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Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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IN THE UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF ARKANSAS

Jeffrey A Jordan Plaintiff

v. No. 4:14‐CV–493‐JLH‐JTK

Carolyn W. Colvin, Acting Commissioner,

Social Security Administration Defendant

Recommended Disposition

Instructions

The following recommended disposition was prepared for U.S. District Judge J.

Leon Holmes.  A party to this dispute may file written objections to this

recommendation.  An objection must be specific and state the factual and/or legal basis

for the objection.  An objection to a factual finding must identify the finding and the

evidence supporting the objection.  Objections must be filed with the clerk of the court

no later than 14 days from the date of this recommendation.1  The objecting party must

serve the opposing party with a copy of an objection.  Failing to object within 14 days

waives the right to appeal questions of fact.2

  If no objections are filed, Judge Holmes

may adopt the recommended disposition without independently reviewing all of the

record evidence.

1

28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b).

2

Griffini v. Mitchell, 31 F.3d 690, 692 (8th Cir. 1994) (failure to file objections

waives right to de novo review and to appeal magistrate judge’s findings of fact).

Case 4:14-cv-00493-JLH Document 11 Filed 04/23/15 Page 1 of 10
Reasoning for Recommended Disposition

Jeffrey A. Jordan seeks judicial review of the denial of his application for social

security disability benefits.3  Jordan last worked as a truck driver for a plastics recycling

company.4

  He claims he has been disabled since in March 2011 when he stopped

working after a workplace back injury.5

  The record documents no workplace injury.

The Commissioner’s decision.  After considering the application, the ALJ

determined Jordan has severe impairments — lumbar degenerative disc disease status

post fusion with radiculopathy, obesity, and depression with anxiety6 — but he can do

some sedentary work.7

  Because a vocational expert identified available sedentary

work,8 the ALJ determined Jordan is not disabled and denied the application.

After the Appeals Council denied review,9 the ALJ’s decision became the

3

SSA record at pp. 128 & 136 (applying for disability benefits on Aug. 8, 2011 and

alleging disability beginning Mar. 21, 2011).  Agency records indicate Jordan also

applied for disability benefits on Mar. 15, 1999 and alleged disability beginning Nov. 1,

1998.  Id. at p. 143.  That application was denied on July 28, 2000.  Id. at p. 154.

4

Id. at pp. 157 & 167.

5

Id. at p. 166.

6

Id. at p. 14.

7

Id. at p. 17.

8

Id. at pp. 59‐60.

9

Id. at p. 1.

2

Case 4:14-cv-00493-JLH Document 11 Filed 04/23/15 Page 2 of 10
Commissioner’s final decision for the purpose of judicial review.10  Jordan filed this case

to challenge the decision.11  In reviewing the decision, the court must determine

whether substantial evidence supports the decision and whether the ALJ made a legal

error.12  This recommendation explains why the court cannot determine whether

substantial evidence supports the decision and why this case should be remanded to the

Commissioner for further proceedings.

Jordan’s allegations.  Jordan challenges the determination that he can do some

sedentary work.  He relies on the orthopedic examiner’s opinion as proof he cannot

work.  The examiner reported that Jordan can sit for six hours per day and stand/walk

for up to one hour per day.13  According to Jordan, this opinion proves he is physically

unable to work on a full‐time basis.  He maintains the ALJ should have given the

10See Anderson v. Sullivan, 959 F.2d 690, 692 (8th Cir. 1992) (stating that “the Social

Security Act precludes general federal subject matter jurisdiction until administrative

remedies have been exhausted” and explaining that the Commissioner’s appeal

procedure permits claimants to appeal only final decisions).

11Docket entry # 1.

12See 42 U.S.C. § 405(g) (requiring the district court to determine whether the

Commissioner’s findings are supported by substantial evidence and whether the

Commissioner conformed with applicable regulations); Long v. Chater, 108 F.3d 185, 187

(8th Cir. 1997) (“We will uphold the Commissioner’s decision to deny an applicant

disability benefits if the decision is not based on legal error and if there is substantial

evidence in the record as a whole to support the conclusion that the claimant was not

disabled.”).

13SSA record at p. 399.

3

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examiner’s opinion significant weight.  For these reasons, he maintains substantial

evidence does not support the decision.14

Applicable legal principles.  The orthopedist’s opinion is probative of Jordan’s

application because Jordan based disability on musculoskeletal impairment.  An

orthopedist specializes in the musculoskeletal system.15  The Commissioner’s

regulations encourage the ALJ to give more weight to a specialist’s opinion about

medical issues related to the specialty than to a medical opinion outside the specialty.16

An ALJ, however, “may reject the conclusions of any medical expert, whether hired by

the claimant or the government, if they are inconsistent with the record as a whole.”17

The court must consider whether the orthopedic opinion is inconsistent with the record

as a whole.

14Docket entry # 9.

15Stedman’s Med. Dictionary 1383 (28th ed.) (defining an orthopedist as “[o]ne

who practices orthopaedics”).  See id. (defining orthopedics as “[t]he medical specialty

concerned with the preservation, restoration, and development of form and function of

the musculoskeletal system, extremities, spine, and associated structures by medical,

surgical, and physical methods.”).

1620 C.F.R. §§ 404.1527(c)(5) & 416.927(c)(5) (“We generally give more weight to

the opinion of a specialist about medical issues related to his or her area of specialty

than to the opinion of a source who is not a specialist.”).

17Pearsall v. Massanari, 274 F.3d 1211, 1219 (8th Cir. 2001).

4

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The opinion is inconsistent with the record as a whole, but the ALJ’s reasoning

reflects a mistake requiring a remand.  The orthopedist’s opinion flowed from a post‐

hearing exam.18  The ALJ ordered the exam because Jordan had little treatment after

back surgery.19  The examiner is a physician who often provides the Commissioner with

medical opinions about a claimant’s ability to work.  Considering the purpose of the

exam,20 the examiner’s speciality, and the Commissioner’s frequent reliance on the

examiner, one might expect the ALJ to give the opinion significant weight, but the ALJ

gave the opinion little weight, reasoning that there is no “objective medical evidence to

support the[] limitations” and that the examiner relied “quite heavily” Jordan’s

subjective reported symptoms.21  

18SSA record at pp. 401‐02.

19Jordan underwent back surgery for what his neurosurgeon described as “a real

small disc protrusion.”  Id. at p. 253.  Although the neurosurgeon didn’t recommend

surgery, id., an orthopedic surgeon performed a minimally invasive spinal fusion after a

discography identified the disc protrusion as the source of pain.  Id. at p. 277 (describing

the disc protrusion as “a tiny herniation at L5‐S1ʺ).  Jordan claims to have seen his

surgeon twice after his surgery, but he reported no followup visits in his agency

paperwork.  See id. at pp. 174 & 184.  The record doesn’t not include the orthopedic

surgeon’s treatment notes.  The record includes only hospital records consisting of the

surgeon’s operative report and discharge summary.  Id. at pp. 275‐81.  Much of the

medical evidence flowed from periodic visits to primary care providers.

20Id. at p. 52 (“I’m going to send you out to an orthopedic specialist or a rehab

specialist to evaluate and see just where we are with your condition.”).

21Id. at p. 23.

5

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Substantial evidence supports many aspects of the ALJ’s reasoning because

earlier medical findings are not as limiting as the orthopedist’s medical findings.

Treating medical providers consistently documented tenderness in the low back,22 but

no problems with function,23 muscle strength, range of motion, or sensation.  In

contrast, the orthopedic examiner documented problems in these areas.  The following

chart illustrates the difference between a treating provider’s medical findings and the

orthopedic examiner’s findings.

emergency room visit

three months before hearing

orthopedic exam

two months & 23 days after hearing

“Neck exam included findings of normal

range of motion, ... no tenderness.”24

“flexion is approximately 40°, extension is

approximately 50°, rotation is approximately

60° right and left side, respectively, and

lateral flexion is approximately 40° right and

left side, respectively.”25

“Back exam included findings of normal

inspection, no tenderness.”26

“flexion is no more than 70°, extension is

approximately 0°, and lateral flexion is

approximately 10 ‐ 15° right and left side,

respectively.”27

22See id. at p. 304 (Aug. 9, 2011), p. 302 (Sept. 12, 2011), p. 338 (Sept. 21, 2011),

p. 326 (Oct. 26, 2011), p. 336 (Nov. 9, 2011) & p. 334 (Jan. 24, 2012).

23But see id. at p. 336 (abnormal gait on Nov. 9, 2011) & p. 334 (abnormal gait on

Jan. 24, 2012).

24Id. at p. 362.

25Id. at p. 401.  See also id. at p. 400.

26Id. at p. 362.

27Id. at p. 401.

6

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“Upper extremity exam included findings of

inspection normal, Range of motion normal,

Motor strength normal.”

“Strength in the upper extremity today is at

5/5.  Sensation is diminished in the right

hand at the ring and small finger.”28

“Lower extremity exam included findings of

inspection normal, Range of motion normal,

Motor strength normal.”29

“Strength in the lower extremity today is at

5/5 on the left side and 4+/5 on the right

side.”30

“Gait normal.”31 “he walks with a limp favoring his right leg.

He cannot squat and come to a full stance.”32

The differences may have flowed from Jordan’s complaints — chest pain at the

emergency room versus musculoskeletal complaints during the orthopedic exam — but

the differences may have flowed from motivation and exaggeration.  Degenerative

changes in the spine likely cause back pain,33 but it’s reasonable to expect that at least

one of Jordan’s several treating medical providers would have observed and

documented problems with range of motion, function, and sensation if Jordan has such

28Id. at p. 401.

29Id. at p. 362.

30Id. at p. 401.

31Id. at p. 362.

32Id. at p. 401.

33Nine months after back surgery, diagnostic imaging showed no disc protrusion.

Id. at p. 386.  The imaging showed only degenerative changes in the form of disc

desiccation; that is, dehydration of the spine’s disc material.  Some people with disc

desiccation experience few symptoms, but disc desiccation can cause back pain because

it can reduce the flexibility and height of affected discs.

7

Case 4:14-cv-00493-JLH Document 11 Filed 04/23/15 Page 7 of 10
problems, especially considering that Jordan sought treatment for back pain.34  The lack

of negative medical findings by treating medical providers, the inconsistency in

Jordan’s reports about the source of his back pain,35 and the omission of treatment

records from the back surgeon, suggest Jordan exaggerated his symptoms during the

orthopedic exam.

Even though the orthopedic opinion is inconsistent with the record as a whole,

the ALJ’s reasoning reflects a mistake.  The mistake is reflected in the following passage:

In addition, there is nothing to show that the claimant is sensitive to

chemicals, noise, humidity, dust/fumes or temperature extremes, as found

by [the examiner].  There is no evidence of emergent care treatment or

hospitalization related to [chronic obstructive pulmonary disease],

emphysema or asthma.  The claimant does not take any medications for

any of these conditions.  [The examiner] noted a past medical history of

asthma but had no records or other information to rely upon other than

the claimant’s own statements.  There is no diagnosis of asthma in the

records.36

This passage reflects criticism for reporting environmental limitations in the absence of

medical evidence of a respiratory impairment.37  Reporting environmental limitations in

34See id. at p. 304 (Aug. 9, 2011), p. 302 (Sept. 12, 2011), p. 338 (Sept. 21, 2011),

p. 326 (Oct. 26, 2011), p. 336 (Nov. 9, 2011) & p. 334 (Jan. 24, 2012).

35Compare id. at p. 38 (attributing back pain to falling at work) with id. at p. 252

(reporting several years of back pain without a significant triggering event).

36Id. at p. 23.

37See id. at p. 399 (marking chemicals, noise, humidity, dust/fumes or temperature

extremes as “N/A”).

8

Case 4:14-cv-00493-JLH Document 11 Filed 04/23/15 Page 8 of 10
the absence of supporting medical evidence is a good reason for discounting a medical

opinion, but the orthopedic examiner reported no environmental limitations.  The ALJ

misread the report; the ALJ made a mistake.

Not every mistake provides a basis for relief, but the mistake in this case requires

a remand because the decision doesn’t indicate the role unsupported environmental

limitations played in discounting the opinion.  Because unsupported environmental

limitations wasn’t the only basis for discounting the opinion, the court cannot

determine whether substantial evidence supports the decision.  Doing so forces the

court to speculate about the role unsupported environmental limitations played in

weighing the opinion.  Because the court may not speculate, this case should be

remanded for reconsideration of the orthopedic examiner’s opinion.

Conclusion and Recommended Disposition

The undersigned magistrate judge recommends REMANDING this case to the

Commissioner, because the court cannot speculate about the role the mistake played in

weighing the opinion.  Only the ALJ can reconcile the mistake.  If the district judge

decides to remand this case, the remand order should include the following

instructions:

This case is remanded to the Commissioner because the ALJ’s

consideration of the orthopedic examiner’s medical opinion reflects a

mistake.  The ALJ criticized the orthopedic examiner for reporting

unsupported environmental limitations, but in actuality, the orthopedic

9

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examiner reported no environmental limitations.  The ALJ did not indicate

what role the environmental limitations played in weighing the opinion,

so the court cannot determine whether substantial evidence supports the

ALJ’s decision.

On remand, the ALJ shall reconsider the orthopedic examiner’s opinion

and assign appropriate weight.  Once the ALJ reconsiders the opinion, the

ALJ shall reassess Jordan’s residual functional capacity and determine

whether work exists that Jordan can do.  The ALJ may exercise discretion

in determining whether to obtain updated medical evidence and whether

to order a second orthopedic exam.

A remand could have been avoided if Jordan’s attorney had alerted the Appeals

Council to the ALJ’s mistake, but the attorney did not mention the mistake to the

Appeals Council38 or to this court on judicial review.  If the attorney moves for attorney

fees, it would be appropriate for the attorney to address the omission in his application.

Dated this 23rd day of April, 2015.

_________________________

United States Magistrate Judge

38Id at pp. 226‐27 (attorney brief asking Appeals Council to review the ALJ’s

decision) & docket entry # 9 (attorney brief for judicial review).

10

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