United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
I. Schenkier United States Magistrate Judge
Daniel S., moves for reversal and remand of the final
decision of the Commissioner of Social Security
("Commissioner") denying his application for
disability benefits (doc. #16; Pl's Mot. For Summ. J.,
doc. # 17: Pl's Mem.). The Commissioner has filed a
response brief, asking this Court to affirm the
Commissioner's decision (doc. # 22: Def.'s Resp.).
Plaintiff has filed his reply (doc. # 23). The matter is
fully briefed. For the following reasons, we grant Mr.
S.'s motion and remand the case.
applied for disability insurance benefits ("DIB")
on May 29, 2014, alleging an onset date of January 1, 2011
(R. 28, 163). The ALJ made a finding that Mr. S.'s date
last insured was March 31, 2017 (R. 28). Mr. S.'s claim
and subsequent appeal for reconsideration were both denied
(R. 105, 111). Shortly thereafter, Mr. S. filed a written
request for a hearing in front of an Administrative Law Judge
("ALJ") (R. 117). Mr. S. and a Vocational Expert
("VE") testified at the hearing held on October 31,
2016 (R. 45). On January 31, 2017, the ALJ issued a decision
denying Mr. S.'s claim for benefits (R. 28). The Appeals
Council declined to review the ALJ's decision, making it
the final word from the Commissioner (R. 1-4). See Varga
v. Colvin, 794 F.3d 809, 813 (7th Cir. 2015); 20 C.F.R.
was born on February 11, 1964 (R. 46). For 10 years prior to
his alleged onset date of January 1, 2011, Mr. S. worked for
the State of Illinois as a home health care professional (R.
48, 90). Following his employment with the state, Mr. S.
worked in a limited capacity as a custodian for the American
Legion (R. 51, 90). Mr. S.'s earnings after the alleged
onset date did not meet the necessary threshold requirements
to constitute substantial gainful activity ("SGA")
(R. 187). Mr. S. contends that he has both disabling mental
and physical impairments; however, we focus on his physical
impairments because the ALJ's treatment of those
impairments forms the basis of our decision in this
has been receiving treatment for various maladies from Dr.
Raymond Weiss since at least 2010 (R. 295). Specifically,
Dr. Weiss has treated Mr. S. for diabetes
mellitus and lumbar spine pain, and has
provided him referrals to other practitioners for his
persistent knee and elbow pain (R. 280-82, 304-16, 517, 530).
On October 26, 2012, Mr. S. visited Dr. Weiss with lower back
pain and was prescribed a Medrol Dosepack (R.
280). Mr. S. returned to Dr. Weiss with
complaints of lower back pain in August 2014, after falling
at work while lifting heavy objects (R. 347). Dr. Weiss
referred Mr. S. to physical therapy for treatment (R. 349).
mid-August 2014, Mr. S. attended the first of several
physical therapy sessions (R. 352). At the session, Jake Tan,
PT, noted Mr. S. had issues with carrying, moving, and
handling objects due to pain in the lower and middle back (R.
352). Subsequent sessions showed that while Mr. S.'s pain
and stiffness in his lower back decreased, he still had
trouble bending and lifting (R. 355-56). Mr. S. continued
physical therapy until December 2014. Mr. S. complained that
his back pain was not improving and that the use of a lumbar
brace while at work made no difference (R. 407). Furthermore,
Mr. S. explained that although he felt better after therapy,
the pain would come back and get worse at work despite his
efforts to take breaks (R. 406).
October 2014, Mr. S. was examined by Dr. Pimentel, a
consultative examiner for the agency, who determined that Mr.
S.'s ability to lift, carry or handle objects was mildly
impaired due to lumbosacral back pain and that his ability to
carry out work-related activities was also mildly impaired
due to that pain (R. 383). Dr. Pimentel stated that Mr. S.
was limited by 10 degrees from normal in flexion to the floor
in the lumbar spine and in the cervical rotation to the left
and right (R. 384). Dr. Pimentel also stated that Mr. S.
could walk greater than 50 feet unassisted with normal gait
and had mild difficulty in squatting and rising and hopping
on one leg (R. 383-85).
early November 2014, state agency examiner Henry Rohs, M.D.,
reviewed Mr. S.'s record and found severe impairments of
spinal disorders and diabetes mellitus (R. 88). Dr. Rohs also
opined that Mr. S. had mildly reduced range of motion and
poorly controlled diabetes (R. 89). Dr. Rohs concluded that
Mr. S. possessed medium work capability and was not disabled
(R. 91).In May 2015, Mr. S. sought
reconsideration of his disability claim (R. 94). State agency
examiner, Roy C. Brown, M.D., concurred with Dr. Rohs and
affirmed that Mr. S. was capable of medium work and thus was
not disabled (R. 102).
December 2014, Mr. S. visited Dr. Weiss with complaints of
back pain and pain in his right knee with ambulation (R.
529-30). Dr. Weiss suggested a plan of pain management for
lower back pain and offered referrals to an orthopedist for
knee pain (R. 530). On March 31, 2015, Dr. Weiss noted that
Mr. S.'s gait and stance were normal and that he retained
normal movement of all extremities but still had pain in his
knees and lower back (R. 528).
April 2015, Mr. S. sought treatment for his persistent knee
pain and was referred to Dr. Makda, an orthopedic surgeon (R.
502). On initial examination, Dr. Makda noted that Mr. S. had
swelling in both knees and that these symptoms had persisted
despite conservative management (R. 505-06). An x-ray of both
knees provided no evidence of arthritis, fracture or
dislocation (Id.). In May 2015, Mr. S. underwent an
MRI of his left knee (R. 567). Dr. Makda opined that the pain
was likely due to fibrocystic degenerative changes with
adjacent degenerative marrow edema (R. 568). An MRI of the
right knee performed several days later found "no
evidence of periarticular soft tissue swelling or joint
effusion" (R. 565).
7, 2015, Dr. Weiss completed a Physical Residual Functional
Capacity Questionnaire ("RFC Questionnaire"). Dr.
Weiss provided a prognosis of "fair" and indicated
that Mr. S. could sit for one hour at a time and stand for an
hour and 15 minutes at one time (R. 594). In addition, Mr. S.
could sit for less than two hours and stand/walk for about
four hours total in an eight-hour working day if provided
extra breaks (R. 595). Dr. Weiss opined that Mr. S. could
"rarely" lift and carry 20 lbs, 10 lbs, or less
than 10 lbs in a competitive work situation (Id.).
Furthermore, Dr. Weiss opined that Mr. S. would likely be
absent from work for more than four days per month
(R.595-96). Dr. Weiss indicated that Mr. S.'s pain would
frequently interfere with the attention and concentration
needed to perform simple work tasks, and that humidity and
wetness would exacerbate the pain (Id.).
December 2015, Mr. S. received a cortisone injection from Dr.
Makda to alleviate pain from lateral epicondylitis in his
left elbow and was advised to wear an armband (R.
517). In May 2016, Mr. S., on referral
from Dr. Weiss, visited Craig Shouse, DPM, to have a diabetic
foot screening. Dr. Shouse opined that Mr. S. had symptoms
consistent with diabetic neuropathy (R. 499).
18, 2016 Mr. S. received MRIs of his lumbar spine regarding
recurrent lower back pain and of his elbows regarding
bilateral elbow pain (R. 542-43). The MRI revealed moderate
to severe degenerative changes of the lumbar spine at L5-S1
(R. 542), but no evidence of elbow effusion, fracture or
dislocation (R. 543).
2016, Mr. S. again followed up with Dr. Weiss with complaints
of pain in his knees, feet, elbows and back (R. 491, 493).
Dr. Weiss suggested treatment of "disc diet and
exercise" and a follow up in three months (R. 494).
October 28, 2016, Dr. Weiss filled out a Medical Source
Statement of Ability to Do Work-Related Activities
("Medical Source Statement") and indicated that Mr.
S. could sit for between 0-2 hours during an eight-hour
workday, stand/walk for 1 hour during an eight-hour workday
and would need to alternate between sitting and standing
every 15 minutes while on the job to relieve pain and
discomfort (R. 601). Additionally, Dr. Weiss found that Mr.
S. could rarely lift less than 10 lbs, occasionally lift 10
lbs, could never push or pull and was limited to rarely
performing various manipulative activities (reaching all
directions, handling, fingering, feeling) (Id.). Dr.
Weiss also stated that Mr. S.'s pain would occasionally
interfere with his concentration to perform work tasks, that
several environmental limiting conditions must be ...