United States District Court, Northern District of Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
James B. Zagel, United States District Judge.
Plaintiff James Carlton Riley III (“Plaintiff”) filed this civil action pursuant to 28 U.S.C. § 405(g) against Defendant Carolyn W. Colvin, Acting Commissioner of Social Security (“Defendant”), seeking review of Defendant’s final decision denying his application for social security disability insurance benefits (“DIB”). For the following reasons, this case is remanded back to the Social Security Administration.
I. FACTUAL BACKGROUND
Plaintiff is 41-years-old, married, and has one child. He is 6 feet and 2 inches tall, weighs approximately 330 pounds, and has a history of back problems. Plaintiff has a high school education and has worked either as a cutting machine tender operator or a grinding machine operator the majority of his adult life. In April 2003, Plaintiff injured his back while picking up sheet metal at work. After conservative treatment proved ineffective, Plaintiff underwent back surgery in July 2003, specifically, a microdiscectomy of his L4-5 to remove a herniated disc. Plaintiff’s condition temporarily improved, but his symptoms soon returned. In November 2003, Plaintiff again underwent surgery. Dr. Richard Lim, the surgeon who performed Plaintiff’s prior surgery, executed another microdiscectomy to remove a re-herniated disc at L4-5 and a newly herniated disc at L5-S1. After his second surgery, Plaintiff’s condition improved but he still reported some tolerable, intermittent back pain.
In March 2009, Plaintiff was laid off from his job as a grinding machine operator. He began an internship in October 2010 in the field of surgical technology. On November 29, 2010, Plaintiff went to the emergency room complaining of lower back pain and numbness in his right leg. At the emergency room, Plaintiff explained his symptoms were likely caused by a long car trip he had taken the previous weekend. The medical records from Plaintiff’s emergency room visit reflect that Plaintiff could not raise his right or left leg and that there was no tenderness in his back. His final diagnosis was back pain with sciatica. Plaintiff was told to follow up with Dr. Lim. As a result of his condition, Plaintiff was unable to complete the internship.
On December 2, 2010, Dr. Lim ordered a Magnetic Resonance Imaging (“MRI”) of Plaintiff’s back, which revealed congenital lumbar spinal stenosis. After consulting with Dr. Lim, Plaintiff elected to undergo another corrective operation. Dr. Lim performed Plaintiff’s third operation on January 10, 2011, namely a posterior spinal fusion at L4-5, decompression at L4-5 and L5-S1, a transforaminal lumbar interbody fusion at L4-5 and L5-S1, a local bone graft, and interbody cage insertion at L4-5.
On January 18, 2011, at his first postoperative meeting, Dr. Lim noted that Plaintiff reported he was feeling overall much better, that most of his pain in his right leg was gone, but that he still occasionally experienced shooting pain. The treatment note is ambiguous regarding what part of Plaintiff’s body the shooting pain came from. Plaintiff’s next appointment with Dr. Lim was on February 18, 2011. At that appointment, Plaintiff indicated that he felt much better and had ceased taking all pain medications. However, Plaintiff remarked that he was having left- sided buttock pain and left-sided posterior leg pain. Dr. Lim ordered Plaintiff to begin a physical therapy program.
Plaintiff underwent an initial physical therapy evaluation at his first physical therapy session on February 22, 2011. The evaluation shows that Plaintiff complained of back pain and tightness in his left leg that radiated to his knee. He also reported that sitting on a hard surface for too long aggravated these symptoms and that on average his pain was between zero and one on a scale from one to ten. The therapist’s assessment also notes that Plaintiff had slow, guarded position changes, a slow gait, minimal lower back pain, a limited range of motion in his trunk, limited muscle flexibility, lower extremity weakness and resulting functional limitations. The assessment is silent on what Plaintiff’s “resulting functional limitations” actually were. The therapist recommended that Plaintiff continue the therapy program twice a week for four to six weeks.
Plaintiff attended physical therapy from February 22, 2011 to May 19, 2011. Therapy notes from this time period reveal that Plaintiff complained of tightness, stiffness, or spasms in his back or buttocks at more than half of his sessions. Records also show that his right leg sciatic pain and condition overall was improving. On multiple occasions, Plaintiff reported that he was feeling good and had no problems at all.
Plaintiff returned to Dr. Lim for a follow-up appointment on April 8, 2011. At that appointment, Plaintiff reported he was feeling about 90% better and off all narcotics. Plaintiff’s x-rays showed “the alignments of his implants [were] good.” His range of motion was still limited, likely because of “the two level fusion, ” as well as the need for further rehab. Dr. Lim ordered Plaintiff return for another appointment in six weeks. At the conclusion of therapy on May 19, 2011, Plaintiff reported that he felt 95% better. The therapist’s final comments on Plaintiff’s condition indicate that Plaintiff had made minimal progress in terms of his range of motion and had reached a progress plateau.
The following day, Plaintiff reported to Dr. Lim that he was very pleased and that 100% of his pain was gone. At this appointment, Plaintiff’s x-rays showed his “fusion to be robust.” However, Plaintiff also reported that he still had some discomfort in his anterior thighs and that his movement was still limited. Dr. Lim opined that Plaintiff’s lower extremity symptoms were likely the result of permanent nerve damage. He noted that Plaintiff had a limited range of motion secondary to his two-level fusion and ordered Plaintiff to continue his at-home exercises, lose weight, and to follow up in three months for additional x-rays.
On August 19, 2011, Plaintiff returned to Dr. Lim, complaining that he was having back pain on an almost daily basis and that a few weeks prior to the appointment “he had a marked flare-up of pain.” He also reported that he had numbness and tingling in his lower left back. Dr. Lim’s treatment note shows that an examination of Plaintiff revealed tenderness over his “PSIS” consistent with where Plaintiff indicated the pain was coming from. To alleviate his symptoms, Plaintiff told Dr. Lim he “redoubled” his home exercises, used his exercise bike, and took anti-inflammatory medication. Dr. Lim recommended that Plaintiff continue his exercise program and return for appointments on a yearly basis.
At the same appointment, Dr. Lim completed a physical residual functional capacity (“RFC”) questionnaire. In his assessment, Dr. Lim diagnosed Plaintiff with severe lumbar degenerative disc disease. He opined that in an 8-hour workday, Plaintiff could only sit or stand for fifteen-minute intervals for a total of four hours of sitting and standing. Dr. Lim also opined that Plaintiff would need to walk at least five minutes after sitting or standing for fifteen minutes and would also need to take at least one or two unscheduled breaks lasting between fifteen and twenty minutes during an 8-hour work day. Additionally, Dr. Lim determined that Plaintiff would need a job that permits shifting position at will from sitting, standing, or walking. Dr. Lim concluded that Plaintiff’s condition allowed him only to occasionally climb stairs, rarely stoop, bend, crouch, or climb, and never twist.
II. PROCEDURAL HISTORY
A. Plaintiff’s Initial Application
On December 13, 2010, Plaintiff filed an application for social security disability insurance benefits (“DIB”) alleging that he had been disabled since November 30, 2010. At the request of the Social Security Administration and as part of his application for DIB, Dr. Reynaldo Gotanco, a non-examining reviewer, completed a RFC assessment of Plaintiff. Dr. Gotanco’s conclusions were drawn from Plaintiff’s November 29, 2010 emergency room records, January 10, 2011 postoperative report and x-rays, and Dr. Lim’s February 18, 2011 treatment note. On March 17, 2011, Dr. Gotanco opined that 12 months after November 30, 2010—Plaintiff’s alleged onset date—that Plaintiff could sit, stand, or walk for around six hours in an 8-hour workday. He also opined that Plaintiff had occasional postural limitations for climbing ramps, stairs, ladders, ropes, and scaffolds, as well as ...