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Peter C. Tsakalakis v. Commissioner of Social Security

August 1, 2011


The opinion of the court was delivered by: Joe Billy McDADE United States Senior District Judge


Monday, 01 August, 2011 03:38:03 PM

Clerk, U.S. District Court, ILCD


This matter is now before the Court on Plaintiff's Motion for Summary Judgment (Doc. 13) and the Commissioner's Motion for Summary Affirmance (Doc. 16). For the following reasons, Plaintiff's Motion for Summary Judgment (Doc. 13) is DENIED, and the Commissioner's Motion for Summary Affirmance (Doc. 16) is GRANTED.


Plaintiff, Peter C. Tsakalakis ("Tsakalakis") was 52 years old at the time of his administrative hearing. He is a high school graduate and has an associate's degree as an electronics technician. From 1979 until August 9, 2005, Tsakalakis worked as an electronic technician. He last worked in 2005. Tsakalakis applied for Disability Insurance Benefits ("DIB") on December 21, 2005, alleging that he became disabled on August 9, 2005.

A.History of Medical Treatments

On August 9, 2005, Tsakalakis injured his left knee and central tendon in his left arm while lifting a heavy television at work. He was treated at an emergency room and advised to see an orthopedic surgeon.

On August 11, 2005, Tsakalakis sought treatment by Dr. Dirk Nelson, an orthopedic surgeon. He had x-rays of his left shoulder and left knee. Dr. Nelson noted that besides the rupture of the left bicep, other musculoskeletal issues were due to aches and pains and should improve within two to three weeks. An MRI revealed spinal stenosis at L3-L4. Dr. Nelson indicated that spinal stenosis, the abnormal narrowing of the vertebral canal, nerve root canals, or intervertebral formania of the lumbar spine, would likely explain Tsakalakis' back and leg symptoms. On August 25, 2005, Tsakalakis sought treatment from Dr. Nelson again. Dr. Nelson found Tsakalakis' hands, wrists and elbows functioned normally. After noting that Tsakalakis was a nervous individual who needed reassurance that his complaints of pain were not serious, Dr. Nelson placed him on temporary duty disability status.

Three days prior, on August 22, 2005, Tsakalakis visited Dr. Sonnenberg, an orthopedic surgeon, for his biceps injury. Dr. Sonnenberg examined Tsakalakis' right shoulder and observed a full range of motion, no significant swelling, and mild tenderness. Dr. Sonnenberg suggested surgery but agreed that Tsakalakis could try therapy. Tsakalakis saw Dr. Sonnenberg again on September 19, 2005. He continued to complain of pain in his left shoulder. Dr. Sonnenberg noted tenderness with positive impingement signs on the left bicep. Dr. Sonnenberg wrote that with therapy of upper extremities, Tsakalakis would probably be ready to return to normal duties at work within four to six weeks.

On September 20, 2005, Tsakalakis saw Dr. Michael Zindrick, an orthopedic surgeon. He reported lower back pain radiating down his left leg. Dr. Zindrick observed pain with flexion beyond 45 degrees, extension beyond 10 degrees, and side bending beyond 20 degrees bilaterally. He observed that Tsakalakis had pre-existing asymptomatic congenital neural spinal canal spondylolisthesis and spinal stenosis at L3-4. X-rays further revealed degenerative changes of lumbar spine at L3-4 with grade 1 spondylolisthesis, which is the forward movement of one lumbar vertebrae on the one below it or on the sacrum. Dr. Zindrick observed that Tsakalakis had full range of motion in his hips, was able to toe walk and heel walk, had no motor weakness, had symmetrical reflexes, and had normal sensation to pin prick and light touch. Dr. Zindrick recommended back surgery for Tsakalakis.

On October 11, 2005, Dr. Nelson ordered an MRI of Plaintiff's knee, which showed a torn medial meniscus and small cyst adjacent to the head of the fibula. Dr. Nelson recommended arthroscopic surgery for the knee. Tsakalakis did not want to pursue surgery, so Dr. Nelson noted that he would not see Tsakalakis for a follow-up unless Tsakalakis wished to discuss arthroscopic surgery at a later date.

On October 17, 2005, Tsakalakis returned to Dr. Sonnenberg. Dr. Sonnenberg noted that while Tsakalakis's left shoulder revealed a rupture of the left bicep, it resulted in only mind impingement pain. He noted that Tsakalakis could lift fifteen pounds with his left arm without problems. Dr. Sonnenberg opined that Tsakalakis could probably return to work with a fifteen pound lifting limit. He also recommended a steroid injection but Tsakalakis declined. Dr. Sonnenberg discharged Tsakalakis from further care as he did not see anything else he could do for him. On November 2, 2005, Tsakalakis sought treatment from Dr. Sonnenberg again. Dr. Sonnenberg noted that Tsakalakis seemed to be a hypochondriac and observed only tenderness and no serious problems in the right arm.

On November 1, 2005, Dr. Michael Orth examined Tsakalakis for his employer's insurer in connection with his worker's compensation claim. Dr. Orth observed the "popeye" muscle in Tsakalakis' left arm, but noted that he had full mobility, no tenderness, and no neurovascular deficit in either extremity. Dr. Orth reported that he did not consider Tsakalakis' problems work-related and concluded that Tsakalakis could return to his regular job.

On December 21, 2005, Tsakalakis interviewed with the Social Security Administration ("SSA") concerning his application for disability benefits. The SSA interviewer observed that Tsakalakis had no difficulty hearing, speaking, sitting, standing, walking or using his hands.

On January 10, 2006, Tsakalakis was seen by Dr. Demetrios Giokaris, Tsakalakis' family doctor. Dr. Giokaris completed a Medical Evaluation-Physicians Report for the State of Illinois. On this form, Dr. Gioarkis checked off boxes to indicate that Tsakalakis had decreased sensation in his legs, could only lift up to ten pounds at a time, had limited ability to walk, bend, stand, stoop, turn, climb, push, pull, speak, travel and perform fine and gross manipulations. Dr. Giokaris noted that Tsakalakis suffered from depression. He further reported that Tsakalakis had limitations in performing activities of daily living, extreme limitations in social functioning, and extreme limitations in concentration, persistence or pace.

On January 30, 2006, Dr. C.C. Prodromos examined Tsakalakis' left arm, shoulder, left knee and lower back. Dr. Prodromos observed the "popeye" deformity in the left biceps but noted that Tsakalakis had good maintenance in other areas. Dr. Prodromos reported abnormalities in the left shoulder and mildly diminished range of motion in the lumbar spine. X-rays of the knees and shoulder were normal. An MRI of the knee revealed chondromalacia of the patella and trochlea and a posterior horn medial meniscus tear. An MRI of the shoulder showed a torn or subluxated biceps tendon, supraspinatus tendinosis, and other possible abnormalities. An MRI of the lumbar spine revealed spinal stenosis and likely spondylolysis. Dr. Prodromos recommended knee surgery to correct the torn meniscus but recommended only epidural injections to treat Tsakalakis' back pain. Dr. Prodromos also observed Tsakalakis' hearing loss and opined that it would be difficult for him to return to work.

On February 7, 2006, Dr. Mahesh Shah examined Tsakalakis for a medical consultative exam. Dr. Shah observed that Tsakalakis moved slowly. Dr. Shah noticed that Tsakalakis could move from the sitting to supine position but needed help to get up from the supine position due to pain. While Dr. Shah recorded that Tsakalakis had decreased hearing, he also noted that Tsakalakis could hear fairly well with hearing aids, which he had been using for thirty-five years. Based on Tsakalakis' history and examination, Dr. Shah indicated ...

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