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Cockream v. Colvin

United States District Court, N.D. Illinois, Eastern Division

December 10, 2014

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

For Andrea N. Cockream, Plaintiff: Barry Alan Schultz, LEAD ATTORNEY, Law Offices of Barry Schultz, Evanston, IL.

For Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant: Kurt N. Lindland, LEAD ATTORNEY, AUSA-SSA, United States Attorney's Office (NDIL), Chicago, IL.


Geraldine Soat Brown, United States Magistrate Judge.

Plaintiff Andrea Cockream brings this action pursuant to 42 U.S.C. § 405(g) for judicial review of the decision of the Commissioner of Social Security denying her application for Disability Insurance Benefits (" DIB") and Supplemental Security Income (" SSI") under the Social Security Act, 42 U.S.C. § § 421, 423. (Compl.) [Dkt 1.][1] Plaintiff filed a memorandum in support of reversing the decision of the Commissioner of Social Security. (Pl.'s Mem.) [Dkt 19.] The Commissioner filed a motion for summary judgment [dkt 23] with a memorandum in support. (Def.'s Mem.) [Dkt 24.] Plaintiff replied. (Pl.'s Reply.) [Dkt 31.] The parties consented to the jurisdiction of a magistrate judge pursuant to 28 U.S.C. § 636(c). [Dkt 12.]

For the reasons set out below, the Commissioner's motion is granted.


Plaintiff applied for benefits on August 6, 2010, and the agency denied her claims initially and on reconsideration. (R. 66-69, 73-79, 150-63.) Plaintiff requested a hearing before an Administrative Law Judge (" ALJ") (R. 115-27), which was held on April 2, 2012 (R. 39-65). On May 8, 2012, the ALJ denied Plaintiff's request for benefits. (R. 24-33.) The Appeals Council declined Plaintiff's request for review (R. 1-4), making the ALJ's decision the final decision of the Commissioner. Villano v. Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009).


Plaintiff was 32 years old when she applied for benefits, alleging that she became disabled a year earlier because of a back injury and arthritis in her right knee. (R. 152, 190.) Before applying for benefits she worked primarily as a cashier and manager at fast-food restaurants. (R. 191.) Her last job was working in a laundromat, cleaning washers and dryers and folding clothes. (R. 44.) Her application for benefits indicated that she finished eleventh grade, but Plaintiff testified at her hearing that her husband made a mistake when he filled out the form, and she actually only finished seventh grade. (R. 56, 190.)

Medical History

In early 2009, Plaintiff began visiting Dr. Moses Tomacruz with complaints of lower back pain. (R. 323, 325, 327.) Dr. Tomacruz noted that Plaintiff had a history of chronic back pain because of a herniated disc. (R. 323.) He also observed that she had been managing the pain with physical therapy and medication, but that her pain nonetheless ranged from 6 to 10on a scale of 10. (R. 323, 325, 327.) Dr. Tomacruz ordered an MRI, which revealed mild disc disease with a slight loss of disc height and partial disc desiccation in the mid-lower back (the " T12-L1" vertebra), and mild loss of disc height, partial desiccation, and small to moderate disc protrusion into the left foramen resulting in moderate stenosis in the lower back (the " L4-L5" vertebra). (R. 355.)[2]

In July 2009, Plaintiff discussed her lower back pain with Dr. Dongwoo Chang. (R. 290.) She reported having back pain since childhood that had gotten worse over time. (Id.) Dr. Chang noted that Plaintiff described her pain as eight or nine out of ten (and as " sharp and dull" with " pins and needles sensations"), but that she had not undergone epidural injections. (Id.) After reviewing the MRI, Dr. Chang concluded that there was evidence of degenerative disc disease at the L4-L5 level and recommended epidural injections and continued physical therapy. (R. 291.) Around this time, Dr. Tomacruz also noted that Plaintiff's back pain was rated as severe and exacerbated by flexion, extension, sitting, and standing. (R. 303.) Plaintiff continued to take pain medication. (R. 303-04.)

In September 2009, Plaintiff followed up with Dr. Chang, who noted that Plaintiff's pain-management specialists did not think that injections would make a difference. (R. 286.) He scheduled Plaintiff for spinal-fusion surgery. (R. 282, 286.) In early November, a pre-surgery CT scan confirmed lumbar disc disease, with chronic L4-L5 disease and likely impingement of an L4 nerve root. (R. 320-21.) Later that month, Plaintiff underwent a lower lumbar spinal fusion and laminectomy. (R. 317-18.)[3]

Shortly after surgery, Plaintiff reported to Dr. Chang that her pain and numbness had improved but that she still had moderate cramping in her right leg and pain in both hips. (R. 278.) She continued to take pain medication. (Id.) Dr. Chang found that she was " in no acute distress." (Id.) Two months later, in January 2010, an x-ray showed " satisfactory postsurgical appearance of the lumbar spine." (R. 316.) At the same time, however, Plaintiff complained to Dr. Tomacruz that she still had " severe pain" (" 10/10 in intensity") in her back that radiated to her left foot. (R. 299.) Dr. Tomacruz noted that she was taking her pain medication " more than she should, " but he nonetheless increased the frequency of her prescription. (Id.) He also observed that her surgical scar was well healed with no swelling or redness of the skin. (Id.)[4] He recommended that she return in three months. (R. 421.) In March 2010, a follow up CT scan showed " [c]ontinued satisfactory postop appearance." (R. 315.)

On August 2, 2010, Plaintiff had an MRI taken of her right knee on order of Dr. Rafael Guerra because of complaints of chronic pain in that knee. (R. 397.) The MRI showed no significant joint effusion (the escape of fluid into a part of the body), and no evidence of meniscal tear. (Id.) The tendons and ligaments were intact. (Id.) There was a small amount of fluid in a cavity behind the knee and mild softening of the cartilage in the knee cap. (Id.)[5]

On August 21, 2010, Plaintiff was seen by Dr. Mitchell Goldflies on a referral from Dr. Guerra. (R. 389.) Plaintiff reported that she had fallen from the stairs three days earlier and was experiencing pain at a severity of 10 out of 10 in her right knee. (R. 389.)[6] Dr. Goldflies diagnosed a patellar femoral sprain and recommended physical therapy and a rehabilitation program. (R. 389.)

On August 31, 2010, Plaintiff's husband submitted a function report to the Social Security Agency about her limitations. (R. 198-205.) The report is written partially in first person, from Plaintiff's perspective, but signed by her husband. (R. 205.) The report states that Plaintiff could not lift anything, stand or sit for long periods of time, or walk for more than about two hours. (R. 198, 203.) It also notes that Plaintiff used a back brace since her surgery in November 2009. (R. 204-05.)

On October 5, 2010, Dr. Pranjal Shah conducted a consultative examination of Plaintiff on behalf of the state agency. (R. 369-75.) Plaintiff told Dr. Shah that her pain is usually eight out of ten and is worse when the weather is cold, when she sleeps, and when she sits for more than 10 to 20 minutes. (R. 369.) She also complained of constant pain in her knee and said that physical therapy was not helping. (Id.) She reported that she was not taking any medication. (R. 370.) Dr. Shah performed a straight leg raising test, which caused pain in the knee and stretching in the back.[7] (R. 371.) Dr. Shah found that Plaintiff had a full range of motion in her knee however painful, had full motor strength in all four extremities, and could walk with an antalgic gait for 50 feet without any assistive device. (Id.) Plaintiff reported tenderness in her lower back but refused to allow Dr. Shah to test her lumbar range of motion because she feared the pain it would cause. (Id.)

Four days after Dr. Shah's examination, Plaintiff followed up with Dr. Goldflies about her knee pain, stating that she finished physical therapy but that it did not help at all. (R. 388.) Dr. Goldflies opined that Plaintiff had possible nerve entrapment in her lower right extremity and recommended that an electromyogram be performed. (Id.) On October 29, 2010, the electromyogram of Plaintiff's legs showed normal results ...

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