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Dionte Harris v. Michael J. Astrue

April 25, 2012

DIONTE HARRIS, 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 Dionte Harris's claim for Disability 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, Harris's motion for summary judgment [Doc. No. 23] is granted. The Court finds that this matter should be remanded to the Commissioner for further proceedings.

BACKGROUND

I. PROCEDURAL HISTORY

Plaintiff Dionte Harris ("Plaintiff," "Claimant," or "Harris") filed a Title II application for a period of disability and disability insurance benefits and a Title XVI application for supplemental security income on June 26, 2007. (R. 23.) In both applications, he alleged disability beginning November 8, 2006. (Id.) Plaintiff's claims were denied initially on September 27, 2007, and upon reconsideration on November 13, 2007. (Id.) Plaintiff timely filed a written request for a hearing by an Administrative Law Judge ("ALJ") on January 3, 2008. (Id.) Plaintiff appeared and testified at a hearing held on January 14, 2010. (Id.) Also appearing and testifying were impartial medical expert Dr. William Newman ("Dr. Newman"), and impartial vocational expert Dr. Richard Hamersma ("Dr. Hamersma"). (Id.)

On March 2, 2010, the ALJ denied Plaintiff's claim and found him "not disabled" under the Social Security Act. (R. 44.) The Social Security Administration Appeals Council denied Plaintiff's request for review on October 21, 2010. (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 Plaintiff filed the instant motion on August 2, 2011. [Doc. No. 23.] This matter has been fully briefed since October 26, 2011. [Doc. No. 26.]

II. FACTUAL BACKGROUND

A. Harris's Reports & Testimony

Mr. Harris was born on May 13, 1977; at the time he claimed that he was unable to work -- November 8, 2006 -- he was twenty-nine years old. (R. 250.) Harris alleged that he was unable to work due to his physical condition; specifically, he complained of elbow, hand, hip, back, buttock, knee, and wrist pain. (R. 26.) Before he claimed he was unable to work, Harris stacked products on pallets and performed quality control at a factory through a temporary employment agency. (R. 42.)

In his Activities of Daily Living Questionnaire, Plaintiff reported that he lived with his fiance and two daughters. (R. 288.) He indicated that his fiance cooked his meals, and that he did very few, if any, of the household chores. (Id.) Harris reported that he first started feeling a problem in 1998, and that he had no problems walking before that time. (R. 289-90.) He also indicated that he rarely or never drove because his knees locked up, and that he watched his children often, but that he could not move around quickly. (R. 291.) Harris reported that "standing up for a short period of time in one spot" or "sitting down in one spot too long" made his knees lock up. (R. 285.) He also reported that it was difficult to use stairs, and that he had to pop his knees to relieve pressure and pain when he got up from chairs or out of bed. (R. 286.) Harris indicated that he needed assistance standing and balancing. (Id.)

In a separate disability report, Harris explained that "arthritis in both knees w/ contusion" were the illnesses, injuries or conditions that limited his ability to work. (R. 279.) He also reported that he wore braces on both legs, that his legs go out without notice, and that due to the pain he was sleep-deprived to the point that it had begun to affect his ability to concentrate and remember things. (Id.) In a subsequent disability report, Harris reported that his condition had gotten worse, that he suffered with constant pain, and that his legs were giving out. (R. 296.) In his most recent disability report, he claimed increased stiffness and pain. (R. 307.) He also complained about stiffness in his left elbow and uncontrollable spasms in his elbow and legs. (Id.)

At the hearing, Harris testified that he stopped working in 2006 because his knees kept giving out on the assembly line, and his employer fired him because he was not able to perform his job. (R. 67-68.) He claimed that he could not work at the time of the hearing because of the pain that he had, the trouble he had getting around, problems with his equilibrium and his medication. (R. 78.) He testified that he had a hard time just standing up, walking, stitting and moving. (Id.) He stated that he had good days and bad days. (Id.) Harris testified that physical therapy provided no benefits. (R. 83.) Harris reported that he can stand only five minutes before he has to change position. (R. 103.) He said that he can walk about a block or two without resting. (R. 104.) After walking any longer than that, Harris testified that he suffered from shortness of breath and that his lower back and knees start to hurt. (Id.) Harris also testified that he can sit about twenty to thirty minutes without changing positions. (Id.) Harris also recounted an incident about how his iPod was stolen from him on the street; he said that he chased after the robber. (R. 84.) He explained that his leg gave out, that "it hasn't been right since," and that the incident led him to discover the severity of his back pain. (Id.)

Harris testified that he received his primary care at Friend Family Health Center. (R. 139.) Harris said that he was prescribed a variety of medications for his pain, and that he also received injections. (R. 85, 87.) He explained that the injections "didn't really work at all period." (R. 87.) Harris also said that he had to go to the emergency room several times for his pain. (R. 87-88, 140.) Harris testified that he had physical therapy at the University of Chicago Medical Center in 2008.

(R. 95.) He also said that he received physical therapy at the Illinois Institute of Rehabilitation and at the Rehabilitation Institute of Chicago. (R. 137-38.) Harris testified that he saw a rheumatologist and an orthopedic specialist at Rush University Medical Center, and that he was referred to and attended the Rush Pain Center for treatment. (R.138-39.) He also said that he performs a home exercise routine in the morning, but that it does not help. (R. 99.) Harris testified that his physical therapist and his primary care doctor, Dr. Deol, prescribed the use of a cane. (R. 95.) He said that he always uses it. (R. 95-96.) He also testified that he uses a leg brace. (R. 98.)

Harris testified that his fiance does the cooking, the laundry, buys the groceries, and takes out the trash. (R. 101.) Harris said that he tries to vacuum and wash the dishes, but that those activities cause him too much pain. (Id.) He explained that during the time he is home with his children, he is the one who is responsible for supervising them. (Id.) He said that he helps the kids with her homework, and that he watches television and plays video games with them. (R. 100, 103.)

B. Medical Evidence & Expert Testimony

1. Plaintiff's Treating Physicians & Therapists

As the ALJ states in her decision, Harris "has been treated extensively, by numerous providers at various facilities." (R. 28.) On November 21, 2006, Plaintiff saw Dr. Ahmad at Provident Hospital of Cook County. (R. 348-70.) Plaintiff complained of a five-year history of bilateral knee pain, which he reported had gotten worse in the preceding two months. (R. 348, 354.) The progress notes indicate that Harris reported that prior courses of medication and physical therapy had not relieved his pain, and that he sought additional treatment. (Id.) Dr. Ahmad noted that Plaintiff ambulated with a steady gait. (R. 354.) Dr. Ahmad ordered x-rays and an MRI and prescribed naprosyn, an anti-inflammatory. (R. 359-60.) On December 26, 2006, Dr. Ahmad increased the dose of naprosyn and referred Plaintiff for physical therapy. (R. 361.) Dr. Ahmad also advised Plaintiff to follow up with an orthopedic specialist. (Id.) On April 10, 2007, Dr. Ahmad noted that a recent MRI exam ruled out a meniscal tear, but showed a small contusion and some swelling. (R. 362.) Dr. Ahmad noted full range of motion of the right knee. (Id.) He advised Plaintiff to continue his home exercise program, and to take regular strength Tylenol as needed. (Id.) Dr. Ahmad also ordered a lumbar x-ray. (Id.) On June 26, 2007, Dr. Ahmad injected medication into Plaintiff's left knee. (R. 366.) On July 10, 2007, Plaintiff told Dr. Ahmad that the knee injections only provided a brief period of relief. (R. 370.) Dr. Ahmad told Plaintiff to continue taking naprosyn and referred him to an orthopedic specialist again. (Id.)

Plaintiff attended physical therapy sessions at Provident Hospital between January and March of 2007. (R. 363-69.) The progress notes indicate that Plaintiff repeatedly complained that his medications were not helping. (Id.) At the time of discharge, the therapist noted some improvement. (R. 367.) Plaintiff's physical therapist reported that Plaintiff demonstrated symptoms consistent with severe osteoarthritis of both knees. (R. 549.) The therapist said that Plaintiff consistently attended therapy sessions and performed his home exercise program, and that the therapy was discontinued because of a lack of progress. (Id.)

On October 29, 2007, Plaintiff visited the Fantus Orthopedic Clinic. (R. 388.) Plaintiff complained of bilateral knee pain, and the doctor noted that Plaintiff's left knee was tender to examination. (Id.) The doctor ordered x-rays of Plaintiff's knees and hips. (Id.) In a follow-up appointment on December 10, 2007, Plaintiff reported that he was still suffering from bilateral knee pain, and that he was using a brace on each knee and taking naproxen. (R. 389.) The doctor diagnosed polyarticular arthritis of unknown origin. (Id.)

On June 25, 2008, Plaintiff commenced a course of primary care treatment at the Friend Family Health Center. (R. 405.) Plaintiff complained of arthritis in both knees, and reported an elbow fracture along with hereditary low back pain and hip pain. (Id.) Dr. Gayle Smith found crepitus with light palpation of Plaintiff's left knee, but did not note any other significant anatomical abnormalities. (Id.) Dr. Smith ordered x-rays of Plaintiff's wrists, knees, and hips, and an MRI. (R. 405-06.) The knee x-rays revealed a small medial compartment osteophyte representing minimal osteoarthritic disease in the right knee, and a multipartite patella in the left knee. (R. 421.) The hip x-rays revealed small ossicales adjacent to the acetabulum and suggested minimal osteoarthritic disease. (R. 423.) The x-ray of the right wrist revealed a soft tissue abnormality, but normal bones. (R. 420.)

Plaintiff saw Dr. Smith again on July 8, 2008. (R. 401.) Dr. Smith noted that Plaintiff's x-rays showed minimal arthritis. (Id.) Dr. Smith re-ordered the MRI. (Id.) After the MRI exam, Plaintiff saw Dr. Smith on July 17, 2008. (R. 403.) Dr. Smith diagnosed Plaintiff with chondromalacia of the left patella, and referred him to an orthopedic specialist. (R. 404.) Dr. Smith also advised Plaintiff to pursue physical therapy and prescribed tramadol and nabumetone. (Id.) The knee MRI results were interpreted as normal. (R. 416.) Plaintiff saw Dr. Smith again on August 18, 2008, and his primary complaint was left hand pain and episodic "locking up" of the hand.

(R. 399.) Dr. Smith recommended physical therapy and occupational therapy. (R. 400.) Plaintiff also saw Dr. Smith on October 8, 2008, November 19, 2008, and December 19, 2008. (R. 439-44.)

On October 2, 2008, Dr. Smith completed an arthritis/pain residual functional capacity questionnaire. (R. 390.) She noted that his likely diagnosis was chondromalacia patella. (Id.) She reported that Plaintiff's pain was severe, and that his knee pain requires the use of a cane. (Id.) Dr, Smith also referenced Plaintiff's osteoarthritis and the pain he experienced in his wrists, hands and hips. (Id.) Dr. Smith reported that Plaintiff had reduced range of motion, reduced grip strength, sensory changes, tenderness, crepitus, swelling, muscle weakness, and abnormal gait. (Id.) She explained that Plaintiff's symptoms would interfere with the attention and concentration needed to perform simple working tasks "ocassionally."

(R. 391.) Dr. Smith opined that Plaintiff could walk less than one block without rest or severe pain, that he could sit for one hour before needing to get up, that he could stand for fifteen minutes before needing to sit down, and that Plaintiff could sit and stand/walk around six hours in an eight-hour workday. (Id.) She also reported that Plaintiff requires a position that permits shifting positions at will. (Id.)

On September 22, 2008, Plaintiff saw Dr. Jeffrey Mjaanes, an orthopedic specialist at Rush University Medical Center. (R. 564.) Dr. Mjaanes found that Plaintiff had full range of motion of both hips and a negative straight leg raising test, but slightly decreased range of motion of both knees and slightly decreased motor power of the left leg. (Id.) Dr. Mjannes explained that most of the findings are "consistent with patellafemoral stress syndrome and MRI findings, although not visualized today, seem to indicate chondromalacia patella." (R. 565.) Dr. Mjannes also noted that Plaintiff's pain was completely out of proportion to his physical exam or imaging findings. (Id.) On October 16, 2008, Dr. Mjannes reported that Plaintiff continued to have tenderness on his patellar facets and had a positive patellar grind test. (R. 563.) The doctor concluded that Plaintiff suffered from bilateral knee pain, and explained that "[b]asically I believe this is patellofemoral syndrome gone awry. I think that there is likely a psychosomatic component to his pain as his exam is out of proportion to this physical findings." (Id.) Plaintiff had follow-up visits with Dr. Mjannes on November 20, 2008 and on January 12, 2009; Dr. Mjannes noted little change at both visits. (R. 561-62.) On March 2, 2009, Dr. Mjannes reported that Plaintiff did not have a rheumatologic condition. (R. 558.) Dr. Mjannes's impression was that Plaintiff had bilateral patellofemoral syndrome with possible chondromalacia patella on the left knee, left medial epicondylitis, and low back pain, "likely muscular." (Id.) Dr. Mjannes explained that Plaintiff's pain "is out of proportion to his exam findings and may not be organic in nature." (R. 558.) At the ...


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