United States District Court, N.D. Illinois, Eastern Division
TORRANCE D. WILLIAMS, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
E. Cox U.S. Magistrate Judge.
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.
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).
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).
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.).
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.
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.
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.).
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
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