Matlock v. Saul

          ORDER

         Plaintiff Marilyn Matlock (“Matlock”), in her appeal of the final decision of the Commissioner of the Social Security Administration (defendant “Saul”) to deny her claim for Disability Insurance benefits (DIB) and supplemental security income (SSI), contends the Administrative Law Judge (“ALJ”) erred by arriving at a residual functional capacity (“RFC”) determination not supported by the evidence. The parties have ably summarized the medical records and the testimony given at the administrative hearing conducted on March 19, 2018. (Tr. 30-51). The Court has carefully reviewed the record to determine whether there is substantial evidence in the administrative record to support Saul’s decision. 42 U.S.C. § 405(g). The relevant period under consideration is from June 30, 2016, the date of alleged onset, through September 14, 2018, when the ALJ ruled against Matlock.

         The Administrative Hearing:

         At the March 19, 2018 hearing Matlock was 52 years old with a high school education. She was 5'6" and weighed 170 pounds. She had previous relevant work experience as a manager for fast food services, and she testified her employment at McDonald’s stretched from 1989 to 2016. She testified she stopped working due to a back problem, arthritis in her spine which hinders her legs, and high blood pressure which induces dizziness. Matlock indicated she could not stand or sit for long periods, and estimated she could stand for 20-30 minutes, sit for 20-30 minutes, and lift 10-20 pounds. Dr. Sumner Cullom (“Cullom”), a treating physician, found Matlock was not a candidate for surgery, according to Matlock. Matlock stated she was taking pain medications for her back and high blood pressure. The medications provide limited relief, according to Matlock, and she had no side effects.

         Matlock described limited daily activities which include lying down for much of the day and cooking and cleaning intermittently. Former activities include singing in her church choir and going to the movies, which she stated she stopped in September 2017 and in 2015, respectively. Matlock resides with her mother and her son, and they assist her with some chores. Matlock stated she could no longer clean her house as quickly as she could previously, with the chore taking her 5-6 hours with rest periods. Matlock is able to drive and she can shop for groceries with assistance. She estimated that she cooks the “majority” of dinners at her home, but needs breaks while cooking. Matlock also stated she does most of the meal cleanup, with breaks and some assistance from her mother and son. Matlock acknowledged that Great River Pain Management recommended that she exercise as tolerated four times a week, but she was unable to do so. (Tr. 30-48).

         Stephanie Ford (“Ford”), a vocational expert, testified. The ALJ posed a hypothetical question to Ford, asking her to assume a worker of Matlock’s age, education, and experience, who had the following abilities: lift and carry 20 pounds occasionally and 10 pounds frequently; stand and walk for 6 hours in an 8 hour day; push and pull 20 pounds occasionally and 10 pounds or less frequently; and occasionally stoop, climb stairs, crouch, crawl, and balance. Ford testified that such a worker could perform Matlock’s past relevant work as a manager of fast food services. The hypothetical question was altered to include a sit/stand option, and Ford indicated such a worker could not perform the past relevant job but could work as a ticket seller or storage facility rental clerk. (Tr. 48-50).

         ALJ’s Decision:

         In his September 14, 2018 decision, the ALJ determined that Matlock had not engaged in substantial gainful activity since June 30, 2016, the alleged onset date. Severe impairments found by the ALJ were degenerative disc disease, obesity, hypertension, and dizziness. The ALJ found Matlock did not meet any Listing, and he explicitly addressed Listings 1.04, 2.00, 4.00, 9.00, and 12.00. The ALJ determined that Matlock had the RFC to perform light work with the restrictions contained in the initial hypothetical question posed to Ford. This RFC formulation was based, in part, upon the ALJ’s determination that Matlock’s subjective statements were “not entirely consistent with the medical evidence and other evidence in the record.” (Tr. 19). The ALJ addressed Cullom’s June 2017 medical source statement, which indicated that Matlock could lift less than 10 pounds, stand and sit for 20 minutes at a time, reach for 2/3 of a workday, could never engage in any postural maneuvers, must avoid concentrated exposure to all environmental elements, and would miss more than three days of work each month. The ALJ found that Cullom’s “opinion is not supported by the evidence of record.” (Tr. 20). Noting normal neurological exams and contrary findings in Cullom’s own treatment notes, the ALJ accorded Cullom’s opinion “little weight.” (Tr. 20). The ALJ also commented that Matlock did not allege any limitations in her ability to reach or handle. In addition, the ALJ cited Matlock’s daily activities, which included driving, cooking, and cleaning, as well as the absence of any atrophy, as evidence that she was not severely impaired. Relying upon Ford’s testimony, the ALJ determined that Matlock was capable of performing her past relevant work and, therefore, was not disabled. (Tr. 15-22).

         Medical Evidence During the Relevant Period:

         On June 30, 2016, Matlock was seen for an initial evaluation by Dr. Alan Kraus (“Kraus”) at the Great River Medical Center. Matlock complained of back, right hip, and right posterior leg pain, worse when on her feet or walking at work. Matlock, who was taking Tramadol, Soma, and prednisone, was assessed with an antalgic gait and positive straight leg raising on the right. Kraus diagnosed her with lumbar disc disease, lumbar spondylosis, and lumbar radiculopathy. Kraus scheduled Matlock for an epidural block and issued a one-time prescription for hydrocodone. (Tr. 345-347).

         On July 1, 2016, Cullom noted marked paraspinal tension in the lumbar spine, prescribed Lisinopril, and directed Matlock not to work until seen at the pain clinic on July 14. (Tr. 309-310). An epidural injection was administered on July 14, and Matlock was disc har ged with a pre scription for hydrocodone. (Tr. 351).

         Matlock saw Cullom four days later and reported that a pain doctor advised her to see a neurosurgeon. Cullom again noted tension in the lumbar spine and also found a positive left straight leg raise. Cullom’s plan was to refer Matlock to a neurosurgeon. (Tr. 307-308). At an August 1, 2016 visit, Cullom wrote that Matlock’s MRI showed “some degenerative disc disease no operative problems. Patient is going to the pain clinic to get back injections. She states that she is no better.” (Tr. 305). Cullom’s physical exam revealed some muscle tenseness in the lumbar spine, negative straight leg raise, and normal neurological exam. Cullom diagnosed acute and chronic lumbar strain and degenerative disc disease and prescribed Flexeril and Prednisone. (Tr. 306).

         The following day, Matlock was seen by Victoria Jacoby (“Jacoby”), A.P.N., at Great River Medical Center for a follow up visit on the pain management plan she agreed to in her initial visit with Kraus in June 2016. Jacoby recorded Matlock’s history as including back, hip, and leg pain which had worsened over the past months, causing her to miss work. Jacoby explained to Matlock that she had violated her “narcotic agreement [by filling a Tramadol prescription] and I am not comfortable giving her any narcotics at today’s visit.” (Tr. 332). Matlock was described as working full time, in no obvious distress, with an antalgic gait, positive straight leg raising on the right, motor testing and light touch sensation normal, with “exaggerated pain behavior.” (Tr. 333). Jacoby recorded that Matlock had lumbar disc disease, lumbar spondylosis, and lumbar radiculopathy.

         When Kraus saw Matlock on August 11, 2016, Matlock indicated she was unaware of the parameters of the narcotic agreement. Kraus agreed to continue seeing her but “the only thing I can offer her is a facet injection and see if she needs RF (radio frequency) ablation.” (Tr. 338). Kraus recorded that Matlock was working full time at McDonald’s, had back pain and tenderness over the lower lumbar facets, and normal neurologic exam with negative straight leg raising and normal motor and reflex testing. Kraus refilled the hydrocodone, prescribed Meloxicam, and stressed Matlock’s adherence to the narcotic agreement. (Tr. 338-339).

         Matlock informed Cullom in an August 17, 2016 visit that she was scheduled for a pain injection the next day but was also scheduled to work. Cullom’s examination indicated that Matlock could move all extremities, had marked paraspinous muscle tenseness of the lumbar spine, and had a positive straight leg raise bilaterally. Cullom assessed Matlock with bilateral low back pain without sciatica and back pain-lumbar strain-acute and chronic. Cullom’s plan was to keep Matlock off work until she received pain injections. (Tr. 302-304). A lumbar spine x-ray taken that day showed ...