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Ronald B. v. Saul

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

August 12, 2019

RONALD B. Plaintiff,
ANDREW SAUL, Commissioner of Social Security, [1] Defendant.



         Plaintiff, Ronald B., moves for summary judgment seeking reversal and remand of the final decision of defendant, the Commissioner of Social Security ("Commissioner"), denying his application for disability insurance benefits ("DIB") (doc. # 14; doc. # 15: Pl.'s Summ. J. Mem.). The Commissioner has filed a cross motion for summary judgment asking us to affirm his decision (doc. # 18; doc. # 19: Def.'s Summ. J. Mem.), and Mr. B. has filed a reply (doc. # 23: Pl.'s Reply). For the following reasons, we grant Mr. B.'s motion, deny the Commissioner's motion, and remand the case for further proceedings.


         On October 31, 2014, Mr. B. applied for DIB, alleging disability due to multiple right shoulder surgeries, chronic pain in his right shoulder and arm, retinal detachment in his right eye, diabetes, and obesity (R. 114-15, 130, 153, 246). Although initially alleging a disability onset date of September 12, 2012, Mr. B. shortly thereafter amended his alleged onset date to February 10, 2014 (R. 229, 232). The Social Security Administration ("SSA") denied Mr. B.'s application at the initial and reconsideration stages of review, after which Mr. B. requested a hearing before an Administrative Law Judge ("ALT) (R. 130, 145, 148-51, 153-56, 158-59). On June 21, 2017, the ALJ held a hearing at which Mr. B. and a vocational expert ("VE") testified (R. 65-113). On September 18, 2017, the ALJ issued a decision denying Mr. B.'s DIB claim (R. 15-33). The Appeals Council denied Mr. B.'s request to review the ALJ's decision, making the ALJ's decision the final decision of the Commissioner (R. 1-6). See Varga v. Colvin, 794 F.3d 809, 813 (7th Cir. 2015); 20 C.F.R. § 404.981.


         Mr. B. was born on May 5, 1965 (R. 229). He is between 5'11" and 6'1" tall and has weighed between approximately 230 and 300 pounds (see, e.g., R. 846 (January 2014 record reporting a height of 71 inches and weight of 230 pounds); R. 908 (August 2015 record reporting a height of 71 inches and weight of 264 pounds); R. 1031 (December 2016 record reporting a height of 6' 1" and weight of 302 pounds)). He is right-handed (R. 81). After graduating high school in 1983, Mr. B. obtained a commercial driver's license ("CDL") in 1988 and worked as a commercial truck driver (R. 86, 91-92, 103, 233-35, 237, 239-40, 247, 265; see also R. 366 (June 2013 record noting that Mr. B. had been employed as a semi-tractor trailer driver for 26 years)).


         In September 2012, Mr. B. injured his right shoulder while off-loading corrugated boxes from a truck (R. 366, 425). About six months later, in March 2013, Michael Maday, M.D., an orthopedic surgeon, performed rotator cuff surgery on Mr. B.'s right shoulder (R. 250, 711-13). Despite the right shoulder injury and surgery, Mr. B. continued to work as a truck driver in some capacity until February 9, 2014 (R. 79-80, 232, 234-35, 237, 240; see also R. 426 (October 2013 record noting that Mr. B. "has not returned to work full duty but is currently working light duty")).[3]The next day, on February 10, 2014 (which is also Mr. B.'s amended disability onset date), Dr. Maday performed a second rotator cuff surgery on Mr. B.'s right shoulder (R. 674-76). In May and June 2014, Mr. B. was taking tramadol and ibuprofen for his right shoulder pain, and his doctor advised him to continue to do so (R. 311-14).

         In July 2014, Mr. B. presented to Preeti Poley, M.D., for evaluation of decreased right-eye vision that he had been experiencing since April 2014 (R. 771). Dr. Poley noted that Mr. B. had cataracts in both eyes and a detached retina in his right eye, and she planned for Mr. B. to have the cataract in his right eye removed and then have another surgery to repair the retina (Id.). Dr. Poley further explained that the primary goal of surgery was to repair the retina and prevent blindness; even with surgery, she did not expect Mr. B.'s vision to improve because of the duration of the retinal detachment (Id.). In August 2014, Dr. Poley operated on Mr. B. to repair the detached retina in his right eye (R. 760-61, 786).

         In October 2014, Dr. Maday completed a residual functional capacity questionnaire regarding Mr. B.'s shoulders and hands (R. 1049-51). Dr. Maday diagnosed Mr. B. with a full rotator cuff tear and an AC joint derangement (R. 1049). Dr. Maday stated that Mr. B. had numbness in his fingers and no strength in his right arm and shoulder (R. 1049, 1051). According to Dr. Maday, Mr. B. could only lift 10-15 pounds and could not reach overhead with his right arm (R. 1049-50).

         In March 2015, Mr. B. underwent cataract surgery on his left eye (R. 801, 813). The same month, Mr. B. reported to the SSA that he took oxycontin (a brand name for oxycodone) and tramadol for pain (R. 248). The next month, April 2015, Mr. B. again reported to the SSA that he was taking oxycodone (325 mg) and tramadol (R. 271). He also reported that he could not lift his right arm over his head or lift over 15 pounds and that he still had a hard time seeing (R. 264, 269).

         In August 2015, non-examining state agency consultants Jerda Riley, M.D., and Craig Billinghurst, M.D., reviewed Mr. B.'s medical evidence at the initial stage of SSA review (R. 114-29). Although the doctors found that Mr. B. had one or more medically determinable impairments and exhibited various exertional, postural, visual, and environmental limitations, they ultimately determined that Mr. B. was not disabled (R. 121-29).

         In September 2015, non-examining state agency consultant Calixto Aquino, M.D., reviewed the medical evidence at the reconsideration stage of SSA review (R. 131-44). He too concluded that Mr. B. had one or more medically determinable impairments and exhibited various functional limitations (R. 137-42). Dr. Aquino opined that Mr. B. could lift and/or carry 20 pounds occasionally and 10 pounds frequently and would be limited to occasional pushing, pulling, and reaching with his right arm (R. 139-40). Dr. Aquino also opined that Mr. B. could stand, walk, or sit for about 6 hours in an 8-hour workday; occasionally climb ramps and stairs, kneel, crouch, and crawl; frequently balance and stoop; and never climb ladders, ropes, or scaffolds (R. 139). Ultimately, though, Dr. Aquino also determined that Mr. B. was not disabled (R. 142-43).

         Around the same time, Mr. B. reported that he took tramadol for pain (R. 278). The following month, October 2015, Mr. B. again underwent another retinal surgery on his right eye (R. 927-29). This surgery was followed by another eye surgery in January 2016, when Mr. B. underwent cataract surgery on his right eye (R. 945).

         In June 2016, Mr. B. returned to work as a truck driver (R. 78-79, 88-89, 92-93, 238).[4]Over the next five to six months, he made about 30 truck runs (R. 92-94, 1047). During this time, in October 2016, Mr. B. underwent YAG laser capsulotomy on both eyes (R. 961-62). On November 24, 2016, Mr. B. fell climbing onto the trailer of the truck and injured his right leg and knee (R. 78, 89-90, 1040, 1047). Mr. B. has not worked since then.

         In December 2016, Mr. B. presented to orthopedic surgeon Jay Brooker, M.D., for evaluation of his right knee (R. 937). Dr. Brooker noted that an MRI and x-rays "revealed degenerative findings and a degenerative meniscal tear that occurred as a result of Mr. B.'s November 2016 work injury (Id.). At a follow-up visit a few weeks later, Dr. Brooker reported that weight bearing films revealed that Mr. B.'s right knee was "bone on bone with medial joint space loss and osteophyte formation" (R. 938). Dr. Brooker noted that Mr. B. had not had symptoms prior to his recent injury, and he stated that the work injury significantly exacerbated Mr. B.'s right-knee arthritis (Id.). Dr. Brooker also surmised that Mr. B.'s "repetitive heavy lifting, climbing, crouching and kneeling" over his 30 years of truck driving were probably "the main contributor[s] to the wear and tear in his knee" (Id.).

         In January 2017, Mr. B. saw Dr. Brooker for another follow-up visit (R. 939). Dr. Brooker stated that the meniscal tear Mr. B. suffered as a result of his November 2016 injury was probably "just the last straw" and the injury "exacerbated his arthritis to the point where he is unable to work" (Id.). Dr. Brooker recommended a right total knee replacement and indicated that until Mr. B. had one, "he is not going to be able to function" (R. 939, 1048).

         In March 2017, in connection with workers compensation and at the request of Zurich North America, Mr. B. underwent an independent medical examination performed by Brian Forsythe, M.D. (R. 1039-48). At the examination, Mr. B. reported that he had not had any treatment for his right knee before his November 2016 work injury (R. 1040). Dr. Forsythe recommended that Mr. B. return to full duty work without restrictions and opined that Mr. B. was at maximal medical improvement as it related to his right knee and the work injury (R. 1042). In April 2017, however, Sandra McGowan, M.D., (who Mr. B. identified as his primary doctor) and the orthopedics group at Advocate Medical Group evaluated Mr. B. and "recommended that he not return to work at this time" (R. 97, 1062).

         On June 6, 2017, Mr. B. presented to Joseph D'Silva, M.D., complaining of severe right knee pain (R. 46-47). Dr. Silva diagnosed Mr. B. with knee osteoarthritis (R. 47). He further noted that Mr. B. ...

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