United States District Court, D. Nebraska
MEMORANDUM AND ORDER
M. Gerrard United States District Judge
matter is before the Court on the denial, initially and upon
reconsideration, of plaintiff Steven Trobaugh's
disability insurance benefits under Titles II and XVI of the
Social Security Act, 42 U.S.C. § 401 et seq.
and § 1381 et seq. The Court has considered the
parties' filings and the administrative record, and
affirms the Commissioner's decision to deny benefits.
filed applications for disability insurance benefits and
supplemental security income in February 2014. Trobaugh's
claims were denied initially (T101-104) and on
reconsideration (T113-115). Following a hearing, an
administrative law judge (ALJ) determined that Trobaugh was
not disabled under the Social Security Act, and therefore not
entitled to disability benefits. T21. The ALJ determined
that, although Trobaugh suffers from severe impairments, he
has the residual functional capacity to perform other jobs
that exist in significant numbers in the national economy.
T11-T21. The Appeals Council of the Social Security
Administration (SSA) denied Trobaugh's request for review
of the ALJ's decision. T1-5. Trobaugh's complaint
seeks review of the ALJ's decision as the final decision
of the Commissioner under sentence four of 42 U.S.C. §
405(g). Filing 1.
medical records reflect a history of physical impairments
and, to a lesser extent, psychological limitations. For the
purposes of this appeal, that history began in 2013, when
Trobaugh visited Dr. Chris Wilkinson, an orthopedic
specialist, with complaints of "bilateral shoulder pain
from a motor vehicle accident in 2011." T267. Based on
those complaints, and Trobaugh's medical history more
generally, Wilkinson scheduled an arthroscopy of
Trobaugh's right shoulder "with an open repair of
the greater tuberosity[.]" T263.
from that procedure reflect Trobaugh's relative good
health: one practitioner described him as a
"well-developed, well-nourished 43-year-old male in no
acute distress." T329. But the notes also describe
Trobaugh's persistent shoulder pain, which "limit[s
his] range of motion." T328. That pain, the arthroscopy
revealed, was due in part to a superior labral tear, which
doctors presumably repaired during the procedure.
filed his claim for benefits immediately following the
arthroscopy, listing "Left and Right shoulders
broken" as a disabling condition. T74. Trobaugh also
listed: chronic obstructive pulmonary disease (COPD), lung
disease, depression, bipolar disorder, and "Neck and
back problems." T189. The SSA, however, determined that
Trobaugh's medical records were insufficient to support a
decision on his claim. T77. So, Trobaugh was required to
undergo additional consultative examinations with Tamara
Johnson, M.D., and Rebecca Schroeder, Ph.D. T270; T279.
examination focused primarily on Trobaugh's physical
capabilities. She observed that Trobaugh could "sit,
stand and walk unassisted" and could "handle
objects with both gross and fine manual motor
dexterity." T277. But she also noted "definite
weak[ness]" in Trobaugh's upper extremities and
"extremely limited" range of motion in his
shoulders. T277. As to his psychological condition, Johnson
described Trobaugh as both "alert and oriented" and
"depressed [and] lethargic." See T272;
performed a psychological evaluation of Trobaugh. T279.
Results from that evaluation are, for the most part,
consistent with Johnson's observations: that Trobaugh
suffers from depression, is often "low energy," and
rarely leaves his home. T281-282. Schroeder opined that
Trobaugh's depression and overall affect may result in
"mild limitations" in his day, including
"issues relating to coworkers and supervisors."
T283. But, she noted, Trobaugh is "capable of sustaining
concentration and attention needed for at least a short
task." T284. Schroeder assigned Trobaugh a global
assessment of functioning (GAF) score of 60.
record contains other medical records, too, that are relevant
to Trobaugh's claim. For example, two state agency
medical consultants-Jerry Reed, M.D., and Steve Higgins,
M.D.-reviewed Trobaugh's medical records. See
T74; T87. Reed determined that Trobaugh's conditions do,
in some respects, limit his ability to work. But overall, he
said, "[w]e have determined that your condition is not
severe enough to keep you from working." T85. Higgins
reached the same result on reconsideration. See T97.
in October 2014, Trobaugh visited Wilkinson (the doctor who
arranged the initial arthroscopy) regarding continued pain in
his left shoulder. T314. After examining the shoulder, and at
Trobaugh's request, Wilkinson issued Trobaugh a note
saying that he was "unable to work because of . . .
chronic shoulder problems." T314. Trobaugh needed the
note, he said, for a legal dispute regarding unpaid child
administrative hearing, Trobaugh testified to his medical
condition and symptoms, which generally mirror the symptoms
discussed above. He explained, for example, the pain he
experiences in his shoulders and back, and the limitations
associated with that pain. T46-47. He also described his
diagnoses for COPD and emphysema, and past surgical
operations on both lungs. T49-50. And he discussed his
general battle with depression, saying that he feels
depressed "[a]ll the time." T51. These conditions,
Trobaugh testified, limit his ability to stand for long
periods of time, lift heavy objects, and meaningfully
interact with other people. T54-58.
then questioned Trobaugh about his physical capabilities and
work history. Trobaugh responded with details of his past
work experience as a construction worker and roofer-jobs
which, Trobaugh said, he can no longer perform because of his
shoulder pain. See T59-61.
presented the vocational expert (VE) with a hypothetical
based on a worker "who has no past relevant work"
is able to perform work that does not require overhead
reaching; [must] avoid extreme and concentrated temperatures,
humidity, fumes and dust; able to perform work that is not
exposed to hazards such as work at unprotected heights; able
to perform work that is simple and to respond appropriately
to routine changes in the work environment; able to perform
work that does not require more than incidental and
superficial contact with the public; and does not require
working in tandem or close coordination with others.
T67. Such a person, the VE opined, could perform sedentary,
unskilled work, such as a document preparer or eyeglass frame
polisher. T68. The ALJ then asked the VE to assume, in
addition to the conditions described above, that the
individual was limited in his ability to reach "in other
planes and other directions." T68. With that addition,
the VE opined that the claimant would be unable to sustain
Sequential Analysis and ALJ Findings
determine whether a claimant is entitled to disability
benefits, the ALJ performs a five-step sequential analysis.
20 C.F.R. § 404.1520(a)(4).
first step, the claimant has the burden to establish that he
has not engaged in substantial gainful activity since his
alleged disability onset date. Gonzales v. Barnhart,
465 F.3d 890, 894 (8th Cir. 2006); 20 C.F.R. §
404.1520(a)(4)(i). If the claimant has engaged in substantial
gainful activity, the claimant will be found not to be
disabled; otherwise, the analysis proceeds to step two.
Gonzales, 465 F.3d at 894; 20 C.F.R. §
case, the ALJ found that Trobaugh had not engaged in
substantial gainful activity since his alleged disability
onset date, and that finding is not disputed on appeal. T13.
Steps Two and Three
second step, the claimant has the burden to prove he has a
"medically determinable physical or mental
impairment" or combination of impairments that is
"severe[, ]" 20 C.F.R. § 404.1520(a)(4)(ii),
in that it "significantly limits his physical or mental
ability to perform basic work activities."
Gonzales, 465 F.3d at 894; see also
Kirby v. Astrue, 500 F.3d 705, 707-08 (8th Cir.
2007). Next, "at the third step, [if] the claimant shows
that his impairment meets or equals a presumptively disabling
impairment listed in the regulations, the analysis stops and
the claimant is automatically found disabled and is entitled
to benefits." Gonzales, 465 F.3d at 894; 20
C.F.R. § 404.1520(a)(4)(iii). Otherwise, the analysis
case, at step 2, the ALJ found that Trobaugh had the
following severe impairments: degenerative joint disease of
the shoulders bilaterally with residuals of surgery; history
of compression fracture in the spine; COPD with residuals of
lung surgery; mood disorder; personality disorder; organic
brain disorder; and degenerative joint disease of the left
knee. T13. At step three, however, the ALJ found that
Trobaugh did not have an impairment or combination ...