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Giddings v. Colvin

United States District Court, E.D. California

March 9, 2015

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


SHEILA K. OBERTO, Magistrate Judge.


Plaintiff Debra Ann Giddings ("Plaintiff") seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying her application for Disability Insurance Benefits ("DIB") benefits pursuant to Title II of the Social Security Act. 42 U.S.C. § 405(g). The matter is currently before the Court on the parties' briefs, which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States Magistrate Judge.[1]


Plaintiff filed an application for DIB on February 25, 2011, alleging disability beginning on April 1, 2010, caused by diabetes with neuropathy in her feet and arms, high blood pressure, and plantar fasciitis. (AR 144.)

A. Relevant Medical Evidence

In March 2010, Plaintiff was examined by podiatrist Clifford Endo for right heel pain. (AR 252-53.) Upon examination, Dr. Endo found an absence of sensation to sharpness in the toes of both of Plaintiff's feet, moderate pain to palpation of the second interspace of Plaintiff's left foot and to palpation of the plantar aspect of Plaintiff's right heel. (AR 253.) Dr. Endo also noted limited dorsiflexion of the right ankle. (AR 253.) Dr. Endo diagnosed plantar fasciitis, suspected neuroma of the second interspace of Plaintiff's left foot, diabetes with neuropathy, and autonomic neuropathy. (AR 253.) Dr. Endo administered a trigger point injection into Plaintiff's right heel and recommended orthotics.

Plaintiff was seen by her treating physician, Mark Cook, M.D., in March 2010 for acute bronchitis, allergies, lower back pain, and diabetes. (AR 235.) It was noted she had no neurological deficits, all her extremities were moving, and her gait was nonantalgic. (AR 235.) The treatment plan included a continued prescription for amylose and a low-cholesterol diet; it was recommended that Plaintiff drink fluids and return for a follow-up in 2 to 3 weeks. (AR 235.) In August 2010, she was seen again by Dr. Cook for a routine physical. (AR 232.)

In April 2010, Plaintiff was seen for follow-up care with Dr. Endo, and she reported improvement after her last heel injection but that she did not obtain much pain relief of her neuropathy. Dr. Endo administered a second trigger point injection, and advised Plaintiff to increase her ibuprofen to six tablets daily. (AR 251.)

On September 20, 2010, Plaintiff was examined by Margaret Dias, a physician's assistant ("PA Dias") at the office of Dr. Andres Arellano, a board certified internist, to establish primary care. (AR 227.) Plaintiff reported she has suffered from diabetes for 13 years, and lower-leg neuropathy for three years. (AR 227-28.) Plaintiff returned to PA Dias on December 30, 2010, complaining that the "bottoms of [her] feet [were] hurting and numb" intermittently. (AR 225.)

PA Dias diagnosed Plaintiff with hypertension, pre-diabetes, and bilateral foot numbness. (AR 220.) On June 1, 2011, Plaintiff again saw PA Dias and complained that, despite an increase in her prescriptions for Neurontin and Requip, her foot pain was "getting worse" and affecting her ability to stand. (AR 350.) PA Dias advised Plaintiff to lose weight and continue her medications as prescribed. (AR 350.) On December 20, 2011, PA Dias completed a Medical Source Statement regarding the functional limitations stemming from Plaintiff's idiopathic distal polyneuropathy. (AR 330-33.) PA Dias noted Plaintiff's primary symptoms included fatigue, dizziness, pain, and loss of sensation in both feet. (AR 330.) PA Dias estimated that, in a regular, eight-hour workday, Plaintiff could sit for no more than one-and-a-half hours and stand and/or walk for no more than two hours; lift and carry up to 10 pounds frequently and 20 pounds occasionally; had significant limitations in performing repetitive reaching, handling, fingering, and/or lifting; and would be capable of tolerating no more than moderate workplace stresses as they affect her nerves and exacerbate her conditions. (AR 330-33.)

On February 1, 2011, Plaintiff was examined by neurologist Jeffrey Levin, M.D., to whom Dr. Arellano had referred her. (AR 282.) She complained of pain in her right arm and elbow, and she reported a history of hypertension and type-2 diabetes. (AR 282.) On examination, Plaintiff's nerves were found to be intact, she demonstrated a positive Tinel's sign[2] in the right lateral epicondyle, and there was weakness of her wrist extension. (AR 282.) In her lower extremities, Plaintiff experienced pain during a left straight-leg raising test, she had weakness of dorsiflexion, [3] and decreased sensation at L5 distribution. Plaintiff reported a slight decrease in sensation peripherally in the lower extremities and the deep tendon reflexes. (AR 282.) Dr. Arrellano found Plaintiff to have mild "stocking glove distribution neuropathy." (AR 282.) Dr. Levin reported Plaintiff ambulated without difficulty, she had no tremor or dysmetria, [4] and there was no spasticity seen. (AR 282.) Dr. Levin gave an impression of right lateral epicondylitis, [5] and left L5 radiculopathy with mild polyneuropathy. (AR 282.) Plaintiff underwent an EMG, which revealed right lateral epicondylitis and left L5 radiculopathy. Dr. Levin referred Plaintiff for a magnetic resonance imaging scan ("MRI") of her lumbosacral spine. (AR 282.)

On March 1, 2011, Plaintiff was again examined by Dr. Levin. (AR 281.) He reviewed the MRI of her lumbosacral spine, and noted disc disease at L5-S1 - impinging on the S1 nerve root, worse on the right. (AR 281.) Dr. Levin also noted a "mild degree of spondylosis, "[6] and opined Plaintiff would benefit from physical therapy or aquatic therapy. (AR 281.)

On April 29, 2011, Walter W. Bell, M.D., a state agency non-examining physician, reviewed Plaintiff's medical record and provided an opinion as to Plaintiff's capacity to work based on medical records from Drs. Cook, Arellano, and Levin. (AR 268-75.) Dr. Bell found Plaintiff's records indicated neuropathy in her feet and arms, with moderate pain. Id. Dr. Bell reported Plaintiff had no effusions, was positive for a Tinel's sign in her right hand, had some weakness in her wrist, experienced some decreased sensation in her lower extremities and deep tendon reflexes, and MRI findings showed spondylosis. (AR 270.) Dr. Bell opined Plaintiff was limited to light work, finding this limitation consistent with her examination findings, Plaintiff's light household activities, and the MRI results. (AR 268-75.)

On May 18, 2011, Plaintiff followed-up with Dr. Levin. (AR 280.) He reported that Plaintiff's medication had been adjusted, and that Plaintiff complained of tingling on the top of her feet at night and sometimes when she walked - worse in her right foot. (AR 280.) On examination, Dr. Levin found Plaintiff had weakness of dorsiflexion and plantar flexion in her left leg, and she had an absence of deep tendon reflexes peripherally and 1 proximally. (AR 280.) Based on this examination, Dr. Levin reported the following impressions: lumbar radiculopathy, most prominent at L5; right lateral epicondylitis; peripheral neuropathy, restless legs syndrome, and "probably" obstructive sleep apnea with insomnia. (AR 280.) He referred Plaintiff for a formal sleep study, increased her prescriptions for Neurontin and Requip, and reported planning to see Plaintiff after her formal sleep study was completed. (AR 280.)

On July 7, 2011, R. Paxton, M.D., reviewed Plaintiff's medical records affirming Dr. Bell's assessment.[7] (AR 287-90.) Also on July 11, 2011, Roger Fast, M.D., reviewed the records affirming Dr. Bell's assessment and opinion, noting Plaintiff's normal examination finding and Dr. Levin's finding that Plaintiff had a normal gait. (AR 289.)

On September 12, 2011, Plaintiff was seen at the University of California, San Francisco Medical Center, Department of Neurology ("UCSF Medical Center") upon referral by Dr. Arellano for further evaluation of dysesthesias[8] in her legs. (AR 318.) She was examined by Jeffrey Ralph, M.D., and reported a 2-year history of pain in her legs, as well as plantar fasciitis. (AR 318.) Shortly after developing plantar fasciitis, she developed numbness in the toes of both feet, and experienced occasional paresthesias in her feet. (AR 318.) Upon examination, Dr. Ralph noted what he described as normal or unremarkable findings. (AR 319.) He found her clinical presentation and examination to be consistent with a distal polyneuropathy, which was generally caused by medical problems such as vitamin deficiencies, toxin exposures, as well as genetic causes - but, in her case, diabetes carried a significant risk of developing polyneuropathy. (AR 319.) Dr. Ralph suggested additional blood tests and she was to contact him after these tests were completed. (AR 320.)

On November 14, 2011, Plaintiff was seen by Dr. Ralph for a follow-up appointment, and he determined all the blood tests performed in September 2011 showed normal results. (AR 316.) Dr. Ralph concluded Plaintiff's neuropathic pain had not been treated adequately, and his plan was to transition Plaintiff to a different kind of prescription treatment. (AR 317.)

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 64-68, 83-84.) A hearing was held on January 17, 2012, before ALJ Trevor Skarda. (AR 18-28.)

1. The ALJ's Decision

On January 24, 2012, the ALJ issued a decision, finding Plaintiff not disabled since April 1, 2010. (AR 18-28.) Specifically, the ALJ found that Plaintiff (1) had not engaged in substantial gainful activity since her alleged onset date of April 1, 2010 (AR 20); (2) had the following severe impairments: distal neuropathy; epicondylitis; diabetes mellitus; degenerative disc disease with radiculopathy; and obesity (AR 20); (3) did not have an impairment or combination of impairments that met or medically equaled of the of listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (AR 22); (4) had the residual functional capacity ("RFC") to perform medium a reduced range of light work as defined in 20 C.F.R. § 404.1567(b) (AR 19). The ALJ found that Plaintiff could "lift and/or carry 20 pounds occasionally and 10 pounds frequently; [Plaintiff] can stand and/or walk about 2 hour in an 8-hour workday; she can sit for about 6 hours in an 8-hour workday; she would need a sit/stand option that would allow her to sit or stand at will and still be able to continue working; she can occasionally climb ramps and stairs; she can never climb ladders, ropes or scaffolds; she can occasionally balance, stoop, kneel, crouch or crawl; she is limited to frequent handling and fingering with her right, dominant, hand; and she must avoid concentrated exposure to excessive vibrations." (AR 22.) The ALJ determined Plaintiff was unable to perform any ...

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