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Crowe v. Saul

United States District Court, D. Massachusetts

August 29, 2019

JUDITH CROWE, Plaintiff,
v.
ANDREW SAUL, Commissioner, Social Security Administration, [1]Defendant.

          ORDER ON CROWE'S MOTION TO REVERSE THE COMMISSIONER'S DECISION AND COMMISSIONER'S MOTION TO [Docket Nos. 23, 29] AFFIRM

          JENNIFER C. BOAL, UNITED STATES MAGISTRATE JUDGE

         This is an action for judicial review of a final decision by the Commissioner of the Social Security Administration (“Commissioner”) denying Judith Crowe's application for disability insurance benefits (“DIB”). Crowe asserts that the Commissioner's decision denying her such benefits - memorialized in an April 5, 2017 decision of an administrative law judge (“ALJ”) - is in error, Docket No. 23, and the Commissioner, in turn, has moved to affirm. Docket No. 29.[2] Crowe filed a reply brief. Docket No. 31. For the following reasons, this Court denies Crowe's motion and grants the Commissioner's motion.

         I. FACTS AND PROCEDURAL HISTORY

         A. Procedural History

         Crowe filed an application for DIB on February 19, 2015, alleging disability as of June 22, 2013 from a herniated disc, spinal stenosis, COPD and osteoarthritis. (Administrative Record (“AR”) 216-17).[3] The application was denied initially (AR 130-41), and on reconsideration (AR 143-59). On December 9, 2016, ALJ Paul W. Goodale held a hearing at which Crowe and vocational expert (“VE”) Larry Takki appeared and testified. (AR 40-107).

         The ALJ issued a decision on April 5, 2017, finding that Crowe was not disabled from June 22, 2013, her alleged onset date, through March 31, 2016, her date last insured (“the relevant period”). (AR 12-31). The Appeals Council denied Crowe's request for review on January 18, 2018, making the ALJ's decision the final decision of the Commissioner. (AR 1-6).

         Crowe filed this action on March 15, 2018. Docket No. 1.

         B. Background

         Crowe was fifty-three years old on her date last insured. (AR 130, 143). She graduated from high school, is married and has three grown children. (AR 51-53).

         She reported past work as a secretary and cashier/stock clerk. (AR 82-83).

         C. Medical Evidence

         On May 20, 2013, prior to her alleged onset date, Crowe visited Michael Marciello, M.D., of Dedham Physiatry, with complaints of ongoing neck pain and tenderness. (AR 393-95). Dr. Marciello assessed myofascial pain and cervical spondylosis and prescribed Vicodin and Klonopin. (AR 394). Crowe had been taking oxycodone at the time, but Dr. Marciello recommended that she cut back. Id. On May 28, 2013, Crowe visited Richard Gottlieb, M.D., her primary care physician, with complaints of neck pain and skin lesions. (AR 65, 468). Dr. Gottlieb recommended that she consider physical therapy and take nonsteroidal anti-inflammatory drugs for “significant arthritis of the neck.” Id.

         On October 18, 2013, Crowe visited Dr. Gottlieb for a follow-up appointment, at which she denied “any specific problems, ” except for some difficulty falling asleep. (AR 466). Examination of her neck and extremities revealed no abnormal findings. Id.

         In November 2013, Crowe visited Dr. Marciello for follow up regarding her neck and parascapular pain. (AR 392). She was not as active due to pain from a slip and fall. She also reported that her back pain had “settled down, ” but she still had tenderness in the right side of her lower back and numbness and tingling in her left arm and right shoulder. Id. Dr. Marciello found that she had tenderness in her lower back, a nonfocal neurologic examination, tightness in her pelvis and hamstrings, symmetric leg strength in both sides, a negative straight leg raise, decreased strength in her right shoulder and normal sensation and reflexes in her hands. Dr. Marciello assessed lumbar strain/contusion of the sacroiliac joint, “[o]verall, stable, ” and chronic cervical spondylosis with myofascial pain and intermittent radiculitis, also “[c]urrently stable.” Id. He renewed Crowe's medications and “encouraged her to keep up with the stretching exercises.” Id.

         In February 2014, Crowe saw Dr. Marciello for increased neck pain and reported that she had had “some falls and strain in the weather and continue[d] stresses.” (AR 390). On examination, she had some decreased neck movement; right-sided neck pain which caused increased distress trying to turn to the right or side bend to the left; and tenderness and tightness over the right base of the neck. Id. She had a nonfocal neurologic examination in the right arm, “fine” reflexes and normal distal strength. Id. Dr. Marciello administered trigger point injections to Crowe's right cervical paraspinal muscles and continued her on oxycodone but indicated that she should try to reduce her opiod use. Id.

         In June 2014, Crowe visited Dr. Marciello and reported that she “ha[d] fallen about 3-4 weeks [prior] whe[n] she slipped being pulled forward by her dog.” (AR 388). Dr. Marciello noted that, “[u]p to this fall, [Crowe] ha[d] been doing about the same, ” i.e., she had chronic daily discomfort around her neck and shoulders. Id. She reported continuing to use Klonopin and pain medications and following up with her primary doctor for weight and “general health.” Id. On examination, Crowe had some back tenderness, but showed “excellent” lumbar range of motion with extension and flexion, negative straight leg raise, intact sensation in her legs, and normal neck range of motion. Dr. Marciello assessed Crowe as “stable” and recommended that she increase her stretching and exercise. (AR 389). Dr. Marciello noted that he “would like to see her be able to wean from her cigarettes and the oxycodone.” Id.

         In August 2014, Crowe visited nurse Debra Brothers-Klezmer at Dedham Physiatry with complaints of neck and shoulder pain that radiated into her right arm. (AR 421). Crowe stated that she had “[n]o structured exercises, ” but reported taking care of her four-month-old granddaughter. Id. She explained that she had “fallen because [she] is clumsy” and took additional pain medications if needed. (AR 422). She reported that “[p]ain medications enable[d] more activity, and greater functioning.” Id. She also stated that she decreased her dosage of medications when the pain subsided and took Aleve about once a week. (AR 422).

         In September 2014, Crowe visited physician's assistant Rebecca Howard at Dedham Physiatry for a follow up appointment regarding her neck and shoulder pain. (AR 417). Crowe reported that she had utilized and benefitted from trigger point injections in the past and requested them again. She also reported that she remained stable with the use of fifteen milligrams of oxycodone. On examination, she had “slight limitation” of cervical range of motion, “acceptable” shoulder range of motion, and full strength (“5/5”) in “all muscle groups of the upper extremities.” (AR 419). Aside from “some mild diminished sensation in the fingertips, ” Crowe had “[n]o other areas of sensory change noted throughout [the] exam.” Id. Howard assessed cervical spondylosis and myofascial pain and recommended that Crowe continue stretching and range of motion exercises. Howard administered trigger point injections which Crowe tolerated well. Id.

         In January 2015, Crowe saw Dr. Marciello for a follow up appointment regarding her “chronic cervical neck pain, myofascial pain, and medication management.” (AR 385). She stated that one week prior to the visit, she had fallen backwards, aggravating her neck and posterior shoulder. Id. She reported that the pain depended on her “level of activity around the house” and extended out to her shoulder, causing general myofascial tenderness. (AR 386). On examination, her shoulder range of motion was “fine, ” although she had some restrictions reaching behind her as well as tenderness in her neck and shoulder. Id. Dr. Marciello assessed chronic cervical and parascapular myofascial pain that was exacerbated by her fall as well as underlying cervical spondylosis that was stable. Id. Dr. Marciello and Crowe discussed reducing her medications over time, but Dr. Marciello recommended that she “keep things the same and focus on increased resistive exercises.” Id.

         On February 12, 2015, Crowe visited Dr. Gottlieb for an annual physical examination. (AR 453). She denied headaches, arthritis pain, joint pain, muscle weakness or any neurologic symptoms. (AR 454). On examination, she was pleasant, alert, fully oriented and in no acute distress. (AR 453-54). She had normal reflexes, motor functioning, mobility and gait, and no joint effusion or tenderness. (AR 454). Dr. Gottlieb found no musculoskeletal or neurologic impairments, but did assess valve prolapse, emphysema and a cough. (AR 454-55).

         In March 2015, Crowe saw Brothers-Klezmer because shoveling had worsened the pain in her right neck and shoulder. (AR 411). She described the pain as shooting, stabbing and intermittent. Id. Brothers-Klezmer continued Crowe on her existing medication regimen. Id.

         In June 2015, Crowe visited Dr. Marciello with increased pain in her right shoulder, especially with activities, such as reaching and trying to carry. (AR 436). She stated that she had experienced a “fair amount of increased exertion trying to care for her house” and was trying to keep up with routine stretching, without much success. Id. She denied any numbness or tingling in the right arm but had persistent numbness in her left arm. (AR 436-37). She reported taking her medications, including Klonopin regularly and fifteen milligrams of oxycodone four times per day. (AR 437). On examination, she had “some” decreased neck movement with side bending and rotation bilaterally and tightness and tenderness in the upper trapezius bilaterally. Id. She showed some signs of right shoulder impingement and some tenderness when externally rotating the rotator cuff, but “no clear weakness.” Id. Dr. Marciello assessed right shoulder impingement and bursitis as well as cervical spondylosis with chronic myofascial pain. Id. He encouraged Crowe to reduce her use of pain medications and “to try to maintain some level of fitness, ” including strength training, for her shoulder. Id.

         On February 28, 2016, Crowe visited Dr. Marciello with increased pain and a loss of range of motion in her right shoulder and parascapular area as a result of a shoveling incident. (AR 473-74). Dr. Marciello administered a trigger point injection in her right shoulder and advised her to continue taking Klonopin and oxycodone. (AR 474).

         On March 23, 2016, Crowe visited Dr. Marciello for “chronic medication management” for her neck and shoulder pain. (AR 524). She complained of limitations in her daily activities due to the pain and reported increased soreness that had lasted three weeks. The February 2016 injection was “somewhat helpful” but had provided “no sustained benefit.” Id. On examination, Dr. Marciello found that, although she had some soreness and impingement to the right shoulder, she was “a bit better than she was a couple weeks ago.” Id. He assessed cervical spondylosis with myofascial pain, right shoulder impingement with associated muscle tightness, and medication dependence. (AR 525). He administered trigger point injections and continued Crowe on her medications. Id. Dr. Marciello indicated a potential need for a surgery referral. Id. He further noted that an MRI had been done in the past, but further imaging might be required. Id.

         During an April 11, 2016 physical therapy evaluation, Crowe reported that six months prior, her right shoulder pain had begun to worsen. (AR 487). She reported that this pain coupled with finger numbness and tingling made it difficult for her to wash her hair and dress herself. An examination revealed positive Neer's, Coracoid Impingement and acromioclavicular signs. The physical therapist indicated that Crowe would benefit from physical therapy to decrease her pain, increase her range of motion and strength, and improve activity tolerance, specifically, the ability to reach and perform grooming and dressing activities without restriction. (AR 487-88). Crowe attended five physical therapy sessions but discontinued treatment because she felt it was causing her more pain and resulting in less range of motion. (AR 485-86, 516).

         At an April 28, 2016 visit to Dedham Physiatry, Crowe reported that she was enjoying family time and walking daily for exercise but was frustrated that pain affected her ability to play with her grandchildren. (AR 516-17). She requested ...


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