United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
Jeffrey Cummings, United States Magistrate Judge
Charles M. (“Claimant”) brings a motion for summary
judgment to reverse the final decision of the Commissioner of
Social Security (“Commissioner”) that denied
Claimant's application for a period of disability and
Supplemental Security Income (“SSI”) under the
Social Security Act. 42 U.S.C. §§ 416(i), 402(e),
and 423. The Commissioner has brought a cross-motion for
summary judgment seeking to uphold the Social Security
Agency's (“SSA”) decision finding that
Claimant is not disabled. The parties have consented to the
jurisdiction of the 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)
and 138(c)(3). For the reasons stated below, Claimant's
motion for summary judgment  is granted and the
Commissioner's cross-motion for summary judgment  is
December 18, 2014, Claimant filed a disability application
alleging an onset date of June 10, 2010. His claim was denied
initially and upon reconsideration. On October 25, 2017, an
Administrative Law Judge (“ALJ”) issued a written
decision denying benefits to Claimant. After the Appeals
Council denied review, the ALJ's decision became the
Commissioner's final decision. 20 C.F.R. §
404.985(d); see also Zurawski v. Halter, 245 F.3d
881, 883 (7th Cir. 2001). Claimant subsequently filed this
action on October 16, 2018.
Evidence from Claimant's Treatment History
was a 62-year old attorney at the time of the ALJ's
decision. Claimant alleges that he began experiencing
disabling symptoms as of June 10, 2010 that included numbness
extending from his upper abdomen to his feet. He also
experienced impairments in his ability to control his bladder
and bowels. (R. 760). Claimant saw his treating physician Dr.
Scott Schieber on July 13, 2013 for his condition. (R. 519).
Dr. Schieber referred him to specialists who diagnosed an
arachnoid cyst at the T2-T3 level of the thoracic
spine. On August 27, 2013, neurologist Dr.
Charles Cybulski carried out a T2-T4 laminectomy to treat
Claimant's condition. (R. 699-700). Dr. Cybulski noted
improvement in Claimant's condition over the following
months: he was able to mow his lawn as of October 25, 2013
and played golf at least once by January 9, 2014. (R.
the symptoms that had accompanied the arachnoid cyst was
spasticity in Claimant's legs. (R. 760). Dr. Cybulski
noted that his gait was “markedly spastic” and
that Claimant was unable to walk with any degree of stability
prior to surgery. (R. 838). By May 14, 2014, Claimant still
displayed spasticity and was prescribed the anti-spasmatic
medications diazepam (Valium) and Baclofen to help with his
symptoms. (R. 760-61). Claimant complained of drowsiness that
resulted from the medications. (R. 760).
also experienced problems with his hands. An x-ray taken on
September 17, 2014 of the left hand showed persistent flexion
of the second and fifth fingers; mild to moderate
degenerative changes in the fourth finger; and moderate
degenerative changes in the first metacarpophalangeal joint.
(R. 794). He was diagnosed with Dupuytren's disease,
which involves a thickening of the fascia beneath the skin in
the palms and fingers that pulls the fingers inwards.
Claimant underwent a subtotal palmar fasciectomy on his small
finger on October 2, 2014 with a release of the proximal
interphalangeal joint and a subtotal palmar fasciectomy of
the left ring finger. (R. 799). A second operation was done
on January 29, 2015. (R. 796). A post-operative x-ray on
February 3, 2015 showed an improved expansion of the fifth
finger but an unchanged severe degenerative alteration of the
first carpometacarpal joint. (R. 781).
Evidence From Treating and Consulting Physicians
March 30, 2015, Dr. Dinesh Jain examined Claimant at the
request of the SSA. Claimant told Dr. Jain that his gait and
balance had improved since his spine surgery but he still
experienced some imbalance. Dupuytren's contractions also
created problems in using a keyboard. Dr. Jain's physical
exam showed contractions in both little fingers and in the
left ring finger and thumb. Claimant demonstrated a normal
gait and could get on and off the exam table without
difficulty. He was able to tandem walk, walk on his toes and
heels, squat, and hop on one leg. Dr. Jain noted that
Claimant continued to have some pain in the upper thoracic
region after his surgery and - despite the normal gait stated
earlier - concluded that Claimant showed “some
limitation of gait.” He diagnosed a decrease in
Claimant's focus and short-term memory and found that
Claimant could sit for two to three hours, stand for one
hour, walk four to six blocks, and lift or carry up to 40
pounds. (R. 732-34).
March 31, 2015, psychologist Dr. Edward Klutcharch
interviewed Claimant for the SSA. Claimant told Dr.
Klutcharch that he could no longer work as an attorney due to
problems in walking and retaining information. Dr. Klutcharch
found that he was oriented to place and time; had an
appropriate demeanor; and was properly dressed. No perceptual
distortions or delusional thinking were noted. Dr. Klutcharch
diagnosed Claimant with a major depressive disorder of
moderate intensity and assigned a current GAF score of
physician Dr. David Chen issued a report on Claimant's
condition on January 20, 2016. Dr. Chen stated that Claimant
suffered from incomplete paraplegia following the surgery on
his arachnoid cyst. Claimant suffers from lower extremity
weakness, impaired balance, and spasticity. He cannot stand
or walk for six hours a day. In addition, Dr. Chen stated
that the side effects of the medications that Claimant took
to control spasticity would affect his attention and
concentration. Combined with his neurological deficits, that
could require Claimant to miss work “on
occasion.” (R. 478-82).
physician Dr. Schieber also met with Claimant on May 5, 2017
for the first time in over three-and-one-half years. He noted
“a dramatic decline in functional status” for
Claimant since he last saw him in July 2013. Dr. Schieber
noted that Claimant had problems in walking due to balance
issues and that he needed to take prescription pain
medication daily to control his pain. Dr. Schieber found
numbness and decreased sensation around the cervical thoracic
region and hyperreflexic lower extremities. Like Dr. Jain,
Dr. Schieber stated that Claimant could only walk for four
blocks without severe pain. He can sit or stand for no more
than 20 minutes at one time and can sit, stand, or walk for
no more than two hours in an eight-hour day. Periods of rest
would be necessary after walking for 60 minutes. Claimant
could only lift or carry less than 10 pounds frequently and
20 pounds occasionally. Claimant would not experience
“good days” and “bad days” and would
need to be off work more than four days each month. (R.
Evidence From State-Agency Experts
16, 2015, non-examining psychologist Dr. Lionel Hudspeth
issued a report finding that claimant suffered from a
non-severe affective disorder. Dr. Hudspeth assessed no
restrictions in Claimant's ability to carry out
activities of daily living (“ADLs”) and mild
limitations in his capacity for social functioning and in
maintaining concentration, persistence, or pace. (R. 267).
Dr. David Biscardi disagreed with that assessment on
reconsideration by finding mild restrictions in all three of
Claimant's functional areas. (R. 284).
Evidence From Claimant's Testimony
appeared at the July 20, 2017 hearing and gave testimony to
the ALJ about his condition. He stated that he first sought
medical treatment for his thoracic numbness after he had
difficulty with his balance, gait, and bowel control. (R.
236). Claimant stated that the loss of his bowel control
began in June 2010 and progressed to the point where he lost
control once every other day. (R. 237). Surgery for the
thoracic cyst in August 2013 helped with his bowel problems
but Claimant still had difficulty with balance after the
operation. That included continuous spasticity with his legs
as he lay in bed at night. Claimant was referred to Dr. Chen
at the Chicago Rehabilitation Institute and was started on a
protocol of drugs that included diazepam and Baclofen. (R.
241). Claimant stated that before starting those medications
he fell down stairs frequently but now has greater control
over his balance. He also takes four Norco tablets each day
for pain. (R. 243-44). These medications cause side effects
like drowsiness that cause Claimant to fall asleep while he
is reading or watching TV. (R. 246).
told the ALJ that he can stand for only 15 minutes and could
walk for four blocks. He can lift up to 35 pounds but not on
a regular basis. Claimant stated that after his hand surgery
he had difficulty with fine manipulation like using zippers
and buttons and would have problems typing on a keyboard. (R.
345-46). The medications also make it difficult for Claimant
to concentrate. He described diminished concentration,
slurred speech, and difficulty in typing to be the biggest
barriers to his employment as a real estate attorney. (R.
249). Claimant told the ALJ that he still had an active bar
membership and that he had done some legal work after his
alleged onset date in June 2010. He described the scope of
his legal work as very limited. Claimant helped his
stepdaughter in a child custody matter, handled a contract
issue for a friend, and ...