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Robin Mendoza v. Michael J. Astrue

November 14, 2011

ROBIN MENDOZA, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Maria Valdez

MEMORANDUM OPINION AND ORDER

This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying plaintiff Robin Mendoza's claim for Disability Benefits and Supplemental Security Income Benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Mendoza's motion for summary judgment [Doc. No. 19] is granted in part and denied in part. The Court finds that this matter should be remanded to the Commissioner for further proceedings.

BACKGROUND

I. PROCEDURAL HISTORY

Mendoza originally filed a Title II application for a period of disability and disability benefits on April 27, 2006. (R. 13.) On the same day, Mendoza also filed a Title XVI application for supplemental security income. (Id.) Both applications were premised on a disability beginning in December of 2005. (Id.) Both of Plaintiff's claims were denied initially on July 31, 2006, and were later denied upon reconsideration on November 9, 2006. (Id.) Mendoza timely filed a written request for a hearing by an Administrative Law Judge ("ALJ") on January 4, 2007, and the hearing was held on May 13, 2008. Mendoza personally appeared and testified at the hearing and was represented by counsel. (Id.) An impartial vocational expert, Grace Gianforte, also appeared at the hearing. (Id.)

On December 15, 2008, the ALJ denied Mendoza's claims and found Mendoza not disabled under the Social Security Act. (R. 23.) The Social Security Administration Appeals Council denied Mendoza's request for review on June 12, 2009. (R. 1.) The ALJ's decision thus became reviewable by the District Court under 42 U.S.C. § 405(g), see Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005), and Mendoza filed this timely complaint for judicial review.

II. FACTUAL BACKGROUND

A. Background

Mendoza was born on September 26, 1973 and was thirty-two years old on December 16, 2005, the date on or around which she claims her disability began. (R. 66.) Plaintiff claims that a work injury caused her disability; she explains that she was shoveling snow off of a school roof for almost two weeks and experienced "basically a burnout of all [her] muscles." (R. 37.) The specific impairments Mendoza alleges include: chronic myofascial pain, bilateral carpal tunnel syndrome, bilateral epichondylitis, medial epichondylitis, fibromyalgia and depression. (R. 28-29, 34.) Before the accident, Plaintiff worked as a construction laborer. (R. 32.) Before that, she worked as a radiation worker, bus driver, a receptionist, a machine operator, a parts inspector, and an Avon salesperson. (R. 32-33, 55-56.)

B. Testimony and Medical Evidence

1. Mendoza's Testimony

Mendoza's main symptoms are chronic pain and depression. (R. 28.) Her pain is everywhere, "in all her muscles," and is exacerbated by any activity. (R. 33-34, 44.) She explains that she must "calculate" everything she does: "if I want to go somewhere, you know, I have to psychologically, you know, tell myself, you know, you got to walk slow, don't walk too fast, don't lift this, don't lift that because the following day, whatever muscles I use flare up and become very painful." (R. 45.) Lifting and walking are difficult, and she cannot walk or stand five minutes an hour over the course of a day without experiencing painful flare-ups. (R. 46-47.) She has to sit with her neck back and her head rested on something. (R. 51.) Essentially, any movement causes an increase in pain. (R. 48-49.) She could not finish an online class because her arms, elbows and hands began to cramp, and eventually she could not even read or concentrate. (R. 50.) She is unable to do any household chores without experiencing painful muscle spasms. (R. 41.) She is easily fatigued, and sometimes sleeps all day due to her exhaustion. (R. 39.) Plaintiff also complains that her pain and depression are interrelated, and explains that her chronic pain and resulting limitations exacerbate her depressed psychological state. (R. 52-53.)

Mendoza has taken Flexeril, Neurontin, Naproxen, Ultracet, Zanaflex, Cymbalta, Lamictal, Lorazepam, Temazepam, Methylphenidate, Provigil, Seroquel, and Sonata for pain, depression and insomnia. (R. 11, 244.) She has also received numerous epidural and trigger point botox injections, as well as steroid / local anesthetic injections for temporary pain relief, and has used a Fentanyl patch and a Flector patch. (R. 50-51, 37.) Prescription medications, however, sometimes did not work and/or gave Mendoza various side effects, including dopiness, drowsiness, shakiness, memory loss, decreased attention span, and limited concentration abilities. (R. 37-38, 244.)

2. Medical Evidence

a. Treating Physicians

On December 16, 2005, Mendoza saw Dr. Asavari Javeri and complained of tingling, numbness and dull pain in both of her upper extremities. (R. 747.) Dr. Javeri noted that there was paraspinal tenderness on both of Plaintiff's sides, and some stiffness in the paraspinal muscles. (Id.) He also reported mild cervical tenderness, and that upper extremity strength, sensation and reflexes were normal, and that shoulder range of motion, and shoulder, elbow and wrist exams were normal. (Id.) Dr. Javeri suggested several days off of work, a Magnetic Resonance Imaging ("MRI") exam, and a prescription for Naproxen. (Id.)

A week after she suffered her work-related injury, Mendoza was diagnosed by Dr. Louis Papaeliou of the Joliet Medical Group with a peripheral neuropathy of questionable source. (R. 657.) Plaintiff's MRI of the cervical spine was reported as normal except for some minimal degenerative changes at C5-6. (Id.) Dr. Papaeliou remarked that a sedentary position excluding strenuous labor and any lifting over five pounds was appropriate, and suggested proceeding with an EMG and nerve conduction velocity studies in both upper extremities. (R. 657-58.) Those studies were reported as normal, (R. 660), and Dr. Papaeliou suggested lower extremity EMGs and nerve conduction velocity studies, and requested a formal consultation with Dr. Surrendra Gulati. (R. 661.) Dr. Gulati reported that while Plaintiff had burning sensations in her hands and arms, and pain around the upper back that became worse with activity, she had normal cervical spine movement, her Adson's maneauver was positive bilaterally, and her shoulder movements were normal. (R. 675.) Dr, Gulati did report that there was some cervical myofascial tenderness in the mid-upper thoracic regions, but no definite spinal tenderness was noticed and there was no lumbar tenderness. (Id.) Additionally, there was no myofascial tenderness in the upper extremities, but there was some lateral epicondyle tenderness. (R. 676.) Dr. Gulati indicated that physical therapy would be initiated. (Id.)

On February 28, 2006, Plaintiff was referred for an independent medical evaluation, to be completed by Dr. Robert Ayers. (R. 688.) Dr. Ayer's diagnosed Mendoza with pain disorder, possible conversion disorder, depression, tobacco use and iatrogenic deconditioning. (R. 699.) He reported that "[a]n etiology for her current symptoms is not apparent in the provided medical records. The testing performed by her physicians . . . is all within normal limits. There is no sign of a neuropathy." (R. 700.) Dr. Ayers also noted that Mendoza's condition may be better explained as a pain disorder: "The central feature of a pain disorder is that pain is a predominant focus of the presentation and causes significant distress. Psychological factors are judged to play [a] significant role in the onset and maintenance of the pain." (Id.)

Mendoza was seen regularly by Dr. Artelia Watson, a pain specialist, from March 22, 2006 until August 4, 2006 for trigger point injections, evaluation and medication management. (R. 710-42.) In her initial evaluation, Dr. Watson reported that Mendoza's range of motion was within functional limits, but that there was right cervical paraspinal muscle tenderness, right cervical facet tenderness, bilateral trapezius muscle tenderness with a palpable trigger point, and mild thoracic spine tenderness at the T6 level. (R. 710-11.) Dr. Watson suggested trigger point injections, continued physical therapy, and stated that they would consider a psychology evaluation for pain management coping therapies. (R. 711.)

From March 16, 2006 through August 31, 2006, Plaintiff attended physical therapy two times per week. The vast majority of Plaintiff's physical therapy progress evaluations indicate that she "is unable to work," and all of them advised continued physical therapy. (R. 716-42.) The last progress note reports that her condition waxes and wanes; she may feel better for a day or two, but then her condition returns to baseline. (R. 742.) Little or no improvement was noted, and she was again deemed "unable to work." (Id.)

Plaintiff was seen by Dr. Jonathan Wang, a neurologist, on August 30, 2006. He reported that there was "electrographic evidence of moderately severe bilateral median neuropathies at the wrists consistent with a diagnosis of carpal tunnel syndrome. . . . [T]he collected data also revealed a left C6/7 nerve root compression."

(R.556.)

On November 29, 2006, Plaintiff was referred for another independent medical examination, this time at the request of Auto Owners Insurance Company.

(R. 547.) The examination was performed by Dr. Charles Carroll, an orthopedic surgeon (Id.) He noted that Plaintiff had myofascial pain syndrome, and that she had bilateral epicondylitis, some mild medial epicondylitis, and some very mild evidence of carpal tunnel syndrome. (R. 550.) He did not find permanent partial impairment, and determined that she could work with a five-ten pound ...


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