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Sherry Summers v. Michael Astrue

May 7, 2012


The opinion of the court was delivered by: Byron G. Cudmore, U.S. Magistrate Judge:


Monday, 07 May, 2012 05:05:45 PM

Clerk, U.S. District Court, ILCD


Plaintiff Sherry Summers appeals from the denial of her application for Social Security Disability Insurance Benefits under Title II of the Social Security Act. 42 U.S.C. §§ 416(i) and 423. This appeal is brought pursuant to 42 U.S.C. §§ 405(g). Summers filed her Brief in Support of Motion for Summary Judgment (d/e 14), and the Defendant Commissioner of Social Security has filed his Motion for Summary Affirmance (d/e 17). The parties consented, pursuant to 28 U.S.C. § 636(c), to have this matter proceed before this Court. Consent to Proceed Before a United States Magistrate Judge, and Order of Reference entered October 4, 2011 (d/e 12). For the reasons set forth below, the Decision of the Commissioner is affirmed.


Summers was born on July 18, 1961. She graduated from high school and was fifteen hours shy of completing her bachelor's degree. She had work experience as a certified nurse's assistant, a baker, and a room service assistant. Answer to Complaint (d/e10), attached Certified Transcript of Record of Proceedings Before the Social Security Administration (R.) 32, 185, 197. On October 23, 2005, she was injured in an accident at work at the Illinois Veteran's Home in Quincy, Illinois. R. 27. She injured her back and right elbow in the accident. She went to the emergency room at Blessing Hospital in Quincy, Illinois. R. 252-56. X-rays of her back and right elbow showed no fractures or dislocations. The x-rays of her back showed some degenerative changes but normal alignment of her lumbar vertebral bodies and no subfluxation. R. 262-63. She was diagnosed with a contusion of her back and elbow. R. 254. The emergency room doctor issued a Work Ability Report. R. 258-59. The Report stated that Summers could return to work on October 24, 2025, but could not lift, push, or pull more than fifteen pounds and could not perform work requiring repetitive bending of her elbow or back. R. 258.

On October 26, 2005, Summers saw Dr. David Arndt, D.O. on a workers compensation referral from her employer. Dr. Arndt diagnosed Summers with a contusion of her elbow and back and muscle spasms.

R. 365. Dr. Arndt prescribed an NSAID anti-inflammatory Relafen and a muscle relaxer Skelaxin, and recommended physical therapy. R. 365. Summers saw a physical therapist the next day. The therapist noted that Summers had limited ability to stand erect, bend forward, and lift due to back pain. Summers also reported pain while lifting with her right arm. Summers rated the pain in her elbow at a 5 on a scale of 1 to 10 with an ache and elbow pain increasing to an 8 when lifting. She rated the pain in her back as a 3. R. 362.

Summers saw Dr. Arndt again one week later on November 2, 2005. Summers stated that the therapy caused pain in her elbow. R. 359.

Dr. Arndt ordered an MRI of Summers' right elbow. The MRI showed a small amount of fluid in the joint, but was otherwise unremarkable. R. 357.

Summers also saw Dr. Ann Roberson, D.O., on November 2, 2005. Summers rated her back pain at a 2 on a scale of 1 to 10. She stated that her right elbow had no pain unless she used it. She stated that the physical therapy helped her back, but caused a burning sensation in her elbow. R. 353. Dr. Roberson found that Summers had full range of motion in her elbow with some mild swelling, and full range of motion in her spine with mild discomfort. R. 353. Dr. Roberson diagnosed contusion and strain of the right elbow and lumbar spine, resolving. R. 353. Dr. Roberson prescribed an NSAID Celebrex and a muscle relaxer Flexeril and recommended alternating applications of heat and ice. She stated that Summers could return to work with light duty restrictions. R. 353.

Summers saw Dr. Roberson again on November 11, 2005. Summers told Dr. Roberson that she felt better and that her injuries were okay if she was not doing anything. R. 351. Summers rated her pain in her back as a 3 or 4. Dr. Roberson reported mild swelling over her right elbow with good rotation and moderate lumbar swelling possibly suggesting overuse of a heating pad. R. 351. Dr. Roberson told Summers to stop the muscle relaxer and prescribed an NSAID Naprosyn. R. 351. Dr. Roberson stated that it was appropriate for Summers to return to light duty work with no lifting more than ten pounds in the right arm, no pushing or pulling more than twenty pounds and only limited use of the right elbow and lifting. R. 352.

On November 21, 2005, Summers saw Dr. Roberson again.

Dr. Roberson noted that Summers was compliant with medication and physical therapy and was somewhat better. Summers rated her pain as a 2 or 3 at most when trying to lift. Summers reported some discomfort, but only when she was trying to lift. Summers reported that she felt more of a stiffness now and the pain had not exceeded a 3 for some time. Dr. Roberson discharged Summers to full regular duties. R. 343.

Summers was also discharged from physical therapy November 21, 2005. Summers told her physical therapist that her pain was a 3 in her elbow and back. Summers reported good compliance with a home exercise program at the time of discharge. R. 336.

The next day, November 22, 2005, Summers went to see Dr. Lee Huang, M.D., her primary care physician. She reported having continuing back and elbow pain. Dr. Huang prescribed a narcotic analgesic Hydrocodone. Dr. Huang limited Summers to light duty and restricted her to lifting no more than fifteen pounds. R. 403.

On March 8, 2006, Dr. Joshua Warach, M.D., saw Summers for a neurologic consultation. She reported that she continued to have persistent constant pain in her elbow and persistent intermittent pain in her back. She reported that the back pain radiated into her left hip and down her left leg. Summers reported that she had a cortisone injection in her elbow four days earlier. She reported that since the injection, her pain was 80 percent better. R. 294. Summers reported that her leg and back pain had not improved since her accident. On examination, Dr. Warach found that Summers' mental status, cranial nerves, sensory motor, cerebellar function and gait were normal; he found no abnormal involuntary movements, tremors, or seizure activity; and he found 5/5 strength in all groups in all four extremities. R. 294. Dr. Warach stated that Summers should avoid heavy lifting, strain, and other provocative activities. R. 295.

Dr. Warach ordered x-rays and an MRI of Summers' back. The x-ray of her lower back showed mild degenerative changes and no acute abnormalities. The x-ray of her pelvis and bilateral hips revealed no significant abnormalities. The MRI of her lumbar spine showed some degenerative changes including mild to moderate disc bulges and lateral disc protrusions. R. 274-76.

On March 29, 2006, and March 30, 2006, Summers underwent EMG/nerve conduction studies. The studies showed evidence of left L4 radiculopathy in her lower extremities with possible involvement of the left L2 and L3 roots. Dr. Warach ordered one to two months of additional therapy, and stated that Summers should remain on light duty work with no heavy lifting, strain, or other provocative activities, as tolerated for three months. At Summer's request, Dr. Warach gave her a note limiting her to light duty with no heavy lifting, strain or other provocative activities for three months. R. 290-91.

On April 5, 2006, Summers underwent a physical therapy evaluation. She reported low back pain. She stated that her worst symptom was left hip pain which occasionally radiated into the front of the thigh. She described the pain as a deep boring pain. Summers rated her hip pain as a 9 at worst on a 1 to 10 scale. The therapist noted tenderness to palpation from the L-5 to S-3 area of the spine on the left side. Summers' walking was stiff and guarded. Summers had 5/5 strength in her extremities except for 4 strength in the left hip flexion and left hamstring, and her gait was independent but with decreased truncal rotation. Summers was assessed with a good rehabilitation potential and given a therapy plan of three sessions a week for four weeks. R. 248-49.

Summers saw Dr. Warach again on May 1, 2006. She told Dr. Warach that she had no elbow pain after a cortisone shot. Dr. Warach stated that therapy also eliminated the pain radiating into her leg. Summers still complained of back pain that radiated into her left hip. She said that the physical therapy had not helped her back pain, but not her left hip pain. R. 288. Dr. Warach found that Summers' strength was 5/5 in all four extremities, and her ambulation was normal and independent. Summers was not taking any medication at this time. Dr. Warach prescribed an NSAID Ibuprofen, a muscle relaxer Chlorzoxazone, and Neurontin to relieve neuropathic pain. Dr. Warach limited her to light duty work with not heavy lifting, strain, or other provocative activities. Summers informed Dr. Warach that she had been sent home from work because her employer did not have any light duty work for her to perform. R. 288.

Summers saw Dr. Warach again on June 29, 2006. Dr. Warach reported that Summers had completed a series of three lumbar epidural injections for pain and two injections in her left hip. Summers reported that her lumbosacral pain with radiation was 95 percent better relative to time of onset. Dr. Warach again stated that Summers should avoid heavy lifting, strain, and other provocative activities. Dr. Warach stated that Summers could perform light duty work. Dr. Warach discontinued the Neurontin because Summers reported that the medication caused headaches.

Dr. Warach continued the Ibuprofen and Chlorzoxazone prescriptions and ordered a TENS unit for pain. He referred Summers to a neurosurgeon, Dr. Terrence Pencek, M.D., for a surgical consultation. R. 284.

Summers went to see Dr. Roberson again on July 26, 2006. Summers reported low back pain and left hip pain, which she rated at a 3 to 4 pain level. R. 332. Dr. Roberson found full range of motion, normal strength, normal gait, and no evidence of radiculopathy. Dr. Roberson diagnosed Summers with status post fall with contusion to the right elbow and stain to the left hip and lower back. ...

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