United States District Court, N.D. Illinois, Eastern Division
JEFF L. WILLIS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration,  Defendant.
YOUNG B. KIM, Magistrate Judge.
Plaintiff Jeff Willis seeks disability insurance benefits ("DIB"), see 42 U.S.C. §§ 416(i), 423, based on his claim that he is unable to work because of orthopedic problems related to leg, hip, and wrist fractures. After his application was denied in a final decision by the Commissioner of the Social Security Administration, Willis filed this suit seeking judicial review. See 42 U.S.C. § 405(g). Before the court are Willis's motion for summary judgment seeking reversal of the Commissioner's decision and the Commissioner's cross-motion for summary judgment. For the following reasons, Willis's motion is granted to the extent that the case is remanded for further proceedings and the Commissioner's motion is denied:
Willis applied for DIB on December 14, 2006, claiming that he became unable to work as of September 20, 2005. (Administrative Record ("A.R.") 151.) After his claims were denied initially and upon reconsideration, (id. at 65, 76), Willis sought and was granted a hearing before an administrative law judge ("ALJ"), (id. at 85-86). A hearing was held on March 11, 2009, and a supplemental hearing was held on September 17, 2009, to allow for additional vocational testimony. (Id. at 19.) The ALJ issued a partially favorable decision on January 15, 2010, finding that Willis was not disabled within the meaning of the Social Security Act prior to January 31, 2009, but became disabled on that date and continued to be disabled through the date of her decision. (Id. at 20.) When the Appeals Council denied Willis's request for review, (id. at 1), the ALJ's denial of benefits became the final decision of the Commissioner, see O'Connor-Spinner v. Astrue, 627 F.3d 614, 618 (7th Cir. 2010). On August 14, 2012, Willis filed the current suit seeking judicial review of the Commissioner's decision. See 42 U.S.C. § 405(g). The parties have consented to the jurisdiction of this court. See 28 U.S.C. § 636(c).
Willis, who is currently 55 years old, received disability benefits from 1987 to 1997 because a motorcycle accident, which caused multiple fractures in his right leg and leg length disparity, rendered him disabled. After being disabled for 10 years, Willis resumed work from 1997 until 2005. Willis claims he has been disabled since September 2005 when he fell and fractured his right hip and wrist while working as a truck driver. According to Willis, he is unable to work now because of limited motion and reduced grip strength in his right hand, as well as pain in his right leg, wrist, and hip. Willis presented both documentary and testimonial evidence in support of his claim.
A. Medical Evidence
The relevant medical record begins in September 2005 when Willis was treated at Morris Hospital for right wrist and right hip fractures after falling from his truck at work. (A.R. 334.) Attending physician Dr. Joseph Chung and Dr. Kevin Draxinger performed surgical closed reduction and pinning of his right hip. (Id. at 353-54.) They also performed a non-operative closed reduction of his right wrist and placed his right hand, wrist, and forearm in a cast. (Id. at 338.) Willis "did very well postoperatively" and was discharged with instructions to take Motrin and Vicodin. (Id. at 334, 338.)
During a follow-up visit to Morris Hospital in November 2005, Willis reported suffering from a lot of pain. (Id. at 403.) Dr. Draxinger noted that his hip x-rays showed no change, but his wrist x-rays showed complete displacement of the distal fragment. (Id.) Dr. Draxinger referred Willis to Dr. Eric Ortinau, an orthopedic surgeon affiliated with Morris Hospital, to determine whether a corrective procedure was necessary. (Id.) Dr. Ortinau determined that Willis's wrist fracture failed to heal properly, so Willis underwent surgery in November 2005 to apply a plate and screws to his wrist. (Id. at 361-62.)
From December 2005 through early 2006, Willis's records show that his fractures continued to heal gradually with physical and occupational therapy. (See id. at 384-85, 393.) In March and April 2006, Willis's physical and occupational therapists recommended that he be transferred to a work hardening program. (Id. at 443-44.) In a July 2006 visit with Dr. Ortinau, Willis reported "no problems with his wrist" and an x-ray showed "a completely healed fracture in good position." (Id. at 380.) But Willis complained of pain in his right hip and Dr. Ortinau observed that Willis walked with a cane. (Id.) X-rays showed the hip fracture had healed and that his screws were well placed, but seemed to be "a little bit prominent outside [the] lateral cortex of the hip." (Id.)
Willis underwent surgery in September 2006 for screw removal in an attempt to alleviate his hip pain. (Id. at 416.) In October 2006, Dr. Ortinau discontinued Willis's crutches and allowed him to be weight-bearing "as tolerated." (Id. at 374.) Dr. Ortinau noted that Willis had a shoe lift which equalized his leg length disparity. (Id.) The following month Willis participated in a two-week work hardening program, (id. at 436), after which Dr. Ortinau reported that Willis was "[d]oing well in all regards" and recommended that he be able to work full-time without restrictions, (id. at 371).
Dr. Richard Bilinsky, a state agency medical consultant, conducted a physical residual functional capacity ("RFC") assessment of Willis in January 2007 in connection with Willis's application for DIB. Dr. Bilinsky listed fracture of the right hip as the primary diagnosis and fracture of the right wrist as the secondary diagnosis. (Id. at 487.) Based on his review of Willis's medical records, Dr. Bilinsky concluded that Willis could occasionally lift 50 pounds, frequently lift 25 pounds, stand or walk for six hours a day, sit about six hours a day, and perform unlimited pushing and pulling. (Id. at 488.) He found no evidence of postural, manipulative, visual, communicative, or environmental limitations. (Id. at 489-91.)
In May 2007, Dr. ChukwuEmeka Ezike conducted a 30-minute consultative examination of Willis for the Bureau of Disability Determination Services. (Id. at 495.) Dr. Ezike reported that Willis "seemed reliable" and that he complained of "constant right leg pain and difficulty walking." (Id.) Willis stated that his leg pain got worse with "prolonged standing and walking, " but that he could walk two blocks, stand for 30 minutes at a time, lift up to 30 pounds, and drive and shop independently. (Id. at 495, 496.) Dr. Ezike made note of Willis's prior trauma in 1987 and the resulting leg length disparity. (Id. at 495.) Willis reported no difficulty with sitting and had normal hip range of motion. (Id. at 496-97.) But his gait was antalgic without the use of assistive devices, and he was unable to perform a "toe/heel walk." (Id. at 497.) Dr. Ezike observed that Willis was able to get on and off the exam table without difficulty and walk more than 50 feet without support. (Id.)
As for his wrist, Willis reported that he had "occasional right wrist pain with decreased grip strength, " and he "drop[ped] objects occasionally from the right hand." (Id. at 495.) Dr. Ezike's notes convey that Willis's right wrist extension was 30 degrees and flexion was about 50 degrees, and his right hand grip was 4/5. (Id. 497.) Willis had a "normal ability to grasp and manipulate objects, " could pick up a coin, and could fully extend his hands, make fists, and appose his fingers. (Id.) Dr. Ezike's impressions included chronic right leg pain, chronic right wrist pain, history of right leg and right wrist fracture, and hypertension. (Id. at 498.)
Dr. Frank Norbury, another state agency medical consultant, completed a second physical RFC assessment in July 2007. He listed traumatic arthritis of the ankle and foot as the primary diagnosis and traumatic arthritis of the hip and wrist as the secondary diagnosis. (Id. at 502.) Based on his review of Willis's medical records, Dr. Norbury concluded that Willis could occasionally lift 10 pounds, frequently lift less than 10 pounds, stand or walk at least two hours a day, sit about six hours a day, and perform unlimited pushing and pulling. (Id. at 503.) Dr. Norbury also determined that Willis could occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl, but could not climb ladders, ropes, or scaffolds. (Id. at 504.) He concluded that Willis could perform unlimited reaching, handling, and feeling, but could not finger constantly due to his ...