UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF INDIANA 

SOUTH BEND DIVISION 

TRACY MCLEAN, ) 

 ) 

 Plaintiff, ) 

 ) 

 v. ) CAUSE NO. 3:14-CV-00008-CAN 

 ) 

 ) 

CAROLYN W. COLVIN, ) 

Acting Commissioner of Social Security, ) 

 ) 

 Defendant. ) 

OPINION AND ORDER 

 On January 3, 2014, Plaintiff, Tracy McLean (“McLean”) filed her complaint in this 

Court. On May 29, 2014, McLean filed her opening brief requesting that this Court reverse and 

remand this matter to the Commissioner for further reconsideration, including a new hearing and 

decision, consistent with the principles outlined in her brief. On September 4, 2014, Defendant, 

Commissioner of Social Security, Carolyn W. Colvin (“Commissioner”), filed her response 

brief. McLean did not file a reply. The Court may enter a ruling in this matter based on the 

parties consent, 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g). 

I. PROCEDURE 

On March 2, 2011, McLean filed an application for Supplemental Security Income 

(“SSI”) and Disability Insurance Benefits (“DIB”) alleging a disability due to back pain and 

diabetes mellitus with peripheral neuropathy beginning May 27, 2010. Her claims were denied 

initially on May 31, 2011, and also upon reconsideration on July 12, 2011. McLean appeared at a 

hearing before an Administrative Law Judge (“ALJ”) on August 28, 2012. 
2 

 On September 11, 2012, the ALJ issued a decision holding that McLean was not disabled 

under section 1614(a)(3)(A) of the Social Security Act. The ALJ also found that McLean met the 

insured status requirements of the Social Security Act through June 30, 2011. In addition, the 

ALJ found that McLean had not engaged in substantial gainful activity since May 27, 2010, and 

that her status post bilateral carpal tunnel release, degenerative disc disease of the cervical spine, 

degenerative joint disease of the left shoulder, diabetes mellitus with peripheral neuropathy, and 

obesity constituted severe impairments. However, the ALJ found that McLean did not have an 

impairment of combination of impairments that met or medically equaled one of the listed 

impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ found that McLean retained 

the residual functional capacity (“RFC”) to perform less than the full range of light work as 

defined in 20 C.F.R. 404.1567(b) and 416.967(b). The ALJ found McLean could lift or carry and 

push or pull up to ten pounds frequently and twenty pounds occasionally; sit, stand, or walk for a 

total of about six hours in an eight-hour workday; never climb ladders, ropes, or scaffolds; crawl 

or kneel, and occasionally climb ramps, stairs, balance, stoop, and crouch. The ALJ further found 

that McLean could occasionally use foot controls with her lower extremities and she must avoid 

concentrated exposure to work hazards such as dangerous moving machinery and unprotected 

heights. The ALJ then found that McLean is capable of performing past relevant work in 

assembly and in packing. 

 On November 4, 2013, the Appeals Council denied review of the ALJ’s decision making 

it the Commissioner’s final decision. See Fast v. Barnhart, 397 F.3d 468, 470 (7th Cir. 2005); 20 

C.F.R. § 404.981. On January 3, 2014, McLean filed a complaint in this Court seeking a review 

of the ALJ’s decision. 
3 

II. ANALYSIS 

A. Facts 

 McLean was a fifty-four year old female at the time the ALJ denied her claims. She has 

an eighth grade education and has obtained her GED. She reported past relevant work as a sewer, 

assembler, and packer. 

 1. Claimant’s Hearing Testimony 

 At the hearing, McLean testified that she suffered from back pain and diabetes mellitus 

with peripheral neuropathy. McLean testified that she experiences constant numbness and 

tingling in her extremities. She testified that since her onset date May 27, 2010, she endured 

blurred vision as a result of cataracts surgery, difficulty remembering things, back pain due to 

degenerative disc disease, diabetes with neuropathy, thyroid issues, and gout, all of which 

prevented her from working. McLean also indicated she was able to take care of her personal 

needs and drive to the store on occasion where she would use an electric cart. She testified that 

she attended church three times weekly and would occasionally go to dinner with her husband or 

friends. 

McLean also testified that her typical day included performing minor household chores, 

watching television, and reading. She explained that her light household work included cooking 

easy meals, dishes, putting laundry in the dryer, dusting, and straightening up the home. McLean 

testified that pain, tingling in her hands and feet, and neuropathy prevented her from completing 

tasks such as vacuuming, mowing, and caring for her disabled grandchild when she visited. 

McLean testified that she could sit for approximately an hour, but found it necessary to prop her 

feet up due to swelling. McLean testified she could walk for approximately a few feet and stand 
4 

with the use of a cane for a short period. In addition, McLean believed she could lift a gallon of 

milk. 

As to her treatment, McLean testified that she regularly experienced pain in her back and 

took prescription medication, including insulin shots, and muscle relaxers for her pain, diabetes, 

neuropathy, thyroid, cholesterol, and high blood pressure. She reported various side effects from 

her medications that included drowsiness, dizziness, lightheadedness, forgetfulness, dry mouth, 

diarrhea, and swelling in her legs and feet. McLean testified that even with her treatments and 

medications, her condition has worsened. 

 2. Relevant Medical Evidence 

 On January 20, 2010, McLean saw neurologist, Dr. Nasar Katariwala, who conducted an 

EMG/NCV for the evaluation of bilateral hand numbness and tingling. The results showed 

bilateral neuropathy in the upper extremities, more prevalent on her right side than her left. Dr. 

Katariwala noted that because McLean had more than a fifteen year history of insulin dependent 

diabetes mellitus, it was unclear whether the bilateral neuropathy was a result of the diabetes or 

whether it was related to carpal tunnel syndrome, indicated by prominent involvement of the 

median nerves. In February 2010, McLean underwent a right carpal tunnel release surgery by Dr. 

William Biehl, which provided complete relief in her right hand numbness. However, McLean’s 

hand numbness returned one day prior to her follow up appointment with Dr. Katariwala on 

March 18, 2010. Dr. Katariwala reiterated the recurrence of McLean’s hand numbness could be 

the result of either diabetes or carpal tunnel syndrome. In April 2010, Dr. Biehl performed a 

second carpal tunnel release surgery on McLean’s left side. Dr. Biehl observed that McLean had 

a full range of motion the following month, but noted that McLean’s sensation may not improve 

to normal despite the successful surgery because of her diabetes. 
5 

 On October 14, 2010, McLean saw Dr. Thomas Ryan, D.O., for a new patient evaluation.

During that visit, McLean presented complaints of upper back pain behind her left shoulder. 

McLean stated her pain level for that day was a zero out of ten, with ten being the worst level of 

pain. She stated that when she did experience pain, it was typically a ten out of ten. Dr. Ryan 

observed that McLean had tenderness, mild spasms, and a slightly reduced range of motion in 

her neck. Dr. Ryan noted that McLean had a decreased range of motion and pain with certain 

maneuvers in her left shoulder, but no specific weakness with rotator cuff testing. Dr. Ryan 

performed a left shoulder x-ray, which revealed some degenerative joint disease, but no 

significant abnormalities. Dr. Ryan diagnosed McLean with impingement syndrome of her left 

rotator cuff and a herniated disc in her cervical spine. 

On April 11, 2011, McLean was examined by consulting physician, Dr. Ralph Inabnit 

who noted McLean’s complaints of burning in her hands that she believed to be neuropathy. 

McLean also reported to Dr. Inabnit that she could lift a gallon of milk and had severe left 

shoulder and left scapular pain, which she rated at a nine out of ten. Dr. Inabnit stated that 

McLean’s symptoms may be related to her previous carpal tunnel syndrome. In addition, 

McLean informed Dr. Inabnit that she had recently begun using a cane to assist with her 

unsteadiness. Dr. Inabnit observed that McLean had slightly reduced grip strength and a mildly 

reduced range of motion in her cervical spine. He further noted that McLean had no edema or 

significant weakness in her feet. During the exam, McLean could also heel-toe walk and walk 

without her cane. Furthermore, McLean’s neurological exam was normal, including normal 

sensation and reflexes. Dr. Inabnit recommended that McLean undergo blood tests, attend a 

dietary consultation, and begin exercising for her diabetes. Dr. Inabnit further suggested that 

McLean obtain a left shoulder and left scapula x-ray and get a trigger point injection to possibly 
6 

relieve her left scapula pain. Dr. Inabnit did not opine as to any functional work limitations 

McLean might have, but did indicate that McLean’s neuropathy symptoms were intermittent and 

related to her blood sugar control. 

 On May 17, 2011, state agency reviewing physician Dr. A. Dobson, completed a physical 

residual functional capacity assessment of McLean. Dr. Dobson reported no postural, 

manipulation, visual, communicative, or environmental limitations. Dr. Dobson further opined 

that McLean could occasionally lift or carry fifty pounds, frequently lift or carry twenty-five 

pounds, stand or walk for a total of about six hours, and sit for a total of about six hours. 

Ultimately, Dr. Dobson noted that McLean’s alleged symptoms were partially credible, but her 

contentions about the severity and the related functional restrictions were not supported. 

On May 24, 2011, McLean’s primary care physician, Dr. Vidya Kora, wrote a letter 

indicating he had advised McLean to use a cane due to her ataxia.1

 Dr. Kora attributed McLean’s 

ataxia to her severe diabetic peripheral neuropathy and degenerative joint disease. On June 23, 

2011, McLean met with Dr. Kora again and complained of severe pain in her neck and cervical 

and thoracic spine. McLean also complained of significant ataxia. Dr. Kora did not observe any 

edema in McLean’s extremities and reported that a neurological evaluation had revealed no focal 

deficits. Dr. Kora instructed McLean to follow up with Dr. Hesham Bazaraa, an endocrinologist, 

and again advised McLean to use a cane due to her ataxia. 

On September 6, 2011, McLean returned to Dr. Bazaraa for an evaluation of her diabetes. 

After reviewing McLean’s symptoms, Dr. Bazaraa reported lower extremity edema, difficulty 

walking, and shortness of breath. Dr. Bazaraa’s notes reflect McLean’s complaints of numbness 

in her hands and feet, difficulty with balance, and her use of a cane. Dr. Bazaraa also noted 

 

1

 Ataxia is “[a]n inability to coordinate muscle activity during voluntary movement”; incoordination. Stedman’s 

Medical Dictionary (27th ed. 2000). 
7 

McLean’s complaints of feeling “dopey” on medication. Doc. No. 12 at 522. He instructed her 

to follow up with her primary treating physician for her shortness of breath and ordered several 

blood and urine tests 

On September 23, 2011, McLean saw Dr. Kora and presented complaints of persistent 

pain in the right thigh area. McLean also complained of diabetic peripheral neuropathy and 

occasional chest discomfort. Dr. Kora noted significant changes of diabetic peripheral 

neuropathy in the extremities, but no focal deficits were noted on a neurological examination. 

Dr. Kora adjusted McLean’s insulin, referred her to Dr. Rosen for bariatric surgery, and referred 

her to Dr. Fletcher for a cardiac evaluation prior to surgery. Further, Dr. Kora referred McLean 

to Dr. Katariwala for the evaluation and management of her severe diabetic peripheral 

neuropathy. 

One week later, on September 30, 2011, McLean saw Dr. Katariwala and complained of 

right lower and left upper extremity numbness. Dr. Katariwala noted that McLean had previously 

been diagnosed with neuropathy in both of her upper extremities. He also noted that McLean’s 

lower extremities were not subject to the previous EMG testing, but that her current symptoms 

were similar to those that led to the previous neuropathy diagnosis. Dr. Kora reported his 

examination of McLean revealed subjective complaints and indicated that McLean had distal 

upper extremity numbness and tingling along with lower extremity numbness. McLean was 

given a sample of the prescription medication Lyrica and diagnosed with “likely diabetic 

polyneuropathy.” Doc. No. 12 at 526. 

On October 12, 2011, McLean saw Dr. Kindra Fletcher, Jr. for a cardiovascular 

evaluation prior to her bariatric surgery. Dr. Fletcher noted that McLean believed she would be 

able to completely come off insulin with the surgery. Dr. Fletcher reported mild obesity in the 
8 

abdomen and no edema in the extremities. Dr. Fletcher did not recommend McLean for bariatric 

surgery, but did suggest a “lifestyle change” with a low-sodium low-cholesterol, and lowtriglyceride diet. Doc. No. 12 at 547. 

On October 11, 2011, McLean saw Dr. Kora with complaints of pain in the right foot. 

Dr. Kora noted some redness and swelling in the medial aspect of McLean’s great right toe. Dr. 

Kora reported no focal deficits in McLean’s neurological examination. Dr. Kora requested that 

McLean see Dr. Biehl for an orthopedic evaluation of her foot and that she follow up in 

approximately one month. 

On December 6, 2011, McLean saw Dr. Bazaraa with complaints of uncontrolled 

diabetes, gout, and uncontrolled blood pressure. McLean requested a cortisone injection. Dr. 

Bazaraa indicated McLean’s physical examination was normal. Dr. Bazaraa adjusted her insulin 

and ordered laboratory tests. Three days later, on December 9, 2012, McLean saw Dr. Kora and 

presented complaints of pain in her left shoulder, left side of her chest, and left shoulder blade. 

Dr. Kora observed no edema in the extremities, but noted changes of diabetic peripheral 

neuropathy. Dr. Kora ordered a bone scan and scheduled a follow up appointment with McLean 

in one week. 

On January 10, 2012, Dr. Kora completed a medical source statement of McLean’s 

ability to do work-related activities. Dr. Kora found that McLean could occasionally lift or carry 

less than ten pounds, frequently lift or carry less than ten pounds, stand or walk at least two hours 

in an eight-hour workday, sit for less than six hours in an eight hour workday, and had 

unspecified limitations on her ability to push and pull with her upper and lower extremities. Dr. 

Kora noted “severe diabetic neuropathy, does not have feeling, and has ataxia, loses balance” as 

support for his conclusions. Doc. No. 12 at 528. Further, Dr. Kora found that McLean could 
9 

never perform postural activities and could only occasionally perform reaching, handling, 

fingering, and feeling. Dr. Kora also checked the “limited” category for all environmental 

limitations to show that McLean’s impairments limited her tolerance of the seven listed 

environmental factors. Doc. No. 12 at 532. Dr. Kora cited “severe diabetic neuropathy” as 

support for his conclusion. Id. 

 B. Standard of Review 

In reviewing disability decisions of the Commissioner, the Court shall affirm the ALJ’s 

decision if it is supported by substantial evidence and free of legal error. See 42 U.S.C. 405(g) 

(2006); Briscoe v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005); Haynes v. Barnhart, 416 F.3d 

621, 626 (7th Cir. 2005); Golembiewski v. Barnhart, 322 F.3d 912, 915 (7th Cir. 2003). 

“Substantial evidence” is more than a mere scintilla of relevant evidence that a reasonable mind 

might accept to support such a conclusion. Richardson v. Perales, 402 U.S. 389, 401 (1971). To 

determine whether substantial evidence supports the Commissioner’s final decision, a Court 

reviews the whole record including evidence that detracts from the Commissioner’s findings in 

the decision. Arkansas v. Oklahoma, 503 U.S. 91, 113 (1992); Universal Camera Corp. v. NLRB, 

340 U.S. 474, 477-88 (1951). A reviewing court is not to substitute its own opinion for that of 

the ALJ’s or to re-weigh the evidence, but the ALJ must build a logical bridge from the evidence 

to his conclusion. Haynes, 416 F.3d at 626. An ALJ’s decision cannot stand if it lacks 

evidentiary support or an adequate discussion of the issues. Lopez v. Barnhart, 336 F.3d 535, 539 

(7th Cir. 2003). However, ALJ need not provide a “complete written evaluation of every piece of 

testimony and evidence.” Rice v. Barnhart, 384 F.3d 363, 370 (7th Cir. 2004) (quoting Diaz v. 

Chater, 55 F.3d 300, 308 (7th Cir. 1995)). An ALJ’s legal conclusions are reviewed de novo. 

Haynes, 416 F.3d at 626. 
10 

To be entitled to supplemental security income under 42 U.S.C. § 1381a, McLean must 

establish that she is disabled. See 42 U.S.C. § 423(a)(1)(D). The Social Security Act defines a 

disability as the “inability to engage in any substantial gainful activity by reason of any 

medically determinable physical or mental impairment which can be expected to result in death 

or which has lasted or can be expected to last for a continuous period of not less than 12 

months.” 42 U.S.C. § 423(d)(1)(A). The Social Security regulations prescribe a sequential fivepart test for determining whether a claimant is disabled. The ALJ must consider whether: (1) the 

claimant is presently employed; (2) the claimant’s impairment or combination of impairments is 

severe; (3) the claimant’s impairment meets or equals any impairment listed in the regulations 

and therefore is deemed so severe as to preclude substantial gainful activity; (4) the claimant is 

able to perform her past relevant work given her RFC; and (5) the claimant can adjust to other 

work in light of her RFC. 20 C.F.R. §§ 404.1520(a)(4)(i)-(v), 416.920(a)(4)(i)-(v);2 Young v. 

Barnhart, 362 F.3d 995, 1000 (7th Cir. 2004). If the ALJ finds that the claimant is disabled or 

not disabled at any step, he may make his determination without evaluating the remaining steps. 

20 C.F.R. § 404.1520(a)(4). An affirmative answer at either step three or step five establishes a 

finding of disability. Briscoe, 425 F.3d at 352. At step three, if the impairment meets any of the 

severe impairments listed in the regulations, the Commissioner acknowledges the impairment 

and finds the claimant to be disabled. See 20 C.F.R. § 404.1520(a)(4)(iii); 20 C.F.R. App. 1, 

Subpart P, § 404. However, if the impairment is not listed, the ALJ assess the claimant’s RFC, 

which is then used to determine whether the claimant can perform her past work under step four 

and whether the claimant can perform other work in society under step five. 20 C.F.R. 

 

2

 Due to the identical thrust of the regulations covering DIB and SSI, the Court will simply refer to 20 C.F.R. § 404 

in the future. 
11 

404.1520(e)-(g). The claimant bears the burden of proof on steps one through four, but the 

burden shifts to the Commissioner at step five. Young, 362 F.3d at 1000. 

 C. Issues for Review 

 In this case, McLean raises three issues that the Court must resolve. First, the Court must 

determine whether the ALJ’s RFC determination is supported by substantial evidence. 

Specifically, McLean argues the ALJ erred in according little weight to the January 2012 opinion 

of her treating physician, Dr. Vidya Kora. Second, the Court must ascertain whether the ALJ’s 

credibility assessment is supported by substantial evidence. Third, the Court must consider 

whether the ALJ erred in his Step Five determination. 

1. The ALJ properly weighed Dr. Kora’s medical opinion evidence in 

assessing McLean’s RFC. 

An individual’s RFC demonstrates her ability to do physical and mental work activities 

on a sustained basis despite functional limitations caused by any medically determinable 

impairment(s) and their symptoms, including pain. 20 C.F.R. § 404.1545; SSR 96-8p 1996. In 

making a proper RFC determination, the ALJ must consider all of the relevant evidence in the 

case record. 20 C.F.R. § 404.1545. The record may include medical signs, diagnostic findings, 

the claimant’s statements about the severity and limitations of symptoms, statements and other 

information provided by treating or examining physicians and psychologists, third party witness 

reports, and any other relevant evidence. SSR 96-7p 1996. “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. However, it is the claimant’s responsibility to provide medical evidence showing how her 

impairments affect her functioning. 20 C.F.R. § 404.1521(c). Therefore, when the record does 

not support specific physical or mental limitations or restrictions on a claimant’s work-related 
12 

activity, the ALJ must find that the claimant has no related functional limitations. See SSR 96-

8p. 

 McLean seeks a remand for further consideration of the medical opinion of her treating 

physician, Dr. Vidya Kora. She contends the ALJ improperly evaluated the opinion of Dr. Kora 

and erred by assigning little weight to his opinion. She also alleges the ALJ erred in finding Dr. 

Kora’s opinion inconsistent with the record. 

 In determining the proper weight to accord medical opinions, the ALJ must consider 

factors including the claimant’s examining and treatment relationship with the source of the 

opinion; the physician’s specialty; the support provided for the medical opinion; and its 

consistency with the record as a whole. 20 C.F.R. § 404.1527(d)(1)-(6); Larson v. Astrue, 615 

F.3d 744, 751 (7th Cir. 2010). A “treating source” is a medical professional who provides 

medical treatment or evaluation to the claimant and has or had an ongoing relationship with the 

claimant. 20 C.F.R. § 404.1502. An ongoing relationship exists when the medical record shows 

that the claimant saw the source frequently enough to be consistent with accepted medical 

practices for the treatment of the medical condition. Id. 

 An ALJ must give a treating physician’s opinion controlling weight if it is well supported 

by medically acceptable clinical and laboratory diagnostic techniques and if it is consistent with 

other substantial evidence in the record. Hofslien v. Barnhart, 439 F.3d 375, 376 (7th Cir. 2006); 

Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000); 20 C.F.R. § 404.1527(d)(2); SSR 96-8p; 

SSR 96-2p. Generally, ALJs weigh the opinions of a treating source more heavily because he is 

more familiar with the claimant’s conditions and circumstances. Clifford, 227 F.3d at 870; 20 

C.F.R. §§ 404.1527(d)(2), 416.927(d)(2). However, a claimant is not entitled to benefits merely 

because a treating physician labels her as disabled. Dixon v. Massanari, 270 F.3d 1171, 1177 
13 

(7th Cir. 2001). A medical opinion may be discounted if it is internally inconsistent or 

inconsistent with other substantial evidence in the record. Clifford, 227 F.3d at 870. While the 

ALJ is not required to award a treating physician controlling weight, the ALJ must articulate, at a 

minimum, his reasoning for not doing so. Hofslien, 439 F.3d at 376-77; see 20 C.F.R. § 

416.927(c)(2). Although the ALJ is required to consider and discuss a treating physician’s 

opinion, the ALJ is not bound by conclusory statements of doctors or medical opinions that are 

unsupported or inconsistent with substantial evidence in the record. See Powers v. Apfel, 207 

F.3d 431, 435 (7th Cir. 2000). The ALJ’s reasoning should be based on the relevant factors 

applied to all medical opinions as stated above. See 20 C.F.R. § 404.1527(d)(2)-(6). 

 In this case, the ALJ accorded little weight to Dr. Kora’s opinion because he found 

inconsistencies between Dr. Kora’s assessment of McLean’s ability to do work-related activities 

and the report of the medical consultative examiner, Dr. Inabnit, who opined McLean’s 

“symptoms related to neuropathy were likely intermittent.” Doc. No. 17 at 7. McLean argues that 

the ALJ’s conclusion was based on an improper evaluation of Dr. Kora’s January 2012 medical 

source statement (“Kora’s 2012 Opinion”), which indicated that McLean could lift less than ten 

pounds, frequently and occasionally; stand or walk for at least two hours in an eight-hour 

workday; sit for less than six hours in an eight-hour workday; and was limited in her abilities to 

push or pull with both upper and lower extremities. McLean supports her contention by citing 

several instances throughout the record where McLean had reported problems related to her 

diabetic neuropathy. McLean’s arguments are misplaced. 

 First, the ALJ articulated that Dr. Kora was McLean’s treating physician. Doc. No. 12 at 

29. Second, the ALJ reviewed and discussed the treatment notes of several doctors, including Dr. 

Kora and the consultative medical examiner, Dr. Inabnit, in considering whether Dr. Kora’s 
14 

opinion was entitled to controlling weight. As seen in his decision, the ALJ considered Dr. 

Kora’s 2012 Opinion describing limitations on McLean’s ability to do work-related activities, as 

described above. The ALJ also cited to Dr. Kora’s opinion that McLean was limited in her use of 

her upper and lower extremities, was unable to engage in any posturals, and could only 

occasionally reach, handle, finger, and feel. In giving this opinion little weight, the ALJ noted 

Dr. Kora’s inconsistency with the evidence of record. The ALJ referenced the treatment notes of 

Drs. Inabnit, Katariwala, and Bazaraa, which failed to place similar limitations on McLean. 

 McLean contends that Dr. Kora’s 2012 Opinion was impermissibly discounted. 

Specifically, McLean argues that the ALJ incorrectly gave great weight to the consultative 

medical examiner, Dr. Inabnit, and incorrectly found McLean’s neurological examinations to be 

generally normal. McLean asserts that because Dr. Kora was her treating physician and treated 

McLean on a regular basis as compared to McLean’s single visit to Dr. Inabnit, his opinion 

should be given more weight. “Greater weight is assigned the more times the treating source has 

examined the claimant and the more knowledge the treating source has regarding the claimant’s 

conditions.” Harder v. Astrue, No. 2:11-cv-00370, 2013 U.S. Dist. LEXIS 4981 at *45 (N.D. 

Ind. Jan. 11, 2013). A one-time examination should be afforded less weight when it is 

contradictory to the other evidence of record. Criner v. Barnhart, 208 F. Supp. 2d, 937, 955 

(N.D. Ill. 2002). 

 In discounting the opinion of Dr. Kora, the ALJ articulated inconsistencies between the 

opinion of Dr. Kora and the record. In doing so, the ALJ highlighted Dr. Inabnit’s opinion which 

stated that McLean’s direct strength testing revealed no significant weakness in her foot, no 

edema, normal sensation, normal tandem heel-toe walk, and the ability to ambulate without a 

cane. The ALJ then noted that Dr. Inabnit did not identify any functional work limitations 
15 

McLean might have. Further, the ALJ considered the opinion of McLean’s treating neurologist, 

Dr. Katariwala, who did not place any limitations on McLean’s functioning. In addition, the ALJ 

considered the opinion of Dr. Bazaraa, McLean’s endocrinologist, who also did not place any 

functional limitations on McLean. Therefore, the ALJ’s reference to the conflicting opinions of 

Drs. Kora, Inabnit, Katariwala, and Bazaraa support his determination that Dr. Kora is entitled to 

little weight. Even so, after giving great weight to the opinion of Dr. Inabnit, the ALJ considered 

other evidence in the record including McLean’s diagnostic testing, some of her positive physical 

examination findings, her treatment with some specialists, her regular treatment with Dr. Kora, 

and her complaints of medication side effects. Based on all the evidence, the ALJ found it more 

appropriate to limit McLean to less than the full range of light work. Doc. No. 12 at 10. In 

reaching this conclusion the ALJ did not ignore Dr. Kora’s opinion. Moreover, he articulated his 

rationale for the weight he gave to Kora’s opinion. 

Nevertheless, McLean’s argument does not stop there. She also argues the ALJ 

incorrectly found McLean’s neurological examinations were generally normal. McLean 

challenges the ALJ’s determination that her neurological examinations were normal by pointing 

to several instances in the record where McLean’s physicians opined differently. Specifically, 

McLean references the March 18, 2010, opinion of Dr. Katariwala, which noted it was unclear 

whether McLean’s condition was solely related to carpal tunnel syndrome or if underlying 

neuropathy had remitted before returning. McLean further highlights the May 3, 2010, opinion of 

Dr. Biehl, which stated McLean had slight decreased sensation in her median nerve distribution 

that he felt was consistent with McLean having diabetic neuropathy. McLean also references the 

September 30, 2011, treatment notes of Dr. Katariwala, who reported that McLean had 

previously been diagnosed with bilateral upper extremity neuropathy and that her current 
16 

symptoms related to her lower extremities were similar to those she exhibited when her upper 

extremities were tested. McLean also noted the December 9, 2011, opinion of Dr. Kora reporting 

changes of diabetic neuropathy. While McLean contends the ALJ erred in his determination that 

McLean presented generally normal neurological examinations, the ALJ’s decision highlights 

evidence in the record suggesting otherwise. 

In support of his conclusion that McLean had generally normal neurological 

examinations, the ALJ highlighted the opinions of Dr. Kora and Dr. Inabnit. The ALJ references 

several of Dr. Kora’s treatment notes including those dated December 15, 2010, June 23, 2011, 

September 23, 2011, and October, 11, 2011, which all stated that no focal deficits were noted on 

neurological exam. The ALJ then highlighted the April 11, 2011, opinion of Dr. Inabnit, which 

stated that McLean’s neurological exam revealed no focal deficits and no evidence of trauma, 

defects, or tenderness. The ALJ also noted several instances in the record where McLean’s 

treating physicians opined normal neurological exams. As such, the ALJ supported his 

conclusion that McLean’s neurological examinations were generally normal with substantial 

evidence. 

Thus, having discussed inconsistencies between Dr. Kora’s findings on his medical 

source statement of McLean’s ability to do work-related activities and reviewing the opinions of 

three other physicians, all of whom failed to find similar limitations on McLean, the ALJ met his 

burden to explain why Dr. Kora’s opinion was entitled to little weight. In addition, the ALJ 

supported his determination that McLean generally had normal neurological examinations by 

reviewing the treatment notes of several doctors. Therefore, the ALJ’s RFC determination is 

supported with substantial evidence and need not be disturbed. 

 
17 

 2. The ALJ’s credibility determination is supported by substantial evidence. 

McLean’s second argument challenges the ALJ’s credibility assessment. Specifically, 

McLean contends the ALJ failed to support his credibility assessment with substantial evidence 

because the ALJ erred in considering the required factors. Once an ALJ has found an underlying 

medically determinable impairment that could reasonably be expected to produce a claimant’s 

pain and other symptoms, he is required to evaluate the intensity and persistence of the 

symptoms. See 20 C.F.R. § 404.1529(c). “An ALJ is in the best position to determine a witness’s 

truthfulness and forthrightness; thus, this court will not overturn an ALJ’s credibility 

determination unless it is ‘patently wrong.’” Skarbek v. Barnhardt, 390 F.3d 500, 505 (7th Cir. 

2004). 

McLean argues the ALJ erred in his credibility assessment for four reasons. First, 

McLean contends that the ALJ’s discussion and consideration of McLean’s symptoms of pain 

and numbness were incorrectly accounted for in the RFC determination because Dr. Kora’s 

opinion suggests McLean’s work-related limitations exceed those reflected in the RFC. Second, 

McLean challenges the ALJ’s finding that McLean’s lack of edema justified the decision to omit 

any restriction requiring her to elevate her feet while in a seated position. Third, McLean argues 

that the ALJ relied too heavily on McLean’s reported zero out of ten pain level because she only 

reported no pain once. Fourth, McLean disagree with the ALJ’s decision to exclude a restriction 

in the RFC relating to McLean’s alleged need to use a cane when ambulating based on Dr. 

Kora’s opinion to the contrary. Despite McLean’s arguments, the Court finds that the ALJ’s 

credibility determination was not patently wrong and therefore is supported by substantial 

evidence. 
18 

In his decision, the ALJ discussed a variety of factors in making his credibility 

determination. Specifically, the ALJ reviewed McLean’s subjective statements, her various 

medical treatments and physician’s notes, as well as statements made by her family members as 

to the nature and intensity of her pain. On review of McLean’s subjective statements, the ALJ 

discussed her reports of pain, numbness, tingling, swelling, loss of balance, and need for a cane. 

The ALJ acknowledged McLean’s complaints and took each into consideration when articulating 

his RFC determination. For example, the ALJ acknowledged McLean’s complaints of lower 

extremity numbness and tingling by limiting her to only occasional use of foot controls with her 

lower extremities. Doc. No. 12 at 26. As already discussed, the ALJ also considered McLean’s 

reported need to elevate her legs even though he ultimately discounted her complaints of leg 

swelling by citing to several instances in the record where McLean exhibited no edema. 

 Further, the ALJ cited to multiple instances where McLean reported pain at the zero out 

of ten level. For instance, the ALJ noted McLean reported a pain level of zero during a visit with 

her endocrinologist, Dr. Bazaraa. The ALJ also discussed McLean’s October 2010 visit with an 

orthopedic surgeon where she also rated her pain as a zero out of ten. Moreover, the ALJ noted 

McLean’s report of pain at the nine out of ten level at her April 2011 visit to Dr. Inabnit. Thus, 

McLean is mistaken in her contention that the ALJ relied on a single report of a zero pain level. 

The ALJ’s decision shows more than one such instance and also demonstrates consideration of 

multiple pain complaints above the zero level. 

Finally, McLean argues the ALJ erred in considering her need for a cane. In support, 

McLean contends that the record shows she used the cane on several occasions. However, the 

ALJ articulated multiple reasons for discounting McLean’s assertion that she required a cane for 

ambulating. For example, the ALJ found that in spite of Dr. Kora’s opinion advising McLean to 
19 

use a cane due to ataxia, evidence showing any signs of ataxia was lacking. The ALJ also noted 

that no other medical professional had opined McLean needed a cane to ambulate. Despite 

McLean’s allegations, the ALJ supported his credibility determination with substantial evidence 

and therefore, it is not patently wrong. As a result, the ALJ’s RFC determination is affirmed. 

 3. Substantial evidence supports the ALJ’s Step Five finding. 

McLean’s final argument challenges the ALJ’s Step Five finding, claiming it was not 

supported by substantial evidence because the ALJ erred in relying on vocational testimony 

elicited in response to an incomplete hypothetical question. In support, McLean argues the ALJ’s 

errors in evaluating the opinion of Dr. Kora, evaluating McLean’s credibility, and formulating 

the RFC render the hypothetical questions posed to the vocational expert witness incomplete. 

At Step Five of the sequential evaluation process, the ALJ must determine whether the 

claimant is able to do any work considering her RFC, age, education, and work experience. 20 

C.F.R. § 404.1520(g). A VE or specialist may offer expert testimony in response to a 

hypothetical question about whether a person with the physical and mental limitations imposed 

by the claimant’s medical impairments can meet the demands of the claimant’s previous work. 

20 C.F.R. § 404.1560(b)(2). The hypothetical question an ALJ poses to a VE need only set forth 

the claimant’s limitations and abilities to the extent they are supported by the record evidence. 

Herron v. Shalala, 19 F.3d 329, 337 (7th Cir. 1994). Where the hypothetical does not include all 

of the applicant’s limitations, there must be some amount of evidence in the record indicating 

that the vocational expert knew the extent of the applicant’s limitations. Young v. Barnhart, 362 

F.3d 99, 1003 (7th Cir. 2004) (citing Steele v. Barnhart, 290 F.3d 936, 942 (7th Cir. 2002). 

In this case, the ALJ posed a hypothetical question that reflected the RFC that has already 

been affirmed by this Court in the analysis above. The hypothetical included the limitations the 
20 

ALJ found to be fully credible based on the record and was based on the ALJ’s proper 

articulation of Dr. Kora’s opinion as discussed above. Therefore, the hypothetical question was 

proper and the ALJ’s Step Five determination is supported by substantial evidence. See Schmidt 

v. Astrue, 496 F.3d 833, 846 (7th Cir. 2007). 

III. CONCLUSION 

For the foregoing reasons, the ALJ’s determination that McLean is not disabled for 

purposes of SSI and DIB is supported by substantial evidence. Therefore, McLean’s motion to 

reverse and remand is DENIED. [Doc. No. 17]. This Court AFFIRMS the Commissioner’s 

decision pursuant to sentence four of 42 U.S.C. § 405(g). The Clerk is instructed to term the case 

and enter judgment in favor of the Commissioner. 

 SO ORDERED. 

 Dated this 6th Day of November, 2014. 

 s/Christopher A. Nuectherlein 

 Christopher A. Nuechterlein 

 United States Magistrate Judge