United States District Court, S.D. Mississippi, Western Division
Keith Ball, United States Magistrate Judge
Willis Harris filed for a period of disability, disability
insurance benefits, and supplemental security income on
December 11, 2013, alleging an onset date of May 16, 2011.
His application was denied both initially and upon
reconsideration. He requested and was granted a hearing
before an ALJ, which was held on March 17, 2016. On April 19,
2016, the ALJ issued a decision finding that Harris was not
disabled. The appeals council denied review. Harris now
brings this appeal pursuant to § 205(g) of the Social
Security Act, 42 U.S.C. § 405(g). Having considered the
memoranda of the parties and the administrative record, the
Court concludes that the decision of the Commissioner should
Facts and Evidence before the ALJ
was born on July 25, 1961, and was 54 years of age at the
time of the decision of the ALJ. He has an eleventh grade
education and past relevant work experience as a truck driver
and as a general clerk. In his applications, he alleged
disability due to bulging discs, shoulder surgery, neck
surgery, hypertension, cervical injury, gout, arthritis, acid
reflux, borderline diabetes, high cholesterol, right leg
pain, and limited use of his right arm and hand.
medical record indicates that Plaintiff underwent cervical
surgery at the age of 25. R. 368,  at 372. In May of 2011,
he sustained an injury at work; thereafter he experienced
neck and right shoulder pain. R. 272,  at 276. EMG and
nerve conduction studies revealed right C8 radiculopathy. R.
273,  at 277. An MRI of the right shoulder indicated
degenerative disease in the AC joint. R. 304,  at 308. In
January of 2012, Dr. Larry Field performed right rotator cuff
surgery. R. 224,  at 228. By May of 2012, following
post-operative physical therapy, his shoulder was doing well;
however, he continued to complain of neck and periscapular
symptoms, as well as elbow pain. R. 216,  at 220. An MRI
of the right elbow in June of 2012 was normal, and Dr. Field
released him with a six percent impairment rating for his
shoulder. R. 288, 215,  at 292, 219.
October 22, 2012, Dr. David Gandy, an orthopedic surgeon,
performed an independent medical examination of
Plaintiff's neck and right shoulder. Plaintiff had full
rotation in his neck to the left and right, with pain on
extremes of motion. R. 371,  at 375. Sensation in his
upper extremities was normal, as was strength. Id.
Plaintiff had tenderness to palpation of the medial and
lateral epicondyles bilaterally, with full range of motion
and full strength. Id. He had no tenderness and had
normal range of motion in his right shoulder. Id.
Dr. Gandy's assessment was cervical spondylosis without
myelopathy, spinal stenosis in the cervical region, sprain
and strain of the supraspinatus muscle, partial tear of the
rotator cuff, epicondylitis of the elbow, and benign
essential hypertension. Id.
sustained a fall in December 2013. A few weeks later he saw
Dr. David Smith for his annual physical and complained of
right hip pain radiating to his foot, right shoulder pain,
and right arm weakness. R. 264,  at 268. Dr. Smith's
diagnosis was lumbosacral radiculopathy and rotator cuff and
shoulder syndrome. R. 266,  at 270.
records do not reveal any further evaluation or treatment
until December of 2014, when he underwent a lumbar MRI. The
MRI indicated degeneration and a disc bulge at ¶ 3-4
causing moderate to severe central spinal stenosis, and mild
listhesis and disc bulge at ¶ 4-5. R. 295,  at 299.
In January of 2015, Plaintiff began seeing Dr. Jennifer
Gholson for his primary care. At his initial evaluation, he
presented using a cane for ambulation and complaining of pain
in the right hip, right knee, and right foot, as well as
depression. R. 319,  at 323. He saw Dr. James Woodall in
February of 2015 for complaints of neck pain, right shoulder
pain, gait imbalance, and loss of fine motor skills. R.
316-17,  at 320-21. Cervical x-ray revealed dynamic
instability at ¶ 4-5. R. 317,  at 321. Dr.
Woodall's assessment was cervical spondylosis with
myelopathy, lumbar disc degeneration, herniated cervical
disc, and cervical disc degeneration. R. 318,  at 322. A
cervical MRI showed central spinal stenosis.at C4-5 with mild
cord flattening, as well as mild foraminal stenosis at ¶
1-T2. R. 290,  at 294. On February 27, 2015, Dr. Woodall
performed a cervical discectomy with placement of a PEEK
interbody device and cervical plate and bone grafting at
¶ 4-5. R. 296,  at 300. At a follow-up visit on March
12, 2015, Plaintiff was doing well. R. 313,  at 317.
Plaintiff reported cramping of his hands at an appointment in
June of 2015. R. 327,  at 331. There is no further mention
of upper extremity symptoms in the medical record.
Examination of the cervical spine by Dr. Woodall in August of
2015 revealed good range of motion with some tenderness and
palpable spasm. R. 310,  at 314. Plaintiff's shoulder
was doing well with some muscular pain. Id. Dr.
Woodall ordered a program of physical therapy. Id.
August 6, 2015, Plaintiff underwent a right total hip
replacement. R. 306,  at 310. At a follow-up appointment
the following October, his surgeon stated that Plaintiff was
doing very well overall and that Plaintiff was happy with the
right hip. R. 340,  at 344.
medications at the time the hearing were as follows: zolpidem
(Ambien), cephalexin (an antibiotic), tizanidine (a muscle
relaxer), hydralazine, duloxetine (Cymbalta), omeprazole,
hydrocodone/acetaminophen, meloxicam, lisinopril, and
amlodipine besylate. R. 210,  at 214.
hearing, Harris testified as follows: He is unable to work
because of neck pain, right shoulder pain, pain in the legs
and feet, hip pain, and lower back pain. R. 34,  at 38.
His worst problems are the pain in his shoulder, neck, hip,
and right knee. Id. He also suffers from
hypertension and depression. R. 34, 41;  at 38, 45.
Plaintiff estimated that he is in pain about 80 percent of
the time. R. 42,  at 46. He takes hydrocodone three times
a day for his pain. R. 41,  at 45. He also uses heating
pads to relieve his pain and soaks in a hot tub at least
twice a day. R. 43,  at 47. In the past, Plaintiff enjoyed
hunting and fishing and drove his church's bus, but he
can longer participate in these activities. R. 36, 38;  at
40, 42. Instead, he stays home most of the time, although he
is able to drive short distances. R. 35, 36, 38, 44;  at
39, 40, 42, 46. Plaintiff's household tasks are limited
to occasional cooking and laundry and a little gardening in
pots. R. 35-36,  at 39-40. He is unable to perform chores
such as sweeping, vacuuming, or mopping because of his
shoulder pain and difficulties standing. R. 36,  at 40. He
has difficulty walking without a cane and has lost his
balance several times. R. 39-40,  at 43-44. Plaintiff
stated that he could lift 8-10 pounds, stand 10-15 minutes,
and climb six stairs. R. 37,  at 41. He can kneel with
pain but would need assistance to get up. R. 45,  at 49.
He cannot stoop down and pick an object off the floor.
testifying at the hearing was a vocational expert (V.E.). The
V.E classified Harris's past relevant work as a tractor
trailer truck driver and a general clerk. R. 47-48;  at
51-52. According to the V.E., the truck driver position
represents medium, semiskilled work, while the general clerk
job is light and semi-skilled. Id. The ALJ posed two
hypotheticals to the V.E. In the first, he described the
following: An individual in the same age range and having the
same education, work history, and transferrable skills as
Plaintiff. He can lift 20 pounds occasionally and 10 pounds
frequently and can walk or stand for four hours in an
eight-hour day, 20 minutes at a time. He can occasionally
stoop and climb but can never crouch, kneel, or crawl.
Pushing/pulling is limited to less than ten pounds with the
left upper and right lower extremities, and he cannot reach
overhead with the left upper extremities. The V.E. testified
that such a person could perform Plaintiff's past job of
general clerk. R. 49,  at 53. In the second hypothetical,
the ALJ added the limitations that the individual can lift 10
pounds occasionally, less than 10 pounds frequently, and can
walk or stand only two hours in an eight-hour day, for only
15 minutes at a time. In response, the V.E. opined that the
individual could perform the sedentary jobs of booth cashier
at a self-service gas station and telephone solicitor.