Mott v. Comm'r of Soc. Sec.

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SONIA MOTT, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

No. 1:21-cv-00010

United States District Court, N.D. Ohio, Eastern Division

April 18, 2022

DAN AARON POLSTER DISTRICT JUDGE

REPORT AND RECOMMENDATION

AMANDA M. KNAPP UNITED STATES MAGISTRATE JUDGE

Plaintiff Sonia Mott (“Plaintiff” or “Ms Mott”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Commissioner”) denying her application for Disability Insurance Benefits (DIB). (ECF Doc. 1, ECF Doc 15.) This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This matter has been referred to the undersigned Magistrate Judge for a Report and Recommendation pursuant to Local Rule 72.2.

For the reasons set forth below, the undersigned recommends that the Court AFFIRM the Commissioner's decision.

I. Procedural History

Ms. Mott filed her application for DIB on August 10, 2018. (Tr. 10, 82, 168-69.) She asserted a disability onset date of March 6, 2018. (Tr. 10, 168, 300.) She alleged disability due to fibromyalgia, arthritis in spine, spondylitis, depression, anxiety, and patella femoral syndrome. (Tr. 67, 84, 104, 113, 300.) Her application was denied at the initial level (Tr. 103-11) and upon reconsideration (Tr. 113-19). She then requested a hearing. (Tr. 120-21.) A hearing was held before an Administrative Law Judge (“ALJ”) on April 23, 2020. (Tr. 38-65.)

On May 27, 2020, the ALJ issued an unfavorable decision, finding Ms. Mott had not been under a disability from March 6, 2018 through the date of the decision. (Tr. 7-28.) Ms. Mott requested review of the ALJ's decision by the Appeals Council. (Tr. 165-67.) On November 3, 2020, the Appeals Council denied Ms. Mott's request for review, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-6.)

II. Evidence

A. Personal, Educational, and Vocational Evidence

Ms. Mott was born in 1970. (Tr. 22, 47, 168.) She has a high school education and attended three years of college at a community college. (Tr. 301, 847.) She worked full time in the positions of customer service manager and retail store manager from 1999 until 2014, and then worked reduced hours until 2018. (Tr. 47-48, 60.)

B. Medical Evidence

1. Treatment History

i. Physical Impairments

Ms. Mott fell and was injured at work in November 2017, resulting in allowed workers compensation claims for bilateral knee contusions, bilateral knee sprains, and lumbar sprain. (Tr. 602-03, 716.) An MRI of the right knee was taken on December 7, 2017, showing: full thickness chondral defect involving the medial patellar facet associated with subchondral cystic change in edema with need to correlate for history of transient lateral patellar dislocation, small bone contusion of the inferior medial aspect of the medial femoral condyle, and mild hyperintensity in the superolateral aspect of Hoffa's fat that may relate to fat pad impingement syndrome. (Tr. 766-67.) She received chiropractic and orthopedic treatment and physical therapy for her work-related injuries throughout the end of 2017 and into 2018. (Tr. 719-20; see generally Tr. 600-844.) Her orthopedic doctor, David Marsh, M.D. with University Hospitals Elyria Medical Center, diagnosed her with patellofemoral syndrome. (Tr. 719, 721, 738, 744.)

Ms. Mott saw her primary care physician Digna Moya, M.D. at the Cleveland Clinic on February 2, 2018, complaining of low back pain, which she felt after repeatedly bending over. (Tr. 827.) She reported that her acid reflux symptoms had improved, and she was taking Nexium less often. (Id.) On examination, she displayed mild tenderness in the paravertebral muscles in the lower thoracic area. (Id.) A February 2018 x-ray of the low back was normal. (Tr. 436-37.)

On March 8, 2018, she saw neurologist Sanjay Parikh, M.D. of University Hospitals for a six-month follow up for restless leg syndrome (“RLS”) with depression, anxiety, and chronic back pain. (Tr. 574-77.) Examination findings were normal except for an unsteady/ataxic gait because of the brace she wore on the right knee. (Tr. 574, 576.) Dr. Parikh renewed her prescriptions of Lexapro and Klonopin for anxiety and RLS. (Tr. 576.)

When Ms. Mott saw Dr. Moya on May 15, 2018 for a routine follow up, Dr. Moya noted that she was seeing Dr. Parikh for fibromyalgia and RLS, and orthopedics for her knee. (Tr. 432, 434.) She complained of a migraine, stating that she had migraines in the past, but they were lasting longer. (Tr. 432.) Specifically, she reported headaches once a week, causing throbbing/stabbing pain that lasted two to three days. (Id.) She denied light sensitivity but reported some sensitivity to noise. (Id.) She indicated that she took Tylenol and would lie down when she had a headache. (Id.) She also complained of numbness in her knees, and epigastric pain for which she was restarting Nexium. (Id.) On examination, she had no musculoskeletal edema, and her gait was normal, but she wore a knee brace on the right. (Tr. 434.) She demonstrated tenderness in the epigastric area. (Id.) She was on steroids and taking ibuprofen for her knee, but Dr. Moya noted that she might have to stop the medication because of the concern over a peptic ulcer. (Tr. 434.)

Ms. Mott returned to primary care on August 16, 2018 for an annual exam, complaining of pain in her fingers, stiffness in her hands, gastric pain that was radiating to her side, increased bowel urgency, feeling nauseous, and worsening anxiety. (Tr. 418.) She reported getting around a little better since her fall in November, and that her heartburn was better. (Id.) Examination findings were normal, including normal gait, good range of motion, and no swelling in the fingers. (Tr. 420-21.) Dr. Moya recommended additional testing/labs due to unspecified joint pain and fatigue, and encouraged Ms. Mott to exercise and to try aquatic exercises. (Tr. 422.) Ms. Mott reported she was afraid of being in the water. (Id.) Dr. Moya considered switching Ms. Mott to Cymbalta for her aches and pains, but did not do so after being reminded that she had side effects in the past when on Cymbalta. (Id.)

On August 20, 2018, Ms. Mott returned to neurology, complaining of headaches both before going to bed and when waking up. (Tr. 570.) On examination, she had an ataxic gait due to pain in the knee and legs. (Tr. 572.) Exam findings were otherwise normal. (Id.) Dr. Parikh continued Ms. Mott on Klonopin and Lexapro for RLS and anxiety, and started her on Qudexy for tension headaches. (Tr. 573.)

An MRI of Ms. Mott's lumbar spine dated September 5, 2018, ordered by her chiropractor Brian Studer, D.C. of the Lorain Injury Center, showed lumbar disc bulges without spinal stenosis or nerve root compression (Tr. 407.)

Ms. Mott returned to primary care on September 12, 2018. (Tr. 413.) She complained of her usual aches from fibromyalgia but also reported more pain and stiffness in her hands. (Id.)

Examination showed good range of motion of the fingers and no swelling in the hands, but some tenderness in the left TMJ. (Tr. 414.) She had a normal gait. (Id.)

Ms. Mott was evaluated by Robert Mark Fumich, M.D. on September 13, 2018 regarding her work-related injuries. (Tr. 716.) She reported no prior injury or problems with her knee. (Id.) She complained of bilateral knee swelling and knee pain with stairs, especially going down the stairs. (Id.) She reported that her treatment had included braces, physical therapy, and viscosupplementation injections in both knees. (Id.) On examination, Dr. Fumich observed crepitus and medial and lateral joint line tenderness in both knees and slight effusion in the left knee, but with a full range of motion and no instability in the knees. (Id.) Dr. Fumich indicated she had failed conservative treatment and needed arthroscopy. (Id.) Dr. Fumich also indicated that her “recognized condition of contusion or sprain [had] caused a substantial aggravation of arthritis in her right knee as documented by the MRI and bone contusion seen” and he planned to “request the additional allowances of substantial aggravation and internal derangement for each knee” and authorization for arthroscopy of both knees. (Id.; Tr. 766-67.)

Ms. Mott returned to neurology on November 19, 2018 for follow up regarding migraines, chronic pain syndrome, and restless leg syndrome. (Tr. 566.) She reported that she stopped her headache medication after about two weeks, stating “she now ha[d] numbness in [her] hands and her jaw hurt[] her badly.” (Id.) Examination findings were generally normal, except for an unsteady/ataxic gait because of the brace she wore on the right knee. (Tr. 568.) She continued to complain of swelling in the hands and aches and pains in the jaw and shoulder. (Tr. 566.) Dr. Parikh observed that her physical and neurological exam was nonfocal except for some swelling in the hands. (Id.) He continued her on Klonopin and Lexapro for RLS and anxiety, stopped Quinidex, and indicated she agreed to see a rheumatologist to look for any other etiology and return in six months. (Tr. 566, 569.)

On December 19, 2018, Ms. Mott had a cervical spine MRI due to neck pain. (Tr. 599.) The impression was: left paracentral bulging disc at ¶ 5/6, posterior disc bulge at ¶ 1-T2, cervical lordotic straightening, and congenitally small spinal canal. (Id.)

On December 18, 2018, Ms. Mott retuned to Dr. Fumich regarding her right knee. (Tr. 604.) Dr. Fumich indicated: “On physical examination of the right knee, she has continued pain. She has crepitus on flexion/extension. She has medial joint tenderness, lateral joint tenderness. She has full motion. There is a slight effusion. She has no instability.” (Id.) At her next appointment on January 22, 2019, examination showed “continued symptomatic right knee” wit...