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Richardson v. Colvin

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

August 23, 2016

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


          SIDNEY I. SCHENKIER United States Magistrate Judge.

         In this Social Security appeal, plaintiff Evette Richardson seeks reversal and remand of the final decision of the Commissioner of Social Security ("Commissioner") (doc, # 1 9). For the reasons set forth below, we grant Ms. Richardson's motion to remand and deny the Commissioner's motion to affirm (doc. # 20).


         Ms. Richardson filed for benefits alleging a disability onset date of November 1, 2008 (R. II).[2] After her claim was denied initially and on reconsideration, Ms. Richardson appeared and testified at a hearing before an Administrative Law Judge ("ALJ") on December 28, 2011 (R. 57). The ALJ issued an opinion denying benefits on January 11, 2012 (R. 90-96), but on March 20, 2013, the Appeals Council vacated the decision and remanded the case to the ALJ (R. 101). The ALJ obtained additional evidence and held another hearing on November 21, 2013 (R. 26). He issued a second written opinion on March 28, 2014, finding that Ms. Richardson was not disabled from her alleged onset date through September 30, 2013, the date last insured (R. 11-20). The Appeals Council denied Ms. Richardson's request for review, making the ALJ's ruling the final decision of the Commissioner. See Loveless v. Colvin, 810 F, 3d 502, 506 (7th Cir. 2016).


         We address below the evidence from before and after the remand by the Appeals Council.


         Ms. Richardson was born on December 21, 1974, and has a tenth grade education (R. 64). In 1994, she fractured her right ankle and left knee in an automobile accident (R. 349). Ms. Richardson underwent surgery on her right ankle and left knee to repair the fractures, followed by physical and occupational therapy (Id.).

         Ms, Richardson stated that she stopped working on September 2, 2008, because she was "unable to stand for any long period of time" due to pain in her knee and ankle (R. 322-26). She did not seek medical attention for her ankle or knee pain, but she went to the emergency room on January 3, 2008, and on January 28, 2009, complaining of chest pain (R. 401, 404). On both occasions, Ms. Richardson's pain resolved, and she was released with no evidence of cardiopulmonary problems (Id.). The January 2009 hospital report indicates that her chest pain might be musculoskeletal or related to her dyslipidemia (high cholesterol) (R. 407).

         On June 1, 2010, Ms. Richardson completed a function report for the Bureau of Disability Determination Services ("DDS"). She wrote that she was "unable to stand for a period of time, " had trouble sleeping because her knee ached and stiffened, could lift up to 10 pounds and walk three blocks before needing to rest for 45 to 60 minutes, and had trouble lifting, squatting, bending, standing, walking, and stair climbing (R. 286-87, 291). Ms. Richardson wrote that she cooked and cleaned the house for herself and her son, did laundry, shopped for food, clothing and household supplies, and had no problem with personal care (R. 287-90). She could pay attention all day and follow instructions well (R. 291). She used a brace/splint every day, but did not see a doctor and took no medications (R. 292-93).

         On June 30, 2010, Mahesh Shah, M.D., took x-rays of Ms. Richardson's left knee and right ankle and completed a consultative examination ("CE") for DDS. The x-ray of the left knee showed that the plates and screws from Ms. Richardson's earlier surgery were in good position, but she had severe tri-compartment degenerative disease in her left knee (R. 347). The hardware in her right ankle was also in good position, but there was evidence of degenerative changes in the ankle joint (Id.). Dr. Shah noted that Ms. Richardson was overweight and walked slowly with a slight right-sided limp, but without an assistive device (R. 350), She had no difficulty getting on and off the examination table, or alternating positions between standing, sitting and lying supine (Id.). Upon examination, Ms. Richardson's right ankle flexion and extension were reduced at 15 degrees, with pain in her right lower leg (R. 351-52). Her left knee flexion was 70 degrees with full extension, and she had severe pain in her left knee (Id.). She had difficulty heel and toe walking and was able to squat partially (R. 351). Dr. Shah opined that Ms. Richardson's obesity could make her knee and ankle pain worse (R. 352). He also tested Ms. Richardson's eyesight; she had corrected vision of 20/25 in the right eye and 20/70 in the left eye (R. 350).

         On July 27, 2010, Vidaya Madala, M.D., completed a physical residual functional capacity ("RFC") assessment for DDS (R. 353). Dr. Madala opined that Ms. Richardson could lift 20 pounds occasionally and 10 pounds frequently; stand, walk, and sit for a total of six hours in an eight-hour workday; occasionally climb ramps or stairs, stoop, kneel, crouch or crawl; and never climb ladders, ropes or scaffolds (R. 354-57). This opinion was affirmed on reconsideration (R. 362-63).

         There are no more medical reports in the record before Ms. Richardson's hearing on December 28, 2011. At that hearing, Ms. Richardson testified that some days the pain in her left knee was so intense that she could not walk, and the pain in her legs often kept her up at night (R. 72, 74-75). Her right ankle hurt, tingled, and went numb when she put too much pressure on it while trying to alleviate her left leg pain (R. 76). Ms. Richardson testified she could sit one to two hours, but would then have to get up and stretch out the leg to avoid stiffening, and she could not bend it all the way (R. 69). She testified that she could not see a doctor for her pain because she did not have medical insurance, and she lived at least an hour away via public transportation from the nearest public treatment facilities (R. 68, 77-78). Ms. Richardson took over the counter Tylenol and Ibuprofen for her pain, but those medications were not as effective as they used to be (R. 68). Her 19 year old son helped her cook, clean, grocery shop, and do laundry (R. 71).

         A vocational expert ("VE") testified that an individual who is limited to light work, but cannot climb ladders/ropes/scaffolds, and only occasionally climb ramps/stairs, stoop, crouch, kneel and crawl, could perform Ms. Richardson's past relevant work as a cashier but not her past work as a laundry aide or housekeeper (R. 79). Ms. Richardson could not perform her past relevant work ...

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