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Dixon v. Colvin

United States District Court, C.D. Illinois, Rock Island Division

November 1, 2016

GEORGE DIXON, Plaintiff,

          ORDER AND OPINION [1]


         The Plaintiff, George Dixon, appeals the Defendant-Commissioner's denial of his application for disability insurance benefits and supplemental security income. He alleges that the Administrate Law Judge's (“ALJ”) finding that Dixon is capable of standing for the time necessary to do light work is not supported by substantial evidence. This Court disagrees and, accordingly, DENIES Dixon's Motion for Summary Judgment (D. 8)[2]and GRANTS the Commissioner's Motion for Summary Affirmance (D. 13).


         Dixon was 47 years old at the time he applied for disability, wherein he alleged onset of disability beginning September 15, 2012. (Tr. 20). In the Function Report Dixon submitted to the Commissioner, he described the effects of his impairments on his ability to work as follows:

5. How do your illnesses, injuries, or conditions limit your ability to work?
Knees swell, ankles and legs swell if working an concrete floor's. Walking and Standing for long periods of time irritates legs, knee replacement in right leg and knee reconstruction on left shoulder surgery limits lifting ability.

(Tr. 234). At his hearing before the ALJ, Dixon elaborated that in 2000 he underwent a total replacement of his right knee and underwent surgery on his left knee in 2006, after which time he testified that he used a cane to walk. (Tr. 52). He maintained full-time employment intermittently after both of these surgeries, but Dixon testified that he could not now work because “I have to elevate my leg to keep the swelling down, heart rate. And there's no facility at a job for me to do that.” (Tr. 48). But for the problems with his knees, Dixon believed he could work. Id.

         He testified that he took no prescription medication for his knee pain, but instead took four or five ibuprofen pills daily, although he did take prescription medication for his blood pressure. (Tr. 50). He explained his sporadic treatment for his knee problems due to a lack of insurance, he not having the funds for the $20 charged by the community health center for a visit, although at the time of the hearing he did have a “medical card.” (Tr. 49).

         Regarding the medical record, it is indeed sparse. On September 14, 2012, Dixon presented at an emergency room complaining of swelling in his legs for the previous two days. (Tr. 294). The treating physician, Dr. Randall Bay, noted “only a mild amount of discomfort, ” “no discrete injury, ” and “no prior history of similar symptoms.” (Tr. 294). Dr. Bay recommended Dixon use nonsteroidal antiinflammatory medication for discomfort and that he rest, limit activity, and elevate his leg “in the interim” between his ER visit and following up with his primary care physician. Id.

         The medical records show no such follow-up visit, but instead next show another ER by Dixon on December 17, 2012 for knee pain due to a fall the previous night from stepping into a hole. (Tr. 330). No mention of previous pain unrelated to the fall was made. An x-ray was unremarkable, Dixon was prescribed Norco “as needed, ” and he was sent home to follow up with his primary care physician. (Tr. 333-34).

         Again, the records reveal no follow-up visits related to Dixon's knee, although he did see Dr. Simran Jit twice in February of 2013 and once in March of that year for his hypertension. (Tr. 312-320). The treatment notes from these visits mention no issues or complaints of pain by Dixon; indeed, the notes don't mention issues with his knees at all. Id.

         Then, in April of 2013, agency doctor James Hinchen examined Dixon. (Tr. 88-90). This doctor reviewed Dixon's medical records and concluded that he had no severe impairments. Id. In reaching this conclusion, Dr. Hinchen noted that Dixon's ER visits revealed no injury to his leg, mild discomfort reported, mild tenderness, some swelling, a normal range of motion, and no gait disturbances. Id. He also noted the lack of evidence of any further treatment beyond the ER visit. Given his conclusion that Dixon had no severe impairment, he did not opine on Dixon's functional abilities. Id.

         Not until June 9, 2013, do any knee issues re-appear in the medical record when Dixon again showed up in the ER complaining of left knee pain that “began this morning when he woke up.” (Tr. 341). Dixon reported that he had been told he needed surgery (although none of the preceding medical records indicate such advice) and that “this has been present for a long time.” Id. The physical exam revealed a normal range of motion, however, and no swelling, albeit with “tenderness.” (Tr. 342). An x-ray was again unremarkable. (Tr. 344). The ER physician made “no acute findings on work up” and, again, sent Dixon home to follow up with his primary care physician. Id.

         The next day, Dixon instead went to ORA orthopedics complaining of knee pain and stating that he was advised to follow up at ORA, although, in fact, he was told to follow-up with his primary care physician. (Tr. 325). At that visit, he told Dr. Michael Berry that “yesterday” he began to experience left knee pain. He claimed he received cortisone injections into his left knee every 6 months “for many years, ” although, again, the medical records are devoid of treatment notes showing such treatment. Id. Dr. Berry examined Dixon and his previous x-ray. He noted radiographic signs of osteoarthritis, “a failed ACL reconstruction on the left, and likely the surgical procedure of choice is total knee arthroplasty.” However, Dr. Berry recommended a cortisone injection and physical therapy. (Tr. 326). Dixon was not interested in physical therapy, however, claiming that it had been ineffective in the past, although no records show any physical therapy previously. Id. Rather, Dixon was “adamant” about having a total knee replacement. Id. He did, however, agree to the cortisone injection recommended by Dr. Berry that day. Id.

         About three months later on September 18, 2013, he again saw Dr. Jit for his hypertension. As with his previous visits with Dr. Jit, no mention is made ...

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