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Migdalia M v. Saul

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

October 28, 2019

MIGDALIA M, [1] Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant.


          Jeffrey Cole Magistrate Judge

         Plaintiff applied for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act (“Act”), 42 U.S.C. §§ 416(I), 423, 1381a, 1382c, nearly four years ago. (Administrative Record (R.) 234-45). She claimed that she became disabled as of March 25, 2013, due to carpal tunnel surgery on her left hand, left arm nerve and muscle damage, bilateral knee pain, right shoulder pain, hepatitis C, and depression. (R. 283). Over the ensuing three years, plaintiff's application was denied at every level of administrative review: initial, reconsideration, administrative law judge (ALJ), and appeals council. It is the ALJ's decision that is before the court for review. See 20 C.F.R. §§404.955; 404.981. Plaintiff filed suit under 42 U.S.C. § 405(g), and the parties consented to the jurisdiction of a Magistrate Judge pursuant to 28 U.S.C. § 636(c) on August 28, 2018. [Dkt. #6]. The case was reassigned to me on January 10, 2019. [Dkt. # 21], and was fully briefed in April 2019. Plaintiff asks the court to reverse and remand the Commissioner's decision, while the Commissioner seeks an order affirming the decision.



         Plaintiff was born on August 30, 1964 (R. 234), and was 48 years old when she claims she became disabled. (R. 234). She has a ninth-grade education, and a sporadic work history, briefly holding jobs at the night desk of hotels, in manufacturing, and in inventory. (R. 302). Most of these were through a temp agency. (R. 38). The only job she's had that lasted more than a few months was in a pharmaceutical plant. (R. 302). While she alleges an array of impairments, she seems to claim the most of her trouble is due to her knees, and to a lesser extent, to carpal tunnel syndrome.

         At about 420 pages, the medical record in this case is of average heft as these cases go and, as is usually the case as well, precious little of it has anything to do with whether the plaintiff is disabled or not. Indeed, the plaintiff, herself, indicates through citations to the record in her brief that not even 20 pages of the record matter to her claim that she is unable to work. [Dkt. # 16, at 3-4]. A summary of the relevant evidence follows.

         Plaintiff began seeing Dr. Randon Johnson for right knee pain in December 2013. (R. 409). Plaintiff indicated she had had right knee surgery in 1998 and 2006. (R. 409). While there was mild swelling and mild crepitus in the knee, range of motion was normal, there was no tenderness, no sign of tear, and the knee was stable. (R. 409). X-rays revealed some medial compartment narrowing. (R. 410). The doctor administered a corticosteroid injection. (R. 410). That worked for about four months, but in April 2014, plaintiff returned and reported that her right knee pain was returning. (R. 412). Again, there was no tenderness, full range of motion, mild swelling and mild crepitus. (R. 412). Plaintiff also reported that her left knee was now locking, and while range of motion was nearly normal, McMurray's test suggested a possible meniscus tear. (R. 412). X-rays of the left knee were normal (R. 412), but an MRI of the left knee did reveal a meniscus tear. (R. 414). Plaintiff opted for another injection over surgery on the right knee in June 2014, but did elect surgery to repair the meniscus on the left. (R. 414-15). Surgery was scheduled for June 26, 2014 (R. 415), but was apparently cancelled for some reason - there are no records - and plaintiff's brief indicates she changed her mind about it. [Dkt. # 16, at 3].

         Everything appears to have been fine with plaintiff's knees until November 2015. [Dkt. #16, at 3]. At that time, a right knee exam revealed mild tenderness, mild swelling, and full range of motion. (R. 551). There was mild tenderness and swelling in the left knee with full range of motion as well. Both knees were stable. (R. 551). Surgery wasn't an option at that time because plaintiff was undergoing Hepatitis C treatment. (R. 553). Bilateral injections were administered. (R. 551). In January 2016, examination was much the same, although there was no longer any swelling, and plaintiff indicated that the injections had been successful. (R. 553). Plaintiff returned in March 2016 complaining of left knee pain and wanted to have arthroscopic surgery, which was scheduled for March 7th. (R. 554). By June 2016, surgical portals were well-healed, and she had full weight-bearing capacity, and used crutches to walk. (R. 554). There was mild swelling and tenderness, and a slight reduction of range of motion from 130 degrees to 115. (R. 554). As of December 2016, Dr. Johnson again reported that plaintiff had full weight-bearing on both knees, but chose to use a crutch to walk. (R. 753). By January of 2016, she had discarded the practice. (R. 553).

         In January 2017, plaintiff was reporting moderate pain, but was not taking anything for the symptoms. (R. 723). A left knee x-ray in February 2017 showed that osteoarthritis and narrowing of the medial compartment had progressed in the previous three years. (R. 754). MRI showed grade IV chondromalacia. (R. 734).

         Then there is plaintiff's bilateral carpal tunnel syndrome. In January 2015, plaintiff reported numbness and tingling in her left arm. (R. 496). She had fallen in November 2014, (R. 496), and underwent left carpal tunnel surgery in July 2015. (R. 400). Follow-up in November revealed mild swelling, but normal range of motion without difficulty in elbow and fingers. (R. 550). Then it was right hand numbness. In September 2016, examination revealed plaintiff could move her fingers without difficulty, but there was a positive Tinel's sign and positive Durjkan's test suggesting carpal tunnel syndrome. (R. 555). She had right carpal tunnel release surgery in November 2016. (R. 753). At follow-up in December, she reported some mild pain and numbness. There was some mild swelling, but she could move her fingers without difficulty. (R. 753).


         After an administrative hearing - at which plaintiff, represented by counsel, and a vocational expert testified - the ALJ determined plaintiff was not disabled. The ALJ found that plaintiff had the following severe impairments: carpal tunnel syndrome and degenerative joint disease of both knees. (R. 17). The ALJ noted that the plaintiff also suffered from Hepatitis C and cervical spine disorder, but found these impairments were not severe. (R. 17). He said that the Hepatitis C was treated conservatively and studies showed that there was only a small disc herniation in plaintiff's neck at ¶ 6 and mild disc bulging at ¶ 4-5 and C6-7. (R. 17). The ALJ also found that plaintiff's depression was non-severe, causing no more than mild limitations in understanding, remembering and applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing herself. (R. 18). The ALJ then found that plaintiff's impairments, either singly or in combination, did not meet or equal a listed impairment assumed to be disabling in the Commissioner's listings. (R. 18-19).

         The ALJ then stated that the plaintiff had the residual functional capacity to perform light work - “lifting/carrying 20 pounds occasionally and 10 pounds frequently, standing/walking about six of eight hours, sitting about six of eight hours” - with the following list of additional limitations: “occasional bilateral pushing/pulling with lower extremities; never climb ladders ropes or scaffolds; occasionally climb ramps and stairs, balance stoop crouch, crawl, and kneel; occasional overhead reaching with the left; occasional bilateral fingering, that is fine manipulation of items no0 smaller than the size of a paper clip; occasional bilateral handling of objects, that is gross manipulation; avoid concentrated exposure to frequent vibration.” (R. 19). The ALJ then found that plaintiff's “statements concerning the intensity, persistence and limiting effects of [her] symptoms are not entirely consistent with the medical evidence and other evidence in the record.” (R. 21). Specifically, the ALJ noted that plaintiff improved following surgery and, thereafter, treatment was routine and conservative, and that she sat through her hearing and did not give any signs of discomfort, responding appropriately to questioning. (R. 21). Finally, the ALJ felt that the plaintiff's daily activities were inconsistent with her alleged limitations. (R. 21).

         The ALJ summarized the medical evidence, discussing treatment of plaintiff's knee impairments and carpal tunnel syndrome. Treatments in both areas moved from conservative to surgical, with injections along the way. The ALJ noted that, in both cases, treatment resulted in improvement, (R. 20). The ALJ referred to a consultative examination in September 2015 with essentially benign results. (R. 20). There were only medical opinions on disability in the record, both from the state agency doctors who reviewed the record during the application process. The ALJ gave greater weight to the second - which found plaintiff capable of light work - than the first - which found plaintiff capable of medium work - explaining that ...

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