United States District Court, N.D. Illinois, Eastern Division
RANDOLPH J. YOUNG, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
MARIA VALDEZ United States Magistrate Judge.
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.
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.
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).
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.)
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.)
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.)
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.)
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.)
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.)
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.)
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.)
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.
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.)
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.)
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.)