IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

ROYAL GLADNEY, *

*

 Plaintiff, *

 *

vs. *

* CIVIL ACTION NO. 15-000171-B

CAROLYN W. COLVIN, *

Commissioner of Social *

Security, *

 *

Defendant. *

ORDER

Plaintiff Royal Gladney (hereinafter “Plaintiff”) seeks 

judicial review of a final decision of the Commissioner of 

Social Security denying his claim for supplemental security 

income under Title XVI of the Social Security Act, 42 U.S.C. §§

1381, et seq. and his claim for disability and disability 

insurance benefits under Title II of the Social Security Act, 42 

U.S.C. §§ 401, et seq. On June 8, 2016, the parties consented 

to have the undersigned conduct any and all proceedings in this 

case. (Doc. 17). Thus, the action was referred to the 

undersigned to conduct all proceedings and order the entry of 

judgment in accordance with 28 U.S.C. § 636(c) and Federal Rule 

of Civil Procedure 73. Upon careful consideration of the 

administrative record and the memoranda of the parties, it is 

hereby ORDERED that the decision of the Commissioner be 

AFFIRMED.

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I. Procedural History

Plaintiff filed his application for benefits on November 

17, 2011. (Tr. 173, 179). Plaintiff alleged that he has been 

disabled since September 30, 2011, due to back pain, respiratory 

problems, carpal tunnel, and acid reflux. (Id. at 74, 223).

Plaintiff’s applications were denied and upon timely 

request, he was granted an administrative hearing before 

Administrative Law Judge Angela L. Neel (hereinafter “ALJ”) on 

June 11, 2013. (Id. at 70). Plaintiff attended the hearing 

with his counsel and provided testimony related to his claims. 

(Id. at 72-85). A vocational expert (“VE”) also appeared at the 

hearing and provided testimony. (Id. at 85-89). On August 5, 

2013, the ALJ issued an unfavorable decision finding that 

Plaintiff is not disabled. (Id. at 56). The Appeals Council 

denied Plaintiff’s request for review on February 2, 2015. (Id.

at 1-4). Therefore, the ALJ’s decision dated August 5, 2013,

became the final decision of the Commissioner. 

Having exhausted his administrative remedies, Plaintiff 

timely filed the present civil action. (Doc. 1). The parties 

waived oral argument on June 8, 2016 (Docs. 16, 18), and agree 

that this case is now ripe for judicial review and is properly 

before this Court pursuant to 42 U.S.C. §§ 405(g) and 

1383(c)(3).

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II. Issue on Appeal

1. Whether the ALJ erred in rejecting the 

opinions of Plaintiff’s treating 

physicians Willie White, M.D. and Walid 

W. Freij, M.D., in favor of the opinion 

of a one-time consultative examiner, Huey 

Kidd, DO? 

III. Factual Background

Plaintiff was born on May 30, 1964, and was forty-nine 

years of age at the time of his administrative hearing on June 

11, 2013. (Tr. 74). Plaintiff has an eleventh grade education, 

and testified that he was in special education classes 

throughout school. (Tr. 75-76). He last worked from January 2005 

to September 30, 2011 at Gate Precast, a cement company, as a 

sandblaster. (Id. at 86, 212). He has a variety of other past 

work, including working as a green chain off bearer at a lumber 

company, as a groundskeeper, and as general construction worker. 

(Id. at 86, 212). 

Plaintiff reports that the pain in his back began in 2003, 

the pain in his back began in 2005, and his breathing problems 

began in 2011. (Id. at 245). Plaintiff testified that he has

carpal tunnel syndrome in both hands. (Id. at 81, 82, 83). 

Plaintiff also testified that his breathing problems occur when 

he walks for long periods or smells any type of strong smells. 

(Id.). Plaintiff further testified that he has had trouble with 

his lower back for “probably about seven, eight years”, and that 

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his back problems occur when he has been standing or sitting for 

long periods of time. (Id. at 83, 245).

Plaintiff reports that he lives at home with his family, 

and that his daily activities include sitting around and 

watching TV, spending time with his family, sitting on the 

porch, and walking around a little outside. (Id. at 79, 201, 

205). Plaintiff reports that his condition affects every aspect 

of his personal care because it is hard to use his hands, and 

occasionally, he needs help getting dressed or has difficulty 

buttoning his clothes1 . (Id. at 80-81, 85, 202, 256.) Plaintiff 

also testified that he drives, but he takes someone along with 

him if he is driving a long distance. (Id. at 204). 

Plaintiff testified that Dr. Freij spoke with him about 

having surgery for his carpal tunnel; however, the surgery was 

expensive and Plaintiff did not have insurance. (Id. at 81). 

Plaintiff further testified that Dr. White has advised him that 

he might need back surgery; however, he does not have insurance. 

(Id. at 84). 

IV. Analysis

 1 Plaintiff also reported that his hand braces make it difficult 

for him to handle money, and that he has difficulty turning door 

knobs, writing with a pencil or typing on a keyboard. (Tr. 204-

205). Plaintiff further testified that he wears the brace on 

his right hand every day to help with the pain, and that he also 

wears it when he goes to bed. (Id. at 81). He wears a brace on 

his left hand only when needed. (Id.).

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A. Standard of Review 

In reviewing claims brought under the Act, this Court’s 

role is a limited one. The Court’s review is limited to 

determining 1) whether the decision of the Secretary is 

supported by substantial evidence and 2) whether the correct 

legal standards were applied. 2 Martin v. Sullivan, 894 F.2d 

1520, 1529 (11th Cir. 1990). A court may not decide the facts 

anew, reweigh the evidence, or substitute its judgment for that 

of the Commissioner. Sewell v. Bowen, 792 F.2d 1065, 1067 (11th 

Cir. 1986). The Commissioner’s findings of fact must be 

affirmed if they are based upon substantial evidence. Brown v. 

Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v. 

Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983) (holding 

substantial evidence is defined as “more than a scintilla, but 

less than a preponderance” and consists of “such relevant 

evidence as a reasonable person would accept as adequate to 

support a conclusion.”). In determining whether substantial 

evidence exists, a court must view the record as a whole, taking 

into account evidence favorable, as well as unfavorable, to the 

Commissioner’s decision. Chester v. Bowen, 792 F. 2d 129, 131 

(11th Cir. 1986); Short v. Apfel, 1999 U.S. Dist. LEXIS 10163, *4

(S.D. Ala. June 14, 1999).

 2 This Court’s review of the Commissioner’s application of legal 

principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th 

Cir. 1987).

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B. Discussion

An individual who applies for Social Security disability 

benefits must prove his or her disability. 20 C.F.R. §§ 

404.1512, 416.912. Disability is defined 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); see also 20 C.F.R. §§ 

404.1505(a), 416.905(a). The Social Security regulations 

provide a five-step sequential evaluation process for 

determining if a claimant has proven his disability.3 20 C.F.R. 

 3 The claimant must first prove that he or she has not engaged in 

substantial gainful activity. The second step requires the 

claimant to prove that he or she has a severe impairment or 

combination of impairments. If, at the third step, the claimant 

proves that the impairment or combination of impairments meets 

or equals a listed impairment, then the claimant is 

automatically found disabled regardless of age, education, or 

work experience. If the claimant cannot prevail at the third 

step, he or she must proceed to the fourth step where the 

claimant must prove an inability to perform their past relevant 

work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In 

evaluating whether the claimant has met this burden, the 

examiner must consider the following four factors: (1) objective 

medical facts and clinical findings; (2) diagnoses of examining 

physicians; (3) evidence of pain; and (4) the claimant’s age, 

education and work history. Id. Once a claimant meets this 

burden, it becomes the Commissioner’s burden to prove at the 

fifth step that the claimant is capable of engaging in another 

kind of substantial gainful employment which exists in 

significant numbers in the national economy, given the 

claimant’s residual functional capacity, age, education, and

work history. Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir. 

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§§ 404.1520, 416.920. 

In the case sub judice, the ALJ determined that Plaintiff 

has not engaged in substantial gainful activity since September 

30, 2011, the alleged onset date, and that he has the severe 

impairments of obesity; asthma; and moderate bilateral carpal 

tunnel syndrome, right worse than left 4 . (Tr. 58). The ALJ 

further found that Plaintiff does not have an impairment or 

combination of impairments that meets or medically equals any of 

the listed impairments contained in 20 C.F.R. Part 404, Subpart 

P, Appendix 1. (Id.). 

The ALJ concluded that Plaintiff retains the residual 

functional capacity (hereinafter “RFC”) to perform light work 

with the following limitations: Plaintiff can lift and carry 20 

pounds occasionally and 10 pounds frequently; can sit, stand, 

 

1985). If the Commissioner can demonstrate that there are such 

jobs the claimant can perform, the claimant must prove inability 

to perform those jobs in order to be found disabled. Jones v. 

Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v. 

Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v. 

Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).

4 The ALJ found that the Plaintiff has the following non-severe 

impairments: acid reflux; borderline right paratracheal 

indeterminate node; diastolic dysfunction, mild tricuspid 

regurgitation, mild pulmonary hypertension, mild pulmonary 

insufficiency, and trace mitral regurgitation; minimal right 

nephrolithiasis with 3 mm diameter calculus in lower right 

ureter; urolithiasis; elevated PSA and enlarged prostate; and 

remote history of ruptured bowel secondary to a stab wound. (Tr. 

59). The ALJ further found that there was no objective evidence 

to support that the claimant has any type of mental disorder. 

(Id. at 58) 

Case 1:15-cv-00171-B Document 20 Filed 09/27/16 Page 7 of 25
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and walk 6 hours each; can push and pull as much as he can lift 

and carry; frequent exposure to right hand controls; frequent 

handling of right hand controls; no climbing ladders or 

scaffolds; and no balancing, stooping, kneeling, crouching and 

crawling. (Id. at 59). The ALJ further limited the Plaintiff to 

work with no exposure to humidity, wetness, and extreme cold or 

heat. (Id.) The ALJ also limited Plaintiff to simple, routine, 

and repetitive tasks with simple work-related decisions. (Id.). 

Utilizing the testimony of a VE, the undersigned concluded that 

considering Plaintiff’s RFC, his age, education and work 

experience, he is unable to perform his past relevant work (Id.

at 63). He further concluded that there are jobs existing in 

the national economy that Plaintiff is able to perform, such as 

“Inserting Machine Operator”; “Checker I/Greeter”, and “Produce 

Weigher”, all light and unskilled positions. (Id. at 64). 

Thus, the ALJ concluded that Plaintiff is not disabled. (Id. at 

64-65).

The Court now considers the foregoing in light of the 

record in this case and the issues on appeal. 

1. Issue

A. Whether the ALJ erred in rejecting the 

opinions of the treating physician, 

Willie White, M.D. and Walid W. Freij, 

M.D., a neurologist, in favor of the 

opinion of a one-time consultative 

examiner, Huey Kidd, D.O.?

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In this case, Plaintiff argues that the ALJ erred in 

rejecting the opinions of his treating physicians, Dr. Willie 

White, M.D, set forth in an “Ability to Work” questionnaire and 

a “Physical Functional Capacity” questionnaire (Tr. 438; 439-

441) and that of Dr. Walid W. Freij, M.D., a neurologist, set 

forth in a “Physical Functional Capacity Assessment” (Tr. 444-

447) in favor of the opinion of Huey Kidd, DO, a one-time 

consultative examiner. (Tr. 365-378). (Doc. 13 at 2-3). The 

Commissioner counters that the medical evidence does not support 

Dr. White or Dr. Freij’s opinion that Plaintiff is unable to 

work, and their opinions are inconsistent with the physical 

findings and sparse treatment history included in the record. 

(Doc. 14 at 4-5). Having carefully reviewed the record in this 

case, the Court concludes that Plaintiff’s claim is without 

merit.

As part of the disability determination process, the ALJ is 

tasked with weighing the opinions and findings of treating, 

examining, and non-examining physicians. In reaching a 

decision, the ALJ must specify the weight given to different 

medical opinions and the reasons for doing so. See Winschel v. 

Commissioner of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011). 

The failure to do so is reversible error. See Williams v. 

Astrue, 2009 U.S. Dist. LEXIS 12010, *4, 2009 WL 413541, *1 

(M.D. Fla. 2009).

Case 1:15-cv-00171-B Document 20 Filed 09/27/16 Page 9 of 25
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When weighing the opinion of a treating physician, the ALJ 

must give the opinions “substantial weight,” unless good cause 

exists for not doing so. Costigan v. Commissioner, Soc. Sec. 

Admin., 2015 U.S. App. LEXIS 2827, *10, 2015 WL 795089, *4 (11th 

Cir. Feb. 26, 2015) (citing Crawford v. Commissioner of Soc. 

Sec., 363 F.3d 1155, 1160 (11th Cir. 2004) and Broughton v. 

Heckler, 776 F.2d 960, 962 (11th Cir. 1985)). The opinion of “a 

one-time examining physician — or psychologist,” on the other 

hand, is not entitled to the same deference as a treating 

physician. Petty v. Astrue, 2010 U.S. Dist. LEXIS 24516, *50, 

2010 WL 989605, *14 (N.D. Fla. Feb. 18, 2010) (citing Crawford, 

363 F.3d at 1160). An ALJ is also “required to consider the 

opinions of non-examining state agency medical and psychological 

consultants because they ‘are highly qualified physicians and 

psychologists who are also experts in Social Security disability 

evaluation.’” Milner v. Barnhart, 275 Fed. Appx. 947, 948 

(11th Cir. 2008) (unpublished) (citing 20 C.F.R. § 

404.1527(f)(2)(i)). “The ALJ may rely on opinions of nonexamining sources when they do not conflict with those of 

examining sources.” Id. (citing Edwards v. Sullivan, 937 F.2d 

580, 584-85 (11th Cir. 1991)). 

Whether considering the opinions of treating, examining, or 

non-examining physicians, good cause exists to discredit the 

testimony of any medical source when it is contrary to or 

Case 1:15-cv-00171-B Document 20 Filed 09/27/16 Page 10 of 25
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unsupported by the evidence of record. Phillips v. Barnhart, 

357 F.3d 1232, 1240 (11th Cir. 2004). “Good cause may also 

exist where a doctor’s opinions are merely conclusory, 

inconsistent with the doctor’s medical records, or unsupported 

by objective medical evidence.” Hogan v. Astrue, 2012 U.S. 

Dist. LEXIS 108512, *8, 2012 WL 3155570, *3 (M.D. Ala. 2012). 

The ALJ is “free to reject the opinion of any physician when the 

evidence supports a contrary conclusion.” Sryock v. Heckler, 

764 F.2d 834, 835 (11th Cir. 1985) (per curiam) (citation 

omitted); Adamo v. Commissioner of Soc. Sec., 365 Fed. Appx. 

209, 212 (11th Cir. 2010) (The ALJ may reject any medical 

opinion if the evidence supports a contrary finding.).

With respect to Plaintiff’s back pain, the record reflects 

that during a September 2011 visit with Dr. White, Plaintiff 

reported that he had hurt his back and neck in a motor vehicle 

accident. (Tr. 437). He was prescribed Lortab. (Id.)

It does not appear that Plaintiff sought any treatment for 

his back in 2012. His next visit with Dr. White was on January 

5, 2013, when Plaintiff presented to the J. Paul Jones emergency 

room complaining of lower back and leg pain. (Id. at 411). On 

that date, Dr. White noted on examination that Plaintiff had a 

decreased range of motion in his lumbosacral spine with a 

paraspinal muscle spasm, but no paresthesia. (Id.). Dr. White 

diagnosed Plaintiff with spasmodic lower back pain, and 

Case 1:15-cv-00171-B Document 20 Filed 09/27/16 Page 11 of 25
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prescribed Decadron, Depomedrol, Dydroxyzine, and Diazepam 

followed by Toradol and Flexeril. (Id.).

At some point, Dr. White completed a “Physical Functional 

Capacity Assessment”. (Id. at 439-441). In the assessment, Dr. 

White opines that due to Plaintiff’s back pain, he cannot carry 

anything, but he can lift 40 pounds or more, at a maximum 

frequency of 1/3 of an 8 hour day. 5 (Id.). Dr. White further 

indicates that Plaintiff can stand and/or walk for a total of 2 

to 3 hours per day, but for no more than 30 to 40 minutes 

without interruption. (Id.). Dr. White also opined that 

Plaintiff can only sit for a total of 2 to 3 hours a day, but 

for no more than 1 hour at a time. (Id. at 440). Dr. White 

further opined that Plaintiff can never climb, balance, stoop, 

crouch, kneel, or crawl, and that Plaintiff’s ability to reach, 

handle, push, and pull are affected by his impairments. (Id.). 

Dr. White opined that Plaintiff has environmental restrictions, 

including working around heights or vibrations, and that 

Plaintiff is unable to climb steps or ladders or “keep up” 

anything greater than 40 pounds. (Id. at 441). 

Dr. White also completed an “Ability to Work” form wherein 

he opines that Plaintiff would be unable to work for eight hours 

 5 The date on which Dr. White prepared this document is not 

clear. The top of the document bears fax dates of June 4, 2013, 

and June 11, 2013. (Tr. 439-441). 

Case 1:15-cv-00171-B Document 20 Filed 09/27/16 Page 12 of 25
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a day, five days a week due to his lower back pain and muscle 

spasms. (Id. at 438). He also opines that Plaintiff has been 

disabled since on or before September 30, 2011, and that his 

condition has lasted or is expected to last at least twelve 

months. (Id.)6. 

The record reflects that Plaintiff’s treatment for carpal 

tunnel began on April 2, 2007, when Dr. White referred Plaintiff 

to Dr. Freij for persistent pain in his left hand and wrist. 

(Id. at 284). Plaintiff reported pain and soreness mostly in his 

left thumb region, but also in the left wrist, with associated 

tenderness and numb sensation. (Id.). He also reported numbness 

that kept him awake at night, and difficulty gripping with the 

left hand due to soreness. (Id.). Upon examination, Dr. Freij 

observed 5/5 motor power throughout, DTRs 2/5 all over, 

unremarkable finger to nose and heel to shins exam, unremarkable 

gait, and negative Tinel’s sign bilaterally. (Id. at 285). Dr. 

Freij’s assessment was carpal tunnel syndrome (suggested by the 

history of numbness and repeated awakening at night) and

arthritis (affecting the first metacarpal phalangeal joint). 

 6 The final treatment notes of Dr. White contained in the record 

are dated February 17, 2014. (Tr. 32). This is after the ALJ’s 

decision. The notes reflect that Plaintiff was seen for 

“palpating” lower back pain that would not allow him to rest. 

(Id.). Dr. White noted that Plaintiff was still taking Lortab, 

but he did not bring the medication with him to the appointment. 

(Id.). No new treatment was discussed. (Id.). 

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(Id.).

A NCV/EMG test for the left upper extremity was performed 

on that date. (Id. at 286). Upon reviewing the results, Dr. 

Freij indicated that he was also sending Plaintiff for x-rays of 

his left hand and wrist, with a special concentration on his 

left thumb. (Id.). Dr. Freij indicated that he would see the 

Plaintiff after the workup for re-evaluation and treatment. 

(Id.). Upon reviewing the NCV/EMG test, Dr. Freij noted that the 

test revealed evidence of a mild bilateral Median neuropathy 

(median nerve entrapment at wrist) affecting sensory components 

without evidence of denervation, and mild left Ulnar neuropathy. 

(Id. at 289). Also, an X-Ray performed on that date showed no 

evidence of fracture or dislocation, and no evidence of acute or 

bony trauma to the left hand. (Id. at 290). 

Plaintiff next saw Dr. Freij on January 21, 2008. (Tr. 

283). Dr. Freij noted that Plaintiff reported that he still had 

pain in his hands, that Plaintiff was given Naproxen and wrist 

braces at the last visit, that those measures apparently were 

not helping, but Plaintiff had failed to show up for his followup. (Id.). Upon examination, Dr. Freij observed some swelling in 

Plaintiff’s hands, and noted that Plaintiff’s condition had 

progressed since the previous year. (Id.). Dr. Freij also noted 

that Plaintiff reported some pain when squeezing and making a 

fist, and that Plaintiff’s strength was 5/5. (Id.). Dr. Freij’s 

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assessment was bilateral carpel tunnel syndrome, with 

progression since last year. (Id.) The treatment plan was to 

repeat the NCV/EMG test, prescribe Lyrica, and consider surgery 

if the Lyrica did not work.(Id.).

Another NCS/EMG test was performed on February 18, 2008. 

(Tr. 291-294). The test results again revealed evidence of mild 

bilateral carpal tunnel syndrome (median nerve entrapment at the 

wrist) affecting sensory components without evidence of 

denervation. (Id.). There was also evidence of mild right 

sensory Ulnar neuropathy across the wrist and elbow without 

evidence of denervation, as well as evidence of mild left 

sensory Ulnar neuropathy across the wrist without evidence of 

denervation. (Id.). Dr. Friej noted that Plaintiff would be 

referred to Dr. Harris to consider surgery for the left median 

nerve release. (Id.).

Plaintiff’s next saw Dr. Friej more than a year later on 

September 21, 2009. Dr. Freij noted that Lyrica and Lortab were 

helping Plaintiff ‘quite a bit’, but that his pain had become 

worse upon running out of Lyrica and Lortab. (Id. at 282). Dr. 

Friej also noted that Plaintiff’s strength was 5/5, and that 

Plaintiff wanted to delay surgery until he had enough vacation 

time. (Id.). Plaintiff was prescribed Lyrica and Lortab as 

needed, and Dr. Friej noted that it would be necessary to repeat 

the nerve conduction exam if Plaintiff opted for surgery next 

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year because it would have been nearly two years since the last 

test was conducted. (Id.)

Plaintiff did not see Dr. Freij in 2010 or 2011. His next 

visit with Dr. Freij occurred on January 16, 2012. (Tr. 381). 

Plaintiff again complained of swelling, pain, and numbness in 

his hands. On examination, Dr. Freij noted that Plaintiff’s 

strength was 5/5, and that there was swelling in his hands. 

(Id.) He diagnosed Plaintiff with carpal tunnel syndrome 

bilaterally, prescribed Lortab and gave Plaintiff wrist braces. 

(Id.). Plaintiff indicated that he was willing to pursue 

surgery, but was unable to do so because of a lack of insurance. 

(Id.). 

Follow up appointments occurred on July 16, 2012 and 

January 14, 2013. (Tr. 380, 393). Dr. Freij noted that Lortab 

and the wrist braces had been helping Plaintiff, and that he 

should continue using them. (Id.). Upon examination, Plaintiff’s 

strength was noted to be 5/5, and his hand grips were normal. 

(Id. at 380, 381, 393). 

During Plaintiff’s June 10, 2013 visit, Dr. Freij noted 

that Plaintiff reported that his hands had been doing relatively 

well until he was mowing his lawn in June 2013, and began 

experiencing numbness, tingling, and pain. (Tr. 35). Upon 

examination, Plaintiff was having some “give way” with his 

hands, but his hand strength was 5/5, and his gait was normal

Case 1:15-cv-00171-B Document 20 Filed 09/27/16 Page 16 of 25
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(Id.). Dr. Freij diagnosed Plaintiff with “bilateral moderate 

carpal tunnel syndrome”, and discussed switching Plaintiff from 

Lortab to Ultram for his pain. (Id.).

On the same day, Dr. Freij completed an “Ability to Work” 

form, and opined that Plaintiff is unable to work eight hours a 

day, five days a week due to his carpal tunnel syndrome and 

ulnar and radial neuropathy. (Tr. 443). He further opined that 

Plaintiff has been disabled since September 30, 2011, and that 

his condition had lasted or was expected to last at least 12 

months. (Id.). Dr. Freij noted that his findings were based on 

Plaintiff having nerve damage affecting both hands, and causing 

pain, numbness, and tingling. (Id.). 

Dr. Freij also completed a Physical Functional Capacity 

Assessment, wherein he opined that Plaintiff can carry/lift

between 10 and 20 pounds. (Tr. 444). He further opined that 

Plaintiff could frequently climb, balance, stoop, crouch, or 

kneel, and could occasionally crawl. (Tr. 445). He further 

opined that Plaintiff’s ability to reach, handle, feel, push, 

and pull would be affected by his carpal tunnel and ulnar radial 

neuropathy, and that Plaintiff should avoid temperature extremes 

and vibrations. (Tr. 447). Dr. Freij further observed that work 

that requires the use of Plaintiff’s hands or repetitive motions 

at his wrists, and work that requires carrying and lifting would 

be impacted by Plaintiff’s physical limitations. (Id.). 

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Plaintiff’s last two visits with Dr. Freij were in December 

2013 and June 2014 7 . (Tr. 15, 34). Dr. Freij noted that the 

nerve tests in 2008 revealed evidence of mild bilateral carpal 

tunnel syndrome affecting sensory and sensory components without 

evidence of denervation, mild right sensory ulnar neuropathy, 

left sensory ulnar neuropathy and bilateral sensory radial 

neuropathy mild. Dr. Freij thought it “most likely” that 

Plaintiff’s “carpal tunnel was worse” since it had been five 

years since the nerve tests. On examination, Plaintiff’s motor 

strength was 5/5 and no atrophy was noted in the APBs 8 . Dr. 

Freij noted that Vicoprofen 7.5 mg seemed to be helping although 

it was a little expensive for Plaintiff; thus, the medicine was 

changed to Vicoden 7.5 mg.(Id.) Plaintiff was advised to avoid 

using his hands in a repetitive motion, to wear a wrist brace, 

and to take NSAID pm. (Id. at 15). Plaintiff again indicated 

that he did not want to consider surgery because he did not have 

insurance. (Id. at 34). 

Upon review, the undersigned finds that the ALJ had good 

cause for rejecting Dr. White and Dr. Freij’s opinions that 

 7 These visits were after the ALJ rendered her decision in 

August 2013.

8 The abductor pollicis brevis (“APB”)is a muscle in the hand 

that functions as an abductor of the thumb. See

https://nervesurgery.wustl.edu/ev/hand/median/thenarbranch/Pages

/AbductorPollicisBrevis.aspx

Case 1:15-cv-00171-B Document 20 Filed 09/27/16 Page 18 of 25
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Plaintiff cannot perform sustained work because of his back pain 

and carpal tunnel. Dr. White’s opinion that Plaintiff is 

disabled is undermined by the spare treatment for back problems 

and his treatment records. Plaintiff’s back problems date back 

to a motor vehicle accident in September 2006. While he 

requested in 2006 to be referred to a neurosurgeon for lower 

back pain and was scheduled for an MRI, there are no further 

records regarding any treatment for back pain until three years 

later, in September 2009. (Tr. 309, 310). In 2009, he was 

prescribed a variety of medicine, including Lortab, Decadron, 

Depo-Medrol, Flexeril, and Mobic. (Id.). 

MRIs were performed in June 2010, January 2011, and June 

2011. (Tr. 301, 315-316, 322-323). Dr. Joseph H. Hagood noted in 

June 2010 that Plaintiff’s alignment was somewhat straightened, 

his vertebral body heights were maintained, and his disc spaces 

appeared normal, though there was some sclerosis about the 

sacroiliac joint that Dr. Hagood believed could indicate some 

early arthritic change. (Id. at 321-322). Aside from these 

findings, Dr. Hagood indicated that the lumbar spine appeared 

otherwise unremarkable. (Id.). Records dated the day after this 

MRI indicate that there was a small shallow broad-based 

protrusion of disc slightly eccentric to right of midline at L4-

L5, and a tiny central protrusion of disc at L5-SI. (Id. at 

301). Radiology records completed in January and June 2011 

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indicate that Plaintiff had normal lumbar spine, and there was 

essentially no change in the results since the June 2010 scan. 

(Tr. 323, 322). Dr. Hagood noted that if Plaintiff had any 

radicular pain, an MR should be obtained to evaluate the discs. 

(Id. at 322). As noted supra, Plaintiff reported back pain to 

Dr. White during a September 2011 visit, and was prescribed 

Lortab. He did not seek any treatment for back pain in 2012, 

and only saw Dr. White once for back pain in 2013, and in 2014. 

Dr. White noted that Plaintiff had a decreased range of motion 

in his lumbosacral spine with a paraspinal muscle spasm, but no 

paresthesia. He diagnosed Plaintiff with lower back pain and 

prescribed medication. (Tr. 32, 411, 437, 439-441). These sparse 

records, and repeated notations that the lumbar spine was 

‘normal’ and ‘unremarkable’ are at odds with the opinions 

expressed in Dr. White’s Physical Functional Capacity 

Assessment, and the Ability to Work form wherein he opined that 

Plaintiff is unable to work 8 hours 5 days a week9. Accordingly, 

the ALJ had good cause for rejecting these opinions of Dr. 

White. 

 9 Dr. White’s opinions are also at odds with those of Dr. 

Freij, who upon examining Plaintiff, opined that Plaintiff can 

lift and carry up to twenty pounds, and that he has no 

limitations in standing or walking. (Tr. 444). It was the ALJ’s 

duty to resolve conflicts in the evidence, and she did so in 

this case. Richardson v. Perales, 402 U.S. 389, 399, 91 S. Ct. 

1420, 28 L. Ed. 2d 842 (1971). 

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The ALJ likewise had good cause for rejecting Dr. Freij’s 

opinion that Plaintiff is disabled due to his carpal tunnel 

syndrome. While Plaintiff has been diagnosed with carpal tunnel 

syndrome and ulnar and radial neuropathy based on nerve studies, 

his treatment with Dr. Freij was infrequent and conservative. 

While Dr. Freij’s treatment notes reflect that surgery was 

discussed with Plaintiff, but declined due to lack of insurance, 

the notes also reflect that earlier, while still gainfully 

employed, Plaintiff declined surgery while he built up his 

vacation. (Tr. 282).

Moreover, Dr. Freij’s treatment notes reflect that during 

Plaintiff’s July 2012 visit, Dr. Freij observed that Plaintiff’s 

wrist braces and Lortab were helping his condition. And, in June 

2013, Dr. Freij’s treatment notes reflect that Plaintiff’s hands 

were doing “relatively well” until he mowed his lawn, and this 

triggered numbness, tingling and pain in his hands. Dr. Freij’s 

treatment notes reflect that his examinations of Plaintiff 

repeatedly showed full strength in Plaintiff’s upper and lower 

extremities and that hand gripping was normal. (Tr. 34, 282, 

380, 381, 393). The records also reflect that during 

Plaintiff’s visit to Dr. Fahoum for shortness of breath 10 on 

 10 Asthma is noted by the ALJ to be a severe impairment. (Tr. 58). 

The Plaintiff does not dispute any finding of the ALJ with 

regards to his asthma. 

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September 20, 2011, Dr. Fahoum noted normal digits and no 

tenderness to indicate any arthritis. (Id. at 338). Dr. Fahoum’s 

treatment records dated March 20, 2014 and May 15, 2014, also 

reflect that upon examination, Plaintiff had full strength in 

his upper and lower extremities and normal digits. (Id. at 17, 

19). This evidence, including Dr. Freij’s own treatment records, 

demonstrate that the ALJ had good cause for rejecting Dr. 

Freij’s opinions that Plaintiff is unable to work. 

Moreover, Dr. Huey Kidd, D.O., examined Plaintiff on 

February 14, 2012 at the request of the Agency and he found that 

Plaintiff had 5/5 grip strength bilaterally, a full range of 

motion in the upper extremities and 5/5 strength and full range 

of motion in the lower extremities. His findings are consistent 

with multiple treatment notes in the record made by both of 

Plaintiff’s treating physicians and the other medical 

professionals. (Tr. 367, see id. at 17, 19, 338, 389). He 

further found that Plaintiff is able to heel walk, able to toe 

walk, is able to bend and touch his toes, and is able to stand 

without difficulty. (Id.). Tests performed showed a reduction in 

FVC that would suggest a restrictive process, though Dr. Kidd 

noted that the presence of restriction should be confirmed by 

measuring long volumes 11 . (Id. at 369). Dr. Kidd diagnosed 

 11 Dr. Kidd notes that Plaintiff had difficulty performing 

the FVC properly and consistently. (Tr. 370). 

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Plaintiff with asthma and carpal tunnel syndrome. (Id. at 367). 

Based on the foregoing, the Court finds that the ALJ had 

good cause to assign no weight to the opinions of Dr. White and 

Dr. Freij that Plaintiff was unable to work. 

Further, there was substantial evidence to support the 

ALJ’s finding that Plaintiff has the RFC to perform the 

positions identified by the ALJ. RFC is a measure of what 

Plaintiff can do despite his or her credible limitations. See

20 C.F.R. § 404.1545. Determinations of a claimant’s RFC are 

reserved for the ALJ, and the assessment is to be based upon all 

the relevant evidence of a claimant’s remaining ability to work 

despite his or her impairments, and must be supported by 

substantial evidence. See Beech v. Apfel, 100 F. Supp. 2d 1323, 

1331 (S.D. Ala. 2000) (citing 20 C.F.R. § 404.1546 and Lewis v. 

Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)); Saunders v. 

Astrue, 2012 U.S. Dist. LEXIS 39571, *10, 2012 WL 997222, *4 

(M.D. Ala. March 23, 2012). Once the ALJ has determined the 

Plaintiff’s RFC, the claimant bears the burden of demonstrating 

that the ALJ’s decision is not supported by substantial 

evidence. See Flynn v. Heckler, 768 F.2d 1273, 1274 (11th Cir. 

1985). Plaintiff has failed to meet his burden in this case.

To determine Plaintiff’s RFC, the ALJ utilized the 

testimony of a vocational expert at the hearing. (Tr. 85). The 

ALJ presented the VE with a hypothetical situation in which an 

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individual is limited to work with a light exertion level and 

the following limitations: frequent use of his right hand for 

hand controls and handling, no climbing ladders or scaffolds, no 

balancing, kneeling, or crawling, and no work around unprotected 

heights, moving mechanical parts, and the humidity and wetness 

and extreme temperatures or the heat, and no respiratory 

irritants. (Id. at 86-87). The hypothetical individual was 

further limited to simple, routine, repetitive tasks and making 

simple work related decisions. (Id.). The VE testified that such 

an individual could not perform any of the Plaintiff’s past 

work, but could perform other work including inserting machine 

operator (unskilled light work at 2 SVP), checker I or ‘greeter’ 

at a retail store (unskilled light work at 2 SVP), and produce 

weigher (unskilled light work at 1 SVP). (Id. at 87-88). The 

hypothetical posed to the VE was consistent with the medical 

evidence discussed above, and the ALJ’s decision was directly 

based upon the testimony that followed. 

Based on the evidence set forth in detail herein, the Court 

finds that the substantial evidence in this case support’s the 

ALJ’s finding that Plaintiff can perform a range of light work, 

with the stated restrictions. Accordingly, Plaintiff’s claim 

must fail. 

V. Conclusion 

For the reasons set forth herein, and upon careful 

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consideration of the administrative record and memoranda of the 

parties, it is hereby ORDERED that the decision of the 

Commissioner of Social Security denying Plaintiff’s claim for 

supplemental security income be AFFIRMED.

DONE this 27th day of September, 2016.

 /s/ SONJA F. BIVINS 

 UNITED STATES MAGISTRATE JUDGE

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