United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER 
I. Schenkier United States Magistrate Judge.
Sabrina Gray applied for Social Security benefits on February
8, 2013, alleging she became disabled on November 7, 2012 (R.
206-15); her date last insured was December 31, 2016 (R. 14).
Ms. Gray's application was denied initially and on
reconsideration. After a hearing before an Administrative Law
Judge ("ALJ"), the ALJ issued a written opinion
denying Ms. Gray's claim for benefits (R. 14-23). The
Appeals Council denied Ms. Gray's request for review of
the ALJ's decision, rendering it the final decision of
the Commissioner (R. 1). Ms. Gray has filed a motion to
reverse and remand the ALJ's decision (doc. # 15), and
the Commissioner has filed a cross-motion asking the Court to
affirm the decision (doc. # 20). For the following reasons,
we grant Ms. Gray's motion to remand and deny the
Commissioner's motion to affirm.
working as a bus driver for the CTA for about 12 years, Ms.
Gray stopped working on November 7, 2012, when she underwent
arthroscopic surgery for a torn meniscus in her right knee
(R. 36, 382, 267-69). Post-surgery, Ms. Gray participated in
physical therapy (R. 407). In follow-up visits, her surgeon,
James Schiappa, M.D., S.C., noted that Ms. Gray's range
of motion and strength in her knee was improving (R. 331-38).
However, in February 2013, Ms. Gray reported pain in her
right knee and received another MRI, which showed moderate
knee joint effusion (excess fluid on the knee), some
degeneration of the knee, softening and instability of the
patella (kneecap), as well as injury and instability in the
medial femoral condyle (the rounded end of the thigh bone)
(R. 497-98). That month, Ms. Gray also had imaging of her
right hip, which showed mild narrowing and degenerative
changes (R. 500), as well as an MRI of her left knee, which
showed mild degenerative changes (R. 501). Nevertheless, on
March 12, 2013, Dr. Schiappa wrote a note stating
"return to duty 3-18-13" (R. 494).
9, 2013, non-examining state agency physician, L.A. Woodard
D.O., opined that Ms. Gray had the residual functional
capacity ("RFC") to perform light work, sit for up
to six hours a day, and stand and/or walk for up to six hours
a day, with unlimited ability to lift, carry and stoop and
the ability to frequently climb ramps/stairs, balance and
crouch (R. 81-83). Dr. Woodard opined that Ms. Gray could
work as a copy clerk, which she had done from 1995 to 2000
(R. 84-85). Dr. Woodard noted that his opinion conflicted
with the June 25, 2013 opinion of the consultative examiner,
Matthew Khumalo, who recommended a sedentary RFC for Ms. Gray
after observing that she limped and walked with an antalgic
gait, was unsteady walking heel to toe, was unable to hop or
squat on her right leg, and had pain in her right shoulder
and knee (R. 79). Dr. Woodard's opinion was affirmed on
reconsideration in December 2013 (R. 97-104).
2013, Ms. Gray sought medical treatment for continued pain in
her right knee, as well as right wrist and low back pain (R.
440-42). The physician's assistant she saw, Jessica
Kappes, recommended that Ms. Gray treat her symptoms with
RICE (Rest, Ice, Compression and Elevation) in addition to
taking pain medication, including hydrocodone (Vicodin) and
gabapentin (Neurontin) (R. 443-45). Ms. Gray continued to
complain of pain in August 2013, and at that visit, Ms.
Kappes noted that Ms. Gray had developed diabetes (R. 474,
478). On November 22, 2013, returning to the same clinic, Ms.
Gray reported daily, constant pain in her right knee which
was not alleviated with Vicodin (R. 484). Ms. Kappes observed
swelling, effusion, decreased range of motion, and diffuse
tenderness in Ms. Gray's right knee (R. 484-87). Ms.
Kappes prescribed Percocet (oxycodone-acetaminophen) instead
of Vicodin, continued Ms. Gray's prescription for
gabapentin, and recommended that Ms. Gray walk with a cane to
alleviate her pain (R. 487-88). Ms. Kappes recommended an MRI
of Ms. Gray's right knee, but Ms, Gray could not afford
one at that time (R. 488).
2, 2014, Ms. Gray visited her family medicine physician, Dr.
Migdonia Delossantos, due to recurrent, severe right knee
pain and to check up on her Type 2 diabetes (R. 531). Dr. M.
Delossantos observed that Ms. Gray's right knee was
tender, with restricted range of motion and minimal swelling
(Id.). Ms. Gray returned to the doctor on July 8,
2014 because she was feeling sick; Dr. M. Delossantos noted
that Ms. Gray had swelling and tenderness in her right knee,
and she was taking Tramadol (a narcotic) for pain (R. 532).
Dr. M. Delossantos's notes from Ms. Gray's visits in
August and September 2014 did not mention knee problems (R.
534-36), but in October 2014, Ms. Gray again complained of
knee pain, and Dr. M. Delossantos observed swelling and
tenderness in her right knee and hand and reduced range of
motion in those areas (R. 539, 542-43). That month, Dr. M.
Delossantos filled out a physical capacities evaluation, in
which she opined that Ms. Gray could sit for five hours
during an eight-hour day and stand or walk for a total of 30
minutes a day, and could only occasionally lift up to five
pounds (R. 517-18). Dr. M. Delossantos also opined that Ms.
Gray could not grasp, push or pull or do fine manipulation
with her right hand (R. 517).
October 2014, Ms. Gray visited doctor of podiatric medicine,
Gregg Delossantos, D.P.M. (R. 551). At the visit, Ms. Gray
complained of numbness in her feet, and Dr. G. Delossantos
observed that she had decreased sensation on both feet, but
the strength and range of motion in her feet was normal
(Id.). On November 25, 2014, Dr. G. Delossantos
diagnosed Ms. Gray with diabetic peripheral neuropathy (R.
549). He wrote that Ms. Gray's gait was guarded to
altered, she needed a cane for balance and she could not walk
or stand more than two hours in an eight-hour workday (R.
548-49). Dr. G. Delossantos further noted that Ms. Gray had
moderate pain and decreased sensation in her feet (R. 550).
January 12, 2015, Ms. Gray arrived at her hearing before the
ALJ using a cane. She testified that she had used a cane for
more than a year on the infrequent occasions when she left
home because her right leg would lock up and/or go numb after
30 minutes of standing (R. 41, 44). She mostly sat around all
day, but after about 30 or 40 minutes of sitting she needed
to stand; she only drives short distances (R. 44, 46-47). Ms.
Gray testified that she had not had knee replacement surgery
because did not have insurance (R. 42).
vocational expert ("VE") testified that Ms.
Gray's previous work was defined as that of an office
helper and a bus driver (R. 52). In response to the ALJ's
hypothetical question, the VE testified that an individual
would be able to work as an office helper if she could
perform light work with unlimited sitting, standing and
walking so long as she could switch positions for five
minutes every 60 minutes (R. 52-54). If the individual had to
use a cane in their dominant hand to stand or walk, the VE
stated that there would be additional limitations (R. 60).
April 21, 2015, the ALJ issued a written opinion finding
plaintiff not disabled through the date of the decision (R.
14). At Step 1, the ALJ found that Ms. Gray had not engaged
in substantial gainful activity since November 7, 2012, the
alleged onset date of the disability (R. 16). At Step 2, the
ALJ found that Ms. Gray had the severe impairments of
degenerative disease of the right knee and diabetes mellitus,
but she did not have a severe mental impairment (R. 16-17).
At Step 3, the ALJ did not find that Ms. Gray's
impairments met or medically equaled the severity of a listed
impairment (R. 17).
found that Ms. Gray had an RFC to perform light work, with no
limitations on the total amount of time she is able to sit,
stand or walk throughout an eight-hour workday so long as she
could alternate her position between sitting, standing, and
walking for up to five minutes every hour while still on task
(R. 17). In addition, Ms. Gray could frequently balance;
occasionally climb ramps and stairs, stoop, kneel, crouch and
crawl; and never climb ropes, ladders or scaffolds
reviewed Ms. Gray's allegations of extensive pain and
functional limitations as well as the opinions of Drs. M. and
G. Delossantos assessing Ms. Gray with severe functional
limitations, but the ALJ stated that Ms. Gray's
allegations and these physician opinions were inconsistent
with the medical record and thus not fully credible. The ALJ
stated that the medical record showed "minimal swelling
and only some tenderness of the right knee" and
"consistently . . . full range of motion of the right
knee, " while it did "not show extreme complains
of pain or even functional limitations" or
"complaints of ongoing pain of the right knee" (R.
19-21). Furthermore, the ALJ found that Dr. Schiappa's
reports showed that "surgery was generally successful in
relieving [Ms. Gray's] symptoms, " she had