United States District Court, N.D. Illinois, Eastern Division
SHEILA FINNEGAN, Magistrate Judge.
Plaintiff Nora Love seeks to overturn the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 416, 423(d), 1381a. The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and Plaintiff has now moved for summary judgment. After careful review of the record, the Court grants Plaintiff's motion and remands the case for further proceedings.
Plaintiff applied for DIB and SSI on February 24, 2011, alleging in both applications that she became disabled on April 14, 2010 due to surgery on her right thumb; an inability to lift; and trembling, swelling, weakness, tingling and pain in her right hand. (R. 217, 229, 267). The Social Security Administration denied the applications initially on April 25, 2011, and again upon reconsideration on July 13, 2011. (R. 99-102, 121-25, 136-43). Plaintiff filed a timely request for hearing and appeared before Administrative Law Judge Victoria A. Ferrer (the "ALJ") on April 25, 2012. (R. 39). The ALJ heard testimony from Plaintiff, who was represented by counsel, as well as from vocational expert Matthew C. Lampley. Shortly thereafter, on May 24, 2012, the ALJ found that Plaintiff is not disabled because she can perform both her past work as a production assembler and conveyor belt sorter, and a significant number of other light jobs available in the national economy. (R. 21-31). The Appeals Council denied Plaintiff's request for review, (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 her request for remand, Plaintiff argues that the ALJ (1) made a flawed credibility determination; and (2) failed to provide adequate support for the residual functional capacity ("RFC") assessment by giving improper weight to the opinions of record. As discussed below, the Court agrees that the ALJ's decision is not supported by substantial evidence and the case must be remanded for further consideration.
Plaintiff was born on November 10, 1959, and was 52 years old at the time of the ALJ's decision. (R. 217, 263). She completed one year of college and spent more than 14 years working in factories as a laborer. (R. 267, 287). Most recently, Plaintiff was a lead assembly worker for World Kitchen, but she had to quit after she was injured on the job in April 2010. (R. 42-43, 67, 335).
A. Medical History
Plaintiff was moving pallets at work on April 14, 2010 when she experienced a sudden, sharp pain in her right biceps and wrist, with radiating pain into the shoulder and across the forearm and elbow at a level of 10 out of 10. (R. 358). The company's physician, Mark T. Veldman, D.O., examined Plaintiff that day and observed tenderness over the proximal biceps, as well as "a 1 × 1.5 cm raised mass over the distal radius." ( Id. ). X-rays of the right elbow, both wrists and right shoulder were all normal, and Dr. Veldman diagnosed tendinitis of the right wrist/forearm and biceps. (R. 358-61). He gave Plaintiff a sling "for comfort, " imposed a 2-pound lifting restriction, and instructed her to ice her wrist and shoulder and take ibuprofen. (R. 358). Two days later, Plaintiff's pain was still at a 10 out of 10, with tenderness in the right wrist and slight puffiness in the right hand. Dr. Veldman diagnosed right forearm tendinitis and left shoulder strain, and limited her to "predominantly office work seated with right arm on table, with nothing over 2 pounds lifting." (R. 353). He also told her to take Vicodin for pain at bedtime and continue icing the area. ( Id. ).
On April 19, 2010, Plaintiff started seeing orthopedist Zain Vally Mahomed, M.D., at the South Side Medical Group, L.T.D. ("South Side"). (R. 373-76). She exhibited decreased range of motion in both shoulders, including positive Neer's tests for impingement of the rotator cuff and decreased sensation in her upper arms, though her deltoid strength was 4. (R. 375). A Phalen's test for carpal tunnel syndrome produced pain on the right and she had myospasm in the "bilateral forearm, extensor, and flexor tendons." ( Id. ). Dr. Mahomed diagnosed bilateral shoulder musculo-ligamentous injury with possible rotator cuff tear; bilateral musculo-ligamentous injury with flexor tendon strain; and musculo-ligamentous injury to the left elbow and right wrist. ( Id. ). He prescribed Ultram, Mobic and Soma for pain, ordered X-rays of both elbows and an MRI of the shoulders and right wrist, and referred Plaintiff to physical therapy. (R. 375-76).
Between April 20 and June 15, 2010, Plaintiff attended physiotherapy at South Side to address her shoulder, wrist and forearm pain. (R. 379-81, 384-87, 392-95). On April 30, 2010, she had an EMG that showed evidence of radiculopathy at C6-C7. (R. 366, 396). A few days later, on May 3, 2010, Plaintiff saw orthopedic surgeon David A. Schafer, M.D., of Advanced Health Medical Group, L.T.D., for further evaluation and treatment of her shoulder injury. (R. 377-78). Dr. Schafer reported decreased range of motion in both shoulders, worse on the right, "significant impingement signs, " and rotator cuff weakness and severe pain to palpation of the right proximal biceps, though there was no evidence of instability. Plaintiff also exhibited pain to palpation of the right wrist, and tested positive for De Quervain's disease with decreased thumb extension strength and swelling "in the area from the first dorsal compartment." (R. 378). Dr. Schafer noted that an April 22, 2010 MRI of Plaintiff's right shoulder showed a small partial thickness tear of the supraspinatus, and an MRI of the right wrist revealed "multiple small cyst[s] near the radial wrist and small fluid collections." ( Id. ). He diagnosed right shoulder tendonitis with proximal bicep tendonitis versus tear; left shoulder tendonitis; and right wrist De Quervain tenosynovitis and cyst with likely tear. ( Id. ). He recommended a cortisone injection and restricted Plaintiff to no lifting with the right arm "because of the severity of her symptoms in the biceps." ( Id. ).
Two weeks later, on May 17, 2010, Plaintiff told Dr. Mahomed that she was feeling 10% better since her last visit, but still had pain at a level of 7/10 that was aggravated by movement. (R. 382). She continued to exhibit tenderness and decreased range of motion in the shoulders, as well as a positive Neer's sign on the right and muscle spasm "in the traps" (trapezius). She also had significant tenderness to palpation and swelling over the right wrist. ( Id. ). Dr. Mahomed instructed Plaintiff to keep taking Ultram, Mobic and Soma and continue with physiotherapy while she remained on "total temporary disability" status from work. (R. 383).
On June 1, 2010, G. Klaud Miller, M.D., conducted an independent medical evaluation of Plaintiff in connection with a workers' compensation claim. (R. 367-68). Based on his examination and a review of the medical file, (R. 363-68), Dr. Miller opined in a June 8, 2010 report that Plaintiff had "completely changed her complaints and examination on several different occasions, " first exhibiting symptoms only on the right side but then developing left-sided symptoms as well. (R. 369). In Dr. Miller's view, Plaintiff complained of "non-atomic and non-physiologic findings, which cannot be explained on any objective/physiologic basis, " and he saw "nothing to support" a diagnosis ...