Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_06-cv-01885/USCOURTS-azd-2_06-cv-01885-0/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)

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WO HJ

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Karen E. Rose, 

Plaintiff, 

vs.

Michael J. Astrue, Commissioner of Social

Security Administration, 

Defendant. 

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No. CV 06-1885-PHX-EHC

ORDER

This is a proceeding to review a final decision of the Defendant Social Security

Commissioner (“Commissioner”) denying disability benefits to Plaintiff Karen E. Rose. The

parties filed a cross-motions for summary judgment (Dkts. 26, 32), which are fully briefed.

I. Background

Plaintiff filed an application for Social Security Disability Insurance Benefits (“DIB”)

under Title II of the Social Security Act on March 11, 2003, alleging disability due to a right

knee problems, back pain, stomach problems, varicose veins, Achilles tendinitis, and heel

spurs. (Tr. 25, 30, 76, 84, 108, 119). Plaintiff originally alleged a disability onset date of

March 8, 2001, which was subsequently amended to June 1, 2001. (Tr. 24). Plaintiff’s DIB

application was denied initially and upon reconsideration, and a request for hearing was

timely filed. (Tr. 24). The ALJ held a hearing on March 23, 2005. (Tr. 24). Plaintiff

appeared at the hearing represented by counsel. (Tr. 24). Plaintiff testified, as did vocational

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1

The administrative record contains medical evidence going back as far as the 1980s,

which is not fully discussed herein. Plaintiff’s Statement of Facts in support of her motion

for summary judgment summarizes much of this evidence, and thus, the Court only

summarizes the key facts herein. In ruling on the pending motions, the Court has, however,

considered all the evidence in the record.

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expert Linda Heiland. (Tr. 24). The ALJ denied Plaintiff’s application in a decision dated

May 23, 2005. (Tr. 24-30). The Appeals Council denied Plaintiff’s request for review. (Tr.

8). Plaintiff now seeks judicial review of the ALJ’s decision under 42 U.S.C. § 405(g).

II. Evidence in the Record

At the time of her alleged onset date, Plaintiff was 57 years old. (Tr. 25). Plaintiff

completed two years of college in 1977 and her past work includes employment as an

applications specialist and as a legal assistant. (Tr. 25, 63, 77-78, 81, 85-86). 

A. Early Medical History1

On August 12, 1988, Dr. Lester E. Mertz, M.D. examined Plaintiff and diagnosed

esophageal motility abnormality and elevated antinuclear antibody–possible early

Scleroderma, history of ulcerative procritis, and moderate obesity. (Tr. 404-406).

On January 30, 1992, Dr. Bernard Shostack, M.D. noted that Plaintiff had been his

patient for a number of years and was last seen on December 3, 1991, for pain in her right

leg. (Tr. 364). Dr. Shostack recommended therapy for treatment of facet joint disease and

sciatica. (Tr. 364). Plaintiff was improved on January 30, 1992, (Tr. 364) and after another

several weeks of physical therapy, Plaintiff reported that she was improved enough to

continue with the exercises at home on March 10, 1992. (Tr. 363).

On May 11, 1992, Plaintiff saw Dr. Gregory S. Johnston, M.D. for her back pain,

which she reported had been present since August of 1991. (Tr. 400). Plaintiff could not

recall any overt injury but noticed increased back pain and pain in the right leg, which were

aggravated by driving and sitting for extended periods of time. (Tr. 400). Dr. Johnston noted

that physical therapy had been helpful and that Plaintiff reported she was 90% better until

just a few weeks prior to her visit when she began using less of the nonsteriodal antiCase 2:06-cv-01885-EHC Document 38 Filed 01/28/08 Page 2 of 32
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inflammatory Lodine. (Tr. 400). The physical examination was positive for the right

shoulder being slightly more elevated than the left, flattening through the thoracic spine, very

mild scoliosis in the lumbosacral region convexed to the right, tenderness to deep palpation

in the right low back and upper sciatic notch region on the right side, and contralateral right

low back discomfort caused by lateral bending to the left at near full range. (Tr. 400-401).

Dr. Johnston’s review of X-Rays taken March 10, 1992, revealed slight scoliosis convexed

to the left side, narrowing at L4-5 and L5-S1 (AP view), minimal vertebral lipping at L3 and

L2, minimal narrowing at L4-5, bony encroachment of the formina at L4-5, and mild facet

degenerative changes. (Tr. 401). Dr. Johnston diagnosed scoliosis and lubosacral

strain/sprain, and suggested ruling out HNP (herniated nucleus pulposus). (Tr. 402;

Plaintiff’s Statement of Facts (“PSOF”) ¶ 21). Dr. Johnston found no need for surgery or an

MRI and instructed Plaintiff on exercises that she could do at home along with her other

exercises. (Tr. 402). At the request of Dr. Johnston, a lumbar spine MRI was taken on

August 28, 1992, and revealed a small central disc herniation at L4-L5 combined with

bilateral ligamentum flavum hypertrophy and resulting in moderate lumbar canal stenosis.

(Tr. 236-237).

On July 20, 1994, Dr. Shostack noted that Plaintiff had been complaining of hip pain

while lying down or sitting, pain in her right knee, and had an accident in March 1994. (Tr.

358). Dr. Shostack diagnosed a left hip strain and possible chondromalacia of the right knee.

(Tr. 358). Dr. Shostack observed that Plaintiff had gained a lot of weight and recommended

Plaintiff lose some weight to see if the situation would improve. (Tr. 358).

On December 15, 1994, Dr. Charles C. Hopmans, M.D. performed an orthopedic

evaluation of Plaintiff related to her complaints of discomfort in her right low back region

to her buttock down to the knee region. (Tr. 393). Dr. Hopmans noted that Plaintiff’s right

low back region and buttock pain is not constant and that Plaintiff usually had the pain when

sitting, especially in her car, but walking was not a major problem for her. (Tr. 393). Dr.

Hopmans also noted that Plaintiff was employed as an applications specialist at Best Western

International, a desk job, and that Plaintiff “state[d] that she is up and down a lot at work.”

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(Tr. 394). Dr. Hopmans observed that Plaintiff presented with fairly marked varicosities

involving the medial and anteromedial aspect of her left leg from the knee distally. (Tr. 396).

Dr. Hopmans concluded that Plaintiff was significantly deconditioned and should go back

on her exercise routine. (Tr. 396-97).

Dr. Hopmans saw Plaintiff again on March 2, 1995, who complained of increasing

back discomfort associated with several unusual episodes including moving from one place

to another with respect to her work routine. (Tr. 392). Dr. Hopmans noted that Plaintiff’s

discomfort was primarily in her back and not in her legs at that time. (Tr. 392). Dr.

Hopmans took X-Rays of her lumber spine, which demonstrated good disc spacing and no

major changes. (Tr. 392). Dr. Hopmans noted that Plaintiff did not have anything more than

a variable degree of mechanical disability. (Tr. 392). He advised Plaintiff to continue with

her Relafen and an active therapy routine, noting that he did “not know what else [they

could] do to improve this situation.” (Tr. 392).

On May 15, 1996, a lumbar spine MRI revealed mild facet degenerative changes at

L5-S1, broad-based central disc herniation eccentric to the left and facet and ligamentous

changes at L4-5 resulting in moderate central canal stenosis, an increase in the size of the

disc herniation since the prior August 28, 1992, exam, small fragment of disc material in the

lateral recess at the L4 pedicle level on the left appearing to originate from the L3-L4 disc

level on the sagittal images. (Tr. 235).

On May 28, 1996, Dr. Terry E. McLean, M.D. examined Plaintiff for her complaints

of left low back pain, left lower extremity radicular pain secondary to lumbar spinal stenosis,

and the disc herniations confirmed by MRI scan. (Tr. 389). Dr. McLean reported that

aggravating factors included sitting, bending, lifting, straining, or standing. (Tr. 389).

Plaintiff could walk about one-half block, could not find a comfortable position sitting, and

had tried working part-time and even full-time but both had aggravated her symptoms. (Tr.

389). Dr. McLean diagnosed lumbar spinal stenosis with disc herniation L4-5 with left L5

radiculopathy, and extruded lumbar disc herniation L3-L4 with left L4 radiculopathy. (Tr.

390). Dr. McClean discussed Plaintiff’s options, which included activity modification,

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working part-time with frequent change of position, trial of lumbar epidural steroid

injections, and continuing with her Volataren and her pain medications as needed. (Tr. 390).

Dr. McClean noted that if Plaintiff failed to improve over the next two weeks he would

recommend surgery. (Tr. 390).

Dr. McClean’s notes from May until August 1996 detail Plaintiffs treatment. (Tr.

386-388). Plaintiff received epidural lumbar injections on June 20, 1996, and during that

visit to Dr. McClean denied any right lower extremity pain. (Tr. 388). Dr. McClean noted

that her exam showed no acute distress, she walked without a limp, had some hamstring

pulling on the left and residual numbness on the left leg. (Tr. 388). Dr. McClean noted that

Plaintiff had progressed overall. (Tr. 388). He instituted formalized physical therapy two

times a week for three weeks, recommended that Plaintiff continue resume working full-time

with necessity for frequent change of position. (Tr. 388). Dr. McClean observed gradual

improvement in subsequent visits and continued giving Plaintiff epidurals. (Tr. 387-388).

On August 16, 1996, Dr. McClean reported that Plaintiff is for the most part pain-free,

though she had some residual weakness that she may always have. (Tr. 387).

On September 9, 1996, Dr. James A. Singer, M.D. evaluated Plaintiff for complaints

of blood and mucus in her bowel movements. (Tr. 378). A Physical examination was

unremarkable, and Dr. Singer opined that Plaintiff possible had irritable bowel syndrome or

procritis, although procritis was never actually documented in Plaintiff and the classic

symptoms were not present. (Tr. 379).

On June 16, 1997, Dr. Shostack reported that Plaintiff had been experiencing back

pain for several days and was on bed rest. (Tr. 349). He noted that Plaintiff had never

obtained a third steriod injection the prior year as part of her prescribed series. (Tr. 349).

Dr. Shostack prescribed steroid injections again. (Tr. 349).

On November 11, 1997, Dr. Niranjan S. Chawla, M.D. examined Plaintiff for her

complaints of low back pain, which had flared up in the preceding weeks. (Tr. 375). A

physical exam showed, inter alia, that Plaintiff walked symmetrically without any antalgia

but experienced back discomfort when walking on her heels, rising up from a bend,

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extending backward and to the left, lateral bending to the left, bringing the knee toward the

shoulder, trunk rotation, and when lifting the left leg in a prone position. (Tr. 376). Dr.

Chawla opined that Plaintiff’s symptoms were a combination of lumbar spondylosis,

degenerative disc disease, anthropathy, obesity and strain on the gluteal muscles because of

her body size. (Tr. 376). He recommended continuation of Plaintiff’s current medications

of Vicodin and Parafon Forte, physical therapy, and tender point injections on an as-needed

basis. (Tr. 377).

On June 16, 1998, Dr. Shostack reported Plaintiff’s complaints of pain in both knees,

worse on the right, and back problems. (Tr. 346). Dr. Shostack X-Rayed both knees and

observed that the left knee seemed okay, but the right had some advanced signs of early

osteoarthritis. (Tr. 346). Dr. Shostack started Plaintiff on Ace bandage, heat, and Aleve and

cautioned Plaintiff about climbing stairs or jogging. (Tr. 346).

On January 14, 1999, Dr. Shostack examined Plaintiff for complaints of a sore on her

right leg. (Tr. 341). He observed severe varicose veins and advised Plaintiff to continue

using her elastic stockings. (Tr. 341).

On March 24, 1999, Dr. Shostack examined Plaintiff for complaints of pain her right

knee caused by walking, particularly on stairs. (Tr. 340). Dr. Shostack opined that Plaintiff

had osteoarthritis in the right knee. (Tr. 340). Dr. Shostack noted that Plaintiff was given

a leave of absence from work starting on that date. (Tr. 340).

On June 8, 1999, Dr. Shostack examined Plaintiff for complaints of a pinched nerve

in her neck, radiating intermittently down her left arm and down to the elbow, and right knee

pain. (Tr. 339). Dr. Shostack noted possible cervical spine neuropathy. (Tr. 339). Plaintiff

expressed a desire for physical therapy. (Tr. 339).

On May 1, 2000, Dr. Shostack conducted a complete physical examination. (Tr. 129-

131, 134). Plaintiff complained of fatigue, headaches, low back pain, and pain in her right

knee, varicose veins with pain around the right Achilles tendon, and hemorrhoid problems.

(Tr. 129). The physical examination was unremarkable except for tenderness in the right

Achilles and right ankle, although Plaintiff had a full range of motion throughout. (Tr. 130).

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No abnormalities were seen in the right ankle X-Ray. (Tr. 134). Dr. Shostack diagnosed

spinal chord stenosis, fatigue, recurrent headaches, allergic rhinitis, severe varicose veins,

tendinitis of the right Achilles tendon, hemorrhoids, and osteoarthritis. (Tr. 130-131).

On March 12, 2001, Dr. Shostack reported that on March 8, 2001, Plaintiff was

walking through a parking lot and fell on her hands, her right breast, and both knees, and hurt

her back, right shoulder, and right knee. (Tr. 126). A physical examination revealed that

Plaintiff was very tender in her right knee particularly medially and over the patella, her left

knee had limited range of motion, and she had tenderness over the shoulder region. (Tr.

126). X-Rays taken on March 12, 2001, showed mild degenerative change in the lateral

compartment of the right knee, with no significant abnormalities on the left. (Tr. 277). 

On March 20, 2001, Dr. Shostack examined Plaintiff for back pain that was worse in

the mornings, difficulty walking, knee pain, sinus headaches, varicose veins, swelling of the

right foot, and a sore right shoulder. (Tr. 124). A physical examination found Plaintiff’s

range of motion in her right shoulder was restricted, range of motion in the knees caused

pain, and Plaintiff had varicose veins in the left leg. (Tr. 124). Dr. Shostack diagnosed

spinal chord stenosis, tendinitis of the shoulder, osteoarthritis, varicose veins, and allergic

rhinitis. (Tr. 125).

B. Mark A. Greenfield, D.O.

On April 9, 2001, Dr. Mark A. Greenfield, D.O., examined Plaintiff’s right knee and

right shoulder injuries incurred when Plaintiff fell on all fours in a parking lot on March 8,

2001. (Tr. 199). Physical examination of the knee and shoulder were both unremarkable.

(Tr. 200). Dr. Greenfield reviewed X-Rays of the Plaintiff’s knees taken March 12, 2001,

and noted some mild degenerative changes affecting primarily the lateral compartment of the

right knee and a normal left knee. (Tr. 200). Dr. Greenfield diagnosed contusion to the right

knee and a sprain to the right shoulder that was “resolved”. (Tr. 200). Dr. Greenfield

recommended physical therapy for Plaintiff’s right knee problems, noted that her right

shoulder symptoms were resolved, and placed Plaintiff on full work status. (Tr. 201, 216).

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On April 30, 2001, Dr. Greenfield saw Plaintiff for a follow-up evaluation and

reported that Plaintiff felt the physical therapy was helping her somewhat, although she still

had symptoms and wished to continue with the physical therapy. (Tr. 198). 

On May 21, 2001, Dr. Greenfield saw Plaintiff for a follow-up evaluation and noted

that her right knee symptoms were improving with the physical therapy. (Tr. 197). Plaintiff

reported some swelling above the knee. (Tr. 197). A physical examination showed no

appreciable joint effusion. (Tr. 197). Plaintiff reported that she also injured both of her

hands at the time of the initial injury and that they were 90% improved. (Tr. 197). Physical

examination of Plaintiff’s hands was unremarkable. (Tr. 197). Dr. Greenfield placed

Plaintiff on full work status and recommended only symptomatic treatment for Plaintiff’s

hand pain. (Tr. 197, 215).

On June 18, 2001, Dr. Greenfield examined Plaintiff for follow-up regarding her right

knee and right shoulder. (Tr. 196). Dr. Greenfield reported that Plaintiff’s knee did not

“bother her every day, but she still does get some discomfort and she still notices some

swelling.” (Tr. 196). Plaintiff felt she had reached a plateau with the physical therapy and,

thus, Dr. Greenfield noted that he would hold off on additional therapy at that time.” (Tr.

196). Dr. Greenfield noted that if Plaintiff continued to improve, “then it is felt she will be

stationary.” (Tr. 196). Dr. Greenfield placed Plaintiff on full work duty. (Tr. 196, 214).

On August 13, 2001, Dr. Greenfield examined Plaintiff for follow-up regarding her

right knee and right shoulder. (Tr. 195). Dr. Greenfield reported that Plaintiff felt about the

same since her prior evaluation on June 18, 2001, and that she was not bothered all the time

or everyday. (Tr. 195). Dr. Greenfield felt Plaintiff was describing more of a suprapatellar

type of swelling. (Tr. 195). A physical examination showed no suprapatellar effusion. (Tr.

195). Dr. Greenfield recommended obtaining an MRI for completeness. (Tr. 195). Dr.

Greenfield placed Plaintiff on full work duty. (Tr. 195, 213).

On August 20, 2001, an MRI revealed a torn medial meniscus and a possible tear in

the anterior horn of the lateral meniscus. (Tr. 281).

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On September 24, 2001, Dr. Greenfield examined Plaintiff for follow-up regarding

her right knee. (Tr. 194). Dr. Greenfield reported that Plaintiff felt about the same since her

last evaluation and still described her discomfort primarily suprapatellar and laterally. (Tr.

194). Dr. Greenfield reviewed the MRI, and noted a tear of the medial meniscus and possible

tear of the anterior horn of the lateral meniscus. (Tr. 194). Dr. Greenfield noted that

clinically Plaintiff really didn’t describe the pain medially and on examination she really

didn’t have tenderness along the medial joint line. (Tr. 194). Dr. Greenfield opined that the

consistent effusion may have been the result of underlying meniscal pathology. (Tr. 194).

Dr. Greenfield applied a cortisone injection and placed Plaintiff on full work status. (Tr. 194,

212).

On October 15, 2001, Dr. Greenfield examined Plaintiff for follow-up regarding her

right knee. (Tr. 193). Dr. Greenfield reported that Plaintiff didn’t feel the injection made

much of a difference for her. (Tr. 193). Dr. Greenfield advised Plaintiff that he had no

further conservative treatment for her and consideration of arthroscopy could be given to

treat the underlying meniscal pathology. (Tr. 193). Dr. Greenfield advised that there would

be no guarantees that arthroscopy would eliminate her symptoms and noted that if Plaintiff

did not want to follow through with arthroscopy he felt “she will be stationary.” (Tr. 193).

Dr. Greenfield placed Plaintiff on full work status. (Tr. 193, 211).

On November 15, 2001, Dr. Greenfield examined Plaintiff for follow-up regarding

her right knee. (Tr. 192). Dr. Greenfield reported that Plaintiff felt she had improved over

time but still had a level of discomfort in her right knee that didn’t bother her with certain

activities. (Tr. 192). Dr. Greenfield reported that Plaintiff described the discomfort

suprapatellar as well as laterally, and that overall she felt she had reached a plateau. (Tr.

192). Plaintiff felt better than in the past but still felt some ongoing symptoms to her right

knee. (Tr. 192). Dr. Greenfield discussed with Plaintiff either declaring her stationary or

trying further treatment. (Tr. 192). Plaintiff requested arthroscopic surgery. (Tr. 192). Dr.

Greenfield provided no guarantees that the surgery would partially or completely eliminate

her symptoms. (Tr. 192). Dr. Greenfield placed Plaintiff on full work duty. (Tr. 210).

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On February 15, 2002, Dr. Greenfield performed arthroscopic surgery, which

confirmed the tear in medial meniscus, tear in lateral meniscus, and also revealed grade three

chondromalacia medial femoral condyle, grade three chondromalacia lateral femoral condyle,

grade four chondromalacia lateral tibial plateau, and grade three chondromalacia patella. (Tr.

150). 

On February 21, 2002, Dr. Greenfield examined Plaintiff one week after her surgery

and noted generalized discomfort in her calf bilaterally (felt to be muscular), which felt better

when Plaintiff rubbed it. (Tr. 191). Dr. Greenfield referred Plaintiff for some physical

therapy and placed her on non-work status. (Tr. 191, 209).

On February 28, 2002, Dr. Greenfield noted that Plaintiff was making progress, had

good motion, and no calf pain or tenderness. (Tr. 190). Dr. Greenfield released her to light

duty status of seated work only. (Tr. 190, 208).

On March 21, 2002, Dr. Greenfield noted that therapy was helping Plaintiff and that

she was making progress. (Tr. 189). Dr. Greenfield reported that Plaintiff felt she could do

an independent therapy program. (Tr. 189). A physical examination showed some mild

swelling, good motion, and no calf pain or tenderness. (Tr. 189). Dr. Greenfield placed her

on light duty status of no kneeling, squatting or climbing, standing and walking as tolerated.

(Tr. 189, 207). Dr. Greenfield planned to see Plaintiff back in three weeks and assess

whether she was stationary at that time. (Tr. 189).

On April 11, 2002, Dr. Greenfield reported that Plaintiff indicated she still had some

swelling in her knee. (Tr. 188). Dr. Greenfield reported some discomfort both medially and

laterally. (Tr. 188). A physical examination showed some swelling. (Tr. 188). Dr.

Greenfield prescribed anti-inflammatory medication and noted that Plaintiff had only

followed through with one visit of physical therapy. (Tr. 188). Dr. Greenfield placed

Plaintiff on light duty status of no kneeling, squatting or climbing, standing and walking as

tolerated. (Tr. 188, 206). 

On May 6, 2001, Dr. Greenfield reported that physical therapy was helping Plaintiff

and that recently she had been experiencing some increased discomfort that she felt may have

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been related to the therapy. (Tr. 187). A physical examination showed that Plaintiff still had

effusion, although less than previously. (Tr. 187). There was no calf pain or tenderness.

(Tr. 187). Dr. Greenfield placed Plaintiff on light duty status with no climbing, standing and

walking as tolerated. (Tr. 187, 205).

On June 3, 2001, Dr. Greenfield reported that Plaintiff was having good days and bad

days and that she felt the Bextra was helping. (Tr. 186). A physical examination showed

joint effusion. (Tr. 186). Dr. Greenfield performed an aspiration of fluid from the right

kneed joint, obtaining thirty-five cc’s of fluid, and then injected the right knee joint with

coricosteriod. (Tr. 186). Dr. Greenfield reported that Plaintiff tolerated this treatment well

and placed her on light duty status with no climbing, standing and walking as tolerated. (Tr.

186, 204).

On July 1, 2002, Dr. Greenfield reported that Plaintiff felt improvement and had much

less swelling. (Tr. 185). Dr. Greenfield reported that Plaintiff did not have any discomfort

medially but that she had started to notice some discomfort laterally. (Tr. 185). A physical

examination showed minimal effusion. (Tr. 185). Dr. Greenfield reported that Plaintiff felt

her motion had improved and there was no calf pain or tenderness. (Tr. 185). Dr. Greenfield

opined that Plaintiff was stationary as it relates to the injury, but explained to Plaintiff that

she had some preexisting degenerative arthritis. (Tr. 185). Dr. Greenfield noted that for

“further treatment regarding that she can be evaluated under her private health insurance.”

(Tr. 185). Dr. Greenfield assessed Plaintiff at a permanent impairment rating of 10% lower

extremity based upon the American Medical Association Guides to the Evaluation of

Permanent Impairment. (Tr. 185).

On November 14, 2002, Dr. Greenfield evaluated Plaintiff’s right knee and noted that

she felt she was a little better. (Tr. 184). Dr. Greenfield reported that Plaintiff had been

walking, and her ease of walking had improved, although she had noticed some discomfort

in her right hip area and into the lateral aspect of her right foot. (Tr. 184). Plaintiff declined

an injection since she had been feeling better over the previous few days. (Tr. 184). A

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physical examination showed mild effusion. (Tr. 184). Dr. Greenfield placed Plaintiff on

full work status. (Tr. 184).

C. Lucia McPhee, M.D.

On September 15, 2003, Dr. Lucia McPhee, M.D., a physical medicine and

rehabilitation specialist, examined Plaintiff at the request of the Arizona Department of

Economic Security, Disability Determination Services (DDS) (Tr. 222-226). A physical

examination found Plaintiff’s gait within normal limits. (Tr. 223). Plaintiff could only

crouch a third of the way to the ground at most, holding on to furniture for support, and

complaining of pain in the knees. (Tr. 223). Plaintiff’s back range of motion was mildly

reduced in all planes, and on palpatation there was tenderness along the lumbar paraspinal

muscles and also at the midthroacic paraspinal muscles. (Tr. 223). There was mild

tenderness at the greater trochanteric regions bilaterally. (Tr. 223). On her upper

extremities, Plaintiff complained of pain in the right shoulder region with full shoulder

abduction. (Tr. 223). Plaintiff had full strength of the rotator cuff muscles, although there

was pain with testing of the right supraspinatus muscle, and Hawkins was positive on the

right. (Tr. 223-224). On examination of Plaintiff’s lower extremities, extensive varicosities

were noted in the right lower extremity, though Plaintiff did not have her usual compressive

stockings on that day. (Tr. 224). No effusion was found in the knees, though there was

tenderness in the right knee along the medial joint line. (Tr. 224). There was no significant

lateral joint line tenderness, but was peripatellar tenderness. (Tr. 224). There was no

significant medial lateral instability anterior drawer testing was negative. (Tr. 224).

Dr. McPhee diagnosed chronic low back pain, extensive varicose veins in the right

lower extremity, bilateral knee pain with history of grade III chondromalacia right knee

based on arthroscopic surgery report, history of a tear of the lateral meniscus of the left knee,

overweight, and right supraspinal tendinitis. (Tr. 224). Dr. McPhee limited Plaintiff to

lifting 20 pounds occasionally, 10 pounds frequently, standing/walking at least two hours in

an eight hour workday with no need for an assistive device, sitting six hours per workday

(sitting one hour at a time followed by a brief change in position), standing/walking less than

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These handwritten notes are largely illegible and the Court only lists those treatments

that it can readily discern were recorded.

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six hours per workday due to complaints of bilateral knee pain and underlying degeneration

and meniscal tear, climbing and stooping limited to occasional, and crouching limited to a

partial crouch with support available. (Tr. 224). Plaintiff was to avoid repetitive reaching

overhead with the right upper extremity. (Tr. 224). Dr. McPhee made no findings that

would restrict gross handling or fine manipulation. (Tr. 224-226).

D. Shari Gibson, M.D.2

Dr. Shari L. Gibson, M.D. treated Plaintiff for various conditions not related to her

disability claim. On April 27, 2001, Plaintiff saw complaining of dizziness and vertigo. (Tr.

261). Dr. Gibson’s handwritten notes reference the March 8, 2001, fall. On May 7, 2001,

Dr. Gibson treated Plaintiff for a large skin tag. (Tr. 260). On August 20, 2001, Dr. Gibson

treated Plaintiff for sore throat. (Tr. 259). On October 24, 2001, Dr. Gibson treated Plaintiff

for sinus problems. (Tr. 258). On December 17, 2002, Dr. Gibson treated Plaintiff for

bronchitis and asthma. (Tr. 257). On January 3, 2003, Dr. Gibson treated Plaintiff again for

bronchitis. (Tr. 256).

On April 1, 2003, Dr. Gibson reported that Plaintiff complained of four left knee

injuries in the preceding five months: a nonspecific fall, a re-injury to the left knee by a

puppy, an incident where Plaintiff tripped over shoes, and a nonspecific twisting incident.

(Tr. 255). A left knee X-Ray ordered by Dr. Gibson on April 4, 2003, was negative except

for mild osteoarthritic changes. (Tr. 274). An MRI of the left knee ordered by Dr. Gibson

on April 18, 2003, showed the cruciate ligaments intact, knee effusion with popliteal cyst,

and a tear of the anterior horn and body of the lateral meniscus extending to the superior

surface. (Tr. 270).

On May 13, 2003, Dr. Douglas B. Freedberg, M.D. evaluated Plaintiff’s left knee at

the request of Dr. Gibson. (Tr. 220). A physical examination showed that Plaintiff walked

with a slight antalgic gait, the left knee showed trace effusion, peripatellar discomfort, and

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no discreet joint line tenderness. (Tr. 221). Dr. Freedberg diagnosed a possible lateral

meniscal tear in an overweight female. (Tr. 221). He injected the knee with Lidocaine and

dexamenthasone, recommended strengthening and weight loss, and suggested considering

arthroscopy if Plaintiff remained significantly symptomatic. (Tr. 221). On June 10, 2003,

Dr. Freedberg administered another injection of Lidocaine and dexamethasone. (Tr. 219).

On July 22, 2003, Dr. Freedberg evaluated Plaintiff who reported that the injection helped

tremendously for two or so weeks and that she feels at least 50% better after doing physical

therapy. (Tr. 218). Dr. Freedberg also reviewed the operative note from Plaintiff’s right

knee surgery and noted that Plaintiff said she was worse after the surgery and is not anxious

to have another surgery on her left knee. (Tr. 218). 

On August 26, 2003, Plaintiff was examined in the emergency department of

Scottsdale Healthcare with a chief complaint of right inner thigh pain. (Tr. 229). A physical

examination showed that Plaintiff’s bilateral lower extremities had a profound amount of

varicose veins superficial on the lower portion of her legs and a palpable varicose vein on her

right inner thigh in the exact area where her pain was. (Tr. 230). Ultrasound was negative

for deep venous thrombosis but there was some evidence of a superficial phlebitis. (Tr. 230).

The diagnoses were phlebitis and myalgias. (Tr. 230). Plaintiff was discharged in good

condition with instructions for superficial phlebitis and myalgia. (Tr. 233). 

On August 28, 2003, Dr. Jack E. Cook, M.D., an associate of Dr. Gibson, diagnosed

superficial thrombophlebitis of the right thigh, and saphenous varicosities of the right leg and

thigh. (Dkt. 13). Dr. Cook advised Plaintiff that she could increase her activities. (Tr. 253).

An esophagogastroduodenoscopy on September 17, 2003, showed that the duodendum

was unremarkable with mild erythema around the pylorus, a diminishment of the lower

esophageal sphincter tone and a minor hiatus hernia. (Tr. 227). Diagnoses were acute and

chronic reflux tendency and mild gastritus. (Tr. 227). 

On September 18, 2003, Dr. Gibson examined Plaintiff for superficial

thrombophlebitis of the right thigh. (Tr. 252). Treatment notes are illegible. (Tr. 252).

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Moderately severe is defined as an impairment which seriously affects ability to

function.

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On April 21, 2004, Dr. Gibson reported right hip/buttock pain and a cervical muscle strain.

(Tr. 305). On October 5, 2004, Dr. Gibson reported right hand pain. (Tr. 302). On

November 2, 2004, Dr. Gibson reported a right trapezius strain with a right upper extremity

radiculopathy. (Tr. 301) The treatment notes from these visits are largely illegible to the

Court.

In November and December of 2004, Dr. Gibson sent Plaintiff to physical therapy.

(Tr. 313-332). The stated goals of the physical therapy were that Plaintiff be independent

with home exercise program, have 25% improvement in cervical range of motion with

manageable pain for activities of daily living, and have normal upper extremity and cervical

thoracic stabilization strength for improved tolerance to sitting, driving and lifting. (Tr. 329).

On March 16, 2005, a Discharge Summary indicates that the physical therapy goals were met

and Plaintiff was discharged. (Tr. 313).

On March 15, 2005, Dr. Gibson completed a Medical Assessment of Physical

Capacity indicating that Plaintiff could sit one hour, stand or walk 15-30 minutes at a time,

sit two hours in an eight hour work day, stand one hour in a workday, walk two hours in a

workday, frequently lift up to five pounds, occasionally carry up to five pounds, and

occasionally reach over head and extend arms out. (Tr. 334). Dr. Gibson noted that Plaintiff

could not use her right arm for pushing and pulling of arm controls or for fine manipulation.

(Tr. 334). Dr. Gibson marked the questions related to Plaintiff’s use of feet for frequent or

continual repetitive movements as “unknown.” (Tr. 334). Dr. Gibson further noted that

Plaintiff did have pain that would likely additionally limit Plaintiff’s activities and designated

Plaintiff’s pain as “moderately severe”3

 noting that this was based on “patient’s report.” (Tr.

335).

E. Richard P. Jocoby, D.P.M.

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On October 1, 2003, Dr. Richard P. Jocoby, D.P.M. saw Plaintiff at the referral of Dr.

Gibson for pain in her left heel. (Tr. 286). Dr. Jacoby documented that Plaintiff

“[a]pparently...obtained a new pair of shoes and she has had pain in the posterior aspect of

the left heel since that time. She also fe[lt] that she may have traumatized the area in

question.” (Tr. 286). A physical examination revealed point tenderness and plantar left

Achilles tendon area at the insertional area. (Tr. 286). X-Rays confirmed Achilles tendinitis

and enthesis. (Tr. 286). Dr. Jacoby reported that Plaintiff was unable to take oral antiinflammatories due to GI upset and ulcers. (Tr. 287). Dr. Jacoby proceeded instead with

orthotics and shoe gear. (Tr. 287).

On October 9, 2003, Dr. Jacoby reported that Plaintiff felt improved and “much better

with good supportive shoes” although she experienced pain when wearing dress shoes. (Tr.

285). Dr. Jacoby injected her with dexamethasone and Xylocaine and instructed Plaintiff to

get better shoes for dress shoes. (Tr. 285).

On October 29, 2003, Dr. Jacoby reported that Plaintiff had three weeks of relief from

an injection of the left plantar heel, though she had tenderness in the medial calcaneal nerve,

and pain of the Achilles tendon area. (Tr. 284). Dr. Jacoby noted that Plaintiff’s left plantar

fascitis seemed to be incrementally improved and overall he opined that Plaintiff was doing

quite a bit better. (Tr. 284). Dr. Jacoby reported that Plaintiff needed good supportive shoes

and needed to avoid going barefoot. (Tr. 284). He injected her again with dexamethasone

and Xylocaine. (Tr. 284).

On December 15, 2003, Dr. Jacoby reported that Plaintiff had multiple varicose veins

being treated by Dr. Mishra, left plantar and left posterior Achilles tendon, and right

fourth/fifth metatarsal pain. (Tr. 283). Dr. Jacoby reported that Plaintiff’s plantar heel pain

was resolving. (Tr. 283). Dr. Jacoby performed another injection and provided Plaintiff with

a prescription for orthotics. (Tr. 283). He also advised Plaintiff to get her veins attended to

by Dr. Mishra before he would consider injecting her Achilles tendon. (Tr. 283).

On January 14, 2004, Dr. Jacoby reported that Plaintiff had varicose veins for which

she was referred to Dr. Wareing, and tenosynovitis of the right fifth metatarsal area. (Tr.

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336). As to the tenosynovitis, Dr. Jacoby noted that Plaintiff had obtained good arch

supports and good supportive shoes and that she felt incrementally improved. (Tr. 336). Dr.

Jacoby manipulated the area and Plaintiff felt better. (Tr. 336).

At some time, Dr. Jacoby completed a medical source statement of Plaintiff’s ability

to do work-related activities (physical). (Tr. 297). Dr. Jacoby indicated Plaintiff could

occasionally or frequently lift less than 10 pounds, stand and/or walk less than two hours in

an eight hour workday without the use of an assistive device, sit six hours in an eight hour

workday with breaks and lunch providing sufficient relief, occasionally climb, balance,

stoop, kneel, crouch, and crawl, with unlimited reaching, handling, fingering, feeling, seeing,

hearing, or speaking. (Tr. 298).

F. Unknown Residual Functional Capacity Assessment Form

On January 14, 2004, a State agency physician (name illegible) completed a physical

residual functional capacity (RFC) assessment form. (Tr. 288). The physician considered

Plaintiff’s primary diagnoses as obesity, left knee osteoarthritic changes, right thigh

superficial throbophlebitis, and varicose veins. (Tr. 288). The physician considered

secondary diagnoses of Achilles tendinitis, chronic reflux tendency, and mild gastritis. (Tr.

288). The physician opined that Plaintiff could occasionally lift 20 pounds, frequently lift

10 pounds, stand and/or walk for at least 2 hours in an 8-hour workday, sit with normal

breaks for a total of 6 hours in an 8-hour workday, unlimited pushing and/or pulling,

occasional climbing, kneeling, crouching, and crawling, frequent balancing and stooping, no

manipulative limitations, no visual limitations, no communicative limitations, and slight

environmental limitations related to hazards. (Tr. 288-293). The physician noted that the

record indicated treatment for mild gastritis and chronic reflux tendency with evidence that

these are under control with treatment. (Tr. 294). The physician further noted that Plaintiff

appeared “to be less than credible” because the degree of symptoms were not consistent with

the evidence including Plaintiff’s report of activities. (Tr. 294). The physician further noted

that the medical source statement from podiatrist Dr. Jacoby indicated less than sedentary

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functional capacity should not be adopted as it was too restrictive for the evidence in the file,

including Plaintiff’s report of activities and Dr. Jacoby’s report of improvement. (Tr. 295).

G. Plaintiff’s Statements in the Record

1. March 11, 2003 Disability Report

Plaintiff filed her application for DIB on March 11, 2003 claiming that she was

limited by her right knee problem because she could not sit or stand for long periods of time,

could not prop up her knee for long periods of time, and because she had pain all the time.

(Tr. 76). Plaintiff indicated that she worked at times after the date her knee started bothering

her and that the knee problem did not cause her to work fewer hours, change her job duties,

or make any job-related changes (i.e. attendance, help needed, or employers). (Tr. 77).

Plaintiff stated in her application that she tried to limit the amount of stair climbing she did

at work and asked her co-workers to carry her papers due to her knee condition. (Tr. 77).

Plaintiff further stated that the last job she had required stair climbing and she couldn’t get

from one place to another without having to climb stairs. (Tr. 82). Plaintiff indicated that

she stopped working to rest her knee and had surgery, but that the surgery made it worse.

(Tr. 82).

On March 21, 2003, Plaintiff sent a letter to the Social Security Claims representative

to provide additional information for consideration. (Tr. 84). Plaintiff stated that she had

chronic back pain due to disc herniation and moderately severe spinal stenosis, which limited

her ability to sit or stand for long. (Tr. 84). Plaintiff referenced an MRI done on May 16,

1996 at the request of Dr. Shostack, and treatments in 1996 and 1997 by Dr. McLean, Dr.

Nenad Jr., and Dr. Chawla. (Tr. 84). Plaintiff indicated that she had severe varicose veins

in her right leg which limited her time sitting. (Tr. 84). Plaintiff further indicated that she

had a history of Ulcerative Colitis and Irritable Bowel Syndrome which limited her ability

to take anti-inflamatories for her knee and back, and that she had experienced intestinal

bleeding from anti-inflamatories in the past. (Tr. 84).

2. May 27, 2003 Activities of Daily Living Questionnaire

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On May 27, 2003, Plaintiff completed an Activities of Daily Living Questionnaire.

(Tr. 103). Plaintiff’s average day included preparing meals, doing knee and back exercises,

doing laundry with assistance from her husband, grocery shopping once a week, and sitting

for one hour at the computer or doing crafts. (Tr. 103). Plaintiff could not cut her own

toenails or take care of her feet and could not take baths because of her back and knee

problems (could only shower). (Tr. 103). Plaintiff needed help with cleaning but could do

the dusting by herself if wearing a back brace, but had to stop frequently. (Tr. 104). Plaintiff

was able to shop for groceries if she could lean on the basket and had her husband carry the

groceries inside. (Tr. 104). Plaintiff could not hike or do much walking, but could sit for an

hour while doing her crafts, quilting, or riding in a car. (Tr. 105). Plaintiff could not kneel

in church. (Tr. 105). Plaintiff indicated that she had not tried to work since her disability

began. (Tr. 105)

3. November 13, 2003, Reconsideration Disability Report

On November 13, 2003, Plaintiff completed a Reconsideration Disability Report

indicating that she was “worse” than before, was in “more pain, more often,” and affected

by cold/damp conditions. (Tr. 108). Plaintiff noted that she could not sit, stand, or walk very

far, needed to lay down periodically to relieve her pain, and often slept poorly and was tired

the next day. (Tr. 108). Plaintiff indicated that there was “nothing new lately” to report

regarding any restrictions being placed on her by a physician, stating that it has been the

“same for [the] past few years.” (Tr. 108). Plaintiff indicated that as to her daily activities,

she was “doing less than before” but provided no elaboration. (Tr. 110). 

4. December 8, 2003, Activities of Daily Living Questionnaire

On December 8, 2003, Plaintiff reported that her average day included preparing

meals, back and knee exercises, and resting off an on throughout the day. (Tr. 115). Plaintiff

needed help from her husband on many activities, hobbies/crafts if done were limited to 1

hour of sitting at a time, and Plaintiff wore a back brace if doing any unusual activity. (Tr.

115). Plaintiff still had problems with foot care and was still unable to take baths. (Tr. 115).

If Plaintiff cooked meals she needed help with cleanup. (Tr. 115). Plaintiff could do laundry

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if her husband carried the laundry basket, could not do yard work, and wore a back brace and

stopped frequently when dusting. (Tr. 116). Plaintiff went grocery shopping weekly if she

could use the shopping cart to lean on and her husband carried the groceries. (Tr. 116).

Plaintiff could not shop in the mall and was limited to one hour and one store. (Tr. 116).

Plaintiff was no longer able to hike or do much walking for recreation and riding in a car for

more than one hour was a problem. (Tr. 117). Plaintiff indicated that her activities had

changed and that she needed more help with activities and errands and could not drive if

taking Tylenol 3. (Tr. 117). Plaintiff had not tried to work since her disability began. (Tr.

117).

5. Claimant’s Statement When Request for Hearing Is Filed

Plaintiff submitted a Statement that described Plaintiff’s conditions. (Tr. 119).

Plaintiff reported that Arthritis in her neck prevented her from looking down for very long,

her hands would go numb, and it was difficult to sit and lookdown and address Christmas

cards in December 2003. (Tr. 119).

6. May 27, 2003, Work History Report

On May 27, 2003, Plaintiff completed a Work History Report indicating that she had

been a certified legal assistant from 1984-1993, and an applications specialist in the

administrative office of a hotel chain from 1993-2001. (Tr. 95). Plaintiff reported that in her

most recent job as an applications specialist required her to walk 8 hours a day, stand 1 hour

a day, sit 8 hours a day, climb 1 hour a day, stoop 2 hours a day, crouch 2 hours a day, reach

1 hour a day, and write, type, or handle small objects 8 hours a day. (Tr. 96). Plaintiff

reported that she lifted no more than 10 pounds, lifting and carrying files a daily basis and

loading and unloading tubs of files in the board room. (Tr. 96).

Plaintiff reported that her earlier work as a certified legal assistant required her to

walk 1 hour a day, stand 1 hour a day, sit 8 hours a day, climb less than 1 hour a day, stoop

1 hour a day, crouch 1 hour a day, reach 1 hour a day, and write, type, or handle small objects

8 hours a day. (Tr. 97). Plaintiff reported that she lifted no more than 10 pounds, lifting and

carrying files, manuals, and boxes on a daily basis. (Tr. 97).

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H. Testimonial Evidence

Plaintiff appeared before Administrative Law Judge (“ALJ”) Ronald C. Dickinson on

March 23, 2005, represented by attorney Patricia J. Stewart. (Tr. 407).

1. Plaintiff’s Testimony

On the date of the hearing, Plaintiff was 61 years old, 5'2" tall, and weighed 220

pounds. (Tr. 412). Plaintiff was not earning any money but had a 401(k). (Tr. 414). Her

husband was retired. (Tr. 414). Plaintiff’s most recent work was as an application specialist

at Best Western, where she was seated for six hours a day, although it could vary. (Tr. 415).

Plaintiff believed that she had to lift 10 pounds or more. (Tr. 415). Plaintiff testified that the

job was very hard on her physically because there were stairs in the office and traversing the

stairs was damaging her knee. (Tr. 417). 

Plaintiff originally injured her right knee at work in 1994, when she slipped in the

parking lot. (Tr. 417). She went to the workman’s compensation doctor who told her that

nothing was wrong. (Tr. 417). A year after that fall, Plaintiff found that going up the stairs

and down the stairs every day took a toll and she started having problems going up the stairs.

(Tr. 418). The problems going up the stairs went away and then Plaintiff’s knee started to

get bothered going down the stairs. (Tr. 418). Plaintiff’s knee problems got progressively

worse. (Tr. 418). In 2001, Plaintiff fell again when she tripped on some uneven pavement

in the parking lot. (Tr. 419). Plaintiff returned to the workman’s compensation doctor and

received benefits. (Tr. 419). Plaintiff had knee surgery in February 2002 and her knee got

worse after that. (Tr. 419).

Plaintiff could not recall the date she first injured her left knee, but thought it

may have been April 2003, or the fall of some year. (Tr. 420). When her husband was

having surgery there was wet carpet or flooring at the hospital and Plaintiff slipped and fell.

(Tr. 420). After this fall Plaintiff’s dog ran into her left knee sideways. (Tr. 420). Plaintiff

tripped over some shoes in her bedroom and fell towards the closet. (Tr. 420). Sometime

later Plaintiff tripped on some uneven sidewalk. (Tr. 420). Plaintiff testified that

immediately she could not walk. (Tr. 420). Plaintiff’s right knee was usually worse than the

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left but it varied. (Tr. 421). On the date of the hearing, Plaintiff reported pain, swelling, and

stiffness in her knees. (Tr. 421). 

Plaintiff had back problems that became acute in 1996 and 1997, though the problems

existed prior to that. (Tr. 419). Sitting and walking on the stairs began getting very difficult.

(Tr. 419). Plaintiff was allowed to cut back her work hours because of that. (Tr. 419). The

back problems consisted of a herniated disc and spinal stenosis in Plaintiff’s lower back. (Tr.

421).

Plaintiff also had arthritis in her neck or a pinched nerve, which she went to physical

therapy for. (Tr. 422). She had arthritis in her right hand, a bone spur on her left foot, and

a heel spur. (Tr. 422). Plaintiff had varicose veins and phlebitis in the right leg. (Tr. 423).

Plaintiff testified that she could only stand for five minutes before her back gets tired

and achy and her knees start to bother her and she has to sit down. (Tr. 423). She could only

sit for one hour at a time before her back hurts. (Tr. 424). Plaintiff thought she could lift a

gallon of milk from the counter but not from the floor because she couldn’t bend her knees

to squat down. (Tr. 424). Plaintiff would also have difficulty with a gallon of milk because

her right hand had arthritis. (Tr. 424-425). 

Plaintiff could only dust. (Tr. 425). Her husband did the rest of the housework. (Tr.

425). Plaintiff could drive a car if she needed to go to the shopping or to the doctor. (Tr.

425). When grocery shopping Plaintiff could lean on the cart. (Tr. 425).

Plaintiff did not believe she could do the work she was doing even if there weren’t

stairs involved because of her back and knees. (Tr. 426). Plaintiff would not be able to sit,

but would have to get up and move around. (Tr. 426). Plaintiff acknowledged having

worked through the pain for several years and eventually stopped working because her pain

wasn’t getting better. (Tr. 426).

Plaintiff’s counsel asked if Plaintiff thought she would be able to work if she could

“sit for a while and then...get up, walk around, leave your job site, walk around for a few

minutes, and then come back whenever you want to.” (Tr. 428). Plaintiff stated that her pain

got worse at the end of the day and she probably would not be able to keep working because

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it would build up. (Tr. 428-429). In 1999, Plaintiff stopped working at Best Western

because she wanted to take care of her knee. (Tr. 429). Her employer asked her to come

back because her replacement didn’t work out. (Tr. 429). Plaintiff returned to work full-time

for a few months and then went part-time. (Tr. 429-430). To relieve her pain, Plaintiff did

exercises, laid down, used traction on her neck, heat on her back four times a week, and ice

on her knee once a week. (Tr. 430-431). 

Plaintiff had not had surgery on her varicose veins. (Tr. 432). The doctors

recommended that she go to a vein specialist. (Tr. 432). To relieve her pain related to the

varicose veins, Plaintiff propped her knee up while sitting and watching TV. (Tr. 432). 

Plaintiff had an MRI in 1996 on her back. (Tr. 433). Doctors discussed surgery with

Plaintiff originally and also gave her the option of epidural blocks. (Tr. 433). Plaintiff chose

the epidural blocks, which she said helped her. (Tr. 433). She had epidural blocks a year

later. (Tr. 433). Plaintiff described different sensations in her back, from pain that went all

the way accross to a pinching pain. (Tr. 434). Plaintiff testified that when she got sciatica

she couldn’t get out of bed and couldn’t do anything. (Tr. 434). When that happened she

would just try to take it easy. (Tr. 434). Plaintiff was dealing with her symptoms by

controlling her activities. (Tr. 435).

Plaintiff started having arthritic symptoms in her right hand in October of 2004. (Tr.

435). Plaintiff also had pain in her neck when sitting and looking down at a desk or table or

sideways. (Tr. 435). Plaintiff would have spasms in her neck and right shoulder. (Tr. 436).

Plaintiff had trouble going to sleep because of the pain, but once she fell asleep she was

usually okay. (Tr. 437). 

2. Vocational Expert’s Testimony

The Vocational Expert (“VE”) summarized Plaintiff’s relevant work history. (Tr.

441). The Dictionary of Occupational Titles (“DOT”) defined the job of application

specialist as sedentary, semiskilled, with an SVP of 4. (Tr. 441). As described by Plaintiff,

the job would be light and semiskilled. (Tr. 441). The job of legal assistant is sedentary,

skilled, with an SVP of 7. (Tr. 441). 

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The VE testified that the nature of semiskilled and skilled work allows a person to get

up and move around from one position to another throughout the day. (Tr. 442). If a person

was sitting and needed to stand up because of knee pain to move around a little they would

be allowed to and could still perform their job duties. (Tr. 442). Although a person would

be able to get up and move around periodically, it would not necessarily be at will, and there

may be tasks that require prolonged periods of sitting. (Tr. 444). 

The VE testified that with an unskilled job, missing one day per month is all that is

tolerated. (Tr. 442). With higher skilled jobs it tends to be a little bit higher, typically two

to three days per month, but no more. (Tr. 442). The VE admitted that unplanned absences

would be less tolerated – i.e. just getting up in the morning and calling in sick – as opposed

to planned absences. (Tr. 442-447). Repeated unplanned absences would lead to dismissal

from a job. (Tr. 447).

I. The ALJ’s Findings

On May 23, 2005, the ALJ issued a written opinion denying Plaintiff’s application for

DIB benefits. (Tr. 21-30). The ALJ discussed Plaintiff’s medical history, noting that even

during the time that Plaintiff was undergoing conservative treatment for her right knee, her

treating physician indicated that she was able to perform light duty work or full duty work.

(Tr. 28). It was only for a short period of time after her right knee surgery that her treating

physician indicated she was on non-work status and soon after she was able to do light duty

seated work. (Tr. 28). As to Plaintiff’s left knee, the ALJ noted that Dr. Freedberg reported

improvement after injections and physical therapy. (Tr. 28). The ALJ gave little weight to

the Medical Source Statement completed by Dr. Jacoby, which indicated that Plaintiff was

limited to less than sedentary work, because the ALJ found that such extreme limitations

were not supported by his treatment records, which showed improvement within a short

period of time with treatment. Nor did the ALJ find Dr. Jacoby’s opinion supported by the

remainder of the objective evidence. (Tr. 28).

As for Plaintiff’s right trapezius/cervical strain with right upper extremity

radiculopathy, the ALJ noted that the condition improved with physical therapy and there

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was no evidence that it caused limitations in Plaintiff’s ability to function for 12 consecutive

months. (Tr. 28). The ALJ gave little weight to Dr. Gibson’s Medical Assessment of

Physical Capacity because such extreme limitations and level of pain were not supported by

either her treatment records or by the remainder of the objective medical evidence in the file.

(Tr. 28). The ALJ noted that Dr. McPhee’s examination established that despite chronic low

back pain, varicose veins of the right lower extremity, bilateral knee pain, and obesity,

Plaintiff would be able to do sedentary work, with a brief change in position periodically.

(Tr. 28).

The ALJ also rejected Plaintiff’s allegations regarding the degree of her impairments

as not credible. (Tr. 28). Specifically, the ALJ found that the testimony of Plaintiff was not

fully credible concerning the severity of her symptoms and the extent of her limitations.

Neither the severity nor th extent was supported by the objective medical evidence of record.

(Tr. 28). Second, the ALJ found that with regard to daily activities, Plaintiff reported on May

27, 2003, that she prepared meals, did laundry and dusting, and shopped for groceries. (Tr.

28). Plaintiff also did knee and back exercises, was able to drive, and was usually able to run

errands by herself. (Tr. 28). The ALJ noted that although Plaintiff reported that her

activities were more limited than in the past, they were not the activities of an individual too

disabled to perform sedentary work. (Tr. 29).

The ALJ found that Plaintiff had the residual functional capacity to perform sedentary

work. (Tr. 29). Plaintiff could sit for six hours in an eight-hour workday, stand and/or walk

for two hours in an eight-hour workday, and lift and/or carry five pounds frequently and ten

pounds occasionally. (Tr. 29). Plaintiff needed to be able to stand periodically and move

around. (Tr. 29). Plaintiff could not crawl, crouch, climb, squat, or kneel, and could not use

her lower extremities for pushing or pulling. (Tr. 29). The ALJ determined that Plaintiff had

the residual functional capacity to perform work as an applications specialist and as a legal

assistant because those jobs did not require the performance of work-related activities

precluded by her residual functional capacity. (Tr. 30). Thus, the ALJ concluded that

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Plaintiff was not under a “disability” as defined in the Social Security Act at any time

through the date of the opinion.

III. Standard of Review

The Court reviews the Commissioner’s final decision under a substantial evidence

standard; the decision will be disturbed only if it is not supported by substantial evidence or

based on legal error. See 42 U.S.C. § 405(g) (“The findings of the Commissioner of Social

Security as to any fact, if supported by substantial evidence, shall be conclusive....”).

“Substantial evidence” means “more than a scintilla,” but “less than a preponderance.”

Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996) (internal citations omitted). In

determining whether the Commissioner’s finding are supported by substantial evidence, the

Court considers the evidence as a whole, giving a full review to all the facts. Smolen, 80

F.3d at 1279.

IV. Discussion

The Social Security Act defines a disability as the “inability to engage in any

substantial gainful activity by reason of any medically determinable physical or mental

impairment which . . . has lasted or can be expected to last for a continuous period of not less

than 12 months.” 42 U.S.C. § 423(d)(1)(A). The ALJ engages in the following five-step

evaluation:

In step one, the ALJ determines whether a claimant is currently engaged in substantial

gainful activity. If so, the claimant is not disabled. If not, the ALJ proceeds to step

two and evaluates whether the claimant has a medically severe impairment or

combination of impairments. If not, the claimant is not disabled. If so, the ALJ

proceeds to step three and considers whether the impairment or combination of

impairments meets or equals a listed impairment under 20 C.F.R. pt. 404, subpt. P,

App. 1. If so, the claimant is automatically presumed disabled. If not, the ALJ

proceeds to step four and assesses whether the claimant is capable of performing her

past relevant work. If so, the claimant is not disabled. If not, the ALJ proceeds to

step five and examines whether the claimant has the residual functional capacity

("RFC") to perform any other substantial gainful activity in the national economy.

If so, the claimant is not disabled. If not, the claimant is disabled.

Burch v. Barnhart, 400 F.3d 676 (9th Cir. 2005); 20 C.F.R. § 404.1520. Here, the ALJ found

that Plaintiff satisfied steps one and two. Plaintiff “has not engaged in substantial gainful

activity since the amended alleged onset date of disability” and has “severe” impairments

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within the meaning of the Act and Regulations. (Tr. 30). In step four, the ALJ determined

that Plaintiff was capable of performing her past relevant work, and on that basis, found that

Plaintiff was not disabled. (Tr. 30).

A. Plaintiff’s Credibility

Plaintiff contends that the ALJ’s credibility assessment of Plaintiff’s testimony

concerning the severity of her symptoms was not supported by specific findings or clear and

convincing reasons. (Plaintiff’s Motion for Summary Judgment (Dkt. 26-2, at 3). “While

an ALJ may find testimony not credible in part or in whole, he or she may not disregard it

solely because it is not substantiated affirmatively by objective medical evidence.” Robbins

v. SSA, 466 F.3d 880, 883 (9th Cir. 2006) (citing SSR 96-7p, 1996 WL 374186, at *1).

Where an ALJ does not make a finding of malingering, as is the case here, the ALJ “may

only find an applicant not credible by making specific findings as to credibility and stating

clear and convincing reasons for each.” Robbins, 466 F.3d at 883 (citing Smolen v. Chater,

80 F.3d 1273, 1283-84 (9th Cir. 1996)). 

Here, the ALJ did not discuss in narrative fashion the evidence he considered in

the analysis of Plaintiff’s credibility. The ALJ stated that he was rejecting Plaintiff’s

“allegations of the degree of her impairments and limitations...for the following reasons:

First, the testimony of the claimant is not fully credible concerning the severity of her

symptoms and the extent of her limitations. Neither the severity nor the extent is

supported by the objective medical evidence of record.” (Tr. 28). General findings of

this nature are insufficient when making a credibility assessment. See Lester v. Chater,

81 F.3d 821, 834 (9th Cir. 1995) (“For the ALJ to reject the claimant’s complaints, she

must provide “‘specific, cogent reasons for the disbelief.’”). “[T]he ALJ must identify

what testimony is not credible and what evidence undermines the claimant’s complaints.” 

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It is not the job of this Court to determine credibility, but the record contains several

examples of inconsistencies between Plaintiff’s testimony and the objective findings. For

example, as to Plaintiff’s right knee, Plaintiff testified that her right knee problems began in

1994, got progressively worse, and that even after her knee surgery in February 2002 her

knee was worse than before.” (Tr. 417-419). After seeing Dr. Greenfield on April 9, 2001,

Plaintiff began physical therapy for her right knee. (Tr. 201). Plaintiff reported on April 30,

2001 and May 21, 2001, that her right knee symptoms were improving with physical therapy.

(Tr. 198, 197). On June 18, 2001, and August 13, 2001, Plaintiff reported that her knee

didn’t bother her every day, but she still got some discomfort and swelling.” (Tr. 196, 195).

On November 15, 2001, Plaintiff reported that she felt improved over time, though she had

a level of discomfort in her right knee that didn’t bother her with certain activities. (Tr. 192).

At that point, Dr. Greenfield discussed either declaring Plaintiff “stationary” – i.e. not

improving or getting worse – or trying further treatment. (Tr. 192). From April 2001 to

November 2001, Dr. Greenfield’s reports demonstrated that Plaintiff had improved, though

her improvement had reached a plateau. Dr. Greenfield had placed Plaintiff on full work

status throughout this time. 

When told on November 15, 2001, that she was no longer improving nor getting

worse, Plaintiff requested arthroscopic surgery. (Tr. 192). Following Plaintiff’s surgery on

February 15, 2002, Plaintiff was immediately in worse pain, though by July 1, 2002, Dr.

Greenfield reported that Plaintiff felt improvement, did not have any discomfort medially,

but had started to notice some discomfort laterally. (Tr. 185). Dr. Greenfield declared

Plaintiff stationary as to her knee injury, but noted that for further treatment regarding some

preexisting degenerative arthritis, Plaintiff could be evaluated under her private health

insurance. (Tr. 185). Dr. Greenfield assessed Plaintiff at a permanent impairment rating of

10%. (Tr. 185). On November 14, 2002, Dr. Greenfield reported that Plaintiff had been

walking, and her ease of walking had improved, although she had noticed some discomfort

in her right hip area and right foot. Dr. Greenfield placed Plaintiff on full work status. (Tr.

184).

While Plaintiff is correct that Dr. Greenfield treated only Plaintiff’s right knee, his

assessments and medical records show that Plaintiff improved with physical therapy, and

though she was not able to work immediately after her surgery, by July 1, 2002, she had no

discomfort medially, was declared stationary as to her knee injury, and was assessed at 10%

permanent impairment rating for her lower extremity. (Tr. 185). This evidence is not

consistent with Plaintiff’s testimony that her knee got progressively worse up until and after

her surgery. (Tr. 417-419). Indeed, Plaintiff’s knee improved with physical therapy from

April 2001 until June 2001. (Tr. 196-199). After recovering from her surgery in July 2002,

Dr. Greenfield reported that Plaintiff’s right knee injury was stationary and neither getting

better nor worse. (Tr. 185).

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Lester, 81 F.3d at 834. The ALJ did not identify the specific testimony or specific

evidence that undermines Plaintiff’s claims.4

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The ALJ also noted that “with regard to daily activities, the claimant reported on

May 27, 2003, that she prepared meals, did clothes washing and dusting, and shopped for

groceries. She was able to drive and was usually able to run errands by herself. She and

her husband both managed the bills and other business matters.” (Tr. 28-29). The ALJ

then stated that “[a]lthough, by her report, her activities are more limited than they were

in the past, they are not the activities of an individual too disabled to perform sedentary

work.” (Tr. 29). This general discussion also lacks specific findings supported by clear

and convincing evidence. Indeed, the ALJ omitted key portions of the record, which

explained how Plaintiff was able to perform these daily activities in light of her physical

limitations – i.e. with help from her husband or by leaning on a shopping cart while

shopping for groceries. (See PMSJ at 2-9). The Court cannot sustain such a finding. See

Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982) (“[Q]uestions of credibility and

resolution of conflicts in the testimony are functions solely of the Secretary.”). 

Because the ALJ made only general findings that Plaintiff was not credible as to

her claimed severity of symptoms and extent of limitations, the Court is unable to assess

whether such findings were legitimate. See Robbins, 466 F.3d at 884-85 (“[E]ven if the

ALJ had given facially legitimate reasons for his partial adverse credibility finding, the

complete lack of meaningful explanation gives this court nothing with which to assess its

legitimacy.”).

B. Plaintiff’s Residual Functional Capacity

Plaintiff further contends that the ALJ’s determination of Plaintiff’s residual

functional capacity was based on the restrictions outlined by Dr. McPhee, who examined

Plaintiff only once in September 2003. (Dkt. 26-2, at 9). Plaintiff contends that the

March 15, 2005, evaluation of Plaintiff’s treating physician, Dr. Gibson, was wrongfully

dismissed. The ALJ’s opinion stated that he had considered the Medical Assessment of

Physical Capacity completed by Dr. Gibson. He, however, decided to give her opinion

“little weight because such extreme limitations and level of pain [were] not supported by

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either her treatment records or by the remainder of the objective medical evidence in the

file.” (Tr. 28). 

“By rule, the Social Security Administration favors the opinion of a treating

physician over non-treating physicians.” See Orn v. Astrue, 495 F.3d 625, 631 (9th Cir.

2007) (citing C.F.R. § 404.1527). The Administration has explained that an ALJ’s

finding that a treating source medical opinion is not well-supported by medically

acceptable evidence or is inconsistent with substantial evidence in the record means only

that the opinion is not entitled to controlling weight, not that the opinion should be

rejected. See Orn, 495 F.3d at 632 (citing § 404.1527). Treating source medical opinions

are still entitled to deference and, in many cases, will be entitled to the greatest weight

and should be adopted, even if it does not meet the test for controlling weight.” Orn, 495

F.3d at 632; see also Murray v. Heckler, 722 F.2d 499, 502 (9th Cir. 1983) (“If the ALJ

wishes to disregard the opinion of the treating physician, he or she must make findings

setting forth specific, legitimate reasons for doing so that are based on substantial

evidence in the record.”). 

The record reflects that Dr. Gibson had been treating Plaintiff since April 2001 and

had detailed notes regarding Plaintiff’s conditions. Specifically, Dr. Gibson documented

Plaintiff’s left knee injury, ordered X-Rays and an MRI, and eventually referred Plaintiff

to Dr. Freedberg, who diagnosed a possible lateral meniscal tear. (Tr. 255, 220, 221). In

September 2003, Dr. Gibson noted Plaintiff’s superficial thrombophlebitis of the right

thigh. (Tr. 227). Dr. Gibson also referred Plaintiff to Dr. Jacoby for the pain in

Plaintiff’s left heel. (Tr. 286). X-Rays confirmed Achilles tendinitis. (Tr. 286). From

April 2004 to November 2004, Dr. Gibson reported right hip/buttock pain, cervical

muscle strain, right hand pain, and a right trapezius strain with right upper extremity

radiculopathy. (Tr. 301-305). Dr. Gibson’s March 15, 2005, Assessment indicated that

Plaintiff could sit one hour, stand or walk 15-30 minutes at a time, sit two hours in an

eight hour workday, stand one hour in an eight hour workday, walk two hours in a

workday, frequently lift up to five pounds, occasionally carry up to five pounds, and

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occasionally reach over head and extend arms out. (Tr. 334). Dr. Gibson noted that

Plaintiff reported pain which was moderately severe that would likely limit her activities. 

(Tr. 335). 

The law in the Ninth Circuit is clear that the ALJ must defer to the treating

doctor’s opinion, even if controverted by another doctor, unless the ALJ makes findings

setting forth specific legitimate reasons for rejecting it that are based on substantial

evidence in the record. See Lester, 81 F.3d at 830-31. Here, the ALJ did not state that

Dr. Gibson’s opinion was contradicted only that the limitations assessed by Dr. Gibson

were not supported by her records or the remainder of the record. Under these

circumstances, Dr. Gibson’s opinion was entitled to deference. Furthermore, the ALJ did

not set forth specific legitimate reasons for rejecting the opinion of Dr. Gibson supported

by substantial evidence in the record. To the contrary, the ALJ’s reasoning was cursory

and the record contains substantial evidence supporting Dr. Gibson’s assessment.

C. Dr. Greenfield’s Opinion

It is important to note that Dr. Gibson’s assessment was completed in March 2005,

nearly four years after Plaintiff’s alleged disability onset date of June 1, 2001. From

April 9, 2001, to February 15, 2002, Dr. Greenfield, another of Plaintiff’s treating

physicians continually placed Plaintiff on full work duty. Plaintiff contends that Dr.

Greenfield only treated Plaintiff’s knee injury and that, even when he discharged her in

July 2002, he acknowledged that Plaintiff could seek other treatment for her preexisting

degenerative arthritis. (Tr. 185). Nonetheless, the Court finds no contemporaneous

medical evidence in the record that contradicts Dr. Greenfield’s continued opinion that

Plaintiff could work full duty from April 2001 to February 2002, and then after

November 2002. (Tr. 184). As a treating physician, Dr. Greenfield’s uncontroverted

opinion is entitled to controlling weight. See Orn, 495 F.3d at 631. On remand,

Plaintiff’s residual functional capacity during her period of treatment with Dr. Greenfield

should be determined because it may be that during that time Plaintiff’s limitations were

not as severe as in 2005, when Dr. Gibson completed the assessment of physical capacity.

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V. Conclusion

The Court has reviewed the Commissioner’s final decision under a substantial

evidence standard and finds that the decision denying benefits is not supported by

substantial evidence. Specifically, the ALJ made an unsupported credibility

determination and gave too little weight to the opinion of Plaintiff’s treating physician,

Dr. Gibson. The case will be remanded for further administrative proceedings. On

remand, the ALJ will make a new credibility determination that meets the requirements of

this Circuit and will give deference to the March 15, 2005, assessment of Dr. Gibson. 

The ALJ will also separately assess Plaintiff’s residual functional capacity during the time

period Plaintiff was being treated by Dr. Greenfield. In the event Plaintiff is determined

to be under a disability, the ALJ may have to change the onset date. Finally, the ALJ

should retain a vocational expert to provide testimony regarding Plaintiff’s past relevant

work, and if necessary, any work that Plaintiff could do in the national economy. The

vocational expert should answer a hypothetical based on Plaintiff’s determined residual

functional capacity, describe the nature of all past relevant work, and consider whether

the relevant work could be done by a person with Plaintiff’s determined residual

functional capacity.

Accordingly,

IT IS ORDERED granting Plaintiff’s Motion for Summary Judgment (Dkt. 26)

and denying Defendant’s Cross-Motion for Summary Judgment (Dkt. 32).

IT IS FURTHER ORDERED reversing the decision of the Commissioner

denying benefits and remanding for further Administrative proceedings consistent with

this Order.

DATED this 26th day of January, 2008.

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