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Pierce v. Colvin

United States District Court, D. Massachusetts

March 24, 2017

CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration, Defendant.


          PATTI B. SARIS Chief, United States District Judge


         Plaintiff Karolyn Pierce, who has had a long history of knee problems and been on a regimen of pain medications, seeks judicial review of the decision by the Social Security Administration (“SSA”) to deny her claim for Supplemental Security Income (“SSI”) benefits. Plaintiff argues that 1) the Administrative Law Judge (“ALJ”) failed to give the opinion of her treating physicians proper weight, 2) the ALJ erred in evaluating Plaintiff's credibility concerning her complaints of pain and the effects of her pain medication, and 3) the ALJ's Residual Functional Capacity (“RFC”) findings were not supported by the medical evidence. Defendant moves to affirm the Commissioner's Decision.

         For the reasons set forth below, the Court ALLOWS Plaintiff's motion to reverse and remand the decision of the Commissioner (Docket No. 11). The Court DENIES the Defendant's motion to affirm the Commissioner's decision (Docket No. 12).


         At the time of the hearing before the ALJ on April 14, 2015, Plaintiff was forty years old. R. 132. The ALJ denied her request for reconsideration on May 20, 2015. R. 11-22.

         I. Work History and Education

         A high school graduate, Plaintiff worked as an underwriting assistant from March 2003 to April 2013. R. 166. In April 2013, Plaintiff was terminated due to “company cutbacks” and has not worked since. R. 157. She alleges disability beginning June 5, 2013. R. 132.

         II. Medical History

         Plaintiff's medical records indicate a long history of knee disorders in both knees. Plaintiff also reports side effects of pain medications that make daily activities difficult. Three treating physicians submitted opinions or evaluations in support of Plaintiff's application for disability benefits: 1) her primary care physician Dr. Steven Flood who treated her beginning in October 2013; 2) orthopedic surgeon Dr. Timothy Foster who treated Plaintiff from 2012 until 2014 and performed multiple surgeries on both of Plaintiff's knees; and 3) orthopedic surgeon Dr. Henry Bedair, who treated Plaintiff from 2014 onward and also performed multiple knee surgeries, including total knee replacements on both of Plaintiff's knees. State Agency physicians Dr. Harold Ramsay and Dr. Rosario Palmeri also submitted opinions for this case but did not physically examine Plaintiff.

         Prior to the claimed disability onset date, the lengthy medical record reflects seventeen knee surgeries dating back to 2001. R. 241-59. Despite these surgeries, the problems in Plaintiff's right knee persisted. In late July 2011, Plaintiff met with orthopedic surgeon Dr. Patz complaining of instability and pain in her right knee. R. 284. The doctor recommended that she use a brace. R. 284. In April 2012, Plaintiff again met with Dr. Patz because “her right knee gave way” a few days before. R. 282. An x-ray taken at the time showed “degenerative changes” in her right knee joints. R. 282. Dr. Patz recommended the continued use of a brace and eventually referred Plaintiff to Dr. Timothy Foster, orthopedic surgeon, for further evaluations. R. 280-82. In June 2013, Plaintiff met with Dr. Timothy Foster regarding her right knee pain, R. 267, he recommended surgery on her right knee. R. 280-82.

         On the disability onset date of June 5, 2013, Plaintiff had a patellofemoral arthroplasty (kneecap replacement) surgery on her right knee. R. 268-69, 331-35. Prior to the surgery, Plaintiff had been prescribed Percocet and Lovenox (a blood thinner). R. 268. After the surgery, Plaintiff was given Valium to be used “as a muscle relaxer” but was “cautioned against its sedative effect.” R. 269. Plaintiff was also administered a refill of Oxycodone for pain and continued to take Lovenox. R. 269. Medical records from appointments with Dr. Foster and Sarah Larch, PA-C (physician's assistant) in July and August of 2013 state that Plaintiff continued to take prescribed narcotic medications for pain and required a brace to walk because her “leg [felt] weak without the brace.” R. 270-71. At these appointments, doctors noted that Plaintiff was taking Vicodin in addition to her other pain medications, but that she “require[d] no narcotic medication during the day.” R. 270.

         At a follow-up appointment in August with Dr. Foster, Plaintiff was cleared to drive and her prescription doses were lowered in order to “begin the weaning process.” R. 270. In October 2013, Plaintiff had “giving way episodes” and reported still needing the brace. R. 272. Dr. Foster recommended that Plaintiff stop using the knee brace as he felt it “may be limiting her ability to strengthen the quadriceps.” R. 272. At the six-month follow up appointment in October 2013, Dr. Foster reported full extension ability of the right knee, flexion to 120 degrees and ability to perform straight leg raises. R. 273. Additionally, he noted that Plaintiff “will wean off the pain medicine as tolerated.” R. 273.

         Plaintiff met with Dr. Steven Flood, a family medicine doctor, on October 10, 2013 to discuss her ongoing knee problems and to discuss her medications, at which point Dr. Flood advised Plaintiff to stop taking Vicodin and start taking Oxycodone. R. 369.

         On March 5, 2014, Dr. Flood again met with Plaintiff regarding her knee problems. R. 367-68. Dr. Flood referred her back to Dr. Patz for a second opinion and “to review her history for any other treatment possible.” R. 368. He also referred her to a local pain clinic “for help in managing her ongoing symptoms” of knee pain. R. 368.

         At her appointment with Dr. Patz on March 7, 2014, Plaintiff reported persisting pain and buckling. R. 277. Plaintiff used various knee braces without improvement, she could not wear high heels, had a decreased activity level, and was finding herself in bed all day, although the pain was “not keep[ing] her up at night.” R. 277. Plaintiff “increase[d] her pain medication of Oxycodone to five times a day” in addition to taking Diazepam four times a day and Neurontin twice a day. R. 277. Her “current medication” list in the record also includes Amitriptyline and Tramadol. R. 278. Dr. Patz referred her to Dr. Schepsis for a follow-up appointment to discuss her ongoing knee pain. R. 277. Additionally, Dr. Patz noted that Plaintiff was “too young for a total knee replacement at this point.” R. 277.

         Later that month, Plaintiff was seen by a nurse practitioner in Dr. Flood's office for a gynecology exam. R. 363. At that exam, Plaintiff reported that she was “discouraged because of her knee pain and limitations on life style because of the knee pain.” R. 363. Plaintiff also mentioned she was looking for work and she wanted to return to work because she was “bored at home.” Plaintiff also stated she was “sick of taking pills” and wanted “to be active and off pills.” R. 363.

         On March 24, 2014, Plaintiff had a pain management consultation with Dr. Anita Sadasivan Dasari, MD. R. 307-09. Plaintiff reported that, in order to make the “pain tolerable to function throughout the day, ” she was taking Oxycodone four times a day (since June 2013), Tramadol four times a day, Diazepam four times a day for muscle spasms and restless leg syndrome, Gabapentin three times a day and Amitriptyline once a night. R. 307. Plaintiff also reported that these medications made her tired, and only provided fifty percent relief. R. 307. She experienced sleep disturbance due to her pain. R. 307. Plaintiff also stated that her average pain score was “5/10- 10/10, ” and the pain increased by walking or standing but improved by lying down. R. 307. At that appointment, Dr. Dasari recommended Plaintiff begin taking Baclofen for muscle spasms and “consider decreasing Valium in the future.” R. 308.

         In April 2014, Plaintiff met again with PA-C Larch in Dr. Foster's office and reported continued pain and frequent buckling in her right knee. R. 274. Plaintiff mentioned being “frustrated with her current state and ongoing pain.” R. 274. PA-C Larch reported that Plaintiff should continue her pain management program and would be considered for another diagnostic arthroscopy surgery (wherein a camera is inserted via a small incision in the knee to inspect and remove bone debris) in 3 months if her condition did not improve. R. 274.

         At her next appointment with Dr. Dasari in May 2014, Plaintiff reported she had to stop taking Baclofen because it caused dizziness and did not relieve her pain. R. 304. Plaintiff also reported that her right knee pain was worse than her left knee pain, and that she did “not trust herself to walk too far.” R. 304. Plaintiff further stated that “her feet and calves start twitching in the night or when she has been in one spot too long.” R. 304. Plaintiff was taking Gabapentin, Tramadol, Amitriptyline, Valium, and Oxycodone and said her current average pain score was a “4-9/10.” R. 304. Dr. Dasari started Plaintiff on Robaxin as an alternative to Baclofen and increased her Amitriptyline dosage. R. 305. Dr. Dasari also recommended that Plaintiff speak to Dr. Flood about restless leg syndrome. R. 305.

         Plaintiff met with Dr. Foster again in May, and continued to report pain in both knees, “however [at this time] the left knee was by far the worse.” R. 275. Dr. Foster and Plaintiff agreed to proceed with a diagnostic arthroscopic surgery of the left knee at that time to assess whether the knee would need a total replacement. R. 275. Dr. Foster performed the surgery on June 16, 2014. R. 322-23. After the surgery, Dr. Foster reported that “the patient is clearly headed for a total knee replacement.” R. 324.

         At a post-operative appointment a few days later, Dr. Foster and Plaintiff discussed and agreed to perform a surgery on the right knee in order to determine whether that knee would also need a total replacement. R. 324. Subsequently, the surgery was performed on the right knee in July 2014. R. 319-20. The surgery revealed significant cartilage defect, but Dr. Foster advised Plaintiff to continue with home exercise and receive further evaluations. R. 321.

         In late July 2014, Plaintiff met with Dr. Flood because of decreased mental clarity, slurred speech, and slow gait in the two months after her diagnostic surgeries. R. 359. Dr. Flood posited that the symptoms were “probably related to over medication” and recommended reducing her Amitriptyline and Gabapentin doses, but continuing her Oxycodone dose. R. 359-60. In August, Plaintiff once again met with Dr. Flood for continued mental confusion and weakness. R. 357. She reported that she had fallen “several times since her last visit and was unable to get up.” R. 357. At the time Plaintiff was taking Robaxin (a muscle relaxer), Amitriptyline, Diazepam, Pramipexole (for restless leg syndrome), Oxycodone, Gabapentin, and Tramadol. R. 357.

         On September 8, 2014, Dr. Bedair performed a total right knee replacement on Plaintff. R. 426-27. During her post-operation appointment in mid-October, Plaintiff reported “occasional discomfort.” R. 400. Dr. Bedair also noted that Plaintiff was weaning off pain medication and that physical therapy was yielding steady progress. R. 400.

         On December 10, 2014, Plaintiff had a total left knee replacement, also performed by Dr. Bedair. R. 447-48. After the surgery, Plaintiff reported “numbness of the right face, scalp, and neck. . . .” R. 450. An MRI revealed no conclusive explanation for the numbness. R. 455. Dr. Bedair advised that Plaintiff see a neurologist to follow up. R. 455.

         At the end of December, Plaintiff met with Dr. Flood for a follow-up appointment after her surgery. R. 487. Plaintiff reported that she was continuing physical therapy at home but she had fallen twice. R. 487. At the time, she was taking Dilaudid for pain in addition to Oxycodone; Dr. Flood recommended she should start taking MS Contin. R. 487. When she met with Dr. Flood again in early January 2015, Dr. Flood reported that “the visiting nurse and visiting physical therapist . . . thought she was dopey or groggy from all the medication.” R. 485. Plaintiff reported that she was taking MS Contin for the pain and that it made her fall asleep but the pain was still significant. R. 485. Plaintiff was also taking Diazepam, Robaxin, Amitriptyline, Oxycodone, and Gabapentin. R. 486. Dr. Flood recommended she stop taking Diazepam and reduce the MS Contin dosage. R. 486. When Plaintiff met with Dr. Flood again a few days later, he reported that she seemed “mentally clearer” because she was taking a reduced dosage of MS Contin, but her pain would come back more quickly. R. 483.

         Around this time, during her post-operative follow up appointment with Dr. Bedair's office in January, Plaintiff reported substantial post-surgery pain in her left knee. R. 474. Plaintiff was trying to manage her pain by taking Oxycodone and Gabapentin and working with Dr. Flood. R. 474. Plaintiff also continued to experience numbness on the right side of her face. R. 474.

         In February, Plaintiff met with Dr. Flood to review her pain management. R. 481. Plaintiff seemed mentally clearer at this time. R. 481. Plaintiff continued to take Oxycodone, Gabapentin, MS Contin, and Robaxin. R. 481-82. Plaintiff had muscle cramps and stiffness of the left leg, and was still experiencing some facial numbness. R. 481. Dr. Flood recommended she stop taking Robaxin and start taking Baclofen. R. 482. When Plaintiff met with Dr. Flood in March 2015, she had been hospitalized two weeks prior for a “change in mental status and concern about overmedication.” R. 479. During that hospital stay, her medications were adjusted and she was discharged on a lower dosage of Morphine and Oxycodone. R. 479. Additionally, upon the administration of a CT scan, Dr. Flood discovered that Plaintiff had a fracture at the site of her left knee replacement. R. 479. A follow-up appointment was scheduled with orthopedics for later that month. R. 479. The medical record ends at this point.

         III. Treating Physicians' Evaluations

         a. Dr. Flood's Treating Source Statements and Medical Assessment

         Dr. Steven Flood provided a treating source statement for this case on July 22, 2014. R. 356. In the statement, Dr. Flood wrote that Plaintiff had been under his care for routine health as well as “a long history of” orthopedic problems with her knees. R. 356. Dr. Flood continued that Plaintiff had multiple surgical procedures and was under treatment for chronic pain with “six different medications.” R. 356. He believed that “as a result of the combined medications' side effects” Plaintiff would not be able to work in any capacity. R. 356. Dr. Flood considered Plaintiff to be “permanently disabled, ” and believed the disability would last for at least 2 years and could be permanent. R. 356. Dr. Flood's office submitted an identical treating source statement on August 11, 2014. R. 394.

         Dr. Flood also completed and submitted a Physical Residual Function Capacity Assessment (“RFC Assessment”) report on November 10, 2014. R. 431-38. In this report, Dr. Flood opined that Plaintiff could occasionally or frequently lift less than 10 pounds, could stand or walk for less than 2 hours in a normal eight-hour workday (and would medically require an assistive device for ambulation), would have to periodically alternate sitting and standing to relieve pain and discomfort, and could push or pull only a limited amount in her lower ...

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