Sanchez v. Saul

CourtDistrict Court, N.D. California
DecidedSeptember 21, 2020
Docket3:19-cv-03228
StatusUnknown

This text of Sanchez v. Saul (Sanchez v. Saul) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Sanchez v. Saul, (N.D. Cal. 2020).

Opinion

1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 E.S., 7 Case No. 19-cv-03228-JCS Plaintiff, 8 ORDER GRANTING PLAINTIFF’S v. 9 M JUO DT GI MON E NF TO ,R D S EU NM YIM NA GR

Y ANDREW M. SAUL, 10 DEFENDANT’S MOTION FOR Defendant. SUMMARY JUDGMENT AND 11 REMANDING FOR AWARD OF BENEFITS 12 Re: Dkt. Nos. 15, 20 13 I. INTRODUCTION 14 Plaintiff E.S.1 applied for disability insurance under Title II of the Social Security Act on 15 November 6, 2015, alleging that she was unable to work due to arthritis, back pain, sciatica, and a 16 right ankle injury starting January 18, 2013. Administrative Record (“AR”) at 66, 163–66. She 17 subsequently amended her onset date to March 1, 2010. Id. at 167. She seeks review of the final 18 decision of Defendant Andrew Saul, Commissioner of the Social Security Administration 19 (“Commissioner”) denying her application. For the reasons stated below, the Court GRANTS 20 Plaintiff’s Motion for Summary Judgment, DENIES the Commissioner’s Motion for Summary 21 Judgment, REVERSES the decision of the Commissioner, and REMANDS the case to the Social 22 Security Administration for award of benefits.2 23 24 25

26 1 Because opinions by the Court are more widely available than other filings and this Order contains potentially sensitive medical information, this Order refers to Plaintiff using only her 27 initials. 1 II. BACKGROUND 2 A. Factual Background 3 1. Education and Employment 4 Plaintiff was born in1975 and completed high school in 1995. AR at 92, 213. Plaintiff 5 worked as a postal clerk from 1996 to 2001, a file clerk at a non-profit in 2001, a retail salesclerk 6 in 2001 and 2002, and a hotel housekeeper from 2004 to 2009. Id. at 213, 296. Plaintiff suffered 7 a work-related injury in 2009 and, as a result, returned to work with limitations. Id. at 41. After 8 two to three weeks on light duty, Plaintiff returned to her usual full housekeeping duties. Id. at 9 608. Plaintiff was laid off on November 27, 2009 due to economic conditions and not her 10 workplace injury. Id. 11 2. Medical History 12 On August 16, 2009, Plaintiff injured her right ankle while working as a hotel 13 housekeeper. Id. at 280. Plaintiff was walking down stairs when she missed a step and twisted 14 her ankle inward. Id. at 339. The following day, Robert Wagner, M.D., examined Plaintiff and 15 diagnosed her with a sprained right ankle. Id. An x-ray found no evidence of fracture or 16 dislocation. Id. at 335. Dr. Wagner provided Plaintiff with naproxen, banalg lotion, ankle 17 support, a cane, and a hot and cold pack. Id. Dr. Wagner allowed Plaintiff to return to work for a 18 sit-down job, limited her standing and walking to two hours per day, and directed her to wear 19 ankle support and keep her ankle elevated. Id. Dr. Wagner prescribed Vicodin for Plaintiff’s pain. 20 Id. at 321. Plaintiff completed six sessions of physical therapy but on October 16, 2009, Dr. 21 Wagner noted that Plaintiff’s condition had not improved significantly. Id. at 319–20. 22 Plaintiff was referred to Thomas Peatman, M.D., who provided an orthopedic surgery 23 consultation on November 4, 2009. Id. at 384. By this time, Plaintiff had returned to full duty as a 24 hotel housekeeper. Id. at 385. Following the consultation, Dr. Peatman did not recommend 25 surgery. Id. at 386. Instead, Dr. Peatman recommended further physical therapy and potentially 26 additional restrictions on Plaintiff’s physical activities. Id. Plaintiff participated in seven 27 additional sessions of physical therapy. Id. at 388. On December 15, 2009, an MRI revealed 1 wearing a CAM walker boot in January 2010 to help her walk and began taking lodine and 2 Ultracet for pain relief. Id. In February 2010, Plaintiff was prescribed Voltaren gel––a topical 3 NSAID––for pain relief. Id. at 393. 4 In March 2010, Plaintiff first reported pain in her right hip’s SI joint to Dr. Peatman. Id. 5 395. During the same appointment, Dr. Peatman administered a steroid injection in her right ankle 6 and prescribed a flector patch for her SI joint. Id. By April 2010, Plaintiff was weaned from the 7 CAM walker boot; however, Plaintiff subsequently reported increased pain in her right ankle and 8 right SI joint. Id. at 400. As a result, Dr. Peatman instructed Plaintiff to resume using the CAM 9 walker boot. Id. at 401. Dr. Peatman also requested approval for eight additional physical therapy 10 sessions. Id. The request was denied by workers’ compensation. Id. 11 With Plaintiff’s continued pain, Dr. Peatman requested approval for a PRP injection in 12 June 2010. Id. at 407. In July 2010, the request for the PRP injection was denied and Dr. Peatman 13 requested a second opinion from Jeffrey Mann, M.D. on potential surgical decompression. Id. 14 409–10. In September 2010, Plaintiff reported that her SI joint pain radiated down her leg and her 15 leg became numb when she sat for extended periods. Id. 415. In October 2010, Plaintiff told Dr. 16 Peatman of back pain that she believed was related to her ankle injury. Id. at 419. 17 On August 10, 2010, an agreed medical examination was performed by John Warbritton, 18 III, M.D. Id. at 608, 628. Dr. Warbritton examined Plaintiff’s lower back and noted no lumbar 19 paraspinal muscle spasm and no tenderness near the lumbosacral junction, the sacroiliac joints 20 bilaterally, or the sciatic notches bilaterally. Id. at 631. Dr. Warbritton noted one half inch of 21 atrophy in each of Plaintiff’s right thigh and calf and noted some limited range on motion in her 22 right ankle. Id. at 632. After reviewing Plaintiff’s records and medical imaging, Dr. Warbritton 23 opined that Plaintiff likely “reached a point of maximal medical improvement” one year after her 24 injury. Id. at 634. He concluded that Plaintiff’s whole person was 10% impaired. Id. at 635. 25 In December 2010, Plaintiff first saw Dr. Mann, an orthopedic surgeon who specializes in 26 foot and ankle surgery. Id. at 375. Following a second MRI of Plaintiff’s right ankle in December 27 2010, Dr. Mann recommended surgical reconstruction of Plaintiff’s right ankle lateral ligaments 1 osteophyte formation, an enlarged os trigonum, and tears of the lateral ankle ligaments. Id. Dr. 2 Mann performed the recommended reconstruction surgery on Plaintiff in March 2011. Id. at 367. 3 Plaintiff was prescribed Vicodin after the procedure. Id. at 365. 4 Ten days after the surgery, Dr. Mann observed that Plaintiff was experiencing “moderate 5 pain in the surgical area” but that her wound was healing well. Id. at 367. He applied a “non- 6 weight-bearing cast” at that visit. Id. A month later, in April 2011, Plaintiff was still experiencing 7 “moderate pain in the surgical area.” Id. at 365. At that point, he described Plaintiff’s weight- 8 bearing status as “partial” and noted that Plaintiff would soon be starting physical therapy. Id. at 9 365. The following month, in May 2011, Dr. Mann noted that Plaintiff “continue[d] to experience 10 moderate pain in the surgical area with walking more than ten minutes.” Id. at 363. At that point, 11 Dr. Mann described Plaintiff’s weight-bearing status as “full weight-bearing in CAM walker.” Id. 12 He noted that Plaintiff had started physical therapy two weeks before. Id. A month later, Plaintiff 13 “continue[d] to have moderate pain in the surgical area.” Id. at 361. In July 2011, Plaintiff was 14 still experiencing “moderate pain” and taking 2-3 Vicodin a day. Id. at 359. She received an 15 injection of dexamethasone into the plantar fascia “due to pain.” Id. She later reported to Dr. 16 Mann that it helped for one month. Id. at 353. Plaintiff was still using a cane “most of the time” 17 and her walking continued to be “very limited.” Id. at 359. Dr. Mann noted at this visit that she 18 had completed her physical therapy. Id.

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Bluebook (online)
Sanchez v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/sanchez-v-saul-cand-2020.