United States District Court, E.D. California
FINAL JUDGMENT AND ORDER REGARDING PLAINTIFF'S
SOCIAL SECURITY COMPLAINT
matter is before the Court on Plaintiff's complaint for
judicial review of an unfavorable decision of the
Commissioner of the Social Security Administration regarding
his applications for supplemental security income and
disability insurance benefits. The parties have consented to
entry of final judgment by the United States Magistrate Judge
under the provisions of 28 U.S.C. § 636(c) with any
appeal to the Court of Appeals for the Ninth Circuit.
hearing on October 31, 2017, the Court heard from the parties
and, having reviewed the record, administrative transcript,
the briefs of the parties, and the applicable law, finds as
reasons announced by the Court on the record at the
conclusion of the parties' oral argument on October 31,
2017, the Court finds that the decision of the Commissioner
of Social Security should be reversed and the case should be
remanded for further proceedings.
applied for disability, disability insurance benefits, and
supplemental security income on May 10, 2012, alleging a
disability onset date of May 15, 2011. The disability onset
date was later amended to January 1, 2013.
August 21, 2012, Emmanuel Fabella, M.D., administered a
consultative internal medicine examination of Plaintiff. AR
380-385. Dr. Fabella observed that Plaintiff had low back
pain with evidence of paralumbar strain and right paralumbar
tenderness, as well as apparent history of lumbosacral spine
x-ray in 2011 showing “some arthritis.” AR 384.
Dr. Fabella also observed right lateral thigh pain.
Id. Based on these impressions, Dr. Fabella opined
as to Plaintiff's physical limitations. Id.
E. Wong, M.D. and A. Nasrabadi, M.D. served as the
Commissioner's non-examining physicians with respect to
Plaintiff's disability application. On October 4, 2012,
Dr. Wong opined as to Plaintiff's physical residual
functioning capacity (“RFC”). AR 80-82. On March
19, 2013, Dr. Nasrabadi also opined as to Plaintiff's
physical RFC. AR 124-126. Drs. Wong and Nasrabadi's
medical opinions concerning Plaintiff's physical
limitations were based upon Plaintiff's spine disorder.
summer of 2013, Plaintiff sustained a right foot injury
diagnosed as fracture dislocation of right Lisfranc joint,
which required surgical repair with pins and other hardware.
AR 640, 646. A February 5, 2014 x-ray revealed a Lisfranc
fracture-dislocation, and orthopedic consultation was
recommended. AR 548-49. On February 28, 2014, Plaintiff
reported pain with weight-bearing and ambulation problems to
Dr. Shah, who recommended a revision surgery on the right
foot. AR 486-87. Plaintiff again reported problems to Dr.
Shah with weight-bearing and ambulation persisting as of
March 21, 2014. AR 563. Plaintiff reported 10 out of 10 pain
in her foot and low back again on June 13, 2014. AR 492.
November 5, 2014, Plaintiff testified before the ALJ. She
testified that her back, right foot pain and anemia
conditions were disabling. AR 45-46. Plaintiff stated that
she believed her right foot would heal after surgery, but it
did not. AR 51. She consistently has pain in the right foot
and swells up to the point where she cannot wear shoes. AR
51-52. Standing on the foot makes the pain excruciating, and
the injury prevents her “from doing a whole bunch of
things.” AR 53. She testified that she could only stand
on the foot for 5-10 minutes at a time and cannot walk for 15
minutes without experiencing the pain. AR 57.
two, the ALJ found severe impairments significantly limiting
Plaintiff's ability to work in the form of cervical and
lumbosacral degenerative disc disease and right foot
disorder. AR 17. Based on these impairments, the ALJ
formulated an RFC finding that Plaintiff has ability to:
perform sedentary work as defined in 20 CFR §
404.1567(a) and 416.967(a) except the claimant can
occasionally stoop, crawl, and climb ramps and stairs, but
she cannot climb ropes, ladders or scaffolds; she can
frequently balance; and she must avoid working around
unprotected heights and moving mechanical parts, and she
cannot perform commercial driving.
AR 20, 22 (stating that Plaintiff “is limited to
sedentary work with postural and environmental limitations
due to back pain and foot pain secondary to a history of mild
degenerative disc disease and Lisfranc fracture of the right
discussing his RFC formulation, the ALJ gave limited weight
to the medical opinion of Dr. Fabella (summarized above)
because “the recent evidence of claimant's foot
fracture and cervical spinal degenerative disc disease
support further limitations in the claimant's ability to
lift and stand/walk.” AR 22. The ALJ further applied
reduced weight to Drs. Wong and Nasrabadi's medical
opinions concerning Plaintiff's physical limitations
inter alia due to Plaintiff's recent and non-healing
right foot injury. AR 24.
Court recognizes that “Residual functional capacity is
an administrative finding reserved to the
Commissioner.” Lynch Guzman v. Astrue, 365
Fed.Appx. 869, 870 (9th Cir. 2010) (citing 20 C.F.R. §
404.1527(e)(2)). The ALJ's RFC determination should be
affirmed “if the ALJ applied the proper legal standard
and his decision is supported by substantial evidence.”
Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th Cir.
Court also recognizes that the ALJ did attempt to take into
account the right foot injury by imposing the sedentary
limitation. While this could possibly be an accurate
functioning limitation to impose, the limitations caused by
the right foot injury could also demand greater than a
sedentary limitation. Prior to the right foot injury,
Plaintiff's disability application had been based
entirely on her spine disorder and associated back pain. As
discussed above, every doctor that issued a medical opinion
regarding Plaintiff's work-related limitations did so