DAVID ANTHONY D. v. LELAND DUDEK, Acting Commissioner of Social Security Administration
Case No. 4:24-CV-6-ACL
UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI EASTERN DIVISION
March 11, 2025
Plaintiff David D. brings this action pursuant to
An Administrative Law Judge (“ALJ“) found that Plaintiff was not disabled because he was capable of performing past relevant work.
This matter is pending before the undersigned United States Magistrate Judge, with12
For the following reasons, the decision of the Commissioner will be affirmed.
I. Procedural History
Plaintiff filed his applications for benefits on December 3, 2020. (Tr. 267-68, 271-76.) He claimed he became unable to work on September 30, 2019, due to depression, bipolar disorder, high blood pressure, and a kidney condition. (Tr. 305.) Plaintiff was 59 years of age on his alleged onset of disability date. (Tr. 267-68, 271-76.) His applications were denied initially and on reconsideration. (Tr. 129-32, 144-47, 151-54, 161-62.) On February 21, 2023, after a hearing, an ALJ found that Plaintiff was not disabled. (Tr. 10-21.) The Appeals Council denied Plaintiff‘s claim for review. (Tr. 1-6.) Thus, the ALJ‘s decision stands as the final decision of the Commissioner. See
In this action, Plaintiff argues that the ALJ “did not properly evaluate the ‘full limiting effects’ of Plaintiff‘s impairments, as he described them and as demonstrated in the consultative examiner‘s findings.” (Doc. 9 at 3.)
II. The ALJ‘s Determination
The ALJ first found that Plaintiff met the insured status requirements of the Social Security Act through December 31, 2024. (Tr. 12.) He found that Plaintiff has not engaged in substantial gainful activity since his September 30, 2019 alleged onset date. Id. Next, the ALJ concluded that Plaintiff had the following severe impairments: chronic kidney disease, degenerative disc disease of the lumbar spine, essential hypertension, and obesity. Id. The ALJ found that Plaintiff did not have an impairment or combination of impairments that met or
As to Plaintiff‘s RFC, the ALJ stated:
After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in
20 CFR 404.1567(b) and416.967(b) except: The claimant can lift up to 20 pounds occasionally, and lift and/or carry up to 10 pounds frequently. He can stand and/or walk for about six hours, and sit for up to six hours in an eight hour work day, with normal breaks. He can frequently climb ramps or stairs, but never climb ladders, ropes or scaffolds. He can frequently stoop, kneel, crouch and crawl. He should avoid concentrated exposure to operational control of moving machinery and hazardous machinery. He should avoid unprotected heights.
(Tr. 16.)
The ALJ found that Plaintiff was capable of performing past relevant work as a production assembler worker and was, therefore, not disabled. (Tr. 19.)
The ALJ‘s final decision reads as follows:
Based on the application for a period of disability and disability insurance benefits protectively filed on December 3, 2020, the claimant is not disabled under sections 216(0) and 223(d) of the Social Security Act.
Based on the application for supplemental security income protectively filed on December 3, 2020, the claimant is not disabled under section 1614(a)(3)(A) of the Social Security Act.
(Tr. 20-21.)
III. Applicable Law
III.A. Standard of Review
The decision of the Commissioner must be affirmed if it is supported by substantial evidence on the record as a whole. 42 U.S.C. § 405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971); Estes v. Barnhart, 275 F.3d 722, 724 (8th Cir. 2002). Substantial evidence is less than a preponderance of the evidence, but enough that a reasonable person would find it adequate to support the conclusion. Johnson v. Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001). This “substantial evidence test,” however, is “more than a mere search of the record for evidence supporting the Commissioner‘s findings.” Coleman v. Astrue, 498 F.3d 767, 770 (8th Cir. 2007) (internal quotation marks and citation omitted). “Substantial evidence on the record as a whole . . . requires a more scrutinizing analysis.” Id. (internal quotation marks and citations omitted).
To determine whether the Commissioner‘s decision is supported by substantial evidence on the record as a whole, the Court must review the entire administrative record and consider:
- The credibility findings made by the ALJ.
- The plaintiff‘s vocational factors.
- The medical evidence from treating and consulting physicians.
- The plaintiff‘s subjective complaints relating to exertional and non-exertional activities and impairments.
- Any corroboration by third parties of the plaintiff‘s impairments.
- The testimony of vocational experts when required which is based upon a proper hypothetical question which sets forth the claimant‘s impairment.
Stewart v. Secretary of Health & Human Servs., 957 F.2d 581, 585-86 (8th Cir. 1992) (internal citations omitted). The Court must also consider any evidence which fairly detracts from the Commissioner‘s decision. Coleman, 498 F.3d at 770; Warburton v. Apfel, 188 F.3d 1047, 1050 (8th Cir. 1999). However, even though two inconsistent conclusions may be drawn from the evidence, the Commissioner‘s findings may still be supported by substantial evidence on the record as a whole. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001) (citing Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000)). “[I]f there is substantial evidence on the record as a whole, we must affirm the administrative decision, even if the record could also have supported an opposite decision.” Weikert v. Sullivan, 977 F.2d 1249, 1252 (8th Cir. 1992) (internal quotation marks and citation omitted); see also Jones ex rel. Morris v. Barnhart, 315 F.3d 974, 977 (8th Cir. 2003). Put another way, a court should “disturb the ALJ‘s decision only if it falls outside the available zone of choice.” Papesh v. Colvin, 786 F.3d 1126, 1131 (8th Cir. 2015) (citation omitted).
III.B. Determination of Disability
A disability is defined as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than twelve months.
To determine whether a claimant has a disability within the meaning of the Social Security Act, the Commissioner follows a five-step sequential evaluation process outlined in the regulations.
Second, if the claimant is not engaged in substantial gainful activity, the Commissioner looks to see “whether the claimant has a severe impairment that significantly limits the claimant‘s physical or mental ability to perform basic work activities.” Dixon v. Barnhart, 343 F.3d 602, 605 (8th Cir. 2003). “An impairment is not severe if it amounts only to a slight abnormality that would not significantly limit the claimant‘s physical or mental ability to do basic work activities.” Kirby, 500 F.3d at 707; see
The ability to do basic work activities is defined as “the abilities and aptitudes necessary to do most jobs.”
Third, if the claimant has a severe impairment, then the Commissioner will consider the medical severity of the impairment. If the impairment meets or equals one of the presumptively disabling impairments listed in the regulations, then the claimant is considered disabled, regardless of age, education, and work experience.
Fifth, if the claimant‘s RFC as determined in Step Four will not allow the claimant to perform past relevant work, then the burden shifts to the Commissioner to prove that there is other work that the claimant can do, given the claimant‘s RFC as determined at Step Four, and his age, education, and work experience. See Bladow v. Apfel, 205 F.3d 356, 358-59 n. 5 (8th Cir. 2000). The Commissioner must prove not only that the claimant‘s RFC will allow the claimant to make an adjustment to other work, but also that the other work exists in significant numbers in the national economy. Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004);
The evaluation process for mental impairments is set forth in
IV. Discussion
Plaintiff challenges the ALJ‘s physical3 RFC determination. Plaintiff argues that, in assessing Plaintiff‘s RFC, the ALJ improperly evaluated Plaintiff‘s “credibility,” failed to include limitations to account for the limited range of motion of his shoulders noted by the consultative examiner, and failed to fully develop the record.
Residual functional capacity is a function-by-function assessment of an individual‘s ability to do work-related activities based on all the evidence. Casey v. Astrue, 503 F.3d 687, 696 (8th Cir. 2007). The ALJ retains the responsibility of determining a claimant‘s RFC based on all relevant evidence, including medical records, observations of treating physicians, examining physicians, and others, as well as the claimant‘s own descriptions of his limitations. Pearsall v. Massanari, 274 F.3d 1211, 1218 (8th Cir. 2001). Ultimately, RFC is a medical question, which must be supported by medical evidence contained in the record. Lauer v. Apfel, 245 F.3d 700, 704 (8th Cir. 2001). The claimant has the burden to establish RFC. Mabry v.
Colvin, 815 F.3d 386, 390 (8th Cir. 2016).
The ALJ found that Plaintiff could perform light work with the following additional limitations:
He can frequently climb ramps or stairs, but never climb ladders, ropes or scaffolds. He can frequently stoop, kneel, crouch and crawl. He should avoid concentrated exposure to operational control of moving machinery and hazardous machinery. He should avoid unprotected heights.
(Tr. 16.)
A. Shoulder Impairment
Plaintiff‘s primary argument is that the ALJ failed to account for the limited range of motion of his shoulders, as found by consulting physician Nicholas Smith, D.O.
Plaintiff saw Dr. Smith for a consultative examination at the request of the state agency on July 17, 2021. (Tr. 424.) He complained of depression, bipolar disorder, hypertension, and kidney disease. Id. Plaintiff was last employed in February 2020 as a “maintenance man.” Id. Plaintiff stated that he was diagnosed with hypertension in 2020, and that he felt his blood pressure was controlled on medications. Id. He indicated that he was also diagnosed with kidney disease in 2020, and that he has “no current issues” related to his kidney disease. Id. On examination, Plaintiff‘s blood pressure was 168/96. (Tr. 425.) He was five feet-ten inches tall and weighed 258 pounds. Id. His musculoskeletal examination revealed no palpable joint
The ALJ summarized Dr. Smith‘s findings from his consultative examination, including Plaintiff‘s reduced range of motion on flexion and abduction of the bilateral shoulders. (Tr. 18.) He stated that, despite the abnormalities noted on exam, Plaintiff had full strength in all extremities, his sensation was intact, his cranial nerve testing was grossly intact, he was able to rise from a seated position without difficulty, he had normal muscle bulk and tone, he had no joint effusion, and his straight leg raise testing was negative. Id.
The ALJ then discussed the medical evidence following Dr. Smith‘s consultative examination. He noted that at a November 2021 follow-up appointment at Affinia Healthcare
The ALJ concluded that, overall, the record shows Plaintiff had high blood pressure and an elevated BMI throughout the relevant period, but physical examinations were “rather normal with no significant physical abnormalities.” (Tr. 19.) He acknowledged that the consultative physical examination “revealed some tenderness in his spine as well as some difficulty with orthopedic maneuvers.” Id. The ALJ stated that a reduction to light exertional work with further postural and environmental limitations is reasonable “given the claimant‘s obesity and high blood pressure so as to not exacerbate his symptoms and to provide for his safety.” Id. He stated that the limitations were further supported by the mild to moderate degenerative changes in his spine as found in June 2021 imaging. (Tr. 19, 417.) Additionally, the ALJ noted that the reduction in exertion to light work would benefit Plaintiff‘s chronic kidney disease so that he does not over-exert himself. Id.
Plaintiff argues that the ALJ erred in failing to discuss Dr. Smith‘s finding that Plaintiff had limited range of motion of his shoulders, “which should have compelled overhead and side reaching limitations.” (Doc. 9 at 9.)
Defendant responds that the ALJ did discuss Dr. Smith‘s findings but also noted that Plaintiff demonstrated full strength in his arms. Defendant further points out that Plaintiff alleged no arm or shoulder impairment contributing to his alleged disability, and the record contains no treatment for such.
The undersigned agrees that it is significant that Plaintiff did not allege a shoulder impairment in his applications for benefits. See Wall v. Astrue, 561 F.3d 1048, 1062 (10th Cir. 2009) (holding that because the claimant did not allege that she suffered from a severe mental impairment, the “AL‘‘s failure to discuss listing 12.05C [was], therefore unsurprising“); Dunahoo v. Apfel, 241 F.3d 1033, 1039 (8th Cir. 2001) (holding that the fact that the claimant
Moreover, Plaintiff failed to report shoulder pain or restriction of motion in his Function Report or to his providers as reflected in the treatment notes. In his Function Report, Plaintiff indicated that his impairments did not affect his ability to reach. (Tr. 330.) When asked by the ALJ at the hearing what physical problems he had that affected his ability to perform daily activities, Plaintiff identified only pain in the lower to middle part of his back and chronic kidney disease. (Tr. 46-47.) The medical record is silent as to complaints of shoulder pain or limitations. Although Dr. Smith found Plaintiff‘s range of shoulder flexion and abduction was reduced, he noted full arm strength and included no reference to a shoulder impairment or restriction in his assessment. (Tr. 426.) Further, the state agency physicians reviewed the findings from Dr. Smith‘s examination and did not include an overhead lifting restriction. (Tr. 83-85, 91-93, 99-101, 107-09.) As explanation for their RFC assessment, they noted that Plaintiff did not allege back pain, reported having no pain at a February 2021 medical visit, reports no use of pain medication, and received no pain management or chiropractic treatment. Id.
Ultimately, Plaintiff did not carry his burden to demonstrate a shoulder impairment requiring a limitation in his ability to reach overhead. See Mittlestedt v. Apfel, 204 F.3d 847, 852 (8th Cir. 2000); Kraus v. Saul, 988 F.3d 1019, 1024 (8th Cir. 2021). The ALJ‘s lack of an overhead lifting limitation is supported by the only medical opinion evidence in the record, Plaintiff‘s treatment notes, and Plaintiff‘s own statements.
B. Credibility
Plaintiff also argues that the ALJ erred in assessing the “credibility”4 of his allegations, regarding his need to frequently change positions from standing, walking, and sitting.
When considering a claimant‘s self-reported symptoms and limitations, the ALJ must evaluate whether the claimant‘s subjective statements are consistent with and supported by the record as a whole.
(8th Cir. 1984).
In addition to evaluating the medical evidence, the ALJ formulated Plaintiff‘s RFC after consideration of the entire record, which included an assessment of Plaintiff‘s subjective symptoms, his testimony, and his daily activities. The ALJ noted that Plaintiff alleges disability due to difficulty lifting, squatting, bending, walking, talking, kneeling, seeing, and remembering stemming from his kidney disease, degenerative disc disease, hypertension and obesity. (Tr. 17.) Plaintiff testified that he could walk about half a block before having to sit down, walk for about twenty minutes, stand for about fifteen minutes, and lift up to twenty pounds. (Tr. 17, 47) The ALJ also noted that Plaintiff reported independence in his activities of daily living. (Tr. 17, 49-50.) Plaintiff testified that on a typical day, he sits down and tries to do some writing; tries to lift weights, but cannot; takes a shower; cleans his room; and rests. (Tr. 49-50.) He stated that he used to earn some money by transporting people to the store and shopping, but he is no longer able to do that because his vehicle was stolen and he has no transportation. (Tr. 50.)
The ALJ found that Plaintiff‘s allegations of disability were not consistent with the record as a whole. (Tr. 17.) He stated that Plaintiff has impairments that could reasonably be expected to produce a certain degree of symptoms, but a restriction to a range of light work adequately addresses the intensity of Plaintiff‘s symptoms. Id.
As previously discussed, Plaintiff‘s treatment notes reveal diagnoses of hypertension and kidney disease, but physical examinations typically revealed no abnormalities. The ALJ also noted that treatment notes do not extend back to Plaintiff‘s alleged onset of disability date of September 30, 2019. Instead, the first treatment note is from an October 2020 examination at
Plaintiff fails to point to error in the ALJ‘s evaluation of his subjective complaints. The ALJ was not required to fully credit all of Plaintiff‘s assertions regarding the limitations given his relative lack of medical treatment during the relevant period; the medical evidence of record showing few abnormalities on examination; his lack of pain medication; and his relatively normal daily activities.
C. Development of Record
Plaintiff finally argues that, because the ALJ found the prior administrative findings unpersuasive, he should have further developed the record by scheduling another consultative examination or obtaining medical expert testimony.
While the ALJ does have a duty to fully and fairly develop the record, the ALJ is not required to obtain additional medical evidence if the evidence of record provides a sufficient basis for the ALJ‘s decision. Martise v. Astrue, 641 F.3d 909, 926-27 (8th Cir. 2011). Moreover, it is ultimately Plaintiff‘s burden to establish his RFC, and he failed to carry this burden by producing any evidence that his RFC should be more limited because of his hypertension, chronic kidney disease, degenerative disc disease of the lumbar spine, or obesity. See Hensley v. Colvin, 829 F.3d 926, 932 (8th Cir. 2016).
The new regulations permit the ALJ to consider medical source evidence as appropriate.
The Court finds that the ALJ‘s RFC determination is supported by substantial evidence on the record as a whole. Under these circumstances, the ALJ was not required to further develop the record.
Accordingly, Judgment will be entered separately in favor of Defendant in accordance with this Memorandum.
/s/ Abbie Crites-Leoni
ABBIE CRITES-LEONI
UNITED STATES MAGISTRATE JUDGE
Dated this 11th day of March, 2025.