Court Opinion

ID: 214081
Source: CourtListenerOpinion
Date Created: 2011-04-06 16:19:21+00
Date Added: 2024-06-11T17:28:18.657255
License: Public Domain

FILED
                                                              United States Court of Appeals
                                                                      Tenth Circuit

                                                                      April 6, 2011
                      UNITED STATES COURT OF APPEALS
                                                   Elisabeth A. Shumaker
                                                                      Clerk of Court
                             FOR THE TENTH CIRCUIT

    VIRGINIA D. PEEPER,

                Plaintiff-Appellant,
                                                           No. 10-5070
    v.                                           (D.C. No. 4:08-CV-00658-TLW)
                                                           (N.D. Okla.)
    MICHAEL J. ASTRUE, Commissioner
    of the Social Security Administration,

                Defendant-Appellee.

                             ORDER AND JUDGMENT *

Before O’BRIEN, ANDERSON, and TACHA, Circuit Judges.

         Virginia D. Peeper appeals 1 from an order of the district court affirming the

Commissioner’s decision denying her application for Social Security disability

and Supplemental Security Income benefits. She filed for these benefits on

*
       After examining the briefs and appellate record, this panel has determined
unanimously to grant the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore
ordered submitted without oral argument. This order and judgment is not binding
precedent, except under the doctrines of law of the case, res judicata, and
collateral estoppel. It may be cited, however, for its persuasive value consistent
with Fed. R. App. P. 32.1 and 10th Cir. R. 32.1.
1
         Our jurisdiction derives from 28 U.S.C. § 1291 and 42 U.S.C. § 405(g).
June 8, 2006, alleging disability beginning on January 1, 2003. The agency

denied her applications initially and on reconsideration.

      On June 10, 2008, Peeper received a de novo hearing before an

administrative law judge (ALJ), who followed a five-step sequential evaluation

process to determine whether she was disabled. See Williams v. Bowen, 844 F.2d
748, 750-52 (10th Cir. 1988). The ALJ found: at step one, Peeper was not

presently engaged in substantial gainful activity, Aplt. App., Vol. 1 at 58; at step

two, she had a combination of impairments that were severe, id.; at step three,

none of the impairments or combination of impairments met or equaled any of the

listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1, Aplt. App., Vol.

1 at 58-59; at step four, her RFC did not allow her to perform the requirements of

her past relevant work, id. at 61; and, at step five, she was not disabled because

other work existed in significant numbers in the national economy she was

capable of performing, id. at 62. In making these findings, the ALJ determined

Peeper retained the RFC to perform light work “except no overhead reaching or

lifting of objects over 10 pounds.” Id. at 60. The Appeals Council denied review,

making the ALJ’s decision the Commissioner’s final decision.

      In this appeal, Peeper raises two issues. First, the ALJ failed to properly

consider her fibromyalgia in that there is a “complete lack of discussion of the

treatment notes by the ALJ.” Aplt. Br. at 12. She asserts “the ALJ simply relied

on one source for his assessment of Peeper’s fibromyalgia, Dr. Malati.” Id. at 13.

                                          -2-
Second, she argues the ALJ’s negative credibility determination was not

adequately supported by the record.

      “We review the Commissioner’s decision to determine whether the factual

findings are supported by substantial evidence in the record and whether the

correct legal standards were applied. Substantial evidence is such relevant

evidence as a reasonable mind might accept as adequate to support a conclusion.”

Cowan v. Astrue, 552 F.3d 1182, 1184-85 (10th Cir. 2008) (quotation omitted).

B ecause cannot confirm the basis for the ALJ’s negative credibility finding, we

must reverse and remand for further proceedings.

                                         I.

      As we are remanding based on Peeper’s second issue, we need not spend

much time evaluating the adequacy of the ALJ’s discussion of her claimed

fibromyalgia. She argues that the ALJ failed to properly consider her

fibromyalgia; specifically, she claims there is a “complete lack of discussion of

the treatment notes by the ALJ.” Aplt. Br. at 12. But her argument minimizes, if

not ignores, a most salient fact—nowhere in the record do we see a formal

diagnosis of fibromyalgia. When she applied for disability benefits in June 2006,

she alleged “[m]obility problems with [her] right shoulder/arm” limited her ability

to work. Aplt. App., Vol. 1 at 144. Specifically, she claimed she couldn’t

“RAISE, LIFT, AND MOVE THE RIGHT ARM WITHOUT SEVERE PAIN. AT

[T]IMES I HAVE TO PUT IT IN A SLING IF I’M WALKING.” Id. Her medical

                                         -3-
records, the earliest of which date from 2002, show her most consistent

complaints have indeed been pain, weakness, muscle spasms, and knots in her

neck and upper extremities, particularly her right arm and shoulder. Her earliest

records show she was treated for osteoarthritis but, starting in the middle of 2005,

osteoarthritis is no longer discussed and the treatment notes begin to refer simply

to chronic pain. In 2005 and 2006, x-rays, a computed tomography (CT) scan,

and a magnetic resonance imaging (MRI) scan of her neck were completed. None

showed any medical reason for her complained-of pain and weakness.

      After filing for disability in June 2006, Peeper underwent a consultative

examination by Dr. Adel Malati on August 24, 2006. The report from that

examination shows that her chief complaint was aches and pains in her shoulders

and arms to the point where she could not raise her right arm without pain in the

middle of her arm. Dr. Malati reported Peeper told him “she did not have any

confirmed diagnosis, but stated that some physician told her that she might have

fibromyalgia.” Aplt. App., Vol. 1 at 207 (emphasis added). Dr. Malati’s range of

joint motion evaluation revealed she had a full range of motion. Id. at 211-12.

He completed an examination of her lumbosacral spine and cervical spine; it was

negative as well, showing that she had no pain, tenderness, or muscle spasms. Id.

at 213. Dr. Malati’s clinical impression was: “Unexplained pain in shoulders.

Osteoarthritis/presumable fibromyalgia.” Id. at 210. He noted:

                                         -4-
             The patient was seen walking in and out of the office without
      any difficulty. The patient did not use any assistive device. The
      patient has a nice, normal, steady gait. The patient was able to sit,
      stand, and lie down without difficulty. The patient has a full range
      of motion in her neck, shoulders, elbows, wrists, and hands. The
      patient has a good hand grip of 5/5 and equal bilaterally. Also the
      patient had full range of motion in her back, hips, knees, and ankles.
      The patient was able to do heel walking, toe walking, and heel-to-toe
      walking without difficulty. On examination of her shoulders the
      patient had some crackles in moving of her shoulders.

Id.

      Based on Dr. Malati’s consultative examination, a Physical RFC

Assessment was completed by Dr. Luther Woodcock on September 5, 2006,

finding Peeper could occasionally lift 50 pounds and frequently lift 25 pounds,

could stand and/or walk six hours in an eight-hour workday, sit for a total of six

hours in an eight-hour workday, and have unlimited pushing or pulling. The

assessment found no other limitations and noted no treating or examining source

statements regarding Peeper’s physical capacities in the file.

      The day after being examined by Dr. Malati, Peeper visited the emergency

room complaining that, because of his exam, she could not turn her head to the

left when she awoke that morning and her left shoulder pain was worse. Id. at

243. A note from her stated that she told Dr. Malati she could not raise her arms

above her head without pain and he stated “I will do it for you then so you

won[’]t cause yourself pain.” Id. at 244. The record also contains a medical

record, evidently from Peeper’s primary care physician, from August 28, 2006,

                                         -5-
wherein she continues to complain of injury during the consultative examination.

She reported how Dr. Malati assisted her to raise her hands above her head as she

was unable to do so by herself without pain. Id., Vol. 2 at 294. During the

manipulation she felt a pop in her left shoulder area and had burning pain that

worsened throughout the day. Id. The record stated: “Needs eval for possible

fibromyalgia” and a referral had been made for a neurology evaluation. Id.

      This was not the first time Peeper had been referred for a neurology

evaluation. A medical record from March 1, 2006, shows she requested, and was

given, a neurology referral after she received the negative results of the MRI. Id.

at 304. But we can find no record of an evaluation by a neurologist in the

administrative record. Nor, as noted above, can we find a formal fibromyalgia

diagnosis by any other provider, although medical professionals treated Peeper as

if she had fibromyalgia as time went by. The record does not show an

examination of whether Peeper had tenderness at any of the eighteen fixed

locations associated with fibromyalgia, see Sarchet v. Chater, 78 F.3d 305, 306

(7th Cir. 1996) (“[T]he only symptom that discriminates between [fibromyalgia]

and other diseases of a rheumatic character [are] multiple tender spots, more

precisely 18 fixed locations on the body . . . that when pressed firmly cause the

patient to flinch.”). Nor does the record indicate how, or if, other possible causes

for her pain were specifically ruled out. See Preston v. Sec’y of Health & Human

Servs., 854 F.2d 815, 817-18 (6th Cir. 1988) (recognizing that a fibrositis

                                         -6-
diagnosis—fibrositis is another term for fibromyalgia—is a “diagnosis by

exclusion and testing of certain focal tenderpoints on the body for acute

tenderness” (further quotation omitted)).

      Nevertheless, Peeper says she has consistently “sought treatment

concerning problems stemming from fibromyalgia,” and the ALJ “failed to

properly consider her fibromyalgia.” Aplt. Br. at 11. But the complete absence

of a fibromyalgia diagnosis in the record undercuts any assertion of error due to

the ALJ’s not specifically addressing “fibromyalgia,” as opposed to “chronic

pain.” 2 The ALJ’s failure to discuss the treatment notes mentioning fibromyalgia

may have meant he did not consider “[t]he longitudinal picture of [her]

fibromyalgia.” Aplt. Br. at 12. But that failure is insignificant. Those notes

provide ample evidence of her long-term claims of chronic pain, a fact credited by

the ALJ, but they wholly fail to prove the presence of fibromyalgia and offer no

proof as to the level of functional disability caused by the reported pain.

2
       Peeper also testified to being tired all the time and asserted that she had
“that fatigue syndrome.” Aplt. App., Vol. 1 at 76. This appears to be a reference
to chronic fatigue syndrome, another diagnosis sharing a number of symptoms
with fibromyalgia. See Wilson v. Astrue, 602 F.3d 1136, 1143 (10th Cir. 2010)
(noting that “complaints of severe pain that do not readily lend themselves to
analysis by objective medical tests are notoriously difficult to diagnose and treat,
and the diagnoses themselves are often overlapping”). However, it is unclear
whether her statement was self-diagnosis or yet another medical diagnosis not
present in the record.

                                         -7-
                                         II.

      Turning to Peeper’s second issue, the ALJ found she was not disabled,

despite her long-term medical treatment for complaints of pain (as discussed

above). This ultimate finding was grounded in the ALJ’s more specific finding

that her subjective complaints of pain lacked credibility. Peeper asserts the later

finding was “just a conclusion in the guise of findings” in that it was not “closely

and affirmatively linked to substantial evidence.” Kepler v. Chater, 68 F.3d 387,

391 (10th Cir. 1995) (quotations omitted).

      The ALJ specifically recognized Peeper’s testimony that

      [s]he stopped working[] because she could not stand any more. She
      has trouble moving her right arm and difficulty writing. The
      claimant reported that she is constantly in pain and tired all the time.
      She takes medication for depression and anxiety, which makes her
      dizzy. Her 10-year-old son does a lot of things for her.

Id., Vol. 1 at 60. And he concluded her medically determinable impairments,

including chronic pain and degenerative disc disease, could be reasonably

expected to produce the pain and fatigue of which she complained, and so

proceeded to determine the credibility of her complaints of disabling pain and

fatigue. See id. at 60-61.

      The ALJ wrote:

      After considering the evidence of record, the undersigned finds that
      the claimant’s medically determinable impairments could reasonably
      be expected to produce the alleged symptoms; however, the
      claimant’s statements concerning the intensity, persistence and
      limiting effects of these symptoms are not credible to the extent they

                                         -8-
      are inconsistent with the residual functional capacity assessment[3]
      for the reasons explained below.

Id. (emphasis added).

      The “reasons explained below” were three: (1) a temporal correlation

between Peeper’s separation from her husband and her application for social

security benefits, (2) some statements by Peeper as to the limitations imposed by

her conditions, which he thought undermined her disability claim, and

(3) Dr. Malati’s report which, as the only objective medical evidence of her

residual functional capacity, found essentially no limitations.

                                         A.

      As to the first reason, the ALJ noted “[t]he claimant reported that she did

not file for disability benefits until she and her husband separated.” Aplt. App.,

Vol. 1 at 61. As it turns out, the statement is incorrect, although explicable. At

the hearing Peeper seemed to agree her filing for disability came right after she

and her husband separated. According to her testimony, her last job was at a

laundry and, although she could not remember “how far back it was,” she quit in

2000. Id. at 69. When the ALJ sought to confirm a 2000 termination date, she

again said, “I’m not sure.” Id. at 70. Later, when the ALJ asked when she had

separated from her husband, she replied 2000. He then asked if there was any

connection between the couple’s separation and her quitting her job. She replied

3
      As noted above, he found Peeper had the RFC to perform light work
“except no overhead reaching or lifting of objects over 10 pounds.” Id. at 60.

                                         -9-
there was not. Id. at 72. But, at the end of his questioning, the ALJ reconfirmed

her separation from her husband was in 2000 and then said, “[j]ust about the time

you filed this application, right?” Id. at 78. Peeper responded, “I think so.” Id.

      The record tells a different story. Peeper’s work history report shows she

worked at “EG’s Laundry” from 2001 to 2002, not 2000. Id. at 168. And she

testified to trying to work a part-time job at the Caroline Inn after she quit the

laundry job but was unable to do so because of her pain and exhaustion. 4 Further,

the record contains June 8, 2006, social security applications alleging a disability

onset date of January 1, 2003. These facts undercut any supposed correlation

between Peeper’s separation and her benefit claim. It appears the ALJ simply

misunderstood the record, and Peeper did nothing at the hearing to correct his

misunderstanding.

                                          B.

      The ALJ’s second reason for finding Peeper’s claims of disabling pain to

lack credibility was:

      In terms of the claimant’s alleged disabling pain and fatigue, she
      reported in a function report that she is able to do laundry, some food
      preparation, shopping, and dusting with her left hand (Exhibit 4E).
      The claimant testified at the hearing that she weeds her flower beds.

Aplt. App., Vol. 1 at 61. But a thorough review of the record, including the

function report relied upon by the ALJ, gives us pause. The first concern is

4
      It appears she held that final job in January 2004 and only worked there for
about a week. Aplt. App., Vol. 1 at 144.

                                          -10-
Peeper’s ability to do laundry. She did report such an ability, but also reported an

inability to do the folding. Moreover, when her sister or mother came to her

house they would do her laundry. Id. at 162, 164. The ALJ next asserts Peeper

reported an ability to do “some food preparation, shopping, and dusting with her

left hand.” Id. at 61. But her report claims she could not cook big meals, but

prepared “[h]amburger helper, frozen dinner, cereal, frozen waffles, frozen

chicken strips, pizza, soup.” Id. at 162. She acknowledged doing grocery

shopping, but also reported a need to have a driver if she was traveling a long

distance, and when driving shorter distances she had a small pillow on which she

rested her right arm. Her report also said she could wipe counters and dust with

her left hand. 5 Finally, the ALJ referred to Peeper’s testimony about weeding her

flower beds. When the ALJ asked Peeper what she did for recreation, she

testified:

       I have, I love to go outside and work in flower beds, but I very rarely
       get to do that now. I’ll go out there and try to pull the weeds out,
       you know, get some of it done, but my son that’s ten years old, he
       helps me do a lot of stuff. He opens doors for me, doors that are
       hard for me to open. He will open doors for me, but recreation I like
       to just go outside and sit out in the yard and watch birds.

Aplt. App., Vol. 1 at 78. But her testimony must be considered along with her

function report (also relied on by the ALJ). In it she wrote she used to grow

5
       None of these minimal activities, standing alone, undercuts a claim of
disability. Hamlin v. Barnhart, 365 F.3d 1208, 1221 (10th Cir. 2004) (holding
that an ALJ may not “rely on minimal daily activities as substantial evidence that
a claimant does not suffer disabling pain.” (quotation omitted)).

                                        -11-
flowers, mow, and pull weeds, but now she “can’t get into flowers—can’t weed

flower bed. Can’t push or pull mower.” Id. at 164. And in a second, later

function report she simply stated “I cannot do outside work now.” Id. at 191.

The ALJ failed to adequately resolve the factual discrepancies.

      Thus, the first piece of evidence upon which the ALJ relied in discrediting

Peeper’s claims of disabling pain (implied secondary gain suggested by the

temporal relation between her marital difficulties and the filing for benefits) is

undercut by the record, and the second (the level of functional disability caused

by pain) is at least somewhat compromised.

      On the other hand, Dr. Malati’s report of the consultative examination is

potent evidence—a hands on evaluation, including range of motion tests, and his

observation of Peeper when she was unaware of being watched. After all, it

appears that Dr. Malati’s consultative examination was the only medical

examination to give a significant opinion as to the limitations of Peeper’s physical

capabilities. While the numerous records of her treating providers all recorded

Peeper’s reported symptoms, discussed her various infirmities, and listed the

medications prescribed for her, the only records (revealed by our record review)

specifically discussing the extent of her physical limitations are records from

January 3, 2007. They show Peeper was treated for a “Myofascial Strain C-

Spine” and told to engage in “Activity As Tolerated,” to be “Careful lifting,

twisting, or bending,” Aplt. App., Vol. 1 at 228, and “Careful lifting > 15 lbs,” id.

                                         -12-
at 223. Since Peeper’s longstanding, but subjective, complaints of disabling pain

are nowhere supported by objective medical evidence of record, Dr. Malati’s

report and observations might well be sufficient, standing alone, to factually

support the ALJ’s adverse credibility determination. But we cannot say it is

necessarily so without substituting our judgment for that of the ALJ. See, e.g.,

Allen v. Barnhart, 357 F.3d 1140, 1142, 1145 (10th Cir. 2004) (holding that

district court’s “post hoc effort to salvage the ALJ’s decision would require us to

overstep our institutional role and usurp essential functions committed in the first

instance to the administrative process”).

      First, Dr. Malati’s report is somewhat ambiguous. The report of his

examination shows no limitations, including—in his examination of Peeper’s

back—no pain, tenderness, or muscle spasms. Nevertheless, his clinical

impression was “[u]nexplained pain in shoulders. Osteoarthritis/presumable

fibromyalgia.” Id. at 210. Although it is not entirely clear, it appears his clinical

impression was not a formal diagnosis (osteoarthritis and fibromyalgia are

separate conditions and Dr. Malati’s examination found no pain or tenderness,

much less tenderness at specified focal points required for a diagnosis of

fibromyalgia) but merely an acknowledgment of Peeper’s past complaints.

Second, we cannot say that Dr. Malati’s report, standing alone, would (as a matter

of law) trump Peeper’s subjective complaints had the ALJ found them to be

                                         -13-
credible. The agency’ evaluation of pain is governed by 20 C.F.R.

§ 404.1529(c)(2), which reads:

      Consideration of objective medical evidence. Objective medical
      evidence is evidence obtained from the application of medically
      acceptable clinical and laboratory diagnostic techniques, such as
      evidence of reduced joint motion, muscle spasm, sensory deficit or
      motor disruption. Objective medical evidence of this type is a useful
      indicator to assist us in making reasonable conclusions about the
      intensity and persistence of your symptoms and the effect those
      symptoms, such as pain, may have on your ability to work. We must
      always attempt to obtain objective medical evidence and, when it is
      obtained, we will consider it in reaching a conclusion as to whether
      you are disabled. However, we will not reject your statements about
      the intensity and persistence of your pain or other symptoms or about
      the effect your symptoms have on your ability to work solely because
      the available objective medical evidence does not substantiate your
      statements.

(emphasis added); see also Huston v. Bowen, 838 F.2d 1125, 1130-31 (10th Cir.

1988) (holding that, absent objective medical evidence of limitations due to pain,

the ALJ still had to consider and make findings regarding the claimant’s

subjective pain evidence).

      Since we cannot say Dr. Malati’s report, standing alone, would be

sufficient to trump Peeper’s subjective pain complaints, any such finding would

constitute our credibility determination, not that of the ALJ. See, e.g., Kepler, 68
F.3d at 391 (holding that “[c]redibility determinations are peculiarly the province

of the finder of fact” (quotation omitted)). We are always hesitant to nitpick the

ALJ’s determination. See Castile v. Astrue, 617 F.3d 923, 929 (7th Cir. 2010) (in

reviewing an ALJ’s credibility determination, an appellate court “give[s] the

                                         -14-
opinion a commonsensical reading rather than nitpicking at it”). But here, the

ALJ gave three specific and somewhat summary reasons for his adverse

credibility finding, with no indication as to the weight assigned to each. Since we

cannot know the relative weight assigned to those factors we must remand for

clarification.

      The judgment of the district court is REVERSED, and the case is

REMANDED for further remand to the agency for additional proceedings in

accordance with this order and judgment.

                                                    Entered for the Court

                                                    Terrence L. O’Brien
                                                    Circuit Judge

                                        -15-