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Salas v. Colvin

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

December 12, 2016

JUDITH SALAS, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          MATTHEW F. KENNELLY, District Judge

         Judith Salas brings this action under 42 U.S.C. § 405(g), seeking review of the Social Security Administration's denial of her claim for disability insurance benefits. Both she and the Acting Commissioner of Social Security have moved for summary judgment. For the reasons stated below, the Court grants Salas' motion, denies the Commissioner's motion, and remands the case for further consideration.

         Background

         Until 2009, Salas worked as a presser at a dry-cleaning plant. She stopped working in August of that year, at the age of 48, because of pain in her hands and her knee. According to Salas, her job required her to lift up to twenty pounds and to stand on her feet for most of the day. In 2010, she underwent carpal tunnel release surgery on both hands. Although her hand pain improved temporarily after the surgeries, she still did not believe her hands were sufficiently strong to handle an iron as her pressing job required. She also alleges that in late 2010 or early 2011, she started to experience back pain, which further limited her ability to work.

         In April 2012, Salas applied for disability insurance benefits, alleging that her disabling condition has prevented her from working since August 2009. The Social Security Administration denied her benefits request in June 2012 and again in November 2012 upon reconsideration. Salas then requested a hearing, which took place before an administrative law judge (ALJ) on December 12, 2013.

         Salas appeared at the hearing without an attorney. The ALJ informed her that she had a right to representation, but she decided to waive that right and to proceed pro se, saying: "Well, might as well; I'm here, you know." R. 28. During questioning by the ALJ, Salas explained that she stopped working in 2009 because of her hand and knee pain. She testified that she still has pain in her hands and knees, as well as her back, and that she also suffers from sciatica, which causes pain from her hip down to her foot and makes it difficult for her to walk and stand. Overall, she complained that her pain is "real bad, my bones; all my bones, they're coming up, you know, popping out." R. 42. To treat that pain, Salas said, she takes one pain medication every eight hours and another medication on an as-needed basis, and she attends a "pain clinic" at Stroger Hospital every two months. She told the ALJ that she did not attend school beyond eighth grade and that she has not worked any jobs since she stopped working as a presser in 2009.

         In response to the ALJ's questioning, Salas described her current day-to-day activities and capabilities. She said that she is able to use her hands to prepare meals, cook, and brush her teeth but that she cannot lift weights greater than fifteen pounds. She is unable to carry a laundry basket down a flight of stairs, she explained, so she throws the basket down the stairs to do the laundry, and although she can fold clothes, she does not use an iron at home. She goes shopping with her husband, she said, but she has difficulty walking when she does so. She also stated that she goes to church every Sunday and sometimes visits her sisters in northwest Indiana but said she does not participate in other social or recreational activities.

         Before concluding the hearing, the ALJ heard testimony from a vocational expert. The ALJ asked whether an individual who is the same age, has the same work history, and has the same education as Salas would be able to work as a presser if that individual were limited to light work, as defined by regulation, and to "no more than frequent climbing, no more than frequent stooping, kneeling, crouching and crawling" and to "frequent reaching and fingering with the right, dominant, right upper extremity." R. 44. The vocational expert responded that such an individual could perform the job of a presser. If the individual were limited to only "occasional" handling and fingering, as opposed to "frequent, " then the individual could not perform the job, according to the vocational expert, and would be limited to working as an usher or a school bus monitor. R. 45. Following the vocational expert's testimony, the ALJ informed Salas that there were medical records missing from her file and told her that he would gather updated records from her treating physician and from Stroger Hospital before reaching his decision on her claim.

         Salas' medical records reveal that she suffers from a number of chronic health conditions, many of which cause physical pain. As mentioned above, she had surgeries on both hands to address her carpal tunnel syndrome in September and December of 2010. X-rays from July of that year show that she had minimal narrowing of the joints in her hands and fingers and minimal degenerative changes; x-rays also showed only minimal degenerative changes in her lumbar spine. But notes from visits in 2011 to her treating physician, Dr. Towanda Harris, reflect that, following surgery, Salas still suffered from joint pain in her knees, hips, and legs; high blood lipid levels; decreased strength and a limp in her right knee; osteoarthritis (a degenerative bone disease) in her upper arm; lumbago (lower back pain); and gastroesophageal reflux disease (GERD). During a series of follow-up visits with Dr. Harris, Salas made the following complaints regarding her pain: in January 2012, constant left knee pain, burning in her left foot, and sharp pain in both hands; in April 2012, chronic back and knee pain, as well as abdominal pain over the previous two months; in June 2012, constant right lower back pain and right buttock/hip pain; and in April 2013, pain in her hands and her left foot. To treat Salas' pain, Dr. Harris prescribed tramadol (an opioid pain medication) and ibuprofen in July 2011, Vicodin (a combination of an opioid pain medication and acetaminophen) in January 2012, and acetaminophen and codeine (another opioid pain medication) in June 2012. During this period, Salas also visited the pain clinic at Stroger Hospital, where she complained, at various times, of bilateral knee pain, right shoulder pain, bilateral wrist pain, lower back pain, and pain in her left foot. Doctors at the pain clinic prescribed muscle relaxants, a steroid injection in her back, and gabapentin, an anticonvulsant medication that can be used to treat nerve pain. In addition to describing her pain, Salas also complained of heart palpitations to Dr. Harris in August 2013. At that visit, Dr. Harris noted that Salas suffered from chronic coronary artery disease and referred her to a cardiologist.

         In addition to the X-rays taken before her surgeries in 2010, the administrative record includes a number of objective medical tests and studies. In September 2012, Salas had x-rays taken of her right hip, right knee, and spine. The x-rays of her hip showed mild narrowing of her hip joint but no evidence of fracture or dislocation and an unremarkable right sacroiliac joint. Her knee x-rays showed mild joint space narrowing and bony productive changes but no fracture or dislocation. The x-rays of her spine showed mild degenerative changes in the lumbar spine, normal curvature of the lumbosacral spine, some mild multilevel degenerative changes of the thoracolumbar spine, mild intervertebral disc space narrowing at one level, and endplate sclerosis.

         The reviewing doctor considered the image of her sacroiliac joint unremarkable. Salas also underwent a computerized tomography (CT) scan of her abdomen and pelvis in December 2012 because of her complaint about abdominal pain. The findings from that scan resulted in diagnoses for coronary artery disease, hepatic steatosis (fatty liver disease) and diverticulosis (a condition in which pouches form in the wall of the large intestine). In June 2013, Salas underwent a magnetic resonance imaging (MRI) scan of her lumbar spine. The MRI returned the following findings:

There is mild straightening of normal lumbar lordosis. The vertebral bodies heights are maintained. Mixed modic types I and III degenerative changes involving anterior inferior vertebral endplate of T12. Partial desiccation of the intervertebral disks at ¶ 2/L1 and L1/L2. The distal thoracic spinal cord is intact with the conus medullaris at the level of L1. Diffuse posterior subcutaneous tissue edema overlying the lumbar spine.
Diffuse epidural lipomatosis at the levels of L5 through S2.
The rest [of the] specific findings at different levels are ...

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