Right Knee Arthritis and Status Post Cervical Spine Fusion with a history of Failed Wire Stabilization.

Among the issues raised by the claimant in his court appeal was that the Administrative Law Judge failed to include all of his impairments in the residual functional capacity finding and in hypothetical questions posed to the vocational expert.

After a comprehensive musculoskeletal evaluation, the claimant’s doctor concluded that his cervical range of motion was severely impaired, including abilities to tilt head forward, to tilt head back, right side bend and left side bend.  Additionally, the claimant’s range of motion for right and left rotations was ten degrees, compared to a normal range of motion of eighty degrees.  The court noted: “Accordingly, Dr. Grunwald opined that plaintiff ‘demonstrates a severely restricted range of motion in the cervical region.’. . . The ALJ gave Dr. Grunwald’s findings ‘great weight.’”

The court stated that in the ALJ’s residual functional capacity assessment, “there are no explicit limitations regarding [the claimant’s] limited cervical range of motion despite the fact that the ALJ gave great weight to the opinion of Dr. Grunwald.”

The court found: “As a primary matter, the ALJ failed to adequately incorporate [the claimant’s] severely limited cervical range of motion into the RFC. As was clearly demonstrated by the VE’s testimony, workplace dangers are not the only issues presented to a person with a limited cervical range of motion. Such limitations preclude the ability to perform a great number of jobs, including, all jobs in the sedentary category. Second, in light of the fact that plaintiff is required to have a sit/stand option because of his knee problems, there is no reason to believe that plaintiff could perform the jobs identified by the ALJ from a seated position in light of his limitations.”

The court ruled that the ALJ’s failed to include “explicit limitations concerning [the claimant’s] cervical range of motion in his RFC and in the dispositive hypothetical . . . .”   Because the court concluded that “this issue is determinative on the question of disability,” the ALJ decision was reserved and remanded for an award of benefits.

ANALYSIS

Social Security requires an ALJ to provide a function-by-function assessment pursuant to 20 CFR 404.1545 and 416.945 and a narrative discussion, citing the evidence and medical facts as required by SSR 96-8p based upon all of the relevant evidence of the claimant’s ability to do work-related activities.  The residual functional capacity assessment is used to determine whether a claimant can perform his past relevant work and any other type of work in the national economy.  20 CFR 404.1520(f)(g), 416.920(f)(g).

Oliver v. Commissioner of Social Security, Case No. 1:12-cv-02143-HA (D. Ore., Medford Div., Feb. 27, 2014).

 

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