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Cruz v. Saul

United States District Court, E.D. California

June 21, 2019

ANDREW SAUL, [1] Commissioner of Social Security, Respondent.



         I. Introduction

         Plaintiff Juan Carlos Cruz (“Plaintiff”) seeks judicial review of a final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying his application for disability insurance benefits pursuant to Title II of the Social Security Act. The matter is currently before the Court on the parties' briefs which were submitted without oral argument to the Honorable Gary S. Austin, United States Magistrate Judge.[2] See Docs. 18 and 19. Having reviewed the record as a whole, the Court finds that the ALJ's decision is supported by substantial evidence and applicable law. Accordingly, Plaintiff's appeal is denied.

         II. Procedural Background

         On January 26, 2015, Plaintiff filed the pending application for disability insurance benefits alleging disability beginning December 6, 2012. AR 15. The Commissioner denied the application initially on June 10, 2015, and upon reconsideration on August 14, 2015. AR 15. On August 19, 2015, Plaintiff filed a timely request for a hearing before an Administrative Law Judge. AR 15.

         Administrative Law Judge Sharon L. Madsen presided over an administrative hearing on April 25, 2017. AR 34-53. Plaintiff appeared and was represented by an attorney and assisted by an interpreter. AR 34. Impartial vocational expert Cheryl Chandler (the “VE”) also testified. AR 34.

         On July 6, 2017, the ALJ denied Plaintiff's application. AR 15-27. The Appeals Council denied review on December 19, 2017. AR 1-3. On February 14, 2018, Plaintiff filed a complaint in this Court. Doc. 1.

         III. Factual Background

         A. Plaintiff's Testimony and Reports

          Plaintiff (born September 17, 1964) lived with his wife, his nephew and his stepson. AR 37-38. He had constant pain in his back and sciatic pain in his right foot. AR 42. Walking was uncomfortable. AR 43. He had difficulty picking things up from the ground and could not kneel or climb stairs. AR 44-45. He took naproxen and used a topical pain reliever. AR 43, 46-47. Epidural injections helped only for a day or two. AR 46. Physical therapy was not helpful. AR 45. Plaintiff also had diabetes and high blood pressure. AR 43-44.

         Plaintiff sometimes needed help showering and putting on his pants and socks. AR 39. He could heat food in the microwave, shop and run errands. AR 39. His nephew generally performed the household chores, but Plaintiff enjoyed cutting the lawn and working in the garden, working for up to 20 minutes before needing to rest. AR 39, 45. He went to church. AR 40. Plaintiff's doctor directed him to walk, which he was able to do for 20-30 minutes. AR 44. Plaintiff enjoyed watching television. AR 40. He lay down and rested three to four hours daily. AR 49.

         Plaintiff completed the twelfth grade in Mexico. AR 39. Although Plaintiff was able to drive, he limited his time and distance because his feet became numb. AR 38. His previous jobs included stacking pallets of boxes in a shoe warehouse, loading potato trucks, driving a garbage truck and weighing cheese. AR 41-42. Plaintiff last worked on May 15, 2013. AR 42.

         B. Medical Records

         Plaintiff was injured in an accident at work on December 6, 2012. AR 253. While pulling a pallet weighing approximately 1600 pounds down a ramp, Plaintiff fell onto his back when the pallet became stuck. AR 262.

         Eric Sorenson, M.D., of Kings Industrial Occupational Medical Center, treated Plaintiff on December 10 and 17, 2012. AR 558-61. By the second appointment Plaintiff was “doing a lot better” and experiencing no pain in his back, buttocks, coccyx or lower extremities. AR 558. He did not require oral pain medications and relieved occasional aches and pains with Biofreeze (menthol), a topical pain reliever. AR 558.

         On March 25, 2013, Dr. Sorenson reopened Plaintiff's workers' compensation claim in response to Plaintiff's complaints of persistent coccyx pain. AR 556. On April 1, 2013, Dr. Sorenson reviewed x-rays showing grade 1 retrolisthesis at the L5-S1 level, but no evidence of fracture or dislocation. AR 309, 555. He wrote:

The patient is in no acute distress. He ambulates into the clinic with a normal gait. He is obese. Back exam has a full range of motion flexion, extension and rotation. There is no pain to palpation. The patient continues to have pain to the sacral when palpated through the rectal area. There is no evidence of any abnormalities appreciated on his exam today. Lower extremity no straight leg raises. DTR's are 2 and motor is intact.

         Diagnosing Plaintiff with “coccyx pain with negative x-ray, ” Dr. Sorenson opined that the reported symptoms did not result from Plaintiff's work injury and referred Plaintiff to his primary care physician for further investigation of other possible causes of the reported pain. AR 555.

         On June 24, 2013, Plaintiff was first treated at Central Valley Comprehensive Care Industrial Services (CVCC). AR 562. His doctor (name indecipherable) diagnosed chronic coccydynia and determined that Plaintiff could return to work with restrictions that limited Plaintiff to lift, carry, pull or push no more than twenty pounds and seldom bend or stoop.[3] AR 253, 562. Because Plaintiff's employer was unable to accommodate the restrictions, Plaintiff remained off work thereafter. AR 253. From July through November 2013, Plaintiff participated in physical therapy including therapeutic exercise and electrical stimulation. AR 228-52, 587-638.

         On August 19, 2013, orthopedist Charles F. Xeller, M.D., conducted an agreed medical examination of Plaintiff's lower back as required by workers' compensation rules. AR 304-307. Dr. Xeller observed that Plaintiff had back pain, more right sided than left, and minor coccygeal pain. AR 306. When Plaintiff stood, he flexed his right leg and listed to the left. AR 306. Plaintiff demonstrated a full range of motion of his knees, ankles and feet. AR 306. Straight leg raising was negative. AR 306. Knee and ankle reflexes and toe and heel stand were normal. AR 306. There were no overt sensory disturbances and no thigh or calf muscle atrophy. AR 306. Dr. Xeller observed back muscle spasm. AR 306. The doctor declined to find Plaintiff permanent and stationary, and requested magnetic resonance imaging to rule out a herniated lumbar disc. AR 306. Review of Plaintiff's magnetic resonance images on November 15, 2013, indicated that Plaintiff's spine was normal other than a mild posterior disc protrusion at ¶ 4-5. AR 300. Dr. Xeller recommended an epidural steroid injection. AR 300.

         On January 30, 2014, anesthesiologist and pain management specialist William von Kaenel, M.D., examined Plaintiff as a workers' compensation consultant.[4] AR 281-86. Plaintiff reported constant lumbo-sacral axial pain, which ranged from 6/10 to 7/10. AR 281. The pain was 35 percent on the left and 65 percent on the right. AR 281. Aggravating activities included sitting, transitions, bending, lifting, driving, standing and walking. AR 281. Plaintiff could walk about 80 feet before needing to stop. AR 281.

         Truncal range of motion testing revealed pain with extension rotation and limited range of motion on extension and left and right lateral flexion. AR 283. Plaintiff had full strength on all reported measures except for right dorsiflexion, which was nearly normal. AR 283. Sensory testing of Plaintiff's lower extremities was fully intact. AR 283. Digital palpation revealed tenderness at the right and left facets. AR 284. Dr. van Kaenel diagnosed disc disorder with radiculopathy, lumbar spine pain and lumbar facet joint arthropathy. AR 285.

         On March 3, 2014, Plaintiff received an epidural steroid injection at ¶ 5. AR 255-57. Dr. von Kaenel, M.D., noted that although Plaintiff's leg pain had resolved, weak toe dorsiflexion and reduced Achilles reflex on the right indicated continued radiculopathy. AR 255. Dr. von Kaenel noted that the disc protrusion at ¶ 4-5 did not cause nerve compression but had an inflammatory effect likely causing Plaintiff's gluteal pain and radiculopathy. AR 255. In his report to the workers' compensation insurer, Dr. von Kaenel wrote:

[Plaintiff] has axial spine pain and has had no appreciable benefit after the epidural steroid injection. The patient's pain is predominant in the axial region. This potentially signifies that his pain is due to other than radicular pain. Possibilities include discogenic pain and facet joint arthropathy. AR 270.

         On June 3, 2014, Dr. Riddle of CVCC filed a permanent and stationary report which stated, “Due to lack of significant MRI findings, the issue of psychological issues must be considered.” AR 742.

         On July 8, 2014, CVCC evaluated Plaintiff and released him to return to modified work limited to lifting, carrying, pulling or pushing no more than five pounds, and seldom climbing stairs or ladders, bending or stooping, and squatting or kneeling. AR 260.

         On July 9, 2014, Plaintiff initiated a primary care relationship with United Health Centers. AR 472-74. Richard Reynolds, P.A., ordered lumbar spine x-rays and requested copies of Plaintiff's workers' compensation records. AR 474. On July 11, 2014, Brian Ewy, D.O., reviewed five x-rays of Plaintiff's lumbar spine and opined that Plaintiff's lumbar spine was normal. AR 320-21. The report of September 3, 2014, magnetic resonance imaging of Plaintiff's lumbar spine revealed hyperlordosis, mild degenerative disc disease, no impingement of nerve roots, and a 3 mm posterior disc protrusion and fissure of annulis fibrosis. AR 308.

         From June 18, 2016, through March 8, 2017, Plaintiff was treated 29 times at United Health Centers, most frequently for back pain without sciatica. AR 846-963. Treating physicians were Drs. Marie Flores and Seunghun Jung. Other diagnoses included diabetes with diabetic polyneuropathy; hip, hand and foot pain; hypertension; hyperlipidemia; nonalcoholic steatohepatis (NASH); and, earache. AR 846-963. As of March 8, 2017, Plaintiff's medications included famotidine (acid reflux), senna (constipation), colace (constipation), clortrimazole (skin rash), cyclobenzaprine (muscle relaxant), citalopram (antidepressive), trazodone (antidepressant), naprozen (pain reliever), hydrocortisone (skin rash), gabapentin (nerve pain), lisinopril (high blood pressure), pravastatin (high cholesterol and triglycerides) and metformin (diabetes). AR 846-47.

         On June 20, 2015, Nader Armanious, M.D., performed an electromyogram study that revealed evidence of chronic L5 and S1 radiculopathy on the right side. AR 522-26.

         On June 21, 2016, family practitioner Samuel Chan (Coast City Medical Group) requested workers' compensation authorization to perform follow-up treatment of Plaintiff ‘s sprained ligaments, cervical and lumbar spine, anxiety disorder and depressive disorder. AR 740-41. On June 26, 2015, he conducted an intake examination of Plaintiff noting that Plaintiff complained of constant sharp, severe, stabbing lower back pain; constant sharp and burning right hip pain; numbness of the right leg; trouble sleeping; weight gain; diabetes; high cholesterol; and, hypertension. AR 837. Plaintiff demonstrated positive straight leg raising, lumbar spine tenderness and muscle spasm; decreased right leg strength; dermatomal hyperestesia from L5 to S1; positive Lasegue's Test on the right; lower back pain on Patrick Fabere's test; and positive Milgram's test. AR 840-41. Plaintiff demonstrated reduced range of motion of the cervical and ...

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