United States District Court, N.D. Texas, Amarillo Division
REPORT AND RECOMMENDATION TO AFFIRM THE DECISION OF
CLINTON E. AVERITTE UNITED STATES MAGISTRATE JUDGE
Alex Suarez brings this cause of action pursuant to 42 U.S.C.
§ 405(g), seeking review of a final decision of
defendant NANCY A. BERRYHILL, Acting Commissioner of Social
Security (Commissioner), denying plaintiffs application for
disability insurance benefits (DIB). For the reasons
hereinafter expressed, the undersigned United States
Magistrate Judge recommends the Commissioner's decision
finding plaintiff not disabled and not entitled to benefits
filled an application for Disability Insurance Benefits on
March 8, 2012, alleging a disability onset date of December
1, 2011. (Tr. 120). Plaintiffs claim was denied initially and
on rehearing, and plaintiff requested a hearing. (Tr. 55-58,
63-67). A hearing was held on March 21, 2014, before
Administrative Law Judge Lantz McClain. (Tr. 26-45). The ALJ
issued an unfavorable decision on April 25, 2014, finding
plaintiff not disabled. (Tr. 10-21). The ALJ found plaintiff
had the following severe impairments: mild degenerative disc
disease of the cervical spine; mild peripheral neuropathy;
status post, left shoulder surgery; history of knee pain.
(Tr. 12). He determined none of plaintiffs impairments met or
equaled the severity of a listed impairment. (Tr. 13). The
ALJ next evaluated plaintiffs RFC, reaching the conclusion he
was able to perform "light work as defined by 20 CFR
404.1567(b) with the following limitations. The claimant is
able to occasionally lift and/or carry twenty pounds,
frequently lift and/or carry ten pounds, stand and/or walk at
least six hours in an eight-hour workday, and sit at least
six hours in an eight-hour workday. The claimant is only
occasionally able to climb such things as ramps or stairs,
kneel, crouch, or crawl. He is frequently able to balance or
stoop, and he needs to avoid work above shoulder level."
(Id.). The ALJ found he was able to perform his past
relevant work as a mail clerk, DOT Code 209.687-026,
unskilled work (SVP of 2) at the light level of exertion.
the Appeals Council's denial of plaintiff s request for
review on July 20, 2015, the ALJ's determination that
plaintiff was not under a disability during the relevant time
period became the final decision of the Commissioner. (Tr.
1). Plaintiff now seeks judicial review of the denial of
benefits pursuant to 42 U.S.C. § 405(g).
medical record shows the following:
Plains Clinic treated plaintiff from January 14, 2010 to
March 8, 2010. (Tr. 198-204). Plaintiff saw providers John C.
Turner, MD and Robert A. Murphy, PA-C. Robert Murphy
prescribed plaintiff with pain medications. Plaintiff
presented with complaints of back pain, neck pain, chest wall
pain, shoulder pain, and increased cholesterol.
Henson, MD, at Panhandle Family Medicine Specialists, treated
plaintiff from March 25, 2010to August 23, 2011. (Tr.
188-96). He was treated primarily for back and neck pain,
left shoulder pain, and right knee pain. (Id.). He
was also diagnosed with cervical degenerative disc disease
and peripheral neuropathy. (Id.). At some point, Dr.
Henson referred plaintiff to Victor Taylor, MD, who saw
plaintiff and continued prescribing plaintiffs pain
Taylor diagnosed him with peripheral neuropathy, in addition
to cervical spondylosis with arthritis and some diffuse
degenerative changes in the cervical spine. (Id.).
Plaintiff had a diffuse sensory deficit to light touch in
lower extremities but a normal circulatory response for
capillary refill and good dorsalis pedis and posterior tibial
pulses. (Id.). Plaintiff had 2 symmetric
reflexes in both lower and upper extremities and 5/5 muscle
strength. (Id.). Dr. Taylor's plan was to
schedule a bilateral lumbar sympathetic block and if approved
by his insurance, do an RF nuerotomy of those areas.
(Id.). If not, a spinal cord stimulator would be
plaintiffs primary care occurred through the Veterans Affairs
(VA) clinic. On October 18, 2011, x-rays of the cervical
spine were performed that indicated moderate disc space
narrowing with moderate marginal spurring anteriorly. (Tr.
211). The impression was degenerative changes without
fracture, spondylolisthesis, or evidence of spondylolysis.
(Id.). Bilateral shoulder x-rays were performed that
showed only a calcific density but no other abnormalities,
including no fracture, dislocation, or subluxation. (Tr.
212). A lumbar-sacral spine x-ray was also performed that
showed only minor abnormalities: There were mild degenerative
end plate changes at the upper lumbar spine as well as at the
L5 inferior end plate with associated mild to moderate
intervertebral disc space narrowing. (Tr. 210). The
impression was mild degenerative changes without fracture,
spondylolisthesis, or evidence of spondylolysis.
had several x-rays of his knees performed at the VA clinic.
On July 7, 2011, bilateral knee x-rays showed no
abnormalities, and on March 16, 2013, a left-knee x-ray also
showed no abnormality. (Tr. 215, 233). On July 13, 2013,
weight-bearing bilateral knee x-rays were performed that
showed mild right knee osteoarthritis involving predominantly
the patellofemoral joint and an unremarkable left knee. (Tr.
was performed on February 15, 2012, as a result of plaintiff
complaining of painful, burning feet for the last eight
years. (Tr. 234). A normal study resulted, with a
"clinical picture consistent with small fiber peripheral
March 20, 2012, the VA occupational therapy records show
plaintiff presented with complaints of left shoulder pain
after having worked in his yard. (Tr. 235-36). Examination
demonstrated a full functional range of motion and good
strength of bilateral shoulders, though plaintiff stated he
felt pain in certain positions. (Id.). It was noted
that patient was independent with activities of daily living.
(Id.). He was educated about a home program of
stretches, strengthening exercises, and pain management.
April 9, 2012, plaintiff saw Rush A. Snyder, Jr., MD, a
neurologist at the VA, who performed a neurological
examination that was intact except for some diminished
sensation. (Tr. 443). He diagnosed plaintiff with small fiber