United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
E. COX U.S. MAGISTRATE JUDGE
Sabrina Loraine McFarland (“Plaintiff”) appeals
the decision of the Commissioner of the Social Security
Administration (“Commissioner”) denying her
disability insurance benefits under Titles II and XVI of the
Social Security Act. For the following reasons,
Plaintiff's motion  is granted, the
Commissioner's motion is denied . This case is
remanded for further proceedings consistent with this
Procedural History and Claimant's Background
filed an application for disability insurance benefits on
August 21, 2012, with an alleged onset date of disability as
of August 27, 2010. (Record (“R”) 142.) Her
initial application was denied on February 19, 2013 and again
at the reconsideration stage on September 24, 2013. (R. 116,
117, 140, 141.) Plaintiff requested a hearing before an
Administrative Law Judge (“ALJ”), which was held
on February 2, 2015. (R. 19.) Plaintiff appeared and
testified. (R. 38-74.) Vocational Expert (“VE”),
Richard T. Fisher also appeared and offered testimony. (R.
74-95.) On February 23, 2016, the ALJ issued a written
decision finding her not disabled within the meaning of the
Act and denying Plaintiff's application for Social
Security Disability Income (“SSDI”). (R. 19-31.)
On April 28, 2016, the appeals council denied Plaintiff's
request for Review, thereby rendering the ALJ's decision
as the final decision of the agency. (R. 1-6); Herron v.
Shalala, 19 F.3d 329, 332 (7th Cir. 1994). Plaintiff
then filed this civil action pursuant to 42 U.S.C.
§§ 405(g) and 1383(c).
Plaintiff was born November 7, 1970 and has two children aged
24 and 22, who live with her in her apartment. (R. 42-43.)
Plaintiff has a high school diploma and worked prior to an
accident in 2010 as a cashier and shift supervisor at various
businesses, including CVS Pharmacy and K & G Fashion. (R.
44, 291.) After 2010, she worked for short periods of time as
a cashier at Moran Foods/Save A Lot and Walmart as well as a
babysitter. (R. 48, 291.)
medical records indicate that the Plaintiff suffers from an
L5 pars defect, obesity, and osteoarthrosis of the knee. (R.
22, 110.) Plaintiff also testified that she suffers from
anemia, and treats it with iron supplements. (R. 62.) The
lower back issues were caused on August 22, 2010, when
Plaintiff accidentally slipped and fell while lifting a case
of tea while working at CVS Pharmacy. (R. 345.) Treating
physician Dr. Anis Mekhail saw Plaintiff at Little Company of
Mary Hospital on August 30, 2010, a week after the accident
occurred, and for several checkups in September 2010. (R.
Mekhail diagnosed Plaintiff with obesity as well as lumbar
strain and referred her for physical therapy three to five
times a week, and a MRI. (Id.) She underwent the MRI
on November 5, 2010, which revealed mild facet hypertrophy in
the lumbar spine, L4-5 and L5-S1 disc space narrowing, and
disc desiccation with a suggestion of bilateral pars defects,
but no evidence of spondylolisthesis. (R. 390.) Plaintiff was
discharged from physical therapy on December 12, 2010. (R.
364) Plaintiff returned in February 2011, continuing to
complain about the pain and an epidural injection was
recommended. (Id.) A year later, in February 2012,
Plaintiff again returned but had not received the injection.
(Id.) Under Dr. Mekhail's recommendation, she
received the epidural injection and underwent a CT myelogram
and a functional capacity evaluation. (Id.)
November 9, 2011 and December 3, 2011, Plaintiff underwent
MRIs of her left and right knees. (R. 680-777.) These MRIs
revealed moderate joint effusion and severe chondromalacia,
also known as “runner's knee, ” of the medial
compartment in the right knee, and moderate chondromalacia of
the medial femoral condyle. (Id.) Plaintiff did not
return to the University of Illinois regarding her knee pain
after she received a corticosteroid injection in the left
knee and a referral for physical therapy. (Id.)
March 28, 2012, at the referral of Dr. Mekhail, evaluating
physician Dr. Daniel Joda conducted a functional evaluation
exam and concluded that the Plaintiff was capable of
functioning at the light physical demand level (R. 408-16.)
Dr. Joda noted that this conclusion was made despite
inconsistent effort shown by the Plaintiff during the exam.
(Id.) The inconsistencies included failing 7 out of
7 validity criteria for upper extremity hand and pinch grip
testing, indicating a sub-maximal effort was given. (R. 409.)
Additionally, Dr. Joda noted that he observed that measured
abnormal pain behaviors (AROM) were significantly different
than observed AROM when in a non-testing situation, possibly
due to symptom magnification. (Id.) In June 2012,
Plaintiff returned to Dr. Mekhail, whose records indicate
that she said she could perform her job as a cashier and that
she was functioning well. (R. 400.) In August 2012, Dr.
Mekhail's records note that Plaintiff's back pain had
returned and he recommended pain management. (R. 401.)
underwent two physical consultative examinations
(“CE”). (R. 551-57, 560-63.) The first CE was
completed by Dr. Dante Pimentel on January 25, 2013, and the
second was completed by Dr. Alexander Panagos on September
13, 2013. (R. 551-57, 560-63.) Dr. Pimentel found Plaintiff
tested normally in most aspects and diagnosed migraines,
right knee arthropathic, lumbosacral back pain, radicular
pain, and obesity. (R. 554.) Dr. Pimentel also found that
Plaintiff's ability to lift, carry, handle objects, and
carry out work-related activities was mildly impaired. (R.
554.) Later that year, Dr. Panagos found that Plaintiff's
musculoskeletal and neurological exams returned normal
results and diagnosed spondylolisthesis of the lumbar spine,
arthralgias of both knees, chronic migraines, and stable
angina. (R. 563.)
record also indicates that Plaintiff received medical source
statements (“MSS”) from two physicians. (R.
442-43, 833-34.) The first MSS was provided by Dr. Daniel
Cammarano on December 7, 2012. (R. 442-43.) Dr. Cammarano
examined Plaintiff once and assessed that she was unable to
stand/walk in an eight-hour workday and able to sit for one
hour in an eight-hour workday. (R. 442-43.) The second MSS
was provided by Dr. Thomas Bilko on December 22, 2014. (R.
833-34.) Two years later, Dr. Bilko saw Plaintiff over the
course of three months and assessed that she could stand/walk
for zero to one hour in an eight-hour workday and sit for one
hour in an eight-hour workday. (Id.)
State Agency physicians have also reviewed Plaintiff's
medical records and supplied assessments of Plaintiff's
condition. (R. 100-13, 123-26.) Dr. Lenore Gonzalez filled
out an RFC assessment on February 4, 2013. (R. 100-13.) Dr.
Gonzalez diagnosed Plaintiff with severe degenerative disc
disease, osteoarthritis, and migraines. (R. 100, 110.) Dr.
Gonzalez also assessed that Plaintiff could sit for six hours
in an eight-hour workday, stand/walk for six hours in an
eight-hour workday, lift/carry ten pounds, and should avoid
exposure to extreme environmental conditions. (R. 101-13.)
The second RFC was provided ...