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Clemente A. v. Saul

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

August 22, 2019

CLEMENTE A.[1] Plaintiff,
v.
ANDREW MARSHALL SAUL, Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          Young B. Kim, United States Magistrate Judge

         Clemente A. seeks disability insurance benefits (“DIB”), claiming that he suffers from back, neck, and shoulder pain that prevents him from engaging in fulltime work. In this lawsuit Clemente seeks judicial review of the Commissioner of Social Security's decision denying his DIB application. See 42 U.S.C. § 405(g). Before the court are the parties' cross-motions for summary judgment. For the following reasons, Clemente's motion is denied, and the government's is granted:

         Procedural History

         Clemente applied for DIB in October 2014, alleging that he became disabled on March 3, 2012, when he was 48 years old. (Administrative Record (“A.R.”) 218.) After his application was denied initially and upon reconsideration, (id. at 96, 113), Clemente sought and was granted a hearing before an administrative law judge (“ALJ”). Clemente appeared and testified at the hearing, after which the ALJ issued a decision finding him not disabled. (Id. at 22-30.) The Appeals Council denied Clemente's request for review, (id. at 1-3), making the ALJ's decision the final decision of the Commissioner, see Jones v. Astrue, 623 F.3d 1155, 1160 (7th Cir. 2010). Clemente then filed this lawsuit, and the parties consented to this court's jurisdiction. See 28 U.S.C. § 636(c); (R. 6).

         Facts

         In November 2011 Clemente was struck by a bus that was moving between five to seven miles per hour. (A.R. 360.) He fell and landed on his side, injuring his left shoulder. (Id. at 359.) A few months after the accident, Clemente stopped working as a construction worker, and he claims that his on-going shoulder, neck, and back pain has rendered him disabled.

         A. Medical Evidence

         The medical records Clemente submitted to the ALJ show that in the year following his accident he underwent two separate surgeries to repair his injured left shoulder. In March 2012 he had a rotator cuff repair surgery, (A.R. 412), followed by seven months of physical therapy, (id. at 436-610). After Clemente continued to suffer pain despite physical therapy and cortisone injections, he underwent a left shoulder arthroscopy procedure in October 2012. (Id. at 619.)

         In the years following his second surgery Clemente sought treatment with an orthopedic specialist and pain specialists, who prescribed Vicodin and Norco for his pain. (See, e.g., Id. at 623, 628, 633, 706-07.) Clemente also received steroid injections. Throughout this time Clemente reported his pain levels in his neck and left shoulder as being between 5 and 8 on a scale of 1 to 10. (Id. at 709, 712, 718, 724, 745.) His doctors' examination notes show that he often had positive Yergason and Speed's tests (tests that measure for shoulder damage), and he exhibited a limited range of motion in his neck and tenderness in his left shoulder on palpation. (See, e.g., Id. at 702, 704, 710, 713.) At the same time, his doctors recorded him as having normal muscle strength, normal sensory exams, and a normal gait. (Id. at 612, 655, 701-02, 710.) One pain specialist opined in November 2013 that Clemente had no specific structural issues with his shoulder but was experiencing chronic pain. (Id. at 655.)

         In November 2014 Clemente underwent a residual functional capacity (“RFC”) evaluation with a rehabilitation specialist, Joseph Santillo. Santillo reported that Clemente exhibited low levels of physical effort during the test and he found minor inconsistencies in Clemente's reports of pain and disability. (Id. at 855.) After putting Clemente through a series of tests, Santillo opined that Clemente's shoulder pain limits his lifting, pulling, pushing, and carrying abilities, but concluded that he would be able to perform sedentary work. (Id. at 856, 859.)

         In February 2014 Clemente's doctor described him as stable taking two Norco a day, which helped with 60% to 70% of his pain, with no side effects and with no new complaints despite on-going back, neck, and shoulder pain. (Id. at 727.) A series of spine and shoulder MRIs taken in January 2015 showed mild tendinopathy in his left shoulder but no evidence of a labral tear. (Id. at 793.) Although the lumbar spine MRI revealed moderate degenerative disc disease, there was no evidence of a compression fracture or other “destructive process.” (Id. at 796.) In March 2015 an examining physician described Clemente as having normal muscle development without atrophy, no decreased range of motion in his spine, a negative straight leg test, 4/5 strength in his left upper extremity, and a slow but steady gait. (Id. at 833.)

         The following month in April 2015, consulting physician Dr. Leonore Gonzalez reviewed Clemente's records and opined that his pain complaints were disproportionate to the objective evidence, given his minimal limitations on examination. (Id. at 94.) Based on her review of the evidence Dr. Gonzalez concluded that Clemente can perform light work with some lifting and carrying limitations. (Id. at 92-93.) A month later consulting physician Dr. Yacob Gawo also reviewed the records and concurred that Clemente is capable of light work with limitations in lifting and carrying, but he added limitations in pushing and pulling. (Id. at 108-10.)

         B. Hearing Testimony

         Clemente testified that his pain has gotten worse over time despite his two surgeries. (A.R. 55-56.) He said that his neck pain runs down his arm to his wrist, causing a stabbing sensation and numbness in his hand. (Id. at 57.) Steroid injections typically provide only a week of relief. (Id.) Clemente testified that bending makes his pain worse and he is unable to sit or stand for extended periods. (Id. at 60.) He also testified that performing chores, tying his shoes, and ...


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