Opinion ID: 164103
Heading Depth: 4
Heading Rank: 1

Heading: Dr. Royal

Text: Dr. Royal is a pain management specialist, and he is board certified in internal medicine and anesthesiology. See Aplt. App., Vol. 2 at 289. Plaintiff saw Dr. Royal for treatment of her back and neck injuries, and the related pain and other limitations, on eighteen occasions between November 1997 and -5- November 2000. Id. at 185-88, 245-64, 310-11. In his medical records, Dr. Royal reported that plaintiff was suffering from “known L4-5 and L5-S1 discogenic disease and L5-S1 facet arthropathy and known cervical discogenic disease at C5-6 with C5 radiculopathy . . . and L5-S1 disc herniation.” Id. at 311. In November 2000, Dr. Royal completed a residual functional capacity form stating that: (1) plaintiff has a lumbar disk herniation and spondylosis, and these conditions cause muscle spasms, tenderness, and decreased range of motion; (2) plaintiff has a cervical disk herniation and radiculopathy, and these conditions cause sensory abnormalities and muscle spasms; (3) plaintiff’s symptoms are credible; (4) plaintiff needs to lie down frequently; (5) plaintiff “is likely to be frequently absent from work due to pain”; (6) during an eight-hour work day, plaintiff is limited to sitting for three hours, standing for two hours, and walking for one hour; and (7) plaintiff “is unable to perform gainful employment even with accommodation and is likely to remain in this capacity for the foreseeable future.” Id. at 305-07. The ALJ rejected Dr. Royal’s opinion that plaintiff is unable to work, finding that this opinion is inconsistent with Dr. Royal’s own medical records. 2 2 The ALJ also found that Dr. Royal’s opinion is inconsistent with the description of plaintiff’s daily activities that she provided during the hearing before the ALJ. See Aplt. App., Vol. 2 at 19. We do not need to address this aspect of the ALJ’s decision, however, because we conclude that the ALJ’s (continued...) -6- Id. at 19. We conclude that the ALJ’s finding that Dr. Royal’s opinion is inconsistent with his medical records is supported by substantial evidence in the record. To begin with, Dr. Royal’s medical records indicate that there is no evidence of any significant spinal stenosis or neural foraminal encroachment in plaintiff’s lumbar spine, and that she suffers from only a mild radiculopathy in her cervical spine. Id. at 187, 257, 258, 259, 260, 262, 263. Dr. Royal’s records also indicate that there is no evidence of any significant neurological deficits in plaintiff’s upper or lower extremities. Id. at 245, 246, 247, 248, 249, 252, 255, 257, 258, 310. In addition, while Dr. Royal reported that plaintiff had “a somewhat stiff posture of the neck and decreased range of motion in the neck and the low back,” he also reported that she had “relatively fluid arm and leg movements.” Id. at 251, 252. We also note that, in November 1997, plaintiff informed Dr. Royal that “[s]he is able to [do] daily routine activities at home, such as the laundry, vacuuming and dishes, . . . [and] continues to try to enjoy social activities, but has curtailed that somewhat.” Id. at 260-61. Importantly, there is no indication in Dr. Royal’s medical records that plaintiff’s ability to perform such activities 2 (...continued) reliance on Dr. Royal’s and Dr. Herman’s medical records was a sufficient basis, standing alone, for rejecting Dr. Royal’s opinion. -7- deteriorated in any significant respect during the time he treated her. To the contrary, Dr. Royal’s records indicate that plaintiff responded reasonably well to his treatment, and it appears that her pain and other limitations were stabilized under his care. In November 1998, plaintiff reported to Dr. Royal that she was “doing somewhat better . . . [and] now doing some volunteer work and feels that getting out of the house and pushing herself is going to be helpful to her.” Id. at 251. In January 1999, Dr. Royal reported that, while plaintiff was “rather medication dependent to remain functional,” she “continues to do reasonably well. She is certainly functional . . . [and] continues to be upbeat about the future and being able to get back to perhaps even working.” Id. at 249. In September 1999, although plaintiff had to increase the dosage of her pain medication, she told Dr. Royal that she was “functional.” Id. at 246. In December 1999, Dr. Royal reported that plaintiff was “doing well . . . and remains quite functional, although at a lower level than normal.” Id. at 245. Finally, in March and June 2000, Dr. Royal reported that plaintiff “denies any new symptomatology. She states she is doing well, but would like to have a little better control of her muscle spasms and perhaps improvement in her sleep.” Id. at 310, 311. During this same time period, plaintiff was also seeing Dr. Herman, a family practitioner. Id. at 285. Dr. Herman’s medical records confirm that -8- plaintiff responded positively to the treatment she received from Dr. Royal. In December 1998, Dr. Herman reported that plaintiff was taking narcotics to alleviate her pain, and he stated that she had “decreased pain and . . . no other problems.” Id. at 207. In August 1999, Dr. Herman reported that plaintiff’s chronic pain was “well controlled” and she had “no complaints.” Id. at 200. In October 1999, Dr. Herman reported that plaintiff “continues with Dr. Royal for her chronic pain and is doing well. At this time she is not back to work, but she is having days where she is functioning at a fairly high level.” Id. at 199. In July 2000, Dr. Herman again reported that plaintiff “continues to see Dr. Royal and is doing well.” Id. at 300. Based on the information contained in the medical records of Dr. Royal and Dr. Herman, we hold that the ALJ did not err in determining that Dr. Royal’s opinion that plaintiff is unable to work is inconsistent with other substantial medical evidence in the record. Thus, the ALJ properly rejected Dr. Royal’s opinion.