Lugo v. Colvin
| Decision Date | 08 March 2016 |
| Docket Number | No. 14 C 577,14 C 577 |
| Parties | CAREY LUGO, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Northern District of Illinois |
MEMORANDUM OPINION AND ORDER
This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying Plaintiff Carey Lugo's claim for disability insurance benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Plaintiff's motion for summary judgment [Doc. No. 12] is denied and the Commissioner's cross-motion for summary judgment [Doc. No. 20] is granted.
On December 20, 2008 Claimant filed a claim for disability insurance and supplemental security income benefits, alleging disability since January 17, 2008.2The claim was denied initially and upon reconsideration, after which Plaintiff timely requested a hearing before an Administrative Law Judge ("ALJ"), which was initially held in April 2011 in Missouri—where Plaintiff was then residing—but was continued so Plaintiff could obtain representation and additional medical records. (R. 131-42.) The hearing resumed in January 2012, but was again continued so that Plaintiff could obtain representation. (R. 111-18.) A full hearing was then held in May 2012 in Orland Park Illinois. (R. 44.) Plaintiff appeared and testified at the hearing and was represented by counsel. Vocational expert Grace Gianforte also appeared and testified.
On July 5, 2012 the ALJ denied Plaintiff's claim for benefits, finding her not disabled under the Social Security Act. The Social Security Administration Appeals Council then denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner and, therefore, reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).
Plaintiff was born on May 25, 1979, and was thirty-two years old at the time of her full hearing. She was working as a certified nursing assistant ("CNA") at a convent until January 2008, when she injured her back while moving a patient. (R. 60-62.) She had previously worked as an accounting clerk, van driver, biller, receptionist, and cashier.
Shortly after her injury, Plaintiff began treatment with Dr. Ilah Heller Bair. Dr. Bair noted that Plaintiff's range of motion was limited by pain in all directions, and diagnosed her with sacroiliitis and sciatica. (R. 617.) Plaintiff underwent an MRI in February 2008, which showed a "tiny central disc protrusion at the L5-S1 level not causing any significant mass effect upon the thecal sac," but which otherwise presented normal results. (R. 627.) Plaintiff was prescribed a course of physical therapy, during which she continued to report pain; however, her range of motion and strength in her extremities improved, and her physical therapist eventually noted that "her subjective reports [were] inconsistent with objective findings of no deficits in lower extremity sensation," and that she was tolerating the therapy well and performing all exercises without difficulty. (R. 633-34.) In March 2008, Dr. Bair noted that, while muscle stretching would help, she believed that Plaintiff's condition "should not keep [her] from returning to work." (R. 642.) Dr. Bair later noted that she did "not feel the discs and bones in [Plaintiff's] back [were] responsible" for Plaintiff's pain, and that her condition "should resolve completely within 3 months" with proper stretching. (R. 647.)
In April 2008 Plaintiff visited orthopedist Dr. Steven Bardfield. Dr. Bardfield noted the MRI results showing "a very small disc protrusion" without "any foraminal or lateral recess narrowing," and with "minimal degeneration in this disc." (R. 580.) Dr. Bardfield found that Plaintiff had a range of motion in her lumbar spine which was "well-preserved in all 3 planes," that her reflexes wereequal in both extremities, and that she showed mild tenderness in her lumbar area. Id. Dr. Bardfield concluded that low back pain from the disc problem should be helped by anti-inflammatories and physical therapy. Id.
In May 2008, spine surgeon Dr. Kern Singh examined Plaintiff. (R. 512.) Dr. Singh's physical examination found that Plaintiff had full sensation and range of motion in her lumbar spine, and "no evidence of sacroiliitis on examination." (R. 512.) Dr. Singh concluded that he believed that there was "minimal radiographic and objective evidence of disease." (R. 513.) Dr. Singh recommended that Plaintiff be allowed to return to work "at a full duty level without restrictions." (R. 514.)
Plaintiff returned to Dr. Bardfield in June; she reported that the physical therapy had helped her pain in general, but that the pain was made worse when she was seated. (R. 579.) Her range of motion, reflexes, and strength and sensation, however, were all reported as normal. Id. Dr. Bardfield recommended more physical therapy, and noted the possibility of epidural injections to help with the "discogenic component of pain." Id. At a follow-up appointment in July, Plaintiff reported that the additional physical therapy had not helped, and her pain had increased. (R. 578.) Dr. Bardfield referred Plaintiff to pain management specialist Dr. Gary Koehn for cortisone and anesthetic injections, with the possibility of radio frequency ablation in the nerves of the sacroiliac joint.4 (R. 506.)
Dr. Koehn saw Plaintiff later that month. (R. 507.) He recorded Plaintiff's complaints of pain and suggested an "epidural steroid injection for therapeutic purposes"; Dr. Koehn noted that Plaintiff's complaints of pain could be due to her sacroiliac joint, or potentially from her lumbar spine; he also noted that Plaintiff's injury at that point was "6 months old, and she needs to move on, so to speak." (R. 509.) At a follow-up with Dr. Bardfield, however, Plaintiff declined to pursue injections, opting instead for chiropractic treatment. (R. 510.) In September, she returned to Dr. Bardfield, who noted no new findings and determined to have Plaintiff continue with chiropractic treatment for two to three weeks, after which time he would obtain a functional capacity assessment. (R. 576.) While he noted the possibility of work restrictions, Dr. Bardfield concluded that he would "not be in favor of writing any type of permanent work restrictions as [he] believe[d] her symptoms will continue to resolve." Id. However, during 2008 Plaintiff had become pregnant; as a result, at her October appointment Dr. Bardfield was unable to refer her for a functional capacity assessment or further evaluate her capacities for a return to work. (R. 575.)
In October 2008 Dr. Singh performed a third-party medical evaluation of Plaintiff, apparently related to her workers' compensation proceedings. Dr. Singh recorded that Plaintiff reported pain as an eight on a one-to-ten scale, and that the pain interfered with her daily activities and housework, and was worsened by walking and standing. (R. 499.) Dr. Singh's physical examination, however, was normal, with the exception of a "self-limited knee extension." Id. Dr. Singhconcluded that he did not believe that Plaintiff's symptoms were "causally related to her work-related injury." (R. 500.) While Dr. Singh diagnosed Plaintiff with a lumbar muscular strain, he found that she had "no evidence on her MRI findings as well as on her examination by multiple physicians to support any of her [other] diagnoses," and that there was "no permanency associated with this injury, and [Plaintiff] should be allowed to return to work at a full-duty level." (R. 500.)
As a result of her reported continued pain during her pregnancy, however, Plaintiff was referred to Dr. Steven Mash at the request of her obstetrician; she saw Dr. Mash in March 2009. (R. 657.) Plaintiff complained to Dr. Mash of "increasing low back discomfort which is unremitting." Id. Dr. Mash, however, found that, "from an orthopedic perspective [he did] not feel she ha[d] an emergent problem," and he was unable to provide further treatment due to her pregnancy. Id.
In April 2009, Dr. B. Rock Oh, a state agency consultant, performed a residual functional capacity assessment based on Plaintiff's records. Dr. Oh noted the reports of Plaintiff's medical providers, along with her complaints of pain, and determined that the limitations Plaintiff alleged were not fully credible given the contrary reports of Drs. Singh and Mash, her otherwise normal evaluations, and the minimal evidence of disk protrusions shown on the MRI. (R. 705-06, 710-11.) Dr. Oh concluded that Plaintiff was capable of lifting 50 pounds occasionally, twenty five pounds frequently, standing or walking and sitting for a total of six hours each in an eight-hour workday without other significant limitations. (R. 706-08.) Thisassessment was affirmed on review by state agency physician Dr. Richard Bilinsky in August 2009. (R. 747-49.)
In August 2009 Plaintiff, also began treatment at the office of Pain Specialists of Greater Chicago, in particular with Dr. Ira Goodman. (R. 773.) In September of that year, Plaintiff received a facet joint injection of the lumbar spine, which was repeated in October 2009. In April 2010, Plaintiff was examined by a physician's assistant in the Pain Specialists' office, who reported that, since her December 2009 office visit, Plaintiff's pain had stayed the same. Plaintiff described "temporary improvement in pain and function," and displayed "normal behavior and no pain behavior." (R. 758.) Plaintiff reported sleeping only five hours per night, and being awakened by pain two to three times per night each night. (R. 758.) She also reported that she needed to sit or lie down several times during the day because of her pain. (R. 758-59.)
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