Martinez v. Saul

CourtDistrict Court, N.D. Illinois
DecidedJanuary 25, 2022
Docket1:18-cv-07230
StatusUnknown

This text of Martinez v. Saul (Martinez v. Saul) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Martinez v. Saul, (N.D. Ill. 2022).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION HECTOR M.,1 ) ) Plaintiff, ) No. 18 C 7230 ) v. ) Magistrate Judge Jeffrey Cole ) KILOLO KIJAKAZI, ) Acting Commissioner of Social Security, ) ) Defendant. ) MEMORANDUM OPINION AND ORDER 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, six and a half years ago, on August 31, 2015. (Administrative Record (R.) 190- 202). He claimed that he became disabled as of February 18, 2015, due to a back impairment and back surgery, radiculopathy, diabetes, high blood pressure, high cholesterol, and depression. (R. 173-87, 243). 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. This case has had something of a difficult time with scheduling and completion. Plaintiff filed suit under 42 U.S.C. § 405(g) four and a half years ago. His case was assigned to a District Judge and was fully briefed as of August 12, 2019. [Dkt. #23]. Thereafter, the Executive Committee randomly reassigned the case to newly appointed District Judge along with 341 other cases on 1 Northern District of Illinois Internal Operating Procedure 22 prohibits listing the full name of the Social Security applicant in an Opinion. Therefore, the plaintiff shall be listed using only their first name and the first initial of their last name. September 16, 2019. The parties were back to square one. [Dkt. #24]. Then on May 12, 2021, the parties consented jurisdiction here pursuant to 28 U.S.C. § 636(c). [Dkt. ##41, 43]. Plaintiff asks the court to reverse and remand the Commissioner’s decision, while the Commissioner seeks an order affirming the decision.

I. A. The facts are not in dispute. The plaintiff was born on March 1, 1963 (R. 173), and was 54 years old at the time of the ALJ’s decision. (R. 42-53). The plaintiff had a high-school-level education in Mexico, and can understand some simple spoken and written English. (R. 63). The plaintiff has a very good work record, working consistently from 1988 through 2008, and again from 2011 through 2015. (R. 194). He worked mostly as a machine operator – packing food items – and in general labor – golf course maintenance. (R. 202). Both jobs required him to be on his feet all

day and do a lot of lifting and carrying of heavy items. (R. 203-05). He had to quit working in 2015 when he injured his back and had to have surgery. (R. 64). Plaintiff had that surgery on May 7, 2015, a lumbar fusion with sacroiliac screws. (R. 319, 321, 346). On May 10, 2015, just a couple of days later, plaintiff reported that he had “zero” pain. Neurological exam was normal, gait and station were normal, there was normal spinal curvature, no tenderness, full range of motion, and extremity strength was only slightly diminished. (R. 314). On June 17, 2015, things were much the same. Neurological exam was normal, gait and station were normal, normal spinal curvature, no tenderness, full range of motion, extremity strength only slightly diminished. (R. 311). Plaintiff’s doctor recommended he continue using a lumbar brace for another

six weeks. (R. 312). On June 29, 2015, plaintiff reported increased gluteal and hip pain. He could 2 not perform prolonged standing, lifting, or bending. (R. 368). On July 27, 2015, plaintiff reported he was still having some pain and numbness. Strength was reduced to 4/5 throughout. There was tenderness to palpation in the lumbar region. Gait was normal, plaintiff was still wearing his brace, and reported he could walk 30 minutes without pain.

(R. 349-50). On July 29, 2015, plaintiff had completed physical therapy and felt significantly improved except for left buttock pain, especially getting in and out of a car. Neurological exam was normal, gait and station were normal, spinal curvature was normal, there was no tenderness, full range of motion, and extremity strength only slightly diminished. (R. 308). X-ray showed solid fusion with excellent positioning of surgical instrumentation. (R. 309). On August 12, 2015, plaintiff reported dull aching pain radiating through his left leg and numbness in both feet. He wasn’t doing his home exercises. Plaintiff’s gait was guarded and pelvic rotation was decreased. Plaintiff was given paraspinal injections. ( R. 359). On August 28, 2015, plaintiff reported his back was doing better – about 70% improved. He still had some soreness and

occasional buttocks pain, as well as numbness in his feet. Range of motion was limited to 55/90 flexion, 20 extension. (R. 346). Gait was normal, plaintiff was still wearing his brace, and reported he could walk 30 minutes without pain. He had made good progress with physical therapy. (R. 347). By September 14, 2015, plaintiff was complaining of left buttocks pain and some leg numbness, Neurological exam was still normal, as were gait and station normal and spinal curvature And, again, there was no tenderness, full range of motion, and extremity strength as only slightly diminished. (R. 394). Two weeks later, plaintiff’s back symptoms were better, but he had left lumbar spine pain, sacroiliac soreness, and he was limping. (R. 397).

3 On October 26, 2015, plaintiff had a consultative examination with Dr. Karri in connection with his application for benefits. The doctor noted that plaintiff was morbidly obese. (R. 385). There was pitting edema in his extremities. His gait was guarded, and he could not tandem gait or heel-toe walk. Range of motion in the lumbar spine was significantly limited: flexion was 50

degrees and extension was zero degrees. Straight leg raising was positive bilaterally and there was tenderness in the lumbar spine and sacroiliac joints. Strength was slightly diminished in both legs, and sensation was decreased. (R. 386). X-ray on October 26, 2015, surgical screws at L5, S1, and bilateral sacroiliac screws. Lordosis was normal but there was trace anterolisthesis of L5 on S1. (R. 388). On November 16, 2015, plaintiff reported numbness in his legs from walking, pain on the left side, and said that physical therapy was no longer helping. Neurological exam was normal, gait and station were normal, spinal curvature was normal, there was no tenderness, there was full range of motion, and extremity strength was normal. (R. 391).

On December 22, 2015, an MRI, revealed post-surgical changes, along with persistent, moderate spondylolisthesis at L5-S1, slight levoscoilotic deformity, mild disc bulge and central disc protrusion at L4-5, but no significant stenosis. (R. 409). On March 7, 2016, plaintiff sought treatment for low back pain radiating down both legs to his feet. Physical therapy – for three months – hadn’t helped. The pain was worse with activity. (R. 424). Reflexes were diminished to 2+/4, lumbar flexion and extension were normal, but there was tenderness of the lower lumbar facet. (R. 424-25). On March 28, 2016, plaintiff sought treatment for constant back pain radiating down his leg,

with numbness and tingling in his feet. (R. 419). Reflexes were diminished to 2+/4, lumbar flexion 4 and extension were normal, but there was tenderness of the lower lumbar facet. (R. 419). Gait was antalgic and straight leg raising was positive bilaterally. (R.

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Martinez v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/martinez-v-saul-ilnd-2022.