United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
MICHAEL T. MASON, Magistrate Judge.
Claimant Jennifer Thomas ("Thomas" or "claimant") brings this motion for summary judgment  seeking judicial review of the final decision of the Commissioner of Social Security (the "Commissioner"). The Commissioner denied Thomas' claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under the Social Security Act (the "Act"), 42 U.S.C. §§ 416(i), 423(d) and 1382(c)(a)(3)(A). The Commissioner has filed a cross-motion for summary judgment , asking that the Court uphold the decision of the Administrative Law Judge ("ALJ"). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, claimant's motion for summary judgment is granted in part and denied in part and the Commissioner's cross-motion for summary judgment is denied.
A. Procedural History
Thomas filed her applications for DIB and SSI in October of 2007. In both applications, Thomas alleged an onset of disability of October 2, 2005. (R. 124-26, 129-35.) The Social Security Administration denied her applications initially on July 24, 2008, and again upon reconsideration on December 23, 2008. (R. 93-101.) Thomas filed a timely request for a hearing on January 28, 2009. (R. 104-05.) On March 2, 2010, Thomas appeared with counsel before ALJ Marlene R. Abrams. (R. 623.) On April 16, 2010, ALJ Abrams issued a written decision denying Thomas' request for benefits. (R. 6-21.) Thomas filed a timely request for review. On October 26, 2011, the Appeals Council denied the request, making the ALJ's decision the final decision of the Commissioner. (R. 2-5); Estok v. Apfel, 152 F.3d 636, 637 (7th Cir. 1998). This action followed. The parties consented to this Court's jurisdiction pursuant to 28 U.S.C. § 636(c) .
B. Medical Evidence
Claimant began receiving treatment for physical and mental impairments after she was involved in a motor vehicle accident in June of 2005. (R. 638-40.) She seeks DIB and SSI for disabling conditions stemming from pain associated with back, neck, and shoulder injuries, as well as chronic pain radiating throughout various parts of her body. (R. 14.) She also suffers from insomnia, depression, and anxiety. ( Id. )
1. Treating Physicians
On June 13, 2005, following her automobile accident, Thomas sought treatment at Saint Margaret Mercy Healthcare Center. (R. 350.) She received an x-ray of her right shoulder, which showed no fracture or dislocation. ( Id. ) An x-ray of her cervical spine demonstrated reversal of normal cervical lordosis with apex of reversal greatest at the C5-6 level. (R. 351.) However, the disc spaces were well preserved, and there was no sign of fracture or dislocation. ( Id. ) Claimant underwent an x-ray of her thoracic spine on August 17, 2005, which showed no evidence of a compression fracture or significant subluxation. (R. 348.) Claimant received an MRI of the cervical spine on October 10, 2005. (R. 346.) It too showed a slight reversal of the normal lordotic curve, unchanged since June 13, 2005. ( Id. ) There was no evidence of herniated disc, osteophyte formation, or neural foraminal narrowing. ( Id. )
Claimant sought treatment at Northern Indiana Neurological Institute on November 28, 2005 for severe pain in her right arm and left elbow, as well as back pain. (R. 311.) The examining physician recommended an MRI, an Electromyography ("EMG"), and physical therapy. ( Id. ) The EMG revealed normal results. (R. 320.) An MRI of the thoracic spine showed degenerative disc disease at T6/7 with a mild to moderate left paracentral disc hernation with a slight superior migration and mild cord flattening. (R. 318-19.) Disc degeneration with slight generalized disc bulging was seen at T9/10. (R. 318.) There was no significant thoracic canal or foraminal stenosis at any level and the thoracic spinal cord demonstrated normal signal intensity. ( Id. ) Ultimately, Thomas was referred to the University of Chicago ("U of C"). (R. 313.)
Thomas presented to the U of C Women's Health Center on December 20, 2005 complaining of upper neck pain and left arm pain. (R. 389.) She reported that she was recently diagnosed with a superficial thrombophlebitis and had been taking Plavix for treatment. ( Id. ) She also reported receiving injections in her neck and left arm several weeks prior. ( Id. ) Mild swelling of the left elbow was observed. ( Id. ) Thomas underwent an upper extremity doppler scan, which showed a brachiocephalic thrombus. (R. 388.) Thomas was prescribed Lovenox. ( Id. )
Also at this time, claimant began seeing primary care physician Dr. Neda Laiteerapong. (R. 403.) Dr. Laiteerapong reported that Thomas' complaints of numbness and tingling were thought to be due to carpal tunnel syndrome and she was advised to wear splints. ( Id. ) She was also diagnosed with anxiety and depression and started on Lexapro. ( Id. )
Thomas saw Dr. Alex Ulitsky at U of C on March 14, 2006. (R. 392.) She reported that the blood clot still caused significant pain in her left arm, and complained of soreness on the right side of her neck, and mid-back, as well as chronic anxiety. ( Id. ) Upon physical examination, Dr. Ulitsky observed spinal tenderness, but noted Thomas exhibited a normal range of motion. (R. 393.) Among other things, Dr. Ulitsky referred patient to physical therapy for relief of her neck and back pain, and encouraged her to take Tylenol. ( Id. )
On May 2, 2006, claimant presented to the neurological department at the U of C. (R. 314.) Her chief complaint was neck and lower back pain. ( Id. ) During her examination, Thomas displayed a normal gait, and demonstrated full range of motion in her arms and legs. (R. 315-16.) She complained of pain in her cervical and lumbar spine upon movement. (R. 316.) Neurologically, Thomas was in tact apart from decreased sensation in her right hand at the C6-7-8 distribution. ( Id. ) The examining nurse noted that the previous MRI revealed a thoracic herniated disk. ( Id. ) It was recommended that Thomas undergo physical therapy, obtain X-rays of the cervical, thoracic, and lumbar spine, an MRI of the cervical and lumbar spine, and obtain pain medication from the Northern Indiana Neurological Institute or her primary care physician. (R. 317.) On May 6, 2006, claimant had an MRI of the cervical and lumbar spine. (R. 407.) It showed a reversal of cervical lordosis, but no evidence of spinal stenosis or neural foraminal compromise at the cervical or lumbar levels. ( Id. )
On July 7, 2006, Thomas followed up with Dr. Laiteerapong. (R. 395.) She reported high levels of stress, depression, insomnia, and chronic pain in her back and left arm. ( Id. ) She reported that she was unable to stand or sit for long periods of time. ( Id. ) She explained that she used to see a physical therapist, but indicated that the stretches seemed to exacerbate her pain so she discontinued treatment. ( Id. ) Other than spinal tenderness, the physical examination was normal. (R. 396.) Dr. Laiteerapong prescribed Xanax and recommended therapy. (R. 397.) Thomas declined a referral for physical or occupational therapy and Dr. Laiteerapong noted that her musculoskeletal symptoms appeared well-controlled. ( Id. )
Thomas followed up with Dr. Laiteerapong again on October 10, 2006. (R. 398.) Thomas reported that she had started seeing a psychiatrist for her depression and was taking Wellbutrin. ( Id. ) Her symptoms had improved and she denied suicidal ideation, though she continued to have trouble sleeping. ( Id. ) She also continued to complain of neck and back pain stemming from her car accident. ( Id. ) She explained that she was having difficulty slicing limes and carrying trays at her waitressing job. (R. 399.) Dr. Laiteerapong prescribed Trazodone, and referred Thomas to occupational therapy to learn better strategies for work related pain. ( Id. )
Thomas visited the U of C Pain Center on October 18, 2006. (R. 400.) She described severe pain in her neck and back that radiates to her extremities, and that is worsened upon ambulation or prolonged sitting or standing. ( Id. ) She reported that physical therapy was unsuccessful, as were previous trigger point injections. ( Id. ) A physical examination revealed tenderness, pain upon certain movement, and limited range of motion of the lumbar spine. (R. 401.) Decreased sensation was seen in the right upper extremity, affecting all fingers on that side. ( Id. ) Her gait was antalgic. ( Id. ) Dr. Gita Rupani assessed right upper extremity shoulder and arm pain, likely consistent with thoracic outlet syndrome, low back pain, likely consistent with myofascial pain syndrome, and right lower extremity pain, likely consistent with referred pain from right trochanteric bursitis. ( Id. ) She recommended further lab work, and gave claimant injections, which provided immediate relief. (R. 401-02.)
Records dated January 7, 2007 reveal that Thomas was treated at Saint Margaret for a left ovarian cyst. (R. 325-30.) At that time, she also complained of pain beginning in her neck and radiating to her right arm. (R. 327.)
On March 28, 2007, claimant returned to the Pain Center because she continued to have back pain, shooting down to her right leg, and pain on the right side of her neck and in the back of her shoulder shooting to her hand, and causing numbness, weakness, and tingling. (R. 358.) Recent testing revealed that claimant did not suffer from thoracic outlet syndrome as previously suspected. ( Id. ) Dr. Rupani did note that a recent EMG (not in the record) showed a left cervical radiculopathy. ( Id. ) At the time, she was taking Trileptal, prescribed by the neurology department. ( Id. ) She was not taking any pain medications because they never provided relief. ( Id. ) The physical examination revealed some limited range of motion and pain upon movement. (R. 359.) Dr. Rupani assessed myofascial pain syndrome, cervical radiculopathy, and whiplash. ( Id. ) Despite her hesitance, Dr. Rupani presented claimant with a treatment plan of injections, neuropathic pain medications, and anti-inflammatory medications. ( Id. )
Claimant's complaints continued at an appointment on April 25, 2007. (R. 361.) Despite a primarily normal MRI and cervical spine x-rays, Dr. Rupani recommended cervical steroid injections, which were performed on May 16, 2007. (R. 363-64.) Shortly thereafter, Thomas reported that the injections provided relief of her neck and back pain, but that she was still experiencing numbness in her arm and hand. (R. 365.)
On August 2, 2007, claimant returned to see Dr. Laiteerapong. (R. 366.) She was prescribed Amitriptyline for her pain and depressive symptoms, but was later switched to Fluoxetine because the Amitriptyline did little for her pain and made her sleepy. (R. 368, 370.)
As of November 5, 2007, claimant was severely depressed, suffered two to three panic attacks a day, and had not left her apartment much in the last four months. (R. 371.) She was taking Vicodin, which did little to ease her severe pain, and she missed her last Pain Center appointment for an injection. ( Id. ) Dr. Laiteerapong noted that controlling her psychiatric disorder would improve her myofascial pain. (R. 373.) Thomas denied much improvement at her next appointment on November 29, 2007, though she had not been fully compliant in taking her depression medications. (R. 374.) As for her pain, she believed the Morphine she recently started taking worked better than the Vicodin. ( Id. ) Thomas returned to the Pain Center on December 5, 2007, at which point it was recommended she get another steroid injection. (R. 377-78.) However, Dr. Rupani decided against the injection after learning Thomas was pregnant. (R. 380.)
On December 19, 2007, claimant was feeling better, but was still having problems keeping up with her activities and had difficulty concentrating. (R. 380.) She reported that she was dissatisfied with the treatment by Dr. Rupani at the Pain Center. ( Id. ) Dr. Laiteerapong recommended that she continue to see her therapist and see a ...