Torres v. Comm'r of Soc. Sec.

Daniel Delgado Torres, Plaintiff, v. Commissioner of Social Security, Defendant.

19-cv-08610 (SDA)

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK

March 5, 2021

OPINION AND ORDER

STEWART D. AARON, UNITED STATES MAGISTRATE JUDGE:

Plaintiff Daniel Delgado Torres ("Torres" or "Plaintiff") brings this action pursuant to § 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of Social Security, denying his application for disability insurance benefits ("DIB"). (Compl., ECF No. 1.) Presently before the Court are the parties' cross-motions, pursuant to Federal Rule of Civil Procedure 12(c), for judgment on the pleadings. (Pl.'s Not. of Mot., ECF No. 29; Comm'r Not. of Mot., ECF No. 31.) For the reasons set forth below, the Commissioner's motion is GRANTED and Plaintiff's motion is DENIED.

BACKGROUND

I. Procedural Background

On December 16, 2015, Plaintiff filed an application for DIB, alleging a disability onset date of December 31, 2014.¹ (Administrative R. ("R."), ECF Nos. 15 & 27, 15.) Plaintiff's application was denied initially on February 5, 2016. (R. 15.) Thereafter, Plaintiff requested ahearing, which was held on March 20, 2018, before Administrative Law Judge ("ALJ") Robert Gonzalez. (R. 600-23.) ALJ Gonzalez denied Plaintiff's claim in a decision dated September 7, 2018. (R. 25). Plaintiff appealed to the Appeals Council. ALJ Gonzalez's decision became the Commissioner's final decision when the Appeals Council denied Plaintiff's request for review on July 11, 2019. (R. 1-3.) This action followed.

II. Non-Medical Evidence

Born on March 9, 1966, Plaintiff was 48 years old on the alleged onset date and 52 years old at the time of the 2018 hearing. (R. 85.) Plaintiff has a high school education from Puerto Rico and past relevant work as a painter and commercial cleaner. (R. 603, 618.) Plaintiff lives with his wife who does the household chores. (R. 615-16.) On March 28, 2014, Plaintiff was involved in a motor vehicle accident in which he was rear-ended while waiting at a stop light. (See, e.g., R. 527, 575.)

III. Relevant Medical Evidence

A. Southern Westchester Family Medicine

Since at least June 2010, and throughout the relevant period, Plaintiff received primary medical care from Dr. Luay Marji, M.D. at Southern Westchester Family Medicine. (R. 514-89.) Dr. Marji was the referring physician for many of the consultations discussed further below. (See, e.g., R. 530, 536.) In addition, Dr. Marji saw Plaintiff for a physical exam approximately every sixmonths, or more, between June 2010 and March 2018, with more frequent appointments following his car accident and wrist surgery in 2014. (R. 548-89.)

B. WESTMED Medical Group

On May 8, 2014, Plaintiff saw Dr. Michael Cushner, M.D. at WESTMED Medical Group for an orthopedic evaluation. (R. 526-29.) Dr. Cushner noted diffuse swelling and weakness in Plaintiff's left wrist, mild paraspinal tenderness in his lower back and tenderness, though no reduced range of motion, in his neck. (R. 526-27.) Dr. Cushner recommended medication, physical therapy for Plaintiff's neck and back, a splint for his wrist and an MRI if the pain persisted. (R. 527-29.)

C. Executive Park Orthopedic & Sports Physical Therapy

On April 17, 2014, Doctor of Physical Therapy ("DPT") Laura Anastasia diagnosed Plaintiff with C6/C7 disc bulge and lumbar strain following a motor vehicle accident on March 28, 2014. (R. 200-01.) Plaintiff had limitations in changing and maintaining body position, remaining seated, carrying, moving and handling objects, pulling and pushing objects, and picking up and grasping. (R. 201.) DPT Anastasia recommended continuing physical therapy 2-3 times per week for six weeks and a home exercise program. (R. 201-02.) Torres saw DPT Anastasia for ten physical therapy sessions between April 17, 2014, and May 9, 2014. (R. 200-21.)

Plaintiff returned to Executive Park on January 26, 2016. (R. 487-89.) Plaintiff complained of pain and difficulty with his left hand and back. (Id.) On exam, Plaintiff had supination of his left elbow at 60 degrees and full pronation with pain. (Id.) Plaintiff had limited range of motion of his wrist and lumbar spine. (R. 490.) Grip strength was 40 psi on the left side and 100 psi on the right. (Id.) Plaintiff's functional limitations included self-care; changing and maintaining body position;mobility; and carrying, moving, and handling objects. (R. 489.) Plaintiff continued physical therapy several times per week through at least April 1, 2016. (R. 455-86.) Plaintiff continued to report difficulty gripping with his left hand with limited range of motion and some lower back pain. (See id.) His physical therapists continued to assess his rehabilitation potential as good. (R. 458, 462, 467, 470, 471, 473, 475, 477, 479, 481, 483, 485.)

D. Uptown Medical Imaging

On April 18, 2014, Plaintiff underwent magnetic resonance imaging ("MRI") of the lumbar spine. (R. 257, 530.) The MRI showed spondylitic² changes at L3-4 and L4-5 and bulging at L4-5, but no stenosis was demonstrated. (Id.)

E. Bruckner Medical, P.C.

Torres saw Dr. Erie Agustin, M.D. at Bruckner Medical, P.C. for an initial consultation on May 13, 2014. (R. 222-28.) Dr. Augustin's initial diagnostic impression was of cervical radiculitis, cervical spine strain, lower back pain syndrome, back pain unspecific, lumbar sprain, lumbar displacement/herniation without myelopathy, and left wrist derangement. (R. 225.) Dr. Agustin recommended physical therapy and referred Plaintiff for an MRI of his left wrist. (R. 226-27.) Dr. Agustin noted that Plaintiff would have limitations with bending/twisting, operating heavy machinery and lifting. (R. 228.) The same day, Plaintiff began physical therapy with a therapist at the Bruckner P.C., which continued approximately two or three times per week through January 2015. (R. 259-60.)

The MRI of the left wrist ordered by Dr. Agustin, completed on May 21, 2014, showed a widening of the scapholunate space, tear of scapholunate ligament,³ tear of the triangular fibrocartilage near the ulnar attachment, and moderate intercarpal joint effusion consistent with trauma or synovitis.⁴ (R. 258.) Dr. Agustin saw Plaintiff for follow-up visits on July 3, 2014, September 2, 2014, October 12, 2014, and November 25, 2014. (R. 229-50.) On December 23, 2014, Dr. Augustin opined that Plaintiff had a good prognosis but had 80% temporary impairment and had limitations bending/twisting, operating heavy equipment, and lifting. (R. 256.)

F. New York Plastic Surgical Group/Manhattan Eye, Ear & Throat Hospital

On June 12, 2014, Plaintiff saw Dr. Joseph Zuckerman for a consultation regarding his left wrist pain. (R. 329-32.) Dr. Zuckerman noted that Plaintiff likely would require surgery and ordered another MRI. (R. 329.)

An MRI of the left wrist on June 23, 2014, showed signs consistent with a tear of the scapholunate ligament. (R. 337-39.) Plaintiff underwent surgery for his wrist on July 24, 2014, specifically left wrist repair of the scapholunate dissociation. (R. 319-25.) Plaintiff's postoperative diagnosis was of left wrist chronic scapholunate ligament disassociation. (R. 319.)

Plaintiff saw Dr. Zuckerman for a post-op visit on July 31, 2014. (R. 317.) Dr. Zuckerman referred him to occupational therapy. (Id.) Plaintiff saw Dr. Zuckerman for additional follow-upvisits on August 12, 2014, August 28, 2014, September 11, 2014 and October 2, 2014. (R. 313-16.)

On January 22, 2015, Dr. Zuckerman examined Plaintiff six months after Plaintiff's wrist surgery. (R. 311.) Plaintiff had returned to work and complained of limited wrist range of motion, lack of endurance with his left hand, "somewhat limiting his ability to carry heavy objects." (Id.) On examination, Dr. Zuckerman noted that Plaintiff's left wrist was stable and nontender, the range of motion of his digits was full, and grip strength was 86 pounds as compared to 120 pounds on the right side. (Id.)

G. Westchester Neurological Consultants

On November 12, 2015, Plaintiff saw Dr. Emad Soliman for a neurological consultation and evaluation based on a referral from Plaintiff's primary care physician, Dr. Marji. (R. 353-56, 536.) Plaintiff complained of pain and difficulty with range of motion at the left wrist, as well as of back pain radiating to both lower extremities. (R. 369-72.) Dr. Soliman observed reduced muscle strength in the upper left extremity. (R. 369.) There was no sign of motor or muscle atrophy. (R. 370-71.) Dr. Soliman diagnosed Plaintiff with questionable complex regional pain syndrome, mechanical trauma to the arm, and lumbar radiculopathy. (R. 372.) Dr. Soliman recommended that Plaintiff avoid heavy weightlifting and referred him for an MRI of the left wrist without contrast and nerve conduction testing. (Id.)

Dr. Soliman also completed a medical questionnaire on the same date. (R. 350.) Dr. Soliman opined that Plaintiff could at most sit for fifteen minutes at a time, stand for five minutes at a time, sit and stand/walk for less than two hours a day, and would need to shift positions atwill. (Id.) Dr. Soliman also opined that Plaintiff could never lift more than 10 pounds; could never reach, feel, bend, handle, push/pull; and could occasionally climb, kneel, and squat. (Id.)

On December 14, 2015, Plaintiff received the MRI ordered by Dr. Soliman, which showed abductor pollicis longus, extensor pollicis brevis, and flexor pollicis longus tendinopathy. (R. 374-75.) On April 5, 2016, Plaintiff underwent an electrodiagnostic study of the bilateral upper extremities, which showed evidence of mild chronic left C8 radiculopathy. (R. 376-80.) On July 16, 2016, an MRI of lumbosacral spine ordered by Dr. Soliman showed minimal degenerative disc disease L3-L4, L4-L5 with straightening of the lumbar lordosis. (R. 381-82.)

H. Dr. Julia Kaci, M.D. - January 22, 2016 Consultative Examination

Dr. Julia Kaci performed a consultative examination of Plaintiff on...