United States District Court, S.D. West Virginia, Huntington Division
PROPOSED FINDINGS AND RECOMMENDATIONS
A. Eifert United States Magistrate Judge
action seeks a review of the decision of the Commissioner of
the Social Security Administration (hereinafter
“Commissioner”) denying Plaintiff's
application for a period of disability and disability
insurance benefits (“DIB”) under Title II of the
Social Security Act, 42 U.S.C. §§ 401-433. The
matter is assigned to the Honorable Robert C. Chambers,
United States District Judge, and was referred to the
undersigned United States Magistrate Judge by standing order
for submission of proposed findings of fact and
recommendations for disposition pursuant to 28 U.S.C. §
636(b)(1)(B). Presently pending before the Court are the
parties' cross motions for judgment on the pleadings as
articulated in their briefs. (ECF Nos. 11, 14). The
undersigned has fully considered the evidence and the
arguments of counsel. For the following reasons, the
undersigned respectfully RECOMMENDS that
Plaintiff's request for judgment on the pleadings be
DENIED, the Commissioner's request for
judgment on the pleadings be GRANTED, the
Commissioner's decision be AFFIRMED, and
that this case be DISMISSED and removed from
the docket of the Court.
28, 2013, Plaintiff, Michelle Ann Bailey
(“Claimant”), completed an application for DIB,
alleging a disability onset date of January 1, 2000, due to
arthritis in her left knee and Morton's neuroma and
arthritis in both feet. (Tr. at 219-221, 258). The Social
Security Administration (“SSA”) denied
Claimant's application initially and upon
reconsideration. (Tr. at 147, 155). Claimant filed a request
for an administrative hearing, which was held on February 16,
2016, before the Honorable Robert B. Bowling, Administrative
Law Judge (“ALJ”). (Tr. at 58-90). Claimant
amended her alleged onset date to January 1, 2009 at the
hearing. (Tr. at 65). By written decision dated March 2,
2016, the ALJ found that Claimant was not disabled as defined
in the Social Security Act. (Tr. at 42-57). The ALJ's
decision became the final decision of the Commissioner on
December 20, 2016, when the Appeals Council denied
Claimant's request for review. (Tr. 1-7).
timely filed the present civil action seeking judicial review
pursuant to 42 U.S.C. § 405(g). (ECF No. 1). The
Commissioner filed an Answer and a Transcript of the
Administrative Proceedings. (ECF Nos. 5, 6). Both parties
filed memoranda in support of judgment on the pleadings. (ECF
Nos. 11, 14). Consequently, the issues are fully briefed and
ready for resolution.
was 55 years old on her alleged onset date and 61 years old
on her date last insured. She completed high school and one
year of college and communicates in English. (Tr. at 63,
257). In the past, Claimant worked as a courthouse marshal,
law office address verifier, landscape gardener,
plumber's helper, and a painter. (Tr. at 87).
Summary of ALJ's Decision
42 U.S.C. § 423(d)(5), a claimant seeking disability
benefits has the burden of proving a disability. See
Blalock v. Richardson, 483 F.2d 773, 774 (4th Cir.
1972). A disability is defined as the “inability to
engage in any substantial gainful activity by reason of any
medically determinable impairment which has lasted or can be
expected to last for a continuous period of not less than 12
months.” 42 U.S.C. § 423(d)(1)(A).
Social Security regulations establish a five-step sequential
evaluation process for the adjudication of disability claims.
If an individual is found “not disabled” at any
step of the process, further inquiry is unnecessary and
benefits are denied. 20 C.F.R. § 404.1520. The first
step in the sequence is determining whether a claimant is
currently engaged in substantial gainful employment.
Id. § 404.1520(b). If the claimant is not, then
the second step requires a determination of whether the
claimant suffers from a severe impairment. Id.
§ 404.1520(c). If severe impairment is present, the
third inquiry is whether this impairment meets or equals any
of the impairments listed in Appendix 1 to Subpart P of the
Administrative Regulations No. 4 (the “Listing”).
Id. § 404.1520(d). If the impairment does, then
the claimant is found disabled and awarded benefits.
if the impairment does not meet or equal a listed impairment,
the adjudicator must determine the claimant's residual
functional capacity (“RFC”), which is the measure
of the claimant's ability to engage in substantial
gainful activity despite the limitations of his or her
impairments. Id. § 404.1520(e). After making
this determination, the fourth step is to ascertain whether
the claimant's impairments prevent the performance of
past relevant work. Id. § 404.1520(f). If the
impairments do prevent the performance of past relevant work,
then the claimant has established a prima facie case
of disability, and the burden shifts to the Commissioner to
demonstrate, as the fifth and final step in the process, that
the claimant is able to perform other forms of substantial
gainful activity when considering the claimant's
remaining physical and mental capacities, age, education, and
prior work experiences. 20 C.F.R. § 404.1520(g); see
also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir.
1983). The Commissioner must establish two things: (1) that
the claimant, considering his or her age, education, skills,
work experience, and physical shortcomings has the capacity
to perform an alternative job, and (2) that this specific job
exists in significant numbers in the national economy.
McLamore v. Weinberger, 538 F.2d. 572, 574 (4th Cir.
claimant alleges a mental impairment, the SSA “must
follow a special technique at every level in the
administrative review, ” including the review performed
by the ALJ. 20 C.F.R. § 404.1520a. First, the ALJ
evaluates the claimant's pertinent signs, symptoms, and
laboratory results to determine whether the claimant has a
medically determinable mental impairment. Id. §
404.1520a(b). If such impairment exists, the ALJ documents
his findings. Second, the ALJ rates and documents the degree
of functional limitation resulting from the impairment
according to criteria specified in 20 C.F.R. §
404.1520a(c). Third, after rating the degree of functional
limitation from the claimant's impairment(s), the ALJ
determines the severity of the limitation. A rating of
“none” or “mild” in the first three
functional areas (activities of daily living, social
functioning, and concentration, persistence or pace) and
“none” in the fourth (episodes of decompensation)
will result in a finding that the impairment is not severe
unless the evidence indicates that there is more than minimal
limitation in the claimant's ability to do basic work
activities. Id. § 404.1520a(d)(1). Fourth, if
the claimant's impairment is deemed severe, the ALJ
compares the medical findings about the severe impairment and
the rating and degree and functional limitation to the
criteria of the appropriate listed mental disorder to
determine if the severe impairment meets or is equal to a
listed mental disorder. Id. § 404.1520a(d)(2).
Finally, if the ALJ finds that the claimant has a severe
mental impairment, which neither meets nor equals a listed
mental disorder, the ALJ assesses the claimant's residual
function. Id. § 404.1520a(d)(3).
the ALJ determined as a preliminary matter that Claimant met
the insured status for disability insurance benefits through
September 30, 2014. (Tr. at 44, Finding No. 1). At the first
step of the sequential evaluation, the ALJ confirmed that
Claimant had not engaged in substantial gainful activity
since January 1, 2009, her alleged onset date, through her
date last insured. (Id., Finding No. 2). At the
second step of the evaluation, the ALJ found that Claimant
had the following severe impairments: “osteoarthritis;
disorders of muscle, ligament, and fascia; fibromyalgia;
hepatitis; and obesity.” (Id., Finding No. 3).
The ALJ also considered Claimant's anxiety and
depression, but determined that these impairments were
non-severe. (Tr. at 45-46). Under the third inquiry, the ALJ
found that Claimant did not have an impairment or combination
of impairments that met or medically equaled any of the
impairments contained in the Listing. (Tr. at 46, Finding No.
4). Accordingly, the ALJ determined that Claimant possessed:
[T]he residual functional capacity to perform light work as
defined in 20 CFR 404.1567(b) except the claimant can stand
and walk for only six hours total in an eight hour workday;
claimant can sit for only six hours total in an eight hour
workday; claimant can occasionally climb ladders, ropes and
scaffolds; claimant can only occasionally climb ramps and
stairs; claimant can only occasionally stoop, kneel, crouch,
and crawl; claimant should avoid concentrated exposure to
extreme cold, extreme heat, and should avoid concentrated
exposure to hazards such as the use of moving machinery and
to unprotected heights.
(Tr. at 46-51, Finding No. 5).
fourth step, the ALJ found that Claimant could perform her
past relevant work as a law office address verifier. (Tr. at
51-52, Finding No. 6). Therefore, the ALJ found that Claimant
was not disabled and was not entitled to benefits. (Tr. at
52, Finding No. 7).
Claimant's Challenge to the Commissioner's
raises numerous challenges to the Commissioner's
decision. First, Claimant argues that the ALJ erred in
placing great weight on the opinions of the non-examining
state agency physicians and no weight on the opinions of the
consultative examiner and Claimant's treating physicians.
(ECF No. 11 at 13-16). Second, Claimant argues that the ALJ
did not fulfill his duty to evaluate whether Claimant's
combinations of impairments rendered her disabled.
(Id. at 16-17). In her third assignment of error,
Claimant contends that the ALJ's conclusions regarding
her activities of daily living are not supported by the
record. (Id. at 17-18). Next, in her fourth
challenge to the Commissioner's decision, Claimant argues
that the ALJ should have found that she was unable to
maintain full-time employment given the volume of medical
appointments that she had in 2013 and 2014 and the vocational
expert's testimony that someone with Claimant's RFC
that had to miss two or more days a month for doctor's
visits could not maintain full-time employment. (Id.
at 18). Finally, Claimant's fifth assignment of error is
that the Appeals Council ignored Claimant's supplemental
evidence, which Claimant argues called the ALJ's decision
into question and necessitated remand. (Id. at
response to Claimant's challenges, the Commissioner first
points out that Claimant worked during and after the period
at issue in this case; although Claimant's work as a
landscape gardener did not constitute substantial gainful
activity, the Commissioner notes that the work was considered
to be at the heavy exertional level by the vocational expert
and involved planting bushes and flowers, digging holes,
using machinery and equipment, and lifting items weighing as
much as 50 pounds, such as bags of mulch. (ECF No. 14 at 1).
Moreover, the Commissioner contends that substantial evidence
supports the ALJ's decision that Claimant was capable of
performing her past relevant work at the light exertional
level, as well as the ALJ's analysis of the opinion
evidence. Further, the Commissioner states that the ALJ
considered Claimant's impairments in combination
throughout the sequential evaluation, as well as her
statements regarding her activities of daily living, social
functioning, and concentration; the hypothetical posed to the
vocational expert included all limitations supported by the
record; and the evidence submitted for the first time to the
Appeals Council would not change the outcome of the case.
(Id. at 16-30).
the undersigned has reviewed all evidence of record, only the
notations most relevant to the disputed issues are summarized
Treatment prior to alleged onset of disability
February 29, 2008, Claimant presented for an initial physical
therapy evaluation with John Oxley, D.P.T., at Huntington
Physical Therapy, Inc., upon a referral from her primary care
provider for treatment of bilateral plantar fasciitis, which
began approximately one year earlier. (Tr. at 361). Claimant
stated that her symptoms were worse on the left and
aggravated by standing all day while working as a court
marshal. (Id.). She reported taking Naproxen from
her primary physician. (Id.). On examination,
Claimant's overall range of motion was normal; her great
toe flexion was normal, but extension was limited to
approximately 30 degrees bilaterally. (Id.).
Claimant also had decreased rear foot motion and tenderness.
(Id.). Claimant was taught home stretching and
modality exercises and was scheduled to receive physical
therapy twice per week for four weeks to improve her range of
motion and decrease her pain and tenderness. (Id.).
had five physical therapy sessions in March 2008. (Tr. at
362-70). On March 17, 2008, Claimant stated that she
continued to feel better and she did not have tenderness in
her feet. (Tr. at 368). However, on March 25, 2008, Claimant
was “really hurting” because she stood the prior
day “cleaning out the garage.” (Tr. at 370). She
had tenderness and her gait was affected. (Id.).
Claimant was scheduled to see a podiatrist. (Id.).
April 7, 2008, Claimant saw podiatrist Kevin D. Brown, D.P.M,
at Scott Orthopedic Center, complaining of bilateral foot
pain and occasional swelling after being on her feet all day.
(Tr. at 424). She stated that the pain changed her gait, and
she was beginning to have pain in her knees and legs.
(Id.). Claimant was assessed with hallux rigidus and
plantar fasciitis. (Id.). Dr. Brown recommended
continuing therapy and wearing orthotics for four more weeks.
(Tr. at 425). Claimant was given a splint to alternate
wearing on each foot at night. (Id.).
April 28, 2008, Claimant followed up with Dr. Brown. (Tr. at
422). She had been wearing the splint prescribed by Dr. Oxley
at night, but had the same complaints. (Id.).
Claimant elected to go forward with a right big toe implant
arthroplasty. (Tr. at 423). Thus, on May 6, 2008, Claimant
had implant arthroplasty on her first metatarsophalangeal
joint (“MJP”) on her right foot. (Tr. at
430-432). Claimant saw Dr. Brown on May 14, 2008 following
surgery and was doing “very well.” (Tr. at 420).
29, 2008, Claimant was still having some pain and swelling,
but admitted that she “may have been overdoing
it.” (Tr. at 418). Dr. Brown recommended that Claimant
decrease her activity and he referred her for physical
therapy. (Id.). Claimant was also prescribed
Voltaren, a topical gel. (Id.).
28, 2008, Claimant reported doing “extremely
well” following her right toe surgery. (Tr. at 416).
She could return to activities as tolerated and Dr. Brown
planned to refer her to an orthopedist for a right knee
evaluation. He considered a possible repair Claimant's
left big toe in the winter. (Id.).
Treatment after alleged onset of disability
saw family medicine physician, Friday Simpson, M.D., monthly
from January 2009 through August 2013. (Tr. at 458-577). On
January 13, 2009, Claimant's weight was 229 pounds and
she was having “more hot flashes” and
“needed something to sleep.” (Tr. at 577). She
also had chronic back, leg, and foot pain; fatigue; and
frequent headaches. (Id.). The following month, on
February 10, 2009, Claimant told Dr. Simpson that she was
having a hard time at work, complaining that her employer was
giving shifts to the young, inexperienced employees and she
had less hours. (Tr. at 575). She weighed 236 pounds, stating
that she gained weight from “stress eating.”
(Id.). Claimant still had chronic back and leg pain
and hot flashes, and she ambulated with mild difficulty. (Tr.
at 575-76). She had normal range of motion in her back, good
flexion at the waist, and no tenderness to palpation.
(Id.). Her neurological and extremity examinations
were normal. (Id.). Dr. Simpson diagnosed Claimant
with back and joint pain, insomnia, headaches, fatigue,
symptoms of menopause, hyperlipidemia, plantar fasciitis, leg
and foot pain, and obesity. (Id.). He prescribed
Lortab for pain, Mobic for inflammation, Ambien for insomnia,
and Premarin for hot flashes. (Id.).
March through July 2009, there were no significant changes in
Claimant's complaints, examinations, or treatment plan
with Dr. Simpson, except that Claimant lost weight. In May
2009, Claimant noted that she quit her job at the courthouse
and was working odd jobs. (Tr. at 563-74). By July, Claimant
weighed 210 pounds; however, she gained three pounds back by
the following month. (Tr. at 561, 563-64). Claimant also
reported to Dr. Simpson during her August 14, 2009 visit that
she was very depressed and cried easily about not having a
job. (Tr. at 561). On September 10, 2009, Claimant told Dr.
Simpson that she was working again and was happy about it.
(Tr. at 559). She still had the same physical complaints, but
largely normal results on physical examination. (Tr. at
559-60). Claimant was diagnosed with anxiety; thus, Valium
was added to her medication regimen. (Tr. at 560).
next visit on October 9, 2009, Claimant told Dr. Simpson that
she was still depressed about the way that she lost her job.
(Tr. at 557). She was not working steadily, but was
“helping out friends on occasion.”
(Id.). Her weight was 216 pounds. Claimant was
continued on Lortab, Valium, Ambien, Mobic, and Premarin.
(Tr. at 558). There were no changes at Claimant's
subsequent monthly visit on November 12, 2009, except that
Claimant had gained three pounds. (Tr. at 555-56).
January 12, 2010, Claimant returned to Dr. Simpson's
office. Claimant still had depression from the loss of her
job, stating that it humiliated her and made her fell
worthless. (Tr. at 551). Her weight was 226 pounds, and she
was assessed with depression. (Tr. at 551-52). Dr. Simpson
asked Claimant if he could refer her to a psychologist. (Tr.
at 552). Otherwise, there were no changes. (Tr. at 551-52).
At Claimant's following visit with Dr. Simpson on
February 9, 2010, she was “doing better, ” but
had depression and anxiety attacks over the loss of her job
that she loved. (Tr. at 549). Her weight was 228 pounds.
(Id.). She was unable to find a psychologist that
would take her as a new patient. (Tr. at 550). Otherwise,
there were again no changes to Claimant's assessed
conditions or treatment. (Tr. at 549-50).
were likewise no significant changes in Claimant's visits
with Dr. Simpson in March 2010 through May 2011 other than
that Claimant continued to lose weight. (Tr. at 516-48). On
June 10, 2010, Claimant stated that she just returned from
vacation and had a good time. (Tr. at 541-42). Later that
month, on June 24, 2010, Claimant had right flank pain,
noting that she had been “laying tile” at a
friend's house and overworked herself, bending over and
hammering for an extended period of time. (Tr. at 539-40).
Dr. Simpson prescribed Flexeril in addition to Claimant's
regular medications: Lortab, Ambien, Premarin, Valium, Mobic,
Vitamin D, and allergy medications. (Tr. at 540). In August
2010, Claimant mentioned that she was very “hurt”
over the lack of relationship with her mother; however, in
September 2010, Dr. Simpson noted that Claimant was doing
well except that she was tired from working all holiday
weekend. (Tr. at 532-35). In November 2010, Claimant was
still doing better, but continued to be depressed and have
panic attacks over her “work situation.” (Tr. at
528-29). Claimant noted in January 2011 that she was feeling
well and had nice holidays with her family; she went to Iowa
to visit her daughter. (Tr. at 524-25, 640). In April 2011,
Claimant stated that she was “so depressed” over
losing her job. (Tr. at 518-19). In May 2011, Claimant
started Fioricet for migraines. (Tr. at 514-15). She was
diagnosed with hyperlipidemia, migraines, fatigue, lumbar
back, leg, and joint pain, anxiety, insomnia, depression, and
allergies. (Tr. at 515). She was still taking Lortab, Mobic,
Ambien, Premarin, Vitamin D, and Valium. (Id.). She
weighed 197 pounds. (Tr. at 514).
11, 2011, Claimant saw Dr. Brown and was given trigger point
injections in the Morton's neuroma sites of both feet.
(Tr. at 414). The following month, on June 21, 2011, Claimant
saw Dr. Simpson for her monthly appointment. She noted that
she had been trying to do yard work, but chronic back and leg
pain kept her “from doing much.” (Tr. at 512).
Claimant was no longer assessed with migraines and her
prescription for Fioricet was not renewed. (Tr. at 513).
11, 2011, Claimant advised Dr. Brown that she did not feel
much different after the previous injections. (Tr. at 412).
She was again given steroid and lidocaine injections in both
feet. (Id.). She saw Dr. Simpson the following week.
Claimant requested Chantix to help her stop smoking. She
reported that she had been doing yard work, but it took her
longer and she “hurt more” when finished. (Tr. at
510). At her next two monthly visits with Dr. Simpson,
Claimant requested another prednisone pack in August 2011
because it helped her feet, and stated on September 15, 2011
that she was doing well except that she was very tired from
doing yard work for a friend and her feet were hurting. (Tr.
at 507). Claimant weighed 194 pounds. (Tr. at 507, 509).
September 21, 2011, Claimant told Dr. Brown that she was
still having a lot of foot pain and the injections did not
help at all. (Tr. at 410). The plan was for Claimant to have
a bilateral Morton's neuroma excision. (Id.).
Claimant saw Dr. Simpson on October 11, 2011, still
complaining of chronic back and leg pain, neuropathy in her
feet from long hours of standing on concrete, and fatigue.
(Tr. at 504).
November 1, 2011, Claimant saw Dr. Brown, again stating that
she was still having a lot of foot pain and the injections
did not help at all. (Tr. at 382). She reported a burning
sensation in the balls of her feet and constant swelling that
was worse in the evening. (Id.). Her physical
examination was normal. (Id.). Claimant was
diagnosed with bilateral Morton's neuroma, which Claimant
elected to have excised surgically the same day. (Tr. at
382-84, 433). On November 14, 2011, Claimant saw Dr. Brown
for post-surgery follow up. She was full weight bearing, but
limping on her right side. (Tr. at 408). Her wound was
healing well and her sutures were removed. (Id.).
Claimant saw Dr. Simpson the next day, noting that she was in
pain, as she was wearing shoes for the first time after
surgery. (Tr. at 502). Claimant began gaining back the weight
that she had lost, weighing 198 pounds at this visit.
(Id.). Claimant related to Dr. Simpson at her next
monthly visit on December 9, 2011 that she had not recovered
as she wanted to after surgery and she was “upset with
her foot pain.” (Tr. at 500-01). Her diagnosed
conditions were night sweats; hyperlipidemia; restless leg
syndrome and feet pain from recent surgery; lumbar back, leg,
and joint pain; migraine headaches; anxiety; fatigue,
insomnia, and depression; and allergies. (Tr. at 501).
Claimant was advised to hold off on taking Ambien and try
Doxepin or Mirapex at bedtime and was prescribed Esgic in
addition to her usual medications of Lortab, Valium, Mobic,
Chantix, Premarin, Vitamin D, Claritin, and Retin A cream.
that month, on December 28, 2011, Claimant saw Dr. Brown and
was doing “pretty well, ” but still had some pain
in the balls of her feet, which was worse on the right. (Tr.
at 406). She limped slightly on the right side, but had no
obvious instability. Claimant had a full range of motion, and
only minimal swelling. (Id.). Claimant was noted to
be “doing well” and was instructed to continue
working on her range of motion daily. (Id.).
Claimant's monthly appointments with Dr. Simpson in
January through June 2012 did not note significant changes,
although Claimant continued to gain weight. (Tr. at 486-99).
Claimant stated in February that she had recovered since
surgery and indicated in April that she still tried to work
despite her pain. (Tr. at 492, 496). By June 29, 2012,
Claimant weighed 219 pounds. (Tr. at 486). Her diagnosed
conditions included fatigue; hyperlipidemia; leg, lumbar
back, and joint pain/arthralgia; anxiety, depression, and
insomnia; migraine headaches; restless leg syndrome and feet
pain; and allergies. (Tr. at 487). She used Lortab for pain,
Valium for anxiety, Esgic, Doxepin for sleep, Aleve for
inflammation, Simvastatin and Lovaza for hyperlipidemia,
Premarin for hot flashes, Vitamin D, Claritin, and Retin A
12, 2012, Claimant followed up with Dr. Brown and was
continued on Relafen. (Tr. at 404). He planned to schedule a
MRI if Claimant showed no improvement. (Id.). The
following month, on August 22, 2012, Claimant reported to Dr.
Brown that she had no improvement and felt worse than before
her surgery. (Tr. at 402). Claimant was continued on Relafen
and given a steroid injection in her right foot.
(Id.). Claimant saw Dr. Simpson two days later. She
weighed 222 pounds. (Tr. at 482). Claimant's complaints
focused on her emotions over losing her job; she noted that
she had filed a lawsuit over it. (Tr. at 480-81).
Claimant's diagnosed conditions and medications remained
the same, except that she was additionally prescribed
Neurontin. (Tr. at 481). Claimant's complaints, diagnosed
conditions, and treatment remained the same over her next two
monthly visits with Dr. Simpson. (Tr. at 476-79). She
remained emotional over the lawsuit and was working odd jobs.
November 14, 2012, Claimant saw Dr. Brown, stating that she
was not any better following surgery and had “mind
blowing pain” and swelling in the evening after being
on her feet all day. (Tr. at 400). Dr. Brown's diagnoses
were plantar fasciitis, hallux rigidus, Morton's neuroma,
and capsulitis. (Id.). Claimant was continued on
Relafen for her plantar fasciitis and elected to proceed with
revision surgery that would probably occur in January.
(Id.). Claimant saw Dr. Simpson on the same date in
November and also followed up in December 2012 and January
2013. (Tr. at 472-77). There were no significant changes, but
Claimant noted in December that she had settled the lawsuit
and felt that she was “ripped off by the city.”
January 31, 2013, Claimant saw Dr. Brown. (Tr. at 374). Her
gait was normal and she showed no instability, had full range
of motion, no obvious deformities or swelling, normal
reflexes, and normal muscle strength. (Id.). Dr.
Brown diagnosed Claimant with capsulitis and hammer toe in
her right second toe. (Tr. at 374-75). Claimant wished to
proceed with surgery. (Id.). Claimant saw Dr.
Simpson on February 6, 2013 and was in a better mood since
her lawsuit settled; however, she stated that she continued
to have hot flashes, even on estrogen. (Tr. at 470). Claimant
weighed 224 pounds. (Tr. at 471). Her assessed conditions and
treatment plan remained the same. (Id.).
February 26, 2013, Claimant underwent surgery to correct her
second MPJ chronic capsulitis with dislocation and hammertoe
on the second toe of her right foot. (Tr. at 372). She
reported to Dr. Simpson on March 6, 2013 that she was doing
better following surgery. (Tr. at 468). Claimant still
complained of having pain “all the time” and
still reported emotional problems over how she was treated in
losing her job. (Id.). She weighed 228 pounds and
her assessed conditions and treatment were unchanged. (Tr. at
469). On March 13, 2013, Claimant followed up with Dr. Brown
following her right foot surgery. (Tr. at 396). She was doing
well, and her sutures were removed. (Id.).
saw Dr. Simpson on April 12, 2013 with no significant
changes. (Tr. at 466-67). She also saw Dr. Brown again on May
8, 2013. X-rays showed that her foot was healing. (Tr. at
394). Dr. Brown continued Claimant on Relafen and prescribed
a a topical compound cream. (Tr. at 395). Shortly thereafter,
on May 14, 2013, Claimant saw Dr. Simpson and was
“having a terrible time” because her dog of many
years died. (Tr. at 464). Her weight was 230 pounds and no
changes were made to her assessed conditions or treatment.
(Tr. at 465).
11, 2013, Claimant saw orthopedist, Jack R. Steel, M.D., for
bilateral knee pain that Claimant stated began six months to
one year earlier and was progressively getting worse. (Tr. at
392). Claimant's x-rays showed moderate medial joint
space narrowing and patello-femoral degenerative joint
disease in her left knee, but only mild patello-femoral
degenerative changes and minimal medial joint space narrowing
in her right knee. (Tr. at 393). Dr. Steel diagnosed Claimant
with chondromalacia patella and osteoarthritis.
(Id.). He explained that the increased discomfort
came from deconditioning due to the previous limitations of
her feet. (Id.). Claimant was referred to physical
therapy. (Id.). On the same date, Claimant presented
for her monthly visit with Dr. Simpson. She stated that her
joints were “killing” her, noting that she had
been helping put in a new kitchen and it was taking too long;
Claimant stated ...