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Charles Williams v. Michael J. Astrue

April 30, 2012


The opinion of the court was delivered by: Magistrate Judge Michael T. Mason


Michael T. Mason, United States Magistrate Judge:

Before the Court is plaintiff Charles Williams' ("Williams" or "claimant") motion for summary judgment [22] in which he seeks judicial review of the final decision of the Commissioner of Social Security (the "Commissioner") denying his application for disability insurance benefits under the Social Security Act, 42 U.S.C. §§ 416(i), 423(d). The Commissioner has filed a cross-motion [27] asking the Court to uphold the decision of the Administrative Law Judge. We have jurisdiction to hear this matter pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, claimant's motion for summary judgment [22] is granted and the Commissioner's cross-motion [27] is denied.


A. Procedural History

On April 15, 2008, Williams filed his application for period of disability and disability insurance benefits alleging disability beginning September 13, 2007 due to back problems and high blood pressure.*fn1 (R. 205-08.) His claim was denied initially on June 23, 2008, and again upon reconsideration on April 9, 2009. (R. 146-50, 154-58.) A hearing was held on September 23, 2009 before Administrative Law Judge ("ALJ") Curt Marceille. (R. 73-132.) On October 16, 2009, ALJ Marceille issued a written opinion denying Williams' application for benefits. (R. 52-68.) Williams filed a timely request for review of the ALJ's decision, but the Appeals Council denied that request on January 28, 2011. (R. 5-8.) The ALJ's decision then became the final decision of the Commissioner. Tumminaro v. Astrue, 671 F.3d 629, 632 (7th Cir. 2011).

B. Medical Evidence

1. Treating Physicians

a. Kildare Clinic and Clearing Clinic

Williams presented to the Kildare Clinic on November 19, 2002 for evaluation and treatment of midline low back pain abruptly presenting at work. (R. 339.) He denied any previous low back injury, but described a twenty-five year history of hypertension. (Id.) Dr. Joan Mankowski examined Williams and noted that he entered the clinic with "a cane for ambulation with persistent right-sided list." (Id.) She diagnosed an acute low back strain and directed Williams to remain off work through the following day. (R. 340.) Dr. Mankowski prescribed Cyclobenzaprine and Ibuprofen, and recommended cold compresses. (Id.) At a follow-up appointment two days later, Williams' back pain was improving gradually. (R. 338.) Dr. F. Annaba noted tenderness to palpitation in the lower back area, mostly on the left side. (Id.) She found no muscle spasms or swelling. (Id.)

By November 25, 2002, Williams no longer had constant pain, but reported that his pain was triggered with forward flexion. (R. 337.) Dr. Mankowski found that Williams' gait was nonantalgic and his seating and standing postures were unremarkable. (Id.) She also noted that Williams was still limited to approximately forty-five degrees of forward flexion. (Id.) At a follow-up appointment on December 2, 2002, Williams described a "small knot" in the left low back "rather than pain per se," which was still triggered by forward flexion or by getting up from a seated position. (R. 336.)Dr. Mankowski noted slight tenderness with deep palpitation of the left lower lumbar paraspinal musculature. (Id.) Dr. Mankowski determined that Williams could work as long as he avoided "lifting/pushing/pulling more than 50 pounds." (Id.) Two days later, Williams reported no problems apart from two "transient bouts of low back pain lasting forty minutes." (R. 334.) The knot in his back was "gradually resolving." (Id.) Dr. Mankowski discharged Williams back to full duty work without restrictions and advised him to take Ibuprofen as needed. (Id.)

On November 2, 2006, Williams visited the Clearing Clinic after he "slipped on some hydraulic fluid and fell backward striking his right low back on a rear bumper." (R. 331.)He described his pain as a six out of ten and stated that the pain radiated down the "right thigh lateral," but not past his knee. (Id.)Dr. James Delis examined Williams and found that his forward flexion was limited to forty degrees due to right low back pain and that extension to ten degrees produced moderate pain. (Id.) There was no tenderness to palpitation of the left lumbar paraspinal musculature, minimal tenderness of the lumbar spine, and moderately severe tenderness with palpitation of the right lumbar paraspinal musculature. (Id.) Williams' rotation and side bending were limited to twenty degrees. (Id.) Motor strength was 5/5 in the left lower extremity, but "a little weaker on the right lower extremity" due to pain. (Id.) Dr. Delis diagnosed a lumbar contusion and provided Williams with a Toradal injection. (Id.) He also prescribed Ibuprofen and told Williams not to return to work the following day. (Id.)

Williams returned to see Dr. Delis the next day, at which time he described his pain as a seven on a ten-point scale. (R. 328.) On examination, Dr. Delis noted moderate tenderness to palpitation of the bilateral lumbar paraspinal musculature and the left upper thoracic area. (Id.) Forward flexion to sixty degrees and extension to thirty degrees resulted in moderate low back pain. (Id.) Dr. Delis found no neurovascular compromise of Williams' lower extremities, deep tendon reflexes were normal, and his motor strength was 5/5 in both extremities with slight low back pain. (Id.) Straight leg raise was negative on the left, but produced mild low back pain on the right. (Id.)

Dr. Delis ordered an x-ray, which revealed mild curvature of the lumbar spine and "marked narrowing of the L4-5 disk space with large anterior osteophytes and facet hypertrophic changes." (R. 329.) The radiologist assessed "moderate degenerative changes of L4-5." (Id.) Dr. Delis commented that the x-ray showed no evidence of any fractures, dislocation, or joint abnormality, but noted the "arthritic changes." (R. 328.) Dr. Delis again assessed a lumbar contusion, as well as a left thoracic strain. (R. 328.) He recommended moist heat and home exercises, and prescribed Cyclobenzaprine. (Id.) As for work restrictions, Dr. Delis determined that Williams should not lift more than ten pounds, and should not lift or reach over his head. (Id.)

A week later, on November 10, 2006, Williams reported he was feeling "better overall" and described his low back pain as a four out of ten. (R. 324.) A physical examination revealed minimal tenderness to palpitation of the bilateral spine. (Id.) Flexion to seventy degrees and extension to thirty degrees produced mild low back pain, as did rotation and side bending. (Id.) Motor strength of the lower extremities was normal and straight leg raise was negative bilaterally. (Id.) Dr. Delis continued to recommend moist heat, exercises, Ibuprofen, and Cyclobenzaprine. (Id.) Although Williams advised Dr. Delis that he was laid off the day before, Dr. Delis discharged Williams to full duty with no restrictions based on his belief that Williams suffered only from a muscle strain with no evidence of a herniated nucleus pulposus. (Id.)

b. Dr. Rama Medavaram

Medical progress notes reveal that Williams has been under the care of family practitioner Dr. Rama Medavaram since 1999. The records illustrate a history of hypertension and repeated non-compliance with blood pressure medication and recommendations to see a cardiologist. (See, e.g., R. 316, 318-19, 321.) Although some of the records are difficult to read, it appears that Williams did not complain of any type of extremity pain or back pain until July 22, 2005 when he complained of pain in his left knee. (R. 310.) Dr. Medavaram noted tenderness in the left knee and assessed degenerative joint disease. (Id.) Later, on May 14, 2007, Williams complained of low back pain and Dr. Medavaram assessed a low back strain. (R. 307.) Among other things, Dr. Medavaram prescribed Advil. (Id.)

On April 21, 2008, Williams reported a ten year history of chronic low back pain and Dr. Medavaram prescribed Naproxen. (R. 306.) At another appointment, likely in 2008, Williams complained of pain in the knees and lower back and reported a history of "old injuries." (R. 360.) Dr. Medavaram noted a decreased range of motion and tenderness in the right knee, and tenderness in the lumbosacral spine. (Id.) He assessed degenerative joint disease and prescribed Motrin, among other things. (Id.)

On September 26, 2008, Williams reported that his low back pain worsened with bending and weight bearing. (R. 391.) He continued to complain of joint pain in his knees. (Id.) Williams also reported feelings of depression, but denied suicidal thoughts or ideations. (Id.) After a physical examination, Dr. Medavaram assessed hypertension, exacerbation of low back pain, depression, and degenerative joint disease. (R. 392.) He prescribed Citalopram for the depression and referred Williams for a psychological evaluation. (Id.) Dr. Medavaram noted similar findings and reached similar conclusions on January 23, 2009. (R. 390.)

Also on January 23, 2009, Dr. Medavaram completed a "Arthritis Residual Functional Capacity Questionnaire." (R. 362-64.) Dr. Medavaram reported that he had treated Williams for ten years for low back pain. (R. 362.) He listed his diagnoses as severe osteoarthritis of the lumbosacral spine and a history of hypertension. (Id.) Dr. Medavaram also reported that Williams suffered from depression, which affects his pain, and that Williams' symptoms would "constantly" interfere with his ability to pay attention and concentrate. (R. 363.) According to Dr. Medavaram, Williams' condition resulted in a reduced range of motion, abnormal posture, swelling, and muscle spasms.

(R. 362.) The condition was treated with Motrin. (Id.) Dr. Medavaram also opined that Williams could walk less than one city block before needing to rest, could sit for twenty minutes at a time before needing to get up, could stand for twenty minutes before needing to sit down, and could sit, stand and/or walk for less than two hours in an eight-hour workday. (R. 363.) He concluded that Williams needs a job that permits shifting positions at will in order to relieve his back pain. (Id.) According to Dr. Medavaram, Williams needed to use a cane while engaging in occasional standing or walking and that he could occasionally lift and carry less than ten pounds. (R. 364.) Lastly, Dr. Medavaram noted that Williams would have "good days" and "bad days" and would likely be absent from work more than four days per month. (Id.)

Dr. Medavaram noted Williams' history of low back pain again on June 3, 2009 and July 10, 2009. (R. 397-99.)

2. State Agency Consulting Physicians

On June 5, 2008,Williams underwent a consultative examination with Dr. M.S. Patil. (R. 350-53.) Williams complained of "recurrent mild pain and stiffness in his knees, wrists and low back area." (R. 350.) He explained that his back pain sometimes radiates to his left leg. (Id.) Williams denied any major injuries or falls, but stated that his job as a mechanic required a "whole lot of bending and kneeling." (Id.) He rated his joint pain a six on a ten-point scale, but denied swelling, redness, or a burning sensation. (Id.) He complained of mild difficulty and pain while bending, lifting more than ten pounds, walking more than two blocks, standing for more than ten minutes, or climbing up or down stairs. (Id.) Williams said that sitting for more than an hour or two results in cramps in his feet. (Id.) He reported that he takes Ibuprofen as needed. (Id.) With respect to his hypertension, Williams stated he takes Vasotec, but denied chest pain, shortness of breath, headaches, dizziness, heart attack, or stroke. (Id.)

Dr. Patil's examination of Williams' spine and back revealed no paravertibral tenderness or spasm and no obvious deformities. (R. 352.) Mild limitations were noted in the range of motion of the lumbar spine. (Id.) A neurological exam revealed that all cranial nerve functions were preserved and that reflexes were brisk and equal bilaterally throughout. (Id.) Williams' motor strength was "5/5 in all upper and lower extremities" and "there was no sign of muscle wasting or paralysis." (Id.) No edema or calf tenderness was noted. (Id.) Williams had full range of motion of all joints except for some mild limitations in the flexion of his knees. (Id.) As for his hands and fingers, grip strength was 5/5 and Dr. Patil determined that he had no difficulty with fine or gross manipulations in either hand. (Id.)

Williams' gait was normal and he did not use an assistive device. (R. 353.) Williams could tandem walk and walked fifty feet normally during the exam. (Id.) Dr. Patil did note, however, that Williams had some difficulty with heel and toe walking, as well as getting on and off the examination table. (Id.) He also had some difficulty with "squats and arises." (Id.) Dr. Patil's examination of all other systems revealed normal results. (R. 351.)

Dr. Patil assessed osteoarthritis, but found no deformity, swelling, tenderness or redness of any joint, normal peripheral pulses and sensation, no shortening of extremities or atrophy of extremity muscles, and no recent trauma or localized neurovascular deficits. (R. 353.) He again noted that "gait, speech, hand dexterity and mentation were normal." (Id.) Dr. Patil also cited Williams' 2006 x-ray revealing moderate osteoarthritis. (Id.) However, he further ...

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