Sanders v. Comm'r of Soc. Sec.

1

CURTIS SANDERS, JR., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

No. 1:21-cv-00118

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

August 30, 2022

DAVID A. RUIZ, DISTRICT JUDGE.

REPORT AND RECOMMENDATION

AMANDA M. KNAPP, UNITED STATES MAGISTRATE JUDGE.

Plaintiff Curtis Sanders, Jr. (“Plaintiff” or “Mr Sanders”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Commissioner”) denying his application for Disability Insurance Benefit (DIB). (ECF Doc. 1.) 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

Mr Sanders filed his application for DIB on April 29, 2019. (Tr. 61, 213-16.) He asserted a disability onset date of August 9, 2018. (Tr. 61, 86, 217.) He alleged disability due to back injury, gunshot wound, PTSD, depression, and sleep apnea. (Tr. 118, 133, 151, 158, 235.) His application was denied at the initial level (Tr. 151-53) and upon reconsideration (Tr. 158-64).

He then requested a hearing. (Tr. 165-66.) A hearing was held before an Administrative Law Judge (“ALJ”) on May 13, 2020. (Tr. 82-116.)

On June 2, 2020, the ALJ issued an unfavorable decision, finding Mr. Sanders had not been under a disability from August 9, 2018, through the date of the decision. (Tr. 58-81.) Mr. Sanders requested review of the ALJ's decision by the Appeals Council. (Tr. 210-12.) On November 12, 2020, the Appeals Council denied Mr. Sanders' 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

Mr. Sanders was born in 1967 and was 51 years old at the alleged onset date, making him an individual who was closely approaching advanced age at all relevant times. (Tr. 117, 132, 213.) He graduated high school, and was living with his wife at the time of the hearing in May 2020. (Tr. 87-88.) Prior to his alleged onset date, he worked for two different companies until August 2018, driving a cement mixer and performing construction and carpentry work. (Tr. 89, 93, 94-96.) He also performed some side jobs, building decks and fences. (Tr. 110.) He then worked for DoorDash from late-2019 through early-2020, making approximately two food deliveries a week. (Tr. 89-92.)

B. Medical Evidence

1. Treatment History

The ALJ identified numerous severe mental and physical impairments (Tr. 63) and provided a detailed discussion of the medical evidence relating to those impairments (Tr. 64-75). The summary below focuses on those records identified and highlighted by the parties on appeal.

i. Physical Impairments

Mr. Sanders is approximately 5' 11” tall and treatment records during the relevant period generally reflect examinations showing a body mass index (BMI) score of 30 or above, with his weight ranging from 234 pounds to 246 pounds. (Tr. 370, 388, 542, 1102, 1187.)

In May 2018, Mr. Sanders' primary care provider at MetroHealth, Joaquin Tinio, M.D., referred him to physical therapy for treatment of patellofemoral syndrome in both knees. (Tr. 406.) During his first physical therapy session on May 14, 2018, Mr. Sanders reported that his left knee pain was worse than the right, and that his pain was worse at night and with prolonged standing, sitting, walking, or getting in and out of the car. (Tr. 402-04.) He reported being able to drive independently but having difficulty performing housework. (Tr. 404.) He did not need an assistive device and presented with limited terminal knee extension bilaterally, decreased strength bilaterally in the knees and hips, and impaired left single leg balance. (Tr. 405.)

On June 20, 2018, x-rays were taken of Mr. Sanders' knees to assess the progression of his known patellofemoral syndrome. (Tr. 492-95.) The x-ray of the right knee showed smoothly marginated remote fragment in relationship to the medial femoral condyle with normal joint space (Tr. 492-93.) The left knee x-ray showed development of small joint effusion, mild degenerative osteoarthritis without significant change, and no evidence of acute fracture or dislocation. (Tr. 494-95.)

An MRI of the left knee was performed on July 6, 2018 due to “new onset of medial pain with block to flexion, r/o displaced medial meniscal tear.” (Tr. 489-90.) The MRI noted a displaced flap tear of the medial meniscus and significant loss of the inner edge of the body of the medial meniscus with medial extrusion (Tr. 489-92.) The report also noted a possible tiny displaced fragment along the intercondylar notch and multiple areas of full thickness cartilage loss in the medial femoral condyle was seen. (Id.)

On July 18, 2018, Mr. Sanders saw Laurel Beverley, M.D. at MetroHealth for follow up regarding his left knee. (Tr. 387.) He reported that he was a construction / concrete worker and had been placed on restricted duty based on a physician's recommendation. (Id.) He reported that resting from work had helped his knee symptoms, with his left knee medial pain somewhat improved, but that he was having intermittent sharp pain in the medial left knee. (Id.) He also reported associated “giving way especially on ladders,” with recurrent swelling. (Id.) His ability to ambulate was mildly limited without use of an assistive device and he reported some relief with NSAIDs and acetaminophen. (Id.) He noted that he had not had injections, but had completed physical therapy and occasionally performed home exercises. (Id.) He was not using a knee brace, even though it provided him relief in the past, because it was uncomfortable to wear while working. (Id.) Physical examination of his bilateral lower extremities showed: mild effusion and medial joint line tenderness on the left, but no effusion or tenderness on the right; knee stiffness; bilateral patellofemoral crepitus; left knee McMurray test positive; pain medially without clicking and negative pain laterally without clicking; positive patellofemoral grinding; left groin tenderness and stiff and mildly painful range of motion of the left hip; full range of motion and no pain in right hip; intact sensation to light touch; and 5/5 bilateral strength in the hip flexors, quadriceps, and hamstrings. (Tr. 387.) Mr. Sanders was diagnosed with: bilateral knee patellofemoral chondromalacia with bilateral quadriceps tightness, improved; left knee degenerative medial meniscal tear and medial compartment arthritis; overweight BMI>30 with partially muscular build; and left hip pain NOS. (Tr. 388.) Dr. Beverley recommended over-the- counter medication and home exercises for the bilateral patellofemoral symptoms and arthroscopy for the left knee mechanical symptoms. (Id.)

On August 9, 2018, Mr. Sanders was the victim of a gunshot wound to his left back. (Tr. 378-86.) He was transported to MetroHealth that day and evaluated by Joseph Piktel, M.D. (Tr. 378, 386.) He reported that he was washing his car at home and “heard a bang” and felt pain in his left shoulder and back and experienced loss of consciousness. (Id.) A chest x-ray showed metallic shrapnel overlaying the left mid-chest and a CT chest scan showed posterolateral left upper chest gunshot wound with a retained bullet fragment between the inferior scapula and lateral seventh rib with no intra thoracic shrapnel / bullet fragment and no pneumothorax. (Tr. 380-81.) A left scapula x-ray showed a nondisplaced fracture through the inferior scapula and retained bullet fragment between the scapular and lateral ribs. (Tr. 380.) A CT of the thoracic spine showed no fracture or destructive lesion, the facets were normally aligned with minimal degenerative changes present, and there was no perivertebral hematoma. (Tr. 381.) Mr. Sanders was diagnosed with a left scapular fracture and discharged in stable condition with information relating to victim services and instructions to follow up with orthopedics. (Tr. 381, 386.)

On August 20, 2018, Mr. Sanders saw Heather Vallier, M.D. at MetroHealth for an orthopedic consultation. (Tr. 374-75.) He reported that his pain was worse with movement of his shoulder and with any standing or walking activity. (Tr 375.) He also reported that he was having trouble sleeping, secondary to pain. (Id.) He relayed that he stopped using his sling, but he was “very apprehensive” about trying to use his arm. (Id.) He also reported that he was afraid to leave his house or get into his car. (Id.) He denied a prior history of shoulder problems or mental health or posttraumatic stress type symptoms. (Id.) Mr. Sanders was observed to be nervous initially, but generally calm, pleasant, interactive, and appropriate throughout the examination. (Id.) The physical examination revealed a normal gait with good balance and coordination, symmetrical chest rise with no focal pain in the chest wall, well-healed gunshot wound, normal muscle tone, and scapulothoracic and glenohumeral active and passive motion that was “smooth with no instability, mechanical block and with normal muscle tone.” (Id.) On examination, Mr. Sanders could “forward flex his shoulder from 0 to 100 degrees with abduction from 0-90 degrees” and Dr. Vallier could passively “get him to 120 and 100 respectively in each of those planes.” (Id.) Dr. Vallier noted that Mr. Sanders' rotator cuff was intact, but strength testing was limited due to his pain and apprehension. (Id.) She also observed a small amount of swelling in the fingers consistent with his injuries. (Id.) Mr. Sanders was diagnosed with statuspost gunshot wound to the left shoulder causing a minimally displaced...