Richard Elliott v. SSA

District Court, D. New Hampshire·Decided September 29, 1998·No. CV-97-276-B·Published

Opinion

Richard Elliott v. SSA CV-97-276-B 09/29/98 UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

Richard Elliott v. Civil No. 97-276-B

Kenneth S. Apfel, Commissioner of the Social Security Administration

MEMORANDUM AND ORDER

Richard Elliott has a history of health problems, including back and respiratory difficulties.1 Elliott first applied for Title II Social Security Disability Income ("SSDI") benefits on September 15, 1992. The Social Security Administration ("SSA") denied Elliott's application at the initial determination level on December 30, 1992. Elliott did not appeal and his insured status expired the following day. Elliott filed a subseguent application for disability benefits on November 29, 1994. The SSA denied Elliott's second claim, with an Administrative Law Judge ("ALJ") rendering an unfavorable decision on September 2 9,

1 Elliott's 1994 application for disability insurance benefits alleged an inability to work since November 17, 1986, due to chest pain, carotid artery disease, arteriosclerosis, pulmonary disease, low back pain, and glaucoma.

1995. The Appeals Council denied Elliott's request for a review of the ALJ's decision on April 10, 1997.

Elliott brings this action pursuant to Section 205 (g) of the Social Security Act, 42 U.S.C.A. § 405(g) (West Supp. 1998) ("the Act"), seeking review of the SSA's 1995 decision denying his claim for benefits. Elliott claims that the ALJ's determination that he was not disabled within the meaning of the Act and that he could perform light work as defined by SSA regulations is not supported by substantial evidence.

For the reasons that follow, I grant Elliott's motion and remand the case to the ALJ for further review.

I. FACTS2

Elliott was born on October 9, 1940, and was 54 years old when ALJ Robert S. Klingebiel denied his second claim in 1995. He is a high school graduate who, prior to his alleged dis­ ability, worked for more than 20 years as a mill man, supply man, mold cleaner, and rubber cutter for Goodyear Tire and Rubber Company. He has not engaged in substantial gainful employment

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

since November 17, 1986. (Tr. 15) .3 Elliott suffered a back injury in July 1986 while carrying a bureau down a flight of stairs. Dr. David Russo diagnosed Elliott with recurrent acute low back strain. Dr. Russo pre­ scribed five weeks of physical therapy before clearing Elliott to return to work on August 21, 1986. A week after returning to work, Elliott was treated for low back muscle spasms and stiff­ ness in the emergency room of M t . Ascutney Hospital. Elliott received prescriptions for Valium and Advil. He returned to the emergency room once again on November 17, 1986, after suffering low back pain while working. Elliott later told Dr. A. S. Goldstein that he had crawled under a machine to remove an object when he felt intense pain, then numbness, before he collapsed on the floor and had to be assisted by co-workers. Dr. Goldstein diagnosed Elliott with "recurrent episodes of disc protrusion probably involving the 5th lumbar root on the right." He indicated that Elliott had a good prognosis for recovery, but that recurrent episodes were likely.

Elliott then saw Dr. C. Frederick Lord, an orthopaedic surgeon, on March 6, 1987, complaining of low back pain radiating

3 "Tr." refers to the certified transcript of record filed by the Commissioner of the Social Security Administration with the Court.

into his buttocks, legs, and feet. He also complained of numb­ ness and tingling, which made it difficult to remain in one position. Dr. Lord diagnosed Elliott with spinal stenosis with superimposed L4-L5 disc herniation. He indicated that Elliott's condition would bar him from returning to his job, as it reguired heavy manual labor. He prescribed continued conservative treat­ ment, but did not rule out surgery. That same month, Elliott saw Dr. William Kois, a physiatrist,4 at the reguest of his insurance company. Dr. Kois observed that Elliott could sit for about 30 minutes, if allowed to continuously shift his weight or position. He could stand for only 10 minutes and could go up and down stairs using safety devices. He also found that Elliott had a limited range of motion in his spine and appeared to be suffering significant pain. Dr. Kois determined that surgery was appropriate.

Dr. Lord performed back surgery on Elliott on October 22, 1987, after a September visit in which Elliott reported worsening symptoms. A CT scan and myelogram performed on October 21, 1987, confirmed bulging of the L5-S1 disc with impingement of the right SI nerve root. After surgery, Elliott reported that he had no

4 The specialization in physical or rehabilitation medicine.

leg pain but did feel tingling in his right leg. Elliott again complained of tingling, coupled with numbness, at follow-up appointments with Dr. Lord in November and December 1987 and January 1988. He also exhibited a stiff range of motion in his back and pain upon backward and lateral bending. Dr. Lord prescribed Motrin, Orudis, and Depo-Medrol. Dr. Lord then referred Elliott to a physical therapist and continued to follow his progress through July 1988.

Elliott participated in physical therapy at M t . Ascutney Hospital during January and February 1988. At one appointment, Elliott was unable to perform due to respiratory problems. At another appointment, he reported increased pain after sneezing the previous week.

Elliott returned to Dr. Lord in February 1988. Dr. Lord found that Elliott had decreased right ankle jerk reflex, decreased sensation to pin prick, muscle spasms in his lower back upon straight leg raising, and hamstring tightness. Dr. Lord referred Elliott to Dr. Leonard Rudolph, an orthopaedic surgeon, who recommended continued conservative treatment. Dr. Lord agreed, and sent Elliott to Dr. Seddon Savage, a board certified anesthesiologist, to consider epidural and trigger point steroid injections.

Elliott saw Dr. Savage in March 1988. She later admini­ stered epidural steroid injections to Elliott, who stated that the injections produced no change in the feeling of his lower back, but that they did decrease neck stiffness for several hours. She also referred Elliott to physical therapist William Cioffredi. Elliott saw Cioffredi for regular physical therapy sessions from March until August 1988.

Elliott's doctors noted some signs of improvement during this time, but also freguent setbacks due to sneezing, trying to remove a car battery, and driving to doctor appointments. Elliott no longer hunted or fished. He spent most of his time reading, listening to the radio, or watching television. He reported that he suffered from night-mares, as well as pain or spasms which woke him up at night. His appetite was poor. He had also become irritable, which led to stressful relationships with his family.

On March 9, 1988, Dr. Lord completed a functional capacity assessment of Elliott, stating that Elliott should never lift or carry more than 10 pounds. He estimated that Elliott could return to work in July 1988 on a part-time basis, working three to four hours a day. (Tr. 395-95) .

In an August 24, 1988, discharge note, Cioffredi wrote that Elliott continued to improve through physical therapy and was probably able to return to "limited periods of light duty activity." He noted that Elliott's symptoms were "periodically aggravated," but that Elliott was able to resolve them with his home exercise program. (Tr. 292).

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