United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
SHEILA FINNEGAN, Magistrate Judge.
Plaintiff Anthony Curtis seeks to overturn the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying his application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. 42 U.S.C. §§ 416(i), 423(d). The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 2 8 U.S.C. § 636(c), and filed cross-motions for summary judgment. After careful review of the record, the Court now grants the Commissioner's motion, denies Plaintiff's motion, and affirms the decision to deny disability benefits.
Plaintiff applied for DIB on January 22, 2010, alleging that he became disabled on November 26, 2004 due to arthritis in his lower back. (R. 123, 152). The Social Security Administration denied the applications initially on April 12, 2010, and again upon reconsideration on July 15, 2010. (R. 57-63, 67-70). Plaintiff filed a timely request for hearing and appeared before Administrative Law Judge Karen Sayon (the "ALJ") on June 21, 2011. (R. 36). The ALJ heard testimony from Plaintiff, who was represented by counsel, as well as from vocational expert Clifford M. Brady. Shortly thereafter, on July 11, 2011, the ALJ found that Plaintiff is not disabled because none of his impairments, alone or in combination, significantly limited his ability to do basic work activities prior to his December 31, 2009 date last insured. (R. 24-30). The Appeals Council denied Plaintiff's request for review on October 12, 2012, (R. 1-3), and Plaintiff now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner.
In support of his request for remand, Plaintiff argues that the ALJ: (1) erred in finding that he does not have any severe impairments; (2) made a flawed credibility determination; (3) improperly characterized the consulting opinion evidence; and (4) failed to consider the effects of his obesity in assessing the severity of his impairments. As discussed below, the Court finds that the ALJ's decision is supported by substantial evidence and does not require reversal or remand.
Plaintiff was born on June 2, 1956, and was 55 years old at the time of the ALJ's decision. (R. 123). He completed two years of college and worked for 30 years as a group leader at a steel container manufacturing company before retiring on November 26, 2004. (R. 39-41, 153-54).
A. Medical History
The first treatment note in the record is from January 29, 2008, when Plaintiff went to his family physician, Peter Neale, D.O., complaining of low back pain for the previous year, as well as nasal problems. He told Dr. Neale that the back pain got worse if he sat too long, including in a car, and it hurt to get out of bed in the morning. Plaintiff said these symptoms had been occurring "for years now" but it was "just getting worse." (R. 225). On examination, Dr. Neale noted tenderness in Plaintiff's back at the LS level and prescribed Mobic for pain. He also diagnosed rhinitis and hypertension. (R. 224). X-rays of the lumbar spine taken the same day showed "prominent discogenic osteophytes at L3-L4, " and "[m]oderate facet degenerative change" at L5-S1 bilaterally. (R. 228).
Plaintiff returned to Dr. Neale for a follow-up visit on February 11, 2008, and reported that he was getting "some relief" from the Mobic. Dr. Neale diagnosed moderate degenerative joint disease and instructed Plaintiff to continue taking the prescribed medication. (R. 226). Plaintiff did not seek further treatment until September 17, 2008, when he told Dr. Neale that he had fallen off a ladder while changing light bulbs a month prior and injured his rib cage. Dr. Neale diagnosed rib cage pain and "low back pain (chronic)." (R. 223). Approximately 10 months later, on July 20, 2009, Plaintiff saw Dr. Neale again for medication refills. (R. 216). His next appointment on September 21, 2009 focused entirely on nasal congestion. (R. 217). Four months later, on January 22, 2010, Plaintiff applied for disability benefits dating back to November 2004.
On April 8, 2010, Reynaldo Gotanco, M.D., evaluated Plaintiff's application for the Bureau of Disability Determination Services. Based on the records from Dr. Neale, Dr. Gotanco found that the information was "insufficient to address [Plaintiff's] condition prior to DLI [date last insured] of 12/31/2009." (R. 236). Plaintiff saw Dr. Neale again on July 3, 2010, still complaining of back pain and nasal problems. Dr. Neale diagnosed chronic arthritis in the back and instructed Plaintiff to take Mobic and/or Relafen for the pain. (R. 243). Shortly thereafter, on July 9, 2010, Calixto Aquino, M.D., affirmed Dr. Gotanco's assessment that there is insufficient evidence to evaluate Plaintiff's condition before the DLI. Dr. Aquino noted that Plaintiff did not allege any changes in his condition, or new illnesses or limitations to support his claim. (R. 247)
Eight months later, on March 21, 2011, Plaintiff started seeing Suneela Harsoor, M.D., for back pain management. (R. 263-65). He claimed to have been symptomatic for more than 10 years and described the pain as constant, throbbing, shooting, aching, and radiating to his legs. The pain reportedly worsened with prolonged walking, standing, sitting, activity, and stair use, but Plaintiff conceded that he had received "no treatment" for his condition aside from medication, and was able to perform "all activities of daily living." (R. 263). On examination, Dr. Harsoor found Plaintiff to have bilateral pain with palpation at L3-S1 and at the lumbar intervertebral spaces; his anterior flexion was reduced with pain; and he exhibited palpable trigger points in the lower back. At the same time, his gait was normal, he could do heel and toe walk, he had full strength, and his reflexes and neurological tests were all normal. (R. 264). Dr. Harsoor ordered an MRI of Plaintiff's lumbar spine and instructed him to supplement the Relafen with Tramadol for pain control. She also encouraged him to start exercising, noting that he was dependent on his mother to perform his daily chores. (R. 265).
Plaintiff's March 24, 2011 MRI revealed hypertrophic spurring at multiple levels representing spondylosis; subligamentous posterior disk herniations at L4-L5 and L5-S1; and mild bilateral neuroforaminal narrowing at L4-L5, which appeared to be exacerbated by mild ligamentum flavum hypertrophy and early facet arthrosis. (R. 262). When Plaintiff returned to Dr. Harsoor on April 11, 2011, his condition was largely unchanged. (R. 259-60). He refused to undergo fluoroscopic guidance at that time, stating that he "cannot afford" it, but he agreed to try a lumbar epidural steroid injection. Dr. Harsoor told Plaintiff to continue taking Tramadol and added Neurontin to his medication regimen. (R. 260).
Dr. Harsoor administered the epidural injection on April 18, 2011. (R. 254). She also completed a Chronic Pain Residual Functional Capacity Questionnaire for Plaintiff the same day. (R. 249-52). Dr. Harsoor stated that she had been treating Plaintiff once or twice a month for two months, and diagnosed lumbar spine pain, lumbar disc protrusion and myofacial pain. She indicated that Plaintiff exhibited tingling, numbness, weakness and muscle spasm, with shooting and throbbing pain radiating to his legs at a level of 9 out of 10. She also reported reduced range of motion in the spine, as well as tenderness and trigger points. (R. 249). Dr. Harsoor opined that Plaintiff requires a low stress job where he is not required to sit for more than 30 minutes at a time, or stand and walk for more than 15 minutes at a time. (R. 250). He can sit, stand and walk for a total of less than 2 hours a day; he must get up and walk for 15 minutes every 10 minutes or so; he needs to be able to shift at will from sitting to standing to walking; he cannot walk more than 6 city blocks; and he needs unscheduled breaks once or twice every 4 hours. (R. 250-51). Dr. Harsoor stated that Plaintiff can frequently lift 10 pounds; occasionally lift 20 pounds; never lift 50 pounds; rarely twist, crouch, and climb ladders and stairs; and occasionally stoop. She also estimated that his condition would cause him to be absent from work about 2 days per month. (R. 252).
B. Plaintiff's Testimony
On March 15, 2010, Plaintiff completed a Function Report in connection with his application for disability benefits. (R. 160-67). He stated that on a typical day he gets up, takes his medicine, microwaves some breakfast, brews coffee, and sits and relaxes reading the newspaper until the medicine "kick[s] in." He then does "any work around the house that I can until I get more pain [and] then I stop." (R. 160). Plaintiff ...