# Elledge v. Social Security Administration, Commissioner

> District Court, N.D. Alabama · January 24, 2020

URL: https://www.frixlaw.com/law-library/cases/9989194

## Case

- **Court:** District Court, N.D. Alabama
- **Decided:** January 24, 2020
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
NORTHEASTERN DIVISION

KARI ELLEDGE, }
}
Plaintiff, }
}
v. } Case No.: 5:19-cv-00176-MHH
}
ANDREW SAUL, Commissioner of }
the Social Security Administration, }
}
Defendant. }

MEMORANDUM OPINION
Pursuant to 42 U.S.C. §§ 405(g) and 1383(c), plaintiff Kari Elledge seeks
judicial review of a final adverse decision of the Commissioner of Social Security.
The Commissioner denied Ms. Elledge’s claims for disability insurance benefits and
supplemental security income. After careful review, the Court affirms the
Commissioner’s decision.
I. PROCEDURAL HISTORY
Ms. Elledge applied for disability insurance benefits and supplemental
security income. (Doc. 6-4, pp. 54, 55). Ms. Elledge alleges that her disability began
on December 2, 2017. (Doc. 6-4, pp. 54, 55). The Commissioner initially denied
Ms. Elledge’s claims. (Doc. 6-4, pp. 54, 55). Ms. Elledge requested a hearing before
an Administrative Law Judge (ALJ). (Doc. 6-5, p. 16). The ALJ issued an
unfavorable decision. (Doc. 6-3, pp. 24-38). The Appeals Council declined Ms.
Elledge’s request for review, making the Commissioner’s decision final for this

Court’s judicial review. (Doc. 6-3, p. 2). See 42 U.S.C. §§ 405(g) and 1383(c).
II. STANDARD OF REVIEW
The scope of review in this matter is limited. “When, as in this case, the ALJ

denies benefits and the Appeals Council denies review,” the Court “review[s] the
ALJ’s ‘factual findings with deference’ and her ‘legal conclusions with close
scrutiny.’” Riggs v. Comm’r, Soc. Sec. Admin., 522 Fed. Appx. 509, 510-11 (11th
Cir. 2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).

The Court must determine whether there is substantial evidence in the record
to support the ALJ’s factual findings. “Substantial evidence is more than a scintilla
and is such relevant evidence as a reasonable person would accept as adequate to

support a conclusion.” Crawford v. Comm’r, Soc. Sec. Admin., 363 F.3d 1155, 1158
(11th Cir. 2004). In evaluating the administrative record, the Court may not “decide
the facts anew, reweigh the evidence,” or substitute its judgment for that of the ALJ.
Winschel v. Comm’r, Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011)

(internal quotations and citation omitted). If substantial evidence supports the ALJ’s
factual findings, then the Court “must affirm even if evidence preponderates against
the Commissioner’s findings.” Costigan v. Comm’r, Soc. Sec. Admin., 603 Fed.

Appx. 783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158).
With respect to the ALJ’s legal conclusions, the Court must determine
whether the ALJ applied the correct legal standards. If the Court finds an error in

the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide
sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis,
then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d

1143, 1145-46 (11th Cir. 1991).
III. SUMMARY OF THE ALJ’S DECISION
To determine whether a claimant has proven disability, an ALJ follows a five-
step sequential evaluation process. The ALJ considers:

(1) whether the claimant is currently engaged in substantial gainful activity;
(2) whether the claimant has a severe impairment or combination of
impairments; (3) whether the impairment meets or equals the severity of the
specified impairments in the Listing of Impairments; (4) based on a residual
functional capacity (“RFC”) assessment, whether the claimant can perform
any of his or her past relevant work despite the impairment; and (5) whether
there are significant numbers of jobs in the national economy that the claimant
can perform given the claimant’s RFC, age, education, and work experience.

Winschel, 631 F.3d at 1178.
In this case, the ALJ found that Ms. Elledge meets the insured status
requirements through December 31, 2022. (Doc. 6-3, p. 12). Ms. Elledge has not
engaged in substantial gainful activity since December 2, 2017, the alleged onset
date. (Doc. 6-3, p. 12). The ALJ determined that Ms. Elledge suffers from the severe
impairment of degenerative disc disease and the non-severe impairments of anxiety
and depression. (Doc. 6-3, pp. 12, 13). Based on her review of the medical evidence,
the ALJ found that Ms. Elledge does not have an impairment or combination of
impairments that meets or medically equals the severity of the listed impairments in

20 C.F.R. Part 404, Subpart P, Appendix 1. (Doc. 6-3, p. 14).
The ALJ determined that Ms. Elledge has the residual functional capacity to
perform light work. (Doc. 6-3, p. 14). “Light work involves lifting no more than 20

pounds at a time with frequent lifting or carrying of objects weighing up to 10
pounds.” 20 C.F.R. §§ 404.1567(b), 416.967(b). The ALJ found that Ms. Elledge
is able:
to lift/carry 20 pounds occasionally and 10 pounds frequently; she can
sit, stand and walk for 6 hours total each; she can never climb
ladders/ropes/scaffolds and can occasionally perform all other postural
activities. The claimant must avoid all exposure to workplace hazards
such as unprotected heights and dangerous machinery.

(Doc. 6-3, p. 14). The ALJ concluded that Ms. Elledge is able to perform her past
relevant work as a floral designer and deliverer. (Doc. 6-3, p. 17).
Relying on testimony from a vocational expert, the ALJ found that other jobs
existed in the national economy that Ms. Elledge could perform, including
photocopy operator, product marker, and assembler. (Doc. 6-3, p. 18). Accordingly,
the ALJ denied Ms. Elledge’s disability claims. (Doc. 6-3, pp. 18-19).
IV. ANALYSIS
Ms. Elledge argues that the ALJ erred in denying her claims because the ALJ

misapplied the Eleventh Circuit pain standard; the ALJ did not give appropriate
weight to the opinion of Ms. Elledge’s treating physician, Dr. Walker; and the ALJ
did not base her RFC determination on substantial evidence. (Doc. 8, pp. 2-3).

Because substantial evidence supports the ALJ’s analysis of Ms. Elledge’s pain
testimony, Dr. Walker’s opinion, and Ms. Elledge’s RFC, the Court affirms the
Commissioner’s decision.

A. Pain Standard
The Eleventh Circuit pain standard “applies when a disability claimant
attempts to establish disability through his own testimony of pain or other subjective
symptoms.” Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991); Coley v.

Comm’r, Soc. Sec. Admin., No. 18-11954, 2019 WL 1975989, at *3 (11th Cir. May
3, 2019). When relying upon subjective symptoms to establish disability, “the
claimant must satisfy two parts of a three-part test showing: (1) evidence of an

underlying medical condition; and (2) either (a) objective medical evidence
confirming the severity of the alleged [symptoms]; or (b) that the objectively
determined medical condition can reasonably be expected to give rise to the claimed
[symptoms].” Wilson v. Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002) (citing

Holt, 921 F.2d at 1223); Chatham v. Comm’r, Soc. Sec. Admin., No. 18-11708, 2019
WL 1758438, at *2 (11th Cir. Apr. 18, 2019) (citing Wilson). If the ALJ does not
properly apply the three-part standard, reversal is appropriate. McLain v. Comm’r,

Soc. Sec. Admin., 676 Fed. Appx. 935, 937 (11th Cir. 2017) (citing Holt).
A claimant’s credible testimony coupled with medical evidence of an
impairing condition “is itself sufficient to support a finding of disability.” Holt, 921

F.2d at 1223; see Gombash v. Comm’r, Soc. Sec. Admin., 566 Fed. Appx. 857, 859
(11th Cir. 2014) (“A claimant may establish that he has a disability ‘through his own
testimony of pain or other subjective symptoms.’”) (quoting Dyer v. Barnhart, 395

F.3d 1206, 1210 (11th Cir. 2005)). If an ALJ rejects a claimant’s subjective
testimony, the ALJ “must articulate explicit and adequate reasons for doing so.”
Wilson, 284 F.3d at 1225; Coley, 2019 WL 1975989, at *3. As a matter of law, the
Secretary must accept the claimant’s testimony if the ALJ inadequately or

improperly discredits the testimony. Cannon v. Bowen, 858 F.2d 1541, 1545 (11th
Cir. 1988); Kalishek v. Comm’r, Soc. Sec. Admin., 470 Fed. Appx. 868, 871 (11th
Cir. 2012) (citing Cannon); see Hale v. Bowen, 831 F.2d 1007, 1012 (11th Cir. 1987)

(“It is established in this circuit if the Secretary fails to articulate reasons for refusing
to credit a claimant’s subjective pain testimony, then the Secretary, as a matter of
law, has accepted that testimony as true.”).
When credibility is at issue, the provisions of Social Security Regulation 16-

3p apply. SSR 16-3p provides:
[W]e recognize that some individuals may experience symptoms
differently and may be limited by symptoms to a greater or lesser extent
than other individuals with the same medical impairments, the same
objective medical evidence, and the same non-medical evidence. In
considering the intensity, persistence, and limiting effects of an
individual’s symptoms, we examine the entire case record, including
the objective medical evidence; an individual’s statements about the
intensity, persistence, and limiting effects of symptoms; statements and
other information provided by medical sources and other persons; and
any other relevant evidence in the individual’s case record.

SSR 16-3p, 2016 WL 1119029, at *4. An ALJ must explain the basis for findings
relating to a claimant’s description of symptoms:
[I]t is not sufficient . . . to make a single, conclusory statement that “the
individual’s statements about his or her symptoms have been
considered” or that “the statements about the individual’s symptoms are
(or are not) supported or consistent.” It is also not enough . . . simply
to recite the factors described in the regulations for evaluating
symptoms. The determination or decision must contain specific reasons
for the weight given to the individual’s symptoms, be consistent with
and supported by the evidence, and be clearly articulated so the
individual and any subsequent reviewer can assess how the adjudicator
evaluated the individual’s symptoms.

SSR 16-3p, 2016 WL 1119029, at *10. In evaluating a claimant’s reported
symptoms, an ALJ must consider:
(i) [the claimant’s] daily activities; (ii) [t]he location, duration,
frequency, and intensity of [the claimant’s] pain or other symptoms;
(iii) [p]recipitating and aggravating factors; (iv) [t]he type, dosage,
effectiveness, and side effects of any medication [the claimant] take[s]
or ha[s] taken to alleviate . . . pain or other symptoms; (v) [t]reatment,
other than medication, [the claimant] receive[s] or ha[s] received for
relief of . . . pain or other symptoms; (vi) [a]ny measures [the claimant]
use[s] or ha[s] used to relieve . . . pain or other symptoms (e.g., lying
flat on your back, standing for 15 to 20 minutes every hour, sleeping on
a board, etc.); and (vii) [o]ther factors concerning [the claimant’s]
functional limitations and restrictions due to pain or other symptoms.

20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3); Leiter v. Comm’r, Soc. Sec. Admin.,
377 Fed. Appx. 944, 947 (11th Cir. 2010).
Here, the ALJ found that Ms. Elledge’s medical records and daily activities
do not support her testimony regarding her pain and limitations. (Doc. 6-3, pp. 16-

17). Accordingly, the Court first examines Ms. Elledge’s testimony and then
compares her testimony to the medical evidence in the record and to the evidence
relating to her daily activities.

Ms. Elledge’s Testimony
Ms. Elledge was 53 years old on her alleged onset date in December 2017.
(Doc. 6-3, p. 17; Doc. 6-3, p. 40). Ms. Elledge has worked as a floral deliverer, a
warehouse clerk, and a floral designer. (Doc. 6-3, pp. 36-39). Ms. Elledge testified

that she had planned to buy the floral business from the owner for whom she was
working in November 2017, but that the plan “all fell apart” because of her
degenerative disc disease symptoms. (Doc. 6-3, pp. 35-36, 39).

According to Ms. Elledge, she cannot work because her back does not support
her “for any duration of time.” (Doc. 6-3, p. 43). Ms. Elledge described her
symptoms during the September 2018 administrative hearing:
My lower back, it fe[els] like my pelvis [i]s stuck forward and
then I ha[ve] all kind of pains going down into my legs. My feet hurt.
In my upper back something [has] popped. That [has gone] nuts. And
then my upper back [has] started hurting a lot and into my neck. I
ha[ve] had a headache every day. Honestly, it [has been] a progression.
It just seem[s] like everything just [has] [fallen] in line over the nine-
month period. It’s always different.

(Doc. 6-3, pp. 29, 43).
Ms. Elledge testified that no doctor has recommended back surgery. (Doc. 6-
3, p. 44). Ms. Elledge reported that she takes tramadol (one 50 mg tablet twice daily)

to manage pain, but she stated that the medication does not enough help. (Doc. 6-3,
pp. 44, 47).1 Ms. Elledge denied experiencing side effects. (Doc. 6-3, p. 44). Later,
Ms. Elledge testified that she falls asleep during the day, but she was uncertain

whether tramadol caused sleepiness. (Doc. 6-3, p. 47).
Ms. Elledge is single and lives with her teenage son. (Doc. 6-3, p. 40). Ms.
Elledge testified that she can drive, clean clothes with breaks, prepare meals, and
shop. (Doc. 6-3, pp. 41, 45-46). Ms. Elledge stated that her pastimes include

watching television, reading, and doodling. (Doc. 6-3, p. 42).
Ms. Elledge testified that her ability to shop decreased after she completed her
functional report in late December 2017—Ms. Elledge shops three times monthly

rather than multiple times weekly. (Doc. 6-7, p. 39; Doc. Doc. 6-3, p. 46).
Accordingly to Ms. Elledge, she stopped attending church after Easter 2018 because
the standing and kneeling periods were “too uncomfortable” for her lower back.

1 Tramadol “is a narcotic-like pain reliever. . . . used to treat moderate to severe pain in adults.”
https://www.drugs.com/tramadol.html (last visited Dec. 31, 2019). The Court does not see a
prescription for tramadol in Ms. Elledge’s medical records. The administrative hearing was held
on September 6, 2018. (Doc. 6-3, p. 29). Ms. Elledge’s record from her August 1, 2018 visit to
Tennessee Valley Pain Consultants does not mention tramadol in her list of prescription
medication. (Doc. 6-10, p. 24). As discussed below, multiple doctors refused Ms. Elledge’s
requests for narcotic pain relievers.
(Doc. 6-3, pp. 41, 42). Ms. Elledge did not testify about other post-report changes
in her daily functioning. (Doc. 6-3, p. 46).

Medical Records
1. Medical History
Ms. Elledge visited Dr. Walker, a primary care physician, in November 2017.

(Doc. 6-9, p. 20). She sought treatment for back pain. (Doc. 6-9, p. 20). Ms. Elledge
reported to Dr. Walker that she was in a car accident several years earlier and that
her work involved a lot of standing and leaning. (Doc. 6-9, p. 20). Ms. Elledge
stated that her pain improved with shifting and was “not too bad sitting[.]” (Doc. 6-

9, p. 20). According to Ms. Elledge, when she lied down at night, it took “a while
[for her] to get comfortable[.]” (Doc. 6-9, p. 20).
After examining Ms. Elledge, Dr. Walker detected no scoliosis, “no pain

elicited [from palpation]; no palpable muscle spasm; no crepitus; [and] no masses.”
(Doc. 6-9, p. 20).2 Dr. Walker observed that Ms. Elledge has a normal lordotic curve
and gait. (Doc. 6-9, p. 20). Dr. Walker reported that Ms. Elledge has a “limited

2 Crepitus “describes any grinding, creaking, cracking, grating, crunching, or popping that occurs
when moving a joint.” https://www.arthritis-health.com/types/general/what-crepitus (last visited
Jan. 9, 2020).
active [range of motion] with flexion.” (Doc. 6-9, p. 20). Dr. Walker performed a
straight leg test; the results were negative. (Doc. 6-9, p. 20).3

Dr. Walker diagnosed Ms. Elledge with low back pain, mild depression, and
anxiety. (Doc. 6-9, p. 20). Dr. Walker noted that Ms. Elledge was under “a bit of
extra stress [due to her] job closing” and her need to search for new employment.

(Doc. 6-9, p. 20).
Dr. Walker prescribed meloxicam (one to two 7.5 mg tablets daily for pain),
and Robaxin (one 500 mg tablet nightly for muscle spasms and pain). (Doc. 6-9, p.
18).4 Dr. Walker ordered an x-ray and MRI of Ms. Elledge’s back. (Doc. 6-9, pp.

21, 22, 24). Dr. Walker provided Ms. Elledge with an acute low back pain handout.
(Doc. 6-9, p. 21).
The mid-November 2017 x-ray results revealed:

FINDINGS: There is good alignment to the lumber spine. No
compressed vertebra. No subluxation. There is disc space narrowing
with small bone spurs at L5-S1.

3 Examiners use the straight leg raise test to evaluate patients “with low back pain and nerve pain
that radiates down the leg.” https://www.ebmconsult.com/articles/straight-leg-raising-test (last
visited Aug. 9, 2019).

4 Meloxicam is a nonsteroidal anti-inflammatory drug “used to treat arthritis . . . [and] reduce[]
pain, swelling, and stiffness of the joints.” https://www.webmd.com/drugs/2/drug-
911/meloxicam-oral/details (last visited Jan. 9, 2020).

Robaxin or methocarbamol is “a central nervous system (CNS) depressant and muscle relaxant
used to treat muscle spasms, tension, and pain.” It is not a narcotic but may be mistaken for one
“due to side effects like drowsiness and dizziness, which can feel like a drug ‘high.’”
https://www.healthline.com/health/is-methocarbamol-a-narcotic (last visited Jan. 9, 2020).
IMPRESSION:

Degenerative changes at L5-S1.

(Doc. 6-9, pp. 2, 22, 28).5 Dr. Walker’s assistant wrote on the x-ray results “arthritis
changes with some narrowing of space. Dr. Walker/aw[.]” (Doc. 6-9, p. 2).
The late November 2017 MRI results showed:
mild reversal of the upper lumbar curvature. There is a mild I
retrolisthesis of L5 on S1 most likely chronic and degenerative with
degenerative disc disease at this level. The remainder of the alignment
appears within the normal range.

There is disc desiccation present particularly at L2-3, L4-5, and L5-S1
and moderate disc space narrowing at L4-S1. The vertebral body
heights appear relatively intact allowing for minimal chronic anterior
wedging of L1 and L2. No acute or active compression fractures are
identified. There are scattered chronic Schmorl’s nodes also seen at
multiple lower thoracic and upper lumbar levels.

T12-L1: The disc appears relatively intact at this level allowing for a
small chronic Schmorl’s node. No significant posterior bulging disc or
any posterior disc herniation is identified. No neural foraminal
encroachment or spinal stenosis is seen.

L1-2: There is minimal diffuse posterior bulging of the disc at this
level. This does not cause any significant neural foraminal
encroachment or spinal stenosis. There are small Schmorl’s nodes also
seen at this level.

L2-3: There is minimal diffuse posterior bulging of the disc at this
level. This does not cause any significant neural foraminal
encroachment or spinal stenosis. There is a benign Schmorl’s node also
seen at this level.

5 Subluxation is the “[p]artial dislocation of a joint. A complete dislocation is a luxation.”
https://www.medicinenet.com/script/main/art.asp?articlekey=5581 (last visited Dec. 31, 2019).
L4-5: There is mild to slightly more moderate diffuse posterior bulging
of the disc at this level. This does cause minimal to mild bilateral neural
foraminal encroachment. No significant spinal stenosis is seen.

L5-S1: There is a smaller herniated disc present with a mild broad
based posterior disc protrusion at this level associated with a disc
osteophyte complex. This does cause mild to slightly more moderate
bilateral neural foraminal encroachment. No significant spinal stenosis
is seen[.]

The lumber cord or conus appears within the normal range.
IMPRESSION:

1. Slight grade I retrolisthesis of L5 on S1 most likely
chronic and degenerative. Mild reversal of the normal
lumbar curvature centered at the L1-2 level.

2. Minimal to mild multilevel degenerative disc disease
from L1-2 through L5-S1 with a smaller herniated disc
present at L5-S1 with a mild broad based posterior disc
protrusion at this level associated with a disc
osteophyte complex. Mild diffuse posterior bulging of
the L4-5 disc, minimal to mild bilateral foraminal
bulging of the L3-4 disc, and minimal diffuse posterior
bulging of the L1-2 and L2-3 discs. Mild to slightly
more moderate bilateral neural foraminal
encroachment at L5 on S1 due to the herniated disc at
this level.

3. No significant spinal stenosis seen.

(Doc. 6-9, pp. 24-25) (emphasis omitted).6

6 Retrolisthesis is the “backward slippage of a vertebra . . . . [which] occurs when a single vertebra
slips and moves back along the intervertebral disc underneath or above it. It’s not the same as a
dislocation.” https://www.healthline.com/health/retrolisthesis (last visited Dec. 31, 2019).
In early December 2017, Ms. Elledge received emergency treatment from the
Decatur Morgan Hospital. (Doc. 6-9, p. 3). Ms. Elledge reported lower back pain

from degenerative disc disease. (Doc. 6-9, p. 3). Dr. Wang, the emergency
physician, examined Ms. Elledge and described her as “well, alert, [and in] no
apparent distress[.]” (Doc. 6-9, p. 4). Dr. Wang noted tenderness in Ms. Elledge’s

lower back. (Doc. 6-9, p. 5). With respect to Ms. Elledge’s extremities, Dr. Wang
observed a normal range of motion, no tenderness, and a normal gait. (Doc. 6-9, p.
5). Dr. Wang diagnosed Ms. Elledge with “moderate degenerative changes of the
spine [without] acute or suspicious bony lesion[s].” (Doc. 6-9, p. 7). Ms. Elledge

received a prescription for cyclobenzaprine (one 5 mg tablet nightly) for muscle
spasms. (Doc. 6-9, p. 7).7
Later in December 2017, Ms. Elledge visited the Cullman Spine Institute for

an evaluation. (Doc. 6-9, pp. 13, 15). Ms. Elledge complained of “back pain and
tingling to [her] bilateral lower extremities.” (Doc. 6-9, p. 12). Ms. Elledge reported
having mild to moderate back pain since 2012 “with it increasing greatly over the
past 4 weeks” unrelated to an accident or injury. (Doc. 6-9, p. 12). Ms. Elledge

described feeling the increased pain in her lower back and right extremity initially
but noted shifting of the pain “to [the] middle and low back . . . and numbness to her

7 Cyclobenzaprine “is a muscle relaxant. . . . [that] works by blocking nerve impulses (or pain
sensations) that are sent to [the] brain.” https://www.drugs.com/drug_interactions.html (last
visited Jan. 21, 2020).
feet” since onset. (Doc. 6-9, p. 12). Ms. Elledge rated her pain five out of ten “on
average” but reported that her pain did get “so severe” that it caused nausea. (Doc.

6-9, p. 12).
Ms. Elledge told the certified registered nurse practitioner (CRNP) who
examined her that Dr. Walker had prescribed muscle relaxer and anti-inflammatory

medication to alleviate pain. (Doc. 6-9, p. 12). According to Ms. Elledge, lying
down provided some pain relief. (Doc. 6-9, p. 12).
The CRNP examined Ms. Elledge and reported that Ms. Elledge “stands with
a normal posture” and “has a normal gait” with good toe and heel walk. (Doc. 6-9,

p. 12). The CRNP noticed “mild tenderness about the lumbar spine” but “no obvious
deformity,” “palpable spasm,” or “tightness.” (Doc. 6-9, p. 12). The CRNP
observed that Ms. Elledge had a limited range of motion from her fingertips to her

knees. (Doc. 6-9, p. 12). The CRNP rated Ms. Elledge’s “strength throughout all
muscles of both lower extremities” five out of five. (Doc. 6-9, p. 12).
The CNRP reported normal sensory testing results for Ms. Elledge “with the
exception of subjective decreased sensation to [the] right lower extremity in multiple

nerve distributions.” (Doc. 6-9, pp. 12-13). Ms. Elledge’s straight leg tests results
were negative. (Doc. 6-9, p. 13).
After reviewing the x-ray results, the CRNP diagnosed Ms. Elledge with

“severe DDD (degenerative disc disease) L5-S1 with retrolisthesis of L5 on S1.”
(Doc. 6-9, p. 13). The CRNP described the MRI results as revealing “mild disc
desiccation L4-5 with broad-based central disc protrusion[;] [m]ild subarticular

stenosis L4-5 bilaterally[; and] [s]evere DDD L5-S1 with retrolisthesis and Modic
changes.” (Doc. 6-9, p. 13). As reported in a January 2016 article posted on the
American Chiropractic Association’s website:

Modic changes represent MRI observations of vertebral marrow and
endplate changes. These changes have been linked to trauma, disc
disruption and degeneration. . . . Degenerative disc disease (DDD)
without Modic changes is a relatively insidious and not particularly
painful condition, whereas DDD with Modic changes is much more
frequently associated with pain. Type 1 Modic changes show bony
edema and inflammation and are strongly associated with back pain.
Emerging evidence indicates there is a progressive nature to Modic
changes. The bony edema of type I Modic changes may progress to type
2, and type 2 may progress to type 3.

https://www.acatoday.org/News-Publications/ACA-News-
Archive/ArtMID/5721/ArticleID/75/Bone-Morphology-and-Modic-Classifications
(last visited Dec. 31, 2019).
The CRNP provided the following assessment and plan:
[Ms. Elledge] will likely require [a posterior lumbar interbody fusion]
in the future. She was provided with a copy of “Treat Your Own Back”
by Robin McKenzie as a source for regular back conditioning exercises.
I encouraged walking regularly for cardiovascular exercise. We
discussed that she may benefit from [a lumbar epidural steroid
injection]. She is a private pay patient, and I discussed that [Cullman
Regional Medical Center] could help her make payment arrangements
if she wishes to pursue [a steroid injection]. She requested narcotic
medication. I explained that our office does not prescribe[] for long-
term pain management. She was recently evaluated by Dr. Walker. He
[has] prescribed Relafen and Robaxin. I offered to refill the anti-
inflammatory and muscle relaxer. She states that she has only seen Dr.
Walker once and has been released to our care. She was under the
impression that we would be prescribing long-term pain management
for her. She was very frustrated that she did not receive narcotic pain
medication. I would like to review her MRI with Dr. Ward. [Ms.
Elledge] will be contacted with additional plan of care after review of
imaging studies.

(Doc. 6-9, pp. 13-14). Ms. Elledge received refills for Relafen (one 500 mg tablet
twice daily) for pain and Robaxin (one 750 mg tablet every eight hours) for muscle
spasms. (Doc. 6-9, p. 15).8
The CRNP added a note after conferring with Dr. Ward about Ms. Elledge’s
December visit:
Case and imaging studies were reviewed with Dr. [W]ard. Imaging
findings are listed above. Dr. Ward agrees with current plan of care.
[Ms. Elledge] may pursue [a steroid injection] at L4-5 if she wishes.
She may discuss payment arrangements for [a steroid injection] with
patient financial at [Cullman Regional Medical Center]. She will follow
up with our office on an as-needed basis.

(Doc. 6-9, p. 14). A nurse left a message for Ms. Elledge about Dr. Ward’s approval
of the care plan. (Doc. 6-9, p. 16). Ms. Elledge called back and reported that “[s]he
was unhappy with her office visit[.]” (Doc. 6-9, p. 16). Ms. Elledge believed that
Dr. Ward would be evaluating her and that the visit would be more informative.
(Doc. 6-9, p. 16). Ms. Elledge stated that she “would pick up her information” and

8 Relafen “is a nonsteroidal anti-inflammatory drug (NSAID). . . . [prescribed to treat]
inflammation and pain in the body.” https://www.drugs.com/mtm/nabumetone.html (last visited
Jan. 21, 2020).
visit another provider. (Doc. 6-9, p. 16). Ms. Elledge’s medical records do not
indicate that she requested a steroid injection.

Ms. Elledge visited Dr. Walker in late December 2017. (Doc. 6-9, p. 18). Ms.
Elledge complained of back and between-the-shoulder blades pain. (Doc. 6-9, p.
18). Dr. Walker examined Ms. Elledge and noted that she showed “no apparent

distress[.]” (Doc. 6-9, p. 18). Dr. Walker detected mild tenderness in Ms. Elledge’s
spine but found “no scoliosis or other abnormal curvatures[.]” (Doc. 6-9, p. 19). Dr.
Walker reported a prominent right sternoclavicular joint and a prominent left
metacarpophalangeal joint and diagnosed Ms. Elledge with segmental dysfunction

of the sternoclavicular region. (Doc. 6-9, p. 19). Dr. Walker ordered x-rays of Ms.
Elledge’s sternoclavicular joints. (Doc. 6-9, p. 19). According to the December
2017 treatment record, Ms. Elledge’s prescriptions included paroxetine (for

depression), meloxicam (one to two 7.5 mg tablets daily for pain), and Robaxin (one
500 mg tablet nightly for muscle spasms and pain). (Doc. 6-9, p. 18).
Ms. Elledge had an MRI in January 2018. (Doc. 6-9, p. 33).9 According to
Dr. Jokich’s findings, Ms. Elledge’s spine alignment is “within the normal range”

and her spine shows “[n]o significant spondylolistheses[.]” (Doc. 6-9, p. 33). Dr.
Jokich provided the following impressions:
1. Minimal to mild two level degenerative disc disease at
C4-5 and C5-6 with mild diffuse posterior bulging of a

9 Dr. Carter referred Ms. Elledge to Dr. Jokich for the January 2018 MRI. (Doc. 6-9, p. 34).
disc osteophyte complex at C4-5 and minimal to mild
bilateral foraminal bulging of the C5-6 disc. Mild to
slightly more moderate bilateral neural foraminal
encroachment at C4-5 due to the disc at this level
slightly worse on the left accentuated by mild
hypertrophic facet disease.

2. No significant spinal stenosis seen.

3. Mild hypertrophic facet disease at C3-4 and C4-5
present.

4. Intact cervical cord allowing for mild scattered artifact.

(Doc. 6-9, p. 34) (emphasis omitted).
Dr. Walker referred Ms. Elledge to The Orthopaedic Center in January 2018.
(Doc. 6-9, pp. 76-77). Ms. Elledge visited Dr. Carter, a physician specializing in
physical medicine and rehabilitation. She complained of “diffuse widespread spine
pain.” (Doc. 6-9, pp. 76, 78, 81). Ms. Elledge described her pain as “all across her
neck, shoulder blades, mid-back, low back, with radiation down both legs.” (Doc.
6-9, p. 78). Ms. Elledge shared with Dr. Carter that she has been dealing with the
pain, “but it has been gradually getting worse.” (Doc. 6-9, p. 78). Ms. Elledge
reported that “pain medication . . . is the only thing that keeps her functional and not
wanting to just sit on the couch.” (Doc. 6-9, p. 78).
After reviewing Ms. Elledge’s MRI films, Dr. Carter noticed “some
degenerative disc space collapse with some mild annular bulge at 5,1 and some mild
annular bulge at 4,5” but identified “no critical central or neural foraminal stenosis.”
(Doc. 6-9, p. 78). Dr. Carter observed “a small cystic structure” on the left spine at
the L1 level but was uncertain about its significance. (Doc. 6-9, p. 78). Dr. Carter’s

impression of Ms. Elledge’s neck x-rays was: “Minimal spondylitic changes at the
cervicothoracic junction consistent with age; otherwise no acute findings.” (Doc. 6-
9, p. 80). Dr. Carter’s impression of Ms. Elledge’s thoracic spine x-rays was:

“Essentially negative . . . some hilar calcification of unclear significance . . . .” (Doc.
6-9, p. 80).
After examining Ms. Elledge, Dr. Carter noted that she appeared “comfortable
and not in any acute distress.” (Doc. 6-9, p. 79). Ms. Elledge had “a normal, non-

antalgic gait,” and Dr. Carter did not observe any “shuffling or ataxia.” (Doc. 6-9, p.
79). Dr. Carter detected generalized tenderness in Ms. Elledge’s cervical and
thoracic spine. (Doc. 6-9, p. 79). Ms. Elledge showed a “good range of motion with

flexion/extension and rotation” in her cervical spine. (Doc. 6-9, p. 79). Dr. Carter
did not detect a “palpable defect” in Ms. Elledge’s thoracic spine. (Doc. 6-9, p. 79).
Dr. Carter noted “diffuse tenderness across” Ms. Elledge’s lumbar spine. (Doc. 6-
9, p. 79). The results of a seated straight leg raise, slump, and flexion abduction

external rotation tests were negative. (Doc. 6-9, p. 79).10 Dr. Carter detected “some

10 “The flexion abduction external rotation (FABER) test is used to evaluate for pathology of the
sacroiliac joint. The patient lies supine on the examination table and is asked to place one foot on
the opposite knee (placing the hip in flexion abduction external rotation).”
https://www.medscape.com/answers/2092651-119404/what-is-the-role-of-patrick-faber-test-in-
the-evaluation-of-low-back-pain-lbp (last visited Jan. 15, 2020).
prominence to th[e] SC joint on the right” and some mild tenderness. (Doc. 6-9, p.
80).

Dr. Carter diagnosed Ms. Elledge with lumbar spondylosis, thoracic
myofascial pain, and mild cervicothoracic spondylosis. (Doc. 6-9, p. 80).11 Dr.
Carter planned to complete a fibromyalgia workup for Ms. Elledge because her pain

pattern, age, and gender were consistent with that diagnosis, and he recommended
“an MRI of the cervical and thoracic spine.” (Doc. 6-9, p. 80). Dr. Carter ordered
weekly physical therapy. (Doc. 6-9, p. 81).12 Dr. Carter denied Ms. Elledge’s
request for a refill of narcotic pain medication consistent with the Pain Society

guidelines and Ms. Elledge’s “nonspecific spine pain.” (Doc. 6-9, p. 81). Dr. Carter
instructed Ms. Elledge to return after the MRI. (Doc. 6-9, p. 81).
Dr. Hogan, an agency consultant, reviewed Ms. Elledge’s records and

provided a physical capacity assessment in late January 2018. (Doc. 6-4, pp. 13-15).
Dr. Hogan determined that Ms. Elledge was able to lift or carry 20 pounds
occasionally and 10 pounds frequently. (Doc. 6-4, p. 13). Dr. Hogan found that
with normal breaks, Ms. Elledge could stand, walk, or sit about six hours in an eight-

hour period. (Doc. 6-4, pp. 13-14). Dr. Hogan placed no limitations on Ms.

11 “Myofascial pain refers to pain caused by muscular irritation.” https://www.spine-
health.com/glossary/myofascial-pain (last visited Jan. 16, 2020).

12 The Court was unable to locate confirmation in the record that Ms. Elledge attended physical
therapy.
Elledge’s ability to push or pull. (Doc. 6-4, p. 14). Dr. Hogan restricted Ms. Elledge
to occasionally climbing ramps and stairs, balancing, stooping, kneeling, crouching,

and crawling and never climbing ladders. (Doc. 6-4, p. 14). Dr. Hogan based her
functional report on the November 2017 MRI results, the December 2017 treatment
records from Cullman Spine Institute, and Ms. Elledge’s reported daily activities.

(Doc. 6-4, p. 15).
Ms. Elledge returned to Dr. Carter in early February 2018 to discuss her MRI
results. (Doc. 6-9, p. 82). Dr. Carter’s impression was: “Mild spondylitic changes
most notable at 4,5 and 5,6 . . . no significant or severe neural compression . . . .”

(Doc. 6-9, p. 82). Ms. Elledge complained of widespread pain with “intermittent
radiating pain in both [her] upper and lower extremities.” (Doc. 6-9, p. 82). Dr.
Carter described Ms. Elledge’s presentation as “mildly hysterical” and her gait as

non-antalgic. (Doc. 6-9, p. 82). Dr. Carter explained to Ms. Elledge his impression
that she has fibromyalgia rather that a “structural problem with [her] spine.” (Doc.
6-9, p. 82). Dr. Carter prescribed Neurontin (one 300 mg capsule nightly) and saw
no reason for “more aggressive intervention with [Ms. Elledge’s] spine at this point.”

(Doc. 6-9, p. 83).13 Dr. Carter planned to refer Ms. Elledge “to an arthritis or

13 Neurontin is “an anticonvulsant . . . [prescribed] to treat neuropathic pain (nerve pain) . . . .”
https://www.drugs.com/search.php?searchterm=neurontin (last visited Jan. 21, 2020).
fibromyalgia specialist.” (Doc. 6-9, p. 82). Dr. Carter instructed Ms. Elledge to
continue with physical therapy and return as needed. (Doc. 6-9, p. 82).

Ms. Elledge visited Dr. Walker in mid-February 2018 and complained of
“pain all over.” (Doc. 6-10, p. 5). Ms. Elledge reported that only pain medication
provided relief. (Doc. 6-10, p. 5). Ms. Elledge was taking Norco (one half to one

5mg/325mg tablet three times daily), meloxicam (7.5 mg tablet once or twice daily),
and Robaxin (one 500 mg tablet three times daily). (Doc. 6-10, p. 5).14 Dr. Walker
detected a decreased range of motion in Ms. Elledge’s neck with extension and side
flexion . . . .” (Doc. 6-10, p. 6). Dr. Walker noted a “prominent R sternoclavicular

joint with crepitus” in Ms. Elledge’s range of motion and tenderness in Ms. Elledge’s
mid-back. (Doc. 6-10, p. 6). The results of Ms. Elledge’s straight leg raise test were
negative. (Doc. 6-10, p. 6). Dr. Walker’s diagnosed Ms. Elledge with chronic pain,

cervical disc degeneration, and generalized osteoarthritis. (Doc. 6-10, p. 6).
Dr. Walker refilled Ms. Elledge’s Norco prescription and prescribed
duloxetine (300 mg capsule starting with one weekly and then twice daily). (Doc.
6-10, p. 6).15 Dr. Walker reported that Ms. Elledge “will need pain clinic” treatment.

14 “Norco 5/325 (hydrocodone acetaminophen and bitartrate) is an opioid analgesic and antitussive
(cough suppressant) combined with a fever reducer and pain reliever and used to treat moderate to
fairly severe pain.” https://www.rxlist.com/norco-5-325-side-effects-drug-center.htm (last visited
Jan. 21, 2020).

15 Duloxetine “is used to treat depression and anxiety. . . . [and] to help relieve nerve pain
(peripheral neuropathy) in people with . . . chronic back pain . . .”
https://www.webmd.com/drugs/2/drug-91491/cymbalta-oral/details (last visited Jan. 14, 2020).
(Doc. 6-10, p. 6). Dr. Walker instructed Ms. Elledge to schedule a thoracic MRI and
an EMG and nerve conduction study of her upper extremities. (Doc. 6-10, p. 6).

Dr. Walker completed a functional capacity questionnaire on Ms. Elledge
during the February 2018 visit. (Doc. 6-9, pp. 38-41). Dr. Walker listed cervical,
thoracic, and lumber pain and arthritis as Ms. Elledge’s diagnoses. (Doc. 6-9, p. 38).

Dr. Walker described Ms. Elledge’s prognosis as “fair” and stated that he expected
Ms. Elledge’s impairments to last twelve months. (Doc. 6-9, p. 38). Dr. Walker
listed Ms. Elledge’s symptoms as neck, shoulder, and back pain. (Doc. 6-9, p. 38).
Dr. Walker explained that Ms. Elledge’s neck sticks when rotating and “has to pop.”

(Doc. 6-9, p. 38). Dr. Walker described Ms. Elledge’s neck and shoulder pain as
“episodic” with “hand numbness [and] tingling[.]” (Doc. 6-9, p. 38). Dr. Walker
reported tenderness in Ms. Elledge’s trapezius and lower cervical spine. (Doc. 6-9,

p. 38). Dr. Walker listed physical therapy and exercising as part of Ms. Elledge’s
pain management. (Doc. 6-9, p. 38).
According to Dr. Walker, Ms. Elledge is not a malingerer. (Doc. 6-9, p. 39).
Dr. Walker reported that “emotional factors contribute to the severity of [Ms.

Elledge’s] symptoms and functional limitations[.]” (Doc. 6-9, p. 39). Dr. Walker
noted that Ms. Elledge’s depression impacts her physical condition. (Doc. 6-9, p.
39).
Dr. Walker stated that without medication, Ms. Elledge could not walk one
city block. (Doc. 6-9, p. 39). Dr. Walker did not give an opinion about how far Ms.

Elledge could walk with medication. Dr. Walker reported that Ms. Elledge would
need seven to eight rest breaks lasting 20 to 30 minutes “in a competitive work
situation” and “a job that permits shifting positions . . . from sitting, standing or

walking[.]” (Doc. 6-9, p. 39). According to Dr. Walker, Ms. Elledge could lift and
carry ten pounds; look up, twist, bend, crouch and squat, climb ladders and stairs
rarely; look down and turn her head occasionally; and hold her head in a static
position frequently. (Doc. 6-9, p. 40). Dr. Walker reported that Ms. Elledge had no

significant limitations with reaching, handling, or fingering. (Doc. 6-9, p. 40).
But Dr. Walker restricted Ms. Elledge’s use of her hands to grasp, turn, and twist
objects to 50 percent of an eight-hour period. (Doc. 6-9, p. 40). Dr. Walker

restricted Ms. Elledge’s ability to reach with her arms to one to five percent of an
eight-hour time period. (Doc. 6-9, p. 40). Dr. Walker stated that Ms. Elledge would
have “‘good days’” and “‘bad days’” and would be absent from work “[m]ore than
four days” monthly. (Doc. 6-9, p. 40).

Ms. Elledge had an MRI of her thoracic spine in February 2018. (Doc. 6-10,
p. 8). Dr. Jokich provided the following impressions:
1. Minimal degenerative disc disease within thoracic
spine with early disc desiccation at many of the mid to
lower thoracic disc levels and minimal focal central
bulging of the T4-T5 disc which does not cause any
significant neural foraminal encroachment or spinal
stenosis.

2. No other significant posterior bulging discs or posterior
disc herniations allowing again for chronic Schmorl’s
nodes at T10-T11, T11-T12, and T12-L1.

3. No spinal stenosis seen.

4. Intact thoracic cord allowing for mild scattered artifact.

5. No compression fracture seen.

(Doc. 6-10, p. 8) (emphasis omitted).
Ms. Elledge returned to Dr. Walker in March 2018 to discuss her MRI results
and pain management. (Doc. 6-10, p. 2). Before this visit, Dr. Walker had tried
referring Ms. Elledge to Valley Pain Clinic, but the practice did not accept her as a
patient. (Doc. 6-10, pp. 11-12). Dr. Walker detected a normal range of motion in
Ms. Elledge’s neck. (Doc. 6-10, p. 2). Ms. Elledge’s diagnoses were consistent with
her January visit. (Doc. 6-10, p. 3). Dr. Walker reported that “specialist[s] do not
see [a] need for chronic pain . . . medication” and that Ms. Elledge “really needs to
pursue other venues for pain management[.]” (Doc. 6-10, p. 3). Dr. Walker noted
that Ms. Elledge would “try to taper medication.” (Doc. 6-10, p. 3).
In April 2018, Ms. Elledge visited Dr. Cole, a physician with Quality of Life
Health Services Inc., complaining of pain. (Doc. 6-9, pp. 42, 49). Ms. Elledge stated
that her back trouble began in 2013 and that the source was unrelated to an injury.
(Doc. 6-9, pp. 42, 44). Ms. Elledge reported visiting a medical provider for back
pain in November 2017 and having had three MRIs and several x-rays of her back.
(Doc. 6-9, p. 44).

Ms. Elledge described her lower back and neck pain as “fluctuating” and
“occurring persistently.” (Doc. 6-9, p. 42); (see also Doc. 6-9, p. 45) (noting positive
for back and neck pain as part of a musculoskeletal system review). Ms. Elledge

reported having “sharp and shooting” pain that radiates into her feet. (Doc. 6-9, p.
42). According to Ms. Elledge, bending, changing positions, performing daily
activities, sitting, standing, twisting, and walking aggravated her pain; medication
alleviated it. (Doc. 6-9, p. 42). Ms. Elledge rated her pain nine out of ten. (Doc. 6-

9, p. 46). Ms. Elledge reported that she had scheduled “an appointment with [a] pain
clinic in May [2018].” (Doc. 6-9, pp. 47, 48).
Ms. Elledge shared that in the two weeks before her visit, she experienced

depression, hopelessness, tiredness, and little energy on several days. (Doc. 6-9, p.
43). According to Ms. Elledge, she also had a poor appetite (or overeating) and
trouble concentrating. (Doc. 6-9, p. 43). Ms. Elledge reported that none of these
problems “made it [difficult] for [her] to . . . work, take care of things at home or get

along with other people[.]” (Doc. 6-9, p. 43).
Dr. Cole examined Ms. Elledge’s back. (Doc. 6-9, p. 47). Dr. Cole noted
tenderness and mild pain with motion in Ms. Elledge’s cervical and lumber spine.
(Doc. 6-9, p. 47). Dr. Cole diagnosed Ms. Elledge with chronic low back pain. (Doc.
6-9, pp. 42, 48).

Dr. Cole prescribed methocarbamol (one 500 mg tablet three times daily for
muscle spasms), nabumetone (one 500 mg tablet twice daily for back pain), and
paroxetine for depression. (Doc. 6-9, p. 45).16 Ms. Elledge’s reported pain

medication included Norco 5-325 (three times daily) and nabumetone (one 500 mg
tablet twice daily). (Doc. 6-9, p. 45). According to the April 2018 treatment record,
Ms. Elledge declined duloxetine, Neurontin, and a Toradol shot. (Doc. 6-9, p. 48).
Dr. Cole instructed Ms. Elledge to schedule a follow up visit for May and to seek

emergency treatment if her symptoms worsened in the meantime. (Doc. 6-9, p. 48).
Using a referral from Dr. Walker (Doc. 6-10, p. 13), Ms. Elledge visited
Tennessee Valley Pain Consultants as a new patient in May 2018 and met with Dr.

Gantt and a licensed practical nurse. (Doc. 6-10, pp. 14, 18, 25). Ms. Elledge
complained of “aching” neck and low back pain and rated the intensity eight out of
ten. (Doc. 6-10, p. 14). According to Ms. Elledge, sitting and bending aggravated
her pain; heat and cold alleviated it. (Doc. 6-10, p. 14).

Ms. Elledge reported “diffuse, uncontrollable pain” in her neck, shoulders,
mid-back, low back, and lower extremities “that limits her ability to function.” (Doc.

16 Nabumetone is the generic form of Relafen.
https://www.drugs.com/search.php?searchterm=nabumetone&a=1 (last visited Jan. 21, 2020).
6-10, p. 18). Ms. Elledge characterized her pain as worsening and stated that Norco
“is the only thing that helps.” (Doc. 6-10, p. 18). Ms. Elledge believed that her

imaging which did not support surgery “was ‘Botched’” and shared that she had an
“attorney looking over [her] case.” (Doc. 6-10, p. 18). With respect to her anxiety
and depression, Ms. Elledge was “very upset” that she would not be receiving a

prescription. (Doc. 6-10, p. 18).
The TVPC providers described Ms. Elledge’s gait as “steady” and “normal[.]”
(Doc. 6-10, pp. 15, 22). They detected no ataxia, range of motion, or strength
difficulties. (Doc. 6-10, p. 22). The TVPC providers noted tenderness in Ms.

Elledge’s neck and trunk. (Doc. 6-10, p. 22).
The TVPC providers diagnosed Ms. Elledge with chronic pain syndrome,
cervicalgia, degenerative disc disease, and fibromyalgia. (Doc. 6-10, pp. 23-24).

They instructed Ms. Elledge to continue Dr. Walker’s medication regimen “only as
prescribed” and her home exercise program. (Doc. 6-10, p. 24). The TVPC
providers discussed “possible interventional procedures” but noted that Ms. Elledge
declined the suggestion citing “financial constraints[.]” (Doc. 6-10, p. 24). The

TVPC did not prescribe new medication and instructed Ms. Elledge to return in four
to eight weeks. (Doc. 6-10, p. 24).
Later in May 2018, the emergency department of Decatur Morgan Hospital

admitted Ms. Elledge for evaluation after she complained of neck and back pain.
(Doc. 6-11, pp. 2, 4, 5).17 A certified registered nurse practitioner met with Ms.
Elledge. (Doc. 6-11, p. 9). Dr. Williams served as Ms. Elledge’s supervising

emergency physician. (Doc. 6-11, p. 9). Ms. Elledge described the pain as chronic
and “present for 6 months.” (Doc. 6-11, p. 4). Ms. Elledge reported having seen
multiple doctors but that she still is experiencing pain. (Doc. 6-11, p. 4). Ms.

Elledge shared that she “is not happy with any of her doctors and that she has an
appointment with a new doctor in June and is going to start from scratch.” (Doc. 6-
11, pp. 4-5).
Ms. Elledge characterized the severity of her pain as “moderate” and denied

any radiating pain. (Doc. 6-11, p. 5). Ms. Elledge reported a gradual onset over six
months and denied any injury. (Doc. 6-11, p. 5). Ms. Elledge described the quality
of her pain as “aching” and denied “burning, cramping, dull[ness], fullness,

indigestion, pressure, sharp[ness], stabbing, tearing, throbbing, [and] tightness.”
(Doc. 6-11, p. 5). Ms. Elledge stated that her pain is “constant” and denied that it
changed over time or was worsening. (Doc. 6-11, p. 5).
The CRNP examined Ms. Elledge’s neck and back and detected no

tenderness. (Doc. 6-11, pp. 6, 7). The CRNP noted that Ms. Elledge had a normal
range of motion in her neck and extremities. (Doc. 6-11, pp. 6, 7). The CRNP

17 One page of the emergency treatment notes reflects that Ms. Elledge’s complained of leg pain.
(Doc. 6-11, p. 2). Other pages do not. (See Doc. 6-11, p. 4) (listing neck and upper back); (Doc.
6-11, p. 5) (noting neck and back pain and denying any extremity pain).
observed that Ms. Elledge had a normal gait. (Doc. 6-11, p. 7). The CRNP told Ms.
Elledge that the specialist “had better diagnostics” available than he did in the

emergency department. (Doc. 6-11, p. 7). The CRNP explained that in the absence
of “a new injury there wasn’t much to be done in the [emergency department].”
(Doc. 6-11, p. 7). The CRNP noted that Ms. Elledge “agree[d] with [the] plan and

verbalize[d] [her] understanding.” (Doc. 6-11, p. 7).
Ms. Elledge returned to Dr. Cole in June 2018 and complained of neck pain
from a car accident injury. (Doc. 6-9, p. 50). Ms. Elledge described the pain as
constant, fluctuating, aching, and sharp. (Doc. 6-9, p. 50). Ms. Elledge reported that

the pain radiates to her shoulder and back. (Doc. 6-9, p. 50). According to Ms.
Elledge, movement aggravated her pain, and medication relieved it. (Doc. 6-9, p.
50). Ms. Elledge denied symptoms of bruising, crepitus, decreased mobility,

difficulty with sleep, joint instability and tenderness, limping, locking, nocturnal
pain, numbness, popping, spasms, swelling, tingling in the arms and legs, and
weakness. (Doc. 6-9, pp. 50, 52). Ms. Elledge rated her pain eight of ten. (Doc. 6-
9, p. 53). Dr. Cole diagnosed Ms. Elledge with chronic back pain and cervicalgia.

(Doc. 6-9, p. 54).18 Dr. Cole ordered spine x-rays. (Doc. 6-9, p. 54).

18 Cervicalgia “describe[s] pain or significant discomfort in [a person’s] neck, especially at the
back and/or sides.” https://www.verywellhealth.com/cervicalgia-definition-296573 (last visited
Jan. 14, 2020).
Ms. Elledge returned to Dr. Cole later in June 2018 to discuss the x-ray results
and pain management. (Doc. 6-9, p. 56). Ms. Elledge’s description of her pain

resembled the earlier June 2018 visit except on this occasion, she reported “no
relieving factors.” (Doc. 6-9, p. 56). Ms. Elledge rated her pain five out of ten.
(Doc. 6-9, p. 56).

Dr. Cole noted weakness in Ms. Elledge’s cervical spine, tenderness in her
lumbar spine, and mild pain with motion. (Doc. 6-9, p. 56). Dr. Cole explained that
Ms. Elledge’s x-ray results showed a collapsed disc at L5 but revealed no changes.
(Doc. 6-9, pp. 59, 70). Dr. Cole declined Ms. Elledge’s request for narcotic pain

medication and instructed her to continue taking ibuprofen as prescribed. (Doc. 6-
9, p. 59). Dr. Cole discussed referring Ms. Elledge to a neurosurgeon for her neck
pain if she quit smoking. (Doc. 6-9, pp. 59, 60). According to the treatment notes,

Ms. Elledge wanted a second opinion. (Doc. 6-9, p. 59). Dr. Cole characterized Ms.
Elledge’s back and neck pain as “[p]oorly controlled.” (Doc. 6-9, p. 60).
Ms. Elledge reported that she was not taking methocarbamol or nabumetone
but using ibuprofen for pain. (Doc. 6-9, pp. 52, 60). Ms. Elledge received a

prescription for ibuprofen (one 800 mg tablet three times daily for back pain) and
tizanidine (one 4 mg capsule three times daily for spasms and pain). (Doc. 6-9, pp.
52, 60). Ms. Elledge received patient education about back and neck pain. (Doc. 6-

9, p. 60).
Ms. Elledge saw Dr. Cole in July 2018 and complained of aching, sharp, and
radiating foot pain and a rash. (Doc. 6-9, pp. 62, 66). Ms. Elledge stated that her

foot pain began three months earlier and was unrelated to an injury. (Doc. 6-9, p.
62). According to Ms. Elledge, movement aggravated the pain, and nothing relieved
it. (Doc. 6-9, p. 62). Ms. Elledge rated her pain seven out of ten. (Doc. 6-9, p. 66).

Dr. Cole ordered x-rays and instructed Ms. Elledge to take ibuprofen for her bilateral
foot pain. (Doc. 6-9, p. 66). According to Dr. Cole’s treatment notes, Ms. Elledge
did not complain of back or neck pain during this visit. Ms. Elledge’s medications
included ibuprofen for back pain and tizanidine for spasms and pain. (Doc. 6-9, p.

68).
2. The ALJ’s Assessment of Ms. Elledge’s Records
In applying the pain standard, the ALJ found that Ms. Elledge’s impairments

“could reasonably be expected to cause some of the alleged symptoms” but that Ms.
Elledge’s “statements concerning the intensity, persistence and limiting effects . . .
are not entirely consistent with the medical evidence and other evidence in the
record.” (Doc. 6-3, p. 15). After summarizing Ms. Elledge’s medical records, the

ALJ determined that the “evidence simply does not support the allegations of
limitation . . . to the extent alleged.” (Doc. 6-3, p. 17). The record contains
substantial evidence that supports the ALJ’s decision to partially credit Ms.

Elledge’s description of her pain.
The record shows that Ms. Elledge does not have a consistent, long-standing
treatment history for back or neck pain. Ms. Elledge visited many different doctors,

often seeking pain medication. From November 2017 to June 2018, Ms. Elledge
visited Dr. Walker, Dr. Carter, the Cullman Spine Institute, the TVPC, Dr. Cole, and
the Morgan County Hospital for back and neck pain. During this eight-month

period, Ms. Elledge rated her pain five in December 2017, nine in April 2018, eight
in May 2018, eight in June 2018, and five in late June 2018. (Doc. 6-9, pp. 12, 14;
Doc. 6-10, p. 14; Doc. 6-9, pp. 53, 56).19 Ms. Elledge was prescribed different
medications by different treating physicians to manage her symptoms, but by the

summer of 2018, she was prescribed only ibuprofen for pain and tizanidine for
spasms, and doctors urged her to taper her medication. Ms. Elledge refused some
proposed treatments. In June 2018, Dr. Cole characterized Ms. Elledge’s back and

neck pain as “[p]oorly controlled,” (Doc. 6-9, p. 60), but that may be because Ms.
Elledge did not take her medication as prescribed (Doc. 6-9, p. 58). Ms. Elledge
asked Dr. Cole to prescribe narcotic pain medicine. He refused and continued Ms.
Elledge on ibuprofen. (Doc. 6-9, p. 60).

19 Ms. Elledge’s seven pain rating in July 2018 pertained to her feet. (Doc. 6-9, pp. 62, 66). Even
when accepting Ms. Elledge’s bilateral foot pain as related to her back and neck pain, the duration
of Ms. Elledge’s pain treatment is still less than the required 12 months. See SSR 82-52, 1982 WL
31376, at *1) (“Severe impairments lasting less than 12 months cannot be combined with
successive, unrelated impairments to meet the duration requirement.”).
The ALJ observed that “[p]hysical examinations consistently showed normal
range of motion, normal gait, negative straight leg raise [tests] and good strength in

the upper and lower extremities.” (Doc. 6-3, p. 17). Ms. Elledge’s medical records
confirm that none of Ms. Elledge’s providers observed an abnormal gait. (See, e.g.,
Doc. 6-9, p. 20) (normal gait with Dr. Walker in November 2017); (Doc. 6-9, p. 5)

(normal gait at Decatur Morgan Hospital in December 2017); (Doc. 6-9, p. 12)
(normal gait at Cullman Spine Institute in December 2017); (Doc. 6-9, p. 82) (normal
gait with Dr. Carter in January 2018); (Doc. 6-10, pp. 15, 22) (normal gait at TVPC
in May 2018); (Doc. 6-11, p. 7) (normal gait at Decatur Morgan Hospital). No

provider reported a positive straight leg raise test or detected poor strength in Ms.
Elledge’s extremities. (See, e.g., Doc. 6-9, p. 20) (negative straight leg test with Dr.
Walker in November 2017); (Doc. 6-9, pp. 12, 13) (negative straight leg test and full

strength in lower extremities at Cullman Spine Institute in December 2017); (Doc.
6-9, p. 79) (negative straight leg test with Dr. Carter in January 2018); (Doc. 6-10,
p. 22) (normal strength in upper and lower extremities at TVPC in May 2018).
Ms. Elledge’s medical records showed different reports of range of motion.

During Ms. Elledge’s initial visit with Dr. Walker in November 2017, Dr. Walker
observed a “limited active [range of motion] with flexion.” (Doc. 6-9, p. 20). In
December 2017, Ms. Elledge had good range of motion in her extremities, (Doc. 6-

9, p. 5), but limited range of motion from her fingertips to her knees. (Doc. 6-9, p.
12). Dr. Carter observed “a good range of motion” in Ms. Elledge’s cervical spine
in January 2018. (Doc. 6-9, p. 79). Dr. Walker reported a decreased range of motion

in Ms. Elledge’s neck in February 2018, (Doc. 6-10, p. 6), but a normal range in
March 2018, (Doc. 6-10, p. 2). In February 2018, Dr. Walker detected a “prominent
R sternoclavicular joint with crepitus” in Ms. Elledge’s mid-back range of motion.

(Doc. 6-10, p. 6). Dr. Cole noted tenderness and mild pain with motion in Ms.
Elledge’s cervical and lumber spine in April 2018. (Doc. 6-9, p. 47). In May 2018,
the TVPC found no range of motion difficulties. (Doc. 6-10, p. 22). During this
same month, Ms. Elledge had a normal range of motion in her neck and extremities

at the Decatur Morgan Hospital. (Doc. 6-11, pp. 6, 7). Consequently, substantial
evidence does not support the ALJ’s finding that Ms. Elledge’s range of motion has
consistently been normal, but this is the only physical finding by the ALJ that the

medical evidence does not fully support.
The ALJ properly considered Ms. Elledge’s unwillingness to try a steroid
injection as evidence relating to the credibility of her pain testimony. (Doc. 6-3, p.
5). The record shows that the CPRN discussed with Ms. Elledge the potential

benefits from a steroid injection and the availability of a payment arrangement plan
for the procedure. (Doc. 6-9, p. 13). Still, Ms. Elledge rejected this recommendation
and requested a prescription for narcotic pain medication. (Doc. 6-9, p. 13). Ms.

Elledge’s rejection of a steroid injection in the absence of a prior ineffective result
or an adverse reaction to this procedure is inconsistent with Ms. Elledge’s allegations
of disabling symptoms.

Substantial evidence supports the ALJ’s finding that no specialist
recommended back or neck surgery to Ms. Elledge. (Doc. 6-3, p. 16, 17). The
CNRP from the Cullman Spine Institute reported that Ms. Elledge will likely need a

back fusion in the future but did not recommend surgery in December 2017. (Doc.
6-9, p. 13); (see also Doc. 6-9, p. 82) (Dr. Carter saw no reason for “more aggressive
intervention with [Ms. Elledge’s] spine” in February 2018.).
The record substantiates the ALJ’s finding that Ms. Elledge denied symptoms

of “crepitus, decreased mobility, difficulty with sleep, joint instability, joint
tenderness, limping, locking, nocturnal awakening/pain, numbness, popping,
spasms, swelling, and tingling in the extremities” during a follow-up visit with Dr.

Cole in June 2018. (Doc. 6-3, p. 16; Doc. 6-9, pp. 50, 52). When Ms. Elledge visited
Dr. Cole in July 2018, she complained of “joint tenderness” but denied “bruising,
crepitus, decreased mobility, difficulty initiating sleep, joint instability, limping,
locking, nocturnal awakening, nocturnal pain, numbness, popping, spasms, swelling,

tingling in the arms, tingling in the legs[,] and weakness.” (Doc. 6-9, p. 62); (see
also Doc. 6-9, p. 66).
Thus, the ALJ provided adequate reasons based on objective medical records

to discount the full extent of Ms. Elledge’s subjective reports of pain. See Markuske
v. Comm’r of Soc. Sec., 572 Fed. Appx. 762, 766 (11th Cir. 2014) (A claimant’s self-
reporting that medication has reduced pain symptoms supports an adverse credibility

finding.); Markuske, 572 Fed. Appx. at 767 (“The objective medical evidence cited
by the ALJ provided ‘adequate reasons’ for her decision to partially discredit
Markuske’s subjective complaints” of pain.).

Daily Activities
The ALJ found that Ms. Elledge’s pain testimony was inconsistent with some
of Ms. Elledge’s daily activities reported in late December 2017. (Doc. 6-3, p. 17);
(see also Doc. 6-7, pp. 32-37, 39). The ALJ identified Ms. Elledge’s ability to

“shop[] in stores for necessities/food, prepare meals for her family, do laundry,
manage her own personal care, care for [a] pet [dog], run errands, use the computer
daily, and attend church . . . occasionally” as activities undermining Ms. Elledge’s

subjective limitations. (Doc. 6-3, p. 17).
The ALJ may consider a claimant’s daily activities when making a credibility
finding. See 20 C.F.R. § 404.1529(c)(3) (listing “daily activities” as a relevant factor
to consider in evaluating a claimant’s subjective pain testimony). When examining

daily activities, an ALJ must consider the record as a whole. See Parker v. Bowen,
793 F.2d 1177, 1180 (11th Cir. 1986) (faulting the Appeals Council’s finding that
claimant’s “daily activities . . . have not been significantly affected” when the

Appeals Council “ignored other evidence that her daily activities have been
significantly affected”). The Eleventh Circuit has recognized that “participation in
everyday activities of short duration” will not prevent a claimant from proving

disability. Lewis v. Callahan, 125 F.3d 1436, 1441 (11th Cir. 1997). Instead, “[i]t
is the ability to engage in gainful employment that is the key, not whether a Plaintiff
can perform chores or drive short distances.” Early v. Astrue, 481 F. Supp. 2d 1233,

1239 (N.D. Ala. 2007); see Flynn v. Heckler, 768 F.2d 1273, 1275 (11th Cir. 1985)
(claimant who “read[s], watch[es] television, embroider[s], attend[s] church, and
drive[s] an automobile short distances . . . . performs housework for herself and her
husband, and accomplishes other light duties in the home” still can suffer from a

severe impairment).
While an ALJ need not discuss “all portions of the function report,” the ALJ
must make it clear that she considered the claimant’s condition “on the whole.”

Miles v. Comm’r, Soc. Sec. Admin., 652 Fed. Appx. 923, 927 (11th Cir. 2016); see
also Foote, 67 F.3d at 1562 (If an ALJ rejects a claimant’s subjective complaints,
“the reasons should be expressed.”); Mitchell v. Comm’r, Soc. Sec. Admin., 771 F.3d
780, 782 (11th Cir. 2014) (An ALJ’s decision must reflect more than a “broad

rejection” of a claimant’s credibility).
Here, the ALJ did not address several limitations that Ms. Elledge mentioned
in her function report. For example, Ms. Elledge reported that she could not walk,
take the dog to the park, or do yard work because of pain. (Doc. 6-7, p. 33).20
According to Ms. Elledge, she could do laundry if she “fe[lt] like doing it” and she

“need[ed] pain medicine . . . to do stuff.” (Doc. 6-7, p. 34). Ms. Elledge
acknowledged that she could “do a little housework” but that the activity made her
pain worse. (Doc. 6-7, p. 35). But Ms. Elledge confirmed that medication “seem[ed]

to be helping [her],” and that with it, she had “a little hope and the huge black cloud
[had] lifted . . . .” (Doc. 6-7, p. 37); (see also Doc. 6-7, p. 34) (medication helped
with some but not all pain). Thus, the omission of these limitations is harmless error
because of Ms. Elledge’s statements confirming her improved functionality with

medication.
B. Dr. Walker’s Opinion
Ms. Elledge maintains that the ALJ should have accepted the physical

capacities opinion of Dr. Walker, one of Ms. Elledge’s treating physicians. (Doc. 8,
pp. 3-8). “Absent ‘good cause,’ an ALJ is to give the medical opinions of treating
physicians ‘substantial or considerable weight.’” Winschel, 631 F.3d at 1179
(quoting Lewis, 125 F.3d at 1440). When an ALJ does not give a treating physician’s

opinion considerable weight, an ALJ must clearly articulate the reasons for her
decision. Winschel, 631 F.3d at 1179. Good cause exists when:

20 In another part of the report, Ms. Elledge stated that she does not know how far she can walk
“before needing to stop and rest” because she has not “tried just walking.” (Doc. 6-7, p. 37).
(1) [the] treating physician’s opinion was not bolstered by the evidence;
(2) evidence supported a contrary finding; or (3) [the] treating
physician’s opinion was conclusory or inconsistent with the doctor’s
own medical records.

Phillips v. Barnhart, 357 F.3d 1232, 1241 (11th Cir. 2004); Lustgarten v. Comm’r
of Soc. Sec., No. 17-14763, 2019 WL 6048534, at *2 (11th Cir. Nov. 15, 2019)
(quoting Phillips for good cause framework).
The ALJ found that the record lacked “significant objective support for Dr.
Walker’s overly restrictive limitations.” (Doc. 6-3, p. 16). The ALJ pointed out that
“one month after completing the restrictive assessment, Dr. Walker . . . [noted] that
specialists had seen no surgical issues and that he found no indication for
[prescribing] chronic pain medication to [Ms. Elledge].” (Doc. 6-3, p. 16). The ALJ

found that Ms. Elledge’s normal gait, negative straight leg raise tests, and good
extremity strength undermined Dr. Walker’s opinion. (Doc. 6-3, p. 17). The ALJ
determined that Ms. Elledge’s daily activities were “more consistent with the
limitations offered by Dr. Hogan,” a consulting physician. (Doc. 6-3, p. 17).

Before completing the functional assessment, Dr. Walker did not place
limitations on Ms. Elledge’s ability to sit, stand, walk, or use her upper extremities.
Dr. Walker’s physical findings, including Ms. Elledge’s normal gait and negative

straight leg raise test results, are inconsistent with his functional report in which he
appears to have fully credited Ms. Elledge’s subjective symptoms.
Consequently, the ALJ demonstrated good cause for assigning little weight to
Dr. Walker’s opinion. See Edwards v. Sullivan, 937 F.2d 580, 583-84 (11th Cir.

1991) (Good cause includes the absence of “clinical data or information to support
[an] opinion” and contradictions within the physician’s treatment notes.).
Ms. Elledge maintains that the ALJ improperly substituted her opinion for that

of Dr. Walker. (Doc. 8, p. 8); see Graham v. Bowen, 786 F.2d 1113, 1115 (11th Cir.
1986) (reversing because the ALJ substituted his lay opinion about the claimant’s
gait for the medical evidence showing more than a moderate limitation); Storey v.
Berryhill, 776 Fed. Appx. 628, 637 (11th Cir. 2019) (citing Graham and observing

that “it is generally improper for an ALJ to substitute his own judgment for that of a
medical expert because ALJs are not medical experts”). But the lay opinion rule
does not apply here because the ALJ formulated Ms. Elledge’s RFC with the benefit

of Dr. Hogan’s functional assessment. (Doc. 6-3, p. 16). The ALJ found that Dr.
Hogan’s opinion was more consistent with the overall record. Reports from other
providers that Ms. Elledge had a normal gait, negative straight leg test results, and
unrestricted strength in her extremities bolster the ALJ’s decision to accept Dr.

Hogan’s opinion over Dr. Walker’s assessment. So does the tapering of Ms.
Elledge’s pain medication in the summer of 2018. Thus, substantial evidence
indicates that the ALJ had good cause to assign little weight to Dr. Walker’s treating

opinion.
Ms. Elledge points out that if the ALJ had accepted Dr. Walker’s opinion
instead of Dr. Hogan’s assessment, the Commissioner’s medical-vocational

guidelines “would direct a finding of ‘disabled’” because of Ms. Elledge’s age, past
relevant work, and lack of transferrable skills. (Doc. 8, pp. 8, 9). Consequently, Ms.
Elledge argues that to deny benefits, “the ALJ had to find that [Ms. Elledge] was

capable of [performing] greater than sedentary work.” (Doc. 8, p. 9). Because the
ALJ identified good cause for rejecting Dr. Walker’s opinion and based Ms.
Elledge’s RFC on substantial evidence, including Dr. Hogan’s less restrictive
assessment, remand is not warranted.

Ms. Elledge also argues that the ALJ’s hypothetical questions to the
vocational expert were inadequate because they did not “comprehensively describe
[Ms. Elledge’s] impairments . . . .” (Doc. 8, p. 9). But the Court has upheld the

ALJ’s treatment of Dr. Walker’s opinion and her credibility determination.
Consequently, the ALJ properly excluded from the hypothetical questions medical
findings “properly rejected as unsupported[,]” Crawford, 363 F.3d at 1161, and
“subjective symptoms that exceed[] the RFC determination.” Carroll v. Soc. Sec.

Admin., Comm’r, 453 Fed. Appx. 889, 894 (11th Cir. 2011) (citing Crawford).
V. CONCLUSION
For the reasons discussed above, the Court affirms the Commissioner’s

decision.
DONE this 24th day of January, 2020.

Modus HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE

44

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/9989194. Public record. Not legal advice.