United States District Court, E.D. Arkansas, Jonesboro Division
Marilyn Matlock (âMatlockâ), in her appeal of the final
decision of the Commissioner of the Social Security
Administration (defendant âSaulâ) to deny her claim for
Disability Insurance benefits (DIB) and supplemental security
income (SSI), contends the Administrative Law Judge (âALJâ)
erred by arriving at a residual functional capacity (âRFCâ)
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 Saulâs decision. 42 U.S.C. Â§
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.
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.
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.
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).
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).
Evidence During the Relevant Period:
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).
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).
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).
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.
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.
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