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James G. v. Saul

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

September 11, 2019

JAMES G., JR., Plaintiff,
ANDREW M. SAUL, Commissioner of the Social Security Administration[1], Defendant.


          Susan E. Cox U.S. Magistrate Judge.

         Plaintiff James G., Jr. (“Plaintiff”)[2] appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying his disability insurance benefits under sections 216(i) and 223(d) of the Social Security Act through March 31, 2017, the last date insured. The Parties have filed cross motions for summary judgment. For the reasons detailed below, the Commissioner's Motion for Summary Judgment (dkt. 23) is granted, Plaintiff's motion (dkt. 12) is denied, and the Administrative Law Judge's decision is affirmed.

         I. Background

         a. Factual Background and Procedural History

         Plaintiff alleges an inability to work due to pain in his lower back and legs resulting from two workplace injuries. (R. 195-99.) Although Plaintiff fully recovered from the first injury occurring in 2008 - which required in an L5-S1 fusion - he was reinjured in 2012. (R. 286, 361.) Plaintiff, a 35-year-old delivery truck driver for a beverage company, injured his back for the second time on January 4, 2012; while attempting to bounce a 250-pound handcart up a flight of stairs, Plaintiff felt a pop with sharp pain to his lower back. (R. 459, 671.) After treatments of injections, pain medications, and physical therapy, Plaintiff's treating physicians and physical therapists released him to light and medium work consistent with an FCE performed in 2013. (R. 295, 685.) However, State agency doctors recommended restricting Plaintiff to sedentary work while noting “subjective complaints of back pain” and that Plaintiff's statements regarding the intensity, persistence, and limiting effects of the symptoms were not substantiated by the objective medical evidence alone. (R. 66, 70, 79.)

         In February of 2013, Dr. Daniel A. Troy deemed Plaintiff to have reached a medium-to-heavy physical demand level from a functional standpoint. (R. 337.) Several months later Frank Berardi OTR revealed Plaintiff's ability to perform light to medium work, with several lifting and postural restrictions including no lifting or carrying weight greater than 30 pounds on an occasional basis. (R. 355.) On May 7, 2013, Plaintiff reported chronic numbness in the left leg related to his previous back surgery performed in 2008. (R. 398-399.)

         In August 2014, orthopedic notes from Dr. Troy indicate Plaintiff was continuing to have chronic pain with radiation to his right leg. (R. 286) Imaging revealed degeneration of the lumbosacral discs consistent with status post L5-S1 fusion in 2008. (R. 287.) Gabapentin and Norco were prescribed for pain. (Id.)

         On November 4, 2014, Plaintiff reported an acute exacerbation of his chronic back pain. (R. 410.) On November 9, 2014, examination revealed tenderness from L1 to L5, limited range of motion, decreased sensation over the lateral aspect of his bilateral legs, muscle spasm bilaterally in the paraspinous muscles, and a positive straight leg raising test. (R. 333-34.) Gabapentin and Norco were again prescribed, and Plaintiff was scheduled for an epidural injection. (Id.)[3] On November 20, 2014, an MRI and CT scan of Plaintiff's lumbar spine revealed Grade 1 anteriolisthesis of L5 on S1 with postsurgical changes, moderate circumferential osteophytes resulting in mild to moderate bilateral neuroforaminal narrowing, and mild degenerative changes elsewhere within the lumbar spine. (R. 342.)

         In December 2014, an orthopedic examination by Dr. Nicholas Angelopoulos noted a moderate antalgic gait and moderate limp while walking, muscle spasm bilaterally in the paraspinous muscles, restricted lumbar range of motion, 4/5 muscle strength in the lower left extremity, and a positive straight-leg raising test bilaterally. (R. 654.) During this examination, Plaintiff also revealed a history of a right knee ligament repair and a family history of osteoporosis. (R. 653.)

         In May of 2015, Plaintiff visited Dr. Alexander Ghanayem. (R. 672.) According to Dr. Ghanayem's examination, Plaintiff had subjective complaints of bilateral leg pain in multiple nerve distributions including L3, L4, L5, and S1 “in the context of a fusion that is radiographically stable at ¶ 5-S1, and no evidence of any adjacent level problems.” (Id.) Additionally, Dr. Ghanayem noted that “there is no objective structural loss of integrity in his lumber spine looking at the postoperative MRI scan” and that “the new onset of leg symptoms is not substantiated by objective testing.” (Id.) Dr. Ghanayem concluded his note recommending that Plaintiff “should return back to work at his pre-January 4, 2012 work status” and that “a brief course of physical therapy on the order of six to eight weeks would have been medically reasonable for the work injury as described.” (Id.)

         In July 2015, Plaintiff underwent a physical consultative examination with Dr. Kimberly Middleton, a family medicine practitioner. (R. 452-56.) The examination was based upon Dr. Middleton's brief examination and a review of Dr. Troy's treatment notes from August 30, 2014. (R. 452.) Plaintiff presented with pain upon palpation along the paraspinal musculature bilaterally throughout the lumbar spine, spasms along the L4-S1 distribution, tenderness with palpation of the right S1 joint, and positive straight leg raising in both the sitting and supine position on the right. (R. 453-55.) He exhibited decreased tactile sensation along the “L5” distribution on the right, decreased tactile sensation along the left thigh, leg, and foot, and decreased flexion and pain with bilateral rotation and extension of the lumbar spine. (Id.)

         Treatment notes from June 2016 through May 2017 from Karuna Sachdeva, PA and Dr. Joel See, MD indicate that Plaintiff displayed a moderate antalgic gait, and that he had reported pain with forward flexion and extension of the lumbar spine and positive tenderness to palpation over the paraspinals. (R. 688, 694, 700, 704, 709, 714, 719.) On June 15, lumbar x-rays revealed mild bilateral perineural fibrosis involving the traversing bilateral S1 nerve roots and mild to moderate multilevel facet osteoarthritis of the mid to lower lumbar spine. (R. 729.)

         Plaintiff was seen eight times by his treating pain management physician, Dr. Joel See, from September 6, 2016 through May 30, 2017. (R. 692-736.) On October 7, 2016, Dr. See noted that the MRI taken on June 15, 2016 showed no significant disc or facet abnormality, spinal stenuosis, or foraminal narrowing on L1-L2 or L2-L3, however there was mild to moderate bilateral facet arthropathy with ligamentum flavum thickening and facet hypertrophy from L4-L5 with no significant disc disease and no significant stenuosis. (R. 729.) In Plaintiff's L5-S1, Dr. See notes evidence of a posterior hardware fusion with bilateral laminectomies and interbody fusion with a grade 1 anterolisthesis of approximately 6 millimeters with mild enhancing granulation tissue or fibrosis extending into the subarticular zones with suspicion for mild bilateral perineural fibrosis. (Id.)[4] On November 7, 2016, Plaintiff reported “having functional improvement on the pain medications.” (R. 721.) On December 7, 2016, Plaintiff received ultrasound guided trigger point injections with a solution containing “6 cc of 1% Lidocaine and 1 cc of Depo-Medrol 40 mg per mL 60 mg Toradol.” (R. 719.) Dr. See noted that Plaintiff “tolerated the procedure well and reported some immediate pain relief.” (R. 720.) On February 1, 2017, Plaintiff reported that the trigger point injection was not very helpful. (R. 711.) Plaintiff also presented with “new complaints of pain and numbness in the left hand.” (Id.) However, Plaintiff did note that “he is taking the pain medication with some improvement.” (Id.) On March 1, 2017, Plaintiff reported that “he does get adequate analgesia, and he has the ability to comfortably perform his activities of daily living.” (R. 710.) Additionally, Dr. See ordered a diagnostic testing nerve conduction study and EMG from his clinic. (Id.) On April 3, 2017, Dr. See noted that Plaintiff's EMG and nerve conduction study of the upper extremities “is significant for moderate to severe carpal tunnel on the right and mild on the left” after demonstrating no signs of physical discomfort during testing conducted in 2013. (R. 372-75, 705.) Further, Plaintiff reported “having improvement of his backpain” with his prescribed medications, which were then refilled by Dr. See. (Id.) On May 1, 2017, Plaintiff reported that he was “having functional improvement with activities on the pain medication.” (R. 697.) On May 30, 2017, Plaintiff followed-up with Dr. See after he had received a right hand carpal tunnel injection 2 weeks prior from Dr. Cohen. (R. 692.) Plaintiff reported good pain relief in that area and conveyed that surgery was being discussed. (Id.) Additionally, Plaintiff reported that he continues taking the prescribed pain medication for back and leg pain “with improvement.” (Id.)

         Plaintiff alleged irritability, impaired sleep patterns, and “feeling down all the time” to State consultative psychological examiner Kathryn Murphy, Psy.D. (R. 449.) He had been diagnosed with depression in approximately 1999, but his symptoms returned after his second back injury. (R. 447.) In July 2015, a State consultative psychological examiner concluded that Plaintiff “endorsed symptoms of Unspecified Depressive Disorder.” (R. 449.)

         Plaintiff field a Title II application for a period of disability and disability insurance benefits on October 29, 2014 alleging disability beginning January 4, 2012. (R. 13.) Initially, the claim was denied on August 26, 2015 and then upon reconsideration on December 4, 2015. (Id.) Plaintiff filed a written request for hearing in front of an Administrative Law Judge (“ALJ”), which took place on July 31, 2017 in Orland Park, Illinois. (Id.) The ALJ issued a written opinion on September 8, 2017, finding that Plaintiff was not disabled under sections 216(i) and 223(d) of the Social Security Act through March 31, 2017, the last date insured. (R. 13-23.) On May 9, 2018, the Appeals Council denied review, thus making the ALJ's decision the final decision of the agency, and vesting the Court with jurisdiction to hear this appeal. (dkt. 13 at 1.)

         b. The ALJ's Decision

         The ALJ, William Spalo, issued a written decision on January 9, 2017. (R. 13-23.) The ALJ found that Plaintiff was not under a disability, as defined in the Social Security Act, at any time from January 4, 2012, the alleged onset date, through March 31, 2017, the date last insured. (R. 23.) At step one, [5] the ALJ found Plaintiff had not engaged in substantial gainful activity since the date of alleged onset, January 4, 2012. (R. 15.) At step two, the ALJ concluded that Plaintiff had the severe impairments of degenerative disc disease of the lumbar, spine status post fusion, and a recent diagnosis of carpal tunnel syndrome. (Id.) The ALJ noted that although the Plaintiff's severe impairments caused more than a minimal impact on his ability to perform work-related activities, his medically determinable mental impairments of depression and anxiety did not cause more than a minimal limitation on his ability to perform basic mental work activities. (Id.) Thus, they were non-severe. (Id.) At step three, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments of 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 17.)

         For the Disability Period, the ALJ found that Plaintiff had the residual functional capacity (“RFC”) to perform sedentary work as defined in 20 CFR 404.1567(a) except that he could never climb ladders, ropes, or scaffolds, could only occasionally balance, stoop, kneel, crouch, crawl, and climb stairs or ramps. (R. 18.) Additionally, the ALJ found that Plaintiff could frequently handle and finger, bilaterally, although he should avoid concentrated exposure to extreme cold and humidity. (Id.) At step four, the ALJ further found that Plaintiff was unable to perform any past relevant work through the date last insured. (R. 22.) The ALJ noted that although the vocational expert testified that the Plaintiff had past worked as a delivery truck driver, which is semi-skilled and generally performed at the medium exertional level, Plaintiff described performing his role at the heavy exertional level. (R. 22.) Because of Plaintiff's residual functional capacity assessment, the ALJ concluded that Plaintiff was unable to perform past relevant work. (Id.) At step five, the ALJ determined that, considering the Plaintiff's age, education, work experience, and RFC, there were jobs that existed in significant numbers in the national economy that Plaintiff could have performed through the date last insured. (Id.) Therefore, the Plaintiff was not disabled at any time from the alleged onset date through the date last insured. (R. 23.) According to the ALJ and based on the testimony of the vocational expert, Plaintiff was capable of making a successful adjustment to other work that existed in significant numbers in the national economy. (Id.)

         II. Social Security Regulations and Standard of Review

         The Social Security Act requires all applicants to prove they are disabled as of their date last insured to be eligible for disability insurance benefits. ALJs are required to follow a sequential five-step test to assess whether a claimant is legally disabled. The ALJ must determine: (1) whether the claimant is currently engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; and (3) whether the severe impairment meets or equals one considered conclusively disabling such that the claimant is impeded from performing basic work-related activities. 20 C.F.R. § 404.1520; 20 C.F.R. § 416.920(a)(4)(i)-(v). If the impairment(s) does meet or equal this standard, the inquiry is over and the claimant is disabled. 20 C.F.R. § 416.920(a)(4). If not, the evaluation continues and the ALJ must determine (4) whether the claimant is capable of performing his past relevant work. Cannon v. Harris, 651 F.2d 513, 517 (7th Cir. 1981). If not, the ALJ must (5) consider the claimant's age, education, and prior work experience and evaluate whether she is able to engage in another type of work existing in a significant number of jobs in the national economy. Id. At the fourth and fifth steps of the inquiry, the ALJ is required to evaluate the claimant's RFC in ...

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