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Frank Cinatl v. Michael J. Astrue

May 6, 2011


The opinion of the court was delivered by: Magistrate Judge Jeffrey Cole


Plaintiff, Frank Cinatl, seeks review of the final decision of the Commissioner ("Commissioner") of the Social Security Administration ("Agency") denying his application for Disability Insurance Benefits ("Disability Benefits") under Title II of the Social Security Act ("Act"),42 U.S.C. §§ 416(i), 423(d)(2). This Court has jurisdiction pursuant to 42 U.S.C § 405(g).


Mr. Cinatl filed for disability benefits on December 21, 2005, alleging disability since March 23, 2001, (R.151-153), as a result of neck pain, shoulder pain, and depression. (R. 155, R. 189). His application was denied initially and upon reconsideration, (R.92, R. 101), and he timely requested a hearing before an Administrative Law Judge ("ALJ"). (R.105).

The Administrative Law Judge ("ALJ") convened a hearing on November 6, 2008. Mr. Cinatl and his wife, Mrs. Rachelle Cinatl, testified along with Dr. Rousch, a medical expert, and Mr. Shwice, a vocational expert. (R.25-89). On April 16, 2009, the ALJ issued a finding that Mr. Cinatl was not disabled. (R. 12, R.24). On February 16, 2010, the Appeals Council denied Mr. Cinatl's request for review, thereby making the decision of the Commissioner final. (R. 1). See 20 C.F.R. §§ 404.995. Shortly thereafter, Mr. Cinatl filed this cause of action, appealing the decision under 42 U.S.C. § 405(g). The parties have consented to the jurisdiction of a Magistrate Judge pursuant to 28 U.S.C. §636(c).


A. Vocational Evidence

Mr. Cinatl was born on July 8, 1966, making him forty-two years old at the time of the ALJ's decision. (R.12). He completed the 12th grade, taking regular classes. (R.160). From 1993 to 2001, he worked as delivery driver for various types of businesses, including a pet food delivery service.

(R.156). He also worked as a ramp agent for an airline at O'Hare Airport. (R. 156). Mr. Cinatl explained in his initial filing for disability benefits that he was injured in a motor vehicle accident in 2000 that made it impossible for him to work. (R. 155). Mr. Cinatl's insured status expired March 31, 2005. (R. 28)

B. Medical Evidence


Physical Impairments Mr. Cinatl's medical records pertinent to this claim begin on April 15, 2000, when he went to an orthopedics clinic complaining of shoulder and neck pain following a motor vehicle accident.

(R. 247). A physician monitored Mr. Cinatl's condition throughout that summer, indicating limited cervical motion, fluctuation in pain, and responses to acupuncture therapy. (R. 233-244). In August 2000, Mr. Cinatl began receiving cervical epidural injections at St. Alexius Medical Center. (R. 221-231). In November 2000, he was diagnosed with Cervical Radiculopathy. (R.221-231).

Later that year, Mr. Cinatl's was also diagnosed with Left Shoulder Impingement Syndrome.

(R.257). On December 7, 2000, Mr. Cinatl's had arthroscopic surgery on his left shoulder. (R.255-256). Treatment notes in the months following the operation show significant improvement in pain, range of motion, and strength. (R. 251-257). However, in August 2001, Mr. Cinatl's surgeon noted the recurrence of neck pain, finding it indicative of cervical irritability at his C-5 and C-6. (R. 251). The surgeon recommended an MRI of his spine. (R.251).

Many of Mr. Cinatl's medical records from 2002 through 2003 come from his primary physician, Dr. Boskovic, and most, if not all, are illegible. (R. 269-279).

In 2004, Mr. Cinatl went to the University of Illinois at Chicago Medical Center complaining of neck pain, shoulder pain, bicept and tricept pain. (R.300). An MRI of Mr. Cintal's cervical spine showed multiple herniated discs at C5-6 and C6-7. (R. 300, R. 340). In November 2005, after several appointments at the UIC Medical Center, Mr. Cinatl was diagnosed with C5-6 and C6-7 degenerative disease with bilateral foraminal stenosis. (R. 293). An orthopedic surgeon at UIC recommended an anterior cervical disketcomy with allograft, arthrodesis, and plate. (R. 292). Mr. Cinatl never underwent the surgery. (R.420)

Throughout 2005, Mr. Cinatl was also treated at a pain clinic for neck and right arm pain.

(R. 319-320). Treatment notes document limited extension flexibility. (R. 344). Notes also indicate that Mr. Cinalt was taking Norco 10/325 seven times per day and receiving cervical facet injections. (R. 319). At times, Mr. Cinatl's pain was livable on a daily basis and the relief provided by medication was 100%. (R. 324; R. 330). However, at the beginning of 2006, he suffered a marked increase in the pain, defined by moderate and constant aching and stabbing. (R. 339).

In 2006, Mr. Cinatl underwent a physical residual functional capacity assessment. (R. 353). The assessment established that Mr. Cinatl had only exertional limitations: occasionally lifting no more than 20 pounds, frequently lifting no more than 10 pounds, standing or walking with normal breaks for about 6 hours in an 8-hour work day, sitting with normal breaks for about 6 hours in an 8-hour work day, unlimited restrictions on ability to push and/or pull. (R. 354). The findings were affirmed in the medical portion of the determination. (R. 362).

In 2007, Mr. Cinatl began treatment at Alexian Brothers. (R. 363-441). His diagnosis there was consistent with those previously made by other physicians, including cervical disc degenerative disease and radiculopathy. (R. 409). Despite these diagnoses, by 2007, Mr. Cinatl had begun general exercising and lifting weights. (R. 424).


Mental Impairments It is difficult to pin down exactly when Mr. Cinatl's mental impairments began. While he claims he was treated for depression as early as 2001, (R. 631), records provided by Mr. Cinatl's attorney to substantiate that claim do not contain dates, thereby preventing a conclusive determination as to when they were composed. (R. 636-637).

Mr. Cinatl's attorney also provided a note from his primary care physician, which stated that he was prescribed medicine for depression since 2003. (R. 639). However, the first legible documentation of Mr. Cinatl's depression comes from a treatment note dated May 6, 2005. (R. 266). This was after Mr. Cinatl's insurance had expired. (R. 28). Although Mr. Cinatl's primary physician documented his depression throughout 2005, medical records from other facilities do not mention him suffering from any mental impairment. (R. 264; R. 318-351).

The clearest indication of Mr. Cinatl's mental health derives from a psychiatric evaluation performed at Alexian Center for Mental Health on April 21, 2006. (R. 497). The evaluation noted that Mr. Cinatl reports low energy, poor interest, adhendonia, decreased motivation, decreased asleep, difficulty sleeping, and feeling overwhelmed, hopeless, and helpless. (R. 506). Following the evaluation, he was diagnosed with "major depressive disorder, recurrent, severe, non-psychotic, and attention deficit disorder, inattentive type." (R. 507). Mr. Cinatl continued psychiatric treatment at Alexian throughout 2007. (R. 507-526).

C. Administrative Hearing Testimony

1.The Medical Expert's Testimony

Dr. Rousch testified that Mr. Cinatl had several medically determined impairments, including cervical spine disease, degenerative arthritis, stenosis with chronic pain, and chronic impingement syndrome. (R. 29). She also testified that Mr. Cinatl has suffered from depression since 2005. (R. 29). Dr. Rousch acknowledged these impairments had "more than a slight affect" [sic] on Mr. Cinatl's ability to perform the universe of work related activities from March 2001 until March 2005, but denied that the impairments equaled the severity of the criteria of any of the Listing of Impairments.

Dr. Rousch testified that Mr. Cinatl's medical records did not contain severe, clinically severe, or significant impairments that would prevent him from working six hours a day prior to the date of last insured. (R. 30). However, she conceded that his physical impairments would have demanded restrictions in his ability to lift, postural activities, and manipulative limitations. (R. 30).She was unable to conclude whether Mr. Cinatl's mental condition improved from treatment by his primary physician, which allegedly began in 2002, or as a result of formal psychiatric treatment, which began in 2007, reasoning that the available records were illegible or scant. (R. 55)


The Plaintiff's Testimony At his administrative hearing, Mr. Cinatl testified that he lived with his wife and two of their three children. (R. 33-34). He stated that he was unemployed but occasionally helped with a day-care center his wife was operating out of their home. (R. 33-34). Mr. Cinatl testified that his depression began after his shoulder operation in 2000 and that he been prescribed anti-depressants by his primary physician since 2002. (R. 36-38). Mr. Cinalt described the effects of his depression as feeling like his "life has been stopped." (R. 37).

Mr. Cinatl further testified that the pain he had previously suffered in his neck and arms were aggravated by a motor vehicle accident. (R. 39). He stated that initially he was placed on medication, administered epidural injections, underwent physical therapy, and received acupuncture.

(R. 39). Mr. Cinatl testified that he experienced pain and tingling, limited motion in his neck and arms, numbness in his fingers, and a loss of strength on his right side. (R. 40-45). He averred his daily pain ranges between six and eight out of ten depending on the severity of the throbbing or stabbing. (R. 52). He testified that the pain keeps him up at night, disrupting his sleep, and causing fatigue the following day. (R. 40). Repeatedly, Mr. Cinatl remarked that pain medication improved his condition in so far as he could function without extreme discomfort. (R. 47-51).


The Plaintiff's Wife's Testimony Mrs. Rachelle Cinatl testified to her knowledge of her husband's physical impairments, depression, and treatment during the period in question. (R. 63-77). She testified that his depression emerged from fear his physical injuries would prevent him from providing for his family. (R. 66). She testified that his mood became progressively worse, and that he was eventually advised by his primary care physician to see a psychiatrist. (R. 71). However, formal treatment was delayed because they needed a psychiatrist who accepted Medicaid. (R. 69-73).


The Vocational Expert's Testimony Mr. Schwice, the vocational expert, testified to Mr. Cinalt's employment potential for the period of time in which he is claiming disability. (R. 79-89). Again, this period is between when Mr. Cinatl first alleges disability (March 31, 2001) and his insurance expires (March 31, 2005). (R. 151-153; R. 28). Mr. Schwice first testified to Mr. Cinatl's past employment, including work as a delivery driver for a pet food supplier (heavy to very heavy range of physical exertion), delivery driver for an appliance store (heavy range of physical exertion), bus driver (medium range of physical exertion) and ramp agent for an airline (heavy range of physical exertion). (R. ...

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