United States District Court, D. Massachusetts
MEMORANDUM AND ORDER
B. SARIS Chief, United States District Judge
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
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).
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.
Work History and Education
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Treating Physicians' Evaluations
Dr. Flood's Treating Source Statements and Medical
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.
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 ...