United States District Court, D. Massachusetts
MEMORANDUM AND ORDER
B. Saris Chief United States District Judge
Tonya Malone, who has a history of pain and mental health
issues, seeks review of the denial of her claim for Social
Security disability benefits, arguing that the Administrative
Law Judge ("ALJ") erroneously failed to consider
the opinion of an examining consultative orthopedist and
disregarded the findings of state agency psychologists that
she has moderate limitations in social functioning that
required a "supportive employer." Because the ALJ
failed to sufficiently explain why he discredited the opinion
of the examining consultative orthopedist, the Court
ALLOWS Malone's motion to vacate and remand the
decision of the Commissioner (Docket No. 19) and
DENIES the Commissioner's motion to affirm
(Docket No. 20) .
applied for Disability Insurance Benefits on August 14, 2012,
claiming disability due to coccydynia, hernia, fibromyalgia,
right hand arthritis, migraine headaches, obesity, bipolar
disorder, depression, and anxiety. Malone claimed that her
disability began on August 28, 2011. Malone was forty-eight
years old when the ALJ denied her application on July 24,
worked most recently as a dual-diagnosis counselor at a Long
Island shelter. R. 33. Prior to that, Malone worked as a
nursing assistant. R. 33. Malone attended high school through
the eleventh grade. R. 32. She did not pursue a GED, but she
did complete a nursing assistant program and receive a
certificate. R. 32-33.
Physical Health Conditions A.
medical record contains frequent references to back pain,
abdominal wall pain, and whole body pain dating back to 1998.
E.g., R. 271, 307, 440, 455.
January 22, 1998 evaluation by Dr. Godwin Darko referenced
complaints of knee pain and middle and upper back pain. R.
271. A February 18, 1998 radiology consultation by Dr. Daniel
O'Connor referenced a history of headaches, neck, and
back pain stemming from an injury one year prior. R. 275. Dr.
O'Connor found no evidence of fracture, tissue swelling,
or abnormality. R. 275.
slipping and falling on water on June 6, 2000, Malone sought
treatment from Dr. Crowley, an emergency room physician, for
neck and back pain. R. 295.
August 10, 2006, Malone sought treatment for abdominal pain
at the incision site of a tubal ligation six years prior. R.
307. Dr. Andrew Glantz performed an incisional hernia repair
and located two incisional hernias at the site of the past
incision. R. 307. During a follow-up visit on September 25,
2006, Dr. Glantz described Malone as "fully
recovered" from the hernia surgery. R. 311.
2, 2008, Malone was injured in a car accident. R. 321. The
next day, she went to the emergency room and reported nausea,
headache, body aches, and migraine. R. 321. On June 25, 2008,
Malone sought treatment from her primary care physician, Dr.
Kathleen Crowley. R. 321. Dr. Crowley indicated that while
Malone reported that she did not feel better, the mechanism
of her injury was unclear. R. 321.
September 14, 2012, Malone sought treatment from Dr. Thomas
Ostrander. R. 455. Dr. Ostrander described Malone as having a
history of '"chronic pain" with headaches and
abdominal wall hernia with cramping. R. 455.
weeks later, on September 28, 2012, Malone sought a
behavioral health evaluation from Social Worker Judith Bello.
R. 4 99. During the appointment, Malone reported pain in her
back, neck, knees, shoulder, head, and tailbone. R. 500.
Malone rated the pain intensity as an eight on a pain
intensity scale of one to ten. R. 500.
November 7, 2012, Malone had a follow-up appointment with Dr.
Ostrander. R. 490. Malone conveyed during the office visit
that the "pain continues." R. 4 90.
November 14, 2012, during a therapy appointment with
Psychotherapist Stephanie Freeman, Malone reported pain in
her head and stomach that rated eight out of ten on a
ten-point pain scale. R. 424. On the same date, Malone was
also evaluated by Dr. Anna L. Fitzgerald. R. 440. Dr.
Fitzgerald noted that Malone suffered from "chronic
pain." R. 440.
December 5, 2012, during a therapy appointment with Freeman,
Malone reported constant whole-body pain of high intensity
(ten on a pain scale of one to ten). R. 412. Freeman's
notes indicated, "[Patient] reported she is still
experiencing a great amount of physical pain and medication
is not relieving the pain." R. 413. During Malone's
next psychotherapy appointment on December 19, 2012, Malone
again reported pain of ten out of ten with constant pain in
her stomach and head. R. 464. A few weeks later, on January
9, 2013, Malone reported physical pain at a severity of four
out of ten. R. 417. Malone again reported physical pain
during a January 16, 2013 therapy session, with a severity of
five out of ten. R. 450.
returned for a follow-up with Dr. Ostrander on February 25,
2013. R. 429. The treatment record described Malone as having
a history of "chronic pain" with codeine "no
longer working for her pain." R. 429. Malone was
diagnosed with Chronic Pain Syndrome and prescribed Fentanyl
pain patches. R. 431.
office visit on March 27, 2013 with Dr. Ostrander, Malone
reported that morphine was "working well" to
control her pain. R. 473.
Anne Fitzgerald evaluated Malone on April 24, 2013, at which
point Malone reported pain of a ten out of ten. R. 485. At
the appointment, Malone reported that she had been prescribed
morphine for her hernia and pain. R. 484. Malone expressed
wariness of narcotics due to her history but deemed the
morphine "necessary." R. 484. Dr. Fitzgerald noted
that "pain persists but improved with current
treatment." R. 487. At a psychotherapy appointment on
the same day, Malone noted "constant head, back, and
stomach pain over the course of two weeks." R. 495. On
August 6, 2013, Malone sought treatment from Dr. Daniel
Cottrell, her new primary care physician, for chronic pain,
abdominal pain, and headaches. R. 513. Malone reported she
could "barely move" and was "unable to walk
long distances." R. 513.
September 30, 2013, Malone sought treatment from Dr. Cottrell
for increased hip and back pain. R. 509. Treatment notes
referenced "chronic pain - Fibromyalgia." R. 509.
No cause, trauma, or injuries were reported. R. 509. Dr.
Cottrell noted that "pain is worse of late for unclear
reasons" and that "she is very concerned about
opiates and worries about addiction." R. 511. Malone was
prescribed Percocet. R. 511.
October 3, 2013, Dr. Cottrell submitted a medical report to
the Massachusetts Disability Evaluation Services stating that
Malone had "chronic pain, fibromyalgia" that would
affect her ability to work for more than a year. R. 538, 542.
Dr. Cottrell stated that Malone was prescribed MS-Contin and
Percocet for pain management. R. 538.
has a history of migraines dating back to her slip-and-fall
incident on June 6, 2000, when she lost consciousness and
suffered a seizure. R. 295. The following day, Malone was
evaluated by Dr. James Otis for severe headaches and seizure.
R. 288. An EEG revealed no abnormalities. R. 288.
September 14, 2012, Malone sought treatment from Dr.
Ostrander, reporting headaches that were "under
moderately acceptable control" with Tylenol with
codeine. R. 455. However, when Malone was evaluated by Social
Worker Judith Bello at Boston Medical Center two weeks later,
Malone reported headaches and rated the intensity of her pain
as eight out of ten. R. 500.
October 4, 2012, Malone sought urgent care from Dr. Jordana
Meyerson and reported "a headache that is not alleviated
by Tylenol with codeine." R. 4 69.
November 14, 2012, Malone sought psychological treatment at
Boston Medical Center and noted head pain of an eight out of
ten on the pain scale. R. 424. Malone reported that her pain
medication had recently been changed from Tylenol with
codeine to codeine. R. 425. During Malone's next
psychotherapy appointment on December 19, 2012, Malone
reported "intense migraines" at a severity of ten
out of ten. R. 464-65.
January 9, 2013, during a therapy appointment with
Psychotherapist Freeman, Malone reported constant head pain
at a severity of four out of ten. R. 417.
February 25, 2013, as described above, Malone reported a
headache to Dr. Ostrander. R. 429-30. Malone was diagnosed
with Chronic Pain Syndrome and prescribed Fentanyl pain
patches. R. 431.
December 15, 2004, Malone sought treatment for difficulty
straightening her finger to full extension. R. 305. Dr.
Andrew Stein opined that she had a reflex inhibition stemming
from residual pain from a past laceration. R. 305. On June
22, 2005, Malone returned for a follow-up appointment, where
she reported no pain in her finger but reported "a droop
when she tries to fully straighten it." R. 306. Dr.
Stein indicated Malone could make a fist without difficulty
and maintain full extension for approximately ten seconds, at
which point her finger joint begins to "droop to
approximately 10 degrees." R. 306. Dr. Stein indicated
that Malone had a partial EDC tendon injury, but that with
time and exercise it was possible she would hopefully be able
to "maintain the long finger in full extension." R.
12, 2007, Dr. Stein diagnosed Malone with chronic partial EDC
tendon laceration and performed a delayed primary repair of
the EDC tendon. R. 313. A follow-up appointment with Dr.
Stein on July 9, 2007 revealed the finger was "well
healed." R. 315. A "slight PIP lag" was
identified and exercises recommended. R. 315.
August 22, 2007, Malone was again seen by Dr. Stein, with
increased functioning in her finger and no complaints of
pain. R. 317. However, Dr. Stein noted that Malone
"still is not satisfied with the PIP extension." R.