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Williams v. Berryhill

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

October 19, 2017

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


          Susan E. Cox U.S. Magistrate Judge.

         Plaintiff Torrance Williams (“Plaintiff”) filed this action seeking reversal of the final decision of the Commissioner of Social Security denying his applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act (“the Act”). Plaintiff has filed a brief, which this Court will construe as a motion for summary judgment [dkt. 15], and the Commissioner has filed a cross-motion for summary judgment [dkt. 17]. After reviewing the record, the Court grants Plaintiff's motion for summary judgment and denies the Commissioner's cross-motion for summary judgment. The ALJ's decision is reversed and the case is remanded for further proceedings consistent with this Opinion.


         I. Procedural History

         Plaintiff filed applications for DIB and SSI on December 20, 2012, alleging a disability onset date of June 1, 2002. (R. 14, 154-57). These claims were denied initially on April 11, 2013 and again upon reconsideration on August 28, 2013. (R. 23, 78-155). Plaintiff timely requested a hearing before an Administrative Law Judge (“ALJ”) on September 30, 2013. (R. 23). On September 18, 2014, Plaintiff, represented by counsel, appeared by video and testified before ALJ Joel Fina. (R. 40-77). The ALJ also heard testimony from medical expert (“ME”) Ashok G. Jilhewar, M.D., and vocational expert (“VE”) Aimee Mowery. (Id.). At the hearing, Plaintiff amended his disability onset date to August, 31, 2013, resulting in a dismissal of his claim for DIB. (R. 23, 234). On March 2, 2015, the ALJ issued a written decision denying Plaintiff's application for SSI. (R. 23-34). The Appeals Council (“AC”) denied review on May 12, 2016, thereby rendering the ALJ's decision as the final decision of the agency. (R. 1-9); Herron v. Shalala, 19 F.3d 329, 332 (7th Cir. 1994).

         II. Medical Evidence

         The records reflect Plaintiff was diagnosed with scoliosis as a child. (R. 487). On August 29, 2013, the amended alleged onset date, Plaintiff sought treatment from the Christian Community Health Center (“CCHC”) for complaints of back pain. (R. 451). His physician referred him to physical therapy and prescribed Naproxen and Flexeril for his pain. (Id.). In November 2013, Plaintiff reported that he had attended his first physical therapy session, and that the pain medications were helpful. (R. 446). The provider referred Plaintiff to the orthopedic clinic and diagnosed scoliosis of the thoracic and lumbar spines. (R. 446-47). A hernia of the abdominal cavity was also documented. (R. 446).

         Plaintiff attended physical therapy at the MetroSouth Medical Center from November 11, 2013, through January 13, 2014. (R. 475-95). At his initial evaluation, Plaintiff reported that he had been diagnosed with scoliosis as a teenager, but had declined surgery secondary to his activity in sports. (R. 487). He indicated that his pain “got bad” approximately 11 years ago, and that he experienced increased symptoms following a recent colon resection surgery. (Id.). Plaintiff stated that he had attempted physical therapy in the past without any lasting improvement, but that he did experience some relief with the use of pain medication and anti-inflammatory medication. (Id.). He presented with scoliosis primarily in his thoracic region that was convex to the left and a prominent rib hump was noted with forward bending. (Id.). At the time of the evaluation, Plaintiff described constant pain (7/10 in severity) in his left mid to lower thoracic region, located in the area of his rib hump. (Id.). The pain was aggravated by prolonged standing. (Id.). Plaintiff attended three therapy sessions during December 2013, where he demonstrated improvement but continued to report only temporary relief from therapy. (R. 476- 78). Plaintiff was discharged from therapy to a home exercise program on January 13, 2014. (R. 493). According to the discharge summary, therapy did help manage Plaintiff's pain, although he continued to experience pain with activity and limited range of motion. (Id.).

         On February 17, 2014, Plaintiff returned to CCHC with complaints of worsening back pain. (R. 444). He rated his current pain level as 5/10 and indicated that the pain worsened with standing and physical activity. (Id.). Physical examination revealed tenderness on the right side of the lower thoracic spine with swelling and decreased flexion and extension. (R. 445). The doctor recommended x-rays of the thoracic and lumbar spines, continued Plaintiff's current medications, and referred him to orthopedics for evaluation and treatment. (Id.). At his next visit on August 18, 2014, Plaintiff complained of severe back pain that began the previous day, which he rated as 8/10 in severity. (R. 454). He reported that he had been discharged from physical therapy due to insurance issues, and requested medication refills. (Id.). He was again referred to physical therapy and remained on Naproxen and Flexeril. (Id.).

         At an August 21, 2014 physical therapy evaluation at the University of Illinois Medical Center at Chicago, Plaintiff described his pain as “sharp” and “spasm, ” and rated it at 5/10 in severity and best, and a 10/10 at worst. (R. 465). He stated that he felt as though he “falls in a hole” when he steps with the left leg. (Id.). The pain worsened with walking, transfers, and bending. (Id.). Plaintiff stated that since his abdominal surgery for diverticulitis in 2012, his back had “never been the same.” (Id.). X-rays of the spine confirmed 57 degree thoracolumbar scoliosis and 54 degree right T12-L4 scoliosis. (Id.). Mr. Williams ambulated with an antalgic gait and demonstrated reduced lumbar flexion, extension, and right bending. (R. 466). Sacroiliac joint testing was positive for low back pain. (R. 467).

         Plaintiff presented to Krzysztof Siemionow, M.D., for an orthopedic evaluation on September 9, 2014. (R. 517-18). He reported that he had been experiencing increased back pain for the past two years, ever since he had surgery for his diverticulitis. (R. 517). Plaintiff stated that he was unable to sit for a long time and his activity was limited. (Id.). Physical examination revealed a right thoracic curve and a lumbar compensatory curve. (R. 518). The right shoulder was noted to be slightly higher than the left. (Id.). Plaintiff was able to walk on his heels and toes, had 5/5 strength, and intact sensation to light touch. (Id.). Dr. Siemionow ordered an MRI of the lumbar and thoracic spines to rule out infection or issues that may have arisen subsequent to his diverticulitis surgery, and recommended continued physical therapy. (Id.).

         When Plaintiff followed up with Dr. Siemionow on October 7, 2014, he reported he had finished physical therapy the previous week, and that it had helped him tailor his activities enough so that he would have mild pain during the day. (R. 503). He stated that he still had some spasms and episodes of moderate to severe pain, but only if he pushed himself too hard. (Id.). Physical examination was unremarkable. (Id.). Dr. Siemionow reviewed the recent MRI results, noting there were no signs of infection, “which correlates with [Plaintiff's] clinical symptoms as he is doing better.” (R. 504). Plaintiff was instructed to follow up once a year or on an as needed basis. (Id.).

         III. Testimony

         Plaintiff testified that he was unable to work because he could not pass physical examinations that many employers required. (R. 48). Following surgery to treat diverticulitis, he experienced a significant increase in his scoliosis related back pain. Id. Doctors informed him that the surgery caused the stomach muscles to go “to sleep” and the back muscles, therefore, needed to compensate. (R. 57). The pain most prominently affected the middle and lower back. (R. 53). The pain was sharp and throbbing. (R. 54). Moving or remaining in a static position aggravated the pain. (R. 55). Pain interrupted his sleep and he napped during the day as a result. (R. 52, 58). He could stand for ten to fifteen minutes at one time before he needed to change positions. (R. 53). He could walk the distance of one block before feeling pain. (Id.). He tried not to lift more than ten pounds at one time. (R. 58). Physical therapy provided only temporary pain relief. (Id.). His prescription ...

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