Shand v. Commissioner of Social Security

Background

Blair Shand sought judicial review under 42 U.S.C. § 405(g) of the Commissioner of Social Security’s final decision denying her application for disability insurance benefits. The administrative law judge, Selwyn Waters, held a hearing on January 22, 2021, and denied the application on April 28, 2021. The Appeals Council denied review on July 27, 2022, making the administrative law judge’s decision final for purposes of judicial review.

Shand alleged that pain and reduced function in her wrists, ankles, and feet limited her ability to work. She testified that she had difficulty using her hands, could not lift more than five pounds with her dominant right hand, and experienced foot pain when standing or walking. The administrative law judge found severe impairments including right-wrist tendonitis, cervical-spine degenerative disc disease, carpal tunnel syndrome, and obesity. He found Shand’s foot impairments non-severe, determined that she could perform a limited range of light work, and concluded that she could perform jobs existing in significant numbers in the national economy.

The parties filed cross-motions for judgment on the pleadings, which asks the court to decide the case based on the pleadings and administrative record. Shand argued that the administrative law judge failed to properly assess her bilateral foot impairments, residual functional capacity, and credibility. The Commissioner argued that the decision was supported by substantial evidence, meaning relevant evidence that a reasonable person could accept as adequate.

The Court’s Analysis

Failure to develop the record about the feet. The court held that the administrative law judge did not adequately develop the record concerning Shand’s foot impairments. The medical opinions differed substantially: some doctors described serious limits on standing and walking, while other opinions stated that Shand could return to work without restrictions or could stand and walk for about six hours during a workday. Because of these conflicts, the administrative law judge should have obtained a functional assessment addressing the effect of Shand’s foot impairments on her ability to work.

The court also found a gap concerning whether Shand received continuing treatment for her feet. Shand testified that she received cortisone injections in her feet and had undergone physical therapy, but the record did not adequately document those treatments. The administrative law judge relied on an absence of ongoing treatment when finding the foot impairments non-severe, without resolving the conflict between that finding and Shand’s testimony and other evidence. The court held that remand was appropriate on this ground.

Severity of the foot impairments. The court concluded that the administrative law judge erred by finding that Shand’s plantar fasciitis and Achilles tendonitis were not severe. The court explained that the step-two severity inquiry is intended to screen out only impairments that have no more than a minimal effect on the ability to work. The record, including opinions from Dr. Brian Dawson and Dr. Matvey Yagudayev and Shand’s testimony, showed more than a minimal effect. But the court found this particular error harmless because the administrative law judge identified other severe impairments and considered the foot conditions later when determining Shand’s residual functional capacity.

Evaluation of symptoms. The court found deficiencies in the administrative law judge’s evaluation of Shand’s statements about the intensity and limiting effects of her symptoms. The administrative law judge stated that her impairments were controlled by conservative and infrequent treatment and medication, but did not give a valid explanation or identify supporting medical evidence. The court also noted treatment records describing continuing wrist and foot pain despite physical therapy and injections. It therefore concluded that the symptom evaluation was not supported by substantial evidence.

Residual functional capacity and medical opinions. Residual functional capacity, or RFC, is the most a claimant can do despite her impairments. The court agreed that the administrative law judge’s omission of explicit hand-use limits from the written RFC was harmless because the hearing questions to the vocational expert and the decision’s discussion showed that the administrative law judge understood Shand to have occasional limits involving the dominant right hand.

The court nevertheless found that the RFC determination was deficient because the administrative law judge did not properly explain the supportability and consistency of the medical opinions concerning Shand’s feet. Supportability concerns how well a medical source explains and supports an opinion; consistency concerns how well the opinion fits with the other evidence. The administrative law judge rejected Dr. Yagudayev’s opinion without addressing its supportability and did not adequately explain why it conflicted with Shand’s testimony. The administrative law judge also failed to address Dr. Dawson’s opinion that Shand could not perform her job because of pain and the demands of standing and walking. These omissions prevented meaningful judicial review.

Disposition

Judge James L. Cott granted Shand’s motion for judgment on the pleadings, denied the Commissioner’s cross-motion, directed the Clerk to mark Docket Number 13 as “Granted” and Docket Number 15 as “Denied,” entered judgment for Shand, and remanded the case for further proceedings. The opinion did not direct an award of benefits.