Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-00028/USCOURTS-casd-3_16-cv-00028-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0405id Review of HHS Decision (SSID)

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UNITED STATES DISTRICT COURT 

SOUTHERN DISTRICT OF CALIFORNIA 

JOEY DALE WHITMAN, 

Plaintiff, 

vs. 

NANCY A. BERRYHILL, Acting 

Commissioner of Social Security, 

Defendant.1

Case No.: 3:16-cv-28-MMA-JMA 

REPORT & 

RECOMMENDATION OF 

UNITED STATES 

MAGISTRATE JUDGE RE 

PLAINTIFF’S MOTION FOR 

SUMMARY JUDGMENT AND 

DEFENDANT’S CROSSMOTION FOR SUMMARY 

JUDGMENT [ECF Nos. 22, 23] 

 Plaintiff Joey Dale Whitman (“Plaintiff”) seeks judicial review of Defendant 

Social Security Commissioner Nancy A. Berryhill’s (“Defendant”) determination 

that he is not entitled to disability insurance benefits (“DIB”) and supplemental 

security income (“SSI”). The parties have filed cross-motions for summary 

judgment. [ECF Nos. 22, 23.] For the reasons set forth below, the Court 

recommends Plaintiff’s motion for summary judgment be DENIED and 

                                                                

1 Nancy A. Berryhill, the new Acting Commissioner of Social Security, is substituted as the 

Defendant in this suit pursuant to Federal Rule of Civil Procedure 25(d). 

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Defendant’s cross-motion for summary judgment be GRANTED. 

I. BACKGROUND

 Plaintiff was born on December 23, 1968 and is a high school graduate. 

(Admin R. at 30-31.) Plaintiff worked as a warehouse manager and delivery 

driver for a party rentals company from 1998 to 2010. Id. at 31, 152. Plaintiff 

stopped working in August 2010 due to swelling and pain in both Achilles 

tendons. Id. at 31. 

On August 16, 2011, Plaintiff filed an application for a period of disability 

and disability insurance benefits. Id. at 16. On October 31, 2011, Plaintiff 

protectively filed an application for supplemental security income. Id. at 16, 141, 

157. In both applications, the Plaintiff alleged a disability onset date of August 

8, 2010. Id. at 16, 141, 157. The Social Security Administration denied the 

claim initially on October 26, 2011 and again upon reconsideration on March 14, 

2012. Id. at 75-84. On April 27, 2012, Plaintiff filed a written request for an 

administrative hearing. Id. at 99-104. On December 9, 2013, a hearing was 

conducted by Administrative Law Judge (“ALJ”) Leland H. Spencer, who 

determined on February 28, 2014 that Plaintiff was not disabled within the 

meaning of the Social Security Act. Id. at 16-23. On April 27, 2014, Plaintiff 

requested a review of the ALJ’s decision. Id. at 12. The Appeals Council for the 

Social Security Administration (“SSA”) denied Plaintiff’s request for review on 

November 6, 2015. Id. at 1-4. Plaintiff then commenced this action pursuant to 

42 U.S.C. § 405(g). 

// 

// 

// 

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II. MEDICAL EVIDENCE 

A. Scripps Clinic, Treating Physicians (August 2010 – October 2011) 

 On August 8, 2010, Plaintiff presented to the urgent care at Scripps Clinic 

and was examined by Scott Krishel, M.D. Id. at 189. Plaintiff complained of 

pain and swelling in the bilateral Achilles heel tendons over the past several 

months, with the right tendon becoming particularly worse, making it difficult to 

walk. Id. Plaintiff had a history of gout. Id. Dr. Krishel reported slight 

tenderness on the right side at the base of the heel and no tenderness or 

swelling in the left Achilles tendon. Id. Dr. Krishel reported 5/5 for dorsiflexion 

and plantar flexion of the ankle against resistance. Id. at 190. Dr. Krishel 

completed x-rays of the ankle and foot bilaterally and indicated no definite acute 

changes, pending the radiologist’s reading. Id. Plaintiff’s right leg was splinted 

and he was given crutches. Id. Dr. Krishel advised Plaintiff to continue nonsteroidal pain medication and prescribed a small dose of Vicodin. Id. 

 On August 9, 2010, Plaintiff presented to Dr. Clifford Feaver, a podiatrist. 

Id. at 191. Plaintiff reported the Vicodin prescribed to him in Urgent Care had 

not helped much. Id. Dr. Feaver noted Plaintiff was a very pleasant man, in no 

acute distress. Id. at 192. Dr. Feaver reported the radiographs of the right 

ankle were negative and (1) there was quite substantial inflammation and 

swelling around the Achilles tendon bilaterally, (2) there was thickening in the 

middle third, (3) it was much more tender on the right than on the left, (4) the 

Thompson test was negative, (5) Homans’ sign was negative, (6) there was no 

particular pain with compression of the calves on either side, (7) mild cavus foot 

structure, (8) dorsiflexion at the ankle was limited bilaterally, and 

(9) neurovascular status was grossly intact bilaterally. Id. Dr. Feaver 

immobilized the right side in a Controlled Ankle Motion (“CAM”) Walker boot for 

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added comfort and protection and advised Plaintiff to increase his medication 

dosage for gout. Id. Dr. Feaver also ordered an MRI for the more symptomatic 

right Achilles tendon and advised Plaintiff to follow up when the study became 

available. Id. 

 On August 10, 2010, Plaintiff presented to Edward V.H. Skol, M.D., a 

rheumatologist. Id. at 194. Plaintiff reported the increased dosage of his gout 

medication had not helped. Id. Dr. Skol noted Plaintiff was well appearing, but 

obviously uncomfortable. Id. at 195. Dr. Skol reported there was a thickening 

and swelling of both Achilles tendons in the proximal aspect and tenderness to 

palpation. Id. The doctor opined that although he could not rule it out 

completely, he did not think this was a gout flare-up because of the duration of 

the pain and the non-responsiveness to the increased medication. Id. at 196. 

Dr. Skol advised Plaintiff to continue to wear the CAM Walker boot on the right 

and to avoid working. Id. 

 On August 16, 2010, Plaintiff returned to Dr. Feaver for the MRI review. 

Id. at 197. The MRI demonstrated a moderate grade intrasubstance tearing 

longitudinally of the right Achilles tendon which clinically correlated to the 

thickening and the area of chief complaint. Id. at 197, 232. Dr. Feaver 

diagnosed Plaintiff with bilateral Achilles tendinosis, greater on the right than the 

left. Id. Dr. Feaver directed Plaintiff to continue wearing the CAM Walker for an 

additional two weeks, at which time physical therapy would be initiated. Id. 

 From August 30, 2010 to June 28, 2011, Plaintiff presented to Dr. Feaver 

approximately every six weeks for follow-up. Id. at 198-211. By the October 4, 

2010 appointment, Plaintiff had developed more significant symptoms on the left 

and a CAM Walker was dispensed for use on that side. Id. at 200. During 

those follow-up appointments, Dr. Feaver advised Plaintiff to try and wean 

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himself off the CAM Walker. Id. at 198, 200, 203, 205, 207. At the June 28, 

2011 appointment, Dr. Feaver noted over the past ten months that Plaintiff 

consistently had physical therapy and had made relatively good progress, but 

Plaintiff still experienced significant symptoms with extended activity. Id. at 211. 

Plaintiff reported he had attended a fair the previous week for much of the day, 

but had taken “mini rest breaks.” Id. Upon physical examination, Plaintiff was 

able to do toe raising, but Dr. Feaver noted tenderness to palpation and fusiform 

thickening in the middle third of the Achilles tendon bilaterally. Id. Dr. Feaver 

also noted the left was worse than the right, but there were no other significant 

changes. Id. Dr. Feaver assessed Plaintiff’s pain had improved by 80%-90%, 

but Plaintiff continued to have significantly restricted activity and was unable to 

work. Id. Dr. Feaver recommended a consultation with Dr. Rosen to discuss 

surgical options. Id. 

On August 10, 2011, Plaintiff presented to Dr. Adam S. Rosen for surgical 

consultation. Id. at 213. Plaintiff reported the CAM Walkers and physical 

therapy had helped somewhat, but he essentially had not improved and 

continued to be out of work due to pain. Id. Dr. Rosen requested an MRI of the 

left ankle and discussed the possibility of surgery on the left Achilles. Id. at 214. 

The MRI of the left ankle, performed on August 25, 2011, showed Achilles 

tendinosis with microscopic intra-substance tearing and mild paratenonitis. Id. 

at 236. 

 From August 30, 2011 to October 12, 2011, Plaintiff presented to Dr. 

John Cronin due to persistent loud snoring and struggling to breathe while 

sleeping. Id. at 216-21, 254-56, 259-61. After completing a sleep study, 

Plaintiff was diagnosed with mild obstructive sleep apnea. Id. at 220, 306. 

During follow-up visits, Dr. Cronin noted Plaintiff responded well to CPAP, and 

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was still responding well as of January 11, 2012. Id. at 243-45. 

B. George G. Spellman, Jr. M.D., Non-Examining Physician 

 (October 2011) 

On October 14, 2011, Dr. George G. Spellman, Jr. completed a physical 

residual functional capacity assessment regarding Plaintiff. Id. at 238-40. Dr. 

Spellman reported limitations due to bilateral degenerative joint disease of the 

feet, Achilles enthesopathy bilaterally, and obesity were evident in the medical 

evidence of record. Id. at 239. Dr. Spellman found Plaintiff was only partially 

credible because the alleged persisting severity was not evident in the 

longitudinal treatment record showing improvement in the Achilles tendon. Id. 

Dr. Spellman further noted Plaintiff’s obstructive sleep apnea was mitigated by 

the CPAP. Id. Dr. Spellman opined Plaintiff was capable of performing at least 

light work. Id. 

C. Adam Rosen, M.D., Treating Physician 

 (October 2011 – January 2012) 

On October 20, 2011, Dr. Rosen operated on Plaintiff for chronic left 

Achilles tendinosis. Id. at 281. At the time of his left Achilles tendon 

debridement and repair surgery, Plaintiff was found to have thickened fibrotic 

tissue in the intrasubstance of the tendon. Id. at 282. No calcific pieces were 

noted and more than 50% of the tendon was intact. Id. 

Beginning on November 2, 2011, Plaintiff presented to Dr. Rosen for postoperative follow-ups. Id. at 252. Dr. Rosen noted that clinically, Plaintiff was 

doing well and converted him into a short-leg cast in slight plantar flexion. Id. 

On November 16, 2011, Dr. Rosen noted there was some slight pulling and 

tightness when he brought Plaintiff up to neutral, but observed he was doing 

well clinically. Id. at 250. On December 7, 2011, Dr. Rosen again noted 

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Plaintiff was doing well and had a well-healed incision. Id. at 248. Plaintiff was 

converted into a CAM Walker and given a prescription for physical therapy. Id. 

On January 11, 2012, Dr. Rosen noted Plaintiff had not yet started 

physical therapy. Id. at 246. Upon examination, Dr. Rosen again noted a wellhealed incision, but also mild palpable nodular thickening over the area of his 

prior surgical debridement. Id. He noted no tenderness on palpation and good 

dorsiflexion and plantar flexion, although it was somewhat stiff compared to the 

contralateral side. Id. Plaintiff was converted from his CAM Walker to a shoe 

with a heel lift and was encouraged to start physical therapy. Id. 

D. James Metcalf, M.D., Non-Examining Physician (March 2012)

On March 13, 2012, Dr. James Metcalf analyzed Plaintiff’s case and 

affirmed Dr. Spellman’s October 14, 2011 finding of a light residual functional 

capacity. Id. at 308. Dr. Metcalf noted that since the initial decision, Plaintiff 

had undergone left Achilles tendon debridement and repair. Id. Dr. Metcalf 

noted Plaintiff was doing well as of January 11, 2012 and was ready to begin 

physical therapy. Id. Dr. Metcalf’s review of Plaintiff’s recent activities of daily 

living showed that Plaintiff reported no problems with personal care, and could 

prepare sandwiches, soups, and cereal daily. Id. Plaintiff also reported he was 

able to fold laundry while sitting, go outside daily, drive short distances, and 

shop in stores for up to 35-40 minutes. Id. Additionally, Plaintiff reported he 

could watch movies, play board games, and visit with others, and could lift up to 

ten pounds and walk up to 100 feet. Id. Plaintiff also reported pain with 

exertional activities and use of the CAM Walker daily. Id. Dr. Metcalf affirmed 

Plaintiff’s light residual function assessment lasting until October 20, 2012, one 

year from the date of surgery. Id. 

// 

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E. Adam Rosen, M.D., Treating Physician (May 2013)

Plaintiff returned to Dr. Rosen, his surgeon, on May 8, 2013. Id. at 335. 

Dr. Rosen noted Plaintiff had undergone a repeat debridement with flexor 

transfer on the left Achilles tendon on October 23, 2012. Id. 2 Plaintiff reported 

he had completed physical therapy and was doing well, but there was pain in 

his right heel. Id. Dr. Rosen noted Plaintiff still had swelling of his left foot and 

as a result, Plaintiff had to increase his shoe size. Id. Plaintiff reported 

occasional burning sensations that worsened after days in which he stood for 

long periods. Id. Plaintiff also noted occasional use of 800 milligrams of 

ibuprofen, which helped. Id. 

Dr. Rosen made the following findings: there was a well-healed incision, 

Plaintiff had mild puffiness to the retrocalcaneal bursa, but no significant edema 

of the lower extremity; calf was supple and nontender; mild tightness 

approximately six degrees of dorsiflexion on the left; sensation was grossly 

intact, and pulses were intact. Id. at 335-36. Dr. Rosen adjusted Plaintiff’s shoe 

by adding heel lifts to use for a number of weeks and noted Plaintiff’s 

ambulation improved with the lifts. Id. at 336. Dr. Rosen advised Plaintiff to 

wean out of the heel lifts as his symptoms allowed. Id. Dr. Rosen 

recommended a five-day course of 800 milligrams of Motrin three times a day to 

help with swelling and pain, and discussed using over-the-counter capsaicin. 

Id. Dr. Rosen also discussed the continued role of stretching and advised 

Plaintiff to use his night split. Id. Dr. Rosen spent twenty-five minutes with 

Plaintiff, noting half the time was spent on patient counseling. Id. 

// 

                                                                

2 Medical records pertaining to Plaintiff’s second surgery on October 23, 2012 are missing 

from the record. (Admin. R. at 49, 59.) 

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F. Arch Health Partners, Treating Physicians (May 2013 - October 2013)

 On May 17, 2013, Plaintiff presented to Dr. Mark Hubbard of Arch Health 

Partners for a second opinion. Id. at 324-26. Plaintiff reported he was still 

seeing Dr. Rosen for bilateral Achilles tendon ruptures, and that he also had 

depression. Id. at 324. Dr. Hubbard referred Plaintiff to Dr. Brad S. Cohen. Id. 

On May 28, 2013, Plaintiff presented to Dr. Cohen and complained of 

clicking and pain in his Achilles tendons, rated as 10/10, that woke him up 

during the night. Id. at 310. Upon examination, Dr. Cohen reported findings 

consistent with the prior surgical procedures. Id. Dr. Cohen recommended 

Plaintiff seek another opinion. Id. at 311. 

On October 25, 2013, Dr. Hubbard reported that Plaintiff saw orthopedic 

surgeons Dr. Sitler and Dr. Copp, both of whom advised against further 

surgeries. Id. at 316. Dr. Hubbard recommended a follow-up in six months. Id. 

at 317. 

G. Adam Rosen, M.D., Treating Physician (December 2013) 

On December 4, 2013, Plaintiff presented again to Dr. Rosen. Id. at 332. 

Plaintiff reported that since completing therapy, he had fluctuating pain, 

sometimes exacerbated without any significant trauma. Id. Dr. Rosen noted 

Plaintiff came to the office in normal shoes and walked with minimal to 

nonantalgic gait. Id. Dr. Rosen’s physical examination revealed a well-healed 

incision, intact pulses, and strength at about 4/5 compared to 5/5 on the 

contralateral side. Id. Dr. Rosen also noted no papable defects, mild 

tenderness along the path of the Achilles and mild tenderness with calcaneal 

squeeze. Id. After a long discussion with Plaintiff wherein Plaintiff reported he 

still suffered from symptoms, Dr. Rosen recommended a conservative approach 

of stepping back and placing Plaintiff back into the CAM Walker for 

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approximately three weeks. Id. at 333. If the CAM Walker did not help to 

decrease symptoms, then Plaintiff was directed to go back on crutches for a 

week or two to decrease the stress across the foot. Id. Dr. Rosen provided a 

sample of diclofenac patches and a prescription for 800 milligrams ibuprofen to 

be taken three times a day for ten days. Id. Dr. Rosen noted that after 

Plaintiff’s pain decreased, they would discuss a gradual return to strengthening 

exercises and possibly a revisit to formal physical therapy. Id. 

III. THE ADMINISTRATIVE HEARING 

The ALJ conducted an administrative hearing on December 9, 2013. 

Id. at 27. 

A. Plaintiff’s Testimony 

 Plaintiff testified he was born on December 23, 1968 and graduated 

from high school. Id. at 30. From 1998 until August 2010, Plaintiff worked 

at a party rental company. Id. at 31. In August 2010, Plaintiff stopped 

working because he ruptured both of his Achilles tendons. Id. Plaintiff 

testified he did not look for other work that allowed him to sit down because 

he could not concentrate due to “excruciating pain.” Id. at 32. 

 Plaintiff underwent two surgeries on his left Achilles tendon, the 

second of which was in October 2012. Id. at 37. Plaintiff testified Dr. 

Rosen wanted to get the left tendon under control before performing any 

work on the right. Id. at 41. Plaintiff worked the left tendon with a stretchy 

band daily to help strengthen the tendon. Id. at 42. Plaintiff took 800 

milligrams of ibuprofen three times a day to help with the swelling of the 

tendons. Id. at 37. 

Plaintiff also testified driving approximately once per month in case of 

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emergencies. Id. at 34. Otherwise, Plaintiff stated he stayed home and did 

not engage in much physical activity. Id. Plaintiff’s daily activities 

consisted of making food and using an iPad. Id. at 34-35. Plaintiff also 

testified he could stand for approximately ten minutes, could walk with 

crutches, and that he elevated his feet while sitting. Id. at 34. Plaintiff 

testified he was prescribed Allopurinol for gout, Zoloft for depression, and 

Lipitor for cholesterol. Id. at 36. Plaintiff noted his gout was under control 

from consistent use of his medication. Id. at 41. 

Plaintiff testified he uses a cane around the house and crutches if he 

leaves the house. Id. at 38. Since August 2010, Plaintiff has used the 

crutches approximately 80% of the time. Id. at 39. Plaintiff also noted 

using a CAM Walker boot since August 2010. Id. Plaintiff told Dr. Rosen 

he was in severe pain and he would sometimes remove the boot because 

he was tired of wearing it. Id. at 40. Plaintiff indicated Dr. Rosen told him 

he cannot take off the boot. Id. 

B. Medical Expert Testimony 

Medical Expert (“ME”) witness Dr. Arthur Brovender testified at the 

administrative hearing. Id. at 42. The ME’s review of Plaintiff’s medical 

records indicated Plaintiff had bilateral Achilles tendonitis in the right and 

left feet. Id. at 46. The ME found Plaintiff was provided crutches in 

preparation for the first surgery, but the record did not support a need for a 

cane or crutches for the years post-surgery. Id. at 51, 53. The ME also 

indicated the record did not support a limitation in the capacity to walk or 

stand. Id. at 53. Upon examination by Plaintiff’s attorney, the ME testified 

the record did not show a need for surgery or other intervention with the 

right Achilles tendon. Id. at 54. The ME also testified the record did not 

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support a listing under Listing 1.02A, even after taking Plaintiff’s obesity 

into consideration, because the record did not indicate Plaintiff needed two 

crutches or canes and he was able to get around. Id. at 55-56. 

 Vocational expert Connie Guillory appeared at the hearing, but did 

not testify. Id. at 16. 

IV. THE ALJ DECISION 

 After reviewing the record, ALJ Spencer made the following findings: 

.... 

2. The claimant has not engaged in substantial gainful 

activity since August 8, 2010, the alleged onset date 

[citation omitted]. 

3. The claimant has the following severe impairments: 

bilateral Achilles tendonitis, left greater than right, status 

post left Achilles tendon debridement on October 20, 

2011 and repeated debridement with flexor tendon 

transfer on October 23, 2012; and obesity [citation 

omitted]. 

4. The claimant does not have an impairment or 

combination of impairments that meets or medically 

equals the severity of one of the listed impairments in [the 

Social Security Regulations]. 

5. After careful consideration of the entire record, the 

undersigned finds that the claimant has the residual 

functional capacity to perform the full range of sedentary 

work standing for no more than two hours in an eight hour 

workday [citation omitted]. 

 

6. The claimant is unable to perform any past relevant work 

[citation omitted]. 

. . . . 

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10. Considering the claimant’s age, education, work 

experience, and residual functional capacity, there are 

jobs that exist in significant numbers in the national 

economy that the claimant can perform [citation omitted]. 

11. The claimant has not been under a disability, as defined 

in the Social Security Act, from August 8, 2010, through 

the date of this decision [citation omitted]. 

Id. at 18-23. 

V. STANDARD OF REVIEW 

 To qualify for disability benefits under the Social Security Act, an 

applicant must show: (1) He or she suffers from a medically determinable 

impairment that can be expected to result in death or that has lasted or can 

be expected to last for a continuous period of twelve months or more, and 

(2) the impairment renders the applicant incapable of performing the work 

that he or she previously performed or any other substantially gainful 

employment that exists in the national economy. See 42 U.S.C. § 

423(d)(1)(A), (2)(A). An applicant must meet both requirements to be 

“disabled.” Id. Further, the applicant bears the burden of proving that he or 

she was either permanently disabled or subject to a condition which 

became so severe as to disable the applicant prior to the date upon which 

his or her disability insured status expired. Johnson v. Shalala, 60 F.3d 

1428, 1432 (9th Cir. 1995). 

A. Sequential Evaluation of Impairments 

 The Social Security Regulations outline a five-step process to 

determine whether an applicant is "disabled." The five steps are as follows: 

(1) Whether the claimant is presently working in any substantial gainful 

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activity. If so, the claimant is not disabled. If not, the evaluation proceeds 

to step two. (2) Whether the claimant’s impairment is severe. If not, the 

claimant is not disabled. If so, the evaluation proceeds to step three. (3) 

Whether the impairment meets or equals a specific impairment listed in the 

Listing of Impairments. If so, the claimant is disabled. If not, the evaluation 

proceeds to step four. (4) Whether the claimant is able to do any work he 

has done in the past. If so, the claimant is not disabled. If not, the 

evaluation continues to step five. (5) Whether the claimant is able to do 

any other work. If not, the claimant is disabled. Conversely, if the 

Commissioner can establish there are a significant number of jobs in the 

national economy that the claimant can do, the claimant is not disabled. 20 

C.F.R. § 404.1520; see also Tackett v. Apfel, 180 F.3d 1094, 1098-99 (9th 

Cir. 1999). 

B. Judicial Review 

 Sections 205(g) and 1631(c)(3) of the Social Security Act allow 

unsuccessful applicants to seek judicial review of the Commissioner's final 

agency decision. 42 U.S.C.A. §§ 405(g), 1383(c)(3). The scope of judicial 

review is limited. The Commissioner’s final decision should not be 

disturbed unless: (1) The ALJ's findings are based on legal error or (2) are 

not supported by substantial evidence in the record as a whole. Schneider 

v. Comm’r of Soc. Sec. Admin., 223 F.3d 968, 973 (9th Cir. 2000). 

Substantial evidence means “more than a mere scintilla but less than a 

preponderance; it is such relevant evidence as a reasonable mind might 

accept as adequate to support a conclusion.” Andrews v. Shalala, 53 F.3d 

1035, 1039 (9th Cir. 1995). The Court must consider the record as a 

whole, weighing both the evidence that supports and detracts from the 

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ALJ’s conclusion. See Mayes v. Massanari, 276 F.3d 453, 459 (9th Cir. 

2001); Desrosiers v. Sec'y of Health & Human Servs., 846 F.2d 573, 576 

(9th Cir. 1988). “The ALJ is responsible for determining credibility, 

resolving conflicts in medical testimony, and for resolving ambiguities.” 

Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009) (citing Andrews, 53 

F.3d at 1039). Where the evidence is susceptible to more than one rational 

interpretation, the ALJ’s decision must be affirmed. Vasquez, 572 F.3d at 

591 (citation and quotations omitted). 

 Section 405(g) permits this Court to enter a judgment affirming, 

modifying, or reversing the Commissioner’s decision. 42 U.S.C.A. § 

405(g). The matter may also be remanded to the SSA for further 

proceedings. Id. 

VI. DISCUSSION 

 Plaintiff contends the ALJ committed error by failing to articulate 

legally sufficient reasons for discrediting his symptom testimony and finding 

him not credible. (Pl’s Mem. at 3-10.) 

 In determining a claimant’s residual functional capacity, the ALJ must 

consider all relevant evidence in the record, including medical records, lay 

evidence, and “the effects of symptoms, including pain, that are reasonably 

attributed to a medically determinable impairment.” See Robbins v. Soc. 

Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006) (citing SSR 96-8p, 1996 WL 

374184, at *5). “Careful consideration must be given to any available 

information about symptoms because subjective descriptions may indicate 

more severe limitations or restrictions than can be shown by objective 

medical evidence alone.” SSR 96-8p, 1996 WL 374184, at *5. An ALJ 

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must provide specific, clear and convincing reasons for rejecting a 

claimant’s testimony about the severity of his symptoms. Treichler v. 

Comm’r, 775 F.3d 1090, 1102 (9th Cir. 2014).3

 Here, the ALJ found Plaintiff’s medically determinable impairments 

could reasonably be expected to cause the alleged symptoms, but 

Plaintiff’s statements concerning the intensity, persistence and limiting 

effects of these symptoms were not entirely credible for the following 

reasons: 

(1) The objective medical evidence did not support the 

Plaintiff’s allegations of a disabling physical impairment or 

combination of impairments and related symptoms; 

(2) Plaintiff experienced improvement with conservative 

treatment; 

(3) Plaintiff’s daily activities were not limited to the extent one 

would expect, given the complaints of disabling symptoms 

and limitations; and 

(4) Plaintiff’s testimony was inconsistent with the medical 

evidence. 

                                                                

3 Plaintiff contends Social Security Ruling (“SSR”) 16-3p applies to this case. (Pl’s Mem. at 4 

& n.3.) Defendant contends it does not because SSR 16-3p became effective on March 28, 

2016, well after the ALJ’s decision. (Def.’s Mem. at 3 n.2.) SSR 16-3p and SSR 96-7p both 

relate to the evaluation of symptoms in disability claims. SSR 16-3p superseded SSR 96-7p 

and removed the term “credibility,” clarifying subjective symptom evaluation is not an 

examination of an individual’s character and an ALJ must instead assess whether the 

claimant’s subjective symptom statements are consistent with the record as a whole. See 

SSR 16-3p, 2016 WL 1119029 (amended at 2016 WL 1237954). Here, the ALJ’s decision was 

issued over two years before SSR 16-3p became effective. Thus, the ALJ could not have 

employed the new SSR, and his decision includes reference to Plaintiff’s “credibility.” In any 

case, because the Court finds the ALJ’s findings pass muster irrespective of which SSR 

governs, the Court need not resolve whether SSR 16-3p retroactively applies. See, e.g., 

Anderson v. Colvin, 2016 WL 7013472, at *10 n.8 (D. Or. Nov. 30, 2016). 

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(Admin. R. at 19-22.) The Court must determine whether the ALJ provided 

clear and convincing reasons to discount Plaintiff’s subjective symptom 

testimony. 

A. Objective Medical Evidence 

The ALJ’s first reason for finding Plaintiff’s pain testimony not 

credible, that the weight of the objective evidence did not support Plaintiff’s 

claims of disabling limitations to the degree alleged (id. at 20), is a clear 

and convincing reason. Although an ALJ may not disregard a claimant=s 

testimony Asolely because it is not substantiated affirmatively by objective 

medical evidence@ (see Robbins, 466 F.3d at 883 [emphasis added]), the 

ALJ may consider whether the alleged symptoms are consistent with the 

medical evidence as one factor in his evaluation. See Lingenfelter v. 

Astrue, 504 F.3d 1028, 1040 (9th Cir. 2007); see also Burch v. Barnhart, 

400 F.3d 676, 681 (9th Cir. 2005) (AAlthough lack of medical evidence 

cannot form the sole basis for discounting pain testimony, it is a factor that 

the ALJ can consider in his credibility analysis.@) 

Here, the ALJ evaluated the medical record, which showed Plaintiff 

had bilateral Achilles tendinosis and tears. (Admin. R. at 20, 197, 293, 

297.) The ALJ reviewed medical examinations and noted Plaintiff 

participated in physical therapy and used a CAM Walker for added comfort 

and protection. Id. at 20, 192, 197, 200, 201, 203, 207. The ALJ reviewed 

early progress notes showing physical therapy and the CAM Walker were 

relatively effective in providing some pain relief. Id. at 20, 203, 209, 211. 

Although Plaintiff worked on weaning himself from using the CAM Walker, 

the record reflects Plaintiff never fully weaned himself off it and appeared at 

the ALJ hearing in the CAM Walker. Id. at 39, 200, 203, 205, 207, 209, 

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213, 246, 333. The ALJ acknowledged the record reflected that Plaintiff 

showed reduced range of motion and some swelling and tenderness, but 

also that Plaintiff’s feet had adequate strength and were neurovascularly 

intact. Id. at 20, 264. The ALJ reviewed other progress notes showing 

Plaintiff had a well-healed incision, intact pulses, minimally decreased 

strength in one foot but full motor strength in his other foot, no palpable 

defects, and only mild tenderness. Id. at 21, 332. 

Plaintiff argues the ALJ did not sufficiently consider treatment notes 

reflecting tenderness on physical examination but fluctuating pain levels, at 

times exacerbated without significant trauma, as well as Plaintiff’s 

nonantalgic gait and shortened stride on the left side and early heel off. 

(Pl’s Mem. at 6-7.) However, these same treatment notes also reflect that 

Plaintiff wore normal shoes, walked with minimal to nonantalgic gait, and 

had a well-healed incision, pulses intact, strength of about 4+/5 compared 

to 5/5 on the contralateral side, no palpable defects, and only mild 

tenderness. (Admin. R. at 332.) The treatment notes also show mild 

puffiness to the retrocalcaneal bursa but no significant edema of the lower 

extremity, mild tightness, and sensation grossly intact. (Id. at 336.) The 

ALJ reasonably found these clinical findings did not support Plaintiff’s 

claims of disabling limitations to the degree alleged. 

The Court finds the ALJ’s determination that the objective medical 

evidence in the record does not support Plaintiff’s allegations of disability is 

clear and convincing. 

B. Plaintiff’s Improvement With Conservative Treatment 

 The ALJ’s second reason for finding Plaintiff’s pain testimony not 

credible, that Plaintiff’s condition improved with conservative treatment, is 

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clear and convincing. Receiving only Aminimal@ and Aconservative@

treatment is a valid reason to discredit a claimant=s symptom testimony. 

Meanel v. Apfel, 172 F.3d 1111, 1114 (9th Cir. 1999). Plaintiff’s treatment 

primarily consisted of physical therapy and a CAM Walker boot. The ALJ 

noted Plaintiff primarily took only ibuprofen and had not alleged any side 

effects from the use of medications. (Admin. R. at 21, 333, 335.) The ALJ 

also noted the advice to Plaintiff to wean off the use of a CAM Walker. Id. 

The ALJ found no indication Plaintiff’s physician recommended permanent 

or long term use of any assistive device and the pattern had been to use a 

CAM Walker for a short period of time and then wean off it. Id. Although 

Plaintiff points to his use of crutches, and infers that crutches are not 

conservative treatment (Pl.’s Mem. at 6), the physician’s suggestion to use 

crutches was part of the conservative approach to step back and use 

assistive devices for only a short period of time (a week or two). (Admin R. 

at 333.) Also, as the ALJ correctly noted, there is no indication Dr. Rosen 

ever recommended permanent or long-term use of any assistive devices. 

Id. The CAM Walker was prescribed for approximately three weeks, and if 

needed, the crutches for one or two weeks only. Id. Although Plaintiff 

underwent surgery, which is generally not considered conservative 

treatment, the surgeries were generally successful in improving Plaintiff’s 

symptoms. Id. at 21. Additionally, treatment notes do not reflect Dr. Rosen 

recommended any further surgeries and Dr. Sitler and Dr. Copp advised 

Plaintiff refrain from undergoing any further surgeries. Id. at 316. 

The ALJ’s finding that Plaintiff’s improvement with conservative 

treatment does not support his allegations of disability is clear and 

convincing. 

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C. Daily Activities 

The ALJ’s third reason for discounting Plaintiff’s pain testimony is that 

Plaintiff’s daily activities were not limited to the extent one would expect 

given Plaintiff’s complaints of disabling symptoms and limitations. Id. at 21. 

It is proper for an ALJ to consider the claimant=s daily activities in making 

his credibility determination. See, e.g., Thomas v. Barnhart, 278 F.3d 947, 

958-59 (9th Cir. 2002); see also 20 C.F.R. '' 404.1529(c)(3)(i), 

416.929(c)(3)(i) (claimant=s daily activities relevant to evaluating 

symptoms). AOne does not need to be >utterly incapacitated= in order to be 

disabled.@ Vertigan v. Halter, 260 F.3d 1044, 1050 (9th Cir. 2001) (citing 

Fair v. Bowen, 885 F.2d 597, 603 (9th Cir. 1989)). A[M]any home activities 

are not easily transferable to what may be the more grueling environment 

of the workplace, where it might be impossible to periodically rest or take 

medication.@ Fair, 885 F.2d at 603. Only if a claimant=s level of activities is 

inconsistent with his claimed limitations would activities of daily living have 

any bearing on the claimant=s credibility. Reddick v. Chater, 157 F.3d 715, 

722 (9th Cir. 1998). 

The ALJ determined Plaintiff’s daily activities did not support his 

allegations of disability because he went to a fair and spent much of the 

day there with only short rest breaks, prepared meals, drove a car, and 

shopped in stores for 35 to 40 minutes. (Admin. R. at 21.) Plaintiff testified 

he drives approximately once a month and although he is able to make 

himself something to eat, he can only stand for ten minutes. (Id. at 34.) 

Plaintiff also testified he used crutches when going out to the store and a 

cane around the house. Id. at 38. Plaintiff also reported going outside 

once a day, folding laundry while sitting, and spending time with others by 

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watching movies, playing board games, and conversing. Id. at 171-73. 

These activities are basic human functions that are not determinative of 

disability. See Vertigan, 260 F.3d at 1050 (“the mere fact that a plaintiff 

has carried on certain daily activities...does not in any way detract from 

[plaintiff’s] credibility as to [plaintiff’s overall disability.”) As for Plaintiff’s trip 

to the fair, this was a one-time only event, and Plaintiff’s taking small rest 

breaks during his visit actually supports his testimony rather than detracting 

from it. In short, Plaintiff’s reported daily activities, mainly staying at home, 

standing for approximately ten minutes at a time, and using assistive 

devices when he leaves the house, do not provide a basis for the ALJ to 

discount Plaintiff’s symptom allegations. Plaintiff’s testimony about his 

daily activities does not necessarily help him establish disability, either, as it 

is not inconsistent with an ability to function in a workplace environment. 

Therefore, this factor weighs neither for nor against the ALJ’s evaluation of 

Plaintiff’s pain testimony. 

D. Inconsistency of Plaintiff’s Testimony With the Medical Evidence 

 The ALJ’s fourth reason for finding Plaintiff’s pain testimony not 

credible, that Plaintiff’s testimony is inconsistent with the medical evidence, 

is clear and convincing. 

The ALJ found by May 2013, after both surgeries, Plaintiff was doing 

well overall, had some pain in his right heel and some swelling in his left 

foot with only occasional burning sensation for which he took ibuprofen, 

which helped. Id. at 20, 335-36. By December 2013, Plaintiff noted 

fluctuating pain after completing physical therapy, but presented in normal 

shoes, walking with a minimal to nonantalgic gait. Id. at 21, 332. The ALJ 

also noted Dr. Rosen found a well-healed incision, intact pulses, minimally 

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decreased strength in one foot but full motor strength in the other, no 

palpable defects, and only mild tenderness. Id. The ALJ found although 

Plaintiff alleged chronic and disabling bilateral foot pain, progress notes 

frequently showed he was in no acute distress on physical examination. Id. 

at 21, 192, 244, 316, 319, 324. The evidence of fluctuating pain, general 

improvement, and the lack of acute distress is inconsistent with Plaintiff’s 

statements of excruciating and disabling pain. Inconsistent statements and 

testimony can bear upon a claimant=s credibility. See, e.g., Verduzco v. 

Apfel, 188 F.3d 1087, 1090 (9th Cir. 1999). The ALJ properly considered 

Plaintiff’s inconsistent statements in discrediting Plaintiff’s symptom 

testimony. 

An ALJ=s assessment of pain severity and claimant credibility is 

entitled to Agreat weight.@ Weetman v. Sullivan, 877 F.2d 20, 22 (9th Cir. 

1989). The Court concludes the ALJ articulated sufficient clear and 

convincing reasons supported by substantial evidence to discount Plaintiff’s 

subjective pain testimony. 

VII. CONCLUSION 

 For the reasons set forth above, Plaintiff’s motion for summary 

judgment should be DENIED and Defendant’s cross-motion for summary 

judgment should be GRANTED. 

 This report and recommendation will be submitted to the Honorable 

Michael M. Anello, pursuant to the provisions of 28 U.S.C. § 636(b)(1). Any 

party may file written objections with the Court and serve a copy on all 

parties on or before June 8, 2017. The document should be captioned 

“Objections to Report and Recommendation.” Any reply to the Objections 

shall be served and filed on or before June 22, 2017. The parties are 

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advised that failure to file objections within the specified time may waive the 

right to appeal the district court’s order. Martinez v. YIst, 951 F.2d 1153 

(9th Cir. 1991). 

DATED: May 18, 2017 

 ___________________ 

 Jan M. Adler 

 U.S. Magistrate Judge 

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