United States District Court, D. Arizona
Bridget S. Bade United States Magistrate Judge.
Kathleen Cathy Muhammad seeks judicial review of the final
decision of the Commissioner of Social Security (the
Commissioner) denying her application for benefits under the
Social Security Act (the Act). The parties have consented to
proceed before a United States Magistrate Judge pursuant to
28 U.S.C. § 636(b), and have filed briefs in accordance
with Rule 16.1 of the Local Rules of Civil Procedure. As
discussed below, the Court reverses the Commissioner's
decision and remands for further proceedings.
February 2012, Plaintiff filed applications for disability
insurance benefits and supplemental security income benefits
under Titles II and XVI of the Act. (Tr. 12.)Plaintiff alleged
a disability onset date of February 10, 2012. (Id.)
After the Social Security Administration (SSA) denied
Plaintiff's initial application and her request for
reconsideration, she requested a hearing before an
administrative law judge (ALJ). (Id.) After
conducting a hearing, the ALJ issued a decision finding
Plaintiff not disabled under the Act. (Tr. 12-23.) This
decision became the final decision of the Commissioner when
the Social Security Administration Appeals Council denied
Plaintiff's request for review. (Tr. 1-6.) See
also 20 C.F.R. § 404.981 (explaining the effect of
a disposition by the Appeals Council). Plaintiff now seeks
judicial review of this decision pursuant to 42 U.S.C. §
record before the Court establishes the following history of
diagnoses and treatment related to Plaintiff's alleged
impairments. The record also includes several medical
Medical Treatment Evidence
First Medical Plus
2011, Plaintiff began treatment at First Medical Plus (FMP)
for injuries she sustained in a car accident earlier that
month. (Tr. 331.) Dr. Lucinda R. Michel, D.O., provided most
of Plaintiff's treatment before the disability onset
date. She diagnosed headaches, neck and back pain and strain,
and upper and lower radiculopathy. (Tr. 321-30.) In February
2012, Plaintiff complained of worsening headaches, spinal
symptoms, and pain or parasthesias in her upper extremities.
(Tr. 320.) Dr. Michel gave Plaintiff a Toradol injection and
prescribed medication. (Tr. 302, 545, 1238.)
2012, Nurse Practitioner (NP) Laura Coe assumed
Plaintiff's care at FMP. (Tr. 304.) Plaintiff complained
of headaches, neck and back pain, pain in her upper and lower
extremities, and right shoulder pain. (Tr. 304.) On
examination, NP Coe assessed Plaintiff with parasthesias,
hand weakness, cervical, thoracic and lumbar pain, arm and
hand pain, shoulder pain, and sleep disturbances.
(Id.) At that time, Plaintiff was pregnant and
declined medications. (Id.) NP Coe continued to
treat Plaintiff during the relevant period and frequently
recorded similar observations of Plaintiff's condition.
(Tr. 303, Jun. 21, 2012; Tr. 458, July 2012 (“not
pregnant, ” medications continued, with the addition of
Vicodin); Tr. 455-56, Aug. 10, 2012; Tr. 453-54, Aug. 24,
2012; Tr. 451- 52, Sept. 21, 2012; Tr. 449-50, Oct. 4. 2012;
Tr. 496-97, Dec. 14, 2012; Tr. 855-56, Feb. 19, 2013; Tr.
851-52, Apr. 5, 2013; Tr. 845-46, June 14, 2013; Tr. 833-34,
Sept. 27, 2013; Tr. 825-26, Oct. 25, 2013; Tr. 822-23, Dec.
30, 2013; Tr. 820-21, Feb. 28, 2014; Tr. 817-18, Apr. 25,
2014; Tr. 812-13, May 30, 2014; Tr. 809-10, June 16, 2014.)
However, other treatment notes include limited findings and
do not mention Plaintiff's back or shoulder pain. (Tr.
853-54, Mar. 5, 2013 (no pedal edema in lower extremities,
elevated blood pressure); Tr. 849-50, Apr. 19, 2013 (no edema
in lower extremities, hypertension (HTN)); Tr. 847-48, May
10, 2013 (HTN); Tr. 843-44, June 28, 2013 (no edema in lower
extremities, HTN); Tr. 841-42, July 19, 2013 (pain in big
toe, no edema, HTN); Tr. 839-40, Aug. 1, 2013 (no edema, big
toe pain, HTN); Tr. 829-30, Oct. 4, 2013 (pelvic density
x-ray showed increased density over sacrum, hip pain).)
Sonoran Pain Management
2011, Dr. Michel referred Plaintiff to Dr. Minesh Zaveri,
D.O., at Sonoran Pain Management. (Tr. 236-38.) On
examination, Dr. Zaveri noted that Plaintiff walked with a
painful gait and had tenderness throughout her cervical and
lumbar spine. (Id.) Plaintiff had full strength in
her upper and lower extremities and a normal range of motion
in her lumbar spine. (Tr. 237.) Dr. Zaveri diagnosed cervical
and lumbar degenerative disc disease and spondylosis.
(Id.) Dr. Zaveri gave Plaintiff lumbar epidural
steroid injections on December 20, 2011 (Tr. 232), and lumbar
medial branch nerve blocks on April 10 and 24, 2012. (Tr.
220, 218.) During a May 9, 2012 appointment, Plaintiff
reported that the injections provided pain relief for twelve
hours. (Tr. 366.) On examination, Plaintiff had a positive
straight leg raise test, full strength in her upper and lower
extremities, tenderness in her cervical, thoracic and lumbar
spine, and a painful gait. (Tr. 367-68.)
Dr. Bogdan Anghel
referral from Dr. Michel, Plaintiff sought treatment from Dr.
Bogdan Anghel at Pain Management and Rehabilitation Medicine
Center for shoulder pain in October 2012. (Tr. 785.) Dr.
Anghel reviewed an MRI that showed evidence of a rotator cuff
tear. (Id.) Plaintiff reported that she had received
physical therapy and pain management for her shoulder pain
and that the treatment was unsuccessful. (Id.) On
examination, Plaintiff's shoulder was positive for pain.
(Id.) Neer and Hawkins range-of-motion tests were
positive for a rotator cuff tear on the right side.
(Id.) Plaintiff had spine tenderness and a positive
Spurling test. (Id.) Plaintiff had weakness on
abduction and external rotation of her right arm.
(Id.) Dr. Anghel diagnosed right shoulder rotator
cuff tendinopathy. (Id.) He administered a steroid
injection and referred Plaintiff to Dr. Jeffrey S. Levine,
M.D. (Tr. 785-86.)
January 17, 2013, Plaintiff returned to Dr. Anghel for low
back and hip pain. (Tr. 779-80.) Plaintiff reported that
lumbar epidural steroid injections in May 2012 had provided
some relief, but the pain had returned. (Id.) On
examination, Plaintiff had a normal gait, weakness, decreased
sensation in her lateral thighs, calves and feet, and a
restricted range of motion. (Id.) Dr. Anghel
diagnosed lumbar spondylosis with facet pain, mechanical back
pain, and lumbosacral radiculitis. (Tr. 780.)
January 28, 2013, Dr. Anghel gave Plaintiff lumbar injections
of Kenalog and Marcaine. (Tr. 777.) In February 2013,
Plaintiff reported that she was “improving.” (Tr.
733.) Dr. Anghel noted that the injections resolved
Plaintiff's low back pain, but not her neck pain.
(Id.) On examination, Plaintiff had right shoulder
pain and a decreased range of motion in her cervical spine.
(Id.) In February 2013, Dr. Anghel administered
Kenalog and Marcaine injections in the cervical spine. (Tr.
2013, Dr. Anghel examined Plaintiff for recurrent pain in the
right cervical and lumbar spine. (Tr. 769.) He found that
Plaintiff had an antalgic gait, tenderness and pain in her
head and neck, and a limited range of motion in her neck and
back. (Tr. 769.) Plaintiff had no pain on palpation of her
hips or extremities, had full range of motion in her upper
and lower extremities, and had full muscle strength in her
hips and upper and lower extremities. (Tr. 770.) Dr. Anghel
concluded that prior pain control treatments were
ineffective. (Tr. 770.) Later that month, Dr. Anghel
administered Kenalog and Marcaine injections for cervical and
lumbar spondylosis. (Tr. 767, 765.) During a May 21, 2013
appointment, Dr. Anghel noted that the spinal injections did
not provide Plaintiff significant pain relief. (Tr. 763.) He
opined that Plaintiff's pain was likely generated in the
musculature and, therefore, recommended trigger point
injections on a bi-weekly basis. (Id.) On
examination, Plaintiff had a limited range of motion in her
cervical and lumbar spine, tenderness on palpation of the
cervical and lumbar paraspinals, and pain in the lumbar and
cervical paraspinals. (Id.) She had normal muscle
strength and reflexes. (Id.)
Jeffery S. Levine, M.D.
noted above, while Plaintiff was receiving treatment from Dr.
Anghel, he referred Plaintiff to Dr. Levine for right
shoulder pain. (Tr. 758.) Dr. Levine examined Plaintiff on
November 2, 2012. (Tr. 758-60.) Plaintiff reported that she
had neck, right shoulder, and low back pain. (Id.)
She also reported that a recent corticosteroid injection to
her right shoulder improved her pain, but she remained
symptomatic. (Tr. 758.) On examination, Plaintiff had a full
range of motion in her cervical spine, a “full range of
motion of passive motion” in the right shoulder, and
positive impingement signs in the right shoulder. (Tr. 759.)
Dr. Levine diagnosed cervical strain and “symptomatic
right partial tear of rotator cuff with the possibility of
concomitant labral pathology.” (Id.) Dr.
Levine noted that Plaintiff was pregnant at the time,
therefore, he did not prescribe injections and recommended
against the use of anti-inflammatories and narcotics.
a December 12, 2012 appointment with Dr. Levine, Plaintiff
reported significant pain in her right shoulder. (Tr. 757.)
She reported that a cortisone injection resulted in a
“substantial decrease in her symptoms, ” but the
pain had returned. (Id.) Plaintiff also reported
neck pain. (Id.) On examination, Plaintiff had a
full range of motion of the neck, a “relatively full
range of motion of the right shoulder, ” and positive
impingement signs. (Id.) Dr. Levine diagnosed
symptomatic partial tear of the rotator cuff and possible
labral pathology of the right shoulder. (Id.) Dr.
Levine recommended and administered a corticosteroid
injection to Plaintiff's right shoulder. (Tr. 757.)
a January 2013 appointment, Plaintiff reported persistent
pain in her right shoulder. (Tr. 753.) On examination,
Plaintiff had a drooping right shoulder, positive impingement
signs, and positive labral loading signs. (Id.) Dr.
Levine noted that MRI results showed “evidence of
labral pathology which is chronic in nature involving both a
complete tear and degeneration, ” along with
“evidence of rotator cuff tendinopathic changes.”
(Id.) Dr. Levine diagnosed “[s]capular
dyskinesia of the right shoulder with evidence of labral
pathology.” (Tr. 753.) Dr. Levine advised Plaintiff
that she had two treatment options: (1) a corticosteroid
injection to the shoulder and a strengthening program; or (2)
surgical reconstruction of the labrum. (Id.)
Plaintiff elected the injection and strengthening program.
(Id.) Dr. Levine informed Plaintiff that if she did
not improve, surgery would be the only other means of
treatment. (Id.) Plaintiff told Dr. Levine that she
would “consider surgery.” (Id.) Dr.
Levine administered a right shoulder steroid injection and
noted that after the procedure, Plaintiff's “pain
was completely abolished and her drooping shoulder was no
longer present.” (Id.)
an April 18, 2013 appointment with Dr. Levine, Plaintiff
reported that she had seen Dr. Anghel and had a spinal block.
(Tr. 752.) Plaintiff stated she did not experience pain
relief, but “her radicular pain seem[ed] to be somewhat
improved.” (Id.) Plaintiff reported ongoing
right shoulder pain. (Id.) On examination Plaintiff
had a limited range of motion in her neck, drooping of the
right shoulder, and pain with impingement. (Id.) Dr.
Levine noted that Plaintiff had evidence of referred pain
from discogenic cervical disease into the right scapular
region. (Id.) He also noted evidence of a right
labral tear and a partial rotator cuff tear. (Tr. 752.)
However, because Plaintiff experienced pain relief after a
trigger point injection, Dr. Levine opined, “surgery is
still not indicated with respect to the shoulder
an April 29, 2013 appointment, Plaintiff reported her
shoulder pain had dramatically improved as a result of
trigger point injections to her neck. (Tr. 750.) On
examination, Plaintiff had a full range of motion in her
neck, a full range of motion in her right shoulder, no gross
motor weakness in her right shoulder, positive impingement
signs, and negative labral loading. (Tr. 750.) Dr. Levine
recommended trigger point injections in the cervical spine.
He stated that if Plaintiff continued to respond, then he
would not recommend additional treatment. (Id.)
However, Dr. Levine noted that he would recommend a more
aggressive treatment plan for Plaintiff's shoulder if she
did not respond. (Id.)
Plaintiff's last recorded visit with Dr. Levine on May
20, 2013, she reported that her shoulder and arm pain had
markedly improved. (Tr. 749.) However, she continued to have
pain when lying on her right shoulder and reported symptoms
that suggested ongoing C6 radiculopathy. (Id.) She
reported pain in her right arm with repetitive overhead use,
but it was “quite moderate.” (Id.)
Plaintiff had instability symptoms in the right shoulder.
(Id.) On examination Plaintiff had a full range of
motion in her neck and in both shoulders. (Id.) She
had no motor weakness. (Id.) Dr. Levine found
evidence of a minor tendinopathy of the right shoulder with
partial tears of the rotator cuff, and “evidence of
resolving cervical radiculopathy post block.”
(Id.) He advised Plaintiff that if her pain
“markedly worsen[ed] she [was] a candidate for a
diagnostic arthroscopy and either repair or debridement of
the cuff.” (Id.) Dr. Levine released Plaintiff
to follow-up on an as needed basis. (Id.)
Jerry Thomas, M.D.
of the initial disability determination, state agency
reviewer Dr. Jerry Thomas, M.D., completed a physical
capacities assessment form. (Tr. 269-76.) Dr. Thomas's
assessment was based on the mistaken belief that Plaintiff
was last insured for disability insurance benefits through
December 31, 2005. (Tr. 269.); see Lester v. Chater,
81 F.3d 821, 825 (9th Cir. 1996) (stating that a claimant
seeking disability insurance benefits must establish that she
was disabled prior to the date last insured). Plaintiff's
date late insured was September 30, 2016. (Tr. 14, 129.) Dr.
Thomas assessed physical capacities consistent with light
work. (Tr. 270.) Specifically, he determined that Plaintiff
could occasionally lift and carry twenty pounds, frequently
lift and carry ten pounds, stand or walk about six hours in
an eight-hour workday, and sit for about six hours in an
eight-hour work day. (Tr. 270.) He found no limitations in
Plaintiff's abilities to push and pull, “other than
as shown for lift and/or carry, ” and no limitations in
her manipulative abilities. (Tr. 271-72.) He also found no
limitations in Plaintiff's abilities to climb, balance,
stoop, kneel, crouch, and crawl. (Tr. 271.) Dr. Thomas cited
medical records from January to April 2012 to support his
findings. (Tr. 276.)
Bill F. Payne, M.D.
December 2012, Dr. Bill Payne, M.D., completed a case
analysis as part of the reconsideration determination. (Tr.
486.) Dr. Payne mistakenly believed that Plaintiff's date
last insured was December 31, 2005. (Tr. 486.) Based on that
belief, he concluded there was no available medical evidence
of record covering the period on or before that date.
(Id.) Therefore, he ...