United States District Court, D. Arizona
William L. Grabowski, Plaintiff,
Carolyn W. Colvin, Defendant.
BRIDGET S. BADE, Magistrate Judge.
William L. Grabowski (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying his application for disability insurance benefits under the Social Security Act (the Act). The parties have consented to proceed before a United States Magistrate Judge under 28 U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons, the Court reverses the Commissioner's decision and remands for further proceedings.
I. Procedural Background
On August 25, 2010, Plaintiff applied for disability insurance benefits and supplemental security income under Titles II and XVI of the Act. (Tr. 9.) Plaintiff alleged that he had been disabled since March 1, 2008. ( Id. ) After the Social Security Administration (SSA) denied Plaintiff's initial application and his request for reconsideration, he requested a hearing before an administrative law judge (ALJ). After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 9-22.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1-5); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council.) Plaintiff now seeks judicial review of this decision under 42 U.S.C. § 405(g).
II. Medical Record
The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff's health. The record also includes opinions from State Agency Physicians who either examined Plaintiff or reviewed the records related to his health, but who did not provide treatment.
A. Christopher Fleming, M.D.
In May 2007, Plaintiff sought treatment from Dr. Fleming. (Tr. 318.) Plaintiff reported that he had injured his left knee, neck, and upper back in an accident at work, and had multiple surgeries on his left knee. ( Id. ) Dr. Fleming noted that a May 2007 x-ray and a June 2007 MRI confirmed "osteochondritis dissecans" in Plaintiff's left knee. ( Id. ) Plaintiff had arthroscopic surgery on his left knee on September 5, 2007. ( Id. ) After that surgery, Plaintiff reported continuing pain in his left knee and that it periodically "gave out." ( Id. )
X-rays and an MRI of Plaintiff's left knee in early 2008 showed "no change in the osteochondritis, " but showed mild degenerative changes in the left knee, including "full thickness defects of articular cartilage and defect of the underlying bone." (Tr. 318-19.) In March and April 2008, Dr. Fleming noted that Plaintiff had had "a couple falls" and had "failed conservative treatment." (Tr. 307-08.) Plaintiff had a repeat arthroscopic surgery on his left knee in August 2008. (Tr. 319.) Plaintiff continued to report left knee pain after that surgery, and also reported left hip pain. (Tr. 319.) In November 2008, Dr. Fleming noted that Plaintiff had "moderate-severe" atrophy of the left quadriceps and had recently reinjured his left knee when getting up from the couch. (Tr. 287.)
Dr. Fleming's treatment notes from December 2008 diagnose chondromalacia patella (also known as patellofemoral pain syndrome or "PFPS"). (Tr. 282-83). Dr. Fleming found mild crepitation in both knees and a "positive patellar grind" on the left knee. (Tr. 284-85.) Following a final orthopedic consultation, on December 14, 2009, Dr. Fleming summarized his findings in a report, noting that Plaintiff's left knee continued to be painful and periodically gave out, his left hip continued to be painful from compensating for the left knee injury, and that similar compensatory overuse had also caused his right knee to become symptomatic. (Tr. 317-24.) Dr. Fleming assessed work restrictions including "[n]o prolonged standing and walking. No running or jumping. No repetitive squatting or kneeling. [And n]o climbing." (Tr. 323.)
B. G. Sunny Uppal, M.D. and Neil J. Halbridge, M.D.
Dr. Uppal began treating Plaintiff' in December 2008. (Tr. 510.) He noted Plaintiff's complaints of bilateral knee pain, mid-back pain that radiated to both legs, left hip pain, and insomnia. (Tr. 510.) Dr. Uppal noted that Plaintiff's knee pain was exacerbated by "[p]ushing, kneeling, squatting, repetitive use, prolonged standing, walking, pulling, lifting, [and] bending." (Tr. 511.) He diagnosed a posttraumatic left-knee osteochondral defect. (Tr. 513.)
On December 3, 2009, Dr. Uppal found the presence of effusion in Plaintiff's right knee, a positive McMurray's test, and that the range of motion (ROM) in flexion was limited to 90 degrees. (Tr. 569.) Based on these findings, he diagnosed Plaintiff's right knee with the same osteochondral defect established in his left knee. ( Id. ) This diagnosis was corroborated by an MRI of the right knee showing tears in the medial and lateral meniscus. (Tr. 579.)
On December 11, 2010, Dr. Uppal reported that the ROM in both of Plaintiff's knees was limited to 90 degrees of flexion, with "medial joint line tenderness" in the right knee and a "[p]ositive patellar apprehension" test of the left knee. (Tr. 414.) He also noted that Plaintiff's past complaints of lower back pain were supported by findings at that visit including observations of lower-back spasms, a ROM limited to ten degrees of extension, and straight-leg-raise tests positive for back, buttock, and leg pain. ( Id. ) Dr. Uppal noted that a lumbar spine MRI confirmed his diagnosis of a 5-millimeter herniated disc at L5-S1. ( Id. )
Dr. Uppal also indicated that Plaintiff had been seeing a cardiologist for congestive heart failure and cardiac dysrhythmia, and that he needed a total replacement of his left knee. (Tr. 413.) Dr. Uppal wrote that Plaintiff was "applying for Social Security Disability. [He felt that] if you add the right knee, left knee, [and] low back [to] his restrictions... he would be limited to sedentary work only. However, when combined with his cardiac problem, he is unable to go to work and he would be a candidate for Social Security Disability." (Tr. 414.)
On January 20, 2011, Dr. Uppal noted another positive McMurray's test and lower back spasms. (Tr. 462.) He diagnosed "right knee chondromalacia with medial meniscal degenerative changes, " "left knee multiple arthroscopies, " and "lumbar radiculitis." (Tr. 463.) He again stated that "because of all these issues of the right knee, left knee, low back pain, [and] cardiac dysfunction, the patient is a candidate for Social Security Disability." ( Id. ) In June 2012, Dr. Uppal reported that he had planned surgery for Plaintiff's right knee, but the cardiologist did not clear Plaintiff for surgery due to his cardiac dysrhythmia. (Tr. 1212.) In several treatment notes, Dr. Uppal indicated that symptoms in Plaintiff's knees, including "swelling, clicking, locking, popping, grinding, stiffness, weakness, and giving way, " were aggravated by prolonged standing and walking, pushing, pulling, kneeling, squatting, bending, climbing stairs, and repetitive use. (Tr. 466, 511.) He determined that Plaintiff was "precluded from doing heavy lifting, prolonged weight bearing with the right and left knees and legs" (Tr. 478), "stair climbing, and walking on uneven surfaces." (Tr. 499.)
During this same period, Plaintiff also saw Dr. Halbridge. (Tr. 426.) During his initial evaluation on July 28, 2009, Dr. Halbridge noted Plaintiff's complaints of pain in his mid-back, left hip, and bilateral knees, and that his lumbar spine ROM was limited to ten degrees of extension and ten degrees of left lateral bending. (Tr. 430.) He diagnosed left-knee problems, and "5-millimeter disc herniation at L5-S1" based on a November 2009 lumbar spine MRI. (Tr. 325, 432.) Dr. Halbridge concluded that Plaintiff's knee pain was aggravated by prolonged standing and walking, climbing, running, squatting, kneeling, and walking on inclined surfaces (especially descending stairs). (Tr. 432.) He found Plaintiff precluded from "squatting, kneeling, climbing, prolonged standing, and prolonged walking, " and from "frequent bending, stooping, lifting, and heavy pushing, pulling, or lifting weight over 20 pounds, " due to his knee and hip pain. (Tr. 433-34.)
C. Chirag N. Amin, M.D.
In November 2011, Plaintiff saw Dr. Amin regarding his bilateral knee pain, lower back pain, and shoulder pain. (Tr. 1055-74.) Dr. Amin's examination revealed tenderness and muscle spasms in Plaintiff's thoracic/lumbar paravertebral muscles, a "[m]arkedly decreased" lumbosacral ROM upon flexion, extension, and lateral bending bilaterally, and positive straight-leg-raise tests. (Tr. 1058.) Dr. Amin also reviewed the records of Plaintiff's treatment with Dr. Uppal, Dr. Halbridge, and Dr. Fleming, and the assessment of Plaintiff's heart condition from Dr. Ramtin Anousheh. (Tr. 1058-61.)
On a Lower Extremity Impairment Questionnaire, Dr. Amin opined that Plaintiff could sit for two hours in an eight-hour workday and stand/walk for "0 to 1" hours; would need to be able to take a ten-minute break from sitting "to get up and move around" every thirty minutes; could not stand/walk continuously in a work setting; could lift up to twenty pounds occasionally and carry up to ten pounds occasionally; would need to have his left leg elevated for ten minutes every one to two hours; would frequently suffer pain, fatigue, or other symptoms that would interfere with his attention and concentration; was capable of no more than "low stress" work; and should avoid exposure to heights, pushing, pulling, kneeling, bending, and stooping. (Tr. 1069-73.)
D. Ramtin Anousheh, M.D.
Dr. Anousheh began seeing Plaintiff in March 2010 and completed a Cardiac Impairment Questionnaire on October 3, 2011. (Tr. 1048-53.) He diagnosed Plaintiff with non-ischemic cardiomyopathy and chronic systolic heart failure, characterized by shortness of breath, fatigue, and weakness, and exacerbated by physical exertion and hot weather. (Tr. 1048, 1050.) Dr. Anousheh further assessed that, in an eight-hour workday, Plaintiff could sit for "0 to 1" hours, stand/walk for "0 to 1" hours, and could lift/carry up to twenty pounds occasionally. (Tr. 1050-51.) He also found that Plaintiff's symptoms would frequently interfere with his attention and concentration, that he could only perform "low stress" work, and that he should avoid temperature extremes, humidity, heights, pushing, pulling, kneeling, bending, and stooping. (Tr. 1051-52.)
E. Reynaldo Abejuela, M.D.
On February 26, 2011, Plaintiff saw State Agency consulting psychiatrist Dr. Abejuela. (Tr. 616-23.) Plaintiff reported depression and anxiety, problems sleeping, low energy, memory problems, and being socially withdrawn. (Tr. 617.) In his mental status examination (MSE), Dr. Abejuela observed that Plaintiff spoke with a mildly depressive tone, exhibited a mildly depressed and anxious affect, and was preoccupied with his pain. (Tr. 619-20.) He diagnosed major depressive disorder (Tr. 620), and assessed Plaintiff's impairments in occupational and social functioning as "none to mild." (Tr. 621-22.) Dr. Abejuela assessed slight impairments in Plaintiff's concentration, persistence, and pace, his ability to understand, carry out, and to remember complex instructions, his ability to respond to coworkers, supervisors, the public, and to respond to ...