Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-2_15-cv-02135/USCOURTS-alnd-2_15-cv-02135-0/pdf.json

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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UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

WILLIAM ERNEST TRAYWICK,

Plaintiff,

v.

CAROLYN W. COLVIN,

Commissioner of the

Social Security Administration,

Defendant.

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}

}

}

}

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Case No.: 2:15-CV-02135-MHH

MEMORANDUM OPINION 

Pursuant to 42 U.S.C. §§ 405(g) and 1383(c), plaintiff William Ernest 

Traywick seeks judicial review of a final adverse decision of the Commissioner of 

Social Security. The Commissioner denied Mr. Traywick’s claims for a period of 

disability and disability insurance benefits and supplemental security income. 

After careful review, the Court remands the Commissioner’s decision. 

I. PROCEDURAL HISTORY

Mr. Traywick applied for a period of disability and disability insurance 

benefits and supplemental security income on June 9, 2014. (Doc. 7-7, pp. 2–12).1 

 

1 The ALJ stated that Mr. Traywick applied for benefits on June 2, 2014. (Doc. 7-3, p. 21). Mr. 

Traywick’s applications for disability insurance benefits and supplemental security income are 

dated June 9, 2014. (Doc. 7-7, pp. 2, 6). The discrepancy is immaterial to the Court’s analysis.

FILED

 2017 Mar-16 PM 01:23

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 1 of 26
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Mr. Traywick alleges that his disability began on September 20, 2013. (Doc. 7-3, 

p. 74; Doc. 7-7, p. 46).

2

 The Commissioner initially denied Mr. Traywick’s claims 

on July 17, 2014. (Doc. 7-5, pp. 2–11). Mr. Traywick requested a hearing before 

an Administrative Law Judge (ALJ). (Doc. 7-5, p. 12). The ALJ issued an 

unfavorable decision on April 22, 2015. (See Doc. 7-3, p. 21; Doc. 7-5, p. 94). 

On June 8, 2015, Mr. Traywick’s attorney requested that the ALJ “reopen 

and/or revise the unfavorable decision based on new evidence vital to Mr. 

Traywick’s allegations of debilitating back pain” and an error in a treatment note 

from one of Mr. Traywick’s treating physicians, Dr. Lloyd Johnson III. (Doc. 7-5, 

pp. 94–95). The ALJ reopened the initial unfavorable decision pursuant to 20 

C.F.R. §§ 404.988 and 416.1488. (Doc. 7-3, p. 21). The ALJ reviewed Mr. 

Traywick’s additional evidence and a modified treatment note from Dr. Johnson. 

(Doc. 7-3, p. 21). The ALJ conducted a supplemental hearing on July 23, 2015. 

(Doc. 7-3, pp. 5–70). The ALJ issued another unfavorable decision on August 13, 

2015. (Doc. 7-3, pp. 18–34). On September 23, 2015, the Appeals Council 

declined Mr. Traywick’s request for review (Doc. 7-3, pp. 2–5), making the 

Commissioner’s decision final and a proper candidate for this Court’s judicial 

review. See 42 U.S.C. §§ 405(g) and 1383(c). 

 

2 Mr. Traywick originally alleged that his disability began on June 1, 2012. (Doc. 7-7, pp. 2, 6). 

Mr. Traywick later amended his alleged onset date to September 20, 2013. (Doc. 7-7, p. 46).

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 2 of 26
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II. STANDARD OF REVIEW

The scope of review in this matter is limited. “When, as in this case, the 

ALJ denies benefits and the Appeals Council denies review,” the Court “review[s] 

the ALJ’s ‘factual findings with deference’ and [his] ‘legal conclusions with close 

scrutiny.’” Riggs v. Comm’r of Soc. Sec., 522 Fed. Appx. 509, 510–11 (11th Cir. 

2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)). 

The Court must determine whether there is substantial evidence in the record 

to support the ALJ’s factual findings. “Substantial evidence is more than a 

scintilla and is such relevant evidence as a reasonable person would accept as 

adequate to support a conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 

1155, 1158 (11th Cir. 2004). In evaluating the administrative record, the Court 

may not “decide the facts anew, reweigh the evidence,” or substitute its judgment 

for that of the ALJ. Winschel v. Comm’r of Soc. Sec. Admin., 631 F.3d 1176, 1178 

(11th Cir. 2011) (internal quotations and citation omitted). If substantial evidence 

supports the ALJ’s factual findings, then the Court “must affirm even if the 

evidence preponderates against the Commissioner’s findings.” Costigan v. 

Comm’r, Soc. Sec. Admin., 603 Fed. Appx. 783, 786 (11th Cir. 2015) (citing 

Crawford, 363 F.3d at 1158).

With respect to the ALJ’s legal conclusions, the Court must determine 

whether the ALJ applied the correct legal standards. If the Court finds an error in 

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the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide 

sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis, 

then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d 

1143, 1145-46 (11th Cir. 1991). 

III. SUMMARY OF THE ALJ’S DECISION

To determine whether a claimant has proven that he is disabled, an ALJ 

follows a five-step sequential evaluation process. The ALJ considers:

(1) whether the claimant is currently engaged in substantial gainful 

activity; (2) whether the claimant has a severe impairment or 

combination of impairments; (3) whether the impairment meets or 

equals the severity of the specified impairments in the Listing of 

Impairments; (4) based on a residual functional capacity (“RFC”) 

assessment, whether the claimant can perform any of his or her past 

relevant work despite the impairment; and (5) whether there are 

significant numbers of jobs in the national economy that the claimant

can perform given the claimant’s RFC, age, education, and work 

experience.

Winschel, 631 F.3d at 1178. 

In this case, the ALJ found that Mr. Traywick has not engaged in substantial 

gainful activity since September 20, 2013, the alleged onset date. (Doc. 7-3, p. 

24). The ALJ determined that Mr. Traywick suffers from the following severe 

impairments: degenerative disc disease of the lumbar and thoracic spine, lumbar 

radiculopathy, atrial flutter, and history of spinal surgeries. (Doc. 7-3, p. 24). The 

ALJ found that Mr. Traywick suffers from the following non-severe impairments: 

hypertension, mild obstructive arterial disease in the left leg, a history of kidney 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 4 of 26
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stones, minimal scoliosis, and history of laparoscopic cholecystectomy. (Doc. 7-3, 

p. 24). Based on a review of the medical evidence, the ALJ concluded that Mr. 

Traywick does not have an impairment or combination of impairments that meets 

or medically equals the severity of any of the listed impairments in 20 C.F.R. Part 

404, Subpart P, Appendix 1. (Doc. 7-3, p. 24). 

In light of Mr. Traywick’s impairments, the ALJ evaluated Mr. Traywick’s

residual functional capacity. The ALJ determined that Mr. Traywick has the RFC 

to perform:

light work as defined in 20 CFR 404.1567(b) and 416.967(b) except 

he would be required to have a sit/stand option with the retained 

ability to stay on or at a work station in no less than 30 minute 

increments each without significant reduction of remaining on task 

and he is able to ambulate short distances up to 50 yards per instance 

on flat[,] hard surfaces. He is able to occasionally use foot controls 

bilaterally and can frequently reach overhead bilaterally. He can 

occasionally climb ramps and stairs but never climb ladders or 

scaffolds. He can frequently balance, but can only occasionally stoop, 

and never crouch, kneel, or crawl. The claimant should never be 

exposed to unprotected heights, dangerous machinery, dangerous 

tools, hazardous processes, or operate commercial motor vehicles. He 

can tolerate occasional exposure to vibration and in addition to normal 

workday breaks, he would be off-task five percent of an eight-hour 

workday, in non-consecutive minutes. 

(Doc. 7-3, pp. 24–25). Based on this RFC and testimony from a vocational expert, 

the ALJ concluded that Mr. Traywick is not able to perform his past relevant work 

as a construction laborer, construction worker I, forklift operator, heavy equipment 

operator, or dump truck driver. (Doc. 7-3, pp. 32–33). Relying on testimony from 

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a vocational expert, the ALJ found that jobs exist in the national economy that Mr. 

Traywick can perform. (Doc. 7-3, p. 33). Those jobs include bench and table 

worker, surveillance system monitor, and telephone quote clerk. (Doc. 7-3, pp. 

33–34). Accordingly, the ALJ determined that Mr. Traywick has not been under a 

disability within the meaning of the Social Security Act. (Doc. 7-3, p. 34). 

IV. ANALYSIS

Mr. Traywick argues that he is entitled to relief from the ALJ’s decision 

because the ALJ did not properly evaluate the credibility of Mr. Traywick’s 

complaints of pain consistent with the Eleventh Circuit’s pain standard. The Court 

agrees.3

“To establish a disability based on testimony of pain and other symptoms, 

the claimant must satisfy two parts of a three-part test by showing ‘(1) evidence of 

an underlying medical condition; and (2) either (a) objective medical evidence 

confirming the severity of the alleged pain; or (b) that the objectively determined 

medical condition can reasonably be expected to give rise to the claimed pain.’”

Zuba-Ingram v. Commissioner of Social Sec., 600 Fed. Appx. 650, 656 (11th Cir. 

2015) (quoting Wilson v. Barnhart, 284 F.3d 219, 1225 (11th Cir. 2002) (per 

curiam)). A claimant’s testimony coupled with evidence that meets this standard is

 

3 Mr. Traywick also alleges that the ALJ did not give adequate weight to the opinion of Mr. 

Traywick’s treating physician, Dr. Lloyd Johnson III, or the opinion of one-time consultative 

examiner, Dr. Harold Settle. (Doc. 11, pp. 10–13). Because the Court finds Mr. Traywick’s first 

argument meritorious, the Court will not address these additional issues. 

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“itself sufficient to support a finding of disability.” Holt v. Sullivan, 921 F.2d 

1221, 1223 (11th Cir. 1991) (citation omitted). When evaluating a claimant’s 

subjective symptoms, the ALJ may consider a range of factors, such as: (1) the 

claimant’s daily activities; (2) the nature and intensity of pain and other symptoms; 

(3) precipitating and aggravating factors; (4) effects of medications; (5) treatment 

or measures taken by the claimant for relief of symptoms; and (6) other factors 

concerning functional limitations. Moreno v. Astrue, 366 Fed. Appx. 23, 28 (11th 

Cir. 2010) (citing 20 C.F.R. § 404.1529(c)(3)). If the ALJ discredits a claimant’s 

subjective testimony, the ALJ “must articulate explicit and adequate reasons for 

doing so.” Wilson, 284 F.3d at 1225. “While an adequate credibility finding need 

not cite particular phrases or formulations[,] broad findings that a claimant lacked 

credibility . . . are not enough . . . .” Foote v. Chater, 67 F.3d 1553, 1562 (11th 

Cir. 1995) (per curiam). 

During his initial hearing on March 23, 2015, Mr. Traywick testified that he 

could not work because of back and leg pain. (Doc. 7-3, p. 88). Mr. Traywick 

testified that from “eight in the morning until five in the afternoon” he needs to lie 

down three to four times a day “anywhere from an hour to [an] hour and a half” at 

a time. (Doc. 7-3, p. 102). Mr. Traywick testified that he has “issues with 

traveling and being able to get around [] day to day.” (Doc. 7-3, p. 88). Mr. 

Traywick estimated that he drives “three to five times a week” and that he limits

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his trips “to the store and home” because “[i]t hurts” to drive. (Doc. 7-3, p. 79).

Mr. Traywick stated that he does not “travel far because of back issues affecting 

[his] legs.” (Doc. 7-3, p. 79). 

Mr. Traywick described his pain as “[g]eneral misery” and “constant.” 

(Doc. 7-3, p. 92). Mr. Traywick explained that his pain “starts out as burning pain 

from [his] back down [his] left leg and grows” into “grinding, numbness pain” that 

occurs “at least three days a week.” (Doc. 7-3, pp. 92–93). Mr. Traywick testified 

that standing for 15 to 20 minutes causes “pain and discomfort.” (Doc. 7-3, p. 94). 

Mr. Traywick testified that he could lift a gallon of milk but not a case of soda. 

(Doc. 7-3, p. 95). Mr. Traywick is able to do some basic chores, and he “pick[s] 

up limbs” around the yard. (Doc. 7-3, pp. 96–99). 

Mr. Traywick takes prescription medication including “oxycodone to 

Naprosyn to Tramadol and . . . some hypertension medicines,” but he testified that 

they do not work. (Doc. 7-3, pp. 88–89). Mr. Traywick testified that “within 15 

minutes of taking [his medication] if [he does not] lay down and go to sleep [he 

will get] sick and throw up.” (Doc. 7-3, p. 89). 

During the supplemental hearing on July 23, 2015, Mr. Traywick testified

that he tried to go back to work by cleaning yards and pulling weeds. (Doc. 7-3, p. 

64). Mr. Traywick worked three four-hour days before he fell on a rock and hurt 

his back. (Doc. 7-3, p. 64). After the fall, Mr. Traywick experienced a bulging 

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disc that “elevated [his] pain ratings.” (Doc. 7-3, pp. 64–65). Mr. Traywick 

explained that when he “physically [tries] to do something, [his] back swells up 

and inflames the nerves in [his] left leg and it impairs [his] ability to walk and [he] 

trip[s] and fall[s] over stuff easy.” (Doc. 7-3, p. 67). Mr. Traywick testified that 

his condition has not improved, and he explained that if the “pain management” 

treatment he was scheduled to receive did not help, then he would opt for surgery. 

(Doc. 7-3, p. 65). 

The ALJ summarized Mr. Traywick’s testimony concerning his back and leg 

pain. (Doc. 7-3, pp. 25–26).4 The ALJ properly recited the pain standard by 

finding that Mr. Traywick’s “medically determinable impairments could 

reasonably be expected to cause many of the alleged symptoms.” (Doc. 7-3, p. 

31). After summarizing Mr. Traywick’s medical record, the ALJ concluded that 

Mr. Traywick’s “statements concerning the intensity, persistence and limiting 

effects” of the symptoms were not credible. (Doc. 7-3, p. 31). The ALJ stated:

[i]n terms of the claimant’s alleged severe back pain and physical 

limitations arising from his back, the medical evidence of record 

shows that the claimant has degenerative changes in his lumbar and 

thoracic spine, but does not show nerve impingement or serious spinal 

stenosis, thus, the medical evidence of record does not support 

claimant’s allegations of severe physical limitations arising from 

moderately severe to severe pain []. Reasonably, the claimant does 

have back impairments that would cause some limitations and pain, 

though reasonably, not to the extent he alleges. The claimant’s disc 

 

4 Mr. Traywick does not challenge the ALJ’s credibility findings with respect to his atrial flutter 

or his mental limitations. (See Doc. 11, pp. 4–10).

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 9 of 26
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bulge at L5-S1 causes mild posterior displacement of the S1 nerve 

root sleeve, which could reasonably cause generally minor symptoms, 

but this is inconsistent with the claimant’s allegations of chronic 

disabling pain []. Indeed, none of his spinal doctors ever opined that 

he had permanent severe limitations or that he would be permanently 

unable to engage in work activities []. Indeed, it was frequently 

reported that his sensation was intact, muscle strength was normal, 

and he had no motor problems. Despite one notation of positive 

straight leg raising, a subsequent treatment note reported that it was 

negative, and other subsequent notes do not show positive straight leg 

raising []. Notably, despite the claimant’s repeated allegations of 

severe pain, Dr. Johnson prescribed some pain medication, performed 

some injections, recommended more exercise, and specifically 

recommended against any surgery for his condition []. Multiple 

diagnostic scans were reported to show some degenerative disc 

disease and a disc bulge, possibly two, with some generally minor 

scar tissue formation. More importantly, his many x-rays and MRI[]s 

did not show any disc herniations, nerve impingement, or spinal 

stenosis.

(Doc. 7-3, p. 31) (internal citations omitted). 

Substantial evidence does not support the ALJ’s interpretation of Mr. 

Traywick’s medical records. Objective medical evidence in Mr. Traywick’s 

treatment notes is consistent with his subjective pain testimony. 

On May 7, 2014, Mr. Traywick began treatment with Dr. Lloyd Johnson, III

at the Alabama Bone & Joint Clinic. (Doc. 7-9, p. 42). Mr. Traywick complained 

of lower back pain that had been present for over 10 years. (Doc. 7-9, p. 42). He 

rated his pain at a level 7 out of 10 and described his symptoms as “constant, 

aching, pressure, radiating and electrical.” (Doc. 7-9, p. 42). Dr. Johnson noted 

that Mr. Traywick had two previous back surgeries: a lumbar discectomy in 1999

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and a revision discectomy in January 2000. (Doc. 7-9, p. 42). Dr. Johnson stated 

that Mr. Traywick had “been unable to work for about 18 months.” (Doc. 7-9, p. 

42). 

A lumbar spine examination showed a positive straight leg raise test on the 

left, but negative on the right. (Doc. 7-9, p. 43). Mr. Traywick had “diffuse 

tenderness [in the] mid to lower lumbar region . . . significant limitation to full 

lumbar range of motion which causes pain . . . [and] decreased sensation [in the] 

left leg as compared to right.” (Doc. 7-9, p. 43). Mr. Traywick had no focal 

deficits in either leg, his lumbar alignment was normal, and his lumbar scar was 

well-healed. (Doc. 7-9, p. 43). 

A thoracic spine examination found “limited thoracolumbar range of 

motion” but no tenderness to palpation and “[s]trength testing 5/5 in all areas 

tested.” (Doc. 7-9, p. 43). Imaging showed “degenerative disease L4-5 and L5-

S1” and “degenerative changes [in the] mid and lower thoracic region.” (Doc. 7-9, 

p. 43). Dr. Johnson prescribed physical therapy, a Medrol Dosepak, and Naprosyn, 

and he instructed Mr. Traywick to follow up in three weeks. (Doc. 7-9, p. 43). 

During a visit with Dr. Johnson on June 4, 2014, Mr. Traywick complained

that his symptoms had “worsened since the last visit,” and he rated his pain on the 

left side as 10 out of 10. (Doc. 7-9, p. 33). Mr. Traywick complained that his back 

pain was “greater than [his] leg pain.” (Doc. 7-9, p. 33). Mr. Traywick reported 

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that he could do light yard work, but it caused him pain. (Doc. 7-9, p. 33). Mr. 

Traywick stated he did not go to physical therapy because the physical therapy 

office did not call him back. (Doc. 7-9, p. 33). Dr. Johnson called the physical 

therapy office and learned that Mr. Traywick received a call from the physical 

therapy office, but he did not respond. (Doc. 7-9, p. 33). 

A lumbar spine examination showed “pain with simulated rotation and with 

axially loading the shoulders.” (Doc. 7-9, p. 33). Mr. Traywick “grimace[d] 

throughout the evaluation.” (Doc. 7-9, p. 33). Dr. Johnson noted that Mr. 

Traywick was “able to feel light touch in both legs,” and Dr. Johnson found “no 

focal motor deficits in either leg.” (Doc. 7-9, p. 33). A thoracic spine examination 

showed “diffuse tenderness of the thoracic spine.” (Doc. 7-9, p. 33). 

Dr. Johnson ordered an MRI of the thoracic spine and the lumbar spine with 

and without contrast. (Doc. 7-9, p. 33). Dr. Johnson recommended that Mr. 

Traywick discontinue nicotine use because it “can lead to ongoing degenerative

disc disease,” and Dr. Johnson prescribed Ultram. (Doc. 7-9, pp. 33–34). 

Mr. Traywick underwent the MRI of his spine on June 12, 2014. (Doc. 7-9, 

p. 45). The MRI showed “moderate disc desiccation and mild disc space 

narrowing” and “broad-based disc bulge at L4-5 with some epidural fibrotic 

enhancement around the thecal sac.” (Doc. 7-9, p. 45). The MRI showed “no 

definite findings to indicate recurrent disc herniation.” (Doc. 7-9, p. 45). 

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On June 15, 2014, Mr. Traywick saw physician’s assistant Vinny Baglini,

PA-C at the Shelby Baptist Medical Center and complained of back pain that 

shoots down his legs. (Doc. 7-10, p. 67). Mr. Traywick also complained of neck 

pain associated with an injury he suffered three or four days earlier when a tree 

branch hit his neck. (Doc. 7-10, p. 67). Mr. Baglini stated that Mr. Traywick’s 

back pain “is a chronic problem.” (Doc. 7-10, p. 67). Mr. Traywick tested positive 

for a straight leg raise on the left but negative on the right, and he exhibited 

tenderness in his lumbar spine. (Doc. 7-10, p. 69). Mr. Baglini diagnosed Mr. 

Traywick with chronic back pain, left-sided sciatica, and neck strain, and

prescribed Prednisone, Orphenadrine, and Meloxicam. (Doc. 7-10, pp. 69–71). 

Mr. Traywick saw Dr. Johnson on July 15, 2014 and complained of back 

pain that “radiates down his left leg.” (Doc. 7-10, p. 84). Mr. Traywick stated that 

his “symptoms had worsened since his last visit,” and he rated the pain on his left 

side as 9 out of 10. (Doc. 7-10, p. 84). Dr. Johnson stated that the pain involves 

Mr. Traywick’s left thigh and calf. (Doc. 7-10, p. 84). Dr. Johnson explained that 

Mr. Traywick’s “[p]ain is sharp. It is worse with any bending and lifting and 

twisting. It bothers him daily. Limits his activity.” (Doc. 7-10, p. 84). Dr. 

Johnson reported that Mr. Traywick “has been unable to work for 18 months.” 

(Doc. 7-10, p. 84). Mr. Traywick told Dr. Johnson that he received a left L5 

selective nerve root block on July 3, 2014, but the block “did not help.” (Doc. 7-

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10, p. 84). Mr. Traywick stated that his back pain “bothers him daily and is 

debilitating.” (Doc. 7-10, p. 84). 

A lumbar spine examination showed:

a well-healed lumbar incision. No redness or warmth. Positive 

straight leg raise on the left, negative on the right. Able to feel light 

touch in both legs. There is weakness to left hip flexors secondary to 

pain. No other focal motor deficits in either leg. Both legs are warm 

and well perfused. 

(Doc. 7-10, p. 84). A thoracic spine examination revealed “normal thoracic

alignment,” but Dr. Johnson stated that Mr. Traywick has “significantly limited 

thoracolumbar range of motion” and “is able to flex to about 30° . . . lacks 10°

from neutral,” and “[h]is back is very sore and spasms today.” (Doc. 7-10, p. 85). 

Dr. Johnson ordered a left L4 and left L5 selective nerve root block. (Doc. 7-10, p. 

85). Dr. Johnson “discussed alternatives including observation, or surgery,” but 

Mr. Traywick was “not interested in surgery” at the time. (Doc. 7-10, p. 85). 

Regarding Mr. Traywick’s ability to work, Dr. Johnson stated that “[Mr. Traywick]

will be off of work. I do not think he is able to work at this time. His pain is 

severe. He has difficulty even standing up straight at this point. He has pain from 

his back that radiates down the leg.” (Doc. 7-10, p. 85). 

During an August 12, 2014 visit with Dr. Johnson, Mr. Traywick 

complained of lower back pain that extended into his left leg. (Doc. 7-11, p. 47). 

Dr. Johnson noted that “there [had] been no significant changes in [Mr. 

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Traywick’s] current symptoms.” (Doc. 7-11, p. 47). Mr. Traywick was “limping 

significantly.” (Doc. 7-11, p. 47). Mr. Traywick reported that the pain on his left 

side was 8 out of 10. (Doc. 7-11, p. 47). Mr. Traywick explained that a left L4 

and left L5 nerve root block performed on July 22, 2014 only “helped for about 36 

hours.” (Doc. 7-11, p. 47). Dr. Johnson noted that Mr. Traywick’s back and left 

leg pain “is worse with ambulation [and] better with rest.” (Doc. 7-11, p. 47). A 

lumbar spine examination showed “[n]o redness or warmth” but “tenderness both 

on the left and the right side in the mid to lower lumbar region.” (Doc. 7-11, p. 

47). Mr. Traywick had a positive straight leg raise on the left. (Doc. 7-11, p. 47). 

He was “able to feel light touch [in] both legs” and had “no focal motor deficits in 

either leg.” (Doc. 7-11, p. 47). Dr. Johnson reported that Mr. Traywick ambulated 

with a limp and that “there [was] some groin pain with left hip range of motion.” 

(Doc. 7-11, p. 47). 

Dr. Johnson proposed surgery as a potential option to remove scar tissue, but 

Mr. Traywick did not want to consider surgery. (Doc. 7-11, p. 47). Dr. Johnson 

ordered an “MRI scan of the left hip to rule out hip pathology as a source of [Mr. 

Traywick’s] pain.” (Doc. 7-11, p. 47). Dr. Johnson also suggested that:

Mr. Traywick may consider getting a disability attorney. His problem 

is [it is] hard even to drive because of the pain. He has to adjust 

position frequently to get comfortable. As a result it is hard to hold 

any employment. [H]e had work restrictions since his work injury 15 

years ago. He was told he was “40% disabled at that time.”

 

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(Doc. 7-11, p. 48). 

On August 26, 2014, Mr. Traywick visited Dr. Johnson and rated the pain on 

his left side as 10 out of 10. (Doc. 7-11, p. 42). Mr. Traywick reported that his 

severe “pain limits his activity.” (Doc. 7-11, p. 42). Dr. Johnson reviewed the 

MRI scan of Mr. Traywick’s pelvis and found no sign of hip pathology, but he did 

see “degenerative disc disease L4-5 and L5-S1” with “some scar tissue formation 

with laminotomy on the left at L4-5.” (Doc. 7-11, p. 42). Dr. Johnson referred Mr.

Traywick to pain management and ordered physical therapy. (Doc. 7-11, p. 42). 

Dr. Johnson noted that he did “not see anything [he] could do surgically to reliably 

diminish [Mr. Traywick’s] leg pain.” (Doc. 7-11, p. 42). 

Also on August 26, 2014, Mr. Traywick saw his primary care doctor at 

Childersburg Primary Care, Dr. Jarod Speer. (Doc. 7-11, pp. 7–9). Mr. Traywick 

complained of “lower back pain from [an] old injury.” (Doc. 7-11, p. 7). Dr. 

Speer noted that Dr. Johnson had been treating Mr. Traywick’s back pain. (Doc. 

7-11, p. 7). Dr. Speer reported that Mr. Traywick recently took Ultram for his 

back pain, but it did not provide “much relief.” (Doc. 7-11, p. 7). Mr. Traywick

also had been taking morphine, but he complained that the morphine was “too 

strong.” (Doc. 7-11, p. 7). Mr. Traywick stated that the nerve blocks he had 

received provided no relief. (Doc. 7-11, p. 7). Dr. Speer reported normal 

neurologic findings, except Dr. Speer stated that Mr. Traywick “walks with a 

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lim[p]” and has “stooped over posture due to pain.” (Doc. 7-11, p. 8). Dr. Speer 

noted that at the time, Mr. Traywick was working full-time, and he occasionally 

walked or did other light activity for exercise. (Doc. 7-11, p. 8). Dr. Speer 

diagnosed Mr. Traywick with degenerative disc disease and prescribed Percocet 

and Zanaflex. (Doc. 7-11, p. 8).

Mr. Traywick visited Dr. Speer on September 15, 2014 for a check-up and 

complained of a reaction to Percocet. (Doc. 7-11, p. 5). Dr. Speer noted that Mr. 

Traywick would be “followed by ortho and will see pain management soon.” 

(Doc. 7-11, p. 5). Dr. Speer did not examine Mr. Traywick’s back during this visit, 

but Dr. Speer diagnosed Mr. Traywick with “chronic pain.” (Doc. 7-11, p. 6). Dr. 

Speer prescribed Lyrica, recommended follow up “with ortho or pain 

management,” and scheduled a return appointment in three months. (Doc. 7-11, p. 

6). 

Mr. Traywick returned to Dr. Speer on September 26, 2014 and complained 

of back pain and an irregular heartbeat. (Doc. 7-11, p. 3). Dr. Speer noted that Mr. 

Traywick’s MRI showed no degenerative disc disease. (Doc. 7-11, p. 3). Dr. 

Speer diagnosed “chronic pain” and encouraged Mr. Traywick to “call and pursue 

pain management” and to continue his medications. (Doc. 7-11, p. 4). Dr. Speer’s 

September 26, 2014 treatment note contains no back examination findings. (Doc. 

7-11, pp. 3–4). 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 17 of 26
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On February 2, 2015, the Disability Determination Service referred Mr. 

Traywick to Dr. Harold P. Settle for a disability evaluation regarding a “history of 

cardiac tachyarrhythmia.” (Doc. 7-12, p. 2). Dr. Settle completed a medical 

source statement and found no cardiovascular limitations, but he did determine that 

Mr. Traywick has several postural limitations because of Mr. Traywick’s back 

pain. (Doc. 7-12, pp. 2–9). Dr. Settle opined that Mr. Traywick can sit, stand, and 

walk for one hour at a time without interruption. (Doc. 7-12, p. 5). Dr. Settle 

opined that Mr. Traywick can sit for one hour, stand for one hour, and walk for one 

hour in an 8-hour work day. (Doc. 7-12, p. 5). Dr. Settle found that Mr. Traywick 

can occasionally operate foot controls with his left and right feet and that he can 

frequently perform the following activities: reaching, handling, fingering, feeling, 

and pushing/pulling. (Doc. 7-12, p. 6). Dr. Settle also found that Mr. Traywick 

can never climb ladders or scaffolds, crouch, or crawl, but he can occasionally 

climb stairs and ramps, balance, stoop, and kneel. (Doc. 7-12, p. 7). 

On February 6, 2015, Mr. Traywick returned to Dr. Speer and complained of

chronic back pain that is steady and exacerbated by movement. (Doc. 7-12, p. 12). 

Mr. Traywick told Dr. Speer that “ortho is now telling [me] that they [will not] 

refer [me] to pain management and ‘that is [my primary care physician’s] job.’” 

(Doc. 7-12, p. 12). Mr. Traywick stated that “ortho made one attempt to refer to 

pain management but [that] they never contacted [him].” (Doc. 7-12, p. 12). A 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 18 of 26
19

back exam revealed that Mr. Traywick’s spine was “normal without deformity or 

tenderness,” and Mr. Traywick had a normal range of motion. (Doc. 7-12, p. 13). 

Dr. Speer stated that he would refer Mr. Traywick to pain management, and he 

encouraged Mr. Traywick to follow up with his orthopedic doctor. (Doc. 7-12, p. 

13). Dr. Speer prescribed Zanaflex, Lyrica, Metoprolol Succinate ER, and

Percocet. (Doc. 7-12, p. 13). 

Mr. Traywick followed up with Dr. Johnson on February 10, 2015. (Doc.7-

12, p. 16). Mr. Traywick reported that his “symptoms [had] worsened since the 

last visit.” (Doc. 7-12, p. 16). Mr. Traywick rated his back pain as a 7 out of 10. 

(Doc. 7-12, p. 16). Under the “lumbar spine examination” and “thoracic spine 

examination” headings, Dr. Johnson wrote: “Examination today reveals definite 

improvement with no new problems or positive findings.” (Doc. 7-12, p. 16). On 

June 1, 2015, Dr. Johnson submitted a letter and a finalized report explaining that 

the original February 10, 2015 treatment note was incorrect. (Doc. 7-12, p. 19). 

Dr. Johnson’s letter stated: 

I recently had an appointment with the patient. The patient brought 

[his] file from his disability hearing. He asked me to review it. I 

noted that there was an error in the file. 

The electronic medical record that we use generates a pending note 

when we see the patient that must be finalized. The pending note is 

generated based on test[s] that we ordered, medications that we order, 

and information that the patient provides to the nurse, as well as the 

diagnosis selected. The doctor then goes in and reviews the note and 

makes additions and corrections [] before finalizing the note. 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 19 of 26
20

Occasionally, the pending note will still be visible in the medical 

record. It appears that the pending note was sent to the disability 

hearing instead of the finalized copy. I have included a copy of the 

pending note with the finalized note as well. As you can see, I added 

additional history prior to finalizing the note. In addition[,] I added a 

physical examination. The electronic medical record automatically 

includes the statement, “examination today reveals definite 

improvement with no new problems or positive findings” until the 

physician enters [an exam] as a placeholder. As you can see from the 

finalized note, the patient had decreased sensation in the left calf. 

Motor function was [i]ntact. He was tender in the lumbar region. 

Please let me know if you need any additional information. 

(Doc. 7-12, p. 19). 

 Dr. Johnson’s revised February 10, 2015 treatment note states “[t]he patient 

has decreased sensation in the left calf. Sensation intact in the right. Motor function 

intact in both legs. The patient does groan and [grimace] during the evaluation. 

Tenderness diffusely in the lumbar region.” (Doc. 7-12, p. 21). Dr. Johnson 

prescribed a Medrol Dosepak, and he recommended a home exercise program and 

“ongoing pain management through [Mr. Traywick’s] primary care physician.” 

(Doc. 7-12, p. 22).5

On May 12, 2015, Dr. Johnson saw Mr. Traywick for a “flare of [Mr. 

Traywick’s] low back pain.” (Doc. 7-12, p. 57). Under a “history of present 

illness” heading, Dr. Johnson stated:

 

5 Mr. Traywick’s attorney requested that the ALJ reopen his initial unfavorable decision based in 

part on this revised medical record that Dr. Johnson submitted on Mr. Traywick’s behalf. (See

Doc. 7-5, pp. 94–95). 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 20 of 26
21

[p]ain will radiate down both legs. The back pain is much more 

severe than the leg pain is. The patient has had therapy in the past for 

his back. When he gets leg pain, it is worse on the left than it is on the 

right. The pain will go into the left buttock thigh and calf. He has 

some pain in the right thigh, usually stopping at the knee.

(Doc. 7-12, p. 57). Mr. Traywick had “tenderness in the mid to lower lumbar 

region” and positive straight leg raise on the left and right. (Doc. 7-12, p. 57). Dr. 

Johnson injected trigger points on the left and right side with 1cc Betamethasone 

6mg/mL mixed with Marcaine. (Doc. 7-12, pp. 57–58). Dr. Johnson stated that 

Mr. Traywick should begin at-home pool therapy and that he should keep his 

appointment with the pain clinic. (Doc. 7-12, p. 58). Dr. Johnson stated that he 

would consider ordering a new lumbar MRI if Mr. Traywick’s condition did not 

improve. (Doc. 7-12, p. 58).

On May 22, 2015, Mr. Traywick reported to Coosa Valley Medical Center 

for treatment for back pain after he fell on a rock. (Doc. 7-12, p. 26). An exam 

showed “left si[de] joint tenderness [and] sacral tenderness.” (Doc. 7-12, p. 26). 

Mr. Traywick had a full range of motion in his extremities. (Doc. 7-12, p. 26). 

The attending physician and nurse practitioner diagnosed back pain, sciatica, and 

coccyx contusion, and they prescribed Meloxicam, Metoprolol, and Robaxin. 

(Doc. 7-12, p. 27). Mr. Traywick was instructed to follow up with his primary 

care physician if his symptoms worsened. (Doc. 7-12, p. 27). 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 21 of 26
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Mr. Traywick saw Dr. Speer on May 26, 2015 because his back pain 

“continu[ed] to get worse.” (Doc. 7-12, p. 41). Dr. Speer reported normal back 

examination findings “except mild/moderate [tenderness to palpation] in lower 

back area.” (Doc. 7-12, p. 42). Mr. Traywick had a normal gait and negative 

straight leg raise. (Doc. 7-12, p. 42). Dr. Speer stated that Mr. Traywick had an 

appointment scheduled with pain management in July. (Doc. 7-12, p. 42). Dr. 

Speer explained that advanced imaging may be necessary if Mr. Traywick’s pain 

persisted. (Doc. 7-12, p. 42). 

On May 29, 2015, Mr. Traywick saw Dr. Johnson. (Doc. 7-12, p. 49). Mr. 

Traywick stated that his “symptoms [had] worsened since the last visit.” (Doc. 7-

12, p. 49). He rated his pain at a level 10 out of 10. (Doc. 7-12, p. 49). Mr. 

Traywick described the pain as “sharp and constant.” (Doc. 7-12, p. 49). Mr. 

Traywick reported that he “slipped in a creek and fell on May 14” and “was 

diagnosed with a contusion of his coccyx.” (Doc. 7-12, p. 49). Dr. Johnson’s 

lumbar spine examination showed: “[n]ormal thoracolumbar alignment. 

Tenderness [in the] mid to lower lumbar region. Mild tenderness over the sacrum 

and coccyx. No groin pain with right left hip range of motion. Motor sensory 

function intact in both legs.” (Doc. 7-12, p. 49). Mr. Traywick had “normal 

thoracic alignment” but a “slow gait.” (Doc. 7-12, p. 49). Imaging showed “no 

right or left hip fracture or arthritic change” and “[m]inimal scoliosis. 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 22 of 26
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Degenerative disc disease L4-L5.” (Doc. 7-12, p. 49). Imaging also showed “no 

evidence of a coccygeal or sacral fracture.” (Doc. 7-12, p. 49). Dr. Johnson 

ordered physical therapy for Mr. Traywick and noted that Mr. Traywick had a pain 

management appointment scheduled on July 25, 2015. (Doc. 7-12, p. 50). Dr. 

Johnson stated that he would order a lumbar MRI scan if Mr. Traywick’s condition 

did not improve. (Doc. 7-12, p. 50).

Mr. Traywick also saw Dr. Speer on May 29, 2015. (Doc. 7-12, p. 39). Mr. 

Traywick complained of “acute” and “chronic low back pain” that was 

“[]aggravated again today with [a] car ride.” (Doc. 7-12, p. 39). Mr. Traywick 

reported that his “pain radiates into [his] leg.” (Doc. 7-12, p. 39). Dr. Speer noted 

“normal” back examination findings except Mr. Traywick’s lumbar spine was

“[tender to palpation],” and Mr. Traywick was “flexed over due to pain.” (Doc. 7-

12, p. 40). Dr. Speer prescribed Toradol and Prednisone, and he recommended 

that Mr. Traywick continue his other medication, including muscle relaxers and 

Percocet. (Doc. 7-12, p. 40). 

On June 15, 2015, Mr. Traywick saw Dr. Johnson again. (Doc. 7-12, p. 45). 

Mr. Traywick reported that his pain was a level 10 out of 10. (Doc. 7-12, p. 45). 

Dr. Johnson noted a straight leg raise assessment bilaterally, pain with torque 

lumbar range of motion, and limited thoracolumbar range of motion secondary to 

back pain. (Doc. 7-12, p. 45). Dr. Johnson reviewed the results of Mr. Traywick’s 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 23 of 26
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most recent MRI. (Doc. 7-12, p. 45). The MRI revealed a “bulge L4-5 centrally to 

the left of midline with enhancing fibrotic scar. No recurrent herniation noted. 

Broad-based bulge at L5-S1. No interval change compared to June 12, 2014.” 

(Doc. 7-12, p. 45). Dr. Johnson prescribed Percocet. (Doc. 7-12, p. 45). He did 

not recommend surgery, but he explained that if Mr. Traywick did not improve 

with pain management, then Mr. Traywick should follow up to discuss surgical 

options. (Doc. 7-12, pp. 45–46).

The ALJ discounted Mr. Traywick’s reports of severe pain largely because 

imaging of Mr. Traywick’s spine provided little to no objective evidence to 

substantiate Mr. Traywick’s description of his back pain. (Doc. 7-3, p. 31). The 

ALJ also based his conclusion on the fact that Dr. Johnson “specifically 

recommended against surgery” for Mr. Traywick’s back condition. (Doc. 7-3, p. 

31). Both observations are correct, but they do not supply substantial evidence to 

support the ALJ’s decision. 

Although Mr. Traywick’s x-rays and MRIs provide no objective medical 

evidence of conditions that would cause severe pain, the record contains objective 

medical evidence such as findings of tenderness in the lumbar region, limping, and 

stooped posture. Both Mr. Traywick’s orthopedist and his general physician 

accepted Mr. Traywick’s description of his pain and routinely prescribed pain 

medication for Mr. Traywick. Mr. Traywick’s orthopedist, Dr. Johnson, 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 24 of 26
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recommended against surgery because he did not believe that surgery would 

resolve Mr. Traywick’s pain. The record contains no statement by a doctor 

indicating that Mr. Traywick’s back or leg pain was less severe than he described, 

and there is no indication that Mr. Traywick’s description of his daily activities 

was inaccurate. See SSR 96-7P 1996 WL 374186 at *7 (“In general, a longitudinal 

medical record demonstrating an individual’s attempts to seek medical treatment 

for pain or other symptoms and to follow that treatment once it is prescribed lends 

support to an individual’s allegations of intense or persistent pain or other 

symptoms for the purposes of judging the credibility of the individual’s 

statements.”); see also Lamb v. Bowen, 847 F.2d 698, 702 (11th Cir. 1988) (“[T]he 

record is replete with evidence of a medical condition that could reasonably be 

expected to produce the alleged pain. No examining physician ever questioned the 

existence of appellant’s pain. They simply found themselves unable to cure the 

pain.”); Edwards v. Barnhart, 319 F. Supp. 2d 1283, 1290 (N.D. Ala. 2004)

(finding that substantial evidence did not support the ALJ’s analysis of the 

claimant’s subjective testimony because the testimony was “well supported by 

objective medical evidence (MRI, decreased ROM, tenderness, abnormal gait, 

decreased strength, atrophy, positive straight leg raise) of underlying conditions 

which could reasonably be expected to produce her pain”). 

Case 2:15-cv-02135-MHH Document 13 Filed 03/16/17 Page 25 of 26
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Accordingly, substantial evidence does not support the ALJ’s decision to 

discredit Mr. Traywick’s testimony regarding his back and leg pain, and the Court 

will remand this action to the Commissioner. Powell v. Astrue, 250 Fed. Appx.

960, 964–65 (11th Cir. 2007) (“[B]ecause neither of the ALJ’s reasons for 

discrediting Powell’s incontinence testimony amounts to substantial evidence 

supporting his decision to reject that testimony, we must remand this case so that 

the ALJ can re-assess the effect of Powell’s claimed incontinence after either 

accepting her testimony or by articulating an adequate reason to reject it.”). 

V. CONCLUSION

For the reasons discussed above, the Court remands the decision of the 

Commissioner for reevaluation of the subjective testimony as it relates to Mr. 

Traywick’s back and leg pain. The Court will enter a separate order consistent 

with this memorandum opinion. 

DONEand ORDERED this March 16, 2017.

 _________________________________

 MADELINE HUGHES HAIKALA

 UNITED STATES DISTRICT JUDGE

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