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Martin v. Colvin

United States District Court, N.D. California

February 8, 2015

EDNALYN C. MARTIN, Plaintiff(s),
CAROLYN W. COLVIN, Defendant(s)


DONNA M. RYU, Magistrate Judge.

Pursuant to 42 U.S.C. § 405(g), Plaintiff ("Plaintiff") seeks review of her application for disability insurance benefits. Defendant Social Security Commissioner ("Defendant" or "Commissioner") denied her application after determining that Plaintiff was not disabled under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. Plaintiff now requests judicial review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g). Both parties filed motions for summary judgment. For the reasons stated below, the court denies Plaintiff's motion for summary judgment and grants Defendant's motion for summary judgment.

I. Procedural History

On May 17, 2010, Plaintiff protectively filed an application for disability insurance benefits under Title II of the Act, alleging disability beginning April 23, 2010. A.R. 88, 146-54. The agency denied Plaintiff's application for benefits initially on June 23, 2011 and subsequently denied it again upon reconsideration. A.R. 116-20. On March 21, 2012, Administrative Law Judge (ALJ) John Heyer held a hearing at which Plaintiff and her attorney representative were present. A.R. 54-87. Plaintiff provided testimony, as did Alena Sala, a vocational expert. A.R. 54-87.

On April 25, 2012 the ALJ issued a written decision finding Plaintiff not disabled under Title II of the Social Security Act. A.R. 25-36. The Appeals Council denied Plaintiff's request for review of the ALJ's decision, making the ALJ's decision the Commissioner's final decision. A.R. 1-6. Plaintiff then filed this action.

II. Factual Background

A. Background

The record contains the following information. Plaintiff was born in January 1961 and was 49 years old as of the alleged onset date of her disability. A.R. 146. Plaintiff was born in the Philippines but is now a citizen of the United States. A.R. 146. Plaintiff completed two years of college in 1978 and several months of specialized training as a certified nurse assistant in 1981. A.R. 173. Plaintiff worked as a certified nurse assistant for approximately 19 years at Laguna Honda Hospital in San Francisco, from October 1990 to April 2010. A.R. 178. Her work as a certified nurse assistant required her to lift patients out of bed and into wheelchairs, bathe patients and brush their teeth, assist patients with eating meals, bring patients to appointments, and take and record patients' vital signs, blood pressure, and temperature. A.R. 179.

Plaintiff began having problems with her neck and shoulders when she suffered a workplace injury while lifting a patient in 2006. A.R. 434-35, 578. A July 2006 MRI of Plaintiff's cervical spine showed discogenic disease at the C5-C6 vertebrae. A.R. 454. In February 2007, Plaintiff had left rotator cuff surgery. A.R. 378-79. In June 2009, Plaintiff had spinal surgery, which fused several of the vertebrae in her neck together. A.R. 251-52, 428-29. Plaintiff left work shortly before her spinal surgery, returned in February 2010 on modified duty (floor patrol), and stopped working altogether in April 2010. A.R. 60, 65. Plaintiff has not worked since April 2010. Plaintiff applied for and was granted a disability retirement from her position on September 2, 2011. A.R. 250-54. In December 2012, after the hearing and after the ALJ issued his written decision, Plaintiff had surgery on her right shoulder. A.R. 624-32.

Plaintiff testified that her pain was worse after her spinal surgery, and that after her surgery she could not do the household chores she used to be able to do. A.R. 71. She testified that she could only lift five pounds, and could only stand for about 15 minutes until she started experiencing discomfort, and 25 minutes before she would have to stop standing. A.R. 60-61. She could sit only 15-25 minutes and walk 10-15 minutes (which she estimated to be half a block in distance). A.R. 61, 75. She experienced pain in her neck and right shoulder, radiating to her lower back, as well as her left shoulder. She also complained of muscle spasms, and numbness and tingling in both arms and hands. A.R. 71-72. She testified that she experienced five headaches a week, each of which lasted half a day. A.R. 73. She had difficulty grasping and frequently dropped things. A.R. 73-74. Plaintiff testified that she had difficulty looking side-to-side or up-and-down, and would have to turn her whole body just to look to the side. A.R. 71. Plaintiff stated that she was "always" in pain. A.R. 72. Plaintiff's pain interfered with her sleep, and she testified that she could only sleep four hours during the night before waking up with pain. A.R. 77.

Plaintiff testified that on a typical day, she woke, had breakfast, sat for a while, took a shower, and then had to rest and lie down because of pain. A.R. 62. In the evenings, she waited for her daughter or husband to prepare dinner, and she attempted to assist with chores. A.R. 62. Plaintiff sometimes did the dishes, sometimes went shopping with her daughter or husband, and also watched television, used a computer, and read. A.R. 63, 76. Plaintiff stated that she took medications (Naprosyn, Zanaflex, Prilosec, Zoloft, and Aleve) that temporarily helped her. A.R. 64. Plaintiff had difficulty driving because she could not look from side to side, but she did drive to pick up her grandchildren twice a week from their school approximately one mile from her house. A.R. 75-76, 78.

Plaintiff also testified about her depression. A.R. 69. Plaintiff stated that her primary care physician Dr. Sally Yu had referred her to psychologist Dr. John Guzman for mental health treatment. A.R. 69. Plaintiff's depression made her want to be alone and not mingle with people, and affected her concentration and memory. Plaintiff gave the example of forgetting once to pick up her grandchildren from school. A.R. 69-70. She testified that the Zoloft was helpful in alleviating her problems, but only for a short time. At the time of the hearing, Plaintiff was not receiving mental health care. A.R. 67.

B. Letters from Relatives and Acquaintances

The record includes several letters from Plaintiff's relatives and acquaintances. A.R. 214-222. Plaintiff's neighbor Idalina Chan stated that she used to see Plaintiff "outside the house sweeping the driveway, cleaning the front door or working in the yard, " and would socialize with Plaintiff. After Plaintiff's surgery, Chan saw Plaintiff less often outside of Plaintiff's house, and they would still chat, but "perhaps within less than 20 minutes" Plaintiff would have to go back into the house because she felt tired. Chan also noticed Plaintiff walking slower and holding onto walls and rails for support. A.R. 214.

Plaintiff's friend of 24 years Nimfa Torrijos-Fernandez stated that she and Plaintiff "used to go out for lunch or dinner" and Torrijos-Fernandez would see Plaintiff in church every Sunday. Torrijos-Fernandez stated that she now "seldom" sees Plaintiff in church and that when Torrijos-Fernandez visited Plaintiff, "[t]here are days when... she'll be lying in bed or in the [couch] and won't get up, still in her pajamas it's either she is in a severe pain or feeling frustrated that she can't do her house chores and things that she always wanted to do before she got hurt." A.R. 215. Torrijos-Fernandez also noted that Plaintiff's "memory was really good before, but now she forgets things easily and I have to remind her to write things down, " and it "seems like she cannot focus on what she's doing for more than 20 minutes." A.R. 215.

Plaintiff's daughter Katherine Martin, who was 29 years old at the time of the hearing, provided a letter that stated that Plaintiff used to be a very outgoing person who enjoyed the family's annual road trips to Reno, but now mostly stayed home and rested. Martin stated that Plaintiff has good and bad days, and "[o]n a good day she will get up and go to church with my dad and out to breakfast." A.R. 216. Plaintiff's daughter also stated that Plaintiff's "condition limits her from having the outgoing social life that she had." A.R. 216.

The record also includes a letter from Plaintiff's nephew and her husband Alfredo Martin. A.R. 218-222. Both describe the drop in Plaintiff's mood, energy, abilities, and socializing, and increase in her pain, since her surgeries. A.R. 218-222.

C. Plaintiff's Relevant Medical History

A. 2006-2012: Dr. Jeffrey Halbrecht

The record includes treatment records from by Dr. Jeffrey Halbrecht, an orthopedic surgeon, from August 2006 until January 6, 2012. A.R. 373, 377-380, 402-412, 454, 451, 531-535.

1. 2006-2007: Records Prior to Left Shoulder Surgery

On August 6, 2006, Dr. Halbrecht recommended surgery on Plaintiff's left shoulder, which he performed on February 2, 2007. A.R. 251. Dr. Halbrecht declared Plaintiff's shoulder to be permanent and stationary as of October 16, 2007. A.R. 251.

2. 2010-2011: Records Regarding Right Shoulder

The record includes a progress report from Dr. Halbrecht regarding Plaintiff's right shoulder dated January 5, 2010. A.R. 471-72. Dr. Halbrecht noted that Plaintiff complained of pain in her right shoulder and tingling in her fingers. Dr. Halbrecht conducted a physical examination and found "no neurologic findings other than the complaints of tingling in the radial aspect of the index finger" and "mild impingement findings, mostly AC joint discomfort and pain with AC joint compression testing." A.R. 471. Dr. Halbrecht's impression was AC joint arthrosis in Plaintiff's right shoulder and mild associated impingement findings, for which he recommended (and performed) a cortisone injection. A.R. 472.

In a report about Plaintiff's right shoulder dated April 8, 2011, Dr. Halbrecht noted that "[t]here is minimal change in [Plaintiff's] exam" and that Plaintiff "still has loss of 10 degrees of active range of motion in all planes and has pain with extremes of range of motion, especially abduction and flexion." A.R. 451. Dr. Halbrecht noted Plaintiff's muscle strength testing to be 4/5. His impression was that Plaintiff had "persisting pain and weakness and development of levator scapulae syndrome due to complications." A.R. 451. Dr. Halbrecht recommended physical therapy to increase Plaintiff's range of motion and strength, and to relieve Plaintiff's levator scapulae syndrome. A.R. 451. Dr. Halbrecht also recommended that Plaintiff continue to take anti-inflammatories, apply ice, and continue to take her other medications. A.R. 451.

Dr. Halbrecht recommended that Plaintiff undergo physical therapy for her right shoulder. A.R. 538-48. The medical evidence of record shows that Plaintiff visited a physical therapist eight times over four weeks between April and May 2011. A.R. 538-48. After eight visits, Plaintiff's physical therapist "recommended that [Plaintiff] discontinue with her conservative care in Physical Therapy in lieu of a home exercise program" and "discharged [Plaintiff from physical therapy] because she has achieved her goals and expected outcomes." A.R. 548.

Dr. Halbrecht treated Plaintiff on about 10 occasions between April 2011 and January 2012, but there are no detailed treatment notes in the record from these visits. A.R. 534-35.

3. 2012: Records Regarding Right Shoulder Provided After ALJ Decision

The record also includes notes and reports from Dr. Halbrecht dated after April 2012, which were submitted after the ALJ's written decision.[1] A.R. 624-32. These records show that an MRI performed on Plaintiff's right shoulder in April 2012 revealed "significant partial tearing" of Plaintiff's right rotator cuff and "significant SLAP[2] tear" causing ...

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