United States District Court, E.D. North Carolina, Southern Division
George D. Hall, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security,  Defendant.
MEMORANDUM & RECOMMENDATION
T. NUMBERS, II UNITED STATES MAGISTRATE JUDGE.
George D. Hall instituted this action on October 11, 2016, to
challenge the denial of his application for social security
income. Hall claims that the Administrative Law Judge
(“ALJ”) Carl B. Watson erred in (1) finding that
he had the residual functional capacity (“RFC”)
to perform a reduced range of light work, (2) considering the
opinion of his treating orthopedist, and (3) evaluating his
credibility. Based these errors, Hall also contends ALJ
Watson incorrectly determined that he could perform
substantial gainful work. Both Hall and Defendant Nancy A.
Berryhill, the Acting Commissioner of Social Security, have
filed motions seeking a judgment on the pleadings in their
favor. D.E. 10, 12.
reviewing the parties' arguments, the court has
determined that ALJ Watson erred in his decision because his
RFC determination is not supported by substantial evidence.
Also, ALJ Watson's evaluations of the medical opinion
evidence and Hall's credibility were flawed. Because of
these errors, the undersigned cannot conclude that ALJ Watson
correctly determined that there is other work which Hall can
perform. Thus, the undersigned magistrate judge recommends
that the court grant Hall's motion, deny Berryhill's
motion, and remand the matter for further
February 1, 2011, Hall protectively filed an application for
disability benefits alleging a disability that began on
October 29, 2009. After his claim was denied at the initial
level and upon reconsideration, Hall appeared before ALJ
Watson for a hearing to determine whether he was entitled to
benefits. ALJ Watson determined Hall was not entitled to
benefits because he was not disabled. Tr. at 16-26.
he unsuccessfully sought review from the Appeals Council,
Hall filed a complaint in this court in July 2014. See
Hall v. Colvin, Case No. 7:14-cv-00153-BO (E.D. N.C.
July 23, 2014). In June 2015, the court remanded the case to
the Commissioner for further consideration of Hall's RFC
and, specifically, additional evaluation of Hall's
treating physician's opinion finding restrictions in the
use of his upper right extremity. Id. at D.E. 25.
remand, ALJ Watson found that Hall had several severe
impairments: status-post right shoulder injury with superior
labral anterior-to-posterior (“SLAP”) tear grade
II lesion, partial bicep tendon rupture, partial anterior
ligament rupture, impingement syndrome, partial thickness
rotator cuff tendon tear, hypothyroidism, and depression. Tr.
Watson found that Hall's impairments, either alone or in
combination, did not meet or equal a Listing impairment.
Id. at 344.
Watson then determined that Hall had the RFC to perform a
range of light work with additional limitations. Id.
at 346. He cannot climb ladders, ropes, or scaffolds.
Id. He can only occasionally reach overhead with his
right upper extremity and he could frequently, but not
constantly, reach in all other directions with his right arm.
Id. Finally, Hall is limited to performing simple,
routine, repetitive tasks in an environment where there is
only casual interactions with the general public and where
changes are infrequent and gradually introduced. Id.
Watson concluded that Hall was incapable of performing his
past relevant work as a tractor-trailer truck driver/trainer.
Id. at 353. But ALJ Watson determined that,
considering Hall's age, education, work experience, and
RFC, there were other jobs that existed in significant
numbers in the national economy that Hall was capable of
performing. Id. at 353-54. These include: garment
tag stringer, stock checker, and drying room attendant.
Id. Thus, ALJ Watson found that Hall was not
disabled. Id. at 354.
unsuccessfully seeking review by the Appeals Council, Hall
commenced this action in October 2016. D.E. 1.
Standard for Review of the Acting Commissioner's Final
social security claimant appeals a final decision of the
Commissioner, the district court's review is limited to
determining whether, based on the entire administrative
record, there is substantial evidence to support the
Commissioner's findings. 42 U.S.C. § 405(g);
Richardson v. Perales, 402 U.S. 389, 401 (1971).
Substantial evidence is defined as “evidence which a
reasoning mind would accept as sufficient to support a
particular conclusion.” Shively v. Heckler,
739 F.2d 987, 989 (4th Cir. 1984) (quoting Laws v.
Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). The
court must affirm the Commissioner's decision if it is
supported by substantial evidence. Smith v. Chater,
99 F.3d 635, 638 (4th Cir. 1996).
Standard for Evaluating Disability
making a disability determination, the ALJ engages in a
five-step evaluation process. 20 C.F.R. § 404.1520;
see Johnson v. Barnhart, 434 F.3d 650 (4th Cir.
2005). The ALJ must consider the factors in order. At step
one, if the claimant is engaged in substantial gainful
activity, the claim is denied. At step two, the claim is
denied if the claimant does not have a severe impairment or
combination of impairments significantly limiting him or her
from performing basic work activities. At step three, the
claimant's impairment is compared to those in the Listing
of Impairments. See 20 C.F.R. Part 404, Subpart P,
App. 1. If the impairment is listed in the Listing of
Impairments or if it is equivalent to a listed impairment,
disability is conclusively presumed. However, if the
claimant's impairment does not meet or equal a listed
impairment, the ALJ assesses the claimant's RFC to
determine, at step four, whether he can perform his past work
despite his impairments. If the claimant cannot perform past
relevant work, the analysis moves on to step five:
establishing whether the claimant, based on his age, work
experience, and RFC can perform other substantial gainful
work. The burden of proof is on the claimant for the first
four steps of this inquiry, but shifts to the Commissioner at
the fifth step. Pass v. Chater, 65 F.3d 1200, 1203
(4th Cir. 1995).
sustained a shoulder injury after a motor vehicle accident in
December 2008. Although he was originally diagnosed with
tendonitis, he underwent surgery with Dr. Andrew Bush in
October 2009 after subsequent testing showed more extensive
injuries to his right shoulder. Tr. at 347. In March 2010,
Hall reported persistent pain despite medications and
injections. Id. Dr. Bush determined Hall was
suffering from bicipital tenosynovitis and administered
another injection. Id. at 209. The next month, Hall
saw Dr. Bush for right shoulder pain despite having received
medications and injections. Id. at 210-15. Dr. Bush
believed Hall was suffering from bicipital tenosynovitis and
rotator cuff syndrome. Id. at 215.
still experienced persistent pain and occasional swelling in
August 2010. Id. at 222. After noting that Hall had
only a fair response to medication, Dr. Bush concluded he had
reached maximum medical improvement and referred him to pain
management. Id. at 222-24.
Bush also completed a Work Status Note at that time.
Id. at 206. He assessed several permanent
limitations: Hall could lift up to 20 pounds, with frequent
lifting and carrying limited to 10 pounds; he could not walk
or stand to a significant degree; and he could not sit with
pushing or pulling of arm/leg controls. Id. Hall
could not lift more than five pounds with his right hand; he
could not perform forceful pushing or pulling of more than
pounds with his right hand; and he could not grip or twist
with his right hand. Id. Dr. Bush also found that
Hall could not reach overhead with his right arm; he could
not use vibratory tools or power tools; and he was unable to
drive a commercial vehicle. Id.
September 2010, Hall saw Dr. Aaron H. Gootman in hopes of
managing his chronic pain. Id. at 255-57. Although
Dr. Gootman prescribed medications for him, Hall returned two
months later complaining of worsening pain. Id. at
225. Dr. Gootman gave Hall an injection after an examination
found tenderness and painful range of motion. Id. at
226, 227, 256. In December, Dr. Gootman found that Hall's
pain was moderately uncontrolled with medication.
Id. at 259-60. Later that month and in February
2011, he found Hall's pain to be slightly uncontrolled.
wife completed a Function Report in March 2011. Id.
at 175-82. She claimed that Hall spent most of his day
watching television and that he got very little sleep at
night. Id. at 175- 76. She assisted him with
dressing and grooming and she said that he had a very limited
ability to perform household chores. Id. at 177. She
also stated that she did most of the driving and that he had
problems focusing. Id. at 178-79. She estimated he
could walk about half a mile. Id. at 180.
returned to Dr. Bush the next month complaining of worsening
pain. Id. at 287-89. Dr. Bush noted decreased range
of motion and administered an injection. Id. at 289.
In May 2011, Dr. Bush remarked that Hall showed decreased
strength in his shoulder and elbow, and he referred Hall to
pain management once again. Id. at 292.
Ayman Gebrail performed a consultative examination later that
month. Id. at 264-68. His examination found a
significantly limited range of motion in Hall's right
shoulder, as well as tenderness. Id. Hall was unable
to perform several testing maneuvers because of his pain.
Id. Dr. Gebrail opined that Hall would have
“significant difficulty with the function of his right
shoulder and right upper extremity due to pain.”
June, Hall saw Dr. Toni Harris, a pain management specialist.
Id. at 284-85. Hall claimed that he experienced pain
in both shoulders, with the right being more severe.
Id. He also reported numbness in his right arm and
an inability to raise his right arm above shoulder-height.
Id. Dr. Harris found that Hall had diminished right
biceps reflex, atrophy of his right trapezius, and limited