Jason Sallaz v. Comm'r of Soc. Sec.

CourtCourt of Appeals for the Sixth Circuit
DecidedJune 12, 2024
Docket23-3825
StatusUnpublished

This text of Jason Sallaz v. Comm'r of Soc. Sec. (Jason Sallaz v. Comm'r of Soc. Sec.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jason Sallaz v. Comm'r of Soc. Sec., (6th Cir. 2024).

Opinion

NOT RECOMMENDED FOR PUBLICATION File Name: 24a0259n.06

No. 23-3825

UNITED STATES COURT OF APPEALS FILED FOR THE SIXTH CIRCUIT Jun 12, 2024 KELLY L. STEPHENS, Clerk ) JASON SALLAZ, ) Plaintiff-Appellant, ) ON APPEAL FROM THE ) UNITED STATES DISTRICT v. ) COURT FOR THE NORTHERN ) DISTRICT OF OHIO COMMISSIONER OF SOCIAL SECURITY, ) ) OPINION Defendant-Appellee. )

Before: GIBBONS, WHITE, and MURPHY, Circuit Judges.

HELENE N. WHITE, Circuit Judge. Jason Sallaz appeals the district court’s order

affirming the denial of his application for Social Security disability insurance benefits. He argues

that the administrative law judge (ALJ) erred in finding unpersuasive two medical opinions

concluding that his physical impairments prevented him from performing sedentary work. We

AFFIRM.

I.

A.

Sallaz has a history of leg and back pain stemming from a 2003 car accident in which he

fractured his right femur and a 2017 tree-cutting accident in which he fractured his left. The 2003

fracture resulted in a surgical rod being inserted in his right leg. After the injury, he worked from

2004 to 2017 as a machine helper for die-casting companies, a semi-skilled heavy exertional

position that sometimes required him to lift up to 150 pounds. Beginning in 2014, he reported leg

and back pain to his primary-care physician, who prescribed the pain medication Ultram. After the No. 23-3825, Sallaz v. Comm’r of Soc. Sec.

2017 accident, Sallaz had another rod inserted, this time in his left leg. He stopped working after

the accident and lost his health insurance about one month later.

In 2019, Sallaz regained insurance and resumed seeking treatment from his primary-care

physician, Dr. Daniel Miller. He told Dr. Miller that “his knees [were] shot” and that he was “in

the process of applying for disability.” R.7, PID 338. On March 13, 2019, Dr. Miller gave Sallaz

“two injections of kenalog with lidocaine” for his leg pain. Id. Sallaz returned to Dr. Miller on

May 28, 2019, and reported that he was concerned that the surgical screws in his left leg were

loose and that “it hurts when he walks all the time.” Id., PID 336.

Dr. Miller referred Sallaz to an orthopedist, Dr. John Stefancin. During his first

examination by Dr. Stefancin, on May 30, 2019, Sallaz told Dr. Stefancin he had pain in both

knees, and that the pain in his left knee was worse. Dr. Stefancin noted that Sallaz was “[p]ositive

for joint pain/stiffness or swelling,” muscle pain and weakness, “numbness or tingling sensations,”

and discomfort. Id., PID 384. After examining Sallaz, he also observed that Sallaz’s knees had

“[g]ood patellar mobility” but “positive effusions” (swelling)1 and “[p]ositive tenderness to

palpation” over the screwheads in his left leg, but not the right. Id. He also found that Sallaz had

no muscle atrophy and “5/5 strength” in his hips, legs, and feet. Id. However, he observed that

Sallaz walked with an “[a]ntalgic gait.”2 Id. Dr. Stefancin’s assessment was that Sallaz had

“[b]ilateral knee medial meniscus tears with bilateral retrograde rods; left knee loose body and

symptomatic distal femoral screw hardware.” Id., PID 383. He recommended Sallaz get MRIs of

1 Joint Effusion (Swollen Joint), Cleveland Clinic, https://my.clevelandclinic.org/health/symptoms/21908-joint- effusion (last updated Oct. 12, 2021). 2 An antalgic gait is a limp caused by pain. Gait Disorders and Abnormalities, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/21092-gait-disorders (last updated Feb. 22, 2023); see also Brooking v. Hartford Life & Accident Ins. Co., 167 F. App’x 544, 549 n.6 (6th Cir. 2006) (“An antalgic gait is a limp in which a phase of the gait is shortened on the injured side to alleviate the pain experienced when bearing weight on that side.”).

2 No. 23-3825, Sallaz v. Comm’r of Soc. Sec.

both knees and advised that “arthroscopic loose body removal” on Sallaz’s left knee and a medial

meniscus evaluation might be needed. Id. Sallaz also told Dr. Stefancin he was “contemplating

having the hardware removed” from his thigh. Id.

Sallaz saw Dr. Stefancin again on July 11, 2019 to review the results of the MRIs. Dr.

Stefancin made observations similar to those in his first examination of Sallaz, finding no muscle

atrophy, full strength in his lower extremities, “small effusion,” “good patellar mobility,” and

tenderness in Sallaz’s left leg over the screws. Id., PID 382. He also noted that Sallaz’s “[l]ight

touch sensation [was] intact,” and that Sallaz had a “[s]lightly antalgic gait.” Id. After reviewing

the MRIs, he noted “no meniscal tear or ligamentous injury” in Sallaz’s left knee, “mild scarring”

in the fatty tissue of both knees, an “ossified body” in the left knee, and “mild medial meniscus

intrasubstance degeneration without tear” in the right knee. Id. Sallaz told Dr. Stefancin he

“want[ed] to consider” removing the screws from his leg, but was unsure of the timing. Id.

On August 2, 2019, Sallaz visited Dr. Miller to follow up on his leg pain. Dr. Miller noted

that Sallaz’s right leg had a “slightly decreased” range of motion, and administered a kenalog

injection in his left knee “without complication.” Id., PID 426. Sallaz returned to Dr. Miller on

June 4, 2020 for additional knee injections and reported that “his chronic back pain ha[d] been

worse,” he was “having lower back weakness and pain radiating to both legs,” and “his legs [were]

numb at times.” Id., PID 428. Dr. Miller again observed a slightly decreased range of motion in

Sallaz’s right leg, and also muscle spasms in Sallaz’s back. He further noted: “Straight leg lift

positive on the left. Motor is 5/5 proximally and distally of bilateral lower extremities. Sensory

is grossly intact to light touch bilaterally. Reflexes 2+ and symmetrical of bilateral knees and 1+

symmetrical of bilateral [A]chilles.” Id. He noted that Sallaz’s gait was within normal limits. For

Sallaz’s leg pain, he again administered injections “in both knees without complication.” Id., PID

3 No. 23-3825, Sallaz v. Comm’r of Soc. Sec.

429. But he noted that Sallaz’s back pain was “chronic and progressive,” had “[f]ailed

conservative therapy,” and required further MRI evaluation. Id.

Sallaz had an MRI on August 27, 2020, and a follow-up appointment with Dr. Miller on

September 11, 2020 to review the results. The radiologist’s summary interpretation of the MRI

showed degenerative disc disease, a small “paracentral annular fissure and disc protrusion . . .

minimally contacting the right L5 nerve root,” “[n]o spinal stenosis nor significant neural

foraminal narrowing,” and an “area of abnormal bone marrow signal intensity.” Id., PID 444–45.

During Dr. Miller’s examination of Sallaz, he recorded the same observations of his gait, motor

function, and reflexes that he had during the August 2 visit. He recommended Sallaz make another

appointment with an orthopedist for his leg pain. He described the MRI as “question[ing]

abnormal bone lesion in T10 [vertebra]” and showing a herniated disc. Id., PID 448. He concluded

that Sallaz’s back pain would require further assessment, specifically a bone scan and “evaluation

for possible epidurals.” Id.

In summary, from 2019 to 2020, Sallaz complained of leg and back pain to his doctors;

their examinations identified impairments in his knees and spine, but they also consistently

observed that he retained function—strength, sensation, some range of motion, etc.—in his lower

extremities.

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