United States District Court, C.D. Illinois, Peoria Division
ORDER AND OPINION
JONATHAN E. HAWLEY U.S. MAGISTRATE JUDGE
Plaintiff, John Judson Grugett, appeals the
Defendant-Commissioner's denial of his application for
Supplemental Security Income benefits, wherein he alleged he
was disabled. He asks this Court to remand this matter back
to the Commissioner for further administrative proceedings,
arguing that the Administrative Law Judge (“ALJ”)
erred by failing to provide adequate reasons for rejecting
the opinions of a treating physician and making an erroneous
determination regarding Grugett's
application for benefits filed on June 19, 2012, Grugett
alleged onset of disability beginning on April 21, 2012. (Tr.
The ALJ found that Grugett's degenerative joint disease
of the left shoulder, hypertension, and obesity were
“severe impairments.” (Tr. 27). However, she also
found that Grugett had the residual function capacity
(“RFC”) to perform light work as defined in 20
C.F.R. § 416.967(b), with the following additional
[H]e cannot climb ladders, ropes, or scaffolds; he can
occasionally climb ramps and stairs; he can only occasionally
balance, stoop, kneel, crouch, and crawl; he can occasionally
reach in any direction with the non-dominant upper extremity;
he can only occasionally push/pull with the non-dominant
upper extremity; and he is limited to frequent but not
constant handling (grasping) with the non-dominant upper
(Tr. 28-29). Although this RFC would not allow Grugett to
perform any of his “past relevant work, ” there
were jobs in the national economy that he could perform,
thereby precluding a finding of disability. (Tr. 31-32).
Grugett's left shoulder issue -- the only impairment he
really discusses on appeal -- the objective medical evidence
reveals as follows. On April 21, 2011, Grugett saw for the
first time nurse practitioner, Holly Killion. (Tr. 303). Her
treatment note lists the reason for the encounter as,
“WANTS TO GET SS DISABILITY-SHOULDER PAIN.”
Id. He complained of shoulder pain which started
over three years before the visit, after he picked something
up at work and “felt a pop.” Id. He
characterized his pain as sharp and stabbing which lasted all
day, but was worse at night when trying to sleep. He had not
had an x-ray or MRI, but did occasionally take Ibuprofen and
his sisters' Vicodin. Id. Killion noted a full
range of motion with all extremities, although with pain.
Id. She started Grugett on naproxen and Vicodin,
ordered an x-ray, and scheduled a follow-up visit six weeks
later. Id. The x-ray revealed “mild left
should osteoarthritis.” (Tr. 314).
follow-up visit on June 10, 2011, Killion again noted a full
range of motion of the shoulder, but with pain. (Tr. 303).
She changed the naproxen prescription to piroxicam because
the naproxen made Grugett sick and increased the Vicodin
prescription from 60 to 90 pills a month, per his request.
Id. Finally, she ordered an MRI and scheduled a
follow-up a month later to discuss the results. Id.
July 14, 2011 MRI revealed a partial thickness articular and
bursa surface tear of the supraspinatus tendon; severe AC
joint degenerative change; advanced glenohumeral joint
osteoarthritis with full thickness cartilage loss, tearing,
and paralabral cysts; and a visualized lesion (later found to
be non-cancerous) in the proximal humeral diaphusis. (Tr.
next saw Killion on July 21, 2011, to discuss his MRI
results. (Tr. 298). She noted no changes in the physical exam
of Grugett's shoulder since her last exam, noted that the
MRI revealed multiple injuries in his left shoulder, and
noted his need to see an orthopedic surgeon for surgery.
Id. She discontinued his piroxicam but kept him on
the Vicodin. Id.
October 27, 2011, Grugett saw physician's assistant
Danielle Johnson for a three month check-up. (Tr. 293). Her
treatment note indicated that Grugett was still in the
process of finding an orthopedic surgeon for a consult.
Id. She kept him on his Vicodin and scheduled him
for another follow-up in three months. Id.
follow-up visit on January 27, 2012, Johnson noted Grugett
had limited movement in his shoulder due to
pain. (Tr. 286). She also repeated the findings
of the previous MRI and noted that Grugett requested that she
complete paperwork for his disability claim. Id.
Grugett's next office visit on October 3, 2012, he saw
Dr. Holden for the first time. (Tr. 368). Dr. Holden noted
the reason for the visit was “disability papers.”
Id. He noted Grugett's symptoms were
“unchanged, ” and that he still complained of
left shoulder pain, it being an 8 out of 10. (Tr. 369). He
also noted tenderness in the shoulder with weakness and
decreased range of motion. Id. Dr. Holden noted a
prescription for hydrocodone, with no other plans for
same visit, Dr. Holden also completed a “Residual
Functional Capacity Questionnaire.” (Tr. 328). He
opined Grugett could sit 60 minutes at one time and for eight
hours total, stand or walk for 30 minutes at one time and for
four hours total, lift and carry ten pounds occasionally and
less than ten pounds frequently, and shift positions at will
between sitting, walking, and standing. (Tr. 328-29). Dr.
Holden opined Grugett could use his left arm for handling and
fingering for ten percent of the workday with no ability to
reach with that arm. (Tr. 329). Dr. Holden also opined
Grugett would likely be absent more than four times per month
due to impairments and treatment. Id. Dr. Holden did
not provide, nor does the form have a space for, any
explanation regarding how or why Dr. Holden reached these
saw Dr. Holden only one other time, on November 29, 2011.
(Tr. 363). The visit was a follow-up and medication renewal
visit, at which Dr. Holden noted Grugett was still waiting on
his “disability, ” ...