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Young v. Colvin

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

October 6, 2015

RANDOLPH J. YOUNG, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          HON. MARIA VALDEZ United States Magistrate Judge.

         This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying Plaintiff Randolph Young's claim for Disability Insurance Benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Plaintiff's motion to reverse the Commissioner's decision [Doc. No. 16] is granted in part and denied in part, and the Commissioner's cross-motion for summary judgment [Doc. No. 27] is denied.

         BACKGROUND

         I. PROCEDURAL HISTORY

         On April 21, 2011, Plaintiff filed a claim for Disability Insurance Benefits, alleging disability since October 5, 2009, due to arthritis and degenerative joint disease in his lumbar and cervical spine. Plaintiff's claim was denied initially and upon reconsideration, and he then timely requested a hearing before an Administrative Law Judge (“ALJ”), which was held on May 24, 2012. Plaintiff appeared and testified at the hearing and was represented by counsel. Medical expert Dr. Ashok Jilhewar and vocational expert James Breen also testified.

         On July 21, 2012, the ALJ denied Plaintiff's claim for Disability Insurance Benefits, finding him not disabled under the Social Security Act. The ALJ determined that, despite his back and neck impairments, Plaintiff could perform a limited range of sedentary work, which allowed him to do his past work as a loan officer. The Social Security Administration Appeals Council then denied Claimant's request for review, leaving the ALJ's decision as the final decision of the Commissioner and, therefore, reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).

         II. FACTUAL BACKGROUND[1]

         A. Background

         Plaintiff was born on January 28, 1955 and was fifty-seven years old at the time of the ALJ's decision. Plaintiff's insured status expired December 31, 2014, and so he must establish he was disabled by that date in order to receive benefits. Plaintiff has a long and fairly steady work history going back to 1972. (R. 169-170.) He's held a number of different jobs in his life, last working as a loan officer from March to July in 2009. (R. 192.)

         B. Medical Evidence

         Plaintiff has an extensive history of treatment of the arthritic and degenerative problems with his back and neck. His troubles began with his neck. In 2001, he had a cervical spine fusion from C2 to C6, and has had three more surgical procedures done on his neck since then. (R. 266, 288, 309.) His lumbar spine is a problem area as well, as a number of studies have confirmed, beginning with an MRI done on February 27, 2008, which showed degenerative changes throughout, small disc herniation at ¶ 4-5, severe disc space narrowing at ¶ 5-S1, and disc space narrowing at T-12-L2. (R. 273.) Another MRI on October 30, 2008, showed mild disc space narrowing, disc dessication, and a mildly bulging disc at ¶ 1-L2; moderate disc space narrowing and disc dessication, and concentric bulging with left side herniation at ¶ 4-5, along with mild encroachment on the neural foramen; and disc space narrowing, disc dessication, and concentric disc bulging at ¶ 5-S1, along with modic type 2 endplate changes and bilateral compromise of the neural forami. (R. 282.) X-rays taken August 11, 2009, revealed decreased disc height and spurring throughout Plaintiff's lumbar spine, as well as facet hypertrophy at ¶ 4-5 and L5-S1, and mild listhesis of L4 on L5. (R. 269.)

         On October 6, 2009, Plaintiff saw Dr. Thomas McNally, seeking treatment- possibly surgical - for his low back pain. (R. 273.) Physical exam was essentially normal in terms of range of motion and motor strength. (R. 272.) At that time, Plaintiff was taking Meloxicam, Naproxen, and Tylenol. (R. 271.) Dr. McNally noted that Plaintiff'‘s complaints of low back pain over the previous two years were consistent with results from previous x-rays and MRIs. (R. 273.) The doctor pointed out the major risks and lack of guarantees associated with lumbar fusion surgery. (R. 273.) Another MRI would be performed before any decisions would be made. (R. 274.)

         That study, done on October 15, 2009, revealed moderate degenerative changes at ¶ 5-S1, along with a central disc bulge possibly causing stenosis, with slight S1 nerve root displacement. There was also disc space narrowing in the lower thoracic spine, and mild facet arthropathy at ¶ 4-S1. (R. 263-264.) When Plaintiff went back to see Dr. McNally to discuss the results on November 12, 2009, he was complaining of increased low back pain, and left leg and foot pain. (R. 275.) He was moving slowly and carefully around the room, and his gait was antalgic. (R. 276.) Dr. McNally again went over the risks of various possible surgical interventions. (R. 277-278.)

         In April 2010, after receiving two epidural steroid injections in the previous four months, Plaintiff saw Dr. Anthony Savino for a follow-up on his back and leg pain. (R. 293.) Plaintiff had gotten some relief with the injections. (R. 293.) Reflexes were symmetrical and straight leg raising was negative bilaterally. (R. 293.) Dr. Savino ordered a CT scan and myelogram of Plaintiff's lumber spine. (R. 293.)

         The studies were done shortly thereafter. On April 29, 2010, the CT scan showed degenerative changes throughout, with mild disc space narrowing at ¶ 3-4; mildly decreased disc height, mild to moderate disc protrusion, mild stenosis, and moderate to severe neural foraminal narrowing at ¶ 4-5; and moderate to severe disc space narrowing, mild osteophyte formation, and moderate to severe neural foraminal narrowing at ¶ 5-S1. (R. 285.) The myelogram was positive for impression on the thecal sac. (R. 286.) When Plaintiff returned to Dr. Savino on May 3, 2010, the doctor explained that surgery would not alleviate his back pain - he would have to live with that. Surgery could only address his left leg pain. (R.292.)

         Plaintiff began suffering from left shoulder pain in the summer of 2010. On September 1, 2010, Plaintiff sought treatment from Dr. Joshua Alpert. (R. 290.) Examination revealed moderate pain in the AC joint at the top of the shoulder, and Speed's and Yergason's testing were positive. (R. 290.) X-rays confirmed AC joint arthropathy. (R. 290.) Dr. Alpert diagnosed a rotator cuff tear, along with AC joint arthritis and biceps tendonitis. (R. 290.)

         Subsequent MRI of Plaintiff's left shoulder showed rotator cuff tenopathy and inflamed bursa. (R. 289.) When Plaintiff returned to Dr. Alpert on September 8, he exhibited a full painless range of motion in the left shoulder, but did have pain in the AC joint and biceps. (R. 289.) Dr. Alpert administered a Lidocaine injection and sent Plaintiff home with instructions on home exercises. (R. 289.)

         Plaintiff returned on October 20, 2010, saying his shoulder had improved, but he still had pain and was now experiencing numbness down his arm. (R. 288.) Examination of the shoulder was essentially normal and Dr. Alpert felt the problem might be stemming from Plaintiff's cervical spine. (R. 288.) Plaintiff was noted to be experiencing financial difficulties which might adversely affect future treatment and testing. (R. 288.)

         On March 31, 2011, the state disability agency arranged for Dr. Roopa Karri to examine Plaintiff, in connection with his application for disability benefits. Plaintiff told Dr. Karri that he had back pain and pain radiating to his left leg and foot, with occasional numbness in his left foot. For the previous six months, Plaintiff had been using a cane. (R. 309.) Dr. Karri noted that Plaintiff walked with a small-stepped gait, limping on the left leg. (R. 310.) Plaintiff could not heel/toe walk, squat, or walk with a tandem gait, and he could not walk fifty feet without his cane. (R. 310.) Straight leg raising was negative. Strength was 5/5 in the upper and lower extremities, and deep tendon reflexes were 2 in the biceps, triceps, knees, and ankles. Lumbar spine flexion was 70/90 degrees; cervical spine flexion was 30/80 degrees. (R. 310.) There was decreased sensation to pinprick in Plaintiff's left foot. (R. 310.)

         On April 8, 2011, Plaintiff began seeing Dr. David Norbeck for his low back pain. Dr. Norbeck noted that straight leg raising was positive at 80 degrees, and that lumbar spine flexion was 80/90 degrees. (R. 321.) Motor strength and sensation were normal. (R. 321.) On May 3, Dr. David Schneider gave Plaintiff an epidural injection at ¶ 5. (R. 322). He was treated without charge as he had no insurance. (R. 331.) He needed another injection by October of 2011, but this time it would not be free; he would have to pay $500. (R. 331.) Plaintiff was hesitant, but went ahead with the procedure on October 25, 2011. (R. 333.) He followed up with Dr. Schneider on November 14, 2011. Neurological exam was normal with the exception of decreased sensation in the left foot. (R. 335.) Straight leg raising was positive at 30 degrees. (R. 335.) The doctor noted that any surgery would be elective as Plaintiff had “no gross deficit.” (R. 335.) By that time, Plaintiff was taking Tylenol, Aleve, and Norco, but the medications were not very effective. (R. 337.)

         On April 13, 2011, Dr. Henry Rohs reviewed Plaintiff's medical file for the agency. He thought that Plaintiff could lift ten pounds frequently, and less than ten pounds occasionally. (R. 314.) He could stand or walk for at least two hours out of every workday but needed a cane to do so. He could sit about six hours out of every workday. (R. 314.) Dr. Rohs said Plaintiff could only occasionally climb ramps or stairs, balance, stoop, kneel, crouch, or crawl; he could never climb ladders, ropes, or scaffolds. (R. 315.) Dr. Charles Kenny then reviewed the file on July 12, 2011, and concurred with Dr. Rohs' opinion. (R. 325.)

         C. The ...


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