy R. Karlsson of M&M Orthopaedics observed that Plaintiff was significantly overweight and discussed weight loss options with her. On examination, Plaintiff had motor strength of 5/5, full sensation, symmetric reflexes to her lower extremities, and negative straight leg raise signs. Dr. Karlsson noted that she had "significant degenerative disc disease at several levels with disc space narrowing and end plate osteophytes," and he recommended a course of physical therapy and back exercises. (Id.).

Plaintiff returned to Dr. Karlsson on November 27, 2006 complaining of occasional pain in her right hand, and an absence of full function in her left hand. (R. 236). Dr. Karlsson observed "a Tinel sign along the course of the ulnar nerve near the wrist," "intact intrinsic function," "mildly positive Spurling test,"*fn4 and no changes in sensation with flexion compression test. (R. 237). He stated that Plaintiff "may have an overlay of cervical radiculopathy" in addition to prolonged healing of the ulnar nerve, but recommended observation only unless further problems arose. (Id.). Shortly thereafter, on December 11, 2006, Plaintiff called Dr. Karlsson because her neck and back pain were constantly at a level of 8 or 9 out of 10. Plaintiff reported taking only Lodine at that time, and Dr. Karlsson advised her to add Ultracet. (R. 236).

On December 15, 2006, Plaintiff saw Dr. Karlsson again for her upper shoulder and back pain, plus additional pain down the right leg and left arm. (R. 235). Plaintiff continued to exhibit motor strength of 5/5 to her lower extremities, symmetric reflexes and no gross loss to the upper extremities. She had some discomfort with a straight leg raise test on the right into the thigh, however, and pain between her shoulder blades. (R. 235-36). Dr. Karlsson ordered an MRI of the cervical spine, which Plaintiff had on December 21, 2006. The test was negative for disc herniation, and the left-sided neural foramina appeared patent. At the same time, there was "posterior lateral right sided spur which narrows the right sided neural foramina C3-C4 level." (R. 271-72). An MRI of the lumbar spine performed the same day showed multilevel small disc bulges but no herniation. The test further revealed "mild right sided neural foraminal narrowing at the L5-S1 level secondary to far lateral disc bulging." (R. 300-01, 323-24).

Dr. Karlsson reviewed the MRI results with Plaintiff on December 29, 2006. He noted "some slight neuroforaminal narrowing" at L5-S1 and "mild narrowing" at C3-C4, but "[n]o severe changes." (R. 235). On physical examination, Plaintiff exhibited motor strength of 5/5, full sensation, symmetric reflexes and negative straight leg raise signs. Dr. Karlsson determined that in the absence of evidence of severe disc herniations or bulges, Plaintiff's treatment should focus on pain management. (Id.).

3. Continued Treatment for Elbow, Back and Neck Pain (Drs. Cavalenes, DePhillips and Chami)

On January 4, 2007, Plaintiff started seeing Dr. Mark P. Cavalenes of Community Orthopedics. Her "biggest problem" at that time was low back and left elbow pain, though she also complained of residual numbness in three fingers of her left hand. (R. 298). Dr. Cavalenes diagnosed pain syndrome, arthritis of the elbow, fibromyalgia, and status-post bilateral carpal tunnel syndrome and ulnar nerve transpositions. He recommended a short course of cortisone, with an injection to her elbow. (R. 297). One week later, on January 11, 2007, Plaintiff's back was not any better and she could barely flex to mid-calf. Her left arm and elbow were 25% to 30% better, however, and she had full range of motion from 0 to 140 degrees. (R. 296). Dr. Cavalenes observed that Plaintiff's grip strength in her left hand was actually stronger, she had full wrist flexion-extension, and supination-pronation was 90/90 without any discomfort. He gave Plaintiff another elbow injection and recommended observation. (Id.).

By January 25, 2007, Plaintiff's elbow discomfort was no better. Dr. Cavalenes diagnosed "[r]esolving elbow arthritis and persistent lateral epicondylitis [inflammation of a rounded projection at the end of a bone]," and gave her another cortisone injection. (R. 294). Plaintiff's elbow pain returned on February 8, 2007, and this time Dr. Cavalenes diagnosed hypersensitivity secondary to inflammation in the elbow, chronic pain syndrome, and "[l]ateral epicondylitis, resolving, left arm." (R. 291). Plaintiff received another injection in her elbow, and Dr. Cavalenes referred her to Dr. George E. DePhillips for a neurosurgical consultation. (R. 291, 463). On February 12, 2007, Dr. DePhillips opined that Plaintiff had degenerative disc disease at multiple levels of her spine as well as inflammation, and stated that her only option was epidural steroid injections. (R. 463).

When Plaintiff saw Dr. Cavalenes again on February 22, 2007, her right arm was 20% better, and she had full range of motion from 0 to 140 degrees with only mild discomfort with the last 20 degrees of flexion, as well as full pronation and supination of 90/90. Dr. Cavalenes diagnosed "[p]ain syndrome resolving inflammatory process secondary to nerve transposition both elbows more on the left than the right." (R. 288).

The next day, on February 23, 2007, Plaintiff started seeing Dr. Antoine Chami of Pain Care Specialists, L.L.C., for help with her back and neck pain. Dr. Chami found that Plaintiff's lower back was nontender to palpation, but she had "significant decrease in range of motion to extension at less than 10 degrees and forward flexion at approximately 30 to 45 degrees." Left-sided flexion elicited mid low back pain, right-sided flexion caused radiating pain into the right buttock, and Plaintiff exhibited an antalgic gait favoring the right side. (R. 310). A straight leg raise test was positive bilaterally at 45 degrees on the left with mid low back pain, and 30 to 45 degrees on the right with radiating pain in the right buttock and hip. Plaintiff could elevate on her heels and toes without limitation, however, and had full motor strength of 5/5, intact sensation "in all the major dermatomes of the lower extremity," and deep tendon reflexes of 2 (normal) on both sides. (R. 311). Dr. Chami diagnosed degenerative disc disease and lumbosacral radiculopathy, and proceeded with a trial of selective nerve root injections at L5-S1. (R. 308-09, 311).

Plaintiff went for a follow-up visit with Dr. DePhillips on March 14, 2007. She reported that her last steroid injection did not relieve her lower back pain, which she described as a level 7 to 8 out of 10, and she complained of neck and interscapular pain and pain radiating into both upper extremities. Her leg pain had improved significantly, however, and she planned to start physical therapy for her neck pain and degenerative cervical disc disease. Although he had only seen Plaintiff once before, Dr. DePhillips opined that she was "not capable of gainful employment and is permanently disabled." (R. 462).

Plaintiff began physical therapy with ATI on March 20, 2007, but was ultimately discharged on June 28, 2007 because she was not progressing. (R. 471-75). In the meantime, on March 22, 2007, Plaintiff returned to Dr. Cavalenes and reported continued discomfort in her left arm, a "little" discomfort in her right arm, but no forearm pain. She also complained of "some pain and stiffness in her hand," which Dr. Cavalenes believed was "more just inflammation." Dr. Cavalenes found moderate tenderness over the medial epicondyle on the left, mild tenderness on the right, and slight tenderness ...

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