United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
JEFFREY I. CUMMINGS UNITED STATES MAGISTRATE JUDGE.
W. (“Claimant”) brings a motion for summary
judgment to reverse or remand the final decision of the
Commissioner of Social Security denying his claim for
Disability Insurance Benefits (“DIBs”). The
Commissioner brings a cross-motion seeking to uphold the
decision to deny benefits. The parties have consented to the
jurisdiction of a United States Magistrate Judge pursuant to
28 U.S.C. § 636(c). This Court has jurisdiction to hear
this matter pursuant to 42 U.S.C. § 405(g). For the
reasons that follow, Claimant's motion for summary
judgment (Dkt. 17) is granted and the Commissioner's
motion for summary judgment (Dkt. 24) is denied.
October 27, 2014, Claimant (then 48 years-old) filed for DIBs
alleging disability beginning on May 14, 2014 due to chronic
back pain and high blood pressure. (R. 105.) His date last
insured was September 30, 2016. (R. 14.) Claimant's
application was denied initially and upon reconsideration.
(R. 73-96, 101-05, 112-16.) Claimant filed a timely request
for a hearing, which was held on October 13, 2016 before an
Administrative Law Judge (“ALJ”). (R. 30-72.)
Claimant appeared with counsel and offered testimony at the
hearing. A vocational expert also offered testimony.
December 21, 2016, the ALJ issued a written decision denying
Claimant's application for benefits. (R. 14-24.) Claimant
filed a timely request for review with the Appeals Council.
(R. 173.) On September 25, 2017, the Appeals Council denied
Claimant's request for review, leaving the decision of
the ALJ as the final decision of the Commissioner. (R. 1-4.)
This action followed.
Medical Evidence in the Administrative Record
alleges disability due to back pain, high blood pressure, and
depression. The records before the Court reveal a history of
four back surgeries, the most recent in 2006, and, as
explained in more detail below, a left hip replacement in
January 2012 following a fall down the stairs. (R. 312-320,
462-587.) The administrative record contains the following
additional medical evidence that bears on Claimant's
Evidence from Claimant's Treating Physicians Primary
Care Physician - Dr. Dalawari
has been under the care of internist Dr. S. Dalawari since as
early as 2010. After falling down the stairs in August 2011,
Claimant saw Dr. Dalawari and complained of lower back pain
and left hip pain. (R. 681, 704.) An x-ray of his hip showed
no fractures or other significant abnormalities. (R. 707.)
Subsequent imaging of the left hip, however, showed
osteoarthritis and labral degeneration with suspicion of a
small tear. (R. 689.) Imaging of the lumbar spine revealed,
among other things, a small disc protrusion at ¶ 3-L4
with mild to moderate central canal stenosis and moderate
right foraminal stenosis at ¶ 4-L5. (R. 691-92.) Dr.
Dalawari recommend physical therapy and prescribed tramadol
for pain and cymbalta for depressive symptoms. (R. 677, 681,
693-95, 704.) Ultimately, Claimant was referred to an
orthopedic surgeon for his continued hip and back pain, and
he underwent a left hip replacement in January 2012. (R.
462-587, 679.) Following his hip replacement, Claimant
continued to occasionally follow-up with Dr. Dalawari for
medication management. (R. 666-70.)
early 2014 - - a few months prior to his alleged onset of
disability - - Claimant had few complaints though he saw Dr.
Dalawari every few weeks for blood pressure checks and
medication management. (R. 660-65.) By that time, Dr.
Dalawari had determined that Claimant had hypertension, high
cholesterol, osteoarthritis of the pelvic region and spine,
depressive disorder, and lumbago. (R. 660). On June 2, 2014,
Claimant complained of upper chest and back pain. (R.
656-57.) A physical exam revealed normal results.
(Id.) Dr. Dalawari started Claimant on medrol and
naproxen for pain a few weeks later (R. 653-54), and he
described Claimant's pain as thoracic spine pain on June
26, 2014. (R. 650-51.)
physical exam in June 2015 revealed tenderness of the
thoracic spine. (R. 751-52.) By that time, Claimant had been
prescribed morphine and vicodin for pain. (R. 752.) Lower
back pain and tenderness were again noted in October 2015 and
February 2016. (R. 754-59.) In June 2016, Claimant told Dr.
Dalawari that his neurosurgeon, Dr. Trombly, recommended
surgery, but that he was interested in a second opinion. (R.
780.) Dr. Dalawari referred Claimant to another neurosurgeon.
(R. 782.) At his annual wellness visit a few weeks later,
Claimant was feeling depressed and had little interest in
doing things. (R. 775.)
Management - Dr. Elborno
31, 2013, Claimant began treatment at Midwest Academy of Pain
and Spine with Dr. A. Elborno. (R. 312, 321-24.) His chief
complaints were left hip and leg pain since his fall, which
he described as “stabbing” and rated a 5/10. (R.
321-22.) The pain was affecting his ability to walk, stand,
sit, and drive. (R. 322.) Claimant also described a history
of high blood pressure, asthma, and depression.
(Id.) On exam, Dr. Elborno noted tenderness and
discomfort of the lumbar spine, left leg and hip, and
decreased range of motion in the left hip. (R. 323-24.)
Claimant exhibited similar tenderness a few days later, at
which time Dr. Elborno diagnosed him with lumbar
radiculopathy and post-lumbar puncture syndrome status post
four back surgeries. (R. 329-30.) Dr. Elborno contemplated a
repeat MRI and “possible discography at ¶
3-L4.” (R. 330.) By June 14, 2013, Dr. Elborno had
reviewed a 2007 MRI, which showed no apparent disc herniation
at ¶ 3-L4. (R. 331-32.) Claimant had begun taking norco
for pain. (R. 332.)
returned to see Dr. Elborno in December 2013 and continued to
complain of left hip and back pain upon sitting, standing,
and walking. (R. 334-35.) Dr. Elborno informed Claimant of
various treatment options, including adult stem cell therapy
or a spinal cord stimulation trial. (R. 335.) Claimant
continued on norco and reported no recent changes at his next
appointment in January 2014. (R. 336-39.) In March 2014, Dr.
Elborno assessed osteoarthritis of the hip and administered a
steroid injection. (R. 342-44.) Claimant's lower back and
hip pain were “well controlled” with medications
in May 2014. (R. 347-48.) But, at his next appointment in
June 2014, Claimant stated that his hip pain was
“getting worse” with additional thoracic back
pain, and that his medication was “not helping
much.” (R. 353.) Dr. Elborno again contemplated a
spinal cord stimulation trial, but first recommended a
psychological evaluation, and further noted that
“patient doesn't want to be on narcotics.”
(Id.) Notwithstanding this, Dr. Elborno prescribed
norco and morphine for Claimant and ordered an MRI of his
thoracic spine. (R. 354.)
August 2014, Claimant's lower back pain was well
controlled with medications and he was “doing
well.” (R. 366-67.) He reported lower and upper back
pain in October 2014, and Dr. Elborno assessed thoracic
spondylosis and degenerative disc disease. (R. 369-70.)
Claimant returned to see Dr. Elborno in April 2015,
complaining of pain in his middle and lower back, aggravated
by lifting, pushing, running, twisting, and walking. (R.
375.) He described his hip pain as “mild, ” but
constant. Aggravating factors included walking, sitting,
running and bending. (Id.) Pain relieving factors
included medication and injections. (Id.) A
musculoskeletal examination was normal. (R. 376.) Dr. Elborno
reported Claimant was “doing well” but
nonetheless directed him to continue taking norco and
morphine. (R. 377.)
followed-up with Dr. Elborno every few months throughout 2015
and into 2016, with continued complaints of back and left hip
pain, which he categorized as “constant, ”
“excruciating, ” and aggravated by activity. (R.
740-49.) Dr. Elborno continued Claimant on the prescribed
pain medication. (Id.) Claimant returned in May 2016
and again complained of pain aggravated by sitting, standing,
and movement. (R. 769.) A lumbosacral exam showed
“tenderness, increased with exertion and lateral
rotation bilateral with restriction and discomfort with range
of motion bilaterally. Spasm [was] noted to palpation of the
lumbar paraspinal areas.” (Id.) Dr. Elborno
described Claimant's pain as “well-controlled on
medication” in June 2016. (R. 788.) Dr. Elborno noted
tenderness and spasms of the lumbosacral area in July 2016.
(R. 793.) Claimant continued taking morphine and vicodin. (R.
794-95.) In September 2016, Claimant's “pain
severity [was] tolerable with medications, excruciating
without medications.” (R. 832.) Tenderness and
discomfort upon range of motion were again noted.
- Dr. Trombly
he had been examined by the state agency's consultants
(infra, at pages 8-9), Claimant - - upon Dr.
Dalawari's referral - - saw neurosurgeon Dr. R. Trombly
on July 30, 2015 for his continued back pain between his
shoulders down to the lower back. (R. 729.) Claimant told Dr.
Trombly that he was doing “pretty well” after his
hip replacement until May 2014 when he began having constant
pain in his back. (Id.) He further reported he had
been out of work since May 2014 due to back pain.
(Id.) Upon examination, Claimant exhibited a
slightly kyphotic (or rounded) posture. (R. 730.) Dr. Trombly
reviewed an MRI of the thoracic spine from September 2014,
which showed “no compression with mild kyphosis most
pronounced in lower thoracic region.” (Id.)
Dr. Trombly assessed mechanical back pain and recommended
physical therapy, posture training, and a CT of the lumbar
spine if the pain continued. (Id.)
October 20, 2015, Claimant had not started physical therapy
due to insurance reasons. (R. 732.) He told Dr. Trombly he
continued to have constant 4/10 sharp pain in his mid-back,
which increased to 10/10 with activity. (Id.) His
back pain was relieved upon laying down and aggravated by
sitting and physical activity. (R. 732.) A physical exam was
normal. (R. 732-33.) Dr. Trombly reviewed the recent lumbar
CT scan and noted postoperative and degenerative changes in
the lumbar spine. (R. 733.) He assessed lumbar degenerative
disc disease, lumbar spondylosis, and thoracic spondylosis
with radiculopathy. (Id.) Dr. Trombly recommended
further imaging, a trial of epidural injections, and, if pain
persists, a L3-S1 laminectomy. (Id.) Claimant's
pain was “the same” in January 2016 and was
limiting his activities to “1-2 hours max then [he] has
to sit.” (R. 735.) The physical exam was normal apart
from Claimant's continued rounded posture. (R. 735-36.)
Updated imaging showed mild degenerative changes in the
thoracic spine. (R. 736.) Dr. Trombly again ordered more
imaging and physical therapy. (Id.)
2016, Claimant reported minimal relief from his pain
medications and said that he could not “walk even
several blocks” or stand for prolonged periods. (R.
783.) Dr. Trombly planned to review recent CT images and then
consider a “revision L3-S1 decompression.”
(Id.) By October 2016, Dr. Trombly reviewed the CT
scans, which showed mild foraminal stenosis of the lumbar
spine and severe foraminal stenosis of the thoracic spine.
(R. 835.) Dr. Trombly again assessed thoracic spondylosis
with radiculopathy and stated that Claimant may need
injections or a thoracic laminectomy to decompress thoracic
nerve roots. (Id.)