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Wehrle v. Berryhill

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

July 25, 2018

MATTHEW WEHRLE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          SUSAN E. COX MAGISTRATE JUDGE

         Plaintiff Matthew Wehrle (“Plaintiff”) appeals the decision of the Commissioner of Social Security (“Commissioner”) to deny his application for disability benefits. The parties have filed cross-motions for summary judgment. For the following reasons, Plaintiff's motion is denied [dkt. 11], the Commissioner's motion is granted [dkt. 20], and the Administrative Law Judge's decision is affirmed.

         BACKGROUND

         I. Medical History

         On July 21, 2010, Plaintiff was working as a bricklayer, when he suffered a back injury while at work, causing back pain and radiculopathy into his right leg. (R. 276.) An MRI of Plaintiff's back in August 2010 showed annular disc bulging at ¶ 4-L5 and central disc herniation causing non-compressive foraminal stenosis. (R. 278.) In the first half of 2011, Plaintiff attempted to treat his back pain with non-invasive options such as steroid injections. (R. 282-285.) When the injections ceased to provide Plaintiff with the desired relief, he sought a second opinion from Dr. Edward J. Goldberg, a spinal surgeon. (R. 285-86, 325.) Dr. Goldberg recommended a surgical fusion at ¶ 5-S1, which he performed in August 2011. (R. 267, 325.) Following the surgery, Plaintiff regularly followed up with Dr. Goldberg. As of October 11, 2011, Plaintiff was “doing extremely well, ” but was not cleared to go back to work. (R. 319.) On November 28, 2011, Plaintiff reported muscle tightness and occasional numbness in his right foot, and Dr. Goldberg cleared Plaintiff to work with a 10-pound lifting restriction and with occasional bending, squatting, and ground work. (R. 317.)

         As part of his recovery from back surgery, Plaintiff also engaged in a physical therapy regimen. As part of his physical therapy, Plaintiff would sometimes undergo a functional assessment. As of January 6, 2012, Plaintiff demonstrated the ability to perform work at the “Medium Demand Level;” specifically, he was able to lift between 43 and 81 pounds, depending on the specific type of lifting, but had functional deficits with kneeling, crawling, and squatting. (R. 358.) However, Plaintiff could not perform his previous work as a bricklayer because that job required the ability to perform at the “Medium to Heavy Physical Demand Level.” (Id.)

         One week later, Plaintiff followed up with Dr. Goldberg. Plaintiff reported that he was doing well and felt “much stronger after completing regular physical therapy.” (R. 317.) He also reported pain in his lower back with “trunk twisting, ” and occasional numbness and tingling down his right leg, “but this is much less frequent.” (R. 314.) Dr. Goldberg recommended that Plaintiff complete a work conditioning program, and released him to work at the light capacity level. (R. 317.)

         Plaintiff completed the work conditioning program in February 2012. (R. 346.) At the time of completion, Plaintiff was able to work at the medium exertion level, and could carry 70 pounds s distance over 100 feet, and overhead press 60 pounds for six repetitions. At Plaintiff's visit with Dr. Goldberg a few days later, Dr. Goldberg opined that Plaintiff could return to work at a medium exertional level, with limited squatting and waist-bending; Dr. Goldberg found that this was maximum medical improvement for Plaintiff. (R. 313.)

         On June 6, 2012, Plaintiff had another functional assessment evaluation. (R. 338.) Plaintiff demonstrated the ability to perform at the medium to heavy exertion level, including occasionally lifting 66-93 pounds. Once again, Plaintiff was not cleared to perform his previous work as a bricklayer. (Id.) Plaintiff demonstrated the ability to stand for 30 minutes, and sit for 63 minutes. (R. 344.)

         There is no medical record of Plaintiff having any additional back pain until May 2014, when he presented with back pain to family nurse practitioner Mary Kennedy, FNP. (R. 471.) Plaintiff reported that his back pain had worsened over the past year, and that he was experiencing burning and numbness in his leg and foot. (Id.) According to Plaintiff, he had “never really been pain free since his surgery.” (Id.) Ms. Kennedy ordered an MRI of Plaintiff's lumbar spine, which revealed mild to moderate spondylosis at ¶ 4-L5. (R. 578.)

         In June 2014, Plaintiff began treatment with Jason Peterman, PA-C, for Plaintiff's back pain, which he reported as causing stabbing and shooting pain in his leg. (R. 492.) Mr. Peterman found that Plaintiff had sacroiliac joint dysfunction, and recommended diagnostic injections to his SI joint with interventional radiology. (R. 494.) At his follow-up with Mr. Peterman, Plaintiff had the same complaints and reported that his injections had provided relief for one hour. (R. 489.) Mr. Peterman recommended that Plaintiff attempt to resolve his issues through physical therapy, after which they could consider “minimally invasive sacroiliac joint fusion” if Plaintiff did not get relief from the physical therapy. (R. 491.) In September 2014, Plaintiff reported “no benefit” from the physical therapy, and Mr. Peterman recommended the aforementioned joint fusion. (R. 485-87.) The procedure was performed in late October 2014. (R. 544-45.) Following the procedure, Plaintiff followed up regularly with the surgeon who had performed it, and showed some improvement in his symptoms. (R. 518-22.) Plaintiff also did physical therapy in an attempt to recover. Although the surgeon noted in January 2015 that Plaintiff's pain was “clearly better, ” the contemporaneous physical therapy records show that he continued to suffer from radiculopathy, back pain, limited range of motion in his lumbar spine, and an abnormal gait. (R. 660-62.)

         Plaintiff also sought treatment for his right shoulder.[1] He reported the issue to Ms. Kennedy in October 2013, who then referred him to an orthopedic specialist. (R. 287, 456.) At his initial appointment with orthopedist Dr. Michael J. Corcoran, Plaintiff exhibited full range of motion in his shoulder, but pain and tightness “with the extremes of flexion and abduction, ” and “strong positive impingement sign.” (R. 288.) He received an injection in his shoulder and was told to follow up in four weeks. (Id.) An MRI from November 2013 showed “mild arthrosis of the acromioclavicular joint.” (R. 297.) After several follow-up visits showing no improvement in his shoulder, Dr. Corcoran performed a right shoulder arthroscopy in January 16, 2014. (R. 406.) On February 24, 2014, Plaintiff reported to Dr. Corcoran's physician's assistant that his shoulder pain was gone and that physical therapy had been a “huge help.” (R. 292.)

         II. Opinion Evidence

         There are several medical opinions in the record, both from treaters and state agency medical consultants. As for the state medical consultants, their findings were mostly similar. Each found that Plaintiff was able to perform work at the light exertional level, see 20 C.F.R. § 404.1567, with a variety of postural, manipulative, and environmental modifications. (R. 70-74, 88-92.) The Administrative Law Judge (“ALJ”) gave great weight to those opinions to the extent they limited Plaintiff to light work, provided for “generous” postural limitations, and limited Plaintiff's exposure to hazards such as ladders, ropes, and scaffolds. (R. 19-20.) However, the ALJ assigned no weight to any limitations on Plaintiff's ability to use his right arm, because the ALJ found that the Plaintiff's right should injury lasted less than 12 months. (Id.) Additionally, the ALJ found there was “no basis in the medical records” for the medical consultants' findings that Plaintiff be limited in exposure to extreme cold and wetness. (R. 20.)

         At the reconsideration level, a psychological consultant found that Plaintiff had mild restrictions in activities of daily living, social functioning, and maintaining concentration, persistence, and pace, and no episodes of decompensation. (R. 86.) The ALJ gave great weight to that opinion because the findings were consistent with the findings of Plaintiff's psychological evaluation on September 3, 2014. (R. 476-78.)

         Plaintiff's physical therapist, Dana Masching, also provided a Musculoskeletal Defects Report, which stated that Plaintiff's pain was too severe to allow him to work in a competitive environment, even in a sedentary capacity. (R. 661.) The ALJ gave Ms. Masching's opinion no weight, because she had “last [seen] the claimant one year prior to the date of ...


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