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Anderson v. Commissioner of Social Security

United States District Court, C.D. Illinois

February 8, 2017

JOHN E. ANDERSON, Plaintiff,



         Plaintiff John E. Anderson appeals from the denial of his application for Social Security Disability Insurance Benefits (Disability Benefits) under Title II of the Social Security Act. 42 U.S.C. §§ 416(i) and 423. This appeal is brought pursuant to 42 U.S.C. § 405(g). Anderson is proceeding pro se. Anderson filed a document entitled Opening Brief (d/e 11) and a document entitled Motion for Error in Law (d/e 21). The Court treated the Opening Brief as a motion for summary judgment and the Motion for Error in Law as a supplemental motion for summary judgment. Text Order entered August 16, 2016. The Defendant Commissioner filed a Motion for Summary Affirmance (d/e 29). The parties consented, pursuant to 28 U.S.C. § 636(c), to proceed before this Court. Consent to the Exercise of Jurisdiction by a United States Magistrate Judge and Reference Order entered June 29, 2016 (d/e 13). For the reasons set forth below, the Decision of the Commissioner is affirmed.


         Anderson was born on March 31, 1963, and completed high school. He previously worked as a millwright in a steel mill. Anderson alleged that he became disabled on June 1, 2012. Anderson suffers from degenerative disc disease of the cervical and lumbar spine; arthritis of his dominant right hand, especially the right thumb, post two crushing injuries and two surgeries; headaches; obesity; and post-traumatic stress disorder (PTSD) secondary to a facial burn injury in 2005. Certified Transcript of Proceedings before the Social Security Administration (d/e 8) (R.), at 11, 13-14, 20, 186.

         In 1987, and again in 2000, Anderson was injured in motorcycle accidents.[1] His dominant right hand was crushed in each of these two accidents. Anderson had hand surgery after each accident. Thereafter, Anderson developed arthritis in his right hand and particularly in his right thumb. R. 315.

         On April 5, 2012, Anderson had an x-ray of his cervical spine. The x-ray showed severe disc space narrowing at ¶ 5-C6 and C6-C7, indicating degenerative disc disease at these levels. R. 298. On April 17, 2012, Anderson had an MRI of his cervical spine. The MRI showed multilevel degenerative changes including severe right-sided neuroforaminal stenosis at ¶ 5-C6 and C6-C7, and moderate left-sided neuroforaminal stenosis at ¶ 6-C7. R. 295.

         On September 11, 2012, Anderson saw his primary care physician Dr. Randy Western, M.D., complaining of back pain; painful numbness in the third, fourth, fifth fingers, and thumb of his right hand; and chronic neck pain. On examination, Anderson was in mild distress, had no areas of point tenderness in lumbosacral spine, but had some tenderness left of spine. Straight leg raising tests caused some pain in the paralumbar area of his back. Dr. Western found no leg weakness. Dr. Western assessed a muscle spasm in his back. R. 267.

         On September 20, 2012, Anderson saw Dr. Western. Anderson reported some intermittent weakness in his legs. He reported that his employer's doctor would not let him return to work. On examination, Anderson weighed 208 pounds, with a body-mass index of 30.81. Anderson had some tenderness on palpitation around L5 area of his spine. Dr. Western did not detect any weakness in Anderson's legs, but observed diminished reflexes in the right ankle. Dr. Western ordered an MRI of Anderson's back. R. 265.

         On October 1, 2012, Anderson had an MRI of his lumbar spine. The MRI showed degenerative changes with foraminal compromise at ¶ 4-L5 moderate on the right side and milder on the left side, and milder foraminal compromise at ¶ 3-L4. R. 292-93.

         On January 7, 2013, Anderson saw Dr. Western. An unnamed orthopedic surgeon had offered Anderson additional surgery on his right hand. Anderson was reluctant because he had problems and complications with his prior surgeries. Dr. Western stated that Anderson was “kind of in limbo in that we really cannot offer him much more besides surgery, but he cannot go back to work at his usual job with inability to use his right hand.” R. 249. On examination, Anderson had some muscle wasting and swelling around the right thumb, as well as 50% reduction in range of motion and loss of grip strength. Anderson stated that he used his left hand more often “for everyday use because the right is just painful.” R. 249.

         On February 5, 2013, Anderson had an x-ray of his right hand. The x-ray showed advanced degenerative arthritis at the first CMC joint, some flattening at the base of the first metacarpal at the CMC joint, and some degenerative change at the STT joint of the wrist.[2] The radiologist assessed “No acute abnormalities are identified. Degenerative changes as described.” R. 228.

         On February 6, 2013, Anderson saw Physician's Assistant David Purves, who worked with orthopedic surgeon Dr. Christopher Wottowa, M.D. Anderson reported pain with gripping and grasping tools at his prior work. He also reported numbness and tingling in his thumb, index, and middle fingers when driving or riding his motorcycle. He also experienced numbness when using power tools. R. 256.

         Purves suspected carpal tunnel syndrome. Purves also noted that Anderson had posttraumatic changes in his first CMC joint and STT joint arthrosis. Purves believed that Anderson was a candidate for additional surgery to relieve his symptoms in his right thumb. Purves ordered an EMG nerve conduction study to check for carpal tunnel syndrome. R. 258.

         On February 20, 2013, Anderson saw Physician's Assistant Purves. Purves reviewed an EMG nerve conduction study with Anderson. The study showed no evidence of compression of the median nerves in Anderson's wrists. Purves stated that an x-ray taken at an earlier visit showed posttraumatic changes at the first CMC joint and degenerative changes at the STT joint. Purves stated that Anderson would be a candidate for basal joint arthroplasty surgery. Purves said the surgery would address the STT joint problems, but not all of Anderson's symptoms. Purves said injections would not affect the limited mobility in his thumb. R. 255.

         On March 1, 2013, Anderson saw Dr. Western to discuss Purves' recommendation to undergo surgery on his right thumb. Anderson was reluctant to undergo a third surgery. Dr. Western recommended going ahead with the surgery. Dr. Western assessed permanent thumb damage from previous crush injuries. Dr. Western gave Anderson a note that said “10 pound work restriction with his right hand and not to work above 3 feet.” R. 253.

         On April 9, 2013, Dr. Western filled out a form for Anderson's former employer regarding Anderson's impairments. Dr. Western diagnosed Anderson with “Right thumb crushed in previous accident.” Dr. Western stated that Anderson was contemplating basal joint arthroplasty surgery. Dr. Western stated that Anderson was limited to ten pound weight restriction and no work above three feet. R. 232.

         On May 29, 2013, Anderson saw Dr. Western. Anderson reported pain and rash in his groin. Dr. Western noted:

Patient is here with this rash. States that he went to go pick up a motorcycle for his friend, and it was like a 36-hour-type-trip, and then he had to mow the lawn for about 7 hours. Then he developed this rash that at times is painful.

R. 251. Dr. Western recommended methods to address the rash. Id.

         On July 25, 2013, state agency physician Dr. J.V. Corcoran, M.D., prepared a Residual Functional Capacity Assessment. R. 63-66. Dr. Corcoran opined that Anderson could lift twenty pounds occasionally and ten pounds frequently; could stand and/or walk a total of six hours in an eight-hour workday; could sit for a total of six hours in an eight-hour workday; could occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; could never climb ladders, ropes, or scaffolds; and could occasionally handle and finger with the right upper extremity, but had no limitations with the left upper extremity. Dr. Corcoran opined that Anderson had to avoid concentrated exposure to hazards and unprotected heights. R. 63-65.

         On September 6, 2013, Anderson saw Dr. Western for a recheck of his right thumb. Dr. Western noted that Anderson was reluctant to undergo another surgery on his thumb. Dr. Western wrote, “Thus, it [the right thumb] is in such bad shape he really cannot work either. At least he cannot go back to his standard customary job.” R. 305. On examination, Dr. Western observed that “he can clamp down with his 2nd-5th fingers, but really cannot hardly use his first finger at all.” Dr. Western assessed a “greatly diminished use of his right hand due to his severe thumb arthritis.” Dr. Western concluded, “It is not that he could not do any type of work, it is just that he cannot go back and work safe in his usual work environment with his current job.” R. 306.

         On January 21, 2014, Dr. Western completed a form for Anderson's former employer. Dr. Western stated that Anderson could not work because he could not grip with his right hand. Dr. Western stated that Anderson had advanced/severe arthritis of the right thumb joint. R. 230.[3]

         On March 12, 2014, state agency physician Dr. Vittal Chapa conducted a consultative examination of Anderson. Dr. Chapa described Anderson's dominant right hand and neck pain:

The claimant states that he has problem with the right hand. He had crush injury to the right thumb. He had surgery on the right thumb in 1987 and year of 2000. He has no grip strength in the right hand. He is right-handed. He was told that his right thumb joint needs to be replaced. Occasionally, he has neck and back pain.

R. 315. Anderson's left hand grip strength was 5/5. Anderson could perform fine and gross manipulations with his left hand. R. 317. Anderson's right hand grip strength was 3/5. Anderson had mild to moderate difficulties performing manipulations such as opening door knobs and tying shoes. Anderson had severe difficulties buttoning and unbuttoning. R. 319.

         Dr. Chapa observed that Anderson had limited range of motion in the first CMC joint of his right thumb. His range of motion in the right thumb was 25% of normal. He had full range of motion in all other joints. His lumbosacral spine flexion was normal and his straight leg testing was negative. R. 317. Anderson could walk and bear weight without ambulatory aids. His gait was normal. R. 316.

         Dr. Chapa assessed status post right thumb injury. Dr. Chapa concluded:

Summary and Discussion: The claimant is a 50-year-old male. He had two surgeries on the right thumb. He has limited functions of the right hand. He has impaired right handgrip. Rest of the physical examination is unremarkable. Please see the enclosed sheet of paper with the consultation report for right handgrip and right hand functions.

R. 317.

         On March 14, 2014, state agency physician Dr. James Madison, M.D., prepared a Residual Functional Capacity Assessment. Dr. Madison agreed with Dr. Corcoran's March 2013 assessment. R. 75-78. Dr. Madison noted that Anderson “has a 10 lb weight restriction with his right hand and not to work above 3 ft.” R. 76.

         On June 20, 2014, Anderson saw neurologist Dr. Koteswara Narla, M.D., for headaches. Anderson reported that his headaches began when he strained his neck. Anderson reported that he had headaches on the left side with blurry vision, nausea, and vomiting. Anderson reported that bright lights bothered him. Anderson reported that the headaches came on when he did any active work. Anderson reported that he used to ride motorbikes. At this visit, Anderson was 69 inches tall and weighed 211 pounds, with a BMI of 31.16. Dr. Narla assessed headaches of the left frontal, most likely of the migraine nature. Dr. Narla stated that “Might be something exertional might be the cause.” R. 339-40.

         On September 16, 2014, Dr. Western wrote a letter summarizing Anderson's condition. R. 221. Dr. Western stated that he first treated Anderson in 2005 for PTSD resulting from a work-related explosion and facial burn injury. Dr. Western stated that, thereafter, Anderson had had intermittent problems sleeping which required medication. Dr. Western discussed Anderson's right hand:

Also well documented is his couple of surgeries he has already had on his right hand, resultant arthritis that we have seen in our x-rays, and his main disability that keeps him from working because he cannot grab his tools, torches, etc., all the implements needed to work he cannot do because his hand is weak and painful.

R. 221. Dr. Western then noted Anderson's neck problems:

In addition to the above, he also has had neck pain leading to headaches, migraines. These had responded to medications as well as cervical blocks. He had an MRI done that showed neuroforaminal stenosis that is severe on the right side between C5-C6, C6-C7.

R. 221. Dr. Western concluded:

Thus, in summary, he has had psychological issues relating from a burn from an explosion that has left him with some insomnia, right hand arthritis producing weakness and some neurologic symptoms, as well as some degenerative ...

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