Shaw v. Kijakazi

PATRICIA PAMELA SHAW, Plaintiff, v. KILOLO KIJAKAZI, ^[1] Acting Commissioner, Social Security Administration, Defendant.

No. 20-CV-5123 (JLC)

United States District Court, S.D. New York

August 11, 2021

OPINION & ORDER

JAMES L. COTT, United States Magistrate Judge.

Plaintiff Patricia Pamela Shaw seeks judicial review of a final determination by defendant Kilolo Kijakazi, the Acting Commissioner of the Social Security Administration, denying Shaw's application for disability insurance benefits under the Social Security Act. The parties have cross-moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, Shaw's motion is granted, the Commissioner's cross-motion is denied, and the case is remanded for further administrative proceedings.

I. BACKGROUND

A. Procedural Background

On January 9, 2017, Patricia Pamela Shaw filed an application for Title II Disability Insurance Benefits. Administrative Record (“AR”), Dkt. No. 14, at 17.^[2]She alleged an onset disability date of September 21, 2015 due to lower back injury, knee injury, and thigh injury. Id. at 51. On March 21, 2017, Shaw's initial application was denied. Id. at 17. On August 29, 2017, Shaw requested a hearing before an Administrative Law Judge (“ALJ”) and, more than two years later, on October 15, 2019, a hearing was held before ALJ JuanCarlos Hunt. Id. In a decision dated December 4, 2019, the ALJ concluded that Shaw was not disabled. Id. at 19-30. Shaw sought review of the ALJ's decision by the Appeals Council, but that request was denied on May 1, 2020. Id. at 1-4.

Shaw timely commenced the present action on July 4, 2020, seeking judicial review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g). Complaint, Dkt. No. 1. The Commissioner answered Shaw's complaint by filing the administrative record on December 28, 2020. Dkt. No. 14. On February 26, 2021, Shaw moved for judgment on the pleadings seeking remand for further administrative proceedings and submitted a memorandum of law in support of her motion. Motion for Judgment on the Pleadings, Dkt. No. 15; Plaintiff's Memorandum of Law in Support of Plaintiff's Motion for Judgment on the Pleadings (“Pl. Mem.”), Dkt. No. 15-1. The Commissioner cross-moved for judgment on the pleadings with supporting papers on April 27, 2021. Cross-Motion for Judgment on the Pleadings, Dkt. No. 17; Memorandum of Law in Support of Defendant's Cross-Motion for Judgment on the Pleadings and in Opposition to Plaintiff's Motion (“Def Mem.”), Dkt. No. 18. Shaw filed her reply papers on May 18, 2021. Plaintiff's Reply in Support of Plaintiff's Motion (“Pl. Reply”), Dkt. No. 19. The parties consented to my jurisdiction on March 10, 2021. Dkt. No. 16.

B. Administrative Record

1. Shaw's Background

Shaw was born on January 12, 1954. AR at 209. At the time of the hearing, she was 65 years old and lived alone in Manhattan. Id. at 23.^[3] She has an eighthgrade education. Id. at 51. Prior to the alleged disability onset date, Shaw worked as a hotel housekeeper for 24 years until September 21, 2015. Id. She has not worked since. Id.

During the hearing, Shaw testified that she suffers from pain in her lower back and left knee, which limits her ability to stand, walk, lift, bend, and carry objects. Id. at 52-53. Shaw also testified that her knee frequently buckles, causing her to fall. Id. at 54-55. As a result of her disability, she explained that she is unable to cook, clean, or carry groceries back from the grocery store, relying on the store's delivery services. Id. at 54-56. She testified that she is able to prepare cereal for herself, but because she cannot cook, her daughter either drops off food for her or she gets food from a center located in her living complex. Id. at 56-57.

2. Relevant Medical Evidence

a. Treatment History

i. Mark McMahon, M.D. - Orthopedic Surgeon

Dr. Mark McMahon treated Shaw for low back pain and issues with her left thigh and knee from February 2010 to July 2016. Id. at 366, 432-51. Dr. McMahon first referred Shaw for an MRI, which was conducted on February 24, 2010 and revealed a left knee effusion and left greater trochanteric bursitis. Id. at 366.^[4]Following a visit to the emergency room on January 21, 2015, Shaw returned to Dr. McMahon on January 30, 2015 due to pain in her left thigh, left knee, low back and difficulty climbing stairs. Id. at 349-50. During this visit, Dr. McMahon noted that Shaw's left knee flexion went to 85 degrees, she had patellar sensitivity, left thigh tenderness, and left thigh pain with hip flexion. Id. at 350.

When Shaw reported back to him on April 3, 2015 for the same reasons as the previous visit, Dr. McMahon found her left knee reached 75 degrees with pain and that she had patella sensitivity. Id. at 346-47. Shaw returned to Dr. McMahon on April 6, 2015 for a medial meniscus tear and chondromalacia of the knee after her thigh problem caused her to fall a few days prior. Id. at 340-41.^[5] Dr. McMahon observed that her left knee flexion went to 90 degrees, and that both her knees were swollen and abnormal. Id. at 341. Dr. McMahon then referred her for an MRI of the left thigh, which took place on April 10, 2015 and revealed intact thigh musculature as well as the possibility of an unencapsulated lipoma. Id. at 343-44.

Shaw reported back to Dr. McMahon on October 6, 2015 due to left knee and thigh pain. Id. at 335-36. Dr. McMahon observed crepitus, tenderness, and instability. Id. at 336.^[6] He found her left knee flexion went from 10 to 60 degrees and that she was unable to return to work due to her left knee, left thigh, and low back pain. Id. Shaw reported back to Dr. McMahon on November 30, 2015 due to a tear of the medial meniscus. Id. at 331. Dr. McMahon found atrophy of the left thigh, left knee flexion of 90 degrees, and permanent impairment. Id. at 332.

Shaw returned to Dr. McMahon on May 13, 2016 because her knee had buckled recently and she had ongoing pain in her left thigh and knee. Id. At 328-29. Dr. McMahon noted that her left knee flexion went to 90 degrees with pain, patellar sensitivity, and thigh tenderness, and he concluded that she was 100% impaired and, thus, could not return to work. Id. at 329. Shaw returned to Dr. McMahon on July 28, 2016 due to ongoing pain in her left thigh and knee as well as her difficulty with using stairs. Id. at 325-26. Dr. McMahon noted that her left thigh and knee were shrinking. Id. at 326. He also found her left knee flexion went to 90 degrees with pain and tenderness in the left thigh and that she was 100% impaired, making her unable to return to work. Id.

ii. Emergency Room, Mount Sinai St. Luke's

On January 21, 2015, Shaw visited the emergency room at Mount Sinai St. Luke's after hearing a snap in her leg that was followed by pain in her left thigh and knee. Id. at 368. The attending radiologist, Dr. Carol L. Hilfer, noted tenderness of the lower anterior thigh on palpation. Id. The imaging studies conducted also revealed that there was a sizeable suprapatellar knee joint effusion; mild narrowing of the medial knee joint compartment with medial, lateral, and tibial spine spurring; a flange of bone at the lateral tibia presumed hypertrophic; degenerative cysts in the left femoral neck; minimal hypertrophy at the lateral acetabulum and femoral head neck juncture; and large spherical calcification in the right pelvis which was presumed to be a uterine myoma. Id. Shaw was consequently diagnosed with a knee ligament injury and degenerative joint disease. Id. at 370, 632. She was prescribed Percocet for the pain. Id. at 623.^[7]

iii. Michael Hearns, M.D. - Physician

On August 1, 2015, Dr. Michael Hearns treated Shaw for pain in her low back, left thigh and knee after she fell and hit a bed frame at work. Id. at 356. She complained of left thigh numbness, burning, and a “dead sensation” which is aggravated by walking and prolonged sitting. Id. She indicated that she had difficulty climbing stairs and that her left knee was buckling. Id. She said that her left knee had not been the same since she fell in January 2015 due to the buckling, which would cause her to fall. Id. In assessing Shaw's back, Dr. Hearns reported that she had positive straight leg raise bilaterally that was greater on the left side. Id. at 357. He also reported that Shaw had muscle spasm and tenderness in her back as well as a limited range of motion to 38 degrees of flexion and 0 degrees of extension. Id. In observing her left leg, he noted that she had decreased sensation in her left thigh and her left knee was positive for popliteal cyst, anterior drawer sign, McMurray sign, crepitus, effusion, and joint line tenderness. Id. Dr. Hearns also noted that she had limited flexion of her left knee to 80 degrees and 5 degrees of extension. Id. Deep tendon reflexes were 0/2 in her right leg and 2+ in the left lower extremity. Id. He observed 4/5 motor strength in the left lower extremity. Id. Dr. Hearns then ordered an MRI of the lumbar spine and an x-ray of the lumbar spine, left knee, and left hip. Id. at 358.

iv. Jotir Ramnarine, M.D. - Physician, Internal

On May 18, 2016, Shaw had an annual exam with Dr. Jotir Ramnarine. Id. at 453. Shaw reported fluctuating pain in her left knee, which was aggravated by movement. Id. at 453-54. A review of systems was positive for arthralgias. Id. at 454.^[8] Upon examination, Shaw exhibited mild tenderness in her left knee, as well as a decreased range of motion. Id. at 456. She had a follow-up visit with Dr. Ramnarine on August 24, 2016 to address her asthma; the pain in her low back and left leg were not addressed in this visit. Id. at 476-77. Shaw returned to Dr. Ramnarine for her annual exam on October 26, 2017. Id. at 470. She...