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Sharon A. Wyatt v. Michael J. Astrue

June 1, 2011


The opinion of the court was delivered by: Jeffrey T. Gilbert Magistrate Judge


Claimant Sharon A. Wyatt ("Claimant") brings this action under 42 U.S.C. § 405(g) seeking review of the decision by Michael J. Astrue, Commissioner of Social Security ("Commissioner"), denying Claimant's application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Title II of the Social Security Act, 42 U.S.C. § 404(a). This matter is before the Court on Claimant's motion for summary judgment [Dkt.#12]. Claimant argues that the Administrative Law Judge's ("ALJ") decision denying her application for DIB and SSI benefits should be reversed and/or that the case should be remanded for further proceedings. Memorandum In Support Of Motion For Summary Judgment [Dkt.#13]. Claimant raises the following issues: (1) whether the ALJ erred in finding Claimant performed substantial gainful activity; (2) whether the ALJ failed to follow the treating physician rule; and (3) whether the ALJ failed to properly evaluate Claimant's credibility.

For the reasons set forth below, Claimant's motion is granted. The decision of the Commissioner of Social Security is reversed, and this matter is remanded to the Social Security Administration for further proceedings consistent with this Memorandum Opinion and Order.


A.Procedural History

Claimant initially filed for DIB and SSI on April 15, 2005, alleging a disability onset date of March 12, 2004. R. 107. The Social Security Administration ("SSA") initially denied her application. R. 141. Claimant then filed a request for reconsideration, which the SSA denied on May 2, 2006. R. 138-140. Shortly thereafter, Claimant requested a hearing before an ALJ. R. 137.

On January 3, 2008, Administrative Law Judge Arthur Cahn ("ALJ") presided over a hearing at which Claimant appeared with her attorney, Brian Woodruff. R. 329. Claimant testified at the hearing. R. 330. The ALJ conducted the hearing via teleconference from Sacramento, California, while Claimant testified from Chicago, Illinois. R 107. No medical or vocational experts testified live. On March 21, 2008, the ALJ rendered a decision that Claimant was not disabled under the Social Security Act. R. 107-118. Specifically, the ALJ found Claimant had "engaged in substantial gainful activity since March 12, 2004, the alleged onset date" and, moreover, that "Claimant has the residual functional capacity to perform the full range of sedentary work. . . ." R. 109-114.

Claimant then filed for review of the ALJ's decision before the Appeals Council. R. 103. On July 27, 2008, the Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner. R. 4-6. Claimant subsequently filed this action for review pursuant to 42 U.S.C. § 405(g).

B.Hearing Testimony - January 3, 2008

1.Sharon Wyatt - Claimant

At the time of the hearing, Claimant was 49 years old. R. 331. Claimant completed school through the 12th grade and had past relevant work experience as a filing clerk. R. 332. In addition to filing, Claimant's prior work experience included data entry and credit research. Id. Claimant claims she has not worked since March of 2003 or 2004. R. 189, 332.*fn1 Claimant testified that she stopped working because she "was having a lot of difficulty with [her] illness," specifically her back. R. 332.

At the hearing, Claimant testified that pain in her back, knee, leg, and buttocks prevent her from working. R. 332-334. To treat her pain, Claimant visited her doctor, a surgeon, a chiropractor, a physical therapist, and a pain specialist. R. 96-97, 338. Claimant testified that Dr. DeLeon, her treating physician, and Dr. Singa, her treating surgeon, reviewed her most recent MRI and told Claimant that her back had deteriorated since they first began treating her.

R. 342. To treat her back, Claimant has had steroid shots and taken pain medication. R. 335, 338-339. Claimant testified that the steroid shots relieved the pain for a short while but, after an hour or two, the pain would return. R. 338-339. Claimant also testified that the medication makes her sleepy and drowsy. R. 335. When Claimant takes her medication, the pain eases, but still lingers. R. 334.

Claimant's pain makes it difficult for her to lift, carry, walk, stand, or sit. R. 335, 337. Claimant testified that she cannot sit or stand for long periods of time. R. 333. When she is sitting, she feels pain from just above her belt line radiating down to her buttocks. Id. Claimant feels pain that is "a lot of pressure like something is going to pop." Id. Claimant also feels pain in her leg when she is sitting. R. 335. Sometimes Claimant feels pain that travels "through the butt down in [her] leg, and some days it is up in the middle part of the back." R. 334. Claimant can stand still for about five minutes, but she must lean against something to do so. R. 336. Claimant testified that she had problems lifting and carrying groceries except for small amounts.

R. 337. Furthermore, during a 9:00 am to 5:00 pm work day, Claimant testified she must lie down five out of the eight hours. R. 338.

Claimant has made efforts to alleviate her pain. Claimant tried to lose weight to relieve the pain and has even followed diets and looked into surgery to help her lose weight though ultimately Claimant did not have surgery. R. 339. Claimant tried physical therapy to ease the pain. R. 340. Claimant went to physical therapy for two months at the time of the hearing. R. 340-341. Physical therapy relieved the pressure and pain while she was at physical therapy, but an hour or two after she came home from physical therapy, she would be in the same pain as before. R. 340-341. Claimant testified that she has made a good faith effort to do everything her doctors have asked her to do to relieve her pain. R. 341.

As a result of her pain, Claimant testified her personal life is severely limited. Claimant cannot run, jog, bowl, or skate anymore. R. 343. Claimant testified that her daughter runs errands for her, does her grocery shopping, and banks for her. Id. Claimant can drive, but she has not driven lately because her medication makes her drowsy. Id. Claimant goes to church to socialize but nowhere else. R. 344. She can no longer perform duties as an usher or fellowshipper at her church. Id. Claimant also testified she limits her church activity because she cannot sit for long enough to participate in a full service. Id.

Claimant's treating surgeon described Claimant as obese. R. 97. In October of 2002, Claimant weighed 231 lbs. R. 205. In 2003, Claimant weighed 237 lbs. R. 203. Later in 2003, her weight increased to 247 lbs. R. 36. By 2006, Claimant weighed 251 lbs. R. 20. In 2007, Claimant weighed 262 lbs. R. 272. By the time of her hearing in 2008, Claimant weighed 267 lbs. R. 301. Throughout this period, Claimant was between 5'5" and 5'6" inches tall. R. 205, 301.

C.Medical Evidence

1.Dr. Lillian DeLeon, M.D. -- Treating Physician

Claimant saw Dr. DeLeon multiple times complaining of various pains. On July 14, 2003, she saw Dr. DeLeon complaining of back pain and insomnia. R. 277. On July 23, 2003, she again complained of back pain. R. 36. On April 26, 2005, she reported pain to the left shoulder and left leg. R. 30. On November 3, 2005, she again complained of back pain. R. 26. On November 28, 2006, she saw Dr. DeLeon and reported ankle swelling. R. 20. On December 12, 2007, she complained of lower back pain. R. 15. On January 10, 2008, Claimant reported she was having trouble lifting and pain in her leg. R. 76. On January 22, 2008, she reported problems sitting and standing. R. 73. On June 23, 2008, she reported right arm pain. R. 69. On June 17, 2008, Claimant complained of numbness and low back pain. R. 67.

On January 22, 2008, Dr. DeLeon completed a Multiple Impairment Questionnaire regarding Claimant and stated she diagnosed Claimant's condition as a degenerative disk at L3-L5. R. 290. She said Claimant had a fair prognosis. Id. She said that Claimant's pain was exacerbated by sitting and standing for too long. R. 292. Dr. DeLeon felt that Claimant was capable of sitting for two hours every day and standing and walking for one hour each day. Id. Dr. DeLeon said it would be "necessary or medically recommended for [Claimant] not to stand/walk continuously in a work setting." R.293. Dr. DeLeon said Claimant was able to lift and carry up to ten pounds. Id. She also stated that, in her opinion, Claimant was not a "malingerer." R.295

2.Dr. Madhaviah Singa, M.D. -- Treating Surgeon

Dr. Madhaviah Singa treated Claimant starting August 29, 2003. R. 95. At that time, he reported that Claimant had tenderness in the lower back. R. 97. He reported that Claimant had trouble bending forward due to her obesity and pain. Id. Dr. Singa reported that Claimant's MRI showed a L2-L3 disk bulge. R. 97. Dr. Singa recommended "lower lumbar epidural steroid administration" to treat the pain as well as for Claimant to lose weight and undergo physical therapy. R. 96-97.

In a Medical Impairment Questionnaire prepared sometime after May 19, 2006, Dr. Singa again reported that Claimant had a L2-L3 disk bulge. R. 255. He diagnosed Claimant with "retrololisthesis with respect to S1 with disc bulge and mild foraminal narrowing bilaterally." R. 255. He also reported Claimant experienced pain in the back lumbar, hips, knees, and tingling in the right lower extremity. R. 256.

3.Radiology Findings

In addition to her visits with Dr. DeLeon and Dr. Singa, various radiologists have examined Claimant or reviewed radiological images taken of Claimant and reported their findings. On January 7, 2003, Dr. Leef examined Claimant's spine and stated that after examining Claimant's lumbar and sacral spine, he could find no definite bone or joint pathology.

R. 89. On August 23, 2003, Dr. Zelch examined an MRI taken of Claimant's spine and found disc dehydration with loss of disc height at L5-S1. R. 88. He also found a slight retrolisthesis with 3mm disc bulging. Id. He reported the canal diameter was adequate, but there was mild bilateral foraminal narrowing. Id. The rest of his analysis was normal. Id. On April 26, 2005, Dr. Marmo analyzed Claimant's knee because of her reported pain but found "no fractures on dislocations" in the knee. R. 87. He also found "[n]o significant joint or soft tissue abnormalities." Id.

On December 24, 2007, Claimant again had an MRI of the lumbar spine. R. 84. Dr. Gorodetsky examined the MRI and found a loss of height at the L5-S1 disc space, "consistent with disc desiccation." Id. Dr. Gorodetsky also found mild disc bulges at L3-L4 and L4-L5 but "without evidence of frank disc herniation, significant central or foraminal stenosis." Id.

On May 28, 2008, Dr. Corrales examined images of Claimant's lower extremities because of her pain and swelling. R. 82. Dr. Corrales found "intraluminal flow and wall-to-wall compression of the common femoral, superficial femoral and politeal veins." Id. He also found augmentation of flow with calf compression maneuvers but "no evidence of obstructing deep venous thrombosis." Id. Dr. Corrales examined a brain scan after Claimant complained of dizziness and headaches and found no abnormalities. R. 81. Dr. Corales examined images of Claimant's cervical spine because Claimant complained of neck pain radiating to her right side.

R. 80. Dr. Corrales found "[d]egenerative changes at the C5-C6 level" and "[s]traightening of the normal cervical lordosis" but no fractures or dislocations. Id.

On July 1, 2008, Dr. Javier examined an MRI of Claimant's right shoulder that was taken because Claimant complained of right shoulder pain and limited range of motion. R. 78. While he found "[a]bnormal signal consistent with tendinopathy of the supraspinatus tendon," he found no evidence of a tear or fracture. Id.

4.Physical Therapy

In a February 2003 physical therapy evaluation, Claimant reported pain in her tailbone and buttocks. R. 38. The physical therapist, Karen Distal, prescribed physical therapy to help alleviate the pain including doing pelvic tilts, bridging and using a hip pillow. Id. On March 17, 2003, Ms. Distal reported back to Dr. DeLeon, Claimant's treating ...

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