Knee Pain Case Study #2
Chronic Knee Pain With History of Unsuccessful Arthroscopic Procedures, and Overlay of Depression, Anxiety and Mood Disorder
Claimant: 50 year old female
Past work: security guard, receiving clerk for hospital, shuttle bus driver for airline, kennel attendant
Education: high school graduate + 2 years college equivalent (in foreign country)
Hearing Info: in the summer of 2006, my client fell on a concrete floor at work and landed directly on her right knee. She began treating with an orthopedist who prescribed pain medications and cortisone shots. When that failed, the orthopedist performed arthroscopic surgery to repair the patella and repair ligament damage. This first surgery was not successful and my client remained in pain and with limited mobility. A different doctor performed a second arthroscopic surgery which did result in slightly more mobility but a minimal reduction in pain.
Following the 2nd surgery, my client was referred to a pain management physician who has prescribed her multiple pain medications including Percocet, Hydrocodone and MS-Contin, and Valium for anxiety. She actually brought her prescription bottles to the hearing. She tells me that she only takes the pain meds as needed, which is reassuring because I don’t see how anyone could function at all if he/she took all of these pain meds as prescribed.
In addition to the chronic knee pain, my client has some mental health issues. She apparently sees a therapist, but the therapist did not want to get involved and my client never mentioned her psychological treatment.
There is a helpful consultative evaluation in the record (Social Security had sent her to a psychologist for a 1 time evaluation) and that psychologist wrote a report that suggests that my client would have difficulty keeping a job because of depression, anxiety, anger management issues and mood disorder.
Hearing Strategy: There were several good things about this case and a few potential issues. On the positive side, my client had a long, consistent work history. Her lifestyle has suffered since she stopped working – she had to sell most of her belongings and she lives in an inexpensive one-room apartment. Self-sufficient people don’t suddenly become lazy and I felt that my client’s long work history would help.
The medical record also showed a consistency in the complaints. My client has been seeking relief from the pain in her knees for over 2 years and she has complied with all treatment suggestions. In my view, knee pain is difficult to live with because it interferes with walking, standing, sitting and even lying down and sleeping.
I felt that the psychological report from the consultative exam added a dimension to this case. My client has no social life at all and has become very withdrawn.
We did have a functional capacity form in the file from the pain management doctor although I am a little concerned that the judge might discount his opinion. The pain management doctor has only treated the claimant for about a year and his decisions about prescribing multiple heavy duty pain meds makes him potentially a less than credible source.
I wanted to paint this claimant as a hard working, formerly self-sufficient lady who has to deal with a high level of pain. She tries to avoid taking narcotic pain medication and would prefer to rejoin the workforce. In addition to her severe level of pain, she has an underlying mental health problem that would disqualify her from jobs requiring interaction with other humans and jobs that involve even minimal levels of stress.
Hearing Report: the judge opened the hearing by asking me for a brief opening. I set out my theory of the case as described above. The judge then turned to the claimant and asked her if she could get through an 8 hour day if she was able to sit or stand at will. My client seemed to have a bit of difficulty understanding what the judge was asking and she never really answered the question. It was unclear to me if the judge felt that the claimant was not being cooperative.
The judge asked a few more questions about the knee pain then turned the questioning over to me. I returned to the “sit/stand” option question and elicited an answer from my client that she could not last more than two or three hours sitting and standing. She testified that after a couple of hours, she would need to take an expanding five to ten minute “walk around” break to stay loose. She also testified that by the end of the day, her pain would be such that she would need to lie down.
I asked the claimant about her medicines and she testified that she tried to avoid taking those medicines except in cases where the pain level was extreme. She further testified that the pain level got extreme at least 2 times a week and that when she took the pain medicine, she ended up in bed for the day.
After taking testimony from the claimant, the judge turned to the vocational witness and asked the following hypothetical question:
Assume that we have an individual with the same age, education and work background as the claimant. Assume further that she is limited to light work (can lift 10 lbs. frequently and 15 lbs. occasionally, and can stand/walk up to 6 hours in an 8 hour work day). Assume that this person needs a job with a sit/stand option (meaning that she can sit or stand at will but cannot take a break to leave the work site). She needs to avoid ladders, ropes, scaffolds, bending and stooping. Could this individual return to past work?
Answer: no because past work would not permit a sit/stand option
Question: are there other jobs in the national economy she could perform?
Answer: yes, there are a number of light, jobs that would meet those criteria, including the job of hand packer and parking lot attendant
The judge then asked me if I had any questions. Not surprisingly, I did:
Ms. VE, let’s add to this hypothetical the following limitations:
1) during the second half of an 8 hours workday, our hypothetical person needs to stretch out and/or lie down for rest periods of 10 minutes twice an hour to relieve the pain and soreness in her knees
2) at least twice a week during the work week, our hypothetical person experiences pain at a level where she needs to consumer narcotic pain medication and the side effects of said medicine would result in drowsiness to the point of sleeping, and a significant interference with attention and concentration persistence and pace.
If either of these two conditions were added to the judge’s hypothetical, could the hypothetical person sustain competitive employment at any exertional level?
Obviously, this case will turn on the claimant’s credibility. If the judge accepts her allegations of pain, we will win, if she does not, we will lose.