United States District Court, C.D. Illinois
JOHN E. ANDERSON, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant,
SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE:
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.
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,
1987, and again in 2000, Anderson was injured in motorcycle
accidents. 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.
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.
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.
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.
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.
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.
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. The radiologist assessed
“No acute abnormalities are identified. Degenerative
changes as described.” R. 228.
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.
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.
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.
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.
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.
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
R. 251. Dr. Western recommended methods to address the rash.
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.
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.
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.
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.
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.
Chapa assessed status post right thumb injury. Dr. Chapa
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
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.
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.
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 ...