United States District Court, N.D. Illinois, Eastern Division
OPINION AND ORDER
JOAN H. LEFKOW, District Judge.
Cosonia Spraags brings this action under 42 U.S.C. § 405(g) for review of the final decision of the Commissioner of Social Security ("the Commissioner"), denying her application for disability insurance benefits under Title II of the Social Security Act ("the Act"), 42 U.S.C. § 423. Spraags asks the court to reverse the decision of Administrative Law Judge Regina M. Kossek ("the ALJ") and to remand this case to the Commissioner for further consideration. The parties have filed cross motions for summary judgment. For the following reasons, Spraags' motion (dkt. 30) is denied, the Commissioner's motion (dkt. 33) is granted, and the Commissioner's decision denying disability insurance benefits is affirmed.
I. Procedural Background
On December 19, 2005, Spraags filed an application for disability insurance benefits alleging an onset date of disability of June 25, 2005. (Administrative Record ("R.") 182-86.) Her application was denied on March 6, 2006 (R. 115-18), and again denied on reconsideration on June 14, 2006. (R. 121-23.) She then requested a hearing before an administrative law judge. (R. 125.) Because Spraags last met the disability insured status on March 31, 2007, she needed to show that she was disabled on or before that date in order to be eligible for benefits. (R. 9.) The hearing commenced on June 25, 2008 and continued on June 17, 2009. On September 2, 2009, the ALJ concluded that Spraags was not disabled during the relevant time period. (R. 9-20.) Spraags timely sought a review of the ALJ's decision, which the Appeals Council denied on December 10, 2010. (R. 1-3.) The ALJ's decision thus became that of the Commissioner. See 20 C.F.R. § 404.981.
II. Factual Background
A. Pre-Onset Medical Interventions
Spraags was born on January 4, 1972, and was thirty-three years old on her alleged onset date. (R. 182.) Spraags, who has an associate of arts degree, worked as a licensed practical nurse with disabled children for the Chicago Public Schools from 1995 through 2002. (R. 30, 532.) She is right-handed. (R. 533.)
On September 26, 2002, Spraags was injured when a school bus she was on was rear-ended by another bus. (R. 97-98.) Spraags experienced pain on the left side of her body following the accident and four days later she visited Dr. Michelle Jaworski at Combined Orthopaedic Specialists in Oak Brook, Illinois. (R. 471-73.) Dr. Jaworski diagnosed Spraags with patellar contusion, cervical strain, lumbar strain, and shoulder contusion. ( Id. )
Because of the accident Spraags had to have two surgeries on her left shoulder. On March 26, 2003, she had arthroscopic surgery on her left shoulder to repair a tear and lesion in the shoulder joint. (R. 231, 343, 477.) After a December 2003 MRI revealed another tear, she had another surgery to repair the tear and remove inflamed and damaged tissue in January 2004. (R. 382.) She remained under her surgeon's care and in physical therapy until May 10, 2004. ( Id. ) She was released to full duty at her job as a school nurse on July 20, 2004, but returned to limited duty a week later. ( Id. )
On September 28, 2004, Spraags underwent a functional capacity evaluation to determine whether she could return to work. (R. 787.) She told the evaluators that her pain was a two out of ten at rest, a four out of ten while performing household chores like dishwashing or combing, and a six out of ten when performing "overhead activity." (R. 787-89.) She also reported that she was taking Naprosyn, Vicodin, and Flexeril for pain. (R. 787.) The evaluation found that she was capable of performing work that required up to lifting fifteen pounds with her left arm. ( Id. ) Although Spraags "want[ed] to return to full duty full time, " the report concluded that she was "restrictive [ sic ] to light duty" but there was "no light duty available at work." (R. 788.)
B. Treatment In Relevant Period (June 25, 2005-March 31, 2007)
On August 18, 2005, Spraags visited her primary care physician, Dr. Diana Chicos, at Advocate Evergreen Health Center after an allergic reaction to seafood. (R. 570.) She also complained of occasional left shoulder pain and low back pain. ( Id. ) Dr. Chicos performed a physical exam on Spraags and found she weighed 196 pounds, was 5 feet, three and a half inches in height, and had no abnormal results on musculoskeletal or neurological exams. (R. 570-71.) Dr. Chicos prescribed refills for Naproxen (the generic for Naprosyn) and Vicodin. (R. 571.) Dr. Chicos discussed results of a cholesterol test with Spraags a few days later and recommended a low fat diet and exercise. (R. 572-74.) Spraags saw Dr. Chicos again on January 10, 2006. (R. 567.) Dr. Chicos reported that Spraags weighed 201 pounds, complained of neck and shoulder pain, and had a decreased range of motion in her left shoulder due to pain. ( Id. ) She prescribed physical therapy, refills of Vicodin and Naproxen, and instructed Spraags to go on a low fat diet. (R. 568.)
On January 18, 2006, Spraags began physical therapy with Debbie Biros at Physiotherapy Associates in Evergreen Park, Illinois. (R. 553.) Spraags told Biros she had no pain at the time of the appointment but that she would have muscle spasms in her left upper trapezoid and increased back pain with sitting, standing, or ambulating for more than 15 minutes. ( Id. ) On March 9, 2006, after four physical therapy sessions, Biros reported to Dr. Chicos that Spraags' physical therapy "goals have been achieved and [Spraags] has attained maximum potential with therapy at this time." (R. 554.) Biros reported that Spraags still had pain but it improved after she did her exercises, but then it would "get[ ] tight again." ( Id. ) Biros also reported that Spraags had improved trunk mobility and left shoulder, scapular, and abdominal muscle strength. ( Id. )
On February 21, 2006, Spraags had a consultative examination with Dr. M.S. Patil, a family practice and emergency medicine physician. (R. 532-35.) The purpose of the exam was solely to provide information to the Illinois Bureau of Disability Determination Service in regards to Spraags' disability claim. (R. 532.) Spraags told Dr. Patil that she had constant "mild to moderate pain" in the left side of her body, including constant pain in the neck, radiating to the left shoulder, arm, and leg. ( Id. ) She also complained of muscle spasms in her left shoulder and back "all day long." ( Id. ) Dr. Patil wrote that Spraags' last orthopedic consult was in September 2004. ( Id. ) Dr. Patil noted she had normal gait, balance, reflexes, strength, and sensation. (R. 534.) In particular, he found that Spraags was able to perform functions such as tying shoelaces, picking up coins, and writing names with no difficulty with her right and left hands. ( Id. ) He also determined that she had no localized tender trigger points on her body and her gait was normal. (R. 535.)
On March 2, 2006, Dr. Kim Young-Ja, a state agency consultant, performed a residual functional capacity ("RFC") examination. (R. 536-43.) Dr. Young-Ja determined that Spraags could occasionally lift twenty pounds and could frequently lift or carry ten pounds. (R. 537.) He also determined that Spraags could stand or walk about six hours in an eight-hour workday, sit for six hours in an eight-hour day, and also push and pull unlimited amounts. ( Id. ) She could balance, stoop, kneel, crouch, and crawl frequently, but could not climb a ladder, rope, or scaffolds. (R. 538.) The exam also showed she was limited in frequency that she could reach above shoulder level with her left arm, but her gross and fine manipulations were unlimited and she had no other communicative or environmental limitations. (R. 539-40.)
On September 20, 2006, Spraags received emergency treatment for lower back pain at Provident Hospital of Cook County. (R. 557.) The doctor diagnosed a back sprain and prescribed Naprosyn. (R. 559.)
On January 5, 2007, Spraags had her first routine physical exam with Dr. R. Mundackal at Cook County Englewood Health Center. (R. 591.) The ALJ noted that Dr. Mundackal did not perform objective testing at that time. (R. 17.) Dr. Mundackal prescribed Naproxen, Ultram, and Toprol for her pain. (R. 594.) Following the visit, Dr. Mundackal completed a medical statement regarding Spraags' shoulder and RFC exam for Spraags to submit with her disability claim. (R. 576-582.) The medical statement noted Spraags' limited motion, weakness, and pain in both her left and right shoulders. (R. 577.) It also noted joint arthritis in her shoulder joint. ( Id. ) Dr. Mundackal wrote that Spraags could work only two hours per day, that she could stand for two hours at a time and four hours total in an eight-hour work day, and that she could sit for two hours at a time and four hours total in an eight-hour workday. ( Id. ) The RFC questionnaire, which she completed at the same time, states that Spraags could only sit for thirty minutes at a time and for two hours total in a work day, and could walk or stand for twenty minutes total and less than two hours in a work day. (R. 579-80.) The RFC examination also indicates that Spraags can "rarely" lift or carry less than ten pounds and never anything ten pounds or greater, could occasionally look up and down but rarely turn her head to the right or left or hold her head in a static position, twist, stop, crouch, climb ladders, or stairs. (R. 579-81.) Dr. Mundackal opined that Spraags suffered from severe pain, and he diagnosed her with degenerative arthritis. He found that Spraags was capable of a low stress job because she could move her elbows, wrists, and fingers without pain and had no significant limitations with "reaching, handling or fingering." ( Id. ) Dr. Mundackal thought Spraags' impairments would cause her to be absent from work about four times per month. (R. 581.)
Spraags saw Dr. Mundackal again on January 26, 2007 for reasons unrelated to her disability claim. (R. 585.) Dr. Mundackal wrote in her notes that Spraags suffered from "chronic muskuloskeletal pain" but that she was "asymptomatic today." ( Id. ) Spraags returned to Dr. Mundackal on April 6, 2007, for a check-up. (R. 584.) She complained of pain in her back, shoulder, and left hip. ( Id. ) Dr. Mundackal thus referred her to a pain clinic at Stroger Hospital. ( Id. )
Spraags underwent her initial assessment at the pain clinic on April 24, 2007. (R. 606.) On her pain assessment form, Spraags said the pain medications she took made her "sleep a lot." ( Id. ) She complained of chronic pain and was instructed to continue taking medication as prescribed. (R. 608-09.) Spraags saw Dr. Mundackal again on May 4, 2007, for knee pain (R. 750.) She saw him two months later, on July 20, 2007, and had her prescriptions refilled but "denie[d] complaints." (R. 749.)
Spraags continued to complain of shoulder pain, however, and had an MRI of her left shoulder on March 2, 2009 at Mount Sinai Medical Center in Chicago. (R. 798.) The MRI was normal but there was not enough contrasting agent in her shoulder to adequately see all possible tears. (R. 799.) She thus had a second MRI on April 13, 2009, this time at Advanced Medical Imaging Center in Chicago. (R. 802.) The second MRI showed a five millimeter tear in a tendon in her left shoulder. ( Id. )
III. Evidence Presented To The ALJ
A. Spraags' Testimony
Spraags testified at her hearing before the ALJ and was represented by counsel, Kenneth Dobbs. She explained that she has not held gainful employment since her 2002 bus accident. (R. 31.) Because she was only released for light work and her former employer, Chicago Public Schools, had no such positions available, Spraags participated in vocational rehabilitation associated with her worker's compensation claim. (R. 34.) Spraags believed that at some point prior to March 31, 2007, she was either hired for or about to be hired for multiple positions, such as case manager and teacher's assistant, but each time she would be unable to perform all attendant duties, such as typing or sitting for long stretches. (R. 34, 37-38.)
Spraags also explained that she "believe[s]" she was living alone from 2005 until 2007 but "had a lot of assistance" from friends and family. (R. 39.) Her mother would stay with her "for periods of time" and Spraags would occasionally stay with her mother. (R. 39-40.) Spraags testified that she could do a little laundry at a time but she was taking multiple medications and sleeping a ...