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Harris v. Saul

United States District Court, D. Massachusetts

July 30, 2019

MARNIE R. HARRIS, Plaintiff,
v.
ANDREW M. SAUL, Commissioner of the Social Security Administration Defendant.

          MEMORANDUM AND ORDER

          Hon. Patti B. Saris, Chief United States District Judge.

         INTRODUCTION

         Plaintiff Marnie R. Harris brings this pro se action under 42 U.S.C. § 405(g) for judicial review of a final decision denying her application for Supplemental Security Income benefits (“SSI”). Plaintiff suffers from cervical degenerative disc disease, obesity, diabetes, bilateral knee osteoarthritis, hammertoe deformities, and right shoulder tendinopathy with a partial rotator cuff tear. She contends that the Administrative Law Judge (“ALJ”) did not properly consider her pain in assessing her ability to work.

         For the reasons set forth below, the Court DENIES Plaintiff's motion to reverse (Docket No. 20) and ALLOWS the Commissioner's motion to affirm (Docket No. 22).

         FACTUAL BACKGROUND

         The following facts are taken from the administrative record. Plaintiff is a 55-year-old woman. She completed four years of college and, in the fifteen years preceding her application, worked as a secretary, saleswoman, liaison, and tax preparer. She stopped working in 2011.

         I. Medical History

         An examination of Plaintiff on July 24, 2013 showed that she suffered from obesity, back and foot pain, and diabetes but had full overhead reach, good range of motion of the neck, and the ability to grasp. She has taken Flexeril for many years for her pain.[1]

         Plaintiff underwent physical therapy to address her upper back pain at Brigham and Women's Faulkner Hospital in 2014. The physical therapy improved the strength of her neck muscles. By the last session on August 6, 2014, Plaintiff reported that she could clean laundry, cook, drive, and sleep and that she did not feel functionally limited by her neck pain.

         On December 2, 2014, Plaintiff went to the emergency room because of shoulder pain. After performing a clinical exam and x-rays, the attending physician diagnosed Plaintiff with a rotator cuff injury. She recommended that Plaintiff rest, take ibuprofen as needed, apply ice, and avoid physical activity.

         A week later, Dr. Edward Phillips, a physiatrist, examined Plaintiff for muscles spasms in her upper back. He noted several additional health problems, including lower back pain and pain in her right foot caused by two hammertoes. Despite her pain, Plaintiff could grasp, had full range of motion of her neck, and had full overhead reach. Dr. Phillips and Plaintiff discussed doing more physical therapy, getting a steroid injection for her right shoulder, and taking either Diclofenac or Aleve.

         On October 5, 2015, Plaintiff was examined by Dr. David Cahan, a state medical consultant. She told Dr. Cahan that, while her pain prevented her from walking more than two blocks and climbing more than one flight of stairs, she could sit adequately, do light cleaning, and stand for only a few minutes as long as she leaned to her left side. She complained about muscle spasms and pain at the base of her left neck and in her shoulders but noted that her pain that was less severe than it had been in the past. Dr. Cahan determined that Plaintiff had good range of motion of the neck despite some muscle tightness and that she could “ambulate[] slowly with a modest limp” and without an assistive device. He also noted that her right shoulder's posterior rotation was marginally limited and that she could not squat.

         The same day, Plaintiff saw Dr. Susan Hata, her primary care physician (“PCP”). Dr. Hata noted that Plaintiff suffered from obesity, diabetes, lower back pain, and foot pain. Plaintiff's neck was “supple, ” and her lymph nodes did not suffer from lymphadenopathy. Dr. Hata examined Plaintiff again on January 15, 2016 and noted that she moved all extremities well and had no pain associated with external and internal rotations of the right shoulder or joints. Dr. Hata instructed Plaintiff to take baby aspirin daily.

         On March 8, 2016, imaging of Plaintiff's right shoulder showed extensive tendinopathy of the rotator cuff, as well as partial tearing and severe degenerative changes at the acromioclavicular joint. An x-ray of Plaintiff's right shoulder two months later showed mild degenerative changes of the acromioclavicular joint and a well-maintained glenohumeral joint.

         On July 8, 2016, Plaintiff saw Dr. Joseph Hanak, a physiatrist, for complaints relating to neck, knee, and shoulder pain. Dr. Hanak noted that she was “cavalier, ” put forth minimal effort when he performed manual muscle testing, and was not complying with her medication regimen. Plaintiff also had “decreased abduction of the right shoulder due to discomfort, but when coached had full range of motion.” Dr. Hanak rated her right-side external rotation weakness as “slight” and a “5-/5” and her other upper body muscles as “5/5.” Two weeks later, Plaintiff underwent radiological examinations that revealed degenerative changes and small joint effusions in her knees and a normal alignment of her cervical spine with multilevel degenerative changes.

         On December 5, 2016, Dr. Kevin Riemer, a podiatrist, examined Plaintiff's feet. Plaintiff reported mild pain but appeared well and in no acute distress. Dr. Riemer rated her muscle strength as 5/5. They discussed the possibility of hammertoe surgery, which Plaintiff declined.

         On January 10, 2017, Dr. Nancy Shadick, a rheumatologist, examined Plaintiff for pain in her left knee due to her osteoarthritis. Plaintiff also complained about her ankles and stated that physical therapy had not helped her. Plaintiff denied fatigue or lower back, chest, or abdominal pain. After examining Plaintiff, Dr. Shadick determined that Plaintiff was a “well-nourished adult in no apparent distress.” Dr. Shadick did not identify any deformity, swelling, tenderness, or limited range of motion in the shoulders, wrists, hands, fingers, and knees.

         II. Dr. Hata's Disability Opinion

         Dr. Hata completed two forms with her opinion on Plaintiff's disability. In the first report, Dr. Hata stated that she believed Plaintiff's pain did not prevent her from working. Plaintiff made an appointment with Dr. Hata to discuss this opinion; during the appointment, Plaintiff was tearful, stated she had no income, and described her ongoing neck pain, back pain, spasms, and bilateral knee pain. Dr. Hata ...


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