United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
MICHAEL T. MASON, Magistrate Judge.
Claimant James Peterson ("Peterson" or "claimant") brings this motion for summary judgment  seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"). The Commissioner denied Peterson's claim for disability insurance benefits under the Social Security Act (the "Act"), 42 U.S.C. §§ 416(i) and 423(d). The Commissioner has filed a cross-motion for summary judgment , asking that this 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). For the reasons set forth below, claimant's motion for summary judgment is granted and the Commissioner's cross-motion for summary judgment is denied.
A. Procedural History
Peterson filed for disability insurance benefits in July of 2010. (R. 164-65.) Peterson alleges that he has been disabled since December 2, 2009 due to right ankle degenerative joint disease/osteoarthritis, left knee reconstruction, bicipital tendonitis, rotator cuff tear, hypertension, chronic low back pain, and numbness in hands. (R. 87.) Peterson's application was denied initially on October 27, 2010, and again on reconsideration on December 30, 2010. (R. 82-87, 92-96.) A hearing was held before ALJ Patricia Supergan on July 6, 2011. (R. 38-73.) On October 13, 2011, the ALJ issued a decision denying Peterson's request for benefits. (R. 23-37.) Then, on December 13, 2011, Peterson filed a request for review by the Appeals Council. (R. 15.) On February 27, 2013, the Appeals Council denied Peterson's request for review, making the ALJ's decision the final decision of the Commissioner. (R. 1-7.) Peterson subsequently filed this action in the District Court. The parties consented to this Court's jurisdiction pursuant to 28 U.S.C. § 636(c) .
B. Medical History
1. Treating Physicians
Peterson's medical conditions relevant to the instant appeal began with a diagnosis of de Quervain's disease (an inflammation of tendons in the thumb that extends to the wrist) in his right wrist in 2005. (R. 270.) He underwent a cortisone injection in November 2006, which only helped temporarily. ( Id. ) On April 3, 2007, Dr. Jerry Chow, noted that Peterson had a mild positive Finkelstein Test in his right wrist and would consider surgical release if the pain increased. (R. 266.)
On October 3, 2007, Peterson underwent surgery to treat the de Quervain's disease in his right wrist. (R. 271-72.) During the pre-surgery evaluation, Dr. Chow noted that Peterson's head and neck examination were normal, as well as his lungs and heart. (R. 270.) An x-ray of the right wrist showed a VISI-deformity, unrelated to the de Quervain's disease. ( Id. ) Two weeks after the surgery, on October 16, 2007, Peterson reported to Dr. Chow that he was beginning to feel better, with the exception of some stiffness in his right wrist. (R. 267.) Dr. Chow removed Peterson's sutures and directed him to undergo physical therapy. ( Id. )
On April 16, 2008, Peterson began receiving treatment from Dr. Alexander Michalow, an orthopedic physician, after complaining of right shoulder and upper arm pain, and pain in his right ankle. (R. 287.) Dr. Michalow noted that Peterson had very good rotator cuff and elbow flexion strength, "mild local ecchymosis, " little pain, and minimal tenderness. ( Id. ) X-rays of the shoulder were unremarkable. ( Id. ) Dr. Michalow concluded that Peterson suffered from a bicipital tendon rupture at the right shoulder. ( Id. ) Dr. Michalow decided that, because the rupture was in the non-dominant arm and resulted in no loss of function or strength, the problem did not warrant surgery or further treatment beyond conservative care at that time. (R. 288.)
During the same appointment, Peterson told Dr. Michalow that he believed the pain in his right ankle stemmed from a fracture caused by a high school injury that was treated improperly. (R. 287.) Dr. Michalow determined that Peterson's right ankle had some reduction in range of motion, and "mild [but] chronic hypertrophic synovitic changes." ( Id. ) After reviewing an x-ray, Dr. Michalow concluded that Peterson suffered from moderately severe degenerative joint disease in the right ankle. ( Id. ) He advised Peterson to continue wearing appropriate footwear and taking over the counter medication, and to consider a fusion if the pain increased. (R. 288.)
On May 29, 2009, Peterson sustained an injury to his left shoulder while working as an electrician. (R. 289.) Dr. Michalow examined Peterson on June 8, 2009, and observed a full range of motion, very good rotator cuff strength, and minimal pain. ( Id. ) Peterson also told Dr. Michalow that pain from his shoulder injury had subsided and required little medication. ( Id. ) Dr. Michalow ultimately concluded that Peterson suffered a left bicipital tendon rupture and he advised Peterson to consider surgical remedies in order to maximize strength. (R. 289-90.) Peterson indicated that, because the tendon tear in his right shoulder had been doing well without surgery, he did not want surgery at that time. (R. 289-90.)
Peterson returned for a follow up appointment with Dr. Michalow on July 13, 2009, reporting increased weakness upon reaching; he described his pain as "not that bad" and reported that he was "getting by ok" at work. (R. 291.) Dr. Michalow opined that the weakness suggested a complete left rotator cuff tear and directed Peterson to undergo an MRI. (R. 291.) Peterson next visited Dr. Michalow on August 12, 2009. (R. 292.) At that time, a physical examination and the results of Peterson's MRI led Dr. Michalow to conclude that Peterson had indeed suffered a complete tear of his left rotator cuff. ( Id. ) He advised Peterson to schedule reparative surgery. (R. 293.)
On December 3, 2009, Dr. Michalow performed surgery on Peterson's left shoulder. (R. 323-24.) The postoperative diagnosis indicated that Peterson had a left shoulder rotator cuff tear with degenerative partial bicep tear and a degenerative labrum tear. (R. 323.)
Dr. Michalow followed up on Peterson's surgery with examinations on December 7 and December 14, 2009. (R. 295.) Peterson described his pain as "not bad, " and Dr. Michalow noted that the shoulder was healing cleanly and on schedule. (R. 295-96.) By his January 11, 2010 follow-up examination, Peterson had regained a 90-degree range of motion in his left shoulder. (R. 297.) Dr. Michalow instructed Peterson on stretching and told him he could perform only "desk light duty" if it was available. (R. 297, 353.) On February 8, 2010, Dr. Michalow concluded that Peterson's range of motion of the shoulder had returned to normal and, though his rotator cuff strength remained weak, it had greatly improved since Peterson's January 11, 2010 examination. (R. 298.) He referred Peterson for physical therapy and advised him to remain off work unless light desk work became available. ( Id. )
Peterson returned for follow-up visits on March 8, April 5, May 3, and June 2 of 2010. (R. 299-303.) Dr. Michalow continued to find Peterson's range of motion in the shoulder to be fully restored and noted continued improvement with the help of physical therapy, despite some weakness in his left rotator cuff. ( Id. ) Dr. Michalow continued to advise only light work duties if available, with no overhead reaching and a limited lifting restriction. ( Id. ) The physical therapy notes show Peterson was making progress, though at times he demonstrated, pain, diminished strength, and fatigue. (R. 325-43.)
At an appointment on June 14, 2010, Peterson complained of pain in his right ankle, left knee, and lower back. (R. 305.) Upon physical examination, Dr. Michalow observed swelling and reduced range of motion in the right ankle, tenderness in the lumbosacral spine, with pain radiating to the right leg, and a positive straight leg test on the right. ( Id. ) He observed good range of motion in the hips, but noted left thigh numbness consistent with meralgia paresthica. ( Id. ) Ultimately, Dr. Michalow concluded that Peterson suffered from osteoarthritis of the vertebral column, post-traumatic osteoarthritis of the ankle and foot, meralgia paresthetica, and sciatica. ( Id. ) Dr. Michalow recommended braces and ice for the ankle pain, and a fusion as a last resort. (R. 306.) For the leg numbness, he provided cortisone injections. ( Id. ) Dr. Michalow also ordered an MRI. ( Id. )
On June 21, 2010, Peterson returned to review the results of the MRI, which showed a herniated disc at L5-S1, a smaller bulge at L4-5, and lesser degenerative changes elsewhere in the spine. (R. 307, 318.) At that time, Peterson explained that his right ankle pain was the major limiting factor for physical activity while on his feet. ( Id. ) Dr. Michalow determined that Peterson's right ankle might require surgery in the future, but that his spinal changes were "not bad enough to consider surgery at this point." (R. 307-08.) Dr. Michalow also advised Peterson to "consider job change for less physical activity." (R. 308.) On July 7, 2010, Dr. Michalow concluded that Peterson had recovered full range of motion in his left shoulder and exhibited "very good" strength in his rotator cuff. (R. 309.)
Peterson underwent an EMG of his hands on July 8, 2010 with Dr. Ashraf Hasan. (R. 320-22.) The EMG showed "[electrodiagnositc evidence of a mild sided carpal tunnel syndrome... demyelinating in nature" and "electrodiagnostic evidence of a moderate left sided carpal tunnel syndrome... demyelinating in nature." ( Id. ) One week later, on July 14, 2010, Peterson complained to Dr. Michalow of bilateral hand pain. (R. 311.) He also continued to complain of ankle, back, and neck pain, and left thigh numbness. ( Id. ) He explained that the injections only relieved his pain for a couple of days. ( Id. ) Dr. Michalow agreed that Peterson suffered from carpal tunnel syndrome in both hands, but more severely in his left dominant hand. (R. 312.) Dr. Michalow explained the need for surgery in the left hand due to progressed nerve slowing. ( Id. ) Dr. Michalow gave Peterson another cortisone injection in his left hip and advised him to continue his home exercise program. ( Id. ) At that time, Peterson had been released to work after a functional capacity evaluation, but there was apparently no work available at the released level. ( Id. )
A few weeks later, Dr. Michalow noted that Peterson was not able to do heavy "standing/walking" type work due to his progressive osteoarthritis and recommended that he consider vocational rehabilitation in the future to do "light duty type work." (R. 314.) Dr. Michalow again recommended surgery for Peterson's left carpal tunnel syndrome, which Peterson was to call to schedule. ( Id. )
Dr. Michalow's most recent medical report, dated August 9, 2010, listed Peterson's active problems as including: "ankle joint pain, bicipital tendonitis, complete tear of the rotator cuff tendon, foreign body in the eye, herniated disc, localized osteoarthritis of the ankle [and] foot, localized primary osteoarthritis of the ankle, localized primary osteoarthritis of the vertebral column, meralgia paresthetica, rotator cuff tendonitis, rupture of the bicipital tendon, sciatica, superior glenoid labrum lesion." (R. 315.) As far as the shoulder was concerned, Dr. Michalow stated that Peterson could return to work, with some limitations, but acknowledged that Peterson remained off work due to his other joint problems. (R. 315-16.)
Dr. Hasan examined Peterson twice in August 2010. (R. 374-77.) Peterson continued to complain of low back pain and left extremity pain, worsened when walking or standing. (R. 376.) Dr. Hasan reviewed the June 2010 MRI of the lumbar spine. ( Id. ) Upon examination, Dr. Hasan noted that Peterson was able to "get on and off the exam table without assistance" as well as "heel walk and toe walk, " though he noted an antalgic gait. (R. 374, 377.) Tenderness was noted across the lower lumbar paraspinal muscles, as was pain upon certain motions. ( Id. ) Dr. Hasan assessed "chronic lower back pain, degenerative disc disease of the lumbar spine, facet arthopathy of the lumbar spine, and sciatica." (R. 377.) Dr. Hasan administered steroid injections, and recommended physical therapy and that he continue to take Norco. ( Id. ) Peterson did not want to evaluate surgical options. (R. 374.)
Peterson returned to see Dr. Hasan on October 18, 2010. (R. 518.) He reported no relief from the steroid injections. ( Id. ) He had started physical therapy, but was unsure whether it was helping. ( Id. ) He reported taking Hydrocodone three times per day, as well as Naprosyn with mild relief of his symptoms. ( Id. ) Additional steroid injections were administered. (R. 523-24.) At a follow up appointment on October 28, 2010, he reported only mild relief from the injections and "some relief" from physical therapy. (R. 515.) He described his back pain as constant in nature, and explained that his leg pain worsened after standing longer than twenty minutes. ( Id. ) The physical examination again revealed a slightly antalgic gait, some tenderness in the spine, and pain upon maneuvering. (R. 515-16.) Injections were ...