# Gonzalez v. Sauls

> District Court, S.D. Texas · January 29, 2021

URL: https://www.frixlaw.com/law-library/cases/10674122

## Case

- **Court:** District Court, S.D. Texas
- **Decided:** January 29, 2021
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10674122

## How later opinions describe it (automated extraction)

- rejecting claimant’s argument that both hands must meet the handling and fingering requirement in the DOT job description

## Opinion text

IN THE UNITED STATES DISTRICT COURT January 29, 2021
FOR THE SOUTHERN DISTRICT OF TEXAS Nathan Ochsner, Clerk
HOUSTON DIVISION

RICHARD GONZALEZ, §
§
Plaintiff, §
§
v. § Civil Action No.: 4:20-cv-00372
§
ANDREW SAUL, §
COMMISSIONER OF THE §
SOCIAL SECURITY ADMINISTRATION, §
§
Defendant. §

MEMORANDUM AND ORDER
Gonzalez filed the present action under the Social Security Act, 42 U.S.C. §§ 405(g) for
review of the Commissioner’s final decision denying his request for supplemental security income.
Gonzalez and the Commissioner filed cross-motions for summary judgment. ECF 11, 13. Having
considered the parties’ filings, the record, and the law, Gonzalez’s Motion (ECF 11) is DENIED,
the Commissioner’s Motion (ECF 13) is GRANTED, and the final decision of the Commissioner
is AFFIRMED.1
I. Background
1. Procedural History
Gonzalez filed a Title II application for disability insurance benefits and a Title XVI
application for supplemental security income on July 20, 2017. Tr. 11, 184-196. Following the
denial of his applications and subsequent request for reconsideration, Gonzalez requested a hearing
before an Administrative Law Judge (“ALJ”). Tr. 124-26. During the November 27, 2018 hearing

1 The parties have consented to the jurisdiction of this Magistrate Judge for all purposes, including entry of final
judgment. ECF 9.
before the ALJ, Gonzalez amended his disability onset date to October 31, 2018, effectively
withdrawing his Title II disability benefits claim.2 Tr. 11, 27, 48. Therefore, only the denial of
his application under Title XVI is at issue in this case.
Gonzalez and a vocational expert testified at the hearing. Tr. 24-49. The ALJ issued a

decision finding that, from the date of alleged onset of disability (October 31, 2018) through the
date of the decision (February 14, 2019), Gonzalez was not disabled within the meaning of the
Social Security Act. Tr. 11-18. The Appeals Council denied review on November 14, 2019 and
the ALJ’s decision became the final decision of the Commissioner. Tr. 1; see 20 C.F.R. §§
404.981, 416.1481.
2. Standard for Review of the Commissioner’s Decision
Federal court review of the Commissioner’s final decision to deny Social Security benefits

is limited to two inquiries: (1) whether the Commissioner applied the proper legal standard and (2)
whether the Commissioner’s decision is supported by substantial evidence. Garcia v. Berryhill,
880 F.3d 700, 704 (5th Cir. 2018); Copeland v. Colvin, 771 F.3d 920, 923 (5th Cir. 2014) (citations
omitted). When reviewing the Commissioner’s decision, the court does not reweigh the evidence,
try the questions de novo, or substitute its own judgment for that of the Commissioner. Masterson
v. Barnhart, 309 F.3d 267, 272 (5th Cir. 2002) (citing Newton v. Apfel, 209 F.3d 448, 452 (5th Cir.
2000)). Conflicts in the evidence are for the Commissioner to resolve, not the courts. Id.
3. Disability Determination Standards
The Social Security Act defines “disability” as the “inability to engage in any substantial

gainful activity by reason of any medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be expected to last for a continuous period

2 Gonzalez’s date last insured for Title II disability insurance benefits was December 31, 2012. Tr. 11, 48.
of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). The ALJ must follow a five-step sequential
analysis to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920.
At the first step, the ALJ decides whether the claimant is currently working or “doing
substantial gainful activity.” Id. at §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If so, the claimant is

not disabled. At the second step, the ALJ must determine whether the claimant has a severe
impairment. Id. at §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). If the claimant’s impairment does not
have a de minimis impact on her ability to work, she is not disabled. Salmond v. Berryhill, 892
F.3d 812, 817 (5th Cir. 2018). The third step of the sequential analysis requires the ALJ to
determine whether the claimant’s severe impairment meets or medically equals one of the listings
in the regulation known as Appendix 1. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii); 20
C.F.R. pt. 404, subpt. p, app. 1. If so, the claimant is disabled. If not, the ALJ must determine the
claimant’s “residual functional capacity” (RFC). “The RFC is the individual’s ability to do
physical and mental tasks on a sustained basis despite limitations from her impairments.” Giles v.
Astrue, 433 F. App’x 241, 245 (5th Cir. 2011). At step four, the ALJ determines whether the

claimant’s RFC permits her to perform her past relevant work. 20 C.F.R. §§ 404.1520(a)(4)(iv),
416.920(a)(4)(iv). If the answer is no, the ALJ determines at step five whether the claimant can
perform other work that exists in the national economy. Fraga v. Bowen, 810 F.2d 1296, 1304
(5th Cir. 1987). The claimant bears the burden to prove disability at steps one through four, but
the burden shifts to the Commissioner at step five. Newton v. Apfel, 209 F.3d 448, 452-53 (5th
Cir. 2000).
4. The ALJ’s Decision
The ALJ performed the standard five-step sequential analysis, finding Gonzalez had not
engaged in substantial gainful activity since his alleged onset date of October 31, 2018 and had
the severe impairments of “left Achilles ankle rupture, history of bilateral hip arthritis, history of
low back arthritis, and history of right hand carpal tunnel syndrome.” Tr. 13. The ALJ also noted
Gonzalez’s non-severe mental impairments of depression, post-traumatic stress disorder
(“PTSD”), and generalized anxiety disorder. Id. The ALJ determined at step three that none of

Gonzalez’s impairments, alone or in combination, met or equaled the severity of one of the listed
impairments in Appendix 1. Tr. 15. The ALJ found Gonzalez has the RFC to perform light work
except he can occasionally climb ramps and stairs; occasionally climb ladders,
ropes, and scaffolds; and occasionally balance, stoop, kneel, crouch, and crawl.
Id. Based on the medical records, opinions, and testimony of the vocational expert, the ALJ
determined Gonzalez can perform his past relevant work as a small business owner. Tr. 17. For
that reason, the ALJ concluded Gonzalez had not been under a disability from October 31, 2018
through the date of her decision. Id.
II. Analysis
Gonzalez argues the ALJ’s RFC determination is not supported by substantial evidence
because she did not include limitations to accommodate for carpal tunnel syndrome despite having
found it to be a severe impairment at step 2 of the sequential analysis. ECF 11 at 5-8. As always,
the Court’s inquiry is limited to a determination of whether there is substantial evidence in the
record to support the ALJ’s findings and whether the proper legal standards have been applied.
See Maharajh v. Barnhart, 424 F. Supp. 2d 915, 925 (S.D. Tex. 2006) (citations omitted).
1. The ALJ’s RFC determination is supported by substantial evidence.

The “RFC assessment is a determination of the most the claimant can still do despite his
physical and mental limitations and is based on all relevant evidence in the claimant's record.”
Perez v. Barnhart, 415 F.3d 457, 462 (5th Cir. 2005) (citing 20 C.F.R. § 404.1545(a)(1)). In
assessing Gonzalez’s RFC, the ALJ properly considered Gonzalez’s subjective complaints and
symptoms, the objective medical record, and the medical opinions given by the state agency
consultants in the record.
Gonzalez’s Subjective Complaints and Symptoms. The ALJ is required to make an
affirmative finding regarding a claimant’s subjective complaints and her finding is entitled to

deference. Chambliss v. Massanari, 269 F.3d 520, 522 (5th Cir. 2001) (citations omitted); Lewis
v. Barnhart, 460 F. Sipp. 2d 771, 785 (S.D. Tex. 2006) (citations omitted). During the disability
hearing, Gonzalez testified that he uses braces to alleviate the carpal tunnel syndrome in his right
hand. Tr. 27. He is left-hand dominant. Id. At the time of the hearing, Gonzalez testified he was
driving around two or three hours per day for Uber. Tr. 30. He testified he was unable to drive
for longer periods because he would develop numbness in his hands after holding the steering
wheel for too long. Id.
The ALJ’s written decision makes clear she considered Gonzalez’s statements about his
symptoms and subjective complaints, but found they were not entirely consistent with the objective
medical record, which is discussed below, and other evidence in the record. Tr. 15. For example,

the ALJ pointed out that Gonzalez did not seek medical treatment for carpal tunnel syndrome or
any other impairment during the relevant period, October 31, 2018 through February 14, 2019. Tr.
15-16. The ALJ also pointed out that Gonzalez’s allegations regarding the severity of his
impairments are inconsistent with his activities of daily living. Tr. 17.
The Objective Medical Record. Gonzalez consistently reported carpal tunnel syndrome as
part of his medical history (Tr. 703, 953, 693), but his medical records show he did not seek
treatment for symptoms related to carpal tunnel syndrome until May 2018. On May 2, 2018, a
doctor at the Houston VA clinic assessed “possible” right hand carpal tunnel syndrome and
referred him to an occupational therapist. Tr. 1176-77. He was seen by an occupational therapist
on May 9, 2018. Tr. 1012. Gonzalez stated his symptoms affected his ability to hold a telephone
and reach overhead but that he was independent with respect to his activities of daily living. Tr.
1012-13. He did not mention any other limitations in his activities. During his May 9, 2018
examination, Gonzalez had a normal range of motion in his wrists but showed some symptoms

“consistent with” carpal tunnel syndrome. Id. The occupational therapist issued a wrist brace to
be worn at night for treatment of his symptoms. Id. In August 2018, Gonzalez was seen again at
the VA clinic for right thumb pain. Tr. 1106. Gonzalez did not seek treatment specifically for
carpal tunnel syndrome at this visit but reported a history of carpal tunnel syndrome for which he
was using a night brace. Tr. 1109. In September 2018, Gonzalez still complained of issues with
his right hand and raised concern about the effectiveness of his wrist braces, but reported he was
independent with his activities of daily living. Tr. 983. His range of motion was within normal
limits, but the examining physician assessed him with “possible carpal tunnel syndrome” and
referred him to occupational therapy for a home exercise plan, pain control methods, and braces.
Tr. 986. At this time, Gonzalez’s physician “anticipate[d] that [Gonzalez] will improve after the

above interventions.” Id. A few days later, a different physician assessed Gonzalez with “likely
carpal tunnel syndrome” and instructed him to complete an electromyelogram and nerve
conduction study. Tr. 990. No results from the recommended tests are included in the record. See
Tr. 28 (counsel indicated at hearing that Gonzalez was “going to undergo a[n] EMG.”). Again,
Gonzalez was simply given additional braces and instructed to treat his pain with Ibuprofen as
needed. Tr. 990. On September 27, 2018, Gonzalez saw an occupational therapist once more and
complained of right hand pain and decreased grip strength due to thumb pain. Tr. 976-77.
Gonzalez was again issued braces and assessed as having good rehabilitation potential. Tr. 977.
Gonzalez has not sought to update the record with medical records dated after September 2018.
No physician ever conclusively diagnosed Gonzalez with carpal tunnel syndrome and no
physician ever imposed limitations on his activities due to carpal tunnel syndrome. The medical
records establish that Gonzalez received only conservative treatment such as braces, therapy, and
over-the-counter medication to treat his possible carpal tunnel syndrome. Gonzalez’s physicians

consistently noted that Gonzalez was likely to improve with conservative intervention. Finally,
despite his complaints at the November 2018 hearing of limiting pain, Gonzalez did not seek
treatment after September 2018. Gonzalez’s medical records support ALJ’s RFC determination
with respect to his carpal tunnel syndrome. See Muniz v. Colvin, No. EP-14-CV-122-ATB, 2015
WL 5062303, at *7 (W.D. Tex. Aug. 27, 2015) (“As the record contains few limitations and
conservative treatment, the Court finds that [the claimant’s] medical records . . . provide substantial
evidence supporting the ALJ’s RFC determination.”).
The State Agency Consultant Opinions. The ALJ is required to consider the opinions of
state agency medical consultants and explain the weight assigned to them because they are “highly
qualified experts in Social Security disability evaluation.” 20 C.F.R. § 404.1513a(b)(1); SSR 96-

6p, 1996 WL 374180, at *2 (Jul. 2, 1996); see also Wycoff v. Berryhill, No. 4:18-CV-885, 2019
WL 699995, at *4 (S.D. Tex. Feb. 19, 2019) (citations omitted). Here, the ALJ considered the
opinions of state agency medical consultants Dr. Scott Spoor and Dr. Randal Reid. Tr. 16-17.
On October 6, 2017, Dr. Spoor opined that Gonzalez retained the ability to occasionally
lift and/or carry 50 pounds; frequently lift and/or carry 25 pounds; and stand, walk, and sit for
about 6 hours in an 8 hour workday. Tr. 57. Dr. Spoor opined that Gonzalez had no postural,
manipulative, visual, communicative, or environmental limitations. Id. On December 6, 2017,
Dr. Reid gave an identical opinion of Gonzalez’s ability, except he added postural limitations that
Gonzalez could only occasionally climb ramps/stairs, climb ladders/ropes/scaffolds, balance,
stoop, kneel, crouch, and crawl. Tr. 82. The ALJ’s written decision makes clear she considered
the opinions given by Dr. Spoor and Dr. Reid. Tr. 16. With respect to Dr. Spoor’s opinion, the
ALJ noted that the opinion was less persuasive and consistent with the longitudinal medical record
because it omitted any postural limitations. Id. In contrast, the ALJ found Dr. Reid’s opinion to

be persuasive and consistent with the record and, therefore, assigned it greater weight. Id.
Gonzalez argues that, although his carpal tunnel syndrome was mentioned in records
created prior to Dr. Reid’s opinion, the extent of his impairments caused by his carpal tunnel were
not known to Dr. Reid at the time of his opinion. ECF 11 at 7. He suggests that medical records
from appointments following Dr. Reid’s opinion establish that he had greater restrictions due to
his carpal tunnel syndrome than accounted for by Dr. Reid. However, the ALJ clearly considered
Gonzalez’s carpal tunnel syndrome and the medical records following Dr. Reid’s opinion in
determining Gonzalez’s RFC. Tr. 16. The ALJ weighed that evidence and determined Gonzalez’s
functional limitations are captured by the RFC she described in the written decision. The ALJ is
only required to include in the RFC limitations that are supported by the record. See Elam v.

Astrue, Civil Action No. 4:11-3587, 2012 WL 5381781, at *7 (S.D. Tex. Oct. 31, 2012) (rejecting
argument that the ALJ failed to account for an impairment in the RFC where the ALJ considered
the evidence regarding the impairment and made an RFC determination that was supported by
substantial evidence). Gonzalez’s argument that the ALJ substituted her own lay opinion for that
of medical experts actually complains about the ALJ’s proper weighing of the medical evidence
to determine Gonzalez’s capacity for work. See Taylor v. Astrue, 706 F.3d 600, 603 (5th Cir.
2012) (“What Taylor characterizes as the ALJ substituting his opinion is actually the ALJ properly
interpreting the medical evidence to determine his capacity for work.”).
Further, Gonzalez cannot show any prejudice from the ALJ’s reliance on the state agency
consultant’s opinion for her RFC determination. Gonzalez argues by implication that had Dr. Reid
considered his 2018 medical records Dr. Reid, and by extension the ALJ, would have reached a
different conclusion. Yet, as discussed above, the ALJ considered those records and concluded

they do not support any additional limitations on Gonzalez’s functional capabilities. No diagnostic
tests or other objective medical evidence in the record support additional functional restrictions.
See Bentley v. Colvin, Civil Action No. 3:13-CV-4238-P (BH), 2015 WL 5836251, at *12–13
(N.D. Tex. Mar. 5, 2015), report and recommendation adopted as modified, 2015 WL 5836029
(N.D. Tex. Sept. 30, 2015) (finding no error when the ALJ relied on a state agency medical
consultant’s opinion that predated some of the medical evidence in the absence of a showing that
an updated RFC assessment would have included more limitations).
Moreover, Gonzalez cannot show prejudice because he has presented no medical evidence
supporting any impairment involving his left hand. The DOT job description relied upon by the
vocational expert and cited in Gonzalez’s summary judgment brief, DOT number 185.167-046 for

retail store manager, does not include a requirement for bilateral handling and does not have a
requirement for grasping, which is the specific limitation Gonzalez contends should have been
included in his RFC. ECF 11 at 7; see Selected Characteristics of Occupations Defined in the
Revised Dictionary of Occupational Titles (SCO), App. D (1993), available at www. westlaw.com
(database SCODICOT); see also Carey v. Apfel, 230 F.3d 131 (5th Cir. 2000) (rejecting claimant’s
argument that both hands must meet the handling and fingering requirement in the DOT job
description); Ardoin v. Saul, Civil Action No. 4:19-cv-02022, 2020 WL 2934814, at *8 (S.D. Tex.
June 3, 2020) (rejecting claimant’s argument that his left hand limitations precluded his
performance of the jobs identified by the vocational expert because the DOT did not require
bilateral handling and fingering).
2. The ALJ’s RFC determination is not inconsistent with her severity determination.

Gonzalez also argues briefly that the ALJ erred by finding at step two that Gonzalez had a
severe impairment of carpal tunnel syndrome but failing to include a limitation in the RFC to
account for carpal tunnel syndrome. ECF 11 at 7. However, “having a severe impairment is not
a sufficient condition for receiving benefits under the Secretary’s regulations,” but “means only
that [the] claimant has passed the second step of the inquiry mandated by the regulations.”
Kozlowski v. Colvin, No. 4:13-CV-020-A, 2014 WL 948653, at *5 (N.D. Tex. Mar. 11, 2014)
(quoting Shipley v. Sec. of Health & Human Servs., 812 F.2d 934, 935 (5th Cir. 1987)). “In other
words, the consideration of whether a claimant’s impairments are severe at Step Two is a different
inquiry than an ALJ’s assessment of the RFC.” Id. at *5 (citations omitted). Therefore, the ALJ
did not err by finding at Step Two that Gonzalez’s carpal tunnel syndrome is severe but failing to
include specific limitations in the RFC based on that impairment. See id. (finding an ALJ did not

err by finding at step two that a claimant has a severe impairment of carpal tunnel syndrome but
failing to include limitations in the RFC to account for that impairment).
III. Conclusion
The ALJ did not err and substantial evidence supports the RFC determination. Therefore,
the ALJ’s decision on disability should be upheld. See Greenspan v. Shalala, 38 F.3d at 237
(“Substantial evidence supports the ALJ’s decision to disregard the [treating] physician’s
conclusions. That basis is enough to survive [the Court’s] review.”); see Chambliss v. Massanari,
269 F.3d at 522 (“[W]hether an applicant is able to work despite some pain is within the province
of the administrative agency and should be upheld if supported by substantial evidence.”).
Gonzalez’s Motion is DENIED and the Commissioner’s decision denying benefits is
AFFIRMED.
Signed on January 29, 2021 at Houston, Texas.

Christina A. Bryan
United States Magistrate Judge

11

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10674122. Public record. Not legal advice.