Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-6_04-cv-06066/USCOURTS-arwd-6_04-cv-06066-0/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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However, the ALJ determined that plaintiff had continued to perform substantial 1

gainful activity through March 2002. (Tr. 14). Therefore, he concluded that her earliest

possible onset date was April 1, 2002. (Tr. 14). Records support this determination, as plaintiff

indicated that she worked until March 2002. (Tr. 142, 168). Further, earnings records reveal

that she earned a total of $5565.03 in 2002, earning approximately $1500 per month from

January through March. (Tr. 127, 160).

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

HOT SPRINGS DIVISION

SHARON R. BALL PLAINTIFF

VS. CIVIL NO. 04-6066

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Sharon Ball (“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 denying her application for disability insurance benefits (“DIB”)

under Title II of the Act. 

Background:

The application for DIB now before this court was protectively filed on October 11, 2002,

alleging an onset date of October 18, 2001, due to depression and a herniated lumbar disc. (Tr. 117, 1

133). An administrative hearing was held on August 20, 2003. (Tr. 26-81). Plaintiff was present

and represented by counsel. 

On January28, 2004, the Administrative Law Judge (“ALJ”) issued a written decision finding

that plaintiff’s condition was severe, but did not meet or equal the criteria of any of the impairments

listed in Appendix 1, Subpart P, Regulations No. 4. (Tr. 21). After discrediting plaintiff’s subjective

allegations, the ALJ concluded that she maintained the residual functional capacity (“RFC”), to

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lift/carry twenty pounds occasionally and ten pounds frequently; stand, walk, and sit six hours during

an eight-hour workday; and, occasionally stoop and crouch. (Tr. 21). As her PRW required the

performance of work-related activities precluded by her RFC, with the assistance of a vocational

expert, the ALJ determined that plaintiff could still perform the positions of cafeteria/counter worker

and factory assembly line checkers. (Tr. 22). 

At the time of the hearing, plaintiff was fifty years old, and possessed a high school

education. (Tr. 30, 32). However, she reported taking special education courses in high school. (Tr.

34). The record reveals that she has past relevant work experience (“PRW”) as a dietary aide and

kitchen helper/dishwasher. (Tr. 32-34, 139, 142-144). 

On May 6, 2004, the Appeals Council declined to review this decision. (Tr. 6-8). Plaintiff

then filed an action in this Court. (Doc. # 1). The case is presently before the undersigned by

consent of the parties. The plaintiff and Commissioner have filed appeal briefs, and the case is now

ready for decision. (Doc. # 7, 8). 

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

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

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

and that prevents her from engaging in any substantial gainful activity. Pearsall v. Massanari, 274

F.3d 1211, 1217 (8th Cir.2001); see also 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 her disability, not simply her 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 her claim; (2) whether the claimant has a severe physical and/or mental

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 her age, education, and experience. See 20 C.F.R. § § 404.1520(a)- (f)(2003), 416.920. 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

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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

subjective complaints. In determining whether the ALJ properly disregarded Plaintiff’s subjective

complaints of pain, the Court must determine if the ALJ properly followed the requirements of

Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984) (subsequent history omitted), in evaluating

her pain and credibility. 

The absence of an objective medical basis which supports the degree of severity of

subjective complaints alleged is just one factor to be considered in evaluating the

credibility of the testimony and complaints. The adjudicator must give full

consideration to all of the evidence presented relating to subjective complaints,

including the claimant's prior work record, and observations by third parties and

treating and examining physicians relating to such matters as:

1. the claimant's daily activities;

2. the duration, frequency and intensity of the pain;

3. precipitating and aggravating factors;

4. dosage, effectiveness and side effects of medication;

5. functional restrictions.

The adjudicator is not free to accept or reject the claimant's subjective complaints

solely on the basis of personal observations. Subjective complaints may be

discounted if there are inconsistencies in the evidence as a whole. 

Polaski, 739 F.2d at 1322 (emphasis in original).

However, in addition to the requirement that the ALJ consider the Plaintiff’s allegations of

pain, he also has a statutory duty to assess the credibility of plaintiff and other witnesses. Nelson v.

Sullivan, 966 F.2d 363, 366 (8th Cir. 1992). The ALJ may discredit subjective complaints of pain

inconsistent with the record as a whole. Ownbey v. Shalala, 5 F.3d 342, 344 (8th Cir. 1993).

In the present case, we are particularly concerned with the ALJ’s failure to properly evaluate

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the progress notes of Drs. Edward Saer, III, and McKay Hugentobler. See Reeder v. Apfel, 214 F.3d

984, 988 (8th Cir. 2000) (holding that the ALJ is not free to ignore medical evidence, rather must consider

the whole record). In his opinion, the ALJ indicated that “[s]evere pain will often result in certain

observable manifestations such as loss of weight due to loss of appetite from incessant pain,

muscular atrophydue to muscle guarding, muscular spasms, the issue of assistive devices, prolonged

bed rest, or adverse neurologic signs.” (Tr. 19). He then indicates that there is no such evidence in

the record. However, when discussing plaintiff’s May 6, 2003 visit with Dr. Saer, the ALJ failed to

acknowledge the complete results of that examination. (Tr. 325-326). On this date, plaintiff

complained of lower back, left leg, and left foot pain. (Tr. 325). She also reported some numbness,

tingling, and swelling in the foot. Plaintiff stated that her pain was usually worse in the morning,

worse if she used a computer, and better ifshe sat in a hot tub. On examination, plaintiff was mildly

tender over the left post-iliac crest. (Tr. 326). She reported some pain with side bending to the left,

but did not appear to have any spasm. However, plaintiff did have some atrophy in the right leg, with

proximal leg circumference on the right measuring 2.5 centimeters or less than the left. Her right

ankle reflex was also diminished compared to the left. Further, plaintiff’s sensation was diminished

on the left, in a somewhat nonspecific distribution. Straight-leg-raising maneuvers caused pain

predominately in the left buttock. (Tr. 326). X-rays showed significant disc narrowing at the L3-4

and L4-5. Dr. Saer also noted that past MRI results had revealed some bulging and postlaminectomy changes at the L4-5 on the left, as well as degenerative changes and narrowing at both

the L3-4 and L4-5 levels. As such, he diagnosed her with mild stenosis, documenting no evidence

of recurrent disc herniation. He did, however, indicate that the L4-5 disc could be irritating the nerve

root. Dr. Saer recommend surgical treatment only as a last resort. Instead, he opted to have plaintiff

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The Lis Franc’s joint is a combination of joints in the middle of the foot. At the point

where the long bones behind the toes, called metatarsals, connect with a grouping of

small cube shaped bones, called cunieform bones, there are several joints the move

together in an interlocking fashion. This grouping of interlocking joints is referred to as

the Lis Franc’s joint.

See Brian Carpenter, D.P.M., Midtarsal Fracture Dislocation, at www.podiatrynetwork.com. 

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Lis Franc’s fracture-dislocations can occur in many different ways. It can be caused by

both a direct crushing type injury or a force applied to the metatarsal heads (ball of the

foot) which both can result in displacement of the Lis Franc’s joint or fractures that in

involve the joint. Common causes are motor vehicle accidents, falls from heights, severe

foot and ankle sprains, crushing force to the top of the foot. These injuries can occur

during strenuous and competitive athletic activities.

See Brian Carpenter, D.P.M., Midtarsal Fracture Dislocation, at www.podiatrynetwork.com. 

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undergo treatment via selective nerve root blocks and transforaminal injections. (Tr. 326).

The ALJ also failed to discuss the findings of Dr. Hugentobler. On July 30, 2003, plaintiff

presented at Dr. Hugentobler’s office with complaints of pain in her left foot. (Tr. 318). She stated

that she could not stand for any amount of time, as the pain was severe and radiated up into her

ankle. On examination, Dr. Hugentobler noted severe pain to palpation of the dorsal aspect of the

left foot directly over the third met cuneiform joint. He reported that the pain seemed to be more

diffuse as he worked away from that area. Plaintiff also had pain localized in the area of the third

met cuneiform joint. X-rays revealed some possible changes on the dorsal aspect of the midtarsal

joint, a possible fracture of the Lis Franc’s joint with a fleck fracture, osteoarthritis changes in the 2

third met lateral cuneiform joint, and buckling of the fourth met as it articulated with the lateral

cuneiform. Therefore, Dr. Hugentobler diagnosed plaintiff with a Lis Franc’s fracture with 3

osteoarthritic changes of the third met lateral cuneiform joint, as well as a possible fleck fracture of

the Lis Franc’s joint between the first and second metatarsal. He stated that her condition, even if

it had been caught from the onset, would have required immobilization for six to eight weeks

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followed by follow-up treatment and possible fusion. Because she was experiencing so much pain,

he recommended immobilization, stating that he may also consider open reduction and fixation of

the third met lateral cuneiform joint. However, he advised plaintiff to discuss her treatment options

with her husband. (Tr. 318).

On August 1, 2003, plaintiff had a follow-up appointment with Dr. Hugentobler. (Tr. 317).

She presented with continued severe pain in her left foot. Dr. Hugentobler noted that she had no

previous treatment for her Lis Franc’s disruption. He then stated that he planned to treat her

conservatively for the next six to eight weeks. Dr. Hugentobler placed her into a nonweight bearing

boot cast and prescribed crutches. (Tr. 317). 

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On August 13, 2003, plaintiff stated that her left foot was still hurting quite a bit. (Tr. 317).

She indicated that it hurt when she was sleeping because she slept on her stomach. Although she was

not scheduled to see Dr. Hugentobler again for about six weeks, due to severe pain, she made an

appointment. He advised plaintiff to sleep on her stomach, but to leave her feet hanging off of the

bed. As she also reported a shooting pain out of the top of her left foot, Dr. Hugentobler suspected

that the dorsal cutaneous nerves were inflamed and irritated. Therefore, he gave her an injection of

Depo Medrol and Xylocaine. (Tr. 317). 

After reviewing this evidence, it is clear that these medical records should have been

considered by the ALJ. “A treating physician’s opinion should not ordinarily be disregarded and is

entitled to substantial weight.” Singh v. Apfel, 222 F.3d 448, 452 (8th Cir. 2000). If a treating

physician’s opinion is well-supported by medically acceptable clinical and laboratory diagnostic

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techniques and is not inconsistent with the other substantial evidence in the record, the opinion

should be given controlling weight.” Id. Clearly, the treatment notes from Drs. Saer and Hugentobler

were not contradicted by any other evidence contained in the file, and were supported by medically

acceptable evidence. Further, contrary to the ALJ’s conclusions, the evidence does indicate that

plaintiff had atrophy in her right leg; was placed in an immobilizer boot; and, was prescribed

crutches, all factors considered by the ALJ to be indicative of severe and possibly disabling pain.

Accordingly, we do not find substantial evidence to support the ALJ’s decision, and believe that

remand is necessary to allow the ALJ to reconsider plaintiff’s subjective complaints in conjunction

with a thorough reassessment of the medical evidence. 

Also of significance is the fact that the record does not contain an RFC assessment from any

of plaintiff’s healthcare providers. See Vaughn v. Heckler, 741 F.2d 177, 179 (8th Cir. 1984.) (If a

treating physician has not issued an opinion which can be adequately related to the disability

standard, the ALJ is obligated to address a precise inquiry to the physician so as to clarify the record).

Instead, the ALJ relied on relied on the RFC assessment of a non-examining, medical consultant,

who concluded that plaintiff could perform medium level work involving only occasional stooping

and crouching. (Tr. 307-315). We note, that the opinion of a consulting physician who examined

the plaintiff once or not at all does not generally constitute substantial evidence. See Jenkins v. Apfel,

196 F.3d 922, 925 (8th Cir. 1999). Therefore, we believe that remand is also necessary to allow for

further development of the record concerning plaintiff’s RFC. 

On remand, the ALJ is directed to address interrogatories to the physicians or counselors who

have evaluated and/or treated plaintiff, asking the physicians to review plaintiff’s medical records and

complete an RFC assessment regarding plaintiff’s capabilities during the time period in question. The

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physicians should also be asked to provide the objective basis for their opinions, so that an informed

decision can be made regarding plaintiff’s ability to perform basic work activities on a sustained basis

during the relevant time period in question. Chitwood v. Bowen, 788 F.2d 1376, 1378 n.1 (8th Cir.

1986); Dozier v. Heckler, 754 F.2d 274, 276 (8th Cir. 1985). 

In addition, the ALJ improperly concluded that plaintiff did not suffer from a severe mental

impairment. “A majority of the Supreme Court has adopted what has been referred to as a ‘de

minimis standard’ with regard to the step two severity standard.” Hudson v. Bowen, 870 F.2d 1392,

1395 (8th Cir. 1989); Funderburg v. Bowen, 666 F.Supp. 1291 (W.D. Ark. 1987). Accordingly, an

ALJ may consider an impairment to be non-severe only if a claimant’s medical impairments are so

slight that it is unlikely he or she would be found to be disabled even if their age, education, and

work experience were taken into account. See Bowen v. Yuckert, 482 U.S. 137, 153 (1987). “Only

those claimants with slight abnormalities that do not significantly limit any ‘basic work activity’ can

be denied benefits without undertaking the vocational analysis.” Bowen, 482 U.S. at 158.

During a mental evaluation, testing revealed that plaintiff functioned in the borderline to

below average ranges, with the exception of average reading comprehension skills. (Tr. 319). The

examiner also concluded that plaintiff’s academic skills and depressive features could manifest in

a vocational setting in the following ways: susceptibility to mistakes in written task performance,

possible difficulty learning complex tasks, difficulty maintaining adequate production level if more

than simple academic skills are required, difficulty with advanced computation or mathematics,

difficulty with spelling tasks, depression may impact job performance, may have difficulty avoiding

distractions, possible difficulty assessing consequences of decision alternatives, possible difficulty

concentrating on work task, emotional intensity may impact task performance, and conflicts may

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affect adequate task performance. (Tr. 321). Due to her reports of suicidal ideations and inability

to pay for treatment, prompt referral to the local mental health center was strongly advised. (Tr.

322). Accordingly, on remand, we believe that the ALJ should re-evaluate plaintiff’s mental

impairment.

Conclusion:

Based on the foregoing, we reverse the decision of the ALJ and remand this case to the

Commissioner for further consideration pursuant to sentence four of 42 U.S.C. § 405(g). 

ENTERED this 30th day of August 2005.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

UNITED STATES MAGISTRATE JUDGE 

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