Jackson v. Commissioner of Social Security Administration

CourtDistrict Court, D. South Carolina
DecidedMay 18, 2021
Docket4:20-cv-01890
StatusUnknown

This text of Jackson v. Commissioner of Social Security Administration (Jackson v. Commissioner of Social Security Administration) is published on Counsel Stack Legal Research, covering District Court, D. South Carolina primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jackson v. Commissioner of Social Security Administration, (D.S.C. 2021).

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF SOUTH CAROLINA FLORENCE DIVISION GLEN FRANKLIN JACKSON, ) Civil Action No.: 4:20-CV-01890-TER ) Plaintiff, ) ) -vs- ) ) ORDER ANDREW M. SAUL, ) Commissioner of Social Security, ) ) Defendant. ) ___________________________________ ) This is an action brought pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. Section 405(g), to obtain judicial review of a “final decision” of the Commissioner of Social Security, denying Plaintiff’s claim for supplemental security income (SSI). The only issues before the Court are whether the findings of fact are supported by substantial evidence and whether proper legal standards have been applied. This action is proceeding before the undersigned by pursuant to 28 U.S.C. § 636(c) and Fed. R. Civ. Proc. R. 73. I. RELEVANT BACKGROUND A. Procedural History Plaintiff filed an application for SSI on August 7, 2017, alleging inability to work since January 3, 2017. His claims were denied initially and upon reconsideration. Thereafter, Plaintiff filed a request for a hearing. A hearing was held on March 29, 2019, at which time Plaintiff testified. (Tr. 15). The Administrative Law Judge (ALJ) issued an unfavorable decision on May 13, 2019, finding that Plaintiff was not disabled within the meaning of the Act. (Tr. 15-22). Plaintiff filed a request for review of the ALJ’s decision, which the Appeals Council denied on April 7, 2020, making the ALJ’s decision the Commissioner’s final decision. (Tr. 1-3). Plaintiff filed this action on May 18, 2020. (ECF No. 1). B. Plaintiff’s Background and Medical History 1. Introductory Facts Plaintiff was born on May 22, 1971, and was forty-six years old on the date the application

was filed. (Tr. 20). Plaintiff had a limited education and had past work as a welder and construction worker. (Tr. 20). Plaintiff alleged disability originally due to severe calcaneal on left heel. (Tr. 50). 2. Medical Records and Opinions 2017 On January 4, 2017, Plaintiff was seen in the emergency room. (Tr. 246). Plaintiff was unable to ambulate after falling 10 feet on both feet. (Tr. 247). Plaintiff was in severe pain. (Tr. 247). Plaintiff smoked two packs a day and drank 12-18 beers a day. (Tr. 247-248). Upon exam, Plaintiff

had edema and tenderness. Plaintiff had marked left calcaneus bruising and swelling. (Tr. 249). Imaging showed severely comminuted and displaced calcaneal fracture. (Tr. 249). There were at least three primary fracture lines. (Tr. 252). Plaintiff received Percocet prescription and IV morphine. (Tr. 249-250). On January 5, 2017, Plaintiff was seen by Dr. Boyer of Lexington Orthopaedics. (Tr. 236). Imaging showed comminuted intra-articular calcaneal fracture. Plaintiff presented on crutches in a splint with swelling and bruising and tender to palpation. (Tr. 236). Plaintiff was prescribed Percocet. (Tr. 236). There was a long discussion about options. (Tr. 237). Plan was to try to keep him

comfortable and he was to remain strictly nonweightbearing. (Tr. 237). On January 19, 2017, Plaintiff was seen by Dr. Boyer. Plaintiff received a Norco prescription. (Tr. 238). 2 On February 2, 2017, Plaintiff was seen by Dr. Boyer. Plaintiff had been comfortable in his boot, was trying to be nonweightbearing, and was using an Ace wrap. (Tr. 239). Exam showed resolving fracture blisters moderately swollen in boot on crutches. (Tr. 239). Imaging showed consolidation posttraumatic deformity. (Tr. 239). Plan was to remain nonweightbearing. (Tr. 239).

On August 8, 2018, Plaintiff was seen by Dr. Boyer. Plaintiff had some pain and swelling. Plaintiff was trying to find work, but it was very difficult with a limp and with difficulty standing and walking. (Tr. 241). Imaging showed healed calcaneus fracture with malunion. (Tr. 242). Upon exam, Plaintiff was swollen and tender. Plaintiff walked with antalgic gait and was tender on ankle calcaneus and subtalar joint. Assessment was calcaneal fracture malunion pain. (Tr. 242). On August 8, 2017, Dr. Boyer wrote a letter that Plaintiff had been under his care for 7 months for a severe calcaneal fracture treated without surgery. “I expect that he will have continued

significant disability as related to his injury, malunion deformity, and post traumatic arthritis. He will likely not tolerate any prolonged standing or walking.” (Tr. 228). On October 2, 2017, Plaintiff completed a pain questionnaire. (Tr. 188). Plaintiff’s pain was located in his left heel and hurt when walking or standing. Pain lasts most of the day. Plaintiff takes 3 Aleve daily. (Tr. 186). Medication relieves pain. (Tr. 186). Plaintiff could not afford surgery. Plaintiff uses ace bandage, stocking, and boot. (Tr. 187). Plaintiff elevates his foot and uses ice to keep swelling down. Plaintiff does chores. Plaintiff cannot walk to go fishing. (Tr. 187). Plaintiff can do errands without assistance. Plaintiff can walk 50 yards. Plaintiff can stand 30 minutes. Plaintiff

is able to sit with elevation and ice. Plaintiff can do light chores. (Tr. 188). 2018 On January 29, 2018, imaging showed comminuted and now healed midbody calcaneal 3 fracture, distortion of the subtalar joints, shortening and some angular deformity of the healed midbody. Fracture was malaligned. (Tr. 265). On February 5, 2018, Dr. Walker, M.D., a non-examining state agency consultant, opined an RFC of sedentary. There are notes that claimant was to be called and asked if he used an assistive

device. “Per DPS,” no assistive device was used. However, Dr. Walker stated “a cane will be needed for prolonged walking to be effective.” (Tr. 57-58). On June 5, 2018, Dr. Burge, a non-examining state agency consultant, affirmed this assessment on reconsideration. (Tr. 73). Plaintiff reported that in April 2018 the swelling was worsening with increasing pain with ambulation and decreased ability to perform daily living activities and increased inability to sit, stand, and ambulate any distance. (Tr. 214). On May 25, 2018, Plaintiff was examined by consultant Dr. Daniels. (Tr. 267). “Because of

his insurance status, the patient did not undergo surgery, so was put in an offloading boot.” Plaintiff reported he still has pain, limps, and has swelling. Plaintiff can stand for 15 minutes. Plaintiff can “walk continuously for 15 minutes, but he must use a four-pronged cane.” Plaintiff reported he could sit without any difficultly. (Tr. 267). Plaintiff still smoked two packs a day. (Tr. 267). Plaintiff was in no acute distress. (Tr. 267). Upon exam, Plaintiff moved from the chair to the table with an obvious limp in his left extremity with obvious deformity of swelling in the left ankle. Plaintiff presented with a four pronged cane. Plaintiff had reduced range of motion in his left ankle. Plaintiff was only able to partially squat. “He was completely unable to perform the tandem walk, heel walk,

and toe walk. Patient tried on two occasions but was unable to.” “In the left lower extremity, [Plaintiff] demonstrated 4/5 strength in the proximal muscle groups above his left knee and 3/5 strength in the distal muscle groups below his left knee.” (Tr. 268). Plaintiff’s left lower extremity 4 had no Achilles tendon reflex. (Tr. 269). Diagnosis were gait abnormality and chronic left ankle and heel pain secondary to traumatic injury. (Tr. 269). “The patient has significant range of motion issues and strength issues in his left ankle and foot. I suspect this would affect his current work status.” (Tr. 269).

In September 2018, Plaintiff reported taking three ibuprofen three times a day for pain. (Tr. 221). In October 2018, a physical therapist Hill wrote Plaintiff’s attorney after being seen in October 2018.

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Jackson v. Commissioner of Social Security Administration, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jackson-v-commissioner-of-social-security-administration-scd-2021.