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
Kimberly Andrea Muller (“Plaintiff”) seeks
judicial review of a final decision of the Commissioner of
Social Security (“Commissioner” or
“Defendant”) denying her 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. 12, 15 and 16. 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
April 11, 2014, Plaintiff filed an application for disability
insurance benefits alleging disability beginning October 15,
2010. AR 17. The Commissioner denied the applications
initially on May 28, 2014, and upon reconsideration on
October 9, 2014. AR 17. On November 21, 2014, Plaintiff filed
a request for a hearing before an Administrative Law Judge.
Law Judge G. Ross Wheatley presided over an administrative
hearing on June 7, 2016. AR 32-74. Plaintiff appeared and was
represented by an attorney. AR 32. Impartial vocational
expert Lorian Ink Hyatt testified. AR 32.
Law Judge Daniel G. Heeley presided over a second
administrative hearing on September 19, 2017. AR 75-102.
Plaintiff appeared and was represented by an attorney. AR 75.
Impartial vocational expert Nina Salla testified. AR 75.
September 28, 2017, ALJ Healey denied Plaintiff's
application. AR 17-26. The Appeals Council denied review on
June 27, 2018. AR 1-4. On August 31, 2018, Plaintiff filed a
complaint in this Court. Doc. 1.
June 7, 2016
(born October 23, 1965) lived in a house with her husband and
their pet dog. AR 49. On a typical day, she was able to
manage her own personal care. AR 49. Depending on her pain
level on a particular day, she might be able to perform light
housekeeping, do a little laundry or cook. AR 49. She enjoyed
reading and television. AR 51. She sometime used a computer
but was no longer able to type for very long. AR 52. On the
days that her joints were swollen and painful, Plaintiff was
less capable of working and needs to lie down and rest. AR
last worked in July 2009, when she was laid off from her job.
AR 40. She had a driver's license and continued to drive.
AR 52-53. Because her husband worked in a supermarket, he
generally shopped for the family. AR 54.
other impairments such as high cholesterol, hypertension and
cervical radiculopathy, Plaintiff's daily functioning was
most affected by rheumatoid arthritis. AR 40. Although
Plaintiff was taking medications daily and biweekly infusions
of Humira, she still experienced daily arthritis pain with
some days worse than others. AR 41-42. Her doctor encouraged
exercise, and Plaintiff was able to walk around two blocks a
few times weekly. AR 42.
September 19, 2017
testimony was generally consistent with the first hearing.
Her husband helped with any heavy task or lifting. AR 84.
rheumatoid arthritis affected her hands, wrists, knees and
ankles on both sides. AR 79. Her left index finger
“lock[ed] up” (trigger finger) but could not be
surgically repaired because of her rheumatoid arthritis. AR
80. About three days a week, her joints swelled, particularly
her knees, ankles and knuckles. AR 89-91. When her hands were
swollen and painful, Plaintiff could only lift three or four
pounds and had difficulty manipulating buttons or using a pen
or pencil. AR 91-92. Pain also reduced her ability to
concentrate. AR 95.
was able to sit for 30 to 60 minutes before needing to get up
and walk for five minutes or so. AR 87. She could lift about
ten pounds. AR 87.
B. Evnin, M.D., a family physician, provided Plaintiff's
primary care records from May 2011 through January 2017. AR
369-419, 558-625, 678-91, 757-65. Dr. Evnin's records
indicate that Plaintiff had a history of
hypercholesterolemia, hypertension, mild-to-moderate mitral
regurgitation, mild tricuspid regurgitation, grade 1
diastolic dysfunction, hyperalphalipoproteinemia, fatty
liver, elevated LFTS, C6-7 radiculopathy, alcohol abuse,
metabolic syndrome, impaired fasting glucose and medication
noncompliance. However, the doctor's notes indicated that
Plaintiff was currently taking medication as directed.
Plaintiff and Dr. Evnin agreed that Plaintiff could do a
better job of watching her diet.
taken May 18, 2011, revealed mild osteoarthritis of the
knees, slightly worse on the right. AR 369. Foot x-rays taken
that day were unremarkable. AR 370. Hand x-rays were
unremarkable but for mild radiocarpal joint space narrowing.
Evnin referred Plaintiff to Kanwal Khanna, M.D., for
treatment of joint pain, joint stiffness and fatigue. The
record includes Dr. Khanna's treatment notes from June
2011 to June 2017. AR 426-92, 499-537, 544-52, 627-60,
696-714, 721-42, 745-56. The doctor's notes illustrate
the variable nature of Plaintiff's disease which caused
severe pain and swelling in various affected joints at
2011, Dr. Khanna noted disproportionate pain in
Plaintiff's left knee and wondered whether the pain,
accompanied by popping and occasional locking, indicated
internal derangement. AR 490-91. Magnetic resonance imaging
of Plaintiff's left knee in July 2011 revealed small
joint effusion and a tiny Baker cyst, but no meniscal tear or
internal derangement. AR 427.
2011, Plaintiff had developed painful right third digit
dactylitis. AR 487. She had chronic pain and swelling in her
other joints. AR 487. Dr. Khanna discontinued
Tramadol and prescribed Vicodin for
Plaintiff's pain. AR 488. In September 2011, Plaintiff
had increased pain in her neck and left ankle, and no
improvement in other affected joints. AR 485. In November
2011, Plaintiff had decreased motion, synovitis, dactylitis
and pain in various joints of her hands and fingers. AR 481.
In May 2012, Plaintiff experienced a severe episode of pain
and swelling in her left elbow for two days. AR 473. In May
and October 2012, Dr. Khanna noted that Plaintiff had
one-half to one-hour morning stiffness and daily pain. AR
467, 470. Plaintiff was limiting her activity to avoid
provoking symptoms. AR 467, 470. Dr. Khanna noted that
Plaintiff did not appear able to work full time, even in a
sedentary job. AR 467, 470. In December 2012, the doctor
noted increasing pain, particularly in the right hand, right
wrist and right elbow, but also in elbows, shoulders, hips,
knees, ankles and feet. AR 463. He also suspected right
carpal tunnel syndrome. AR 463.
February 2013, Dr. Khanna noted triggering of Plaintiff's
second digits bilaterally. AR 460. In April 2013, Plaintiff
had pain in her second through fifth MCP joints as well as
hands, wrists, elbows, knees, ankles and feet. AR 505.
Plaintiff was getting minimal exercise by walking. AR 505. In
June 2013, Plaintiff's knees and ankles were painful and
stiff. AR 502. In September 2013, Dr. Khanna began
considering whether to change Plaintiff's medication
since the Humira did not give Plaintiff a full two weeks of
relief. AR 522. The doctor discussed alternative medications
and their side effects with Plaintiff and advised her to
consider whether she wanted to change to another biologic. AR
522. In November 2013, Plaintiff was symptomatic in her
hands, wrists, elbows, knees, ankles and feet. AR 519-20. She
had increased pain in her left hand and decreased grip
strength. AR 520. Current medications were not controlling
Plaintiff's pain. AR 520.
January 2014, Plaintiff continued to exhibit disease activity
with pain in her hands, wrist, elbows, shoulders, knees,
ankles and feet and occasional triggering of several digits.
AR 517-18. Because Plaintiff did not want to change
Humira for another biologic, Dr. Khanna increased
the dosage of Azulfidine. AR 518. The doctor also prescribed
zolpidem (Ambien) for insomnia. AR 518. In March 2014,
Plaintiff reported mild to moderate joint pain and occasional
triggering of her left hand second digit. AR 514. Dr. Khanna
opined that the triggering was not yet serious enough to
require an injection, but that increased triggering would
require an injection to prevent a permanent flexion
deformity. AR 515. Plaintiff was trying to walk regularly but
walking occasionally caused ankle pain. AR 514. Dr. Khanna
explained appropriate and inappropriate limits and regimens
for exercise and suggested that soft ankle supports could
decrease Plaintiff's ankle pain. AR 515.
2014, Plaintiff was tolerating Humira in combination with
leflunomide and sulfasalazine, and elected not to make
therapeutic changes. AR 545. Plaintiff's husband told Dr.
Khanna that Plaintiff was not sleeping well and sometimes
seemed more forgetful than usual. AR 545. Plaintiff reported
that she did not find Ambien helpful and did not take it
regularly. AR 545. She had difficulty staying asleep but did
not think her pain was the problem. AR 546. Dr. Khanna
prescribed a trial of off-label Elavil to be taken at
bedtime. AR 546. In December 2014, Plaintiff's trigger
finger had begun to return after injected medication had
alleviated it. AR 645, 647. Thinking that her dog's leash
might be injuring Plaintiff's finger, Dr. Khanna
suggested an accommodation using a vascular [clip?]. AR 647.
The doctor encouraged walking and stretching to promote
healthy muscle tone and range of motion. AR 647.
January 2015, Plaintiff accidentally injured her neck and
shoulder while trying to control her dog. AR 566. She could
lift her arm only with severe pain. AR 566. X-rays revealed
no fracture or dislocation of Plaintiff's shoulder or
neck. AR 564-65. In December 2015, Dr. Evnin expressed
concern about Plaintiff's obesity, noting that Plaintiff
was only walking about twenty minutes every other day and was
not watching her diet carefully. AR 558. Dr. Evnin advised
Plaintiff to stop drinking any alcohol, walk 45 to 60 minutes
daily and reduce stress. AR 561.
August 2015, Plaintiff was experiencing pain and swelling of
the right thumb metacarpal joint. AR 638. Plaintiff thought
she was doing fairly well and because she was struggling with
the large number of medications prescribed for her, had not
yet tried Rayos. In October 2015, Plaintiff was
experiencing severe pain and triggering of her left second
digit. AR 636.
January 2016, Dr. Khanna noted that Plaintiff was still
experiencing inflammation but that her medication was
sufficient to prevent progressive deformities. AR 635. Her
fatigue appeared to be manifestation of her autoimmune
disease. R 635. In March 2016, Dr. Khanna noted that
Plaintiff took pain medications sparingly and showed no signs
of narcotic impairment. AR 627. Her knees were more painful
than other joints, including hands, wrists, elbows,
shoulders, ankles and ...