United States District Court, N.D. Illinois, Eastern Division
HARRIET P. HOLMES, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner, Social Security Administration,  Defendant.
MEMORANDUM OPINION AND ORDER
B. Kim, Magistrate Judge.
Holmes filed applications for Disability Insurance Benefits
(“DIB”) and Supplemental Security Income
(“SSI”) alleging that she is disabled by
degenerative arthritis, bronchitis, difficulty walking after
surgery on her toes, and problems breathing while walking.
After the Commissioner of the Social Security Administration
denied her applications, Holmes filed this suit seeking
judicial review. See 42 U.S.C. § 405(g). Before
the court are the parties' cross-motions for summary
judgment. For the following reasons, Holmes's motion is
denied, and the government's is granted:
filed her DIB and SSI applications on March 31, 2014,
alleging a disability onset date of October 15, 2013.
(Administrative Record (“A.R.”) 15.) After her
claims were denied initially and upon reconsideration, (id.
at 87-120), Holmes sought and was granted a hearing before an
Administrative Law Judge (“ALJ”), (id.
at 31-84). The ALJ issued his decision on July 25, 2016,
denying Holmes's applications. (Id. at 15-25.)
When the Appeals Council denied Holmes's request for
review, the ALJ's denial of benefits became the final
decision of the Commissioner. See Minnick v. Colvin,
775 F.3d 929, 935 (7th Cir. 2015). Holmes filed this suit
seeking judicial review of the Commissioner's decision,
(R. 1); see 42 U.S.C. § 405(g), and the parties
consented to this court's jurisdiction, (R. 9);
see 28 U.S.C. § 636(c).
May 2016 administrative hearing before the ALJ, Holmes,
represented by counsel, submitted both documentary and
testimonial evidence in support of her claims.
medical evidence of record shows that Holmes receives primary
care treatment through the Midtown Medical Center where she
is seen by Dr. Syed Husain. Holmes saw Dr. Husain once or
twice a month between August 2014 and April 2016, primarily
for management of her ongoing low-back and hip pain. (A.R.
January 10, 2014, Holmes underwent x-rays of her lumbosacral
spine, pelvis, and bilateral hips. (Id. at 343-44.)
The lumbosacral x-rays revealed no acute fracture and only
mild degenerative facet disease and mild degenerative disk
disease. (Id. at 344.) The pelvic and hip x-rays
indicated that the pelvic ring was intact, the sacroiliac
joints were unremarkable, there was pseudo-articulation
between the right transverse process of L5 vertebra and the
sacrum, and that there were calcifications in the right and
left pelvis. (Id. at 343.) Views of the hips were
unremarkable, demonstrating no acute fracture or dislocation
and that the hip joints were preserved. (Id.)
September 3, 2014, Holmes underwent an internal medicine
consultative examination performed by Dr. Liana Palacci.
(Id. at 356-59.) Holmes reported a past medical
history of low-back pain since approximately November 2013.
(Id. at 357.) She denied any history of trauma.
(Id.) She indicated that she had x-rays of her back
and was diagnosed with arthritis. (Id.) Holmes told
Dr. Palacci that her pain radiated into the right buttock and
leg, but she denied having numbness or weakness.
(Id.) She stated that walking and standing
exacerbated her pain and that sitting alleviated her
discomfort. (Id.) Holmes also indicated that she had
been using a non-prescribed cane for balance since February
2014 and that she needed the cane in order to walk more than
50 feet. (Id.)
than noting that Holmes had a mildly antalgic gait, Dr.
Palacci reported that the physical examination was otherwise
unremarkable. (Id. at 358.) She found that
Holmes's grip strength was normal, that she could make
fists and oppose fingers, that her range of motion of the
shoulders, elbows, wrists, hips, knees, and ankles were
normal, and that her reflexes were present, equal, and
symmetric. (Id.) Her strength was 5/5 in the upper
and lower extremities. (Id.) Holmes was able to
heel-and-toe stand, perform knee squats, and walk 50 feet
without the use of any assistive devices. (Id.) The
range of motion of her cervical and lumbar spine were normal
and her straight leg raise test was negative. (Id.)
The mental status examination was also normal. (Id.)
Holmes's consultative examination, non-examining agency
consultant Dr. Charles Kenney reviewed her records and opined
that Holmes retains the capacity to lift up to 20 pounds
occasionally and up to 10 pounds frequently, and can sit,
stand, or walk for approximately six hours in an eight-hour
workday. (Id. at 99.) He further opined that Holmes
could occasionally climb ramps, stairs, ladders, ropes, or
scaffolds, balance, stoop, kneel, crouch, and crawl.
(Id. at 99-100.)
January 21, 2015, another non-examining agency consultant,
Dr. Bernard Stevens, reviewed Holmes's records. Dr.
Stevens noted that Holmes had not alleged worsening symptoms
or limitations at the reconsideration level and affirmed Dr.
Kenney's assessment of Holmes's exertional
limitations. (Id. at 99, 106, 108.) However, Dr.
Stevens assessed less restrictive postural limitations than
Dr. Kenney. (Id. at 99-100, 109.) He opined that
Holmes would be limited to occasionally climbing ladders,
ropes, or scaffolds, and frequent climbing of ramps or
stairs, stooping, kneeling, crouching, and crawling. Dr.
Stevens found no limitations with regard to balancing.
(Id. at 109.)
Dr. Husain's 2014 and 2015 treatment records typically
show Holmes reporting either low-back pain or hip pain made
worse with ambulation and prolonged standing. (Id.
at 403-41.) Musculoskeletal findings upon physical
examination revealed either low-back tenderness or hip or
bilateral hip tenderness. (Id.) Overall, the notes
reflect various diagnoses such as low-back pain, hip pain,
joint stiffness, pain in the joint involving the lower leg,
and pain in the joint involving the pelvic region and thigh.
(Id.) In January 2015 Holmes began reporting
myalgias and lower extremity pain and tightness, for which
Dr. Husain prescribed Flexeril. (Id. at 412-15.)
Then in June 2015, Holmes began reporting lower extremity
neuropathic pain. (Id. at 423.) The records also
reflect prescriptions for a walker and a shower bench for
mobility assistance. (Id. at 418, 427.)
2015 Holmes reported to Dr. Husain that she had been
“feeling more depressed recently.” (Id.
at 421.) Dr. Husain noted that Holmes cried during the
interview but that she had not followed up with a previous
psychiatric referral. (Id.) Dr. Husain assessed
depression and provided a new referral to a psychiatrist.
(Id. at 421-22.)
September 1, 2015, Dr. Husain completed a physical Medical
Source Statement. (Id. at 366-71.) He noted
diagnoses of degenerative arthritis, hip pain, and
depression. (Id. at 366.) He indicated a
satisfactory prognosis and reported that treatment had
consisted of physical therapy and oral pain medication.
(Id.) He noted, among other things, Holmes's
bilateral hip pain, borderline diabetes mellitus, lower back
tenderness, and bilateral hip tenderness. (Id.) Dr.
Husain opined that Holmes's pain, symptoms, or medication
side effects are frequently severe enough to interfere with
her attention and concentration, and that she is incapable of
tolerating even low-stress jobs. (Id. at 367.) He
further opined that Holmes's symptoms prevent her from
maintaining the persistence and pace to engage in competitive
employment. (Id.) He indicated that she is incapable
of functioning on a part-time basis, and that her symptoms
have a moderate impact on her ability to perform activities
of daily living. (Id. at 368.)
to Dr. Husain, in an eight-hour day Holmes could sit, stand,
and walk less than two hours each. (Id. at 371.) He
wrote that she would have to shift positions from sitting to
standing or walking every 30 minutes, (id. at 370), but that
she could sit continuously for 60 minutes, (id. at 369).
Further, Holmes would need to elevate her legs or feet to 90
degrees. (Id. at 370.) According to Dr. Husain, if
Holmes had a sedentary job her legs should be elevated 100%
of the workday. (Id.) He also opined that Holmes
requires the use of an assistive device and is unable to
ambulate effectively ...