United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
E. Cox, U.S. Magistrate Judge.
Randall M. appeals the decision of the Commissioner
of the Social Security Administration
(“Commissioner”) denying his disability insurance
benefits (“DIB”) under the Social Security Act.
The Parties have filed cross motions for summary
judgment. For the reasons detailed below, the
Commissioner's Motion for Summary Judgment (dkt. 24) is
granted and Plaintiff's motion (dkt. 16) is denied.
Factual Background and Procedural History
injured his back while working as a warehouse worker for
Jewel Osco; while lifting a 90-pound case of meat, he felt
pain in his lower back. (R. 268, 591.) An MRI from August
2013 showed “[s]ingle level left paracentral
broad-based disc protrusion with visible annular tear at
¶ 4-L5, causing left lateral recess and left neural
foraminal narrowing with compression of the exiting left L4
and traversing left L5 nerve roots.” (R. 272.) On
August 8, 2013, Plaintiff presented to his treating
physician, Dr. Kevin M. Koutsky, M.D., who diagnosed
Plaintiff with lumbar spondylosis, recommended physical
therapy and light-duty restrictions at work, and prescribed
pain medications. (R. 269.) During the remainder of 2013,
Plaintiff underwent a conservative treatment regimen,
including physical therapy and epidural injections, but his
condition did not show significant improvement. (R. 262-68.)
Despite seeing some improvement during the first quarter of
2014, Plaintiff reached a plateau, and began discussing the
possibility of surgical interventions more seriously with Dr.
Koutsky. (R. 259-62.)
2, 2014, Dr. Howard An, M.D., performed an Independent
Medical Examination (“IME”). (R. 228.) Dr. An
diagnosed Plaintiff with “axial back pain with
left-sided L4 radiculopathy due to protruding disc into the
foramen at ¶ 4-L5 with L4 radiculopathy.”
Id. Dr. An noted that Plaintiff had received
“all appropriate treatment so far, but his symptoms
persist, therefore microscopic laminoforaminotomy at ¶
4-L5 may be a reasonable option for this patient to relieve
his radicular symptom and improve his condition.” (R.
229.) Dr. An opined Plaintiff had reached maximum medical
improvement with therapy and could perform light duty work,
provided he did not lift more that 20 pounds, and avoided
frequent bending and twisting. Id. According to Dr.
An, Plaintiff's prognosis with the aforementioned surgery
would be a return to work in two to three months following
surgery, with maximum medical improvement following the
surgery being reached in four or five months. Id.
the IME, Plaintiff continued treating with Dr. Koutsky with
physical therapy and pain medication for breakthrough pain.
(R. 258.) On June 26, 2014, Plaintiff indicated he would like
to go forward with lumbar decompression surgery, and Dr.
Koutsky prescribed a surgical back brace, a cold therapy
unit, a TENS unit, and a home exercise kit to aid Plaintiff
in his recovery from the surgery. (R. 256-257.) A July 11,
2014 MRI showed L4-L5 disc bulging and narrowing of the
foramina. (R. 271.)
August 12, 2014, Dr. Koutsky performed a decompressive
laminectomy L4-L5 with foraminotomy for lateral recess
stenosis on Plaintiff. (R. 316.) In the weeks following
surgery, Plaintiff continued to follow-up with Dr. Koutsky
and participate in physical therapy. (R. 455, 459.) An MRI
from September 18, 2014, showed: 1) postoperative changes
following laminectomy L4-L5; 2) enhancing fluid collection in
the subcutaneous fat in the operative site and the epidural
space at ¶ 4-L5; and 3) residual mild disc bulge and
endplate spurring at ¶ 4-L5 without new disc herniation
or spinal stenosis. (R. 463.) Approximately six weeks
post-surgery, Plaintiff began to notice some drainage in his
surgical wounds, and Dr. Koutsky believed that an irrigation
and debridement surgery would need to be performed. (R. 454.)
Plaintiff had that surgical procedure done on September 30,
2014, and was discharged from the hospital October 2, 2014.
three weeks of healing, Plaintiff was cleared to resume
physical therapy. (R. 450.) On December 11, 2014, Dr. Koutsky
opined that Plaintiff would “likely need a few more
months of therapy” and would remain off work during
that time. (R. 448.) Plaintiff continued physical therapy and
treating with Dr. Koutsky until May 4, 2015, when he was
transitioned to a work hardening/conditioning program; the
plan was to conduct a functional capacity examination
(“FCE”) following completion of the work
hardening/conditioning program. (R. 671.) Following 20
sessions of work conditioning, Plaintiff was able to walk
without pain for 30 minutes at two miles per hour, his lumbar
range of motion was within normal limits, and could lift 20
pounds from floor to his waist 10 times with minimal
complaints of low back pain. (R. 730.) His physical therapist
reported that he was able to tolerate constant standing, and
frequent squatting, stooping, bending, and twisting. (R.
731.) After, 30 sessions of work conditioning, Plaintiff was
additionally able to lift 45 pounds from knee to waist for
two sets of ten repetitions. (R. 732.)
29, 2015, Plaintiff had an FCE with Agnes C. Lim, P.T. (R.
722.) Ms. Lin made the following findings regarding
Plaintiff's functional activity tolerance: 1) frequent
sitting, standing, and walking; 2) frequent stooping/bending;
3) constant twisting; 4) frequent squatting; 5) frequent
pushing/pulling a sled with 45 pounds for 25 feet; 6)
occasional pushing/pulling a sled with 60 pounds for 25 feet;
7) frequent lifting/carrying 25 pounds from floor to chest
for 15 feet; 8) occasional lifting/carrying 45 pounds from
floor to chest for 15 feet; 9) frequent reaching with
deficits; and 10) constant grasping/handling. (R. 727.) She
concluded that Plaintiff's “current functional
abilities and musculoskeletal findings demonstrate that he
cannot return to his previous full work activity.” (R.
723.) However, she found that Plaintiff “demonstrated
the physical capabilities to function at the Light-Medium
Physical Demand Level as defined by the U.S. Department of
Labor, which is indicative of a 2-hand occasional lift of 45
lbs. from floor to chest level.” (R. 722.)
follow-up with Dr. Koutsky after the FCE on August 6, 2015.
(R. 667.) Dr. Koutsky noted that Plaintiff's therapist
recommended Plaintiff continue with work conditioning until
the end of the month, kept Plaintiff off work, and gave
Plaintiff bilateral paralumbar muscle trigger point
injections. (R. 667.) Plaintiff continued work conditioning
into September 2015, at which time he was scheduled for a
final FCE. (R. 752.) According to Dr. Koutsky, “[w]e
anticipate returning him to work per the FCE restrictions,
however, he remains off, pending the evaluation.”
second FCE was performed by Ms. Lim on September 23, 2015.
(R. 782.) She concluded that Plaintiff's “current
functional abilities and musculoskeletal findings demonstrate
that he cannot return to his previous full work
activity” because he was unable to meet the necessary
push/pull and lift/carry requirements to perform his
essential job demands. (R. 783.) However, she found that
Plaintiff “demonstrated the physical capabilities to
function at the Medium Physical Demand Level as defined by
the U.S. Department of Labor, which is indicative of a 2-hand
occasional lift of 50 lbs. from floor to chest level.”
October 22, 2015, Plaintiff reported to Dr. Koutsky that he
had completed his work conditioning program and he had been
improving. (R. 751.) On November 19, 2015, Dr. Koutsky noted
that Plaintiff had completed all of his physical therapy,
advised Plaintiff to continued his physical therapy exercises
at home, and released him to work with restrictions
consistent with his FCE. (R. 750.) Plaintiff continued to
follow up with Dr. Koutsky through the first half of 2016;
although he occasionally had increased back pain, he reported
he was managing his condition “fairly well”
through home exercise and as-needed pain medication. (R.
filed his application for disability insurance benefits on
June 9, 2014. (R. 21.) His claim was denied initially on
August 25, 2014, and upon reconsideration on April 15, 2015.
Id. Plaintiff requested a hearing before an
Administrative Law Judge (“ALJ”), which was held
in Chicago on October 27, 2016. Id. The ALJ issued a
written opinion on January 9, 2017, finding that Plaintiff
had been disabled from October 18, 2013, through July 28,
2015, but was not disabled beginning on July 29, 2015. (R.
21-38.) Plaintiff requested a review by the Appeals Council,
which was denied on January 24, ...