Jared H. v. Kijakazi
| Decision Date | 21 September 2022 |
| Docket Number | 21 C 4587 |
| Parties | JARED H.,[1] Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Northern District of Illinois |
MEMORANDUM OPINION AND ORDER
Plaintiff applied for Disability Insurance Benefits and Supplemental Security Income under Titles II and XVI, respectively, of the Social Security Act, 42 U.S.C. §§416(I), 423, 1381a, 1382c just over two years ago in February and December of 2020. (Administrative Record (R.) 209-16). He claimed that he has been disabled since May of 2016 (R. 242, 246) due to “shattered . . . whole foot . . . put a metal plate screws, . . . removed bone fragments, put in cadaver bone put metal back.” (R. 246). Over the next year plaintiff's application was denied at every level of administrative review: initial, reconsideration, administrative law judge (ALJ), and appeals council. It is the final 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) on August 27, 2021, and the parties consented to my jurisdiction pursuant to 28 U.S.C. § 636(c) on November 9, 2021. [Dkt. #10]. 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 April 22, 1983, making him just 33 years old when he claims he became unable to work. (R.209). With the exception of a year and a half, he worked steadily from 1998 through 2016. (R. 232-33). For most of that time, he was a dock worker and a forklift operator. (R. 235, 247). But sometime in 2016, he tried to jump over a railing on his porch and fell, injuring his left foot. (R. 40-42). Since then, he's had a couple more surgeries and at the time of his hearing in March 2021, he was using a knee scooter. (R. 42).
That jump off the porch left plaintiff with a displaced navicular fracture in his left foot. (R. 801). On October 3, 2016, plaintiff reported pain at 6/10 and had bruising. Review of systems and physical exam were completely normal aside from that. (R. 425-26). An open reduction and internal fixation (ORIF) surgery was recommended (R. 426), and performed the next day. (R. 428). A week later, plaintiff reported he was doing well with his progress. He said his pain was 7/10, but tolerable. (R. 428). He was in a boot, but on non-weight-baring status. (R. 428).
On November 17, 2016, plaintiff reported “doing fine.” Imaging showed good position and alignment of the surgical hardware. He was neurovascularly intact with no focal deficits. The doctor felt he could begin weight-bearing as tolerated with the walking boot and begin physical therapy. (R. 793). During the initial physical therapy evaluation on November 29, 2016, plaintiff reported having only 2/10 pain, and 5/10 at its worst (R. 798). There was tenderness to palpation and the ankle/foot were warm to the touch. Range of motion and strength were somewhat decrease. (R. 789).
On December 8, 2016, plaintiff reported he was “doing well,” had “decreased” pain, was walking with the boot without any complication, and was “very happy with his progress thus far” (R. 776). Imaging showed good alignment and near-complete fracture healing. He was to wean himself out of the boot. (R. 776). On January 5, 2017, he was ambulating in a “regular shoe” without discomfort and “doing okay,” though he reported not going to physical therapy recently and said he had had some episodes of extreme pain across the front of his foot. (R. 772). Exam revealed tenderness to palpation where the medial screw had been placed. There was a little bit of swelling. X-rays continued to show good positioning. (R. 774).
On March 1, 2017, he reported his left foot pain had improved. (R. 768). Upon examination, gait was normal. There was no tenderness, swelling, or sensation or strength deficits. (R. 769). On March 16, 2017, a CT scan of his left foot revealed a comminuted fracture of the navicular bone status post open reduction and internal fixation as well as an abutting and indenting screw, but intact hardware and most of the fracture fragments appeared to be in near anatomic alignment. (R. 740). Plaintiff tested positive for benzos, cocaine, and marijuana. (R. 741). He was drinking daily as well, and his liver enzymes were elevated. (R. 761, 763).
On April 3, 2017, after plaintiff reported “doing pretty well” and “feeling pretty well,” the plan was to remove the hardware. (R. 758). Examination was normal aside from some tenderness around the hardware, and x-rays showed good position and alignment. (R. 759). The hardware was removed, he was put in a boot, and was doing very well as of April 27, 2017, (R. 757). By May 18, 2017, plaintiff said he noticed a huge improvement. Doctors felt he could return to normal activity and footware as tolerated. (R. 754). He continued to improve and increased activity through June, although he was unable to do heavy lifting. Physical therapy was recommended. (R. 753). He reported drinking a pint of vodka and a beer every day. (R. 749). He was diagnosed with uncomplicated alcohol dependence and advised to get counseling.
In September 2017, he reported having uncontrolled pain, but an exam revealed no distress and no deficits in his extremities (R. 742). He was referred to a pain management specialist. On October 4, 2017, liver enzymes were still elevated and plaintiff was advised to diet, exercise, lose weight, and cut down on his alcohol use. (R. 744). At plaintiff's first pain clinic visit on November 1, 2017, he reported a number of new problems: severe pain that radiated, problems standing more than 90 minutes, some numbness, swelling, and problems doing the exercises in physical therapy. (R. 738). There were no problems with his gait. (R. 738, 740). He reported using marijuana. (R. 738). An exam revealed mild swelling, some warmth, and some mild tenderness, but no erythema, normal color, no unusual hyportrophic changes, a well-healed surgical scar, and an active range of motion that was neutral with dorsiflexion and an extra 10 degrees of range with passive stretching. The doctor advised plaintiff he “may be left with pain in the area for at least several more months, possibly for years and possibly permanently.” He was given anti-inflammatories, over-the-counter Tylenol, and diclofenac. (R. 738-40).
In January 2018, an ultrasound of his liver showed fatty liver disease: increased echogenicity of liver parenchyma most consistent with hepatic steatosis. He was again advised to avoid alcohol. (R. 847).
At a June 2018 pain clinic followup, plaintiff reported he had been doing well, but developed a popping sensation in his foot. He also reported that he had felt increased pain after he jumped into a pool over the weekend, rating it at 7/10. (R. 734). Physical examination revealed moderate tenderness over the navicular, but was otherwise completely normal with no neurovascular deficits, 5/5 strength, a full range of motion, and a normal gait. (R. 736). The doctor recommended removing the fragment off the navicular bone. (R. 736).
After that procedure, by August 2, 2018, plaintiff was able to wear a walking boot. There was only a mild amount of swelling and range of motion was appropriate. (R. 729). Plaintiff continued to do well through August. (R. 725-27). He reported mild pain on September 20, 2018, and there was mild swelling, but range of motion was again appropriate. (R. 724). He began a course of physical therapy in October 2018. (R. 712). At the initial session, plaintiff reported having 8/10 pain in his left foot in the morning, 5/10 when standing, 3/10 when walking around his house, 6/10 when walking outside, 5/10 when ascending stairs, and 4/10 when descending. (R. 71720). He said he wore a boot and used crutches, but was wearing shoes at the session. (R. 713). On October 15, 2018, plaintiff reported his ankle was stiff in the morning but denied any pain. (R. 702). On a visit to his surgeon at that time he reported he was progressing well and pain was 3/10. (R. 694). Exam was normal aside from some swelling; range of motion was good, joint strength was 5/5, there was no tenderness, and neurological signs were normal. (R. 696). On November 15, 2018, plaintiff reported that his ankle was tight, pain was 3/10 with movement, and was not too bad. (R.690).
On February 2019, plaintiff returned to the pain clinic complaining of left foot pain at 7/10 and problems standing/walking for extended periods (R. 678). An exam revealed tenderness but was otherwise normal: gait was normal, reflexes and strength were normal, and range of motion was full. (R. 681). Plaintiff had a left foot medial column fusion in March 2019. On April 11, 2019, although plaintiff reported moderate pain controlled by Norco, exam revealed mild swelling, appropriate range of motion, acute distress, a full range of motion in his extremities, and no swelling. He was doing well post-operatively and was place in a cast and would be non-weight-bearing for two weeks.
(R. 677). On May 16, 2019, he was “doing very well” and imaging showed good position and alignment. (R. 672). He was to discontinue wearing the boot, start weight-bearing, and participate in physical therapy. (R. 672).
On June 27, 2019, plaintiff reported pain was present but manageable. Physical exam was normal aside from minor swelling. The doctor said the plaintiff could be weight-bearing with the boot. (R. 668). On July 25, 2019, although he felt pain and discomfort, particularly when bearing any weight, plaintiff was “doing well” and walking in a “regular shoe” (R. 663). Gait was normal, range of motion was normal, Strength and reflexes were normal. (R. 666). Plaintiff admi...
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