Lord v. SSA

District Court, D. New Hampshire·Decided June 14, 1998·No. CV-97-505-B·Published

Opinion

Lord v. SSA CV-97-505-B 06/14/98 UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

Richard Lord

v. C-97-505-B

Kenneth S. Apfel, Commissioner of the Social Security Administration

MEMORANDUM AND ORDER

Richard Lord suffers from a degenerative disc disease affecting his lower back. Lord first applied for Title II Social Security Disability Income ("SSDI") benefits on July 18, 1991, alleging that he was unable to work because of his back condition and the resulting pain his condition causes. The Social Security Administration ("SSA") denied Lord's application at the initial level of review, and Lord did not appeal that denial. Lord again applied for SSDI benefits on April 26, 1994. The SSA denied this application at each stage of administrative review, rendering a final decision denying the application on January 31, 1997.

Lord brings this action pursuant to Section 20 5 (g) of the Social Security Act, 42 U.S.C.A. § 405(g) (West Supp. 1998),

seeking review of the SSA's final decision to deny him SSDI benefits. He asserts that the SSA Administrative Law Judge ("ALJ") who reviewed his case erred in two respects, namely that: (1) the ALJ erroneously found that Lord had the residual functional capacity to perform the full range of light and sedentary work; and (2) the ALJ failed to take into account certain non-exertional limitations on his ability to work and, therefore, improperly relied upon the Medical-Vocational Guidelines, 20 C.F.R. P t . 404, Subpt. P, Ap p . 2 (1997), in finding him not disabled.

For the reasons that follow, I grant Lord's motion in part and remand the case to the SSA for further review.

I. FACTS1

A. Lord's Health Problems Lord was born on July 26, 1947 and was 47 years old when the ALJ rendered his decision finding him not disabled. He has an eighth-grade education with no additional educational or vocational training. He previously worked in housing maintenance both at an apartment complex and, most recently, at a mobile home park. His duties included caring for buildings and grounds,

1 Unless noted otherwise, the following facts are taken from the Joint Statement of Material Facts submitted by the parties to this action.

plowing snow, shoveling, ditch-digging, and repairing broken eguipment. Lord has not worked since August 16, 1990.

On August 16, 1990, Lord twisted his back while descending backwards off of a ladder. Complaining of stiffness in his lower back. Lord visited the emergency room at a local hospital on August 20, 1990. At that time, plaintiff was prescribed an anti­ inflammatory agent and a muscle relaxant, and was referred to an orthopedist.

Pursuant to that referral. Lord was examined by Dr. Jamie Smolen on August 27, 1990. Lord complained of pain and stiffness in his lower back and stated that the pain increased with bending in all directions. Plaintiff also complained of a limited range of motion. At that examination, plaintiff performed prone press- ups and abdominal curls with no problem. His heel and toe walking, hopping, reflexes, motor examination, and straight leg raising were all normal.

At a follow-up visit on September 17, 1990, Lord continued to complain of pain, but also noted that it had decreased and that his flexibility had increased. Dr. Smolen started plaintiff

on back-strengthening exercises. Dr. Smolen subseguently noted that over the next several weeks. Lord's condition improved with exercise and that he experienced less pain. Despite the progress. Dr. Smolen suggested that plaintiff remain out of work until his condition further improved.

After a December 19, 1990 office visit. Lord continued to complain of lower-back pain and stated that he had difficulty sitting, bending, twisting, and turning. Testing showed that the strength of Lord's back muscles had decreased since the previous testing. Examination revealed discomfort with bending, knee to chest flexion, abdominal curl, and prone extension. Dr. Smolen indicated that plaintiff should not return to work. A subseguent MRI revealed a large herniated disk at L5-S1 and a bulging disk at L4-L5. As a result of the MRI, Dr. Smolen referred Lord to Dr. Jonathon Sobel for a surgical consult.

Lord complained to Dr. Sobel of severe pain in his lower back, left buttock, and left leg as well as difficulty moving. Dr. Sobel found "mild" nerve root tension and "slightly" deep tendon reflexes at the ankle and discussed surgical options with Lord. A subseguent CT scan confirmed Lord's herniated and bulging disks. When compared to the previous MRI, the CT scan

results showed no significant worsening and even slight improvement.

On May 10, 1991, Lord visited Dr. Anthony Marino for a second opinion on surgery. At that examination. Lord noted pain in the left buttock and occasional numbing of the left foot, but also noted intermittent improvement. Lord also stated that physical therapy provided "some relief." Dr. Marino noted that plaintiff moved about the examination room and stood on one leg, his heels, and his toes, all without difficulty. Dr. Marino concluded that surgery might help to relieve Lord's leg pain.

One June 20, 1991, plaintiff reported to Dr. Sobel that he had been told to "take it easy for the summer" and that he was "doing guite well after a period of rest." Dr. Sobel was of the opinion that Lord should be vocationally retrained. In July 1991, plaintiff entered a work hardening program. Though Lord complained of pain following therapy. Dr. Sobel attributed this pain to Lord's "sedentary" lifestyle. On September 1991, Lord expressed his desire to remain in physical therapy and to return to light duty work. Dr. Sobel noted "[t]hat will be fine."

After an October 10, 1991 examination. Dr. Sobel noted that residual functional capacity testing indicated that Lord could perform medium to heavy work. Unable to sguare these results with Lord's continued complaints of pain. Dr. Sobel recommended

more objective testing. On January 13, 1992, Dr. Sobel noted that Lord's flexibility and leg pain had improved and that he reguired paraspinal muscular strengthening. Dr. Sobel referred Lord to Dr. Smolen to pursue this program.

Dr. Smolen reported on January 30, 1992, that Lord was no longer having leg pain and that his back was "simply achy, stiff and sore." Lord reported that he was comfortable leading a sedentary, low activity lifestyle. Although examination revealed "slightly limited and slightly uncomfortable" back bending, plaintiff performed toe and heel walking, hopping, and abdominal curls all without difficulty. Dr. Smolen recommended against surgery and that Lord should continue in physical therapy.

Lord next visited Dr. Smolen nearly a year later, on January 21, 1993. Lord complained of lower-back pain and discomfort performing activities around the house as well as those related to sitting, standing, bending, twisting, and turning. Examination revealed that Lord was able to slowly and cautiously bend toward the floor, reaching below the level of his knees. His back extension was limited and uncomfortable, though straight-leg raising tests, reflexes, motor strength, and sensory examination were all normal. Dr. Smolen recommended continued physical therapy.

Over the next few months. Lord's condition remained unchanged and he continued to complain of lower-back pain and stiffness. On April 8, 1993, Dr. Smolen stated that he believed Lord was unable to return to work. Dr. Smolen further noted that he expected "that realistically he will not return to work until his [Worker's Compensation] case is settled." Additionally, Dr. Smolen noted that Lord "will remain partially and permanently disabled. He will never be able to perform a job that requires repetitive twisting, turning, lifting, carrying, or bending. . .

He will always be at a light duty work capacity, if he ever works again." Dr. Smolen then referred Lord to Dr. John Thomas for more physical therapy.

During a May 4, 1993 physiatric2 consultation with Dr.

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