United States District Court, N.D. Illinois, Eastern Division
RICHARD T. GENTRY, Mr. Gentry,
CAROLYN W. COLVIN, Acting Commissioner of Social Security,  Defendant.
MEMORANDUM OPINION AND ORDER
MARY M. ROWLAND, Magistrate Judge.
Richard R. Gentry filed this action seeking review of the final decision of the Commissioner of Social Security denying his application for Disability Insurance Benefits under the Social Security Act ("SSA"). 42 U.S.C. §§ 416, 423(d), 1381a. The parties have consented to the jurisdiction of the United States Magistrate Judge, pursuant to 28 U.S.C. § 636(c). For the reasons stated below, this case is remanded for proceedings consistent with this opinion.
I. PROCEDURAL HISTORY
Mr. Gentry applied for disability insurance benefits ("DIB") and supplemental security income ("SSI") on November 27, 2007, alleging disability as a result of back problems, with an onset date of April 30, 2006. (R. 168-70, 198). The Social Security Administration denied Mr. Gentry's applications initially and on reconsideration, after which Mr. Gentry filed a timely request for a hearing. (R. 87-91, 93-96, 97-100). On March 9, 2010, Mr. Gentry, represented by a non-attorney representative, appeared at a hearing before an Administrative Law Judge ("ALJ"). (R. 45-82). The ALJ also heard testimony from a vocational expert ("VE"). (R. 75-81).
The ALJ denied Mr. Gentry's request for benefits on June 7, 2010. (R. 28-39). Applying the five-step sequential evaluation process, the ALJ found that Mr. Gentry was still capable of performing light work as defined in 20 C.F.R. §§ 404.1567(a) and 416.967(a) and was, therefore, not "disabled, " as that term is defined by the Social Security Act. (R. 39).
The Appeals Council denied Mr. Gentry's request for review on January 19, 2012, rendering the ALJ's decision final. (R. 1-6). Mr. Gentry now seeks judicial review of the ALJ's decision. Villano v. Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009).
II. SUMMARY OF ADMINISTRATIVE RECORD
The record indicates that Mr. Gentry was first treated for back pain at Hinsdale Orthopedic Associates S.C. on January 25, 2002 by Marie Kirincic, M.D., a pain specialist. (R. 407). On January 9, 2006, an MRI of the lumbar spine revealed that Mr. Gentry had severe stenosis at L4-5 and left paracentral disc protrusion with mild stenosis at L5-S1. (R. 302). Mr. Gentry reported that he had stopped working as of April 30, 2006 due to back problems. (R. 198). He had previously been self-employed as a carpenter.
On December 15, 2006, Mr. Gentry was examined by Dr. Kirincic. (R. 312, 314). He complained of ongoing thoracolumbar discomfort and lower extremity discomfort. (R. 312). Mr. Gentry reported that he sometimes had to lie down with his lower extremity propped up on several pillows. He also reported that it was difficult for him to work in carpentry. ( Id. ). On examination, Dr. Kirincic noted that Mr. Gentry's pain score was 10/10, marked dural tension testing was positive with tight hamstrings, and there was pain on extension with lumbar range of motion. Dr. Kirincic's clinical impression was that Mr. Gentry had L1-S1 annular tears with severe canal stenosis, and mild encroachment on S1 nerve with mild stenosis. ( Id. ). On January 24, 2007, Mr. Gentry returned to see Dr. Kirincic complaining of left lower extremity discomfort with sharp and shooting pain. (R. 311). Dr. Kirincic recommended epidural steroid injections, discogram, and surgical discectomy/fusion. ( Id. ).
On May 16, 2007, Mr. Gentry reported he was involved in a motor vehicle accident with resulting chest discomfort, back pain, and difficulty transferring and walking. (R. 306). On examination, Mr. Gentry had difficulty transferring and ambulating, multiple abrasions, positive dural tension testing with slump sit, and multiple spasms in his cervicothoracolumbar musculature. (R. 307). Dr. Kirincic's clinical impression was that Mr. Gentry suffered a cervicothoracolumbar strain with pectoralis strain status post seat belt injury with chest contusion, and paresthesias. ( Id. ).
On June 13, 2007, in a follow-up session with Dr. Kirincic, Mr. Gentry complained of lumbar pain radiating in both legs, more on the right than the left. (R. 319). Dr. Kirincic noted worsening of Mr. Gentry's pre-existing L4-L5 stenosis. (R. 319). Mr. Gentry also reported that, although he had given up his carpentry business, he had tried to return to work for a previous employer, but was finding it difficult to keep up with the job. (R. 818).
On July 11, 2007, an MRI of Mr. Gentry's lumbar spine revealed a left paramedian intervertebral disc protrusion moderate at L5-S1, and a central right paramedian disc protrusion with moderately severe spinal stenosis at L4-5. (R. 325-26). On August 1, 2007, Mr. Gentry reported that his back and leg pain had returned to levels existing before his accident. (R. 299). Dr. Kirincic concluded that Mr. Gentry had resolved cervicothoracolumbar strain and pectoralis strain with continued chronic low back pain from his degenerative joint disease and spinal stenosis. (R. 300).
On September 4, 2007, Mr. Gentry was examined by Amanda Kennedy, MS, LCPC. (R. 367). She noted that Mr. Gentry had owned his own construction business, and that he was unable to work since his car accident in May 2007. ( Id. ).
Beginning on September 25, 2007 and continuing through at least July 29, 2009, Dr. Kirincic reported that Mr. Gentry was "unable to return to work" in at least seven different work status reports. (R. 868, 402, 830, 827, 825, 821, 762). On September 26, 2007, Mr. Gentry stated that he had tried to return to work, but that he could not make it more than a week. ( Id. at 297). Mr. Gentry reported awakening at night due to pain and using a cane and walker for ambulation. ( Id. ). Dr. Kirincic noted that Mr. Gentry's lumbar range of motion was markedly decreased and that there was a sensory disturbance in the left L5. ( Id. ). Medrol and Lyrica were prescribed. (R. 298). On October 19, 2007, x-rays taken with flexion and extension views showed no evidence of significant instability but showed some motion at the L4-5 level. (R. 322).
On December 14, 2007, one of Mr. Gentry's physicians, Dr. Cary Templin, noted that Mr. Gentry had recently had a discogram, but that the doctor, Dr. Koehn, had not been able to even enter the disc with a needle. (R. 328). Mr. Gentry had severe pain running through his legs and back with needle insertion. ( Id. ). Mr. Gentry had 10/10 pain at all levels despite Lidocaine. ( Id. ).
On February 17, 2008 and again on April 28, 2008, Mr. Gentry reported his daily activities in two separate Disability Reports. (R. 204-11, 235-42). Mr. Gentry reported that he shopped, drove, and was able to feed and get his son off to school. (R. 205, 207, 238). Mr. Gentry could prepare frozen dinners, sandwiches, and snacks. (R. 206, 237). He sometimes had trouble getting out of bed by himself. (R. 236). Mr. Gentry reported that he could no longer work, go boating, or go camping due to his pain. (R. 205). He could not stand or sit for a long time before needing to lie down and also had trouble sleeping. (R. 206, 236). Mr. Gentry reported he could not lift more than five pounds, and could walk for 100 feet or half a block before ...