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Ballard v. Berryhill

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

February 28, 2017

NANCY A. BERRYHILL, Acting Commissioner of the U.S. Social Security Administration[1], Defendant.


          HON. MARIA VALDEZ United States Magistrate Judge

         This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying Plaintiff Reginald Ballard's (“Plaintiff”) claims for Disability Insurance Benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Plaintiff's motion for summary judgment [Doc. No. 13] is denied and the Commissioner's cross-motion for summary judgment [Doc. No. 23] is granted.



         On April 10, 2012, Plaintiff filed a claim for Disability Insurance Benefits, alleging disability since January 28, 2012. (R.188-96.) The claim was denied initially and upon reconsideration, after which he timely requested a hearing before an Administrative Law Judge (“ALJ”). (R. 96-99, 102-04, 112-13.) The hearing was held on February 4, 2014. (Id.) Plaintiff personally appeared and testified at the hearing and was represented by counsel. (R. 30-76.) Vocational Expert (“VE”) Thomas Upton also testified. (R. 30-76.)

         On February 27, 2014, the ALJ denied Plaintiff's claim for Disability Insurance Benefits, finding him not disabled under the Social Security Act. (R. 11- 29.) The Social Security Administration Appeals Council then denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner and, therefore, reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005) (R. 1-6.)


         Plaintiff was born on November 17, 1960, and was fifty-three years old at the time of the ALJ hearing. (R. 30, 190.) He has his high school diploma. (R. 45.) Plaintiff was last employed as a print operator, but stopped working in December 2011 after he fell off a ladder while on duty. (R. 35, 340.)

         A. Medical Evidence

         As an initial matter, the record contains medical evidence for treatment that occurred prior to Plaintiff's injury at issue in the present case. In August 2010, Plaintiff injured his back at work after climbing inside of a machine that required repair. (R. 500.) Following the incident he experienced sharp low back pain that travelled to his left leg and knee, prompting him to see Scott Fladland, D.C., who designed a treatment plan to help return Plaintiff to his full work duties. (R. 500- 01.) Dr. Fladland's treated the Plaintiff until October 2010. (R. 500-59.)

         Over one year later, on December 14, 2011, Plaintiff was injured again when a ladder he was standing on at work slipped out from beneath him, causing him to twist his body and fall to the ground. (R. 340, 350.) Immediately after the incident, Plaintiff experienced the onset of sharp and severe low back pain accompanied by numbness and tingling in his left toes - symptoms he had not experienced with his prior back issues. (R. 340.) He declined to visit a doctor or a hospital on the date of the injury. (R. 350.)

         The first doctor of record to examine Plaintiff following his injury was Lawrence Okafor, M.D., whom Plaintiff presented to on February 2, 2012. (R. 1108.) Dr. Okafor provided Plaintiff with a note which opined that he had been unable to work since January 29, 2012 and would remain unable to work until February 9, 2012. (R. 1107, 1109-10.) Due to residual back pain from his fall, Plaintiff continued his treatment relationship with Dr. Okafor through October 2012, resulting in six more visits. (R. 1089-106.) Typically, Dr. Okafor treated him with medication. (Id.)

         Shortly after his initial appointment with Dr. Okafor, Plaintiff returned to Scott Fladland, D.C., complaining of low back pain that radiated to his lower left extremity. (R. 350, 636-39.) On February 20, 2012, Dr. Fladland ordered an MRI of Plaintiff's lumbar spine which revealed visible spinal changes, including central canal stenosis[3] with bilateral foraminal stenosis. (R. 356, 637.) Following his appointment, Dr. Fladland provided Plaintiff with a note removing him from his work duties for six weeks. (R. 404, 637.)

         In the following months, Dr. Fladland frequently treated Plaintiff with trigger point therapy, chiropractic adjustments, rehabilitative exercises, and electrical muscle stimulations to help return him to his full work duties. (R. 573- 607, 613-22.) The treatment relationship lasted from the end of February 2012 to May 2012, during which time Dr. Fladland continually provided Plaintiff with notes extending his leave from work. (R. 385, 392, 404, 573, 677, 686.)

         Next, on May 9, 2012, Plaintiff was seen for a surgical consultation by Kern Singh, M.D., at the behest of Dr. Fladland. (R. 352-54.) After examining Plaintiff, [4]Dr. Singh recommended that he undergo a minimally invasive laminectomy and transforaminal lumbar interbody fusion.[5] (R. 354.) In a form he sent to Dr. Fladland, Dr. Singh opined that Plaintiff was unable to work. (R. 386-87.)

         On June 6, 2012, Plaintiff presented to Steven Mash, M.D., for an Independent Medical Examination. (R. 1251-56.) Aside from tenderness upon palpitation in Plaintiff's lower back, Dr. Mash's examination revealed normal results. (R. 1252-53.) Dr. Mash first opined that Plaintiff's condition was not related to his December 2011 injury, but rather his symptoms were a temporary exaggeration of his previously diagnosed condition. (R. 1255.) Due to this finding, he stated that the surgery recommended by Dr. Singh was reasonable, but that Plaintiff “would be able to return to work only in a position which would not require any significant lifting, pushing, or pulling with a [ten] pound lifting restriction.” (Id.) Dr. Mash concluded his note by stating that the treatment he indicated was not related to Plaintiff's workplace injury. (Id.)

         Finally, Plaintiff's medical records were reviewed on August 23, 2012 by Richard Lee Smith, M.D., a state agency consultant. (R. 77-84.) Due to Plaintiff's back pain, Dr. Smith found that he was limited to occasionally climbing ramps, stairs, ladders, ropes, and scaffolds, and occasionally stooping, kneeling, crouching, and crawling. (R. 81.) Ultimately, he opined that Plaintiff was not disabled. (R. 83.) On February 20, 2013, another state agency consultant, Michael Nenaber, M.D., reviewed ...

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