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Rodriguez v. Colvin

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

January 5, 2017

JOSE RODRIGUEZ, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of the U.S. Social Security Administration, Defendant.

          MEMORANDUM OPINION AND ORDER

          SUSAN E. COX U.S. MAGISTRATE JUDGE.

         Plaintiff Jose Rodriguez (“Plaintiff”) appeals the decision of the Commissioner of the Social Security Administration (“SSA”) denying his Social Security disability benefits under Title II (“DIB”) of the Social Security Act (“the Act”). Plaintiff has filed a brief, which this Court will construe as a motion for summary judgment [dkt. 15] and the Commissioner has filed a cross-motion for summary judgment [dkt. 20]. After reviewing the record, the Court grants Plaintiff's motion for summary judgment and denies the Commissioner's cross-motion for summary judgment. The ALJ's decision is reversed and remanded for further proceedings consistent with this opinion.

         BACKGROUND

         I. Procedural History

         Plaintiff filed a DIB application on September 24, 2012, alleging a disability onset date of August 23, 2012. (R. 258.) His initial application was denied on December 11, 2012 and again at the reconsideration stage on March 21, 2013. (R. 158-170.) Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”) on March 26, 2013; the hearing was held on February 20, 2014. (R. 79, 202-03.) Plaintiff appeared at the hearing with his attorney. (R. 79.) Vocational Expert (“VE”), Aimee Mowery, and Medical Expert (“ME”), James McKenna, were also present and offered testimony. (R. 79.) On May 14, 2014, the ALJ issued a written decision denying Plaintiff's application for DIB. (R. 38-48.) The Appeals Council (“AC”) denied review on August 24, 2015, thereby rendering the ALJ's decision as the final decision of the agency. (R. 1-7; Herron v. Shalala, 19 F.3d 329, 332 (7th Cir. 1994).)

         II. Medical Evidence

         Plaintiff's history of back pain began in 1990 while he was on duty at a bakery. (R. 127, 469.) Plaintiff stated that he had lifted a heavy object when he felt an immediate pinch in his lower back, followed by severe pain. (R. 469.) He presented to a neurosurgeon who administered a series of lumbar epidural steroid injections (“injections”) which significantly improved Plaintiff's radiating pain; however, he continued to report constant low back pain. (Id.)

         Plaintiff's history of knee surgery began in 1991 when he underwent an anterior cruciate ligament (“ACL”) reconstruction on his right knee (R. 731.) In 2001, he underwent a knee revision and an exploratory arthrogram;[1] then, in 2008, he had both a right knee revision and a total right knee replacement. (R. 731, 421.) Following his knee replacement, Plaintiff continued to experience pain and stiffness in his knee. (R. 421.)

         In November 2011, Plaintiff presented to Dr. John Gashkoff M.D., with complaints of low back pain and left thigh numbness that had gradually increased over the past year. (R. 469.) Dr. Gashkoff examined Plaintiff, diagnosed him with lumbar disc degeneration and lumbar radiculopathy, then administered a series of injections to help alleviate Plaintiff's low back pain. (R. 465, 471-72.) At his follow-up appointment, Dr. Gashkoff ordered a magnetic resonance imaging (“MRI”) of Plaintiff's lumbar spine, which revealed a slightly more prominent disc bulge at ¶ 1. (R. 460.) He advised Plaintiff to continue normal activities as tolerated and not to engage in bedrest. (Id.)

         In December 2011, Plaintiff presented to Dr. Jack Casini M.D., due to soreness and swelling in his right knee. (R. 449.) Dr. Casini observed some instability in Plaintiff's knee, but noted he could walk without interruption. (Id.) He diagnosed Plaintiff with an unstable right knee total replacement and discussed the possibility of a revision surgery with Plaintiff. (Id.)

         In January 2012, Plaintiff underwent a right total knee replacement. (R. 414.) Two weeks later Plaintiff returned for a follow-up appointment, where Dr. Casini opined that Plaintiff was healing well from his surgery. (R. 426.)

         In January 2013, Plaintiff returned to Dr. Casini for an x-ray on his right knee which revealed it was in good position. (R. 763.) Plaintiff also complained of increasing pain in his left knee, but an x-ray revealed that it was normal. (Id.)

         In February 2013, Plaintiff presented to Dr. Lena Shahbender, M.D. for his low back pain and knee pain. (R. 747.) Dr. Shahbender reviewed Plaintiff's medical history, diagnosed him with degenerative disc disease, chronic low back pain, and Iliotibial band syndrome, [2] and recommended physical therapy for his left knee pain. (R. 748.)

         In July 2013, Plaintiff returned with complaints of back and hand pain, difficulty walking, and the constant need to sit. (R. 928.) Dr. Shahbender ordered him a seated walker, but she advised him to continue normal activities as tolerated and not to engage in any form of bedrest. (R. 929-30.) In February 2014, Dr. Shahbender noted that Plaintiff ...


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