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Willie J. Harris, Jr v. Michael J. Astrue

December 10, 2010

WILLIE J. HARRIS, JR.,
PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Hon. P. Michael Mahoney U.S. Magistrate Judge

MEMORANDUM OPINION AND ORDER

I. Introduction

Willie J. Harris, Jr. ("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 June 19, 2009. See 28 U.S.C. § 636(c); Fed. R. Civ. P. 73.

II. Administrative Proceedings

On May 10, 2007, Claimant applied for DIB and SSI, alleging a disability onset date of June 15, 2002. (Tr. 78.) Claimant's initial application was denied on August 2, 2007. (Tr. 80-89.) His claim was denied a second time upon reconsideration on September 14, 2007. (Tr. 91-98.) Claimant then filed a timely request for a hearing before an Administrative Law Judge ("ALJ") on October 15, 2007. (Tr. 99.) The hearing took place on June 2, 2008, via video teleconference between Evanston, Illinois and Rockford, Illinois, before ALJ Robert Karmgard. (Tr. 28.) Claimant appeared and testified in Rockford with his attorney present. (Tr. 28, 33-65.) Vocational expert ("VE"), Richard Willette, also testified before the ALJ. (Tr. 28, 65-75.)

On June 26, 2008, the ALJ held that Claimant was not disabled and denied his claims for DIB and SSI. (Tr. 13-21.) Afterwards, on August 19, 2008, Claimant filed a Request for Review with the Social Security Administration's Office of Hearing and Appeals. (Tr. 7.) The Appeals Council denied Claimant's Request for Review on February 5, 2009. (Tr 5-7.) As a result of this denial, the ALJ's decision is considered the final decision of the Commissioner. See 20 C.F.R. §§ 404.981, 404.981, 416.1455, 416.1481. Claimant now files a complaint in this Federal District Court, seeking judicial review under 42 U.S.C. §§ 405(g), 1383(c)(3).

III. Background

Claimant was born on April 6, 1967, and was forty-one years old at the time of the hearing. (Tr. 33, 130.) Claimant stood six feet and three inches tall, and weighed approximately 280 pounds when he appeared in front of the ALJ. (Tr. 34, 130, 162.) At the date of onset, Claimant weighed 320 to 340 pounds. (Tr. 34.) He attributes his weight-loss to a doctor-prescribed low-carbohydrate diet. (Tr. 35.) At the time of the hearing, Claimant resided in Rockford, Illinois with a friend of his sister. (Tr. 33.) He has earned a G.E.D.; he can read, write, and understand the English language; and reported no problems with basic mathematics. (Tr. 33-34.)

Claimant testified that he usually spends his days "laying in [a] recliner," sleeping, watching television, and doing "nothing." (Tr.41.) Claimant maintains that he is unable to help with any household chores or cleaning. (Tr. 41.) He seldom does any shopping or visits friends and family. (Tr. 42.) He alleges that he only regularly leaves the house to see his doctor or lawyer. (Tr. 44.) Claimant does not drive, and has not had a driver's license since 1996. (Tr. 35.) From 1992 to 2005, Claimant has been employed as a delivery driver, car detailer, warehouse worker, line cook, dietary aide, shoe repairer, child caregiver, and janitor. (Tr. 177.)

On August 30, 2000, while working for Midwest Temp Agency, Claimant was "struck in the leg by a fork lift [sic] truck." (Tr. 220.) Claimant suffered a "left leg contusion with [a] hairline fracture of the distal tibia." (Tr. 206, 231.) Claimant asserts that the pain associated with this injury was later compounded by an injury to his left knee, sustained in an automobile accident in 2004. (Tr. 35, 245.) It must be noted, however, that Claimant's first relevant injury appears to be a gunshot wound to the right knee in 1997. (Tr. 47.) Yet, no medical records were submitted concerning the gunshot wound, and Claimant only mentions the shooting injury twice within the record: once during his consultative evaluation (Tr. 251.), and again at the ALJ hearing. (Tr. 47.) Claimant asserts that he became disabled on or around June 15, 2002 and is unable to perform any substantial gainful activity due to the pain in his ankle and knees. (Tr. 76-79.) Claimant also testified that, between 2004 and 2007, he was unable to seek medical treatment because he did not have a medical card and could not otherwise afford the deductible. (Tr. 55.)

IV. Medical History

1. Left Ankle Fracture

On August 30, 2000, Claimant was admitted to Edward Hospital in Naperville, Illinois, after he was struck in the leg by a forklift. (Tr. 200.) Dr. Patricia A. Higgins, D.O., noted that there were "[f]indings suspicious for hairline fracture of the distal fibula and possibly the medial malleolus of the tibia." (Tr. 222.) Upon follow-up, on September 1, 2000, Dr. Higgins diagnosed Claimant with "[L]eft leg contusion with hairline fracture of the distal tibia and possible medial malleolus." (Tr. 231.) Claimant was put on crutches and prescribed Anaprox*fn1 and Vicodin. (Tr. 231-232.) Initially, according to his "After Care Instructions," Claimant was to return to sedentary work for seven days, "or until seen by orthopedics." (Tr. 206.) Dr. Higgins then referred Claimant to Dr. Kenneth P. Sanders, M.D., at Naperville Orthopedics.

Dr. Sanders saw Claimant that same day, and found that Claimant "[had] nondisplaced fractures in his medial and lateral malleolar areas" and that Claimant's "ankle mortise [was] intact." (Tr. 229.) Claimant was placed in a "short-leg walking cast," and asked to return in two weeks for re-fitting. (Tr. 229.)

Claimant returned to see Dr. Sanders on September 15, 2000. (Tr. 233.) Dr. Sanders observed that the cast was "markedly loose" because Claimant's swelling had "diminished[,] but [was] still present." (Tr. 233.) Claimant was fitted with a new "short-leg nonwalking cast[,]" and asked to return "at which time the current . . . cast [was] to be removed[,] and x-rays taken of the ankle . . ." (Tr. 233.)

On October 6, 2000, Claimant returned as requested. (Tr. 234.) Dr. Sanders removed Claimant's cast, ordered that Claimant now use an "Aircast," and noted that the "x-rays demonstrate good early healing of both medial and lateral malleolar fractures." (Tr. 234.) The doctor continued, "[Claimant] is to return . . . on [October 30, 2000]" and "[w]e will have [Claimant] return to work on [October 31, 2000]." (Tr. 234.)

Upon Claimant's return, on October 31, 2000, Dr. Sanders reported that Claimant's "ankle is doing relatively well. His x-ray is looking good. Further progress to healing is noted." (Tr. 235.) However, "[t]here is some arthritic change noted at the talonvicular joint which is of a chronic nature." (Tr. 227.) He continued, "[Claimant] may return to his regular duty activity as of November 1, 2000. He is to return to [this] office in six weeks for a follow-up x-ray at would likely be his final visit." (Tr. 235.)

On December 12, 2000, Dr. Sanders reported, "[Claimant's] ankle is doing well. His x-ray shows complete healing. He is healed. His ankle mortise is intact. He is discharged. I would anticipate no element of permanency emanating from this injury." (Tr. 221.) No further medical records concerning Claimant's ankle fracture have been produced.

2. Left Knee Contusion

Claimant was involved in a automobile accident on August 5, 2004, when the vehicle he was riding in was "rear-ended." (Tr. 245.) Dr. Todd H. Chaffin, M.D., reported, "[Claimant] struck his left knee . . . on the [dashboard]. He complains of pain with walking. This is the only injury." (Tr. 245.) Claimant was given Vicodin for his pain, and his knee was placed in an immobilizer. (Tr. 246.) He was further advised to keep his knee "extremely elevated" with an ice pack, and to take Advil for any pain. (Tr. 246.) Claimant was discharged home in "satisfactory condition," and no imaging studies were recommended due to the "apparent soft[-]tissue nature of the injury." (Tr. 246.) Claimant was invited to follow-up in eight-to-ten days if he still experienced pain, but there is no record of any follow-up pertaining to this injury. (Tr. 246.)

3. Social Security Administration Evaluation

After applying for SSI and DIB, Claimant underwent a twenty-minute consultative evaluation at the request of the Social Security Administration on July 11, 2007. (Tr. 250.) In his report, the evaluator, Dr. Kamlesh P. Ramchandani, M.D., noted:

[Claimant] continues to have burning pain in the left ankle, occasionally cramping, precipitated on weight bearing, standing for [ten-to-fifteen] minutes, walking with the cane for [two and a half] blocks, without the cane for [one and a half] blocks, going up and down the stairs, cold and damp weather. He uses the cane for weight bearing and support.

Lifting and carrying more than [five] pounds also tends to aggravate the pain. (Tr. 250.)

According to Dr. Ramchandani's report, Claimant discussed his ankle injury in 2000, and a 1999 gunshot wound to his right knee*fn2 . (Tr. 251.) Claimant made no mention of his ...


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