Pad-Change Logs as Substantial Evidence and SSR 96-9p’s Specificity Requirement: Tenth Circuit Affirms RFC Without Extra Restroom or Assistive-Device Accommodations

Introduction

In S.J.B. v. Commissioner, SSA, the Tenth Circuit affirmed a district court judgment upholding the Social Security Administration’s denial of disability insurance benefits. The case arises from a long administrative history: two prior ALJ denials, two district court remands, and a de novo hearing before a new ALJ who issued the May 2023 decision that became the final agency action after Appeals Council denial.

On appeal, the claimant limited her challenge to three areas: (1) the adequacy of the residual functional capacity (RFC) in accounting for digestive impairments (Crohn’s disease and related symptoms), (2) whether the RFC sufficiently addressed urinary incontinence, and (3) whether the ALJ erred in finding no medical necessity for an assistive device (cane, walker, or wheelchair).

Exercising jurisdiction under 28 U.S.C. § 1291 and 42 U.S.C. § 405(g), the Tenth Circuit held that the ALJ’s decision was free of legal error and supported by substantial evidence. Although designated as an unpublished order and judgment (and therefore not binding precedent except under law-of-the-case, res judicata, and collateral estoppel), the decision is citable for its persuasive value under Fed. R. App. P. 32.1 and 10th Cir. R. 32.1. The opinion provides instructive guidance on three recurring SSA adjudication issues:

How controlled Crohn’s disease and IBS may be reflected in exertional and postural RFC limitations;
How contemporaneous pad-change logs can constitute substantial evidence supporting an RFC with “normal breaks” for urinary incontinence; and
What SSR 96-9p requires to demonstrate the medical necessity of an assistive device, and why evidence of an antalgic gait alone is insufficient.

Summary of the Opinion

The Tenth Circuit affirmed. Applying the deferential substantial evidence standard, the court held:

Digestive impairments: The ALJ reasonably concluded that the claimant’s Crohn’s disease and overlapping IBS were largely controlled with medication (Humira and mesalamine) aside from limited flares, and that a “range of seated light work” with postural and exertional restrictions adequately accounted for those impairments. The ALJ permissibly found the treating gastroenterologist’s more restrictive 2019 opinion unpersuasive given treatment notes reflecting symptom control and the contrary assessments of state agency physicians.
Urinary incontinence: Even assuming arguendo a step-two error in deeming incontinence non-severe, any error was harmless because the ALJ considered the condition at RFC. Substantial evidence—especially the claimant’s own two-day urinary frequency log showing two to three pad changes per eight-hour period—supported the ALJ’s determination that “normal breaks” were sufficient, without additional restroom-access limitations.
Assistive devices: Citing SSR 96-9p, the court affirmed that an assistive device must be medically required, with documentation describing the need and the circumstances of use. Given mixed gait findings, largely mild objective testing (lumbar MRI and EMG/NCV), lack of prescription, and persuasive state-agency opinions, substantial evidence supported the ALJ’s finding that no assistive device was medically necessary. The ALJ reasonably discounted a physical therapist’s functional capacity evaluation (FCE) and a primary care provider’s extreme limitations as inconsistent with the broader record and lacking objective support.

Analysis

Precedents and Authorities Cited

Richardson v. Perales, 402 U.S. 389, 401 (1971): Defines “substantial evidence” as “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Biestek v. Berryhill, 587 U.S. 97, 103 (2019): Emphasizes that the substantial evidence threshold “is not high.”
O’Dell v. Shalala, 44 F.3d 855, 858 (10th Cir. 1994): Evidence is insubstantial only if “overwhelmingly contradicted by other evidence.” This frames the appellate posture: unless the contrary evidence overwhelms, the court will not disturb the ALJ’s weighing.
Hendron v. Colvin, 767 F.3d 951, 954 (10th Cir. 2014): Prohibits reweighing evidence or substituting judicial judgment for the Commissioner’s.
Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005): Confirms de novo review of legal questions and substantial evidence review of factual findings.
Allman v. Colvin, 813 F.3d 1326, 1330 (10th Cir. 2016): Step-two errors are harmless if at least one severe impairment is found and the ALJ considers all impairments at the RFC stage.
White v. Barnhart, 287 F.3d 903, 907 (10th Cir. 2001): Approves discounting a treating physician’s opinion when inconsistent with the physician’s own notes. Although predating the post–March 27, 2017 SSA regulations (which eliminate controlling weight for treating-source opinions), its logic aligns with 20 C.F.R. § 404.1520c’s focus on supportability and consistency.
SSR 96-9p, 1996 WL 374185, at *7: An assistive device (cane, walker, etc.) must be “medically required,” with documentation establishing the need and “describing the circumstances for which it is needed.”
Henrie v. Dep’t of Health & Human Servs., 13 F.3d 359, 360–61 (10th Cir. 1993): Disability must be established on or before the date last insured (DLI).
Wall v. Astrue, 561 F.3d 1048, 1051–52 (10th Cir. 2009): Appeals Council denial makes the ALJ’s decision the Commissioner’s final decision; summarizes the five-step sequential evaluation.
Allen v. Barnhart, 357 F.3d 1140, 1142 (10th Cir. 2004): Standards regarding step-three listings.
20 C.F.R. § 404.1520c: Governs evaluation of medical opinions for claims filed on or after March 27, 2017, emphasizing supportability and consistency rather than “controlling weight.”

These authorities together set the analytical frame: a deferential review standard, a harmless-error lens at step two, a consistency/supportability rubric for medical opinions, and a specific documentary threshold for assistive devices.

Legal Reasoning

1) Digestive Impairments (Crohn’s and IBS)

The court upheld the ALJ’s finding that medication largely controlled the claimant’s gastrointestinal symptoms across the insured period, with identifiable but limited exacerbations. The ALJ:

Documented the claimant’s own testimony that Humira “worked perfectly,” corroborated by multiple normal or stable colonoscopy/imaging results outside flare periods.
Recognized an early-2019 flare (addressed with budesonide) and symptom increase after a temporary cessation of Humira in late 2020 due to eczema, but also noted stability upon resumption of treatment and favorable response in 2021.
Weighed competing medical opinions: the treating gastroenterologist’s 2019 restrictive assessment versus state-agency physicians’ opinions supporting a range of seated light work. The ALJ found the treating opinion inadequately supported by contemporaneous treatment notes reflecting control with medication and inconsistent with the record’s longitudinal findings.

Crucially, the court rejected the argument that postural and exertional limitations are not “rationally related” to digestive conditions. Not only did the ALJ explain the relationship (fatigue, pain, bathroom-related symptomatology, and activity tolerance), but the treating specialist himself identified sitting, standing, walking, and lifting as functions affected by gastrointestinal symptoms. Although the ALJ found the extent of the treating limitations unpersuasive, that linkage undercut the claimant’s facial challenge to the type of RFC limitations the ALJ adopted.

The court also declined to reweigh the claimant’s testimony, third-party statements, and the asserted breadth of treatment. Under the substantial evidence standard, the adverse resolution of conflicting evidence does not constitute reversible error unless the contrary evidence overwhelms—which it did not.

2) Urinary Incontinence and “Normal Breaks”

The court treated any non-severe designation at step two as harmless because the ALJ considered incontinence at the RFC stage. The decisive point was the evidentiary value of the claimant’s two-day pad-change log (two to three pad changes per eight hours). The ALJ reasonably inferred that this frequency could be accommodated by normal work breaks without additional restroom-access restrictions; the Tenth Circuit deemed that inference supported by substantial evidence.

The claimant argued that the record did not establish a pad as “100% reliable.” The court held that this speculative concern did not “overwhelmingly contradict” the specific log-based evidence the ALJ relied upon. The decision thus signals that contemporaneous self-monitoring logs can be potent evidence for both claimants and the Commissioner, and—when consistent with the broader record—may support RFCs that rely on “normal breaks” to accommodate urinary incontinence.

3) Assistive Device (SSR 96-9p’s Medical-Necessity and Specificity Requirements)

SSR 96-9p states that a hand-held assistive device must be “medically required,” and the record must describe “the circumstances for which it is needed.” The court affirmed the ALJ’s finding that this standard was not met:

Objective findings were mild to moderate: lumbar MRIs showed only mild degenerative changes; EMG/NCV was “essentially normal.”
Clinical observations were mixed: while there were instances of antalgic gait or reduced strength, other examinations showed normal gait and strength, including a normal neurological exam in August 2021.
No provider of record prescribed an assistive device or documented specific circumstances of use (e.g., distances, terrain, duration, or necessity for uneven surfaces).
State-agency physician opinions supporting a range of seated light work with postural limits were found persuasive for being consistent with the overall record.

The ALJ reasonably discounted a physical therapist’s FCE (which found very limited sit/stand/walk tolerances) because it incorporated subjective reports and self-limiting behavior, lacked multiple corroborative tests, and conflicted with other 2021 examinations. The ALJ similarly found extreme limitations offered by the primary care provider unsupported by objective evidence and at odds with the record; additionally, there was no indication that provider ever prescribed an assistive device. The court emphasized that the ALJ did not ignore these opinions but weighed them against the full record—an evaluative process the court would not re-do on appeal.

Impact and Implications

Digestive Impairments in RFCs

This decision validates the use of exertional and postural limitations to address gastrointestinal impairments when the record shows medically managed control with episodic flares. It also illustrates how state-agency opinions can be persuasive when they are consistent with longitudinal treatment evidence, particularly where treating-source restrictions are not supported by contemporaneous notes.

Urinary Incontinence and Workday Structure

The opinion is noteworthy in treating a claimant’s detailed pad-change log as substantial evidence to support an RFC that includes no restroom accommodation beyond “normal breaks.” While not a categorical rule, it provides persuasive authority that:

When pad-change frequency aligns with typical workplace break patterns, additional bathroom-access limitations may not be required; and
Speculative reliability critiques will not defeat otherwise consistent and specific log evidence absent overwhelming contrary proof.

For claimants, this underscores the strategic importance of detailed symptom logs; for ALJs, it offers a defensible evidentiary basis for tailoring RFCs around normal break structures where the record permits.

Assistive Devices Under SSR 96-9p

The decision reinforces SSR 96-9p’s two-part threshold: medical documentation must establish both the need for an assistive device and the specific circumstances of its use. The court’s rejection of an “antalgic gait equals device” shortcut has practical consequences:

Claimants seeking cane/walker/wheelchair accommodations should procure medical documentation that specifies when and why the device is required (e.g., continuous vs. intermittent use, distances, uneven terrain, weight-bearing limitations, or balance issues).
ALJs may reasonably discount opinions—especially extreme functional restrictions—when they lack objective support, conflict with longitudinal findings, or fail to meet SSR 96-9p’s specificity.

Medical Opinion Evaluation Post–March 27, 2017

Although the court cites White v. Barnhart, the operative regulation is 20 C.F.R. § 404.1520c, which assesses persuasiveness based on supportability and consistency. This decision exemplifies how treating-source opinions may be deemed unpersuasive where treatment notes show stable control, objective tests are mild, and other medical opinions better align with the totality of evidence.

Standard of Review and Appellate Deference

The opinion reiterates that “substantial evidence” is a low threshold and that courts will not reweigh disputed evidence. Litigants must therefore develop clear, consistent, and specific records at the administrative level, particularly where episodic conditions and device necessity are claimed.

Complex Concepts Simplified

Residual Functional Capacity (RFC): The most a claimant can do despite limitations, across a regular workday and workweek. ALJs must consider all medically determinable impairments—severe and non-severe—when crafting an RFC.
Step Two Harmless Error: Even if an impairment is mistakenly found non-severe at step two, the error is harmless if the ALJ finds at least one severe impairment and still considers the non-severe impairment’s effects when formulating the RFC.
Substantial Evidence: A deferential standard; the ALJ’s decision stands if reasonable evidence supports it, unless the opposing evidence overwhelmingly contradicts it.
“Seated” Light Work: Light work generally involves lifting up to 20 pounds with frequent 10-pound lifting. Some light jobs are performed mostly seated, often involving use of hand or foot controls. Thus, “seated light work” is not a contradiction; it reflects light exertion with limited standing/walking.
SSR 96-9p (Assistive Devices): To include a cane, walker, or wheelchair in the RFC, there must be medical documentation that the device is required and a description of when and why it is needed (e.g., all ambulation, uneven terrain, distance thresholds).
Antalgic Gait: A limping gait adopted to avoid pain. It can be evidence of impairment but does not by itself establish the medical necessity of a hand-held assistive device under SSR 96-9p.
Date Last Insured (DLI): The claimant must prove disability existed on or before the DLI for Title II (Disability Insurance Benefits). Post-DLI deterioration generally does not establish disability absent relation back.
Normal Breaks: In SSA cases, “normal breaks” refers to standard employer-provided rest and meal periods during an eight-hour shift. Whether symptoms can be accommodated within those breaks is a fact-specific determination.

Conclusion

The Tenth Circuit’s decision offers three practical, persuasive takeaways for Social Security disability adjudications:

Digestive impairments and RFCs: When treatment records show medication-controlled Crohn’s/IBS with intermittent flares, an RFC limiting a claimant to a range of seated light work with postural restrictions can be sustained, especially where state-agency opinions align with longitudinal evidence and treating-source restrictions lack supportability and consistency.
Urinary incontinence: Detailed pad-change logs (e.g., two to three changes in an eight-hour period) may constitute substantial evidence that “normal breaks” suffice, obviating extra restroom-access restrictions in the RFC absent stronger contradictory proof.
Assistive devices and SSR 96-9p: A claimant must produce medical documentation that an assistive device is necessary and specify the circumstances for which it is needed. Mixed gait findings, mild objective studies, lack of prescription, and contrary persuasive medical opinions will support an ALJ’s finding that no assistive device is medically required.

Beyond its specific facts, the opinion underscores the centrality of contemporaneous, objective, and specific evidence—treatment notes demonstrating symptom control, monitoring logs capturing functional impact, and medical documentation satisfying the precise requirements of SSR 96-9p. Given the deferential substantial evidence standard, claimants and practitioners should tailor record development accordingly, while ALJs should clearly tie RFC limitations to the evidentiary record—both of which this decision exemplifies.