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Muldoon v. Colvin

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

September 22, 2016

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


          Michael T. Mason 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 (the “Commissioner”) denying Claimant Timothy Muldoon's claim for Disability Insurance Benefits and Supplemental Security Income. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). Claimant has moved for summary judgment (Dkt. No. 12), asking that the court reverse the decision of the ALJ. The Commissioner has responded (Dkt. No. 20), arguing that the decision of the ALJ should be affirmed. For the reasons that follow, Claimant's motion for summary judgment is granted and the Commissioner's request for summary judgment is denied.



         Claimant applied for benefits in September 2012, alleging disability since October 13, 2010 due to low back pain, limited mobility, arthritis in his knees, and depression. (R. 168-76, 217.) Claimant's application was denied initially and upon reconsideration, after which he timely requested a hearing before an Administrative Law Judge (“ALJ”). (R. 122-24.) At a hearing held on December 5, 2013, Claimant personally appeared and testified before the ALJ. (R. 32-55.) On January 24, 2014, the ALJ issued a decision denying Claimant's request for benefits. (R. 24-34.) When the Appeals Council denied his request for review, the ALJ's decision became the final decision of the Commissioner, reviewable by the district court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).


         A. Treatment Records

         Claimant worked as a sheet metal worker, producing and installing HVAC ductwork, until his alleged onset date in October 2010. He has a history of back pain and had three surgeries, including a spinal fusion at the L4-L5 level, in 2001 and 2004. (R. 35-37, 303.)

         Claimant has also had knee trouble. In November 2010, Claimant consulted orthopedist Terry I. Younger, M.D. about right knee pain that he had been experiencing for about a year. (R. 311.) An MRI revealed a medial meniscal tear, chondromalacia, [1]and iliotibial band syndrome. (R. 312.) Claimant elected to undergo arthroscopic surgery, which was performed on November 16, 2010. (R. 297.) Six days later, he was doing very well and walking without difficulty. (R. 298.)

         On August 6, 2011, Claimant reported to Stephen P. Behnke, M.D. that for two days he had been experiencing increasing back pain. (R. 319.) He reported that he had been doing home remodeling but did not know how he had injured himself. (Id.) Dr. Behnke observed tenderness in Claimant's sacroiliac region and prescribed Mobic, an anti-inflammatory drug, in addition to rest and back exercises. (Id.) In September 2011, Claimant visited orthopedist Richard S. Rabinowitz, M.D. with continued complaints of lower back pain radiating to both legs, which he stated had been happening for about two months. (R. 300-02.) He had “done great up until this episode” since his back surgery in 2004. (R. 300.) Dr. Rabinowitz noted tenderness and mildly restricted ranges of motion in his lower back and a positive straight leg raise bilaterally. (R. 301.) A September 29, 2011 MRI revealed moderate to severe degenerative changes, disc bulging, or foraminal narrowing at all levels of Claimant's lumbar spine.[2] (R. 303.) On a return visit to Dr. Rabinowitz in October 2011, Claimant reported no improvement in his back and leg pain. (R. 306.) The orthopedist again noted mild generalized tenderness in the lumbar area, mildly restricted lumbar movement in all directions, and a positive bilateral straight leg test. (R. 307.) He referred Claimant for physical therapy. (Id.)

         In November 2011, Claimant again visited Dr. Rabinowitz, this time reporting improvement in his back and leg pain following physical therapy, though he acknowledged that he was still taking Mobic daily for pain. (R. 309.) Upon physical examination, he no longer had lumbar tenderness, though his movement was still mildly restricted. (R. 309.) A straight leg raise test was negative. (R. 310.)

         In January 2012, Claimant suffered from anxiety due to a difficult family situation. (R. 318.) His primary care physician, Michael J. Osten, M.D., prescribed a fifteen-day course of Xanax. (Id.)

         In the summer of 2012, Claimant worked as an overnight stocker at a Walmart store. (R. 241. 247.) In August 2012, Claimant saw orthopedist Ciro Cirrincione, M.D. for pain in his left knee, which was treated with an injection. He stated that he was taking Mobic (a nonsteroidal anti-inflammatory drug) for back pain. (R. 287-89.) On September 4, 2012, he reported to Dr. Rabinowitz that he had been experiencing back pain and bilateral thigh pain since starting his job at Walmart, and that his pain had worsened in the last week. (R. 342.) Dr. Rabinowitz noted that he was sensitive to touch over his lumbosacral nerve roots on both sides, but his straight leg raise tests were negative. (R. 343.) He also noted that Claimant's lumbar MRI revealed a herniated nucleus pulposus (hernitated disc) at the L5/S1 level and another at the L3-L4 levels of the spine. (Id.) He gave Claimant a Medrol Dose Pack, an oral steroid intended for short term use. (Id.) See “Oral Steroids, ” (last visited September 8, 2016.)

         On September 14, 2012, Claimant consulted with a new orthopedist, Bruce J. Montella, M.D., regarding the pain in his lower back and legs. Claimant reported that the pain had built up gradually over his career as a sheet metal worker. (R. 356.) His pain was at 6/10 on the right and 8/10 on the left, and caused him trouble walking, bathing, kneeling, squatting, cleaning, putting on shoes or socks, reaching above the head, reaching behind, driving, and sitting. (Id.) Dr. Montella observed mild lumbar spasms in the lower lumbar spine, diminished ranges of motion, and a positive straight leg raise. (R. 357.) He also noted that Claimant displayed zero out of five Waddell signs.[3] (Id.)

         When he returned to Dr. Montella in October 2012, Claimant stated that his low back pain was constant and had not changed since his last visit, though a home exercise program did “help a little.” (R. 354.) Dr. Montella again observed a positive straight leg test and noted no signs of incongruence or malingering. (R. 355.) Dr. Montella's notes from that visit include his opinion that Claimant was under “full and total disability.” (Id.) In his third visit to Dr. Montella in February 2013, Claimant recounted that he was having low back pain with radiating pain and numbness to feet and toes. (R. 368.) He indicated that he had trouble sitting or standing for a long period of time. (Id.) Dr. Montella documented intermittent paraspinal spasms, limited lumbar ranges of motion, decreased motor function in the affected area, and a positive straight leg test. (R. 368-69.) The doctor again wrote that Claimant displayed zero out of five Waddell signs. (R. 369.)

         In June 2013, Dr. Montella completed a questionnaire about Claimant's Residual Functional Capacity (“RFC”). (R. 379-81.) He reported that he had been treating Claimant since September 2012 for a diagnosis of lumbar disc herniation and symptoms including low back pain with bilateral radiating leg pain. (R. 379.) He opined that Claimant could sit for fifteen to twenty minutes continuously, stand for fifteen to twenty minutes continuously, and could alternate between sitting and standing for no more than thirty minutes at a time. (R. 380.) Claimant must lie down twice a day to relieve pressure on his back, can walk up to one bock, and uses a cane for stability. (Id.) He can carry or lift between five and ten ...

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