United States District Court, E.D. California
ORDER DIRECTING ENTRY OF JUDGMENT IN FAVOR OF
COMMISSIONER OF SOCIAL SECURITY AND AGAINST
S. Austin, UNITED STATES MAGISTRATE JUDGE
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. 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
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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. 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.
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.
January 30, 2014, anesthesiologist and pain management
specialist William von Kaenel, M.D., examined Plaintiff as a
workers' compensation consultant. 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.
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.
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.
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.
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.
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.
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.
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.
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 ...