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Zimmerman v. Commissioner of Social Security Administration

United States District Court, D. Arizona

August 14, 2019

Zelpha Tami Zimmerman, Plaintiff,
Commissioner of Social Security Administration, Defendant.



         Plaintiff Zelpha Tami Zimmerman brought this action pursuant to 42 U.S.C. § 405(g) seeking judicial review of a final decision by the Commissioner of Social Security (“Commissioner”). Plaintiff raises two issues on appeal: 1) the Administrative Law Judge (“ALJ”) erred by failing to give germane reasons before rejecting the limitations suggested by Karen Lunda's functional capacity evaluation report; and 2) the ALJ erred by failing to evaluate Plaintiff's symptoms pursuant to Social Security Ruling (“SSR”) 16-3p. (Doc. 15).

         Before the Court are Plaintiff's Opening Brief, Defendant's Response, and Plaintiff's Reply. (Docs. 15, 22, & 25). The United States Magistrate Judge has received the written consent of both parties and presides over this case pursuant to 28 U.S.C. § 636(c) and Rule 73, Federal Rules of Civil Procedure. For the reasons stated below, the Court finds that this matter should be remanded for further administrative proceedings. . . .

         I. Procedural History

         Plaintiff filed an application for social security disability benefits on December 13, 2013. (Administrative Record (“AR”) 133). Plaintiff alleged disability beginning on November 26, 2013 based on inability to walk, severed tendons in both feet, and bilateral ankle problems. (AR 67). Plaintiff's application was denied upon initial review (AR 73) and on reconsideration (AR 80). A hearing was held on August 1, 2016 (AR 36), after which ALJ Yasmin Elias found, at Step Four, that Plaintiff was not disabled because she could perform her past relevant work as an optician. (AR 25). On January 24, 2018 the Appeals Council denied Plaintiff's request to review the ALJ's decision. (AR 1).

         Plaintiff's date last insured (“DLI”) for DIB purposes is December 31, 2018. (AR 19). Thus, to be eligible for benefits, Plaintiff must prove that she was disabled during the time period of her alleged onset date (“AOD”) of November 26, 2013 and her DLI of December 31, 2018.

         II. Factual History[1]

         Plaintiff was born on February 3, 1964, making her 49 years old at the AOD of her disability. (AR 67). She completed two years of college and has worked as a licensed optician since 1990. (AR 164).

         A. Treating Physicians

         On December 18, 2012 Plaintiff was seen for evaluation of left thumb pain. (AR 250). X-rays showed basal joint arthritis, subluxation mild, some loss of joint space, and some sclerosis, and Plaintiff opted to treat with a splint.

         On February 8, 2012 Plaintiff reported severe headaches on a daily basis, was forgetful, and losing her balance. (AR 410).

         On February 1, 2013 Plaintiff reported an average of two headaches monthly, lasting several days at time, associated with visual changes. (AR 387). She also had occasional head tremor and clenching of the right arm.

         On March 21, 2013 Plaintiff reported severe headaches in the right temporal area that come and go, not relieved with Aleve, Imitrex, or Vicodin. (AR 389).

         On April 11, 2013 Plaintiff reported her headaches were improved with Topamax. (AR 385). She also reported almost daily left arm shaking, and vague left eye visual changes at night.

         On August 2, 2013 Plaintiff was seen for left foot and ankle pain and reported significant pain with weightbearing, worse with activity. (AR 248). The impression was heel cord tendinitis and bilateral plantar fasciitis, and she was recommended for shoe orthosis and dorsiflexion splint.

         On September 13, 2013 Plaintiff complained of left ankle pain after rolling her ankle and was referred for a MRI. (AR 246).

         On October 8, 2013 Plaintiff reported a significant amount of pain in the feet and ankles that limited her activity. (AR 244). Plaintiff rejected injections and casting and was recommended to do stretching, physical therapy, wear a boot, and limit weightbearing on the left.

         On November 7, 2013 Plaintiff was doing physical therapy and was slightly better, but reported right ankle problems and instability and was referred for a MRI. (AR 242).

         On November 26, 2013 Plaintiff reported significant left foot pain. (AR 240). The MRI showed some changes in the navicular joints consistent with arthritis, fibrocartilaginous calcaneonavicular coalition, and some evidence of osteochondral lesion. She chose to have surgery on the left foot for excision of the calcaneonavicular coalition and release of the plantar fascia.

         On December 4, 2013 Plaintiff had surgery on her left foot. (AR 254).

         On December 16, 2013 Plaintiff had minimal complaints of pain after surgery. (AR 238).

         On January 7, 2014 Plaintiff was doing well and complained of mild pain and stiffness, and was referred for physical therapy. (AR 236).

         On February 7, 2014 Plaintiff complained of mild discomfort and had a mild limp; range of motion was significantly improved with PT but she still had problems with long walks. (AR 234).

         On May 9, 2014 Plaintiff reported bilateral thumb and hand pain, and ring and small fingers catching and locking. (AR 228). Plaintiff reported months to years of joint pain in her thumbs, but recently getting worse and over the counter medications not helping. The assessment was lateral thumb CMC arthritis, left worse than right, and swan-neck deformity/locking of bilateral ring and small fingers. Plaintiff did not want an injection but would try a brace and Voltaren gel.

         On May 12, 2014 Plaintiff had an ankle sprain and contusion after she rolled her ankle and a trashcan fell on her. (AR 224). X-rays of the ankle showed no abnormalities.

         On June 13, 2014 Plaintiff was doing significantly better after surgery and with PT, complaining of less pain, and walking better. (AR 221).

         On July 3, 2014 Plaintiff had improved hand arthritis and de Quervain's after injections, no numbness and tingling, no locking or clicking, and no sharp pains. (AR 219).

         On October 6, 2014 Plaintiff reported pain in both ankles, worse with activity, and episodes of popping and rolling. (AR 273). On exam she had some tenderness with palpation, full range of motion, no swelling on the right, and walked with a slight limp.

         On October 9, 2014 Plaintiff reported headaches for the past 3-4 months. (AR 367).

         On October 16, 2014 Plaintiff had a MRI of the right ankle which showed calcaneonavicular coalition, mild posterior tibialis tendinosis, moderate middle and anterior subtalar joint degenerative arthrosis, mild/moderate plantar fasciitis, and mild sinus tarsi edema. (AR 265-67). A MRI of the left ankle showed bifurcate ligament sprain, low-grade extensor digitorum brevis strain, and mild insertional posterior tibialis tendinosis. (AR 269-71).

         On November 14, 2014 Plaintiff had pain in the left ankle after a twisting injury and was recommended to continue using her ankle brace, icing, and inflammatory medication. (AR 263).

         On November 25, 2014 Plaintiff had increased pain in the right foot and was recommended for surgery. (AR 261). The impression was bilateral foot and ankle pain, tarsal ...

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