United States District Court, D. Colorado
Michael E. Hegarty, United States Magistrate Judge.
Nicholas Paul Espinoza, appeals from the Social Security
Administration (“SSA”) Commissioner's final
decision denying his application for disability insurance
benefits (“DIB”), filed pursuant to Title II of
the Social Security Act, 42 U.S.C. §§ 401-33, and
his application for supplemental security income benefits
(“SSI”), filed pursuant to Title XVI of the
Social Security Act, 42 U.S.C. §§ 1381-83c. I find
that the ALJ properly analyzed the opinion statements of Mr.
Espinoza's treating physician. Additionally, the ALJ did
not err in formulating Mr. Espinoza's residual functional
capacity (“RFC”). Accordingly, I affirm the
ALJ's decision that Mr. Espinoza is not disabled.
Mr. Espinoza's Relevant Medical History
Espinoza was born on August 3, 1983; he was thirty-one years
old when he filed his application for DIB and SSI. [AR 178].
Mr. Espinoza claims he became disabled on October 1, 2014 due
to physical impairments. [Id.]
February 2012, Mr. Espinoza began seeing Dr. Lisa K. Gieseke
at Cornerstone Family Practice for sleep apnea, asthma,
tonsillitis, and elevated blood pressure. [AR 557]. Dr.
Gieseke listed Mr. Espinoza's allergies as pollens, dust,
animal dander, mold, tree spars, and grasses. [Id.]
Dr. Gieseke ordered Mr. Espinoza a new mask for his CPAP
machine and refilled his asthma medication. [AR 558]. At a
follow-up appointment on March 6, 2012, Dr. Gieseke reported
that Mr. Espinoza was experiencing wheezing and joint pain.
[AR 554-55]. However, the results of his physical exam were
normal. [AR 555]. Mr. Espinoza regularly visited Dr. Gieseke
at least through the SSA's denial of his application. [AR
November 2013, Dr. Gieseke referred Mr. Espinoza to Dr.
Katherine Tsai for a consultation regarding his allergies and
asthma. [AR 436]. Dr. Tsai performed allergy skin testing and
a spirometric evaluation, both of which appeared normal.
[Id.] Dr. Tsai told Mr. Espinoza to start using
Zyrtec to control his allergies. [AR 416]. Shortly
thereafter, Dr. Gieseke allowed him to return to work with no
restrictions. [AR 437].
Espinoza returned to Cornerstone Family Practice with
complaints of back pain on February 24, 2014. [AR 412]. Dr.
Gieseke noted that Mr. Espinoza had chronic back pain, and
she referred him to Rocky Mountain Osteopathic Medicine
(“RMOM”) for a consultation and physical therapy.
days later, Mr. Espinoza visited Dr. Mark C. Winslow at RMOM.
[AR 351]. Mr. Espinoza informed Dr. Winslow that he fractured
his vertebra six or seven years prior. [Id.] He
reported his current lower back pain as six out of ten.
[Id.] Dr. Winslow ordered an x-ray to confirm a
potential stress fracture in Mr. Espinoza's lower back.
[AR 355]. Although the x-ray did not reveal a spinal
fracture, it showed a “[n]ondisplaced bilateral L5 pars
defects.” [AR 465]. Dr. Winslow also informed Mr.
Espinoza that his moderate to severe obesity is contributing
to his lower back pain, and he has “[v]ery poor use of
hips.” [AR 355]. Dr. Winslow recommended osteopathic
manipulative treatment and set a follow-up appointment for
one week later. [AR 355-56].
February 26, 2014, Mr. Espinoza visited Candice Brueck for
physical therapy. [AR 345-50]. Ms. Brueck's evaluation of
Mr. Espinoza revealed “lumbar extension/rotation
syndrome.” [AR 350]. She created short-term and
long-term goals and recommended physical therapy one to two
times per week. [Id.]
March 6, 2014, Dr. Winslow performed sixty minutes of
therapeutic exercises designed to increase Mr. Espinoza's
flexibility, strength, and balance. [AR 343]. Dr. Winslow
informed Mr. Espinoza that he may want to participate in a
professional weight management program to improve his back
pain. [AR 344]. Dr. Winslow recommended that Mr. Espinoza
remain off work until the following week due to his back
Espinoza continued to regularly see Dr. Winslow for
approximately six months. [AR 366]. During many of these
visits, he also had a physical therapy session with Ms.
Brueck. [AR 339]. Mr. Espinoza was unable to work as a bus
driver during this time. [AR 331, 335]. On March 14, 2014,
Dr. Winslow noted that Mr. Espinoza tolerated exercise well
but had difficulty engaging his hamstrings. [AR 340]. During
physical therapy on March 20, 2014, Ms. Brueck stated that
Mr. Espinoza was able to exercise well and had better
recruitment of abdominals; however, he complained of
increased pain. [AR 339]. Approximately two weeks later, Dr.
Winslow and Ms. Brueck noted that Mr. Espinoza was involved
in a recent car accident that increased his pain and
inability to walk. [AR 320, 329].
April 11, 2014, Mr. Espinoza underwent an MRI of his lumbar
spine. [AR 299-300]. The MRI revealed minor shallow broad
based disc protrusion at ¶ 1-2, negligible posterior
disc bulge at ¶ 2-3, coincidental nondisplaced bilateral
pars interarticularis defects at ¶ 5-S1, but no osseous
trauma or spondylolisthesis. [AR 300].
an April 18, 2014 visit with Dr. Winslow, Mr. Espinoza
reported intermittent pain that increases while standing. [AR
316]. Because of this he stated that he “[d]oes not
feel ready to return to work.” [AR 315, 327]. Dr.
Winslow reviewed the results of his MRI and performed sixty
minutes of osteopathic manipulation. [AR 317-18].
14, 2018, Dr. Winslow worked on additional therapeutic
exercises with Mr. Espinoza. [AR 312]. Dr. Winslow noted that
“recent exacerbation seems to have improved, ”
and “the patient is safe to return to work activities .
. . .” [AR 313]. On June 13, 2014, Mr. Espinoza
reported having “good relief” from his back pain
after an injection. [AR 306]. However, he noticed increased
pain when he began working due to the seat bouncing while
driving the bus. [AR 308]. As a result, Dr. Winslow noted,
“If patient fails to improve m[a]y need to consider a
different line of work due to his underlying back complaints
and preexisting medical problems.” [AR 308]. By June
27, 2014, Mr. Espinoza stopped working due to his back pain.
[AR 309, 375].
Espinoza had another injection on July 25, 2014, which
decreased his pain level to three out of ten. [AR 379]. Mr.
Espinoza reported to Ms. Brueck that he would try to return
to work without restrictions. [Id.] However, on
August 22, 2014, Dr. Winslow noted that Mr. Espinoza
“tried to return to work and again [was] unsuccessful
in spite of modifications in mechanics, back brace, [and]
seat cushion.” [AR 369].
Mr. Espinoza's September 19, 2014 osteopathic
manipulation appointment, Dr. Winslow stated that Mr.
Espinoza “has attempted to return to work several times
and in my opinion he will not be able to return due to
persistent lower back pain.” [AR 366]. On the same day,
Mr. Brueck noted that Mr. Espinoza “has not been
compliant with his home program, ” and he should
“consider weight loss surgery.” [AR 368]. Because
Mr. Espinoza had received only limited relief from therapy at
RMOM, Dr. Winslow terminated his care. [AR 366].
19, 2016, Mr. Espinoza visited Dr. Gieseke regarding his
ongoing back pain and his pars fracture at ¶ 4-5. [AR
530]. Mr. Espinoza reported to Dr. Gieseke that his
injections have failed to eliminate his back pain, and he
wants to undergo surgery but cannot proceed due to his
27, 2016, Mr. Espinoza told Dr. Gieseke that he had been out
of his new job as a customer service representative for two
and one half weeks due to his back pain. [AR 528]. He
described his pain as “radiat[ing] everywhere”
and “sharp and stabbing.” [Id.] However,
Mr. Espinoza reported that medical marijuana has been
relieving his pain. [Id.] Dr. Gieseke encouraged Mr.
Espinoza to return to work. [AR 529].
July appointment with Dr. Gieseke, Mr. Espinoza stated that
his back pain “seems to be improving, ” but he
still uses a cane to walk and complete his work duties. [AR
526]. He requested a referral for bariatric surgery, even
though he has lost some weight on his own. [Id.] Dr.
Gieseke referred him to Dr. Georgescu. [AR 527].
Espinoza visited the emergency room at Denver Health Medical
Center on October 28, 2016, where he was diagnosed with a
lumbar sprain. [AR 449]. Mr. Espinoza was discharged after
being provided with information on lambrosacral strains.
November 1, 2016, Mr. Espinoza returned to see Dr. Gieseke
and noted he had lost almost one hundred fifty pounds without
seeing any improvement in his back pain. [AR 523]. He told