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Rachel P. v. Saul

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

August 16, 2019

Rachel P., Plaintiff,
Andrew M. Saul, Commissioner of Social Security, Defendant.


          Manish S. Shah United States District Judge.

         Rachel P. worked as a security guard at O'Hare airport until an accident at work resulted in neck, back, and other injuries. When surgeries, physical therapy, and other treatments failed to alleviate her pain and other symptoms, Rachel applied for disability benefits. The ALJ who reviewed her application concluded that Rachel could perform limited light work and so was not disabled. Rachel filed this action for review of that decision.

         I. Legal Standards

         Because the Appeals Council denied review, the ALJ's decision constitutes the final decision of the Commissioner. Jozefyk v. Berryhill, 923 F.3d 492, 496 (7th Cir. 2019). The ALJ's decision will be upheld if it applies the correct legal standards and is supported by substantial evidence. 42 U.S.C. § 405(g); L.D.R. by Wagner v. Berryhill, 920 F.3d 1146, 1151 (7th Cir. 2019). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)).

         II. Background

         Rachel applied for disability insurance benefits and supplemental security income on August 10, 2015, alleging a disability onset date of July 14, 2013. A.R. 20, 189-201.[1] Her claims were twice denied before she received a hearing on June 16, 2017. A.R. 20, 41, 75-90, 93-110. The ALJ concluded that Rachel was not disabled and that she was able to perform a limited range of light work, including her previous jobs as a telemarketer or small products assembler. A.R. 31-32. The Appeals Council declined to review the ALJ's decision. A.R. 1-6.

         Rachel's health problems stem largely from injuries she sustained in July 2013, when-while working as a security officer at O'Hare Airport-she tripped on an x-ray machine and fell, injuring her neck, shoulders, wrists, lower back, and knees. A.R. 392. Since her injury, Rachel has complained of neck and back pain, as well as numbness and tingling in both hands and in her left foot. See, e.g., A.R. 368, 433, 437, 448. A 2013 x-ray revealed multilevel degenerative changes, spinal stenosis, and facet arthropathy. A.R. 367-68, 519-20. Arthrograms of Rachel's shoulders showed small tears and were consistent with impingement. Id.

         In February 2014, Dr. Espinosa, a neurosurgeon, treated Rachel and noted she had paraspinal tenderness, antalgic weakness of the bilateral deltoids, and decreased sensation in fingers on both of her hands. A.R. 462-64. Dr. Espinosa reviewed a 2013 MRI of Rachel's spine and concluded it showed herniations of vertebrae, causing moderately severe central canal stenosis (an abnormal narrowing), as well as signs of myelopathy (a functional disturbance or pathological change in the spinal cord). A.R. 464; see also stenosis and myelopathy, Dorland's Online Medical Dictionary (32nd. ed. 2012), An orthopedic surgeon, Dr. Patari, performed a right shoulder arthroscopic surgery on May 27, 2014. A.R. 521-23. A few months later, Dr. Espinosa performed a cervical discectomy and fusion. A.R. 444-45, 464.

         After her surgeries, Rachel continued to report neck and shoulder pain and stiffness, as well as burning, numbness, and tingling in her hands. A.R. 447-58, 466- 68, 474-84. Dr. Patari diagnosed impingement, recommended more aggressive therapy for Rachel to regain her range of motion, and told Rachel that she should expect a normal return of function. A.R. 504. A January 2015 upper extremity EMG showed signs of peripheral neuropathy. A.R. 472. In March, Rachel tried to return to work. See A.R. 226. A few months later, a traveler ran over her left foot with a suitcase, and Rachel was treated for neuritis and contusion. A.R. 542, 551. By early July, she stopped working because her employer could not accommodate her restrictions. A.R. 244, 258-59; see also A.R. 76 (Dr. Dow noting that this period was an unsuccessful work attempt and should not affect the potential onset date). Rachel did not work in 2016 or 2017. A.R. 226.

         Rachel visited Dr. Patari again in April 2016, complaining of left hand and shoulder pain and noting that she still had tingling in both hands. A.R. 500. Dr. Patari's exam indicated left scapular and shoulder strain. Id. He ordered an MRI and recommended physical therapy for scapular strengthening. Id. The MRI revealed a high-grade partial-thickness interstitial tear, and Dr. Patari recommended a left shoulder arthroscopy and rotator cuff repair. A.R. 499. In January 2017, Dr. Patari noted that Rachel continued to suffer from right shoulder and joint impingement. A.R. 497.

         Dr. Espinosa completed a Work Capacity Evaluation for the Department of Labor on May 1, 2015, noting that Rachel had reached maximum medical improvement and had permanent work limitations. A.R. 431. He noted Rachel could only sit for four hours, walk for three, and stand for two; should never reach overhead; and could only reach, twist, and bend and stoop up to two hours each. Id. He further noted that Rachel could perform repetitive movements with her wrists for only one hour and repetitive movements with her elbows for one hour. Id. Finally, he noted she was limited to pushing, pulling, and lifting up to 21 pounds for 4 hours. Id.

         Rachel testified at the hearing. When the ALJ asked her about her wrist braces, Rachel responded that she had peripheral neuropathy and that bending her hands caused a kink in the nerve and made her hands tingle and burn. A.R. 55-56. Rachel said she wore the braces at home and when she slept, but that she usually did not wear them outside of the house because they prevented her from picking anything up. A.R. 56-57. The ALJ noted that she had not seen the peripheral neuropathy diagnosis in the record but that she may have missed it, and Rachel's attorney pointed her to citations in the record. A.R. 56.

         Rachel testified that despite her right shoulder surgery, she could not reach behind her or above her head and that when she reached in front of her she felt pulling in her shoulder, neck, and in the middle of her back. A.R. 58. She said she suffered unpredictable episodes, where her hands would hurt and shake, and she would have to lay down until the episode passed. A.R. 58. Rachel also testified that her left foot burned and tingled, requiring her to sit down and elevate her foot four or five times a day. A.R. 59-60. Rachel stated her daughter opened any cans or bottles for her and got things out of upper cabinets so she would not have to reach overhead. A.R. 61. She also noted that while she could clean her condo, it took her much longer than it used to and that her daughter had to help move any furniture. A.R. 61. Rachel testified that she tried not to be on her feet more than a couple of hours per day to try to prevent the tingling and burning, because once it started it could last for days. A.R. 62. Sitting for extended periods caused severe back pain, which she described as feeling like somebody was stabbing her. A.R. 62-63. Rachel said she rarely used a computer, because of her hand condition, and she explained she could not work as a telemarketer, for example, because the constant reaching for the phone would be extremely painful. A.R. 64.

         At the hearing, both the ALJ and Rachel's attorney questioned the vocational expert. The ALJ asked whether there was relevant work for Rachel assuming she could never climb ladders, ropes or scaffolding; could not kneel or crawl, but could occasionally stoop and crouch; and could frequently reach in all directions except overhead; but could only occasionally use left foot controls. A.R. 67. The expert responded that with those restrictions an individual could work as a telemarketer or a small products assembler. A.R. 67. Next, she asked whether any of those jobs would allow Rachel to alternate sitting and standing every thirty minutes. A.R. 68. He responded that the added condition of alternating sitting and standing would eliminate all of Rachel's past work. Id. The ALJ then asked whether further ...

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