United States District Court, M.D. Florida, Tampa Division
ORDER AFFIRMING COMMISSIONER'S DECISION
Patricia D. Barksdale United States Magistrate Judge
a case under 42 U.S.C. § 1383(c)(3) to review a final
decision of the Commissioner of the Social Security
Administration (“SSA”) denying Marie
Prather's claim on behalf of her minor son, M.C., for
supplemental security income. She seeks reversal, Doc.
24; the Commissioner, affirmance, Doc. 25. This
order adopts the summaries of facts and law in the
Administrative Law Judge's (“ALJ's”)
decision, Tr. 10-23, and in the parties' briefs, Docs.
presents three issues: (1) whether substantial evidence
supports the ALJ's finding M.C. has no impairment or
combination of impairments that functionally equals an
impairment in the Listing of Impairments, 20 C.F.R. Part 404,
Subpart P, Appendix 1; (2) whether the ALJ properly
evaluated Prather's testimony; and (3) whether the ALJ
properly evaluated M.C.'s subjective complaints. Doc. 24
at 3, 10-16.
was born in 1997 and was an adolescent at all relevant times.
Tr. 127; see 20 C.F.R. §
416.926a(g)(1)(v) (defining adolescent as “age 12 to
attainment of age 18”). In April 2012, Prather applied
for supplemental security income on M.C.'s behalf,
alleging M.C. has been disabled since October
due to juvenile rheumatoid arthritis, Sjögren's
syndrome,  and asthma. Tr. 127, 159. She proceeded
through the administrative process, failing at each level.
Tr. 1-6, 10-23, 41-59, 61- 67, 73-79. This case followed.
April 2011, M.C. reported to his primary care physician, Dr.
Amanda Puentes, that his knees had been giving out during
physical-education classes and he had been experiencing pain
in his wrists, ankles, and knees for more than a year. Tr.
303. She advised him to take ibuprofen as needed and apply
heat. Tr. 304.
August 2011, M.C. returned to Dr. Puentes complaining of
right-shoulder pain. Tr. 301. She ordered an MRI of the
shoulder and recommended ibuprofen and alternating heat and
ice after school and after using the shoulder. Tr. 301-02.
October 2011, M.C. saw Dr. Drew Warnick for evaluation of a
right-shoulder injury he had sustained a few months earlier
when trying to open a cattle gate. Tr. 314-16. Dr. Warnick
observed he had “full pain-free range of motion of
the” shoulder, full rotation strength, nearly full
abduction strength, and “slight discomfort with the
empty drawer test.” Tr. 315. Dr. Warnick observed no
swelling of other joints and slight tenderness of the left
ankle. Tr. 315. He opined M.C. had synovitis in the right
shoulder with no tear and “stressed the importance of
him seeing a rheumatologist to be placed on appropriate
medication” for arthritis. Tr. 315.
October 2011, M.C. saw Dr. Robert Nickeson for evaluation for
possible arthritis. Tr. 434-35. Dr. Nickeson observed he had
mild swelling in the knees, joint hypermobility,
his small hand joints were unremarkable. Tr. 435. He started
him on piroxicam. Tr. 435.
December 2011, M.C. returned to Dr. Nickeson complaining of
occasional dry eyes and joint pain about two days a week. Tr.
433. Dr. Nickeson observed his shoulder seemed to be a
particular problem and his hand and leg joints did not show
significant swelling. Tr. 433. A few days later, Dr. Nickeson
contacted another doctor about performing a lip biopsy to
test for Sjögren's syndrome. Tr. 286.
February 2012, M.C. returned to Dr. Puentes complaining of
ongoing joint pain “due to baseball and FHA
activities.” Tr. 295. Dr. Puentes noted Prather
reported M.C.'s arthritis causes him to be tardy on days
when he needs to take longer showers to relieve pain. Tr.
295. Dr. Puentes provided a note indicating M.C. should be
allowed to be tardy “at most 2 times a week due to
flare up of joint pain.” Tr. 296. She encouraged
Prather to call any time M.C. would be tardy so they could
keep a record of the frequency. Tr. 296.
February 2012, M.C. returned to Dr. Warnick and stated
“his shoulder has completely resolved, [but] he has
developed right knee, right hip, and right ankle pain.”
Tr. 311. Dr. Warnick observed M.C. had started baseball
within the previous two weeks, “which seemed to
exacerbate this pain.” Tr. 311. He observed mild
tenderness to palpation but normal gait. Tr. 311. He stated,
“The treatment for [M.C.'s] knee, hip, and ankle
are stretching and strengthening exercises” and advised
M.C. to continue taking medication as prescribed. Tr. 312.
twice a week from February to April 2012 and again a few
times in May 2012, M.C. participated in physical therapy. Tr.
October 2012, M.C. returned to Dr. Nickeson complaining of
continuing joint pain. Tr. 423-24. Dr. Nickeson observed no
problems in M.C.'s arms and “2-plus” swelling
in his ankles, and he advised him to continue taking
prednisone at the current dose for another three to four
weeks and reduce the dose after that. Tr. 423.
January 2013, M.C. returned to Dr. Nickeson. Tr. 421. Dr.
Nickeson observed he continued to experience ankle, knee, and
wrist swelling, had been playing “a number of
instruments, including piano, guitar, sax[ophone], and
ukulele, ” was teaching computer skills to other
people, wanted to play more baseball, and was intermittently
participating in homebound education. Tr. 421. He observed
M.C.'s arthritis was not responding well to current
medication, so he introduced weekly methotrexate injections.
September 2013, M.C. returned to Dr. Nickeson and reported
“feeling better with methotrexate” and having
more pep. Tr. 419. Dr. Nickeson observed he had been playing
baseball with friends, enjoyed being in the outfield, and
intended to practice pitching. Tr. 419. He observed swelling
in the elbows, small hand joints, ankles, and right knee. Tr.
419. He concluded, “[M.C.] is doing well with
methotrexate. I think we could push the dose higher, due to
his size.” Tr. 419.
December 2013, M.C. returned to Dr. Nickeson. Tr. 415. Dr.
Nickeson observed, “Energy is good and is increased
with slight raising of his methotrexate dose. He is playing
baseball and is more active. He is down 15 pounds from last
year with increase in activity. He is not complaining of
nausea.” Tr. 415. He concluded, “Assessment is
good arthritis control.” Tr. 415. He reduced the
prednisone dose and left the methotrexate dose unchanged. Tr.
April 2014, M.C. returned to Dr. Nickeson reporting his right
shoulder (his “biggest problem” since October
2013) had improved over the previous month. Tr. 417. Dr.
Nickeson observed M.C. had been off methotrexate around that
time because Prather had had difficulty keeping up with
refills due to a combination of transportation and insurance
problems. Tr. 417. At the time of examination, he was taking
prednisone daily, methotrexate weekly, and Tylenol as needed.
Tr. 417. Dr. Nickeson observed he had limited range of motion
of the right shoulder but could “extend both arms over
his head pretty well.” Tr. 417. A joint exam showed
“no particular problems except for [mild] swelling in
the right wrist” and swelling in the knees and ankles.
Tr. 417. He maintained M.C. on the same methotrexate dose and
reduced the prednisone dose. Tr. 418.
2012, Pauline Correia, M.C.'s eighth-grade exceptional
student education (“ESE”) teacher for math and
language arts, completed a questionnaire. Tr. 165-67. She
stated she sees him twice each school day, and he is on grade
level for reading, math, and written language. Tr. 165. She
stated he has an unusual absenteeism “[d]ue to his
illness-Sjogrens' [sic]; migraine headaches[;]
arthritis.” Tr. 165.
domain of acquiring and using information, Ms. Correia opined
M.C. has an obvious problem expressing ideas in written form,
stating, “Due to stiffness in joints, difficulty
holding writing instruments.” Tr. 166.
domain of attending and completing tasks, Ms. Correia opined
M.C. has obvious problems weekly with completing class or
homework assignments and working at a reasonable pace and
finishing on time. Tr. 167. She stated, “The student is
independent, however, due to physical difficulties, [he]
cannot write at an excellerated [sic] pace and in a large
amount for his grade level. For ex: can barely write 3 full
sentences during written assignments.” Tr. 167.
domain of moving about and manipulating objects, Ms. Correia
opined M.C. has obvious problems moving his body from one
place to another and managing the pace of physical activities
or tasks. Tr. 169. She stated, “Dexterity is minimal
when grasping a pencil to write. Due to arthritis, kneeling,
sitting for long periods, standing, and crouching are painful
activities.” Tr. 169.
Correia opined M.C. has no observed problems in the domains
of interacting and relating with others and caring for
himself. Tr. 168, 170.
domain of health and physical well-being, in response to the
question asking her to describe “any chronic or
episodic condition” and whether its physical effects
interfere with his functioning, she responded, “none
seen at school.” Tr. 171. She stated M.C. “has
morning stiffness causing severe difficulties in moving with
pain. There may be some mornings when he arrives tardy as a
result. Very unpredictable and unavoidable physical
state.” Tr. 171.
in June 2012, state-agency medical consultant Dr. Edith Davis
opined M.C. has severe impairments of inflammatory arthritis,
Sjögren's syndrome, and asthma. Tr. 44. She opined
he has less-than-marked limitations in the domains of moving
about and manipulating objects and health and physical
well-being, and no limitations in the domains of acquiring
and using information, attending and completing tasks,
interacting and relating with others, and caring for himself.
Tr. 44- 45. Regarding moving about and manipulating objects,
she stated, “There may be limitations due to painful
joints. Teacher Questionnaire: difficulty writing at a fast
pace.” Tr. 45. On health and physical well-being, she
14 yr old boy with dx of JRA, Sj[ö]gren's Syndrome.
Sinding-larsen-johnson syndrome of rt knee. Bursitis of rt
hip & rt ankle stain [sic]. Responding to present
treatment. OrthoPedic OV: 2/24/12: Rt shoulder pain
resolved[.] Has rt knee, rt hip, & rt [ankle] pain. PE:
Tenderness over inferior pole of patell [sic] & tendon.
Mildly tenderness [sic] on rt trochanter. Tenderness of
anterior talofibular lig[a]ment. Nl gait. No joint effusion.
X-Ray of pelvis: WNL. Plan: Strengthening exercises. f/u PRN.
12/9/11 Rhe[u]matology OV: Has dry eyes, not daily. Has tear
production. Joint pains about 2 days a week. Wt
111kg@>97%. Ht 175cm @ 50%. PE: Joint[s] are not showing a
lot of swelling in hand or lower extremities. Less than
October 2012, state-agency medical consultant Dr. Shakra
Junejo found the same severe impairments and limitations in
the functional domains. Tr. 54-55. For the domain of health
and physical well-being, besides the evidence Dr. Davis
cited, she cited new ...