United States District Court, N.D. Illinois, Eastern Division
YOUNG B. KIM, Magistrate Judge.
Adrian Gonzalez seeks disability insurance benefits ("DIB"), 42 U.S.C. §§ 416(i), 423, based on his claim that he is disabled by a combination of knee pain and depression. After the Appeals Council declined to review an administrative law judge's ("ALJ") decision denying his application, Gonzalez filed this suit seeking judicial review. See 42 U.S.C. § 405(g). Currently before the court are the parties' cross motions for summary judgment. For the following reasons, Gonzalez's motion for summary judgment is granted and the government's motion is denied:
In August 2009 Gonzalez filed an application for a period of disability and DIB, claiming a disability onset date of July 16, 2005. (Administrative Record "A.R." 159.) After his claims were denied initially and upon reconsideration, (id. at 79-80), Gonzalez requested and was granted a hearing before an ALJ. That hearing took place on April 7, 2011. (Id. at 34-78.) On June 8, 2011, the assigned ALJ denied Gonzalez's application. (Id. at 29.) The Appeals Council declined review, (id. at 7-13), making the ALJ's decision the final decision of the Commissioner of Social Security, see Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). After seeking and receiving an extension of time to file a suit seeking judicial review of the Commissioner's final decision, Gonzalez filed his complaint on December 21, 2012. See 42 U.S.C. § 405(g). The parties have consented to this court's jurisdiction. See 28 U.S.C. § 636(c).
Gonzalez's 22-year career as a carpenter came to an abrupt end on July 16, 2005, when he fell to the ground from a height of six feet while at work, suffering what his doctor later would describe as a "severe and devastating injury" to his right leg. (A.R. 195, 288, 324.) After surgery and extensive physical therapy, Gonzalez reinjured his knee in 2007 by falling down a set of stairs. (Id. at 689.) He claims that the leg pain, knee swelling, and depression stemming from his injuries make it impossible for him to work. At his hearing before the ALJ, Gonzalez presented both documentary and testimonial evidence in support of his claim.
A. Medical Records
Gonzalez's July 2005 fall caused a right tibial plateau fracture which required surgery. (A.R. 362.) Two months after his surgery Gonzalez began what would be a ten-month course of physical therapy. (Id.) At his initial evaluation his physical therapist noted that Gonzalez was experiencing moderate right knee pain, significant swelling throughout his lower right leg, and severely decreased mobility. (Id. at 595.) At the end of his physical therapy Gonzalez's physical therapist provided a residual functional capacity ("RFC") assessment in which he opined that Gonzalez is capable of performing at the medium physical demand level for activities above the knees but only the sedentary level below the knee. (Id. at 606.) After Gonzalez reinjured his right knee in a July 2007 fall, his physical therapist noted that he had increased swelling in his right knee and moderate impairments with walking, sitting, and standing. (Id. at 689-92.)
Gonzalez sought medical treatment for his knee pain with Dr. Miguel Jimenez, who noted in November 2007 that Gonzalez was tearful, despondent, and depressed. (Id. at 345.) Because Gonzalez was experiencing popping, clicking, and swelling in his right knee, Dr. Jimenez recommended arthroscopic surgery. (Id. at 345-46.) Over a year later, in December 2008, Dr. Jimenez performed the surgery to correct what he described as the residual deficits stemming from medial and lateral meniscal tears. (Id. at 263-64.) Gonzalez re-enrolled in physical therapy the following month, reporting severe pain in walking, sitting, and standing. (Id. at 362, 364.) At a February 2009 surgical follow-up Dr. Jimenez noted that Gonzalez had developed post-traumatic degenerative changes in his knee and that he was suffering from pain and swelling. (Id. at 272-73.) Dr. Jimenez wrote that Gonzalez should be permanently restricted from work and would likely need total knee arthroplasty if his post-traumatic osteoarthritis continued. (Id. at 273.)
In October 2009 Gonzalez underwent a psychological evaluation with Glen Wurglitz, Psy.D., at the behest of the state disability determination services office. (Id. at 282.) Dr. Wurglitz observed that Gonzalez sat uncomfortably, was tearful and anxious, and had trouble remaining focused. (Id.) Gonzalez told Dr. Wurglitz that he was seeing a psychiatrist who prescribed him Cymbalta, but that he was unable to take the medication because his insurance would not cover it. (Id. at 283.) Dr. Wurglitz diagnosed Gonzalez as having major depressive disorder of moderate severity. (Id. at 286.)
Gonzalez next underwent an internal medicine consultative examination with Dr. Stanley Simon, who noted that Gonzalez reported having leg pain at a level of five out of ten. (Id. at 288.) Gonzalez reported that he relieved the pain by elevating his leg. (Id.) Dr. Simon examined Gonzalez and noticed no swelling in the right knee, but observed diffuse tenderness and reduced range of motion in the knee. (Id. at 290.) He also noted that Gonzalez was obese, carrying 224 pounds on his 5'-10" frame. (Id. at 289.)
Following these examinations, in December 2009 two state agency doctors reviewed Gonzalez's records and gave their opinions regarding his RFC. Consulting psychologist Dr. Kirk Boyenga rated Gonzalez as having moderate difficulties in social functioning and only mild difficulties in activities of daily living or concentration, persistence, or pace. (Id. at 303.) He reported that he found Gonzalez only partially credible, because "objective medical evidence in the file does not support the severity of the claimant's allegations." (Id. at 305.) Dr. Richard Bilinsky completed a physical RFC, opining that Gonzalez can sit, stand, or walk for six hours in an eight-hour day with only occasional kneeling or crouching. (Id. at 312-13.) He used the same language as Dr. Boyenga in justifying his finding that Gonzalez's statements were only partially credible. (Id. at 318.)
Beginning in February 2010 Gonzalez began seeking medical treatment from Dr. Mary Hensley. He reported that he had been in bed for two weeks because he was depressed. (Id. at 498.) Dr. Hensley noted that Gonzalez walked with a limp and had a right knee deformity. (Id. at 499.) She assessed him as having depression, obesity, fatigue, and a lower leg joint disorder. (Id.) In the months that followed Hensley prescribed Prozac which improved Gonzalez's depression, although she observed that his lower leg joint disorder was worsening. (Id. at 514, 521.) In her most recent examination notes dated February 10, 2011, Dr. ...