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Beebe v. Saul

United States District Court, W.D. Wisconsin

October 31, 2019

CANDINA L. BEEBE, Plaintiff,
v.
ANDREW M. SAUL, Commissioner of Social Security, Defendant.

          OPINION AND ORDER

          BARBARA B. CRABB, District Judge.

         Plaintiff Candina Beebe is seeking review of a final decision by defendant Commissioner of Social Security denying her claim for disability insurance benefits under the Social Security Act. 42 U.S.C. § 405(g). Dkt. #10. (I have amended the caption to reflect that the new Commissioner of Social Security is Andrew M. Saul.) Plaintiff contends that the administrative law judge who decided the case erred by (1) rejecting the opinions of her treating physician and the state agency physicians that she could not use her right hand for any work activity; (2) failing to assess her complex regional pain syndrome in her right hand in accordance with Social Security Ruling (SSR) 03-02p; (3) inadequately evaluating her subjective complaints under SSR 16-3P; and (4) not considering the left arm limitations assessed by her treating physician and the state agency physicians.

         For the reasons explained below, I find that the administrative law judge did not provide an adequate explanation for rejecting the physician opinions and plaintiff's subjective complaints regarding her right hand limitations. Therefore, I will reverse the commissioner's decision and remand this case for further proceedings.

         The following facts are drawn from the administrative record (AR).

         FACTS

         A. Social Security Application and Background

         Plaintiff filed an application for disability insurance benefits on June 24, 2014, contending that she had been disabled since April 5, 2013 because of complex regional pain syndrome of the right hand. She was born on March 26, 1973, making her 41 years old when she applied for benefits. AR 246-48. Plaintiff has prior work experience as a switchboard operator and customer service representative. AR 29. She stopped working in April 2013 because pain and weakness in her right hand and pain in her right elbow were making it difficult to do her computer work. AR 478.

         In a function report dated August 28, 2014, plaintiff wrote that she could not use her right hand for most tasks because of pain and swelling. She reported that she had problems holding things because she dropped them without warning and that she was not able to drive, brush her hair, fasten buttons or snaps, fold clothes, make the beds, sweep, open containers or hold dishes to wash them. Plaintiff reported that she could wash and dry clothes, make meals with some help, vacuum and grocery shop. AR 262-63, 265, 267.

         B. Relevant Medical Evidence

         1. Initial symptoms and carpal tunnel surgeries in 2013

         Plaintiff first reported having pain in her right elbow and pain and weakness in her right hand at a doctor's visit on April 9, 2013. An examination revealed that she had some swelling in her right wrist and hand, a notably weak grasp in her right hand and could supinate (face her palm up) for only a short period. She had full range of motion in her right hand as far as grasping and could abduct and oppose her thumb without a problem. AR 327-28. Following unsuccessful treatment with medications and a steroid injection, plaintiff saw physiatrist Dr. Jay Loftsgaarden on April 24, 2013. AR 478. A physical examination revealed that plaintiff had full range of motion in her right extremity and overall normal strength in her right arm, but the physician noted that both tests caused plaintiff a lot of pain. She also had marked tenderness in her right elbow and forearm, a positive Tinel sign at the elbow and some weakness in the finger flexors of her right hand. AR 479.

         A May 9, 2013 nerve conduction study showed median neuropathy on both arms, but worse on the right. AR 472-73. On May 30, 2013, plaintiff saw orthopedist Dr. Jose Ortiz. Her grip strengths and pinch were the same on the right and left sides, and she had full range of motion of the right elbow, wrists and fingers. Dr. Ortiz diagnosed bilateral carpal tunnel syndrome. AR 464.

         Plaintiff underwent carpel tunnel release surgery on the right side on May 31, 2013. AR 458-60. Dr. Ortiz told plaintiff that the surgery was designed to prevent further nerve damage and should address some of the pain and numbness in her wrists and hands, but it would not reduce her elbow or shoulder pain. AR 462-64.

         On June 13, 2013, plaintiff saw physician assistant Troy Stoneberg for a post-surgical follow-up. She reported improvement in the numbness and tingling in her right hand but continued pain in her right elbow and shoulder, and significant pain, swelling and decreased range of motion in her right hand. Left-sided carpel tunnel release was scheduled for July 8, 2013. AR 455-57 Although plaintiff was scheduled to return to work within a week, she reported that she could not use a mouse or keyboard at that point. AR 455. Stoneberg noted with respect to plaintiff's right hand that she had markedly suboptimal digital range of motion, flexion lag in all digits, no grip and significant tenderness and swelling. He recommended occupational therapy to “aggressively” work on her digital range of motion. AR 456-57.

         Plaintiff restarted occupational therapy on June 25, 2013. (Plaintiff's last therapy visit had been on April 30, 2013, prior to her surgery. AR 451.) The therapist noted that plaintiff might be focusing too much on her pain and needed to be assertively working her hand. AR 452-53. Plaintiff cancelled her next therapy session scheduled for July 5, 2013, stating that she was undergoing left-sided carpal tunnel release surgery on July 8. The therapist noted that plaintiff had partially met her goals with respect to her right hand but had work to do to increase her strength and range of motion. Plaintiff was discharged from therapy in light of her need for additional surgery. AR 449-50.

         Physician assistant Stoneberg saw plaintiff for a post-operative visit on July 24, 2013. He noted that plaintiff's left hand and wrist were healing well after surgery but that she still had significant problems on the right side. Stoneberg referred plaintiff to occupational therapy and extended her leave of absence by two weeks because she did not feel ready to return to work. AR 447-48.

         2. Continued symptoms and treatment in 2013

         Plaintiff had an occupational therapy appointment on August 5, 2013. AR 443. Although additional therapy was recommended, plaintiff did not show up for her next appointment on August 13, 2013 or reschedule the appointment. AR 439. (Although no explanation was noted in the record for the missing appointments, on October 28, 2013, plaintiff reported to her occupational health physician, Dr. Michael Fitzgerald, that she had not been to occupational therapy for a couple of months because of difficulties with transportation. She stated that she had been doing home exercises and that she would see whether her insurance would approve therapy at a local hospital. AR 426-27.)

         On September 9, 2013, Dr. Fitzgerald noted that plaintiff had a good range of motion in her left hand, which was healing well, but that she could not make a fist with her right hand and had zero grip strength. She also had pain in her long and ring fingers on the right side, for which she had received steroid injections a few days earlier. Dr. Fitzgerald's examination also revealed that plaintiff could elevate her arms overhead and could move all of the fingers in her left hand without restriction, but she had pain on the right when reaching behind and swelling in the right long and ring fingers. He noted that plaintiff was likely to be off work for a while and could not perform any keyboarding or other work with her right hand for the next six weeks. He stated the opinion that plaintiff could use her left hand moderately for pinching, simple gripping and fine manipulation on a part-time basis. AR 433-34.

         On October 28, 2013, Dr. Fitzgerald noted that plaintiff would be off work until he saw her again in six weeks. Because of worsening symptoms in her right hand, plaintiff was scheduled for ...


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