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Cynthia H. v. Commissioner of Social Security

United States District Court, C.D. Illinois, Rock Island Division

April 11, 2019

CYNTHIA H., Plaintiff,



         Now before the Court is the Plaintiff's Motion for Summary Judgment (Doc. 10) and the Defendant's Motion for Summary Affirmance (Doc. 14). This matter has been referred for a report and recommendation. The Motions are fully briefed, and for the reasons stated herein, the Court recommends the Plaintiff's Motion for Summary Judgment be denied and the Defendant's Motion for Summary Affirmance be granted.[1]


         Cynthia H. filed her applications for disability insurance benefits (DIB) and supplemental security income (SSI) on March 18, 2014 and alleged disability beginning on March 28, 2013. Her claims were denied on August 5, 2014 and were denied on reconsideration on May 11, 2015. Cynthia filed a request for hearing concerning her DIB and SSI applications on June 25, 2015. A hearing was held on December 6, 2016 before the Honorable Shreese M. Wilson (ALJ). At that hearing, Cynthia was represented by an attorney and a vocational expert (VE) testified. The ALJ issued an unfavorable decision on May 2, 2017. Cynthia's request for review by the Appeals Council was denied on February 15, 2018, making the ALJ's decision the final decision of the Commissioner. Cynthia timely filed the instant civil action seeking review of the ALJ's Decision on March 17, 2018.


         At the hearing, Cynthia testified that she was 45 years old and lived in a house with her grandparents and mother. She was previously a licensed practical nurse. She last worked in October 2010. She testified back pain caused her to quit working at that time. Cynthia testified she became worse since 2010; she now used a walker and had to sit at least two times to rest when she went to Walmart. She started using a cane about a year before the hearing and had been using the walker for about for or five months. She constantly [had] pain in [her] back.” AR 46. Cynthia explained that lifting caused her pain and said she could not even walk around and hold her seven-month-old, 19-pound grandson. It was a “tag team effort” between Cynthia and her mother to lift the grandson out of his crib. AR 48. When asked whether any doctors recommended Cynthia not lift a particular amount of weight, she responded, “I think [Dr. Santiago, her treating doctor] said not to lift more than 20 pounds.” AR 48. Cynthia elaborated that she could lift 20 pounds but “I'm going to pay for it.” Id.

         Cynthia also testified about the pain in her hands. She said she slept in different positions, “pretty weird positions, ” in an attempt to relieve the pain in her hands. AR 50. She was diagnosed with carpal tunnel in both wrists. She had corrective surgery on the left wrist:

It relieved the pain that I had, but I still have the numbness and tingling, and I don't have a good grip. I can't like when I go to get up, like you can push yourself up with your hands, I can't do that. I have to use my elbows or my - what are these - forearms.

AR 51. No. permanent limitations were put on Cynthia following the surgery on her left wrist. She said “occasional pain has started back up. Nothing like it was before.” Id. She said before the surgery both of her hands would be in such pain as to cause her tears. Cynthia did not yet have surgery on her right hand. She wore a brace but it caused her more pain. She affirmed surgery was planned for her right hand when she was ready to proceed with it. She used her walker by pushing it with her forearms. As for daily activities, Cynthia tried to help her mother prepare supper and would sit on a stool and stir whatever was being cooked but then would have to quit because her hands would start hurting. She was able to dress herself.

         Cynthia later testified that she no longer babysat her grandchildren but instead simply spent time with them because she could not lift her seven-month-old grandson: “I mean I will do it [lift up her grandson when he cried] but we will have to immediately sit on the couch and then I'll be in extreme pain for a while and - .” AR 56. Cynthia also testified she could lift her five-year-old, 27-pound granddaughter but she would have to sit down and then be in “extreme pain” for a while or would even have to lay down. Cynthia guessed she would be able to lift “[m]aybe five pounds” though she had not tested it to know exactly what she could lift. AR 56.

         Cynthia's attorney then questioned her. Cynthia testified she could use her right dominant hand for gripping, grasping, and handling things for five to 10 minutes before “I have to, well, things will just fall through my hands.” AR 61. After that, she would rest them or rub them. She confirmed her left hand carpal tunnel surgery reduced the pain in her left hand but she still had numbness and tingling in it. She could use her left hand for the same amount of time as her right hand - five to 10 minutes. She thought she could use her hands for “[p]robably about two hours” in an eight-hour period of a day for gripping, grasping, and handling. AR 62. Cynthia's attorney pointed out that Dr. Santiago indicated over two years prior to the hearing that Cynthia had limitations using her hands to five to 10 percent of the time. Cynthia stated she thought those limitations were the same at present. “Or it might even be worse now because that pain is so, when I get that pain, oh, it just brings me to tears.” AR 62.

         The VE was then questioned.


         In her Decision at Step Two, the ALJ determined Cynthia had the following severe impairments: bilateral carpal tunnel syndrome and status post left carpal tunnel syndrome release; right knee and left hip degenerative joint disease; lumbar spine degenerative disc disease; right shoulder tendinitis and bursitis; diabetes; obesity; fibromyalgia; and hypertension. AR 17. At Step Three, the ALJ determined Cynthia did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. At that step, the ALJ first detailed consultative examiner Peter Sorokin, M.D.'s April 25, 2015 examination results.

         As for Cynthia's back issues, the ALJ included treating doctor Julio Santiago, M.D.'s August 2016 notes that examination revealed normal range of motion with the ability to walk with a cane, and Cynthia showed some lumbar tenderness but the back examination was otherwise within normal limits. His earlier March 2016 notes included that physical examination revealed normal joint range of motion with no swelling, no sensation loss, and abnormal reflexes were not reported. Cynthia's chronic back pain was treated with medication at that time. In September 2016, Cynthia displayed normal range of motion of all joints with no tenderness, no swelling, no deformity, and a normal gait. At that time, Dr. Santiago did not report symptoms of radiculopathy, muscle atrophy, or motor weakness, no abnormal reflexes, and no sensation loss was detected. Radiographic imaging in October 2016 showed lumbar disc disease with mild spinal stenosis and an annular tear of the lateral aspect of the L4-L5 disc, and June 2015 nerve conduction studies revealed no evidence of left lower limb radiculopathy or neuropathy.

         The ALJ also included that Cynthia was diagnosed with carpal tunnel syndrome, bilaterally, which was confirmed by nerve conduction studies:

She had corrective surgery on the left successfully completed October 17, 2016 . . . she testified that this relieved pain, but she alleged residual numbness. The claimant has been treated for right carpal tunnel syndrome with medication, splints, and injections[.]

AR 22.

         The ALJ made the following residual functional capacity [RFC] finding:

[T]he claimant has the [RFC] to perform sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) except she is able to lift and carry 20 pounds occasionally and 10 pounds frequently; she is able to walk and stand for one hour each per workday, sitting for the remainder of the day; she is unable to climb ladders, ropes, or scaffolds; she is able to occasionally climb ramps or stairs as well as stoop, kneel, crouch, and crawl; she is able to reach overhead with the dominant upper extremity only occasionally; she is limited to frequent bilateral fingering and handling; she must avoid concentrated exposure to extreme cold (less than 50°F); she is to avoid concentrated exposure to unprotected heights in hazardous machinery; she is able to ambulate to and from the workstation with the assistance of a cane; she is to be allowed to alternate between sitting and standing once every 30 minutes for five minutes.

AR 23. The ALJ stated, pointing to evidence of record, that “the objective medical evidence [was] inconsistent with the claimant's allegation of complete and total disability.” AR 23. Then, the ALJ stated, “the claimant's description of daily activities belies the allegation of complete and total ...

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