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Cruz v. Berryhill

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

October 17, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.



         Plaintiff Milburga Aide Cruz applied for Social Security benefits on September 7, 2012, alleging she became disabled on July 31, 2006; her date last insured ("DLI") was December 31, 2011 (R. 22-23). Ms. Cruz'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. Cruz's claim for benefits. The Appeals Council denied Ms. Cruz's request for review of the ALJ:s decision, rendering it the final decision of the Commissioner (R. 1). Ms. Cruz has filed a motion to reverse or remand the ALJ's decision (doc. # 13), and the Commissioner has filed a cross-motion asking the Court to affirm the decision (doc. # 22). For the following reasons, we deny Ms. Cruz's motion to remand and grant the Commissioner's motion to affirm.


         Ms. Cruz was born in Mexico in 1967 and moved to the United States when she was 23 years old (R. 49). She has a sixth grade education, and her primary language is Spanish (R. 193- 95). After performing repetitive work on an assembly line for more than 20 years, Ms. Cruz developed ganglion cysts, bone spurs and carpal boss (bump) in her right wrist, which David Norbeck, M.D., surgically removed in January 2001 (R. 738). At a post-operative follow-up visit in May 2001, Dr. Norbeck opined that Ms. Cruz was at maximum medical improvement after surgery and recommended that she no longer use an "air ram" (a pneumatic, or air powered, screwdriver) on the assembly line and limit her lifting to no more than 10 pounds on her right side (R. 743).

         In 2002, Ms. Cruz returned to Dr. Norbeck and reported "some recurrent pain in her right wrist" after having to do a lot of repetitive activity at work (R. 744). Dr. Norbeck noted that Ms. Cruz had some tenderness, but full range of motion and no swelling in her wrist (Id.). X-rays showed no abnormalities, but an MRI showed numerous ligament tears (R. 744-45). In September 2002, Jay Pomerance, M.D., performed surgical repair of the ligaments and an ulnar shortening (procedure using plate and screw fixation) (R, 911). Ms. Cruz returned to working light duty by January 2003, but continued to have some pain with wrist flexion (R. 991-97, 1013).

         Dr. Pomerance removed the plate in March 2003 because it was causing Ms. Cruz discomfort (R. 1013). He released Ms. Cruz to work using her right hand "as a light assist only while wearing the splint" (1078-79). Though x-rays revealed normal healing, Ms. Cruz continued to report pain and tenderness (Id.). In May 2003, Dr. Pomerance gave Ms. Cruz a local steroid injection in her right wrist, but she reported that the injection provided no relief (R. 1079-80). He gave her a second injection on May 15, 2003, which gave her minimal relief, and Dr. Pomerance stated that Ms. Cruz could continue her present duty work, avoiding heavy grip (R. 1080-81). Ms. Cruz continued to report pain throughout 2003, but other than some tenderness, her examinations were normal (R. 1082-83). Dr. Pomerance prescribed Ultram (narcotic) and opined that she could return to work other than doing heavy lifting or gripping, with a 25 pound restriction (R. 1083-84).

         In June 2005, Ms. Cruz returned to Dr. Pomerance, reporting that her pain continued in her right forearm, and she had experienced intermittent numbness and tingling in her right hand for the previous two to three months (R. 1075). Upon examination, Ms. Cruz had tenderness and reduced range of motion in her wrist, but her X-rays and bone scans were normal (R. 1075-76). Dr. Pomerance opined that Ms. Cruz may benefit from a tenolysis (surgery to release a tendon from adhesions or scar tissue that binds tendons to surrounding tissue); however, he also stated that Ms. Cruz "could also just simply live with the ulnar forearm discomfort since it does not appear that those adhesions are functionally disabling" (R. 1076). Dr. Pomerance stated that Ms. Cruz could continue in her present duty job, self-limiting as needed (Id.).

         On July 21, 2006, Ms. Cruz began treating with orthopedist Serafin DeLeon, M.D., (and her colleague Dr. Meltzer) for numbness and pain in her left thumb radiating up her forearm, which Ms. Cruz reported had begun two months before (R. 322). In her report of the July 2006 visit, Dr. DeLeon wrote that since the surgeries on her right hand and forearm in 2001, Ms. Cruz had been moved to a different place on the assembly line at work and instructed to use only her left wrist due to residual weakness and limited range of motion on her right side (R. 323). On examination, Ms. Cruz had marked tenderness and pain over her left thumb, where Dr. DeLeon felt a palpable nodule, and she had tenderness and pain and some limited range of motion in both wrists and hands (Id.). Dr. DeLeon gave Ms. Cruz steroid injections in her left wrist area and thumb and recommended that Ms. Cruz not return to work at the assembly line (Id.). Dr. DeLeon diagnosed Ms. Cruz with left deQuervain's disease (painful condition affecting the tendons on the thumb side of the wrist), [3] left symptomatic trigger thumb (stenosing tenosynovitis, where fingers get stuck in a bent position and straighten with a snap)[4] and chronic right wrist pain (R. 324). Dr. DeLeon opined that these conditions were the result of Ms. Cruz's work activities involving repetitive gripping and twisting (R. 313). Dr. DeLeon also noted that Ms. Cruz had to be in Mexico the following week for "an acute family problem" (R. 324). Ms. Cruz has not worked since July 31, 2006 (R. 194-95).

         Ms. Cruz had good pain relief for two weeks after the injections (R. 324). At an examination in September 2006, Dr. DeLeon observed that Ms. Cruz had "very minimal tenderness to palpation" along her left thumb, with full flexion and extension, and tenderness over a portion of her left wrist (R. 325). Along her right wrist, Ms. Cruz had some signs of mild tenosynovitis, but mainly signs of chronic pain and some limited motion (Id.). In October 2006, Ms. Cruz decided to undergo surgery on the tendons in her left thumb and wrist because prior injections did not provide lasting relief (R. 317). On December 22, 2006, Dr. DeLeon performed surgery to release the pressure around the tendons in Ms. Cruz's left thumb and wrist (R. 320).

         Ms. Cruz received physical therapy, and at a follow-up appointment with Dr. DeLeon on January 26, 2007, Ms. Cruz had minimal pain and full flexion at her thumb, with some residual mild tenderness over her wrist (R. 316). The next month, Dr. DeLeon wrote that Ms. Cruz's range of motion and grip strength were gradually improving, but she still had a little bit of soreness in her left wrist (Id.). By her appointment in April 2007, Dr. DeLeon wrote that Ms. Cruz was "much improved, " with only some residual weakness in her left hand and tightness and mild tenderness along her wrist (Id.). Dr. DeLeon released Ms. Cruz to full duty work (Id.).

         The record does not contain any medical evidence of Ms. Cruz's hand or wrist pain for the next five years (R. 22). While the record contains medical reports during these years of other ailments that afflicted Ms. Cruz__ such as stomach pain, cysts in her ovaries, difficulty urinating, irritable bowel syndrome and gastrointestinal reflux disease ("GERD") __ Ms. Cruz does not address these other ailments in her motion to remand, and so we do not need to do so here.

         On May 11, 2012, Ms. Cruz returned to Dr. DeLeon, stating that about two to three years earlier, she started experiencing pain in both wrists, worse on the right (R. 341). Examination showed some tenderness in both wrists, and Dr. DeLeon gave Ms. Cruz steroid injections in both wrists (Id.). At a follow-up visit on June 15, 2012, Ms. Cruz reported that the injections did not alleviate her pain (R. 337). Dr. DeLeon diagnosed Ms. Cruz with bilateral DeQuervain's and bilateral wrist synovitis (Id.). Dr. DeLeon wrote that Ms. Cruz's options were "either to live with the pain or undergo a surgery, " but Dr. DeLeon was "not 100% confident" that the surgery would help her pain (Id.). On June 18, 2012, Dr. Deleon performed bilateral tendon release surgery and bilateral wrist arthroscopy with synovectomy to remove certain connective tissue and repair certain tendons in Ms. Cruz's wrists (R. 343).

         After surgery, Ms. Cruz received occupational therapy (R. 755). During July 2012, she showed mild improvement in range of motion, pain and functional activities, but she still had some pain and discomfort when performing activities such as opening jars, dressing, and washing dishes (R. 755-60).

         In November 2012, a state agency physician found there was "insufficient evidence" to evaluate plaintiffs disability claim from her alleged onset date through her DLI of December 2011 (R. 82-85). On reconsideration, Ms. Cruz submitted additional evidence of her impairments from 2012 and 2013, but in March 2013, the state agency physician affirmed the earlier determination, finding that there was "insufficient evidence to support severity prior ...

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