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Pettit v. Saul

United States District Court, W.D. Wisconsin

September 25, 2019

TRACY PETTIT, Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.



         Plaintiff Tracy Pettit seeks judicial review of an adverse decision of the Commissioner of Social Security, pursuant to 42 U.S.C. § 405(g), which denied her eligibility for Supplemental Security Income Benefits (“SSI”) under Title XVI of the Social Security Act, codified at 42 U.S.C. §§ 1614(a)(3)(A). Pettit contends that the administrative law judge (“ALJ”) erred when he omitted from his residual functional capacity (“RFC”) assessment certain limitations related to Pettit’s neck pain. In particular, Pettit asserts that the ALJ erred when he (1) found that she could perform bilateral overhead reaching on a “frequent” basis, (2) failed to account for her limitations in moving her head, and (3) failed to account for her testimony that she would require significant rest breaks.

         Having considered Pettit’s arguments in light of the administrative record and the ALJ’s decision, the court finds that the ALJ’s RFC assessment is adequately supported by evidence in the record and his reasons for rejecting contrary evidence are clear enough to withstand scrutiny. Accordingly, the decision of the Commissioner will be affirmed.

         BACKGROUND [1]

         A. Social Security Application

         On August 15, 2013, Pettit filed a Title XVI application for SSI, alleging disability beginning April 1, 2012. Her application was denied initially on October 29, 2013, and again upon reconsideration on May 29, 2014. (AR 68-78, 79-89.) A hearing to reconsider the denial of SSI was held on February 2, 2016 October 30, 2012, before ALJ John Martin, at which Pettit was both represented by counsel and also testified. (AR 36-67.) The ALJ also heard and considered the testimony of Jacquelyn Wenkman, a neutral vocational expert.

         On April 12, 2016, the ALJ issued a written decision denying Pettit’s application for SSI. (AR 18-31.) The ALJ found that although Pettit has severe impairments, including cervical degenerative disk disease and a history of two neck surgeries, she was not disabled within the meaning of the Social Security Act from April 1, 2012, through the date of the opinion. This decision became the final decision of the Commissioner of Social Security on May 23, 2017, when the Appeals Council declined Pettit’s request for review of the ALJ’s decision. (AR 1-3.)

         B. Plaintiff’s Background

         Pettit was born on May 25, 1972, making her 43 years old on the date of the ALJ’s decision. She has a 9th grade education, having dropped out of school in 10th grade because of problems with dyslexia, truancy and tardiness. She later obtained a certified nursing assistance certificate. She was last employed as a housekeeper for Rusk County Hospital. At the time of the hearing, she was married and lived with her husband and 17-year-old daughter.

         C. Overview of Medical Issues

         Pettit has a history of neck problems with associated radiating arm pain and weakness and carpal tunnel syndrome on the left. She has undergone two cervical surgeries in which discs were removed and the joints fused: the first performed by Dr. Philip Porter on January 5, 2012, at the C6/C7 joint, and the second performed by Dr. Neal on July 11, 2013, at the C5/C6 joint. (AR 224-25, 326-27). During the July 11, 2013 procedure, Dr. Neal also performed carpal tunnel release surgery on Pettit’s left wrist. (AR 326-27). Pettit received physical therapy for her neck and wrist after the surgery. (AR 242, 341-50.)

         Although the surgeries and physical therapy helped to alleviate her arm pain and carpal tunnel symptoms, Pettit complained to her doctors that she still had pain in the back of her neck and shoulders, which sometimes radiated into her right arm and hand, as well as pain in the thumb and forefinger of her left hand. (AR 398-403.) Testing showed, however, that Pettit’s arm strength, tone and reflexes were good and none of her nerves were impinged. She had tenderness in her neck and upper back which her doctors concluded was caused by muscular irritation. Pettit was also noted to have limited range of motion in her neck, with her ability to turn her head left or right limited to somewhere between 30 and 45 degrees. With respect to her upper extremities, however, plaintiff was noted in January 2014 to have “good gross passive pain-free range of motion.” (AR 402.) Her doctor prescribed medication for her myofascial pain and advised her to learn about biofeedback and relaxation techniques and consider alternative treatments such as acupuncture and massage. (AR 403.)

         Despite relatively normal objective findings, Pettit continued to complain of and seek treatment for neck and upper back pain that radiated into her arms, mainly on the left. In February 2014 and October 2014, she had nerve conduction studies, which were normal. (AR 409, 1153). In April and May 2015, she received nerve root block injections at the C6 level, but neither provided any long-term benefit. (AR 1255.)

         The latest medical records before the ALJ showed that Pettit had a pain clinic visit with nurse practitioner Lisa Tennyson in December 2015, at which Pettit reported being in constant pain that she rated a 10 out of 10 over the preceding week. (AR 1254.) Tennyson observed, however, that Pettit did not appear to be in any acute distress, walked with a normal gait and did not demonstrate any abnormal movements. On examination, Pettit had normal strength, bulk, tone and reflexes, although she did not have full range of motion in her cervical or lumbar spine. Tennyson also noticed that Pettit had myofascial pain and tenderness with trigger points present along the muscles in her upper back. (AR 1256.)

         Tennyson noted that a recent x-ray of Pettit’s neck showed that her fusions remained solid. She recommended that Pettit get an updated MRI of her cervical spine to see if there was any nerve root impingement that might explain her ongoing cervical and neck pain complaints. She also prescribed a muscle relaxer, a medication to treat nerve pain, and lidocaine patches. (She could not prescribe opioids because Pettit had previously had a urine screen that showed the presence of methamphetamine and alcohol.) Tennyson also recommended that Pettit return to physical therapy, try a TENS unit and stop smoking. (AR 1256-57.)

         D. Medical Opinions

         The administrative record contains few medical opinions. In December 2012, after plaintiff’s first surgery but before the second, Dr. Porter indicated that he was not issuing specific work restrictions for plaintiff but advised her to look for employment that did not involve repetitive neck movements or work above shoulder level. (AR 213.) A month later, Porter completed a work restrictions form on which he indicated that Pettit should work above shoulder level only occasionally (11 -33% of the time). (AR 214.) On August 26, 2013, approximately six weeks after Pettit’s second surgery, Dr. Steven Lamberson opined that after Pettit recovered, he expected “that she would be limited to light to light-med work for the foreseeable future[.]” (AR 244-45.) Dr. Lamberson did not offer any opinion on Pettit’s ability to perform overhead work.

         Two months later, on October 25, 2013, Mini Khorshidi, M.D., a consultant for the state disability agency, reviewed Pettit’s medical record and concluded that Pettit could perform light work (which is defined as lifting or carrying up to 20 pounds occasionally and 10 pounds frequently, and either standing or walking a good deal or sitting most of the time with some pushing and pulling of arm or leg controls), but that her ability to perform overhead reaching on both sides was “limited” due to her cervical fusion surgeries. (AR 75-76.) On reconsideration seven months later, a different state agency ...

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