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Caine v. Astrue

November 3, 2010


The opinion of the court was delivered by: P. Michael Mahoney, Magistrate Judge United States District Court

Hon. P. Michael Mahoney U.S. Magistrate Judge


I. Introduction

Darryl E. Caine ("Claimant") seeks judicial review of the Social Security Administration Commissioner's decision to deny his claim for Disability Insurance Benefits ("DIB"), under Title II of the Social Security Act, and Supplemental Security Income ("SSI") benefits, under Title XVI of the Social Security Act. See 42 U.S.C. § 405(g). This matter is before the Magistrate Judge pursuant to the consent of both parties, filed on April 27, 2009. See 28 U.S.C. § 636(c); Fed. R. Civ. P. 73.

II. Administrative Proceedings

On August 10, 2004, Claimant applied for DIB and SSI, alleging a disability onset date of November 30, 2000. (Tr. 61-65, 306-310.) Claimant's initial application was denied on November 4, 2004 (Tr. 24-28.) His claim was also denied a second time upon reconsideration on December 21, 2004. (Tr. 34.) Claimant then filed a timely request for a hearing before an Administrative Law Judge ("ALJ"). (Tr. 36.) The hearing took place on June 7, 2007, via video teleconference between Evanston, Illinois and Rockford, Illinois, before ALJ Maren Dougherty. (Tr. 326.) Claimant appeared and testified pro se, and vocational expert ("VE"), Susan Etenberg was present at the hearing, but did not testify. (Tr. 326-351.)

On July 5, 2007, the ALJ found Claimant was not disabled between November 30, 2000 ("onset") and May 18, 2005*fn1 , and denied his claims for DIB and SSI. (Tr. 13-19.) Afterwards, on August 7, 2007, Claimant filed a Request for Review with the Social Security Administration's Office of Hearing and Appeals. (Tr. 8.) The Appeals Council denied Claimant's Request for Review on April 12, 2008. (Tr 5-7.) As a result of this denial, the ALJ's decision is considered the final decision of the Commissioner. 20 C.F.R. §§ 404.981, 404.981, 416.1455, 416.1481. Claimant now files a complaint in Federal District Court, seeking judicial review under 42 U.S.C. §§ 405(g), 1383(c)(3).

III. Background

Claimant was born on July 29, 1961, making him thirty-nine years old on his alleged date of disability onset. (Tr. 61.) Claimant is six feet and three inches tall, and weighs approximately 170 pounds. (Tr. 82, 296.) As of the date of the hearing, Claimant lived in an apartment in Rockford, Illinois. (Tr. 340.) Claimant testified that he completed his high school education, had no difficulties reading and understanding the newspaper, and experienced no problems keeping track of his finances. (Tr. 340-341.) Claimant was able to drive himself to the hearing, and only reported problems driving when "the vehicle doesn't work right." (Tr. 341.)

On his Social Security Activities of Daily Living Questionnaire ("ADLQ"), completed on August 25, 2004, Claimant reported no difficulties using his arms or hands in any of the listed daily activities (i.e.: Using kitchen utensils to prepare a simple meal, carrying bags or groceries, taking out the trash, or opening lids on jars). (Tr. 99.) He also reported no problems while standing or moving about (i.e.: No issues getting in or out of a car, going up or down stairs, or performing various household chores). (Tr. 99-100.)

At the time of the hearing, Claimant was employed as a full-time "powder coating specialist" at Bergstrom Manufacturing. (Tr. 342.) Claimant's job required him to spray paint assorted metal parts in an assembly line. (Tr. 342.) According to Claimant, the job sometimes entailed lifting parts weighing up to seventy pounds. (Tr. 344.) Claimant reported no difficulty performing this work, and that his supervisors were satisfied with his performance. (Tr. 343.) Claimant testified that he has worked for Bergstrom in this capacity since 2005. (Tr. 343.) Claimant's record indicates that he was unemployed and received no income in 2004. (Tr. 79.)

From March of 2002 to the fall of 2003, Claimant was employed as a part-time janitor for Cardinal Building Services ("Cardinal"). (Tr. 102, 345.) Claimant's job consisted of polishing floors using a buffing machine, cleaning, and emptying the trash. (Tr. 345-346.) Claimant testified that he was required to regularly lift his equipment, buckets of water, and garbage bags. (Tr. 346.) According to the Claimant, these items would generally weigh between twenty and forty pounds. (Tr. 346.) At the hearing, he reported no difficulty lifting this weight. However, Claimant marked that he stopped working for Cardinal due to his "medical condition" in the Work Activity Report. (Tr. 93.) The record indicates Claimant had an income of $1,565.05 in 2001. (Tr. 79.) Yet, the record does not specify where Claimant was employed during that time.

From 1994 through 2000, Claimant was employed in various capacities, most notably as an "oven loader" for Holsum Baking Company ("Holsum") from 1997 to 2000. (Tr. 102, 347.) As an oven loader, Claimant was required to lift trays of bread products and place them into the oven for baking. (Tr. 347.) Claimant testified that "a tray of regular buns weighed maybe . . . [twenty] to [thirty-five] pounds. A tray of sesame seed buns maybe [forty-five] to [sixty] pounds." (Tr. 347.) According to his Work Activity Report, Claimant marked twenty pounds as the heaviest weight he lifted in his capacity at Holsum. (Tr. 104.) Claimant has not claimed to have any difficulty performing his duties as an oven loader. In fact, he continued to work at Holsum until the bakery closed and his position was terminated in November of 2000. (Tr. 102, 347.)

Claimant asserts that he became disabled on or around November 30, 2000. (Tr. 61.) Claimant reported that he was disabled due to chronic shoulder and back pain. (Tr. 22, 34-35.) Claimant also has a record of abdominal pain and nausea.

IV. Medical Evidence

1. Shoulder Pain

From Feburary 5, 2000 to January 3, 2001, Claimant entered Rockford Clinic (hereinafter referred to as "RC") on six separate occasions, complaining of shoulder pain. (Tr.162, 164, 165, 169, 179, 181.) During Claimant's first two visits in February and March, Dr. Paul R. Schroeder, M.D., diagnosed Claimant with "left shoulder pain" and prescribed Motrin tablets for relief. (Tr. 179, 181.) According to the reports, both shoulders had a full range of motion and Claimant's grip strength was normal. (Tr. 179, 181.)

On August 7, 2000, Dr. Schroeder noted that x-rays of the shoulder were normal, diagnosed Claimant with "right shoulder pain," and prescribed Naprosyn*fn2 . (Tr. 169.) On October 20, 2000, Dr. Richard B. Fellars, M.D., diagnosed Claimant with bursitis ("inflammation") of the shoulders and prescribed Naprosyn for relief as well. (Tr. 165.)

Claimant returned to see Dr. Schroeder on November 6, 2000. (Tr. 164.) Dr. Schroeder noted that "both shoulders have full range of motion[, and] [t]here is no point tenderness." (Tr. 164) Dr. Schroeder prescribed Relafen*fn3 for Claimant's bursitis. (Tr. 164.) Upon follow-up on January 3, 2001, Dr. Schroeder's assessment was that Claimant's shoulder pain was resolving and added, "[h]e is still having some . . . discomfort, but it is better than before." (Tr. 162.) Dr. Schroeder noted that an MRI had been scheduled for the following week. (Tr. 162.) The MRI results showed no signs of a "full-thickness rotator cuff tear[, but] [t]here [were] findings . . . compatible with tendinopathy [or] tendinosis." (Tr. 215.)

Claimant did not return to RC with shoulder pain again until May 1, 2001. (Tr. 158.) Dr. Schroeder again prescribed Naprosyn for relief. (Tr. 158.) On May 21, 2001, Claimant saw Dr. Schroeder, complaining of more pain in his left shoulder. (Tr. 156.) Dr. Schroeder recommended Claimant undergo physical therapy. (Tr. 156) On June 20, 2001, Dr. Schroeder noted that Claimant "does not feel [that] he is really getting better," but added that "[Claimant] is able to reach over his shoulder and also under . . . to touch his back[,] and he has full ranger of motion without any . . . tenderness." (Tr. 153.) During the follow-up exam on July 17, 2001, Dr. Schroeder reported that "[Cliamant's] shoulders do feel better." (Tr. 152.)

On August 14, 2001, Claimant saw Dr. David J. Dansdill, M.D., concerning his shoulder pain. (Tr. 146.) After a physical examination, Dr. Dansdill diagnosed Claimant's left shoulder with subacromial bursitis and biceps tendinitis. (Tr. 146.) Dr. Dansdill gave Claimant Vioxx*fn4 samples, and suggested a subcromial injection if Claimant did not improve within three weeks. (Tr. 146.)

Three weeks later, on September 9, 2001, Dr. Dansdill reported that "[t]he Vioxx helped a little bit[,] but the pain continues." (Tr. 145.) Therefore, Dr. Dansdill injected Claimant's shoulder ("subacromal space") with Kenalog and lidocane. (Tr. 145.) Claimant was asked to return in eight to ten weeks. (Tr. 145.)

On October 30, 2001, Dr. Dansdill reported that Claimant "return[ed] today doing much better. Basically, the shoulders are much better since we injected them." (Tr. 144.) Dr. Dansdill spoke to Claimant "about the importance of stretching these areas before he does any heavy work, as this [pain] has a tendancy to reoccur." (Tr. 144.) The doctor's impression was that the rotator cuff tendinitis had been "resolved." (Tr. 144.)

On November 14, 2001, Claimant entered RC with an upper respiratory infection. (Tr. 149.) Claimant also complained of right shoulder pain. (Tr. 149.) Dr. Schroeder gave Claimant Motrin to treat the pain. (Tr. 149.)

From Feburary 9, 2002 to November 9, 2003, Claimant sought treatment for shoulder pain on twelve occasions. (Tr. 124, 125, 126, 128, 130, 133, 134, 137, 193, 258, 264, 289.) On February 9, 2002, Claimant entered Rockford Memorial Hospital (hereinafter referred to as "RMH") complaining of left shoulder pain. (Tr. 258.) Dr. Jason Bredenkamp, M.D., noted that Claimant had "taken no over-the-counter pain medication." (Tr. 258.) Dr. Bredenkamp gave Claimant Toradol*fn5 and reported, "[a]fter that he felt much better." (Tr. 258.) Claimant was given a prescription for ibuprofen and was "discharged home in good and improved condition." (Tr. 258.)

The following week, Claimant saw Dr. Schroeder on February 13, 2002 for a follow-up appointment. (Tr. 137.) Dr. Schroeder reported that Claimant was "feeling somewhat better regarding his shoulder." (Tr. 137.) "Both shoulders [had] full range of motion." (Tr. 137.) The doctor further noted in his assessment that the "left shoulder pain [was] resolving." (Tr. 137.)

The record does not indicate that the Claimant reported any significant shoulder issues again until September 24, 2002, when he returned to RC with left shoulder pain. (Tr. 126.) Dr. Schroeder reported that Claimant "was picking up some lawn chairs recently and had some pain in his left shoulder[,] which has continued." (Tr. 126.) The doctor noted that "[Claimant] has full range of motion of [both] shoulders with some pain . . . . [and] [t]here is no impingement sign." (Tr. 126.) The x-ray of the shoulder "appeared normal," but identified a "small subchrondral cyst." (Tr. 126, 183.) "[The cyst] may be a subtle indication of rotator cuff disease or impingement process." (Tr. 183.) The x-ray report added, "[I]f there is clinical indication, MRI may be of benefit. . . ." (Tr. 183.)

The MRI results returned on October 1, 2002. (Tr. 193.) According to the MRI report, there was "no definite evidence for a full-thickness rotator cuff tendon tear," and that "some tendinosis, bursitis, or small superior surface partial tear [could not] be excluded." (Tr. 193.)

Claimant continued to follow-up with Dr. Schroeder on October 25, 2002. (Tr. 125.) Dr. Schroeder noted:

[Claimant] took . . . Vioxx for a month and it did seem to help. There is no current medicine use. . . . He did have the MRI which showed a possible abnormality. He was seen by Dr. McCarty for consultation . . . [Dr. McCarty] did not think there was a problem. . . . [Claimant] is doing some maintenance work, has no other complaints or problems." (Tr. 125.)

Dr. Schroeder advised Claimant to take Advil for any shoulder pain. (Tr. 125.) He also offered to call in a prescription for Vioxx at any time upon Claimant's request. (Tr. 125.) Dr. Schroeder's assessment was that ...

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