Riggs v. Commissioner of Social Security, 5:21-cv-00111

Plaintiff applied for Social Security Disability Insurance and SSI on September 7, 2018, alleging disability beginning August 1, 2018; claims were denied and an ALJ issued an unfavorable decision on January 20, 2021; Appeals Council denied review.
ALJ found multiple severe impairments (including obesity, diabetes, chronic kidney disease, gout, psoriatic arthritis, MCTD, CTS, emphysema, torn meniscus, osteoarthritis) and assessed an RFC for light work with various limitations (no ladders/ropes/scaffolds, occasional ramps/stairs/balance/stoop/kneel/crouch/crawl, avoid concentrated pulmonary irritants/extremes/hazards; frequent handling/fingering, occasional overhead reaching).
At step five the ALJ concluded Plaintiff could perform past relevant work as a telephone solicitor and thus was not disabled.
Plaintiff challenged the RFC for failing to account for (1) a medically supported need for a cane and (2) a treating-provider recommendation that she elevate her legs.
Record evidence: PT evaluation (April 7, 2020) found decreased balance, need for cane; PCP Dr. Saad Butt prescribed a cane (April 16, 2020); treating dermatologist Dr. Janelle King recommended leg elevation “as much as possible.”
The magistrate judge concluded the ALJ misstated/omitted these medical findings, failed to resolve conflicts or explain why the RFC excluded a cane or elevation requirement, and therefore recommended granting plaintiff’s summary-judgment motion and remanding for further proceedings.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether the ALJ erred by not including a cane requirement in the RFC	Record shows PT recommended a cane; PCP prescribed a cane; cane is needed for standing/walking	ALJ reasonably declined cane limitation; cane was used only for sit-to-stand transitions or evidence insufficient	Magistrate: ALJ mischaracterized evidence and failed to explain omission; remand required for further findings
Whether the ALJ erred by not including a leg-elevation limitation in the RFC	Treating dermatologist advised elevating legs “as much as possible”; record contains a treating-provider recommendation	No doctor documented a specific timeframe requiring long periods of leg elevation; omission is harmless	Magistrate: ALJ’s statement that no treating instruction exists is incorrect; conflict not addressed; remand required

Mascio v. Colvin, 780 F.3d 632 (4th Cir. 2015) (remand appropriate where ALJ fails to assess claimant’s capacity in light of contradictory evidence)
Hays v. Sullivan, 907 F.2d 1453 (4th Cir. 1990) (scope of judicial review: substantial-evidence standard)
McLain v. Schweiker, 715 F.2d 866 (4th Cir. 1983) (framework for five-step disability evaluation and burden-shifting)
Pierce v. Underwood, 487 U.S. 552 (1988) (definition of substantial evidence)
Laws v. Celebrezze, 368 F.2d 640 (4th Cir. 1966) (substantial evidence exists if refusal to direct a verdict is justifiable)
King v. Califano, 599 F.2d 597 (4th Cir. 1979) (ALJ/Commissioner duty to make findings of fact)
Seacrist v. Weinberger, 538 F.2d 1054 (4th Cir. 1976) (courts defer to Commissioner’s factual findings but ALJ must resolve evidentiary conflicts)