Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_14-cv-00247/USCOURTS-alsd-1_14-cv-00247-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

---

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

CYNTHIA A. JONES, :

Plaintiff, :

vs. : CA 14-00247-C

CAROLYN W. COLVIN, :

Acting Commissioner of Social Security,

:

Defendant.

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking 

judicial review of a final decision of the Commissioner of Social Security denying her

claims for disability insurance benefits and supplemental security income. The parties 

have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 

U.S.C. § 636(c), for all proceedings in this Court. (Docs. 18 & 19 (“In accordance with

the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to 

have a United States Magistrate Judge conduct any and all proceedings in this case, . . . 

order the entry of a final judgment, and conduct all post-judgment proceedings.”).) 

Upon consideration of the administrative record, the plaintiff’s brief, the 

Commissioner’s brief, and the arguments of counsel for the parties at the February 4, 

2015 hearing before the Court, it is determined that the Commissioner’s decision 

denying benefits should be affirmed.

1

 

 1 Any appeal taken from this memorandum opinion and order and judgment shall 

be made to the Eleventh Circuit Court of Appeals. (See Docs. 17 & 19 (“An appeal from a 

judgment entered by a Magistrate Judge shall be taken directly to the United States Court of 

(Continued)

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 1 of 45
2

Plaintiff alleges disability due to degenerative disc disease, cervical and lumbar 

radiculopathy, history of subcutaneous lipoma left posterior shoulder, hypertension, 

and history of headaches. The Administrative Law Judge (ALJ) made the following 

relevant findings:

1. The claimant meets the insured status requirements of the Social 

Security Act through September 30, 2012.

2. The claimant has not engaged in substantial gainful activity

since July 30, 2009, the alleged onset date (20 CFR 404.1571 et seq., and 

416.971 et seq.).

* * *

3. The claimant has the following severe impairments:

degenerative disc disease, cervical and lumbar radiculopahty, history

of subcutaneous lipoma left posterior shoulder, hypertension and 

history of headaches (20 CFR 404.1520(c) and 416.920(c)).

* * *

4. The claimant does not have an impairment or combination of

impairments that meets or medically equals the severity of one of the 

listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR

404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).

* * *

5. After careful consideration of the entire record, the undersigned

finds that the claimant has the residual functional capacity to perform

a reduced range of light work as defined in 20 CFR 404.1567(b) and 

416.967(b), in function by function terms (SSRs 83-10 and 06-8p), with

certain non-exertional restrictions associated with that level of exertion. 

The claimant's specific physical capabilities during the period of

adjudication have been the ability to lift/carry up to 10 pounds

frequently and 20 pounds occasionally; sit for about 6 hours per day;

stand and/or walk for up to 6 hours per day; perform limited pushing 

and/or pulling with the upper extremities; perform pushing and/or

pulling with the lower extremities without limitation; use the right

 

Appeals for this judicial circuit in the same manner as an appeal from any other judgment of 

this district court.”))

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 2 of 45
3

hand for reaching (including overhead), handling, fingering and

feeling without limitation; use the left hand for reaching (including 

overhead) occasionally, and for handling, fingering and feeling

without limitation; climb stairs and ramps, climb

ladders/ropes/scaffolds, balance, stoop, kneel, crouch and crawl 

without limitation. The claimant could work in a job environment

that would allow her to avoid concentrated exposure to extreme heat, 

extreme cold, hazardous machinery and heights. The claimant is

capable of performing unskilled work.

In making this finding, the undersigned has considered all symptoms

and the extent to which these symptoms can reasonably be accepted as

consistent with the objective medical evidence and other evidence, based 

on the requirements of 20 CFR 404.1529 and 416.929 and SSRs 96-4p and 

96-7p. The undersigned requirements of 20 CFR 404.1527 and 416.927

and SSRs 96-2p. 96-Sp, 96-6p and 06-3p.

In considering the claimant's symptoms, the undersigned must follow a 

two-step process in which it must first be determined whether there is 

an underlying medically determinable physical or mental

impairment(s)--i.e.. an impairment(s) that can be shown by medically

acceptable clinical and laboratory diagnostic techniques--that could

reasonably be expected to produce the claimant's pain or other

symptoms.

Second, once an underlying physical or mental impairment(s) that

could reasonably be expected to produce the claimant's pain or other

symptoms has been shown, the undersigned must evaluate the intensity, 

persistence, and limiting effects of the claimant's symptoms to

determine the extent to which they limit the claimant's functioning. For

this purpose, whenever statements about the intensity, persistence, or

functionally limiting effects of pain or other symptoms are not 

substantiated by objective medical evidence, the undersigned must make 

a finding on the credibility of the statements based on a consideration of 

the entire case record.

In a Disability Report submitted on April 26, 2010, the claimant alleged

that her ability to work is limited by knots in the left shoulder, muscle

spasm, migraines, nerve problems and 2 bulging discs. She reported 

that she stopped working on July 30, 2009, her alleged onset date. She 

completed the 10th grade (See also Exhibit 1 E), and was not in special

education classes. The claimant reported that she cannot do her

children's hair or her own hair, cannot drive tor long periods, and does

not get much sleep. (Exhibit 9E).

Another Disability Report completed by a 3rd party was submitted on

June 16, 2010, which indicated the claimant still has pain, and her arm

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 3 of 45
4

is numb when she lies on it while sleeping. She said the pain “comes 

and goes” in the neck and shoulder. She reported, "I stay depressed

and it is very painful.'' At that time, she was taking Amitriptyline to

sleep, Butalbital and Topiramate for migraines, Cyclobenzaprine for

muscle spasms, Neurontin for nerves/bulging disc and Propoxyphene

(Darvocet) for “nerves and disc.” She reported no side effects to these 

medications. (Exhibit 20E).

At the December 20, 2011, hearing, the claimant testified that she lives

with her grandmother and her three children, ages 16, 13 and 10. She

quit school after the l0th grade, and passed all sections of the GED

exam except math. However, the claimant said she can read, write and 

perform simple math calculations.

The claimant said she stopped working in July 2009, because she had

pain in her neck and arm. She reported having CTS in the left hand,

severe nerve damage in left arm and bulging discs. She sees Otis

Harrison, MD, her treating internal medicine physician at Franklin, and

is now "just on medications.'' She said she has had several MRls, but

Medicaid would not pay for anything else. When asked about the

problems she has with her left hand and arm, she responded that she

has severe swelling, lifting her arm is painful, and her neck feels "like 

weight and pressure on [her] back.'' She said it burns and tingles, and 

she really cannot use the left arm.

The claimant drove herself to the hearing, and said none of her 

physicians have restricted her driving. She said her oldest daughter and

son help her cook, as she is not able to cook or clean on her own. She

said she does no cleaning and has to have help getting dressed because 

she can only lift her left arm "so high.” However, she said she can

bathe herself without help.

The claimant said she receives child support for youngest child. She has 

Medicaid coverage. However, she noted that she was turned down for

Medicaid when she first applied because she was working. The

claimant related that she found out that they would be able to give her

Medicaid if she stopped working so she reapplied and was granted 

insurance.

The claimant said Medicaid would cover treatment with a neurologist;

and she has had an injection, which did not help. She said she did not

want to have any more injections because it hurt and did not relieve

her symptoms. When asked if she has been told she needs surgery for

her shoulder, the claimant said she was told by someone at Mobile

Infirmary that she would have to see a neurologist, and surgery would 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 4 of 45
5

be most likely necessary. However, she said she w as told that surgery 

would be dangerous because they would have to go through her throat, 

so it could cause paralysis. The claimant also said the physician at

Mobile Infirmary said her neck and arm problem is not going to get any

better; and the best thing to do is see a neurologist so it will not get

worse.

The claimant said she lies around all day because her medications

cause nausea. She mentioned that she was taking Lortab, Valium, a

blood pressure medication and Prednisone for muscle spasms. The

claimant reported that Amitriptyline makes her itch but "it helps a lot.”

She also said she was just put on for fibromyalgia, and commented that

she thinks Lyrica causes some kind of stomach discomfort. The claimant

said she was on Neurontin in the past but was changed to Lyrica

because "it is better for my nerves.''

At the April 9, 2012, hearing, the claimant testified that she still lives

with her children; and she drove herself the hearing. She said she has

seen Dr. Harrison once since the last hearing. She said she is still

taking the same medications, with the same side effects. The claimant

said her condition has gotten worse; and Dr. Harrison ordered an MRI

and prescribed the cane on March 1, 2012. She related the cane was

prescribed to help with her balance due to problems with her hip

"slipping ... and it catches in my leg and my lower back.” She said her 

balance problems occur with just walking and her pelvis area "just slips." 

The claimant said she fell on her left leg and shoulder about 2 weeks ago, 

when she was outside with her son. She said she sees Dr. Harrison again 

on April 22. 2012.

The claimant's recent medications include Lortab 10 as needed for pain; 

Gabapentin (Neurontin) for inflammation; Simvastatin for cholesterol; 

Topiramate (Topamax) for muscle spasms and migraines; Amlodipine 

(Norvasc) for high blood pressure; Amitriptyline (Elavil) daily and 

Diazepam (Valium) as needed for ''nerves," anxiety and/or muscle 

spasms; Orphenadrine (Norflex) for muscle spasms; Lexapro for 

depression; Meloxicam (Mobic) for inflammation; and Lyrica for neck 

pain and/or fibromyalgia. (Exhibits 22E, 25E and 29E).

After careful consideration of the evidence, the undersigned finds that the 

claimant's medically determinable impairments could reasonably be 

expected to cause some of the alleged symptoms; however, the claimant's 

statements concerning the intensity, persistence and limiting effects of 

these symptoms are not credible to the extent they are inconsistent with

the above residual functional capacity assessment.

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 5 of 45
6

The claimant has history of subcutaneous hematoma left posterior 

shoulder, which results in the limitation on her ability to lift/carry up to

10 pounds frequently and 20 pounds occasionally; use the left hand for

reaching (including overhead) occasionally, and for handling, fingering

and feeling without limitation; perform limited pushing and/or pulling 

with the upper extremities; and use the right hand for reaching

(including overhead), handling, fingering and feeling without limitation.

The claimant presented to Franklin on August 24, 2009, complaining of

a knot on her left shoulder since July 2007, and inability to hold her

arm up. She said the knot began to irritate her 2-3 months ago, and

rated her pain a 6/10 on the pain scale (0 = no pain, 10 = worst 

possible pain). She was treated by a nurse practitioner, who noted the

physical exam showed soft tissue swelling in the left shoulder with no

induration or erythema. The nurse practitioner referred the claimant to

James Lawrence, MD, a rheumatologist, at Franklin for further

evaluation on September 12, 2009. The claimant told Dr. Lawrence that

she was involved in a motor vehicle accident (MVA) in 2007, but she did

not actually recall the specific shoulder problem. Dr. Lawrence noted the

x-rays done on August 25, 2009 showed elevation of the distal clavicle

at the AC joint, which may be secondary to a separation of the joint,

"almost assuredly it was caused by the MVA.'' Dr. Lawrence noted the

review of systems was negative for any signs of a connective tissue 

disorder. The physical exam showed definite tenderness on internal

rotation of the left shoulder and limited abduction. Dr. Lawrence noted

that he strongly suspected that she had a rotator cuff tear. He

prescribed Tramadol and Diazepam for the muscle spasm in the 

trapezius muscle on the left. He also noted he would give her

Ketoprofen pending an MRI scan. (Exhibit 6F).

Dr. Lawrence sent the claimant for an MRI of the left shoulder on

September 18, 2009, which showed findings suggestive of a subcutaneous

lipoma, and clinical follow-up was recommended. There was also a

question of mild supraspinatus and infraspinatus tendinosis. The

interpreting radiologist noted the marker might cause minimal 

deformity of the underlying deltoid muscle. The AC joint was normal

and there was a type II acromion process with mild lateral down 

sloping. No significant glenolhumeral joint effusion was identified; and

the supraspinatus and infraspinatus tendons demonstrated areas of mild

signal increase, which might reflect mild tendinosis. (Exhibit 1F).

The claimant saw Dr. Harrison initially on September 24, 2009, for her

left shoulder pain, which she rated a 10/10. The physical exam was

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 6 of 45
7

positive for pain on palpation and range of motion of the left shoulder. 

Dr. Harrison refilled her Ketoprofen, Diazepam and Tramadol tor left

shoulder pain. (Exhibit 6F).

The claimant was initially seen by Stephen B. Cope, MD, an

orthopedist, for left shoulder pain on October 5, 2009. Dr. Cope noted

the claimant was involved in an MVA in January 2007, and has had

intermittent problems with the left shoulder since then. She stated that

she has noted a small mass on the posterior left shoulder since that

time that has not enlarged, but has caused some pain in the left

shoulder. Dr. Cope noted the claimant has never had any therapy or

any real treatment to address the left shoulder complaints. On physical 

exam, the claimant had full cervical motion. She had no tenderness at

the AC joint; but Dr. Cope said there was a small mobile apparent

lipoma in the posterior superior aspect of the shoulder. She has a full

range of motion of the shoulder, but a positive impingement sign. Dr.

Cope noted she had a lot of pain on testing of the supraspinatus, but

appeared to have normal strength of supraspinatus and 

internal/external rotation. The lift-off test was negative, and the

neurologic examination of the upper extremity was normal. Dr. Cope

noted that x-rays of the left shoulder taken at the exam were

unremarkable. He also noted the MRI scan report showed an apparent

lipoma, but otherwise maybe just some tendinosis about the

supraspinatus and infraspinatus. Dr. Cope assessed the claimant with

subcutaneous lipoma left posterior shoulder and rotator cuff tendinitis. 

He planned to try the claimant on Aleve and physical therapy. 

(Exhibits 2F and 5F).

The claimant attended 6 physical therapy sessions between October 7-21,

2009. The physical therapist noted at her initial visit that she had 4-/5

muscle strength on the left shoulder and 5/5 on the right. There was

tenderness in the subacromion space of the left shoulder, which was

treated with Ketoprofen via iontophoresis. On October 21, 2009, the 

physical therapist noted the claimant had made improvements in range

of motion in the left shoulder. However, the claimant still had some

pain and inflammation in the anterior shoulder. She reported still

having trouble with reaching overhead, picking up her child and

sleeping comfortably; however, she stated she had seen improvements

in these functional areas since therapy started. Her pain level was a

4/10 at this visit. (Exhibit 3F).

The claimant returned to Dr. Cope on November 2, 2009, and stated 

that the modalities and therapy all tended to aggravate her shoulder. 

He noted the claimant also now complained of significant pain in her

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 7 of 45
8

neck radiating into the scapula and even down into the left arm and

hand, "·which is somewhat new." She stated that the shoulder keeps

her from working, but now she is having significant neck pain. The

physical exam showed full cervical motion. She had pain on range of

motion of the left shoulder with a positive impingement sign. She had

normal strength of the rotator cuff, but had a lipoma on the posterior 

aspect of the shoulder. Dr. Cope decided to order an MRI of the

cervical spine due to the radicular pain complaints. (Exhibit 5F).

The claimant had the cervical spine MRI on November 4, 2009, which Dr.

Cope interpreted as negative. The MRI report indicated that it showed

mild reversal of the normal cervical lordosis, likely due to patient

positioning, and minimal disc protrusion at T1-2 of doubtful clinical 

significance (See Exhibit 3F). Dr. Cope offered the claimant an injection 

in the subacromial space, and commented that he did not see anything

that would be helped significantly by surgery at that point. The

claimant returned on November 10, 2009, for a follow up of her neck

and shoulder. Dr. Cope again noted the MRI of her cervical spine was

negative, but she still had pain in the shoulder. The physical exam

showed full motion and normal strength. She had a lipoma 

posterolaterally; but Dr. Cope said he did not think this was the source 

of her pain. However, he told the claimant the only other option would

be to excise it. He gave her an injection of the subacromial space with

Aristospan and Xylocaine, and told her to return for follow up as

needed. She was a no-show for her December 7, 2009, appointment. 

(Exhibit 5F).

The claimant did not return to Dr. Cope until June 17. 2010, when she

stated that she would like to have the mass excised in the posterior 

superior aspect of the left shoulder. Dr. Cope noted the previous MRI

showed what was compatible with subcutaneous lipoma. The claimant 

followed up after her excision procedure on July 19, 2010, and Dr. Cope

noted it was confirmed to be a lipoma by pathologic examination. Dr.

Cope said the claimant was doing well, and had no swelling about the

incision site, which was well healed, clean and dry. He told the

claimant to return for follow up as needed. (Exhibit 8F).

On December 7, 2009, Gregory K. Parker, MD, a State agency internal

medicine consultant, completed a Physical Residual Functional Capacity

Assessment, and noted medically determinable impairments of rotator

cuff tendinitis, subcutaneous lipoma left posterior shoulder and

hypertension. Dr. Parker found that the claimant was capable of the

following in an eight­ hour workday: lifting and/or carrying 20 pounds

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 8 of 45
9

occasionally and 10 pounds frequently; standing and/or walking for a

total of about 6 hours per day; sitting for about 6 hours per day;

performing limited pushing and/or pulling in the upper extremities and

unlimited pushing and/or pulling in the lower extremities; reaching with

the right upper extremity without limitation reaching with the left

shoulder occasionally; and handling (gross manipulation), fingering (fine 

manipulation) and feeling (skin receptors) without limitation. Dr.

Parker said the claimant should avoid concentrated exposure to extreme 

cold, extreme heat and hazardous machinery and heights; but could be

exposed to wetness, humidity, noise, vibration, fumes, odors, dusts,

gases and poor ventilation without limitation. Dr. Parker noted he

assigned the limitation to occasional reaching with the left shoulder due

to pain. (Exhibit 4F).

In terms of the claimant’s alleged history of subcutaneous lipoma left

posterior shoulder, the claimant underwent successful surgical removal of

the lipoma. Dr. Cope noted the claimant did well after her excision 

procedure, and told her to follow up as needed. (Exhibit 8F). However, 

the claimant sought no further treatment from Dr. Cope or any other 

orthopedic specialist for her shoulder problems.

Additionally, the objective evidence regarding the claimant's left

shoulder revealed minimal findings in most instances. The MRI of the 

left shoulder on September 18, 200, showed findings suggestive of a

subcutaneous lipoma, which was later surgically removed. Otherwise, 

there was a question of mild supraspinatus and infraspinatus tendinosis. 

(Exhibit 1F). Dr. Cope said the claimant’s cervical spine MRI on

November 4, 2009, was negative, and showed nothing that would be

helped by surgery. (Exhibit 5F). The MRI report showed minimal disc

protrusion at T1-2 of doubtful clinical significance. (Exhibit 3F).

At the December 20 2011, hearing, the claimant testified that she has

burning and tingling, and really cannot use the left arm. However, this

allegation is not supported by the medical evidence of record. The

physical exams consistently show no neurological deficits. (Exhibits 2F,

5F, 6F, 10F, 19F 20F, 23F, 24F and 28F). The claimant told Dr. Cope that

she had intermittent problems with her left shoulder since her 2007 MVA 

(See also Exhibit 20E). On physical exam, the claimant had full cervical 

motion and no tenderness at the AC joint. While Dr. Cope also noted 

she had a positive impingement sign, she had full range of motion of

the shoulder and what appeared to be normal strength. Dr. Cope also

noted that x-rays of the left shoulder taken at the exam were

u n remarkable. (Exhibits 2F and 5F). The claimant's physical therapy 

records document only a slightly diminished muscle strength of 4-/ 5 on

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 9 of 45
10

the left shoulder. (Exhibit 3F). Her muscle strength in the upper

extremities was 5 / 5 in January 2010 and November 2011. (Exhibit 6F

and 20F).

The claimant also related at the December 20, 2011 hearing that she

went to the emergency room recently, and found out that her left arm

complaints are starting to happen in her right arm as well. She testified 

that she was told she needs to see a neurologist and an orthopedist. 

However, the record shows that she presented to the emergency room

on November 18, 2011, complaining of right shoulder and neck pain

since earlier that night. She denied injury, but had extreme tenderness

to palpation of the right shoulder, limited range of motion of the right

arm and weak grips. The emergency room note reflects that she was

told to go by Dr. Harrison's office and request a referral to USA

neurosurgery. The emergency room physician noted she reported that

her MRI showed disc "bulges,” and she was diagnosed with cervical

disc displacement. The emergency room physician, however, noted that

she needs to have a neurosurgeon review her MRI to determine the

significance of the disc displacement. (Exhibit 20F). Yet as noted

previously, the MRI of the claimant's cervical spine showed only a

minimal disc protrusion at T1-2 of doubtful clinical significance. (Exhibit 

3F). The claimant returned to Franklin on November 28, 2011, and

requested a referral to a neurologist. (Exhibit 22F). At this time, the

claimant was referred to Dr. Hewitt, who found the NCS showed no

abnormality. (Exhibit 23F).

Given the claimant's history of subcutaneous lipoma left posterior 

shoulder with subsequent excision, the undersigned finds that she is

capable of lifting/carrying up to 10 pounds frequently and 20 pounds; 

occasionally; using the left hand for reaching (including overhead)

occasionally; and for handling, fingering and feeling without limitation; 

performing limited pushing and/or pulling with the upper extremities;

and using the right hand for reaching (including overhead), handling,

fingering and feeling without limitation. However, no greater limitation

is warranted due to the overall minimal objective findings. The

undersigned has accounted for her complaints of difficulty using and

lifting the left arm with the restriction to only occasional reaching with

the left upper extremity.

The claimant has degenerative disc disease and cervical and lumbar 

radiculopathy, which results in the limitation on her ability to lift/carry

up to 10 pounds frequently and 20 pounds occasionally; sit for about 6

hours per day; stand and/or walk for up to 6 hours per day; perform 

pushing and/or pulling with the lower extremities without limitation;

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 10 of 45
11

and climb stairs and ramps, climb ladders/ropes/scaffolds, balance, 

stoop, kneel, crouch and crawl without limitation.

The claimant went to Franklin on December 17, 2009, for left shoulder

and back pain related to her MVA. She also reported having migraines

since the 2007 MVA, and reported that she suffered a whiplash injury. It

was noted that the left shoulder MRI was negative per Dr. Cope. The

physical exam showed tenderness in the cervical and lumbar spine with

the SLR performed to 90 degrees. She was diagnosed with a cervical 

strain and arthralgia, and was prescribed Meprobamate, Ketoprofen,

Neurontin and Elavil. She was also told to engage in aerobic exercise.

(Exhibit 6F).

The claimant saw a nurse practitioner at Franklin on January 20, 2010, 

for a follow up on her back and neck pain. She reported having another 

MVA 6 days ago resulting in left shoulder and neck pain, but she did

not go to the emergency room. She rated her pain a 7/10. The

physical exam showed tenderness along the left shoulder and back of

neck, but 5/5 muscle strength in the upper extremities. X-rays were

ordered, and she was told to continue taking her Neurontin, 

Meprobamate and Amitriptyline daily. (Exhibit 6F).

She returned to Franklin on February 10, 2010, for medication refills, 

and requested that her Social Security form be completed. Her treatment

provider's name was not legible, but he or she noted, "I see no

restrictions preventing work." The physical exam showed full range of

motion, no tenderness to palpation and no visible abnormalities. She

w as diagnosed with residual pain, 3 years post whiplash, with negative

x-rays and negative exam. She was told to continue Elavil and was

given Zanaflex and lndocin. (Exhibit 6F).

She saw Dr. Harrison on February 15, 2010, for increased back pain and

a knot on her left shoulder. She rated her pain a 10/10. She

complained of having migraines and left side spasms. She was

diagnosed with low back pain and bilateral knee pain, migraines, left

shoulder pain, left shoulder lipoma, and fatigue. Dr. Harrison

prescribed Neurontin, Fioricet, Topamax and Amitriptyline for sleep,

and ordered a lipid screen due to fatigue complaints. She followed up

on March 9. 2010, and Dr. Harrison noted she rated her pain a 10/10. 

The physical exam showed pain on range of motion of the cervical spine

and left shoulder with pain on palpation of the cervical spine. (Exhibit

6F).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 11 of 45
12

On April 14, 2010, Dr. Harrison noted the claimant continued to

complain of left shoulder, neck and lower back pain and migraines. 

The physical exam showed pain with range of motion of the cervical and

lumbosacral spine. Dr. Harrison assessed her with cervical 

radiculopathy, lumbar radiculopathy, left shoulder pain and migraine

headaches. He prescribed Darvocet, N eurontin and Topamax. (Exhibit

6F).

The claimant reported that her pain medication was not working

during her July 7, 2010, follow up, so Dr. Harrison prescribed Lortab 10. 

The physical exam was positive for pain the neck. He gave her Lortab

as needed for DDD of the cervical spine, Elavil for insomnia and

Valium as needed for muscle spasm. He noted no abnormalities on

physical exam; and the claimant reported her pain was a 5/10. (Exhibit 

9F). Dr. Harrison refilled her medications on October 26, 2010. She

reported pain that was a 9/10, and complained of neck pain and

muscle spasm. The physical exam was positive for pain over the

cervical spine on range of motion: but no other physical exam

abnormalities were noted. Dr. Harrison sent the claimant to Robert C.

Calin, MD, a anesthesiologist on November 8, 2010, for pain

management with a left C5-6 and C6-7 epidural block (See Exhibit 13F). 

Dr. Harrison's January 19, 2011, reflected no changes, except her

Topamax was also refilled for headache. (Exhibit 12F).

The claimant saw Dr. Harrison March 18, 2011, and reported her pain

was a 1/10. However, she stated that her medication was not helping 

and the epidural did not help. Dr. Harrison noted her general

appearance was normal but she had pain on range of motion over the

cervical spine area. Dr. Harrison continued her on Lortab as previously

prescribed, ordered a repeat MRI and referred her to a neurosurgeon. 

(Exhibit 12F).

The claimant underwent the MRI on March 29, 2011, which showed mild

degenerative changes of the cervical spine. The interpreting radiologist

noted he compared the findings to the previous MRI dated March 17,

2010. The radiologist found the claimant's vertebral body heights and 

alignment appeared maintained. There was no fracture or subluxation;

and there was no abnormal signal seen within the cord. Mild

osteophytic changes and mild disc bulging was seen at C5-C6 and C6-

C7, with no significant areas of canal stenosis and no neural foraminal 

narrowing present. There did not appear to be abnormal enhancement

following the administration of intravenous contrast; and the remainder

of the examination appeared unremarkable. (Exhibit 14F).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 12 of 45
13

On May 5, 2011, the claimant followed up with Dr. Harrison for her left

shoulder pain, and rated her pain an 8/10. Her general appearance was

normal; but the physical exam again showed pain over the cervical

spine. Dr. Harrison refilled her Lortab for pain and Valium for muscle

spasm to be taken as needed. Dr. Harrison prescribed Lexapro on June 

1, 2011, and diagnosed her with anxiety and depression. At this visit,

she complained of an anxiety attack, and followed up with Dr. Harrison

after going to the emergency room and being diagnosed with anxiety 

and depression. N o physical exam abnormalities were reported. On

August 22, 2011, the claimant reported her pain was a 10/10, and Dr.

Harrison noted pain with range of motion in the cervical spine. He

continued her on her pain medications as previously prescribed. 

(Exhibit 15F).

The claimant underwent a consultative exam with Thomasina Sharpe, 

MD, a family practitioner, on August 27, 2011. Dr. Sharpe noted the

claimant's chief complaints included spinal problems causing left arm, 

back and neck pain. Dr. Sharpe noted the claimant's symptoms began

in 2007 when she had a car accident and went to the emergency room. 

She was diagnosed with injury to neck and left side bruise. She

continued to have neck pain, and then had second MVA in January

2010, and was hit on driver side. The claimant reported this worsened

her neck, and she started to have left arm and shoulder pain. The

claimant also stated that she had a knot surgically removed from her

shoulder in November 2010, which she said was a "Lymph node."' She

had physical therapy and modalities. She denied neck/back surgery, but

said she had one epidural that did not help. The claimant said she now

goes to pain management. (Exhibit 18F).

Dr. Sharpe noted the claimant "manages activities of daily living and

instrumental activities of daily living; sweeping, washing dishes and

making the bed."' The claimant reported that she was then taking 

Gabapentin (1-2 a week), Lortab (3 a week), Diazepam (3-4 a week),

Topiramate (3-4 weekly). Amitriptyline (1-2 a week), Amlodipine

(nightly), Lexapro (daily) and Simvastatin (nightly). Her past medical

history was also significant for hypertension and hyperlipidemia. The

claimant was living with her children and her children's grandmother. 

Dr. Sharpe noted the claimant's only hospitalization in the last 2 years

was for an ectopic pregnancy in 2010 (See Exhibit 10F). She reported

going to the emergency room in the last 2 years for anxiety attack.

(Exhibit 18F).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 13 of 45
14

Dr. Sharpe noted the claimant was in no acute distress, and was able to

get up and down off the exam table without difficulty, and took her

shoes and socks off and on without difficulty. The claimant is 5 '8"' tall

and weighed 158 pounds. Her blood pressure was 137/88. Her vision

was 20/15 in the left eye and 20/15 in the right eye without correction. 

Her pupils were equal, round and reactive to light and accommodation. 

Extraocular movements were intact. Her lungs were clear to

auscultation throughout. Her heart had a regular rate and rhythm. 

Pulses were 2+ and equal throughout. The claimant's gait was normal.

There was no Romberg present. She had normal heel-shin, toe-heel and

tandem gait. She did not use or need an assistive device. (Exhibit 18F).

Dr. Sharpe reported the claimant had slightly diminished range of

motion in the cervical region with flexion 0-45 degrees, extension 0-50

degrees, lateral flexion 0-40 degrees and rotation 0-70 degrees bilaterally;

in the lumbar region with flexion 0-80 degrees, backward extension 0-20 

degrees and lateral flexion 0-20 degrees bilaterally; in the hip joints with

rotation-internal 0-20 degrees, rotation-external 0-30 degrees, abduction

0-25 degrees and adduction 0-15 degrees bilaterally; in the knee joints

with flexion 130 degrees bilaterally; and in the finger thumb joints with

flexion/extension or the proximal phalanx 70 degrees and distal

phalanx 90 degrees bilaterally. The claimant's range of motion in the

hips was otherwise normal with forward flexion 0-100 degrees and

backward extension 0-30 degrees. Her ankle joints had full range of 

motion with dorsiflexion 0-20 degrees and plantar flexion 0-40 degrees 

bilaterally. Other than some slightly decreased range of motion in the

elbow joints with flexion 0-140 degrees, she otherwise had full motion 

with supination 0-80 degrees and pronation 0-80 degrees. Her wrist

joints had full range of motion with extension 0-60 degrees, flexion 0-60 

degrees, radial deviation 0-20 degrees and ulnar deviation 0-30 degrees 

bilaterally. Dr. Sharpe noted the claimant gave poor effort with left arm,

but with coaching, she had decreased range of motion with forward

flexion 0-130 degrees and extension 0-40 degrees; but had normal range

of motion with abduction 0-150 degrees, adduction 0-30 degrees, 

internal rotation 0-90 degrees and external rotation 0-90 degrees

bilaterally. The straight leg raise (SLR) was negative. Dr. Sharpe noted

the claimant had 5/5 muscle bulk, strength and tone; and there was no

atrophy. Bilateral grip strength was 5/5. The sensory exam showed

light touch and pinprick was intact throughout the upper and lower

extremities. Deep tendon reflexes were 2+ and equal in the bilateral

upper and lower extremities. The cranial nerves were intact. Dr. Sharpe 

diagnosed the claimant with neck and back pain with left arm

radiculopathy. (Exhibit 18F).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 14 of 45
15

Dr. Sharpe also completed a Medical Source Statement (MSS) of Ability

To Do Work-Related Activities (Physical) Form, and found the claimant

could do the following activities in an 8-hour work day: lift/carry up to

10 pounds frequently and 20 pounds occasionally: sit for 2 hours at a 

time, for up to 6 hours per day; stand for 1 hour at a time, for up to 3

hours per day: walk for 1 hour at a time, for up to 3 hours per day; use

the right hand for reaching overhead, all other reaching, handling, 

fingering, feeling and pushing/pulling continuously; use the left hand

for reaching overhead, fingering and feeling continuously; use both feet

for repetitive movements as in operation of foot controls occasionally;

climb stairs and ramps and climb ladders or scaffolds occasionally; and 

balance, stoop, kneel, crouch and crawl frequently. Dr. Sharpe said the 

claimant can be exposed to unprotected heights, moving mechanical parts

and operating a motor vehicle frequently; and assigned no limitations 

regarding exposure to humidity and wetness, dust, odors, fumes, and 

pulmonary irritants, extreme cold, extreme heat and vibrations. Dr.

Sharpe assigned the lifting/carrying restrictions due to limiting pain and 

decreased range of motion; the sitting, standing and walking restrictions,

manipulative restrictions, postural restrictions and pushing/pulling with

the feet restrictions due to pain; and the environmental limitations due

to pain, range of motion and side effects to pain medications. Dr.

Sharpe noted the claimant did not require the use of a cane to ambulate. 

Based solely on the claimant's physical impairments, Dr. Sharpe opined 

that she is capable of performing activities like shopping; traveling

without a companion or assistance; ambulating without using a

wheelchair, walker or 2 canes or 2 crutches; walking a block at a

reasonable pace on rough or uneven surfaces; using standard public 

transportation; climbing a few steps at a reasonable pace with the use of

a single hand rail; preparing a simple meal and feeding herself; caring

for personal hygiene; and sorting, handling and using paper/files. 

(Exhibit 18F).

The claimant followed up with Dr. Harrison on September 28, 2011, and

reported her pain was a 5/10. Again, pain with range of motion was

noted over the cervical spine. Her medications were refilled as

previously written. (Exhibit 22F).

As noted above, the claimant went to the emergency room on

November 18, 2011, for right shoulder and arm pain. She reported the 

pain is similar to the pain she experiences in her left shoulder from a

herniated disc. She also complained of numbness and tingling down

both arms and pain with active movement of the shoulders radiating up 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 15 of 45
16

the neck. The physical exam showed full range of motion in the neck 

with tenderness over the trapezius muscle bilaterally. 

The back exam showed no deformities. The neurological exam

revealed no focal deficits, 2/4 deep tendon reflexes, and 5/5 muscle

strength bilaterally. She was diagnosed with cervical disc displacement

and hypertension, not otherwise specified (NOS), and was given

prescriptions for Mobic, Prednisone, Lyrica and Lortab. (Exhibit 20F).

The claimant saw a physician's assistant at Franklin on November 28,

2011, for follow up and a referral to see a neurologist. She reported her

pain was a 6/10. She reported that she went to the hospital on

November 18, 2011, for pain on the right side. She said she was advised

to see a neurologist, and was given Lyrica for pain. She reported that

she has been having lightheaded episodes. Her heart, lungs and

abdominal exams were normal; but the claimant had pain in the back

and down the arms. She was assessed with muscle spasm, and was

referred for a NCS. Her current medication regiment was continued as

previously prescribed for her DDD, hypertension and

hypercholesterolemia. (Exhibit 22F).

Dr. Harrison sent the claimant for a NCS on December 1, 2011 and Dr.

Hewitt found no abnormalities whatsoever. Dr. Hewitt’s impression

was that this was a normal NCS. He noted there was no evidence or a

median neuropathy on either side or of a left ulnar neuropathy. (Exhibit

23F).

The claimant returned to the emergency room on January 8, 2012,

complaining of neck pain and left wrist pain after falling the night

before. She reported having a history of cervical disc disease and

fibromyalgia. She complained of "swelling"' to the left deltoid area, but

denied numbness/tingling. The physical exam showed spasms over the

left deltoid; but the extremities had no clubbing, cyanosis or edema. She

had 2+ radial pulses and no obvious deformity, but there was decreased

range of motion of the wrist secondary to pain. The neurological exam 

showed no focal deficits. The claimant reported that she felt better after

rece iving Nubain and Decadron. She was diagnosed with chronic neck

pain secondary to disc disease, deltoid muscle spasms, hypertension and

hyperlipidemia. She was given Norflex to use for muscle spasms. Xrays of the left wrist were unremarkable. The cervical spine x-rays

showed straightening of the normal cervical lordosis, but no disruption

of the anterior or posterior spinal lines. There was no prevertebral soft

tissue swelling. No definite fracture was seen in the cervical spine. 

(Exhibit 24F).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 16 of 45
17

The claimant saw Dr. Harrison on March 1, 2012, complaining of back

pain and to have a Functional Capacity Evaluation completed. The

physical exam again showed pain with range of motion in the cervical

spine. At this visit, the claimant reported her pain was an 8/10. Dr. 

Harrison assessed her with "Functional Capacity Evaluation," 

hypertension, hypercholesterolemia, muscle spasms, DDD of the cervical

spine, neuropathy and insomnia. He instructed the claimant to continue

her current treatment. (Exhibit 28F).

Dr. Harrison ordered an MRI of the lumbar spine on March 12, 2012,

w hich showed a right paracentral posterior disc protrusion worrisome

for the presence of disc herniation at L5-S1. The disc protrusion was not

significantly affecting the thecal sac or neural foramina. The remainder

of the included disc spaces were without significant finding, and the

facet joints appeared grossly unremarkable. (Exhibit 29F).

In terms of the claimant's alleged degenerative disc disease of the spine

and lumbar radiculopathy, the claimant has received essentially routine,

conservative treatment. The claimant's physical exams from Franklin

generally show some spinal tenderness, left shoulder with pain on

palpation of the cervical spine and/or pain with range of motion in the

cervical and/or lumbar spine. (Exhibits 6F, 12F, 15F, 22F and 28F). The

physical exam from the claimant's emergency room visit on November

18, 2011, showed full range of motion in the neck with tenderness over

the trapezius muscle bilaterally, but no deformities of the back, no focal 

neurological deficits, and 5/5 muscle strength bilaterally. (Exhibit 20F). 

Dr. Harrison has prescribed Lortab to be used on an as needed basis

only. (Exhibits 22E, 25E, 29E, 12F, 15F, 20F, 22F and 28F). The claimant

also told Dr. Sharpe that she was taking only 3 Lortab a week during her

consultative exam. (Exhibit 18F).

Additionally, the objective evidence reveals minimal findings in most

instances. Dr. Cope said the claimant's cervical spine MRI on November

4. 2009, was negative, and showed nothing that would be helped by

surgery. (Exhibit 5F). The MRI report showed minimal disc protrusion

at T1-2 of doubtful clinical significance. (Exhibit 3F). The claimant's xrays were noted to be negative at Franklin on February 10, 2010.

(Exhibit 6F). The March 29, 2011, cervical spine MRI showed mild

degenerative changes of the cervical spine noted as mild osteophytic

changes and mild disc bulging was seen at C5-C6 and C6-C7. (Exhibit

14F). The December 1, 2011, NCS showed no abnormalities whatsoever. 

(Exhibit 23F). The cervical spine x-rays taken in the emergency room on

January 8, 2012, showed straightening of the normal cervical lordosis,

but no other abnormalities. X-rays of the left wrist were also

unremarkable. (Exhibit 24F). The March 12, 2012, MRI of the lumbar

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 17 of 45
18

spine showed a right paracentral posterior disc protrusion worrisome

for the presence of disc herniation at L5-Sl; yet, the disc protrusion was

not significantly affecting the thecal sac or neural foramina. The

remainder of the included disc spaces were without significant finding,

and the facet joints appeared grossly unremarkable. (Exhibit 29F).

The claimant has reported daily activities that are limited to a varying

degree. In a Pain Questionnaire completed on May 17, 20l0, the claimant

said her activities have changed since her left arm, neck and lower back

pain began in July 2007. She reported changes related to the use of her

left arm, holding her head down for long periods and spending time

outside with her children. However, she reported her daily activities

included household chores, outside chores, doing hair and driving. 

(Exhibit 13E). The claimant is apparently able to care for her children at 

home with some assistance from her older children. The claimant also

completed a Function Report on May 17, 2010, and reported that on a

typical day, she gets her children ready for school, cleans up as much as

she can, walks for about 15 minutes, gets her children from school, cooks

with help from her oldest child, and does homework before getting her

children ready for bed. She takes care of her children. She reported

some difficulties with personal care, including difficulty putting on

shirts, using her left arm for a long period of time to care for hair and 

inability to pick up heavy things while doing outside work. She said

she goes outside every day, walks and drives a car. (Exhibit 12E).

The claimant testified that she lies around all day because of her

medication. She said her oldest daughter and son help her cook, as she

is not able to cook or clean on her own. She also said she does no

cleaning and has to have help getting dressed. However, she said she is

able to bathe herself without help.

The claimant testified that she has various medication side effects. She

said Amitriptyline causes itching, but "it helps a lot." She commented

that she thinks Lyrica causes some kind of stomach discomfort. The

previously reported in a Pain Questionnaire that she has medication

side effects including weight gain, constipation, drowsiness, blurred

vision, dry mouth and tiredness. (Exhibit 13E). However, she reported

no side effects to these medications in her June 16, 2010, Disability

Report. (Exhibit 20E). Although the claimant has alleged various side

effects from the use of medications, the medical records, such as office

treatment notes, do not corroborate those allegations. There is no

supporting evidence that the medications prescribed for the claimant

have the incapacitating side effects to the extent that she described. 

Therefore, the undersigned does not find that this allegation has been

established as an actual 12-month functional work-related limitation.

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 18 of 45
19

The claimant also testified at the most recent hearing that Dr. Harrison 

prescribed a cane to help with her balance due to problems with her hip

"slipping ... and it catches in my leg and my lower back.” The record

reflects that Dr. Harrison prescribed the claimant a cane with

instructions to use as directed on March 1, 2012. Dr. Harrison noted

ICD9 diagnosis code 719.7, which corresponds with the diagnosis of

effusion of joint, ankle and foot. (Exhibit 26F). However, the

undersigned notes that none of Dr. Harrison's treatment records include

notations for balance problems, that she is prone to falls or complaints of

hip symptoms as described at the hearing. (Exhibits 6E 9F. 12F, 15F, 22F

and 28F). In fact, Dr. Harrison indicated that she is not prone to falls

during the March 1, 2012, physical exam. He diagnosed her with

neuropathy at this visit, but did not indicate any neurological

abnormalities on physical exam. (Exhibit 28F).

The claimant testified at the December 2011, hearing that she was 

recently put on Lyrica for fibromyalgia. However, the record does not

reflect that she carries this diagnosis. On September 12, 2009, Dr.

Lawrence, a rheumatologic specialist, noted the review of systems was

negative for any signs of a connective tissue disorder (See Exhibit 6F),

and Dr. Lawrence never diagnosed the claimant with fibromyalgia. 

Likewise, Dr. Harrison has not diagnosed the claimant with 

fibromyalgia. The claimant testified that she was diagnosed with

fibromyalgia by an emergency room doctor; however, the emergency

room records from November 18, 2011, show she was diagnosed with

cervical disc displacement and hypertension, NOS. (Exhibit 20F). The

claimant returned to the emergency room on January 8, 2012,

complaining of neck pain and left wrist pain after falling the night

before. At this visit, she reported having a history of fibromyalgia; but

the claimant was not diagnosed with fibromyalgia at that time. (Exhibit

24F).

The undersigned finds that she is capable of lifting/carrying up to 10

pounds frequently and 20 pounds occasionally; sitting for about 6 hours

per day; standing and/or walking tor up to 6 hours per day; performing 

pushing and/or pulling with the lower extremities without limitation;

and climbing stairs and ramps, climbing ladders/ropes/scaffolds,

balancing, stooping, kneeling, crouching and crawling without

limitation.

The undersigned notes the claimant testified at the December 20, 2011

hearing that she has had no mental health treatment; however, she

reported that she has had anxiety attacks. She said she went to the

emergency room tor an anxiety attack once in the past. She said she

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 19 of 45
20

had another anxiety attack in October, but her family was around and

calmed her down. She takes Valium, which Dr. Harrison told her was

''like a depression medication," but he also prescribes this for muscle

spasm. The claimant stated that she was on Lexapro at one time, but it

caused a lot of discomfort. She reported that she was “on a lot of

different medications” at that time, so Dr. Harrison preferred to just keep

her on Valium. The claimant said she has not been referred to mental 

health for evaluation and treatment.

On June 16, 2010, the claimant reported, "I stay depressed and it is very 

painful." (Exhibit 20E). However, the claimant told a DDS

representative on June 8, 2010, that she is not alleging mental illness,

and reported that she takes Amitriptyline at night because of her pain. 

(Exhibit 15E). Indeed, the claimant has been prescribed several 

medications that are indicated for depression and/or anxiety treatment. 

However, the medical evidence of record documents that she has been 

prescribed Valium for muscle spasm (See Exhibits 6F, 9F and 15F);

Meprobamate for cervical strain (See Exhibit 6F); and Amitriptyline tor

pain/sleep (See Exhibits 6F and 9F).

The claimant has hypertension, which results in the limitation on her

ability to work in a job environment that would allow her to avoid

concentrated exposure to extreme heat, extreme cold, hazardous

machinery and heights.

The medical evidence of record from Franklin documents sporadic

elevations in blood pressure during the relevant period of adjudication. 

(Exhibits 6F, l0F, 15F and 16F). The claimant has also complained of

chest pain in the emergency room. The claimant complained that her

heart was "fluttering" with dizziness and increased blood pressure on

May 27, 2011. Her blood pressure was 142/80. An EKG showed sinus

rhythm and abnormal Q wave suggestive of anterior infarct. Yet, she

was treated with aspirin, Nitroglycerin and Morphine, which improved 

her condition. (Exhibit 16F). She was transferred to the cardiac unit,

and was ultimately diagnosed with atypical chest pain and chronic back

pain and left arm pain. Her cardiac enzymes were normal, and a repeat 

EKG was borderline, with probable left atrial abnormality. She was

counseled on good eating habits, stress relief with relaxation exercises

and drinking plenty of fluids. (Exhibit 17F).

The claimant was started on Norvasc for hypertension by a nurse

practitioner at Franklin on July 25, 2011. She also complained of

headaches, but no dizziness, blurred vision, chest pain or shortness of

breath. No physical exam abnormalities were noted, except her blood

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 20 of 45
21

pressure was 141/93. She was also prescribed Zocor due to high

cholesterol on July 26, 2011. Her blood pressure was 120/72 during her

August 22, 2011, follow up visit, and has remained within normal limits 

since then, and she has had no complications. (Exhibits 19F, 22F and

28F).

The claimant's diagnosed hypertension has been shown to respond well

to properly administered conservative treatment, and the record contains

no indication of end-organ damage causing significant functional

impairment of the heart, kidneys and eyes, such as hypettensive 

cardiovascular disease, hypertensive nephropathy or retinopathy. The

undersigned finds that she is capable of working in a job environment

that would allow her to avoid concentrated exposure to extreme heat,

extreme cold, hazardous machinery and heights.

The claimant also has history of headaches, which results in the

limitation on her ability to work in a job environment that would allow

her to avoid c onc entrated exposure to extreme heat, extreme cold,

hazardous machinery and heights; and perform unskilled work.

The claimant completed a Headache Questionnaire on May 17, 2010,

and reported having severe headaches 2-3 times a week, but daily

headaches. She said her headaches are always on the left side of her

head, and it makes her stomach hurt. She said the headaches sometimes

last all day. She has been having headaches since 2007-2008, and they are

occurring more frequently. She reported no after effects of her

headaches, but being in hot places or under stress causes headaches. She

reported that her medications, Butalbital and Topiramate, relieve her

headaches, but cause constipation, dry mouth, drowsiness and loss of

appetite. She has not required emergency room treatment for her

headaches. (Exhibit 14E). The undersigned notes that she reported no

side effects to these medications on June 16, 2010. (Exhibit 20E).

The claimant said she takes Topamax for migraines, which she has had

since 2007. The claimant said she has maybe 2 migraines a week, which

last about 5 hours. She said she has to lie down when she gets a

migraine due to the headache and accompanying nausea and dizziness. 

She related that she used to have more headaches when it is hot outside. 

She rated her headache pain as a 10/10 on the pain scale (0 = no pain, 10

= worst possible pain), and said she cannot concentrate during

headaches.

In terms of the claimant’s alleged history of headaches, the claimant has 

been prescribed and has taken appropriate medications for headaches at

Franklin, which weighs in the claimant's favor, but the medical records

reveal that the medications have been relatively effective in controlling 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 21 of 45
22

the claimant's symptoms. Although the claimant testified that she has

headaches 2-3 times a week, she has not required emergency room

treatment tor her headaches, and did not c omplain of headache

symptoms occurring to this degree during her visits to Franklin. 

However, based on the fact that she has been prescribed medications for

migraines, the undersigned finds that she is capable of working in a job

environment that would allow her to avoid concentrated exposure to 

extreme heat, extreme cold, hazardous machinery and heights. The

undersigned also finds that the claimant is capable of performing

unskilled work based on her testimony that she has problems 

concentrating when she has a headache. The undersigned further notes

that unskilled work is appropriate based on her education level. She

testified that she quit school after the 10th grade, and passed all sections

of the GED exam except math. However, the claimant said she can

read, write and perform simple math calculations.

The undersigned notes the claimant has made several inconsistent

statements regarding matters relevant to the issue of disability that

supports the finding that she is less than fully credible.

The claimant told Dr. Cope that the modalities and physical therapy all

tended to aggravate her shoulder. (Exhibit 5F). However, her physical

therapy noted at her last visit that the claimant stated she had seen

improvements since therapy started, and her pain level had decreased. 

(Exhibit 3F).

When asked at the December 2011, hearing if any physician has advised

the claimant to exercise, the claimant responded "no one has ever told

me to exercise because if I do a lot, it causes pain and runs my blood

pressure up." However, treatment records from Franklin in Exhibit 6F

note that she was instructed to exercise.

The claimant testified that she was on Lexapro at one time. However,

she was "on a lot of different medications'' at that time, so Dr. Harrison

preferred to just keep her on Valium. The claimant also said she was on

Neurontin in the past, but was changed to Lyrica because "it is better for

my nerves." Yet the emergency room record from November 18, 2011,

reflects that she was prescribed Lyrica "since off Neurontin," and that she

reported that she was off Neurontin due to "too much med[ication]."

(Exhibit 20F).

The undersigned also notes that the claimant testified that she was

initially turned down for Medicaid when she first applied because she

was working. The claimant said she then found out that she could get

Medicaid if she stopped working. She said she reapplied and was

granted insurance after she stopped working. Therefore, this could

have influenced her decision, at least in part, to stop working. Indeed,

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 22 of 45
23

her motivation to work was questioned by her treatment provider at

Franklin on February 10, 2010, when she requested that her Social

Security form be completed. However, her treatment provider noted

that a specific concern was "motivating [the claimant] to work post pain

[with] absence of any sig[nificant] pathology ... certainly no disabling

path[ology] found." (Exhibit 6F).

As for the opinion evidence, the undersigned notes that Dr. Harrison,

the claimant's treating physician, has offered several opinions regarding

her functional abilities and limitations. However, no significant weight

is given to his opinion in Exhibits 7F, 11F and 27F, for the reasons

discussed below.

On April 26, 2010, Dr. Harrison completed a Clinical Assessment of Pain

(CAP) Form, and noted the claimant's pain is present to such an extent

that bed rest is necessary; physical activity, such as walking, standing,

bending, stooping and moving of the extremities, would increase 

symptoms to such an extent that bed rest is necessary; and pain impacts

the individual's ability to perform her previous work to the extent that

the claimant will be totally restricted and thus unable to function at a

productive level of work. Dr. Harrison noted that he had treated the

claimant since September 2009, and the MRI of her neck showed disc

bulging at C5-6 and C6-7, which is the underlying cause of her pain. Dr.

Harrison noted the claimant was prescribed narcotic pain medication,

Darvocet and will require pain management in the next year. Dr. 

Harrison did not answer the question regarding whether the claimant

could engage in any form of gainful employment on a consistent basis

without missing more than 2 days of work per month or frequent

interruptions to her work routine; but he did note she complains of pain. 

(Exhibit 7F).

The undersigned gives no weight to Dr. Harrison's responses in the

CAP form for several reasons. First, the course of treatment pursued by

Dr. Harrison has not been consistent with pain to such an extent that bed

rest is necessary. While Dr. Harrison had been treating the claimant for

less than a year when he completed the CAP, he noted her general

appearance was normal on several occasions around the time he

completed this form. (Exhibits 6F and 9F and 12F). Despite his

responses in the CAP, Dr. Harrison has prescribed Lortab to be used on

an as needed basis only. (Exhibits 22E, 25E, 29E, 12F, l5F, 20F, 22F and

28F). Second, his more recent treatment notes reflect no increase in

dosage or frequency of administration of her medications prescribed for

pain. Third, Dr. Harrison identified the November 2009, MRI, which he

said showed disc bulges at C5-6 and C6-7, as the underlying cause of

her pain. However, Dr. Cope, her former treating orthopedist

interpreted this MRI as being negative (See Exhibit 5F); and the report of

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 23 of 45
24

the M RI from the radiologist does not mention issues at the C5-6 or C6-7 

disc levels. (Exhibit 3F). Finally, the claimant's office visit on February

10, 2010, less than three months before Dr. Harrison completed the CAP

form, shows that she requested that her Social Security form be

completed. However, her treatment provider at Franklin said, "I see no

restrictions preventing work.” (Exhibit 6F).

Dr. Harrison later wrote a letter on March 18, 2011, stating that she was 

currently unable to work because of her medical condition. He noted the

current therapy she has received has not controlled her symptoms, and

she is currently being referred to another specialist. (Exhibit 11F). 

However, no weight is given to this letter because Dr. Harrison's own

treatment note from this date fails to reveal the type of significant

clinical and laboratory abnormalities one would expect if the claimant 

were in fact disabled, as Dr. Harrison reported. Specifically, the

treatment note from this date reflected the claimant reported her pain

was only a 1/10. He noted that her general appearance was normal;

and she had pain on range of motion over the cervical spine area. 

While she stated that her medication was not helping and the epidural

did not help, Dr. Harrison continued her on Lortab as previously

prescribed. (Exhibit 12F). As noted previously, Dr. Harrison has also

characterized her general appearance as ''normal” no physical exam.

Dr. Harrison completed a Physical Capacities Evaluation (PCE) form on 

March 1, 2012, and found the claimant had the following limitations in

an eight-hour workday: sit for 2 hours at a time, for up to 2 hours per

day; stand/walk for 2 hours at a time, for up to 2 hours per day; lift up 

to 5 pounds for 1 hour during an 8-hour workday; carry up to 5 pounds

for 2 hours during an 8- hour workday and up to 25 pounds for 1 hour

during an 8-hour workday; bend, squat and crawl for up to 2 hours in

an 8-hour workday; and climb for up to 1 hour in an 8-hour workday.

Dr. Harrison assigned mild restriction of activities involving unprotected

heights, being around moving machinery, exposure to marked changes

in temperature and humidity, driving automobile equipment and

exposure to dust fumes and gases. Dr. Harrison said the claimant 

cannot reach; use her hands for repetitive action such as simple grasping,

pushing and pulling of arm controls and fine manipulation; or use her

feet for repetitive movements as in pushing and pulling of leg controls.

Dr. Harrison did not answer the questions about the length of time the

claimant has been impaired or whether she can work 8 hours per day,

40 hours per week on a sustained basis, within the limitations above,

without missing more than 2 days of work per month. (Exhibit 27F).

The undersigned gives no weight to Dr. Harrison's PCE in Exhibit 27F

because it is conclusory, internally inconsistent, and not supported by his

own treatment records. In the PCE, Dr. Harrison found the claimant

could sit for 2 hours at a time, for up to 2 hours per day and

stand/walk tor 2 hours at a time, for up to 2 hours per day. Howvever,

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 24 of 45
25

he provided no explanation of the evidence relied on in forming that

opinion: and as noted above, the claimant's physical exams from

Franklin generally show some spinal tenderness, left shoulder with pain

on palpation of the cervical spine and/or pain with range of motion in

the cervical and/or lumbar spine. (Exhibits 6F, 12F, 15F, 22F and 28F). 

Additionally, some of the limitations set forth in the PCE are internally

inconsistent. For example, he said the claimant could only lift up to 5

pounds, but was able to could carry up to 25 pounds. Dr. Harrison also

said the claimant cannot reach, but can climb for 1 hour a day. He said

the claimant cannot use her feet for pushing/pulling, but can bend, 

squat and crawl for up to 2 hours in an 8-hour workday. Dr. Harrison

also said she cannot use her hands for repetitive action such as simple

grasping, pushing and pulling of arm controls and fine manipulation;

however, she has received no significant treatment for problems with

her hands that would affect her manipulative abilities during the period

of adjudication. The undersigned notes that Dr. Harrison assigned mild

restriction of activities involving environmental irritants, which does not

readily translate into vocational terms.

The undersigned notes that the possibility always exists that a treating

physician may express an opinion in an effort to assist a patient with

whom he or she sympathizes for one reason or another. While it is

difficult to confirm the presence of such motives, they are more likely in 

situations where the opinion in question departs substantially from the

rest of the evidence of record, as in the current case. Dr. Harrison 's

opinion is without substantial support from the other evidence of

record, which obviously renders it less persuasive. Social Security

Rulings 96-2p and 96-5p indicate that controlling weight may not be

given to a treating physician's opinion unless it also is "not inconsistent"

with the other substantial evidence in the case record. Therefore, Dr.

Harrison’s opinion cannot be given controlling weight.

The claimant's representative objected to Dr. Sharpe's consultative exam

in a later dated September 15, 2011. The claimant's representative

argued that the report by Dr. Sharpe contains an explicit admission that

no records were reviewed by Dr. Sharpe (See Exhibit 18F). He noted the

claimant informed him that the examination of the claimant by Dr.

Sharpe lasted about 10 minutes. The report stated that the claimant

"takes shoes and socks off and on without difficulty." However, the

claimant told the claimant's representative that she was not wearing 

socks, and merely removed her sandals by using her feet. Additionally,

the report stated that the claimant can wash dishes, sweep and make the

bed. However, the claimant informed the claimant's representative that

she told Dr. Sharpe that she could use one arm to pull a blanket over

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 25 of 45
26

the bed, and that she could probably do limited sweeping with a broom

by using one hand. The claimant also said that no pinprick testing was

done despite the statement in the report that "pinprick is intact

throughout upper and lower extremities.'' The claimant also told him

that no testing of the range of motion of the spine was performed that

she could recall. Additionally, the claimant felt that Dr. Sharpe was

unnecessarily rude. The claimant's representative said Dr. Sharpe

apparently made no attempt to discover the claimant's medical history

according to the report and to the claimant. Therefore, he requested

that Dr. Sharpe’s opinion be given no weight. (Exhibit 24E).

Based on the claimant's representative's objections, the undersigned

requested assistance from DDS on January 4, 2012, to re-contact Dr.

Sharpe, send her a copy of all pertinent medical records, and ask her to

clarify the time spent with the claimant and the records she relied upon,

if any, prior to her assessment. (Exhibit 30E). Dr. Sharpe responded on

February 4, 2012, and stated that she spent 25 minutes with the

claimant, and reviewed no medical records at the time of the exam. 

(Exhibit 25F).

The claimant's representative wrote another letter on February 29, 2012,

objecting to Dr. Sharpe's consultative exam reports in Exhibits l8F and

25F. Pursuant to Social Security Regulations 20 CFR 404.1519p and

416.919p, he objected to the consultative examination report because Dr.

Sharpe did not adequately assess all of the claimant's diseases,

impairments and complaints described in the claimant's history and

because the report does not provide evidence that serves as an adequate

basis for decision-making. Dr. Sharpe stated that she had not reviewed

any of the claimant's medical records and had only spent 25 minutes

with the claimant before completing an examination report indicating

that the claimant could perform more than sedentary work (See Exhibit

25F). The claimant's representative asserted that those findings are 

starkly inconsistent with the opinion of the claimant's treating physician,

Dr. Otis Harrison, MD, who indicated on pain questionnaire that the

claimant would not be able to work (See Exhibit 7F). Moreover, the

claimant's medical records showed that the claimant suffered from,

among other things, degenerative disc disease with cervical and lumbar

radiculopathy and the presence of a cyst in the left shoulder (See Exhibits

6F, 9F, and 15F). Dr. Sharpe did diagnose pain and arm radiculopathy,

but did not diagnose a medical ailment that would result in that pain

(See Exhibit 18F). As such, the claimant objected to Exhibits 18F and 25F

pursuant to 20 CFR 404.1519p and 416.919p and respec1lttlly requested

that no evidentiary weight be assigned thereto. (Exhibit 28E).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 26 of 45
27

The undersigned notes that the January 4, 2012, request tor DDS

assistance to re-contact Dr. Sharpe was proffered to the claimant’s 

representative on April 24, 2012, after he submitted his February 29, 2012,

objection letter. (Exhibit 31E). His office subsequently submitted

another letter noting that the information requested from Dr. Sharpe

was not attached to the January 4, 2012, request. Therefore, a

subsequent notice with that evidence attached thereto and additional 

time to respond was requested. (Exhibit 32E). However, it was

explained to the representative's office that the January 4, 2012, request

for DDS assistance was what was sent to Dr. Sharpe and initiated her

response that is in Exhibit 25F, and no additional response is expected

from Dr. Sharpe. Therefore, the representative said their office would be

submitting no further response regarding their objection to Dr. Sharpe's 

report in Exhibits 18F and 25F and did not need additional time to

respond as requested in Exhibit 32E. (Exhibit 33E).

Based on the above mentioned objections, the undersigned gives no

weight to Dr. Sharpe's findings and opinion in Exhibits 18F and 25F. 

While Dr. Sharpe's report in both Exhibits 18F and 25F states: "REVIEW

OF RECORDS: None" as noted by the claimants representative in his

objections, her report included a '"HISTORY OF PRESENT ILLNESS''

narrative that was generally consistent with the claimant's reports

throughout the medical evidence of record. The claimant told Dr.

Sharpe that her symptoms began in 2007 when she had n MVA. She

continued to have neck pain, and then had second MVA in January 2010,

which the claimant said worsened her neck, left arm and shoulder pain. 

The claimant also stated that she had a knot surgically removed from

her shoulder in November 2010, and had physical therapy and

modalities. (Exhibit 18F).

While the undersigned gives no weight to Dr. Sharpe's opinion, it is

important to note that her findings did not differ greatly from the

remaining medical evidence of record. Although the claimant told her

representative that she did not recall undergoing range of motion testing

during her exam with Dr. Sharpe, the claimant's physical exams from

Franklin generally showed pain with range of motion in the cervical 

and/or lumbar spine (See Exhibits 6F, 12F, 15F 22F and 28F), and the

claimant had diminished range of motion in these areas per Dr. Sharpe's

report in Exhibit 18F. Dr. Sharpe also noted the claimant had 5/5

muscle bulk, strength and tone, which was also noted in Exhibits 6F and

20F. The claimant also told her representative that she did not recall

undergoing a sensory exam with Dr. Sharpe; however, no neurological

deficits have been noted in the record, even in the recent NCS studies. 

(Exhibits 2F, 5f, 6F, l0F, 19F 20F, 23F, 24F and 28F).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 27 of 45
28

Therefore, the undersigned gives significant weight to Dr. Parker's

Physical Residual Functional Capacity Assessment in Exhibit 4F. 

Although Dr. Parker was non-examining, and therefore his opinions

does not as a general matter deserve as much weight as those of

examining or treating physicians, his opinion does deserve some weight, 

particularly in a case like this in which there exist a number of other

reasons to reach similar conclusions. While Dr. Parker gave his opinion 

in December 2009, the medical evidence of record as discussed in detail

above reflects that the claimant's condition has not varied much over

the relevant time period. Dr. Parker noted he assigned the limitation to

occasional reaching with the left shoulder due to pain, which is 

consistent with the medical evidence of record.

The record as a whole reflects that the claimant is capable of

performing light work as set forth above, and that she was not disabled

for any 12-month period. There is little to no objective support for the

claimant’s assertion that her impairments are of disabling severity.

6. The claimant is unable to perform any past relevant work (20 

CFR 404.1565 and 416.965).

* * *

7. The claimant was born on January 21, 1976 and was 33 years old, 

which is defined as a younger individual age 18-49, on the alleged 

disability onset date (29 CFR 404.1563 and 416.963).

8. The claimant has a limited education and is able to communicate 

in English (20 CFR 404.1564 and 416.964).

9. Transferability of job skills is not material to th edetermiantion 

of disability because using the Medical-Vocational Rules a framework 

supports a finding that the claimant is “not disabled,” whether or not 

the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 

404, Subpart P, Appendix 2).

10. Considering the claimant’s age, education, work experience, and 

residual functional capacity, there are jobs that exist in significant 

numbers in the national economy that the claimant can perform (20 CFR 

404.1569, 404.1569(a), 416.969, and 416.969(a)).

* * *

11. The claimant has not been under a disability, as defined in the 

Social Security Act, from July 30, 2009, through the date of this decision 

(20 CFR 404.1520(g) and 416.920(g)).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 28 of 45
29

(Tr. at 28-51 (emphasis in original)). The Appeals Council affirmed the ALJ’s decision 

(Tr. 1-7), and, thus, the hearing decision became the final decision of the Commissioner 

of Social Security.

DISCUSSION

In all Social Security cases, the claimant bears the burden of proving that he is 

unable to perform his previous work. Jones v. Bowen, 810 F.2d 1001 (11th Cir. 1986). In 

evaluating whether the claimant has met this burden, the examiner must consider the 

following four factors: (1) objective medical facts and clinical findings; (2) diagnoses of 

examining physicians; (3) evidence of pain; and (4) the claimant’s age, education and 

work history. Id. at 1005. An ALJ, in turn:

[U]ses a five-step sequential evaluation to determine whether the claimant 

is disabled, which considers: (1) whether the claimant is engaged in 

substantial gainful activity; (2) if not, whether the claimant has a severe 

impairment; (3) if so, whether the severe impairment meets or equals an 

impairment in the Listing of Impairments in the regulations; (4) if not, 

whether the claimant has the RFC to perform her past relevant work; and 

(5) if not, whether, in light of the claimant’s RFC, age, education and work 

experience, there are other jobs the claimant can perform.

Watkins v. Comm’r of Soc. Sec., 457 Fed. App’x 868, 870 (11th Cir. 2012)2 (per curiam) 

(citing 20 C.F.R. §§ 404.1520(a)(4), (c)-(f), 416.920(a)(4), (c)-(f)); Phillips v. Barnhart, 357 

F.3d 1232, 1237 (11th Cir. 2004)) (footnote omitted).

If a plaintiff proves that he cannot do his past relevant work, as here, it then 

becomes the Commissioner’s burden—at the fifth step—to prove that the plaintiff is 

capable—given his age, education, and work history—of engaging in another kind of 

substantial gainful employment that exists in the national economy. Phillips, 357 F.3d at 

 2 “Unpublished opinions are not considered binding precedent, but they may be 

cited as persuasive authority.” 11th Cir.R. 36-2.

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 29 of 45
30

1237, 1239; Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999), cert. denied, 529 U.S. 1089, 

(2000); Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir. 1985). 

The task for the Magistrate Judge is to determine whether the Commissioner’s 

decision to deny claimant benefits, on the basis that she can perform those light jobs 

identified by the vocational expert (“VE”), is supported by substantial evidence. 

Substantial evidence is defined as more than a scintilla and means such relevant 

evidence as a reasonable mind might accept as adequate to support a conclusion. 

Richardson v. Perales, 402 U.S. 389 (1971). “In determining whether substantial evidence 

exists, we must view the record as a whole, taking into account evidence favorable as 

well as unfavorable to the Commissioner’s] decision.” Chester v. Bowen, 792 F.2d 129, 

131 (11th Cir. 1986).3 Courts are precluded, however, from “deciding the facts anew or 

re-weighing the evidence.” Davison v. Astrue, 370 Fed. App’x 995, 996 (11th Cir. 2010) 

(per curiam) (citing Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005)). Also, “’[e]ven 

if the evidence preponderates against the Commissioner’s findings, [a court] must 

affirm if the decision reached is supported by substantial evidence.’” Id. (quoting 

Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158-59 (11th Cir. 2004)).

On appeal to this Court, Jones asserts three reasons why the Commissioner’s 

decision to deny her disability insurance benefits and supplemental security income is 

in error (i.e., not supported by substantial evidence): (1) the ALJ erred by relying upon 

the opinion of Dr. Gregory K. Parker, M.D. (“Dr. Parker”), a non-examining, reviewing 

physician, to support the residual functional capacity (“RFC”) for Plaintiff in violation 

of Dillard v. Astrue, 834 F. Supp. 2d 1325, 1332 (S.D. Ala. 2011), citing in part, Swindle v. 

 3 This Court’s review of the Commissioner’s application of legal principles, 

however, is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 30 of 45
31

Sullivan, 914 F.2d 222, 226 (11th Cir. 1990); (2) the ALJ erred by refusing to develop the 

record by ordering an additional orthopedic consultative examination after the ALJ (a) 

gave no weight to the opinion of Dr. Thomasina Anderson Sharpe, M.D. (“Dr. Sharpe”), 

an examining physician, and (b) disposed of the opinions of Dr. Otis Harrison, M.D. 

(“Dr. Harrison”), Jones’ treating physician, in violation of Dillard v. Astrue, 834 F. Supp.

2d 1325, 1333 (S.D. Ala. 2011) and Ingram v. Commissioner of Social Security 

Administration, 496 F.3d 1253, 1259 (11th Cir. 2007); and (3) the ALJ’s RFC determination 

at the fifth step of the sequential evaluation process was not supported by substantial 

evidence and entirely abrogated the medical opinions by Dr. Harrison that indicated the 

Plaintiff could not perform substantial gainful activity. The undersigned will first 

address the ALJ’s assessment of Dr. Harrison’s opinion before considering Jones’ three

claims together within the context of the ALJ’s RFC assessment. See, e.g., Thomas v. 

Astrue, No. CA 11–0406–C, 2012 WL 1145211, at *9 (S.D.Ala. Apr. 5, 2012) (“Because the 

undersigned finds that the ALJ did not explicitly articulate an adequate reason, 

supported by substantial evidence, for rejecting a portion of [the treating physician's] 

PCE assessment, this Court must necessarily find that the ALJ's RFC determination is 

not supported by substantial evidence.”).

A. The ALJ’s Assessment of Dr. Harrison’s Opinions

Dr. Harrison, Jones’ treating physician, provided his opinion through three (3) 

avenues: (1) a Clinical Assessment of Pain (CAP) form dated April 26, 2010 (Tr. at 447-

48); (2) a March 18, 2011 letter (Tr. at 509); and (3) a Physical Capacities Evaluation 

(PCE) dated March 1, 2012 (Tr. at 605). In the CAP form, Dr. Harrison noted that he had 

treated the claimant since September 2009, and the MRI of her neck showed “disc 

bulging” at C5-6 and C6-7, which is the underlying cause of her pain. (Tr. at 447). He 

also stated that the claimant's pain is intractable and virtually incapacitating; that 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 31 of 45
32

physical activity, such as walking, standing, bending, stooping and moving of the 

extremities, would increase symptoms to such an extent that bed rest would be

necessary; that the pain impacts the claimant’s ability to perform her previous work to 

the extent that she is totally restricted and thus unable to function at a productive level 

of work; and that the claimant has existed at this level since August 24, 2009. (Tr. at 

447-48). He noted that Jones was prescribed narcotic pain medication, Darvocet, and 

will require pain management within the next year. (Tr. at 448). Finally, Dr. Harrison

did not answer the question regarding whether the claimant could engage in any

form of gainful employment on a consistent basis without missing more than 2 days

of work per month or frequent interruptions to her work routine, but he did note that 

she complains of pain. (Tr. at 448).

In the March 18, 2011 letter addressed to “Whom It May Concern,” Dr. Harrison 

stated, “[Jones] is currently unable to work because of her medical condition. The 

current therapy that she has received has not controlled her symptom. She is currently 

being referred to another specialist.” (Tr. at 509). In the PCE, Dr. Harrison stated Jones 

had the following limitations in an eight-hour workday: sit for 2 hours at a time, for

up to 2 hours per day; stand/walk for 2 hours at a time, for up to 2 hours per day;

lift up to 5 pounds for 1 hour; carry up to 5 pounds for 2 hours, and up to 25

pounds for 1 hour; bend, squat and crawl for up to 2 hours; and climb for up to 1

hour. (Tr. at 605). Dr. Harrison assigned mild restriction of activities involving

unprotected heights, being around moving machinery, exposure to marked changes in

temperature and humidity, driving automotive equipment, and exposure to dust,

fumes, and gases. (Tr. at 605). Dr. Harrison said the claimant cannot reach; use her

hands for repetitive action such as simple grasping, pushing and pulling of arm

controls and fine manipulation; or use her feet for repetitive movements as in

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 32 of 45
33

pushing and pulling of leg controls. (Tr. at 605). Dr. Harrison did not answer the

questions about the length of time the claimant has been impaired or whether she can

work 8 hours per day, 40 hours per week on a sustained basis, within the limitations

above, without missing more than 2 days of work per month. (Tr. at 605). 

The ALJ gave “no weight” to Dr. Harrison’s opinions included in the CAP form, 

the March 18, 2011 letter, and the PCE for the following reasons:

The undersigned gives no weight to Dr. Harrison's responses in the

CAP form for several reasons. First, the course of treatment pursued by

Dr. Harrison has not been consistent with pain to such an extent that bed

rest is necessary. While Dr. Harrison had been treating the claimant for

less than a year when he completed the CAP, he noted her general

appearance was normal on several occasions around the time he

completed this form. (Exhibits 6F and 9F and 12F). Despite his

responses in the CAP, Dr. Harrison has prescribed Lortab to be used on

an as needed basis only. (Exhibits 22E, 25E, 29E, 12F, l5F, 20F, 22F and

28F). Second, his more recent treatment notes reflect no increase in

dosage or frequency of administration of her medications prescribed for

pain. Third, Dr. Harrison identified the November 2009, MRI, which he

said showed disc bulges at C5-6 and C6-7, as the underlying cause of

her pain. However, Dr. Cope, her former treating orthopedist

interpreted this MRI as being negative (See Exhibit 5F); and the report of

the M RI from the radiologist does not mention issues at the C5-6 or C6-7 

disc levels. (Exhibit 3F). Finally, the claimant's office visit on February

10, 2010, less than three months before Dr. Harrison completed the CAP

form, shows that she requested that her Social Security form be

completed. However, her treatment provider at Franklin said, "I see no

restrictions preventing work.” (Exhibit 6F).

* * *

However, no weight is given to [the March 18, 2011] letter because Dr.

Harrison's own treatment note from this date fails to reveal the type of

significant clinical and laboratory abnormalities one would expect if the

claimant were in fact disabled, as Dr. Harrison reported. Specifically, the

treatment note from this date reflected the claimant reported her pain

was only a 1/10. He noted that her general appearance was normal;

and she had pain on range of motion over the cervical spine area. 

While she stated that her medication was not helping and the epidural

did not help, Dr. Harrison continued her on Lortab as previously

prescribed. (Exhibit 12F). As noted previously, Dr. Harrison has also

characterized her general appearance as ''normal” no physical exam.

* * *

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 33 of 45
34

The undersigned gives no weight to Dr. Harrison's PCE in Exhibit 27F

because it is conclusory, internally inconsistent, and not supported by his

own treatment records. In the PCE, Dr. Harrison found the claimant

could sit for 2 hours at a time, for up to 2 hours per day and

stand/walk for 2 hours at a time, for up to 2 hours per day. However,

he provided no explanation of the evidence relied on in forming that

opinion: and as noted above, the claimant's physical exams from

Franklin generally show some spinal tenderness, left shoulder with pain

on palpation of the cervical spine and/or pain with range of motion in

the cervical and/or lumbar spine. (Exhibits 6F, 12F, 15F, 22F and 28F). 

Additionally, some of the limitations set forth in the PCE are internally

inconsistent. For example, he said the claimant could only lift up to 5

pounds, but was able to could carry up to 25 pounds. Dr. Harrison also

said the claimant cannot reach, but can climb for 1 hour a day. He said

the claimant cannot use her feet for pushing/pulling, but can bend, 

squat and crawl for up to 2 hours in an 8-hour workday. Dr. Harrison

also said she cannot use her hands for repetitive action such as simple

grasping, pushing and pulling of arm controls and fine manipulation;

however, she has received no significant treatment for problems with

her hands that would affect her manipulative abilities during the period

of adjudication. The undersigned notes that Dr. Harrison assigned mild

restriction of activities involving environmental irritants, which does not

readily translate into vocational terms.

The undersigned notes that the possibility always exists that a treating 

physician may express an opinion in an effort to assist a patient with 

whom he or she sympathizes for one reason or another. While it is 

difficult to confirm the presence of such motives, they are more likely in 

situations where the opinion in question departs substantially from the 

rest of the evidence of record, as in the current case. Dr. Harrison 's 

opinion is without substantial support from the other evidence of record, 

which obviously renders it less persuasive. Social Security Rulings 96-2p 

and 96-5p indicate that controlling weight may not be given to a treating 

physician's opinion unless it also is "not inconsistent" with the other 

substantial evidence in the case record. Therefore, Dr. Harrison’s opinion 

cannot be given controlling weight.

(Tr. at 45-47).

As the plaintiff's treating physician, Dr. Harrison's opinions “must be given 

substantial or considerable weight unless ‘good cause’ is shown to the 

contrary.” Gilabert v. Comm'r of Soc. Sec., 396 Fed. App’x 652, 655 (11th Cir. 2010) (per 

curiam) (quoting Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)). Good cause is 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 34 of 45
35

shown when the: “(1) treating physician's opinion was not bolstered by the evidence; (2) 

evidence supported a contrary finding; or (3) treating physician's opinion was 

conclusory or inconsistent with the doctor's own medical records.” Id. (quoting Phillips 

v. Barnhart, 357 F.3d 1232, 1241 (11th Cir. 2004)). “Where the ALJ articulate[s] specific 

reasons for failing to give the opinion of a treating physician controlling weight, and 

those reasons are supported by substantial evidence, there is no reversible 

error.” Id. (quoting Moore v. Barnhart, 405 F.3d 1208, 1212 (11th Cir. 2005)).

The Court finds that the ALJ has shown good cause by articulating specific 

reasons supported by substantial evidence for giving “no weight” to the Dr. Harrison’s 

opinion. As the ALJ stated, Dr. Harrison’s conclusions in the CAP form are inconsistent 

with the physician’s own medical records, and the evidence of record supports a 

contrary finding. Despite indicating that Jones’ pain was “virtually incapacitating” and 

that physical activity would necessitate “bed rest,” Dr. Harrison stated in multiple 

treatment notes from multiple physical examinations around the same time the CAP 

form was completed that Jones’ appearance was normal (Tr. at 411, 413, 453, 455, 510 & 

512) and that Jones should take Lortab for pain on an as needed basis only (Tr. at 350, 

357, 364, 511, 513, 515, 524 & 586). In addition, Dr. Harrison provided in the CAP form 

that a MRI of Jones’ neck showed that she has a disc bulging at C5-6 and C6-7, which is 

the underlying cause of her pain. However, Dr. G. H. Martindale, M.D., the reading 

radiologist, did not mention any issues at the C5-6 or C6-7 disc levels in his final report 

accompanying Jones’ most recent MRI preceding the completion of the CAP form. (Tr. 

at 388 (“There is straightening and very mild reversal of the normal cervical lordosis 

which is likely due to patient position. Vertebral body height and signal intensity are 

with normal limits. The disc spaces are well preserved and no disc herniation is seen in 

the cervical spine. At T1-2, there is a very small left posterolateral disc protrusion 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 35 of 45
36

which minimally effaces the thecal sac but which is of doubtful clinical significance.”)). 

Indeed, Dr. Stephen B. Cope, M.D., the claimant’s former treating orthopedist,

interpreted this MRI as being negative in his treatment records. (Tr. at 409). In 

addition, three months prior to the date Dr. Harrison completed the CAP form, a 

treatment physician at Franklin Primary Health Center, Inc. (“FPHC”), where Dr. 

Harrison is employed, stated the following after Jones’ office visit: “I see no restrictions 

preventing work.” (Tr. at 417). 

As for the March 18, 2011 letter, the ALJ stated that Dr. Harrison’s conclusions in 

the letter are inconsistent with Dr. Harrison's own treatment note from the same date, 

which reflects that Jones’ reported pain assessment was only a 1/10, her general 

appearance was normal; she had pain on range of motion over the cervical spine area;

and Dr. Harrison continued her on Lortab as previously prescribed. (Tr. at 510-11). 

Finally, the ALJ stated that Dr. Harrison’s PCE was conclusory, internally inconsistent, 

and not supported by his own treatment records. First, Dr. Harrison did not provide

any explanation (in the PCE or the accompanying treatment notes) of the evidence he 

relied on in forming his conclusions that Jones could sit for 2 hours at a time, for up to

2 hours per day and stand/walk for 2 hours at a time, for up to 2 hours per day (Tr. 

at 605-07), whereas Jones’ physical exams from FPHC generally only show some

spinal tenderness, left shoulder with pain on palpation of the cervical spine and/or

pain with range of motion in the cervical and/or lumbar spine. (Tr. at 411-24, 427-32, 

436-46, 510-14, 521-24, 583-86 & 606-10). Also, Dr. Harrison stated that Jones cannot use

her hands for repetitive action such as simple grasping, pushing/pulling arm

controls, and fine manipulation, but, as the ALJ points out, Jones has not received any

significant treatment for problems with her hands that would affect her manipulative

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 36 of 45
37

abilities during the period of adjudication. Finally, some of the limitations set forth by 

Dr. Harrison in the PCE are internally inconsistent, such as Dr. Harrison’s conclusions 

that Jones could only lift up to 5 pounds but could carry up to 25 pounds; that Jones 

could not reach but could climb for 1 hour a day; that Jones could not use her feet for

pushing/pulling but could bend, squat and crawl for up to 2 hours in an 8-hour

workday. (Tr. at 605). 

For the foregoing reasons, the Court finds that the ALJ articulated good cause for 

giving “no weight” to Dr. Harrison’s opinions and, thus, did not commit reversible 

error. Having made that determination, the Court now turns to Jones’ three claims on 

appeal and whether the ALJ’s RFC assessment is supported by substantial evidence. 

B. The ALJ’s RFC Assessment

Initially, the Court notes that the responsibility for making the RFC 

determination rests with the ALJ. Compare 20 C.F.R. §§ 404.1546(c) & 416.946(c) (“If 

your case is at the administrative law judge hearing level . . . , the administrative law 

judge . . . is responsible for assessing your residual functional capacity.”) with, e.g., 

Packer v. Comm’r, Soc. Sec. Admin., 542 Fed. App’x 890, 891-92 (11th Cir. 2013) (per 

curiam) (“An RFC determination is an assessment, based on all relevant evidence, of a 

claimant’s remaining ability to do work despite her impairments. There is no rigid 

requirement that the ALJ specifically refer to every piece of evidence, so long as the 

ALJ’s decision is not a broad rejection, i.e., where the ALJ does not provide enough 

reasoning for a reviewing court to conclude that the ALJ considered the claimant’s 

medical condition as a whole.” (internal citation omitted)). A plaintiff’s RFC—which 

“includes physical abilities, such as sitting, standing or walking, and mental abilities, 

such as the ability to understand, remember and carry out instructions or to respond 

appropriately to supervision, co-workers and work pressure[]”—“is a[n] [] assessment 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 37 of 45
38

of what the claimant can do in a work setting despite any mental, physical or 

environmental limitations caused by the claimant’s impairments and related 

symptoms.” Watkins, 457 Fed. App’x at 870 n.5 (citing 20 C.F.R. §§ 404.1545(a)-(c) & 

416.945(a)-(c)). Here, the ALJ determined Jones’ physical RFC as follows: 

After careful consideration of the entire record, the undersigned finds

that the claimant has the residual functional capacity to perform a

reduced range of light work as defined in 20 CFR 404.1567(b) and

416.967(b), in function by function terms (SSRs 83-10 and 06-8p), with

certain non-exertional restrictions associated with that level of exertion. 

The claimant's specific physical capabilities during the period of

adjudication have been the ability to lift/carry up to 10 pounds

frequently and 20 pounds occasionally; sit for about 6 hours per day;

stand and/or walk for up to 6 hours per day; perform limited pushing 

and/or pulling with the upper extremities; perform pushing and/or

pulling with the lower extremities without limitation; use the right

hand for reaching (including overhead), handling, fingering and

feeling without limitation; use the left hand for reaching (including 

overhead) occasionally, and for handling, fingering and feeling

without limitation; climb stairs and ramps, climb

ladders/ropes/scaffolds, balance, stoop, kneel, crouch and crawl 

without limitation. The claimant could work in a job environment

that would allow her to avoid concentrated exposure to extreme heat, 

extreme cold, hazardous machinery and heights. The claimant is

capable of performing unskilled work.

(Tr. at 30 (emphasis in original)).

To find that an ALJ’s RFC determination is supported by substantial evidence, it 

must be shown that the ALJ has “’provide[d] a sufficient rationale to link’” substantial 

record evidence “’to the legal conclusions reached.’” Ricks v. Astrue, No. 3:10-cv-975-

TEM, 2012 WL 1020428, at *9 (M.D. Fla. Mar. 27, 2012) (quoting Russ v. Barnhart, 363 F. 

Supp. 2d 1345, 1347 (M.D. Fla. 2005)); compare id. with Packer v. Astrue, No. 11-0084-CGN, 2013 WL 593497, at *4 (S.D. Ala. Feb. 14, 2013) (“’[T]he ALJ must link the RFC 

assessment to specific evidence in the record bearing upon the claimant’s ability to 

perform the physical, mental, sensory, and other requirements of work.’”), aff’d, 542

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 38 of 45
39

Fed. Appx. 890 (11th Cir. 2013);

4 see also Hanna v. Astrue, 395 Fed. Appx. 634, 636 (11th 

Cir. 2010) (per curiam) (“The ALJ must state the grounds for his decision with clarity to 

enable us to conduct meaningful review. . . . Absent such explanation, it is unclear 

whether substantial evidence supported the ALJ’s findings; and the decision does not 

provide a meaningful basis upon which we can review [a plaintiff’s] case.” (internal 

citation omitted)).5

In her brief, Jones relies on one of this Court’s prior decisions, Dillard v. Astrue, 

834 F. Supp. 2d 1325 (S.D. Ala. 2011), for the proposition that the ALJ’s RFC 

determination must be supported by the assessment of an examining or treating 

physician. (See Doc. 12). In order to find that the ALJ’s RFC assessment is supported by 

substantial evidence, however, it is not necessary for the ALJ’s assessment to be 

supported by the assessment of an examining or treating physician. See, e.g., Packer, 2013 

 4 In affirming the ALJ, the Eleventh Circuit rejected Packer’s substantial evidence 

argument, noting, she “failed to establish that her RFC assessment was not supported by 

substantial evidence[]” in light of the ALJ’s consideration of her credibility and the medical 

evidence. Id. at 892.

5 It is the ALJ’s (or, in some cases, the Appeals Council’s) responsibility, not the 

responsibility of the Commissioner’s counsel on appeal to this Court, to “state with clarity” the 

grounds for an RFC determination. Stated differently, “linkage” may not be manufactured 

speculatively by the Commissioner—using “the record as a whole”—on appeal, but rather, 

must be clearly set forth in the Commissioner’s decision. See, e.g., Durham v. Astrue, No. 

3:08CV839-SRW, 2010 WL 3825617, at *3 (M.D. Ala. Sept. 24, 2010) (rejecting the 

Commissioner’s request to affirm an ALJ’s decision because, according to the Commissioner, 

overall, the decision was “adequately explained and supported by substantial evidence in the 

record”; holding that affirming that decision would require that the court “ignor[e] what the 

law requires of the ALJ[; t]he court ‘must reverse [the ALJ’s decision] when the ALJ has failed to 

provide the reviewing court with sufficient reasoning for determining that the proper legal 

analysis has been conducted’” (quoting Hanna, 395 Fed. App’x at 636 (internal quotation marks 

omitted))); Id. at *3 n.4 (“In his brief, the Commissioner sets forth the evidence on which the ALJ 

could have relied . . . . There may very well be ample reason, supported by the record, for [the 

ALJ’s ultimate conclusion]. However, because the ALJ did not state his reasons, the court 

cannot evaluate them for substantial evidentiary support. Here, the court does not hold that the 

ALJ’s ultimate conclusion is unsupportable on the present record; the court holds only that the

ALJ did not conduct the analysis that the law requires him to conduct.” (emphasis in original)); 

Patterson v. Bowen, 839 F.2d 221, 225 n.1 (4th Cir. 1988) (“We must . . . affirm the ALJ’s decision 

only upon the reasons he gave.”).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 39 of 45
40

WL 593497, at *3 (“[N]umerous court have upheld ALJs’ RFC determinations 

notwithstanding the absence of an assessment performed by an examining or treating 

physician.”); McMillian v. Astrue, No. 11-00545-C, 2012 WL 1565624, at *4 n.5 (S.D. Ala. 

May 1, 2012) (noting that decisions of this Court “in which a matter is remanded to the 

Commissioner because the ALJ’s RFC determination was not supported by substantial 

and tangible evidence still accurately reflect the view of this Court, but not to the extent 

that such decisions are interpreted to require that substantial and tangible evidence 

must—in all cases—include an RFC or PCE from a physician” (internal punctuation 

altered and citation omitted)); but cf. Coleman v. Barnhart, 264 F. Supp. 2d 1007 (S.D. Ala. 

2003). Therefore, the Court finds that Jones’ reliance on Dillard is misguided, and her 

assertion that the ALJ’s RFC determination must be supported by the assessment of an 

examining or treating physician is without merit. 

In this case, there are physical assessments of record from a treating physician 

and an examining physician. As previously discussed, however, the ALJ properly gave

“no weight” to Dr. Harrison’s opinions. In addition, the ALJ appropriately gave “no 

weight” to the opinions and findings contained in examining physician Dr. Sharpe’s

consultative examination report (see Tr. at 543-54 & 602-03).

6

 Contrarily, the ALJ 

properly accorded Dr. Parker’s physical RFC assessment “significant weight,” a 

determination consistent with substantial evidence in the record, as explained more 

fully below.

 6 As the ALJ details in her decision (Tr. at 47-49), Jones’ counsel objected to Dr. 

Sharpe’s consultative examination via letters (see Tr. at 354-56, 362-63) requesting that the ALJ 

give Dr. Sharpe’s examination and opinion no weight for several reasons, including that Dr. 

Sharpe’s report contained an admission that he did not review any records. The ALJ agreed 

with Jones’ counsel and accordingly gave Dr. Sharpe’s opinion “no weight.” (Tr. at 48).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 40 of 45
41

Importantly, in establishing Jones’ RFC, which means determining Jones’

“remaining ability to do work despite her impairments[,]” Packer, 542 Fed. App’x at 

891—keeping a focus on the extent of those impairments as documented by the credible 

record evidence—the ALJ painstakingly sifted through the medical evidence of record 

(see Tr. at 32-49), along with the claimant’s testimony (see Tr. 31-32 & 41-45), to conclude 

that Jones “is capable of lifting/carrying up to 10 pounds frequently and 20 pounds 

occasionally; sitting for about 6 hours per day; standing and/or walking tor up to 6 

hours per day; performing pushing and/or pulling with the lower extremities without 

limitation; and climbing stairs and ramps, climbing ladders/ropes/scaffolds, balancing, 

stooping, kneeling, crouching and crawling without limitation.” (Tr. at 42). For 

instance, the ALJ considered Jones’ numerous medical records, including her multiple

MRI reports, x-rays, nerve conduction study (NCS) results, and treatment notes from 

multiple physicians. (See Tr. at 32-49). The ALJ also considered Jones’ own function 

report regarding her abilities and daily activities (see Tr. at 41), her own questionnaires 

regarding pain and headaches (see Tr. at 41-44), and her testimony at the hearing before 

the ALJ about the severity of her impairments and disabilities. (Tr. at 31-32 & 41-45).7 

As previously discussed, the ALJ also considered Dr. Parker’s December 7, 2009 

physical RFC assessment; Dr. Sharpe’s August 2011 physical consultative examination; 

and Dr. Harrison’s April 26, 2010 CAP form, March 18, 2011 letter, and March 1, 2012 

PCE. Because the ALJ articulated good cause to reject the opinions of Dr. Harrison and 

Dr. Sharpe, the ALJ did not err in giving “significant weight” to non-examining state 

agency physician Dr. Parker’s assessment that Jones: (1) can occasionally lift and carry 

 7 Specifically, the ALJ found that Jones’s testimony was “less than fully credible” 

because she made several statements regarding her disability that were inconsistent the 

evidence of record. (See Tr. at 44-45). 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 41 of 45
42

up to 20 pounds and frequently up to 10 pounds; (2) can stand and/or walk for about 6

hours in an 8-hour workday; (3) can sit for about 6 hours in an 8-hour workday; (4) can 

perform limited pushing and/or pulling in the upper extremities and unlimited 

pushing and/or pulling with the lower extremities; (5) can reach with the right upper 

extremity without limitation; (6) can reach with the left shoulder occasionally; (7) can 

perform unlimited handling (gross manipulation), fingering (fine manipulation), and 

feeling (skin receptors); (8) has no communicative, postural, or visual limitations; and 

(9) should avoid concentrated exposure to extreme heat, extreme cold, and hazardous 

machinery and heights. See Thomas v. Colvin, No. 11-00569-B, 2015 WL 4458861, at *14 & 

n.8 (S.D. Ala. July 21, 2015) (“Because the ALJ had good cause to discount [the treating 

physician’s] opinions, the opinions of non-examining State Agency [physician] do not 

conflict with any credible examining source, and thus, they were properly considered 

by the ALJ.”); Milner v. Barnhart, 275 Fed. App’x 947, 948 (11th Cir. 2008) (“The ALJ is 

required to consider the opinions of non-examining state agency medical and 

psychological consultants because they ‘are highly qualified physicians and 

psychologists who are also experts in Social Security disability evaluation.’ 20 C.F.R. § 

404.1527(f)(2)(i). The ALJ may rely on opinions of non-examining sources when they do 

not conflict with those of examining sources. Edwards v. Sullivan, 937 F.2d 580, 584-85 

(11th Cir. 1991).”).

8

 8 The Court notes that Dr. Parker properly explained and “linked” his RFC 

findings/limitations to substantial evidence in the record. (See Tr. at 401-05 (referring 

specifically to the claimant’s symptoms as well as the results of a “lift-off test,” “neurologic 

exam,” radiographs and MRI scans). Cf. Woods v. Colvin, NO. 15-0020-C, 2015 WL 5679750, at *9 

(S.D. Ala. Sept. 24, 2015) (“And perhaps the ALJ’s reliance upon [the non-examining, reviewing 

physician’s] RFC assessment would have sufficed had [the physician] properly “linked” his 

RFC findings/limitations to substantial evidence in the record, as is even directed on the form 

he completed.”). 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 42 of 45
43

This analysis shows to this Court that the ALJ considered Jones’ physical

condition as a whole in determining her physical RFC. Accordingly, the ALJ’s physical

RFC determination provides an articulated linkage to the medical evidence of record. 

The linkage requirement is simply another way to say that, in order for this Court to 

find that an RFC determination is supported by substantial evidence, ALJs must “show 

their work” or, said somewhat differently, show how they applied and analyzed the 

evidence to determine a plaintiff’s RFC. See, e.g., Hanna, 395 Fed. Appx. at 636 (“[An 

ALJ’s] decision [must] provide a meaningful basis upon which we can review [a 

plaintiff’s] case”); Ricks, 2012 WL 1020428, at *9 (an ALJ must “explain the basis for his 

decision”); Packer, 542 Fed. App’x at 891-92 (“[An ALJ must] provide enough reasoning

for a reviewing court to conclude that the ALJ considered the claimant’s medical 

condition as a whole[]” (emphasis added)). Thus, by “showing her work,” the ALJ has 

provided the required “linkage” between the record evidence and her RFC 

determination necessary to facilitate this Court’s meaningful review of her decision.

As for Jones’ argument that the ALJ erred by failing to develop the record, in 

violation of Dillard, by ordering an additional orthopedic consultative examination after 

she gave no weight to the opinions of Dr. Harrison and Dr. Sharpe, the Court reiterates 

that the claimant’s reliance on Dillard is misguided and that it is not necessary for the 

ALJ’s assessment to be supported by the assessment of an examining or treating 

physician. See, e.g., Packer, 2013 WL 593497, at *3; McMillian, 2012 WL 1565624, at *4 n.5. 

Instead, while the ALJ has a “basic duty to a basic duty to develop a full and fair 

record,” Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003) (per curiam); see also 

Ingram v. Commissioner of Social Security Administration, 496 F.3d 1253, 1269 (11th Cir.

2007), the ALJ “is not required to order a consultative examination as long as the record 

contains sufficient evidence for the [ALJ] to make an informed decision.” Ingram, 496 

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 43 of 45
44

F.3d at 1269; see also Hollis v. Colvin, NO. 14-00268-B, 2015 WL 4429051, at *5-6 (S.D. Ala. 

July 20, 2015). Here, the Court finds that the evidence of record, which includes an

immense amount of physician treatment notes and testing results, a credible RFC 

assessment conducted by a non-examining state agency physician, and reports and 

questionnaires completed by the claimant herself, contains sufficient evidence for the 

ALJ to have made an informed decision. Accordingly, the Court finds that the ALJ did 

not err by failing to further develop the record.

Because substantial evidence of record supports the Commissioner’s 

determination that Jones can perform the physical and mental requirements of a 

reduced range of light work as identified by the ALJ (see Tr. at 30-49), and the plaintiff 

makes no argument that this RFC would preclude her performance of the light

unskilled jobs identified by the VE during the administrative hearing (compare Doc. 12

with Tr. 50-51 & 66-76), the Commissioner’s fifth-step determination is due to be 

affirmed. See, e.g., Owens v. Comm’r of Soc. Sec., 508 Fed. App’x 881, 883 (11th Cir. 2013) 

(“The final step asks whether there are significant numbers of jobs in the national 

economy that the claimant can perform, given his RFC, age, education, and work 

experience. The Commissioner bears the burden at step five to show the existence of 

such jobs . . . [and one] avenue[] by which the ALJ may determine [that] a claimant has 

the ability to adjust to other work in the national economy . . . [is] by the use of a VE[.]”

(internal citations omitted)); Land v. Comm’r of Soc. Sec., 494 Fed. App’x 47, 50 (11th Cir. 

2012) (“At step five . . . ‘the burden shifts to the Commissioner to show the existence of 

other jobs in the national economy which, given the claimant’s impairments, the 

claimant can perform.’ The ALJ may rely solely on the testimony of a VE to meet this 

burden.” (internal citations omitted)).

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 44 of 45
45

CONCLUSION

In light of the foregoing, it is ORDERED that the decision of the Commissioner 

of Social Security denying plaintiff benefits be affirmed.

DONE and ORDERED this the 30th day of September 2015.

s/WILLIAM E. CASSADY

UNITED STATES MAGISTRATE JUDGE

Case 1:14-cv-00247-C Document 20 Filed 09/30/15 Page 45 of 45