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Michael Castro v. Michael J. Astrue

August 8, 2011


The opinion of the court was delivered by: Sheila K. Oberto United States Magistrate Judge


Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying his application for disability insurance benefits ("DIB") pursuant to Title II of the Social Security Act (the "Act"). 42 U.S.C. § 405(g). The matter is currently before the Court on the parties' briefs, and was referred to the Honorable Sheila K. Oberto, United States Magistrate Judge. 28 U.S.C. § 636; Local Rule 302(c)(15).


Plaintiff was born in 1962, has a high school education, and has completed approximately one year of college; Plaintiff previously worked as a janitor. (Administrative Record ("AR") 28, 44.) On March 31, 2006, Plaintiff filed an application for DIB, alleging disability beginning December 10, 2005, due to carpal tunnel syndrome, tendinitis, and pain in his neck, shoulder, arm, elbow, forearm, wrists, hand, back, hips, knees, and ankles. (AR 67, 73.)

A. Medical Evidence

On February 1, 2006, Plaintiff presented with a history of bilateral carpal tunnel syndrome to Dr. Robert M. Mochizuki. (AR 235-39.) He complained of aching in both hands with sensory loss in his thumb, index, and middle finger of his right hand. (AR 235.) Plaintiff related to Dr. Mochizuki that his condition was aggravated by repetitive hand use and indicated that the onset of the pain occurred while he was using a broken vacuum cleaner at work, holding it together as he performed his work activities. As a result, his hand began to hurt on or around December 5, 2005. (AR 235.) Dr. Mochizuki reported that Plaintiff underwent an electromyogram in December 2005 which demonstrated severe right carpal tunnel syndrome and a mild median neuropathy of the left hand. (AR 235.) Dr. Mochizuki also noted that Plaintiff was treated by Dr. Jose L. Ibarra for carpal tunnel syndrome, and Plaintiff was provided with braces, prescribed Naprosyn, and was placed on light duty. (AR 235.) Plaintiff had also been prescribed Vicodin and Ambien. (AR 235.)

Dr. Mochizuki assessed Plaintiff as having bilateral carpal tunnel syndrome, with the right hand and arm more symptomatic than the left; repetitive strain injury of the upper extremities; and extensor tenosynovitis of the right wrist and hand. (AR 238). He recommended that the Naprosyn prescription be discontinued and that Plaintiff begin to take Daypro. Plaintiff was precluded from repetitive grasping, pushing, and pulling activities with his upper extremities, and was scheduled for a right carpal tunnel release surgery. (AR 238.) Dr. Mochizuki also reported that Plaintiff would be temporarily and totally disabled for two weeks after the surgery, followed by a period of light duty activity for six weeks. He anticipated that Plaintiff would require physical therapy three times per week for three weeks; he stated that some permanent residuals were anticipated following surgery. (AR 238.)

On April 10, 2006, Dr. Mochizuki performed a right carpal tunnel surgical release on Plaintiff's right hand. (AR 393-94.) Plaintiff returned for a follow-up examination on April 19, 2006. (AR 388.) Dr. Mochizuki determined that Plaintiff was temporarily and totally disabled for three weeks and recommended physical therapy, which Plaintiff declined. (AR 388.)

On May 10, 2006, Plaintiff returned to Dr. Mochizuki for a follow-up examination. The treating note indicated that Plaintiff reported that he was experiencing aching of the dorsum of the right wrist and all of the radial side of the right wrist. (AR 381.) His symptoms were aggravated by wrist movement, but the sensation of the right upper extremities was improved. However, Plaintiff reported sensory loss of the left hand. Dr. Mochizuki observed that Plaintiff's right hand was tender to palpation of the dorsum of the right wrist, and there was tenderness to palpation of the extensor digitorum communis and the flexor carpi ulnaris. (AR 381.) Dr. Mochizuki recommended a left carpal tunnel release as well as an injection of the right wrist to alleviate some of the symptoms. (AR 381.)

On June 30, 2006, Plaintiff underwent both a left carpal tunnel release and an injection of the flexor carpi ulnaris tendon sheath and extensor digitorum tendon sheath. (AR 367.) On July 13, 2006, Plaintiff presented to Dr. Mochizuki for a follow-up examination. (AR 361.) Dr. Mochizuki stated that Plaintiff had a full range of motion in his left hand, and the sensory testing appeared normal. (AR 361.) Plaintiff was to complete a home exercise program, and was to return in three weeks for a follow-up examination. (AR 361.)

In July 2006, Plaintiff presented to Dr. Ibarra with complaints of right shoulder pain. (AR 275.) A magnetic resonance imaging ("MRI") scan was performed which demonstrated tendinosis of the rotator cuff as well as partial tearing. (AR 275.)

On August 3, 2006, Plaintiff presented to Dr. Mochizuki for a follow-up examination. (AR 358.) Plaintiff complained of pain in his right hand as well as pain around both his elbows. (AR 358.) On examination, Plaintiff had mild swelling of the right palm, but there was a full range of motion in both hands. (AR 358.) Sensory testing results were normal. (AR 358.) Dr. Mochizuki recommended a home exercise program, and again noted that Plaintiff declined physical therapy. (AR 358.)

On September 6, 2006, Plaintiff was again examined by Dr. Mochizuki. (AR 355.) Plaintiff presented with complaints of bilateral cervical spine pain, bilateral shoulder pain, and pain in his upper extremities from his elbows to his forearms and hands. (AR 355.) Dr. Mochizuki noted cervical spine tenderness as well as tenderness around the paracervical muscles, the rhomboids, the trapezius, and all of the shoulder girdle muscles. (AR 355.) He also noted tenderness to palpation of the triceps, biceps, and extensor musculature of the forearm. However, there was no obvious swelling. (AR 355.) Plaintiff's right hand demonstrated very minimal swelling, but Dr. Mochizuki observed there was tenderness when touching the thenar eminence. (AR 355.) In Plaintiff's left hand, there was tenderness to palpation of the thenar eminence and around the area of the incision; there was also tenderness to palpation of the volar forearm and the dorsum of the wrist. (AR 355.) Dr. Mochizuki completed a physician activity status report indicating that Plaintiff could return to work on September 7, 2006, but he was restricted to no repetitive lifting over five pounds and no pushing or pulling over five pounds of force. (AR 513.) He noted that Plaintiff was unable to grasp repetitively with the entire hand. (AR 513.)

On October 1, 2006, Plaintiff presented to Dr. Juliane Tran, a state examining physician, for evaluation. (AR 282-86.) Dr. Tran reported that Plaintiff had back pain with possible chronic left lumbar radiculopathy. (AR 285.) However, Plaintiff had a negative straight leg raising test, which did not indicate acute left lumbar radiculopathy. (AR 285.) Plaintiff had a decreased left ankle reflex, decreased lumbar range of motion with some abnormal sensory examination in the left lower extremity in the left L5 dermatome. (AR 285.) With regard to his hands, Plaintiff had no muscle atrophy, no loss of muscle strength, and the decreased sensation in both his hands was described as non-specific. (AR 286.) Dr. Tran also reported that Plaintiff had probable fibromyalgia, "multiple pain complaints and pain throughout the upper and lower extremities throughout the body with multiple tender points palpated." (AR 286.) Dr. Tran opined that this was quite consistent with fibromyalgia. Dr. Tran also noted that there was no evidence of a rotator cuff tear. (AR 286.)

Dr. Tran concluded that Plaintiff was restricted with lifting to no more than 25 pounds occasionally and no more than 10 pounds frequently. Plaintiff was also restricted from activities involving frequent left wrist movement, frequent bending, stooping, kneeling, or crouching. He was restricted from standing or walking more than six hours a day. She did not find that Plaintiff had any sitting restrictions, fingering or grasping restrictions, or restrictions related to overhead work, climbing, balancing, or working with height restrictions. (AR 286.) She also determined that Plaintiff had no visual or environmental restrictions. (AR 286.)

On October 11, 2006, Plaintiff was examined by Dr. Mochizuki who reported nearly identical findings as noted in September 2006. (AR 350.)

On October 20, 2006, non-examining state agency consultant Dr. A. M. Khong completed a physical residual functional capacity assessment of Plaintiff. (AR 288-92.) Dr. Khong opined that Plaintiff could (1) occasionally lift and/or carry and pull 20 pounds; (2) frequently lift and/or carry and pull 10 pounds; (3) stand and/or walk about six hours in an eight-hour work day; (4) sit for a total of about six hours in an eight-hour workday; and (5) push and/or pull an unlimited amount. (AR 289.) Although the form requested that the physician explain how and why the evidence supports the limitations listed, nothing was completed with regard to this. (AR 289.) Dr. Khong determined that, while Plaintiff could frequently stoop, he could only occasional climb, balance, kneel, crouch, or crawl. Plaintiff was limited in his ability to "handle," but no explanation as to why Plaintiff was "limited," was not provided. (AR 290.) Rather, Dr. Khong remarked that Plaintiff could perform no frequent handling with the upper left extremity. (AR 290.)

On November 28, 2006, chiropractor J. Greg Clark, D.C. completed a questionnaire regarding his observations of Plaintiff's limitations. (AR 296-97.) He provided a statement of Plaintiff's limitations: Plaintiff is precluded from any full-time work at any exertional level; he is able to sit up to four hours in an eight-hour workday; stand or walk for up to two hours eight-hour workday; use his hands to reach less than one-third of an eight-hour workday; push or pull up to five pounds; but can only handle up to five pounds, and he can do no grasping. (AR 297.)

On November 29, 2006, Plaintiff presented for a follow-up examination, and Dr. Mochizuki made nearly identical findings on examination as those reported in September 2006. (AR 345.) Plaintiff was given two refills of Vicodin. (AR 345.) In April 2007, Dr. Mochizuki completed another physician activity status report indicating that Plaintiff could return to work with no repetitive lifting over five pounds, no pushing and/or pulling over five pounds of force, and no reaching above the shoulders. (AR 509.)

On June 21, 2007, Plaintiff was examined by Dr. James L. Strait for the purposes of Worker's Compensation. (AR 453.) Dr. Strait reported that Plaintiff suffered from degenerative lumbar disc disease status post discectomy at L4-5; degenerative cervical disc disease; minor degenerative thoracic disc disease; status post anterior cruciate ligament reconstruction, right knee; and normal examination of both ankles, both elbows, left knee, and both shoulders. (AR 453.) He also noted that Plaintiff had undergone bilateral carpal tunnel releases and was found to have compression of the median nerves at the time of surgery. Dr. Strait stated that these impairments "would preclude [Plaintiff] from repetitive heavy lifting and repetitive heavy grasping with both hands." (AR 455.)

B. Administrative Proceedings

The Commissioner denied Plaintiff's application initially and again on reconsideration; consequently, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). (AR 53-62, 63-66, 72, 78.)

1. Plaintiff's Testimony

On July 8, 2008, ALJ Stephen W. Webster held a hearing where Plaintiff testified that he lives with his daughter, completes a few household chores including washing dishes, light laundry, and dusting, and is able to attend to his personal grooming needs without assistance. (AR 34-35.) However, performing the household tasks cause his pain to increase. (AR 34-35.)

Plaintiff testified that his hands are affected by carpal tunnel syndrome, and when he last attempted to work in May 2008 servicing vacuum cleaners, he only worked for nine days because he could not complete the work required. (AR 37.) He is also affected by fibromyalgia and tendinitis with the right hand worse than the left. (AR 38-39.) As he does not have any medical insurance, Plaintiff is treated by a chiropractor. His pain is constant; he takes some medication; he can only sit for a half-hour at a time; he can stand for one hour at a time and he can walk for approximately one hour. (AR 39-41.) The heaviest thing he can lift is less than five to seven pounds. (AR 41.) When Plaintiff lifts his arms over his head, it increases the pain in his shoulders, and he has difficulty picking up small objects with his fingers. (AR 41.) The longest he can use his hands for an activity ...

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