United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
M. ROWLAND, United States Magistrate Judge.
Dorlene Williams filed this action seeking reversal of the
final decision of the Commissioner of Social Security denying
her application for Disability Insurance Benefits under Title
II of the Social Security Act (Act). 42 U.S.C. §§
405(g), 423 et seq. The parties have consented to the
jurisdiction of the United States Magistrate Judge, pursuant
to 28 U.S.C. § 636(c), and Plaintiff has filed a motion
for summary judgment. For the reasons stated below, the case
is remanded for further proceedings consistent with this
THE SEQUENTIAL EVALUATION PROCESS
recover Disability Insurance Benefits (DIB), a claimant must
establish that he or she is disabled within the meaning of
the Act. York v. Massanari, 155 F.Supp.2d
973, 977 (N.D. Ill. 2001). A person is disabled if he or she
is unable to perform “any substantial gainful activity
by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period
of not less than 12 months.” 20 C.F.R. §
404.1505(a). In determining whether a claimant suffers from a
disability, the Commissioner conducts a standard five-step
1. Is the claimant presently unemployed?
2. Does the claimant have a severe medically determinable
physical or mental impairment that interferes with basic
work- related activities that is expected to last at least 12
3. Does the impairment meet or equal one of a list of
specific impairments enumerated in the regulations?
4. Is the claimant unable to perform his or her former
5. Is the claimant unable to perform any other work?
20 C.F.R. §§ 404.1509, 404.1520; see Clifford
v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000). “An
affirmative answer leads either to the next step, or, on
Steps 3 and 5, to a finding that the claimant is disabled. A
negative answer at any point, other than Step 3, ends the
inquiry and leads to a determination that a claimant is not
disabled.” Zalewski v. Heckler, 760 F.2d 160,
162 n.2 (7th Cir. 1985). “The burden of proof is on the
claimant through step four; only at step five does the burden
shift to the Commissioner.” Clifford, 227 F.3d
applied for DIB on February 11, 2013, alleging that she
became disabled on February 1, 2013. (R. at 40, 198-204).
Plaintiff claimed that she suffered from 14 disorders,
including pulmonary hypertension, memory problems, fatigue,
dyspnea (shortness of breath), asthma, syncope (a temporary
loss of consciousness), lack of concentration, cardiac
arrhythmia, Raynaud's disease (numbness or coldness in
the extremities), a heart murmur, a heart valve disorder, a
herniated disc, and bursitis of the hips. (Id. at
133). The application was denied initially and upon
reconsideration, after which Plaintiff filed a timely request
for a hearing. (Id. at 134- 37, 144-67, 148-49). On
December 19, 2014, Plaintiff, who was represented by counsel,
testified at a hearing before an Administrative Law Judge
(ALJ). (Id. at 58-98). The ALJ also heard testimony
from vocational expert (VE) Ronald Malik. (Id.).
denied Plaintiff's request for benefits in a January 7,
2015 written decision. (R. at 40-51). Applying the five-step
sequential evaluation process, the ALJ found at step one that
Plaintiff had not engaged in substantial gainful activity
since her alleged onset date of February 1, 2013.
(Id. at 42). At step two, the ALJ found that
Plaintiff's severe impairments included a lumbar spine
disorder, degenerative disc disease, bursitis, asthma, and
Raynaud's disease. The ALJ also concluded that Plaintiff
suffered from several nonsevere impairments. These included a
right toe bunion, visual impairments, arterial and pulmonary
hypertension, premature ventricular contractions, bipolar
disorder, obesity, dyslipidemia, depression, and post-
traumatic stress disorder (PTSD). (Id.). At step
three, none of these impairments met or medically equaled,
either singly or in combination, the severity of the listings
enumerated in the regulations. (Id. at 43-44). The
ALJ then assessed Plaintiff's Residual Functional
Capacity (RFC) and determined that Plaintiff has the RFC
to perform sedentary work
except that she can occasionally push or pull with the upper
extremities, climb ramps or stairs and stoop. She should
never climb ladders, ropes or scaffolds, balance, crouch,
kneel or crawl. [Plaintiff] is limited to frequent reaching
(including overhead), handling and fingering. She should
avoid concentrated exposure to environmental irritants such a
fumes, odors, dusts, and gases, poorly ventilated areas and
(Id. at 46). Based on this RFC and the VE's
testimony, the ALJ determined at step four that Plaintiff was
able to perform her past relevant work as an office manager.
(Id. at 50). Accordingly, the ALJ did not proceed to
step five and concluded that Plaintiff was not under a
disability from the alleged onset date through the date of
his decision. (Id. at 50-51).
filed a timely request for review of the ALJ's decision.
(R. at 24). As part of that request, Plaintiff submitted
evidence that she claimed was new and material. (Id.
at 19-36). The Appeals Council denied her request on June 24,
2015. (Id. at 1-6). Plaintiff now seeks judicial
review of the ALJ's decision, which stands as the
Commissioner's final decision. Villano v.
Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009).
STANDARD OF REVIEW
review of the Commissioner's final decision is authorized
by § 405(g) of the SSA. In reviewing this decision, the
Court may not engage in its own analysis of whether the
plaintiff is severely impaired as defined by the Social
Security Regulations. Young v. Barnhart, 362 F.3d
995, 1001 (7th Cir. 2004). Nor may it “reweigh
evidence, resolve conflicts in the record, decide questions
of credibility, or, in general, substitute [its] own judgment
for that of the Commissioner.” Id. The
Court's task is “limited to determining whether the
ALJ's factual findings are supported by substantial
evidence.” Id. (citing § 405(g)).
Evidence is considered substantial “if a reasonable
person would accept it as adequate to support a
conclusion.” Indoranto v. Barnhart, 374 F.3d
470, 473 (7th Cir. 2004); see Moore v. Colvin, 743
F.3d 1118, 1120-21 (7th Cir. 2014) (“We will uphold the
ALJ's decision if it is supported by substantial
evidence, that is, such relevant evidence as a reasonable
mind might accept as adequate to support a
conclusion.”) (internal quotes and citation omitted).
“Substantial evidence must be more than a scintilla but
may be less than a preponderance.” Skinner v.
Astrue, 478 F.3d 836, 841 (7th Cir. 2007). “In
addition to relying on substantial evidence, the ALJ must
also explain his analysis of the evidence with enough detail
and clarity to permit meaningful appellate review.”
Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345,
351 (7th Cir. 2005).
this Court accords great deference to the ALJ's
determination, it “must do more than merely rubber
stamp the ALJ's decision.” Scott v.
Barnhart, 297 F.3d 589, 593 (7th Cir. 2002) (internal
quotes and citation omitted). “This deferential
standard of review is weighted in favor of upholding the
ALJ's decision, but it does not mean that we scour the
record for supportive evidence or rack our brains for reasons
to uphold the ALJ's decision. Rather, the ALJ must
identify the relevant evidence and build a ‘logical
bridge' between that evidence and the ultimate
determination.” Moon v. Colvin, 763 F.3d 718,
721 (7th Cir. 2014). Where the Commissioner's decision
“lacks evidentiary support or is so poorly articulated
as to prevent meaningful review, the case must be
remanded.” Steele v. Barnhart, 290 F.3d 936,
940 (7th Cir. 2002).
RELEVANT MEDICAL EVIDENCE
stopped working in January 2013 after being employed for 18
years as an office manager in a medical clinic. (R. at 63).
She stated at the hearing that she was unable to continue
working because the pain that she experienced in her back and
hips made it difficult for her to concentrate on what she was
doing or to remember what she was reading. (Id. at
had sought medical treatment for these conditions long before
her last employment date. Some records suggest that she
received epidural steroid injections in her lower back as
early as 1994. (R. at 799). A November 2004 MRI of
Plaintiff's lumbar spine revealed a left-sided disc
herniation and degenerative disc bulging at ¶ 5-S1.
(Id. at 412). A CT scan performed the same month
suggested moderate central canal stenosis and moderate to
severe bilateral foraminal stenosis. (Id. at 788).
An epidural steroid injection was administered to lessen
Plaintiff's discomfort on November 23, 2004.
(Id. at 463). Although Plaintiff complained of back
pain during treatment sessions for other conditions, the next
treatment note concerning her back pain was given on October
27, 2014. A recent MRI showed that she had degenerative disc
disease, a disc bulge at ¶ 5-S1, and a small diffuse
bulge at ¶ 4-L5. (Id. at 788). Orthopedist Dr.
Anis Mekhail diagnosed her with lumbar radiculopathy and gave
her an epidural injection. (Id. at 794, 797). He
then referred Plaintiff to pain specialist Dr. Neema Bayran.
(Id. at 799). Dr. Bayran noted full lower-extremity
extension but also found that Plaintiff had no deep tendon
reflexes. She recommended that Plaintiff receive additional
injections at the L4-L5 and L5-S1 levels. (Id. at
submitted for the first time to the Appeals Council show that
Plaintiff received those injections at some unspecified date.
(R. at 32). The relief they gave lasted less than one week.
(Id.). Dr. Mekhail noted on January 26, 2015, that
Plaintiff was experiencing numbness and tingling in her feet
and diagnosed her with diabetic peripheral
neuropathy. (Id. at 33). A subsequent EMG
study confirmed that diagnosis. (Id. at 28, 31). On
February 20, 2015, she also received a lumbar medial branch
nerve block at ¶ 3, L4, and L5 on the right side.
(Id. at 21-22). Dr. Bayran noted three days later
that Plaintiff experienced relief for four to five hours
after the procedure but it gradually returned to its baseline
level. (Id. at 20). Dr. Bayran thought that
Plaintiff should receive only conservative care.
(Id. at 23, 28). She therefore administered a
radiofrequency ablation of the lumbar medial branches that
gave Plaintiff significant pain relief for the first two
weeks. (Id. at 8). The pain then returned in full on
the left side, with radiating symptoms through the left hip
and calf. Dr. Bayran recommended further epidural injections.
also experienced ongoing pain in her hips. A May 2004 MRI was
administered to evaluate her complaints, but it revealed a
normal left hip. (R. at 413). A June 2007 x-ray showed a cyst
in the femoral neck of the left hip, with mild degenerative
changes and space narrowing. (Id. at 409). A
follow-up MRI for Plaintiff's hip was performed in
December 2012 by Dr. Bruce Dolitsky. It revealed bilateral
trochanteric bursitis, which was treated with a steroid
injection. (Id. at 558). Dr. Dolitsky gave Plaintiff
another injection in her hips in February 2013. (Id.
at 556, 562). An exam in June of that year showed that
Plaintiff had mild pain with a normal range of motion and a
normal walking posture. (Id. at 640). She had an
additional x-ray study of the hip done in February 2014 that
showed normal hips with no degenerative changes.
(Id. at 746). Nabumetone and tramadol were both
administered to relieve her pain. (Id. at 772).
Plaintiff's orthopedic complaints were largely limited to
the hips and back, she also experienced pain in her fingers.
Treating physician Dr. Hajat noted in March 2011 that
Plaintiff had been experiencing numbness in her left hand and
the two medial fingers for the past two months. She diagnosed
a possible case of carpal tunnel syndrome. (R. at 580).
Plaintiff then saw neurologist Dr. Anthony Stephens. He noted
that an EMG study had shown evidence of ulnar neuropathy at
the elbow but found that it did not require further treatment
other than therapy. (Id. at 325). Nevertheless,
Plaintiff's pain continued, and she received a steroid
injection in her left middle finger at some unspecified point
by July 2013. (Id. at 609). Records concerning her
other medical consultations record ongoing complaints of
finger pain throughout 2013. (Id. at 638, 679).
claimed in a written April 2013 Function Report that her
joint pain, particularly her back discomfort, affects almost
all of her functional abilities except hearing and getting
along with others. (R. at 248). She is unable to lift more
than ten pounds or to walk more than five to ten minutes at a
time. Even then, she must rest for five to ten minutes before
resuming her activities. (Id.). Plaintiff further
claimed at the administrative hearing that her back pain had
become worse over time. (Id. at 67-68). She now
experiences back and hip pain on a daily basis. (Id.
at 86). In addition, her legs became painful and her right
foot began to go numb four months prior to the August 2014
hearing. (Id. at 86-87). The pain is so great that
she must lie down in a reclining chair for four or five hours
during the day and nap for up to an hour-and-a-half daily.
(Id. at 88-89). Plaintiff explained to the ALJ that
she would be unable to carry out her former work because she
could no longer sit for the required time. (Id. at
88). The pain in her fingers, which Plaintiff attributed to
Raynaud's disease, would also prevent her from typing or
writing for the five hours she used to carry out those tasks
at her prior job. (Id. at 76, 89). Plaintiff
expressed particular concern over ability to handle small
objects. (Id. at 76). Repetitive move- ments like
writing for more than 20 minutes or even stirring something
while cooking can bring on serious pain. (Id. at
also claimed at the hearing that her multiple joint problems
significantly limited her ability to carry out many
activities of daily living (ADLs). She described her day as
limited to walking to the end of the block and back, watching
television, napping, and doing light dusting and
housekeeping. (R. at 82). She only uses paper plates and
utensils. Her boyfriend prepares most meals and walks the
dog. (Id. at 81-82). An October 2013 Function Report
states that Plaintiff can only do light laundry once a week.
(Id. at 278). She goes outside twice a week, mostly
to visit her mother, to keep a doctor's appointment, or
to go to the grocery store for 15 to 20 minutes.
(Id. at 279).
addition to pain in her back and joints, Plaintiff also
claims that she is impaired by episodes of dizziness and
syncope. She was treated for dizzy spells as early as August
1999, when Dr. Arvind Kumar found that an MRI of
Plaintiff's brain was normal. (R. at 304, 310-11). A
tilt-table test, which assesses the causes of a fainting
episode, itself triggered an episode of syncope in July 1999.
(Id. at 315, 520). Dr. Kumar suggested that
Plaintiff's light headedness might be due to orthos-tatic
hypotension but noted that medication helped to relieve her
symptoms. (Id. at 310-11). Neurologist Dr. Anthony
Stephens was also unable to identify a specific cause for the
syncope. (Id. at 326). Two years later, Plaintiff
appeared at South Suburban Hospital in June 2001 with
complaints of light headedness, which the ...