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Saenz v. Colvin

United States District Court, D. Massachusetts

November 24, 2014

KEVIN L. SAENZ, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant

Decided November 21, 2014.

For Kevin L. Saenz, Plaintiff: Beth R. Levenson, Epstein, Lipsey & Clifford, P.C, Hanover, MA.

For Carolyn W. Colvin, Defendant: Anita Johnson, LEAD ATTORNEY, United States Attorney's Office, John Joseph Moakley Federal Courthouse, Boston, MA.

For Social Security Administration, Interested Party: Thomas D. Ramsey, LEAD ATTORNEY, Office of the General Counsel, Social Security Administration, Boston, MA.

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F. Dennis Saylor IV, United States District Judge.

This is an appeal of the final decision of the Commissioner of the Social Security

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Administration denying an application for social security disability insurance (" SSDI" ) and supplemental security income (" SSI" ) benefits. Plaintiff Kevin L. Saenz alleges disability based on physical impairments related to his lower back, left knee, and left arm. The Administrative Law Judge (" ALJ" ) determined that plaintiff retained a sufficient residual functional capacity (" RFC" ) to perform work existing in the national economy, and thus that he was not disabled under the Social Security Act, 42 U.S.C. § 216(i) and § 223(d).

Plaintiff has moved to reverse the ALJ's decision. He contends that (1) the ALJ failed to consider additional evidence added to the record and (2) failed to give controlling weight to his treating physiatrist's opinions. Defendant has cross-moved for an order affirming the ALJ's decision.

For the reasons set forth below, plaintiff's motion to remand and reverse the ALJ's decision will be denied, and defendant's motion to affirm the ALJ's decision will be granted.

I. Background

A. Educational and Occupational History

Kevin Saenz was born on August 3, 1985. He was 26 years old at the time of his hearing before the ALJ on March 15, 2012. (A.R. 31). He completed the eighth grade, but did not go any further in school. ( Id. at 31).

From 2001 to the end of 2004, and again in 2008, Saenz worked for Lighthouse Masonry as a manual laborer. From summer 2007 through the end of that year, he worked for A1 Concrete Cutting and Construction as a manual laborer. ( Id. at 226). At those jobs, he was " on [his] feet and [did] a lot of heavy lifting." ( Id. at 32). In early 2009, he worked at Niche, Inc. as a stitcher in a factory, where he sewed parachutes using a large commercial sewing machine. ( Id. at 226). At that job, he stood for the duration of the workday, and did some heavy lifting. ( Id. at 33, 35). He left that job in April 2009 because of a work-related injury. The alleged disability onset date is April 14, 2009. ( Id. at 151).

B. Medical History

On April 14, 2009, Saenz sustained a work-related injury while working as a stitcher. He was standing on a table approximately five feet high, and when he attempted to step down onto a smaller table, he rolled backward, striking the back of his upper trapezius and upper neck. He also caught his left arm between the two tables, and hyperflexed his knee while attempting to get up. (A.R. at 343, 372, 400).

That day, he visited St. Luke's Hospital Emergency Room complaining of neck pain and numbness in his left arm. ( Id. at 270-71, 372). A CT scan of the cervical spine provided no evidence of traumatic injury. ( Id. at 374). A radiology report demonstrated mild lumbar spondylosis, most pronounced at L5-S1 level, and a Schmorl's node in the superior endplate of L5. ( Id. at 370).[1] A physician at St. Luke's diagnosed muscular contusions and prescribed Percocet and Ibuprofen. ( Id. at 271).

On April 15, 2009, Saenz returned to St. Luke's Emergency Room. He reported that the prescribed medications were not dissipating the pain, and that he now felt

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pain throughout the left side of his body, down his leg. ( Id. at 387). Matthew Brown, N.P., prescribed Ibuprofen for pain and Flexiril to control knee spasms, and gave him a knee brace and crutches to use as needed. ( Id. at 385, 398).

On April 16, 2009, Saenz visited St. Luke's Occupational Health Clinic. He explained to Richard Santos, N.P., that he had been experiencing some numbness in his left hand and pain in his left knee and lower back. ( Id. at 400). Santos noted that Saenz had a " slightly antalgic gait," restricted motion in his neck, and restricted shoulder rotation, but was able to sit in a normal fashion.[2] Santos also concluded that Saenz had suffered from a left neck strain, an upper trapezius strain, a thoracolumbar strain, and a left knee strain. ( Id. at 401). Santos instructed him to continue taking Ibuprofen and Flexiril, gave him a knee brace, and recommended a homeexercise program. ( Id.).

Saenz visited Santos again on April 22, reporting " a lot of pain in the upper neck and upper trapezius area with some numbness in the left arm." Santos increased Saenz's Percocet dosage, and noted, " I anticipate that this will heal with conservative management." ( Id. at 403-04). Saenz visited Santos again on April 29, reporting continuing pain in his left knee. ( Id. at 406).

From April 21 through June 18, 2009, Saenz saw Ryan M. Knowles, D.C., for chiropractic therapy. ( Id. at 425). Knowles's treatment plan for Saenz included chiropractic adjustments " in order to correct spinal misalignment and to restore bio-mechanical integrity to the spine." ( Id. at 413). On May 21, Knowles noted that Saenz's neck and lower back pain had diminished since his initial evaluation due to a combination of chiropractic treatment and prescription medication. ( Id. at 418). He also noted that he considered Saenz to have been " totally disabled from work activities and will remain such for a period of two to four more weeks." ( Id. at 420). In his June 18 discharge report, Knowles noted a general lack of progress, and that some of Saenz's symptoms had actually worsened over the course of the therapy. ( Id. at 426). He also noted that he considered Saenz to be " totally disabled" from April 14 through June 18. ( Id.). He diagnosed (1) cervical radiculitis and cervicalgia related to cervical disc protrusion and cervical sprain/strain injury, (2) lumbar radiculitis and low back pain related to moderate lumbar sprain/strain injury, and (3) ongoing post-traumatic left knee pain. ( Id. at 427).[3]

Knowles referred Saenz to Sergey Wortman, M.D., a physiatrist. Dr. Wortman first saw Saenz on May 4, 2009. ( Id. at 343). During an examination of his knee, Saenz reported pain in the medial portion of the left knee joint, in the inferior pole of the left patella, and due to bilateral displacement of the patella. ( Id. at 344). During examination of his lower back, he reported pain on extension and compression. ( Id.). Examination of his left arm revealed swelling in the lower third of his forearm, and a limited range of motion. ( Id. at 345). During examination of his neck, Dr. Wortman noted limited rotation on the left and rigidity due to pain. ( Id.). Dr. Wortman noted that Saenz appeared " not in acute distress but rather discomfort." ( Id. at 344). He recommended an MRI of the left knee, and prescribed Medrol and Relafen. ( Id. at 345-46). He

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also noted: " It is my medical opinion to within a reasonable degree of medical certainty that patient presently is temporarily totally disabled from gainful employment due to work related injuries." ( Id. at 346).

On May 9, 2009, Saenz underwent an MRI of his left knee that revealed a small radial tear of the posterior horn lateral meniscus. ( Id. at 341-42). On June 13, he underwent an MRI of his cervical spine that revealed broad-based disc protrusion with mild mass affect upon the thecal sac. ( Id. at 328-29). On July 2, he underwent a nerve conduction test that revealed evidence of compression of the left motor ulnar nerve at the elbow, but no evidence of nerve damage. ( Id. at 311, 313-14). Dr. Wortman recommended a second opinion evaluation by orthopedic surgeon Henry Toczylowski, M.D., and a trial of physical therapy. ( Id. at 311).

Saenz saw a physical therapist at New Bedford Physical Therapy from July 8 through September 16, 2009, who noted " minimal progress in neck and back pain" and a slight improvement in strength. ( Id. at 236).

On July 15, 2009, Saenz again saw Dr. Toczylowski, who noted that he walked with a marked antalgic gait, but had good flexion and stability. ( Id. at 474). Dr. Toczylowski recommended a course of physical therapy. ( Id. at 475). On August 7, 2009, Saenz underwent an MRI of his lumbar spine that revealed a broad-based posterior and right lateral disc bulge with superimposed central protrusion contacting nerve roots, moderate neural foraminal narrowing, and mild spondylitic changes of the lumbar spine. ( Id. at 301-02).[4]

On September 18, 2009, Saenz visited the St. Luke's Hospital Emergency room after being involved in a motor vehicle accident. He reported sharp pains in his neck, lower back, and left knee. He was released the next day with ...

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