Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-6_05-cv-06060/USCOURTS-arwd-6_05-cv-06060-0/pdf.json

Nature of Suit Code: 865
Nature of Suit: Social Security - RSI (405(g))
Cause of Action: 42:405g Review of HHS Decision (RSI)

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

HOT SPRINGS DIVISION

RAYMOND WALLACE PLAINTIFF

VS. CIVIL NO. 05-6060

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Raymond Wallace (hereinafter “plaintiff”), brings this action pursuant to § 205(g) of the

Social Security Act (“the Act”), 42 U.S.C. § 405(g), seeking judicial review of a final decision of

the Commissioner of the Social Security Administration terminating his disability insurance benefits

(hereinafter “DIB”).

Background:

The application for DIB now before this court was filed on September 9, 1997, alleging a

disability due to a left leg fracture. (Tr. 50-51, 93-96). Plaintiff was found to be disabled and

entitled to DIB with an onset of disability as of October 7, 1996. (Tr. 15). However, pursuant to a

continuing disability review of plaintiff’s case, plaintiff’s condition was found to have improved, and

benefits were terminated as of May 1, 2000. (Tr. 15). Plaintiff filed a reconsideration request, and

appeared before a hearing officer on August 21, 2000. (Tr. 66-79). On August 23, 2000, the hearing

officer entered a decision affirming the cessation of benefits. Pursuant to plaintiff’s further request,

an administrative hearing was scheduled for September 12, 2001. (Tr. 31-34, 56-58). However,

plaintiff failed to appear for the hearing, and on September 27, 2001, the Administrative Law Judge

(“ALJ”), dismissed his request for a hearing. Plaintiff then requested review of the ALJ’s dismissal

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order, and the Appeals Council remanded the case to the ALJ on March 22, 2002. (Tr. 84-86). An

administrative hearing was held on October 31, 2002. (Tr. 252-266). Plaintiff was present, but was

not represented by council.

At the time of the hearing, on October 31, 2002, plaintiff was forty-seven years old and

possessed a high school education. (Tr. 256). His past relevant work (“PRW”), included

employment as an electrician and an electrician’s assistant. (Tr. 102).

On February 24, 2003, the ALJ issued a written decision finding that plaintiff’s condition had

substantially improved as of May1, 2001, and that he was currently capable of performing light work

requiring him to stand and walk no more than two hours during an eight-hour workday with no more

than occasional climbing, crouching, or crawling. (Tr. 18). 

On June 28, 2005, the Appeals Council declined to review this decision. (Tr. 5-7).

Subsequently, plaintiff filed this action. (Doc. # 1). This case is before the undersigned by consent

of the parties. The plaintiff and Commissioner have filed appeal briefs. (Doc. # 11-13). Plaintiff

has also filed a motion to supplement the record with additional medical evidence consisting of

medical records from the Veteran’s Administration dated between 2002 and 2003. (Doc. # 8, 9).

The case is now ready for decision.

Applicable Law:

This Court’s role is to determine whether the Commissioner’s findings are supported by

substantial evidence on the record as a whole. Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir.

2002). Substantial evidence is less than a preponderance but it is enough that a reasonable mind

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would find it adequate to support the Commissioner’s decision. The ALJ’s decision must be

affirmed if the record contains substantial evidence to support it. Edwards v. Barnhart, 314 F.3d

964, 966 (8th Cir. 2003). As long as there is substantial evidence in the record that supports the

Commissioner’s decision, the Court may not reverse it simply because substantial evidence exists

in the record that would have supported a contrary outcome, or because the Court would have

decided the case differently. Haley v. Massanari, 258 F.3d 742, 747 (8th Cir. 2001). In other words,

if after reviewing the record it is possible to draw two inconsistent positions from the evidence and

one of those positions represents the findings of the ALJ, the decision of the ALJ must be affirmed.

Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000).

It is well-established that a claimant for Social Security disability benefits has the burden of

proving his disability by establishing a physical or mental disability that has lasted at least one year

and that prevent him from engaging in any substantial gainful activity. Pearsall v. Massanari, 274

F.3d 1211, 1217 (8th Cir. 2001); see 42 U.S.C. § § 423(d)(1)(A), 1382c(a)(3)(A). The Act defines

“physical or mental impairment” as “an impairment that results from anatomical, physiological, or

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.” 42 U.S.C. § § 423(d)(3), 1382(3)(c). A plaintiff must show that his

disability, not simply his impairment, has lasted for at least twelve consecutive months.

The Commissioner’s regulations require her to apply a five-step sequential evaluation process

to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful

activity since filing his claim; (2) whether the claimant has a severe physical and/or mental

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impairment or combination of impairments; (3) whether the impairment(s) meet or equal an

impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past

relevant work; and, (5) whether the claimant is able to perform other work in the national economy

given his age, education, and experience. See 20 C.F.R. § § 404.1520(a)- (f)(2003). Only if the final

stage is reached does the fact finder consider the plaintiff’s age, education, and work experience in

light of his or her residual functional capacity. See McCoy v. Schweiker, 683 F.2d 1138, 1141-42

(8th Cir. 1982); 20 C .F.R. § § 404.1520, 416.920 (2003).

Discussion:

Of particular concern to the undersigned is the ALJ’s failure to properly consider plaintiff’s

residual functional capacity (“RFC”). RFC is the most a person can do despite that person’s

limitations. 20 C.F.R. § 404.1545(a)(1). A disability claimant has the burden of establishing his or

her RFC. See Masterson v. Barnhart, 363 F.3d 731, 737 (8th Cir.2004). “The ALJ determines a

claimant’s RFC based on all relevant evidence in the record, including medical records, observations

of treating physicians and others, and the claimant’s own descriptions of his or her limitations.”

Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004); Guilliams v. Barnhart, 393 F.3d 798,

801 (8th Cir. 2005). Limitations resulting from symptoms such as pain are also factored into the

assessment. 20 C.F.R. § 404.1545(a)(3). The United States Court of Appeals for the Eighth Circuit

has held that a “claimant’s residual functional capacity is a medical question.” Lauer v. Apfel, 245

F.3d 700, 704 (8th Cir. 2001). Therefore, an ALJ’s determination concerning a claimant’s RFC must

be supported bymedical evidence that addresses the claimant’s ability to function in the workplace.”

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The diaphysis is the “elongated cylindrical portion (the shaft) of a long bone, between

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the ends or extremities (the epiphyses), which are usually articular and wider than the shaft.” 

See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY, p. 493 (29th ed. 2000). 

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Lewis v. Barnhart, 353 F.3d 642, 646 (8th Cir. 2003). The ALJ is “required to set forth specifically

a claimant’s limitations and to determine how those limitations affect [his or] her RFC.” Lewis v.

Barnhart, 353 F.3d 642, 646 (8th Cir. 2003). 

In the present case, plaintiff was awarded benefits due to the non-union of a fracture in his

left leg. (Tr. 72, 186, 192). An orthopaedic examination in April 2000, revealed a mild bony

deformity of the distal lower left leg with mild tenderness to palpation. (Tr. 210-212). Examination

of the left knee showed mild ligamentous laxity with varus stress of the knee. There was a zero

degree of extension noted in each knee, and plaintiff was noted to have some instability when

attempting to walk on his heels. (Tr. 210).

X-rays of plaintiff’s leg dated May 16, 2000, revealed a deformity of the distal left tibia

consistent with a healed, deformed fracture. (Tr. 213). The major distal fracture fragment was offset

laterally approximately fifty to seventy percent, and fused with the proximal fragment. Smooth bone

formation abutted, but did not appear to be fused with the adjacent fibular diaphysis. (Tr. 213).

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There was also a deformity of the healed proximal, fibular fracture. Further, the distal tibial fracture

also suggested some mild shortening. (Tr. 213).

On July 2, 2002, x-rays of plaintiff’s leg revealed old traumatic changes in the distal shaft of

the left tibia and fibula. (Tr. 248). As such, plaintiff was diagnosed with degenerative joint disease.

(Tr. 248). 

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On July 14, 2002, Dr. Shepard Fountaine, a non-examining, consultative physician,

completed an RFC assessment based upon plaintiff’s medical records, and concluded that plaintiff

could perform light work, but could only occasionally balance; stoop; kneel; crouch; crawl; and,

never climb ladders, ropes or scaffolds. (Tr. 223-224). Dr. Fountaine noted that plaintiff had a

healed tibial and fibular fracture with some resulting shortening and deformity. (Tr. 229). 

 On October 16, 2002, x-rays of plaintiff’s left ankle showed a healed fracture of the distal

tibia, and minor arthritic changes in the tibial taylor joint. (Tr. 246). An x-ray of his left knee

revealed hypertrophic spur formation of the distal femur on the medial aspect and an old, healed

fracture of the proximal fibula. (Tr. 246).

While we note that the ALJfound plaintiff capable of only light work, requiring no more than

two hours of standing and walking per day with only occasional crawling, crouching, and climbing,

the ALJ failed to consider plaintiff’s ability to stoop; kneel; balance; climb ladders, ropes, and

scaffolds; and, operate foot controls. The ALJ is required to make explicit findings regarding the

actual physical and mental demands of the claimant’s past work. See Lewis, 353 F.3d at 646. The

RFC should “identify the individual’s functional limitations or restrictions and assess his or her

work-related abilities on a function-by-function basis. See 20 C.F.R. § 404.1545(b); see also SSR

96-8p (1996). This ruling cautions that a failure to make the function-by-function assessment “could

result in the adjudicator overlooking some of an individual’s limitations or restrictions.” Id. Given

the nature of plaintiff’s injury and the fact that the ALJ failed to make specific findings regarding his

ability to climb ladders, ropes, and scaffolds; balance; kneel; stoop; and, use foot controls, activities

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that would clearly be affected by his impairment, we believe that remand is necessary to allow the

ALJ to reconsider plaintiff’s exertional and non-exertional limitations. Id. On remand, the ALJ is

directed to make specific findings regarding plaintiff’s ability to perform any and all activities

requiring the use of his left leg and/or foot. 

As the plaintiff has filed a motion to submit additional medical evidence, both parties are

reminded that, on remand, all pertinent medical evidence should be submitted to the ALJfor review.

Conclusion:

Accordingly, we conclude that the ALJ’s decision is not supported by substantial evidence,

and therefore, the denial of benefits to the plaintiff, should be reversed and this matter should be

remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. §

405(g). By so doing, we hereby deny plaintiff’s motion to submit additional medical evidence. 

DATED this 21st day of September 2006.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

UNITED STATES MAGISTRATE JUDGE 

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