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Boydston v. Colvin

United States District Court, Seventh Circuit

January 24, 2014

RYAN M. BOYDSTON, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

OPINION

BYRON G. CUDMORE, Magistrate Judge.

Plaintiff Ryan M. Boydston appeals from the denial of his application for Social Security Disability Insurance Benefits and Supplemental Security Income (collectively "Disability Benefits") under Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 416(i), 423, 1381a, and 1382c. This appeal is brought pursuant to 42 U.S.C. §§ 405(g) and 1383(c). Boydston has filed a Brief in Support of Motion for Summary Judgment (d/e 10) (Boydston Brief), and Defendant Commissioner of Social Security has filed a Motion for Summary Affirmance (d/e 12). The parties consented to have this case heard before this Court. Consent to the Exercise of Jurisdiction by a United States Magistrate Judge and Reference Order entered May 7, 2013 (d/e 9). For the reasons set forth below, this the Decision of the Commissioner is affirmed.

STATEMENT OF FACTS

Boydston was born on November 19, 1979. Boydston completed high school and some additional vocational training. Boydston previously worked as a truck driver, telemarketer, sales attendant, and warehouse/department manager. Answer to Complaint (d/e 6), attached Certified Transcript of Proceedings before the Social Security Commission (R.), at 72, 10.

On July 18, 2007, Boydston was delivering 500 pounds drums of chemicals in the course of his employment. Boydston slipped and fell, and one of the 500 pound drums fell on him, injuring him severely. R. 453. Boydston has not worked since that accident. Since the accident, Boydston has suffered from myofascial pain, headaches, obesity, chronic neck pain, and back pain. R. 58.[1]

On July 18, 2007, Boydston went to see Dr. Ernest Wallace, M.D., for evaluation after the accident. Dr. Wallace diagnosed Boydston with low back pain without radiation, chest contusion, and right knee pain. Dr. Wallace found that Boydston's injuries from the accident appeared to be muscular and superficial. Dr. Wallace restricted Boydston to light duty for a week. R. 656.

On July 19, 2007, Boydston underwent a CT scan of his brain; MRI scans of his brain and cervical spine; and x-rays of his left hip, pelvis, and chest. The MRI of the cervical spine showed a strain of the apical ligament. The results of these tests were otherwise unremarkable. R. 538, 546-47, 648, 651,

On July 19, 2007, Boydston saw Dr. Phillip Wilson, M.D., for evaluation. Dr. Wilson diagnosed a left hip contusion, closed head injury, chest contusion, and right knee pain. R. 652. On July 23, 2007, Boydston saw Dr. Wilson. Boydston reported that he was doing much better. He was able to walk and climb stairs. He could bend his back, and could lift a child weighing twenty-nine pounds. Boydston had normal range of motion and straight leg testing was negative. Dr. Wilson released Boydston to work. R. 649.

On August 9, 2007, Boydston saw Dr. Wilson. Boydston reported getting severe headaches when he returned to work. Dr. Wilson prescribed Ultram. Dr. Wilson restricted Boydston to sitting work and no lifting or driving a truck. R. 646.

On August 13, 2007, Boydston saw Dr. Wilson. Boydston reported continued pain. Dr. Wilson noted marked tenderness in the cervical spine. Boydston had full range of motion in his cervical spine with some discomfort. Dr. Wilson put Boydston on no work unless sitting work is available. R. 645.

On August 29, 2007, Boydston started a course of physical therapy. R. 642-43.

On August 30, 2007, Boydston saw Dr. Wilson. Boydston reported that he started physical therapy. Dr. Wilson directed Boydston to continue with the physical therapy and return on September 17, 2007. Dr. Wilson stated that he would recommend an independent medical evaluation if Boydston had not improved by then. Dr. Wilson noted,

COMMENT: I think the prognosis on this gentleman is guarded. I think there may be some type of secondary gain because I feel the subjective symptoms are more significant than objective findings. This is my reason for recommending an independent medical evaluation if improvement is not dramatic over this approximately 2 week period of time.

R. 641.

On September 6, 2007, Boydston saw Dr. Joshua Warach, M.D., for a neurological consultation. R. 539-41. Boydston complained of back pain, cervical pain, and dull aching pain in the occipital region of his head. Dr. Warach's examination was unremarkable. Dr. Warach ordered x-rays, MRIs, an EEG, and EMG/NCV studies. He also referred Boydston to a neurosurgeon, Dr. Terrence Pencek, M.D., for a consultation. R. 541.

The results of the tests ordered by Dr. Warach were largely unremarkable. X-rays of Boydston's shoulders and spine taken on September 6, 2007, showed no fractures and were otherwise unremarkable. R. 400-03. An EEG taken on September 14, 2007, was normal. R. 404. An MRI of the lumbar and cervical spine taken on September 14, 2007, showed some degenerative disc disease at L5-S1, but was otherwise normal. R. 405-06. The EMG/NCV studies conducted on September 20, 2007, were largely unremarkable and showed no cervical radiculopathy, plexopathy, or other neuropathy to explain Boydston's symptoms. Dr. Warach instructed Boydston to avoid heavy lifting, strain, or other provocative activities. R. 449-50.

On September 17, 2007, Boydston saw Dr. Wilson. Boydston reported that he still had pain. Dr. Wilson stated that Boydston would continue seeing his neurologist Dr. Warach, and would continue also seeing him for pain medications and physical therapy. R. 634.

On September 26, 2007, Dr. Wilson responded to a request from Boydston's employer for documentation of the reason why Boydston could not work. Dr. Wilson stated that Boydston was experiencing severe neck pain and spasms with persistent headaches. Dr. Wilson stated that Boydston could not work because of the pain and the need for pain medication. R. 633.

On September 27, 2007, Boydston saw Dr. Wilson. Dr. Wilson reported no change in Boydston's condition. Dr. Wilson released Boydston to light duty work. Boydston reported that his employer stated that light duty was not available. R. 632.

On October 3, 2007, Boydston was discharged from physical therapy. The therapist reported that Boydston reached twenty-five percent of his goals. Boydston continued to report pain and headaches. R. 631.

On October 25, 2007, Dr. Warach conducted additional EMG/NCV testing on Boydston. The results were again unremarkable. Dr. Warach noted that other testing had been unremarkable as well. Boydston reported some daytime sleepiness due to his medications. He also reported low back pain with extended walking and heavy lifting. Dr. Warach again told Boydston to avoid heavy lifting, straining, and other provocative activities. He also referred Boydston to a sleep specialist and a pain clinic. R. 451. A subsequent sleep study showed no significant sleep apnea. The sleep specialist stated that Boydston's medications could be contributing to his sleepiness. R. 484-85.

On December 7, 2007, Boydston saw Dr. Terrence Pencek, M.D. Dr. Pencek found tenderness in the back of the neck and scalp. Boydston's motor strength was 5/5 and his gait was steady. Dr. Pencek recommended against surgery. Dr. Pencek reviewed Boydston's MRI results. He stated that Boydston could benefit from physical therapy and epidural steroid injections in the cervical spine. R. 409-10. Dr. Pencek ordered x-rays of Boydston's cervical and thoracic spine. The results were unremarkable. R. 411.

On January 3, 2008, Boydston saw Dr. Wilson. Dr. Wilson stated, "On casual observation of this gentleman, he appears to be in good health, no distress. Does not appear to be in any discomfort." R. 627. On examination, Boydston had limited range of motion in his neck and tenderness in the posterior of his neck. The range of motion of his lower back was markedly limited. Straight leg testing was negative. Dr. Wilson noted Dr. Pencek's recommendation for injections. Dr. Wilson stated that Boydston was on no work at this time. R. 627.

On January 23, 2008, Boydston saw Dr. Warach. Boydston reported continuing pain in his neck, worse with flexion of the head and neck, with no improvement. Boydston also reported persistent headaches and back pain. Dr. Warach recommended another MRI of Boydston's brain, but Boydston did not want to do this. A past MRI showed a hyperintense area in the basal ganglia of unclear etiology. Boydston also refused to undergo physical therapy. Boydston stated that physical therapy aggravated his pain. Dr. Warach recommended injections. R. 447-48.

On January 30, 2008, Boydston saw a pain specialist, Dr. Babu Prasad, M.D. Boydston underwent a series of injections on January 30, February 12, March 4, and March 26, 2008. R. 412-36. Boydston reported that his back was doing a little better at the end of the series, but had numbness in his right leg. R. 415

On February 13, 2008, Boydston saw Dr. Warach. Boydston stated that after the first injections from Dr. Prasad, he had significant improvement for about three days, but then his neck and headache pain worsened. Boydston reported, however, that he had only mild neck pain which was 90% better with no headaches and only mild intermittent back pain. His back pain in the thoracic region was also 90% better. On examination, Boydston reported that he felt as though his neck was "lifting off his spine" when he turned his head to the left or right. At this time, Boydston was taking Hydrocodone, Ultram, and Nurofen for pain. R. 443.

On March 10, 2008, Boydston saw Dr. Warach. Boydston reported again that he had 90% improvement in neck and back pain and headaches. Boydston reported that the pain was worse with lifting. He reported that Dr. Prasad's injections helped temporarily. Dr. Warach adjusted Boydston's medications. R. 560.

On April 1, 2008, Boydston saw a headache specialist, Dr. Mark Greenfield, M.D. in Kansas City, Missouri, metropolitan area.[2] Dr. Greenfield observed tenderness in the cervical, thoracic, and lumbar spine. Dr. Greenfield noted positive straight leg testing with sciatic notch tenderness on the right and left. Dr. Greenfield diagnosed cervical radiculopathy, headache, and neuralgia/neuritis/radiculitis. R. 458-61.

On April 10, 2008, Boydston saw Dr. Warach. Boydston reported that his pain and headaches had plateaued at 90% improvement since the onset of the pain after the accident. Dr. Warach referred Boydston for a functional capacity evaluation. R. 562.

On April 21, 2008, Boydston saw Dr. Wilson. According to Dr. Wilson, Boydston had no improvement since his initial injury. On examination, Dr. Wilson found normal range of motion in the neck and back, both with some minimal discomfort. Straight leg testing was negative. Patrick's maneuver of the lower extremities revealed a questionable positive on the right side. Dr. Wilson noted that Boydston was a truck driver on no work because light duty was not available. Dr. Wilson opined that Boydston was at his maximal medical improvement. R. 622-23.

On April 30, 2008, Boydston saw Dr. David Gelber, M.D., for an independent medical evaluation. On examination, Dr. Gelber found mild to moderate tenderness in the cervical and lumbar paraspinous muscles bilaterally with no significant spasm. Boydston's muscle tone was normal and strength was 5/5. Boydston's gait was normal. Dr. Gelber diagnosed myalgia and myositis. Dr. Gelber opined that Boydston's pain was myofascial, involving the neck and back. The myofascial ...


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