United States District Court, N.D. Indiana, South Bend Division
OPINION AND ORDER
DEGUILIO JUDGE UNITED STATES DISTRICT COURT.
August 2011, Michael Kevin Frederick was working as a
self-employed data communications systems (satellite/cable)
installer when he fell eight feet causing injury to his left
hand, wrists, elbows, shoulders, knees, neck, and back. In
January 2013, he applied for disability insurance benefits
alleging disability as of the date of his accident. (R. at
258-59, 276-290). After holding two hearings, the
administrative law judge (“ALJ”) disagreed and
found that jobs existed which Mr. Frederick was capable of
performing. The Appeals Council denied Mr. Frederick's
request for review. Mr. Frederick then filed this action
seeking judicial review of that decision, thereby invoking
this Court's jurisdiction under 42 U.S.C. §§
405(g) and 1383(c)(3). For the reasons stated below, the
Court remands this matter to the Commissioner for further
since his fall, Mr. Frederick has consistently sought
treatment from various doctors and specialists for his
multiple injuries while presenting with complaints of ongoing
pain. He initially sought treatment from Dr. Anthony
McPherron in 2011 through December 2012, whose medical
records reflect that despite medication management and
physical therapy, Mr. Frederick continued to experience pain.
(R. at 652-87).
Frederick was referred to an orthopedic surgeon, Dr. Thomas
Magill, who recommended surgery for his left shoulder based
on MRI results and recommended only occupational therapy for
his left hand. (R. at 352-70). On January 19, 2012, Dr.
Magill performed a left shoulder arthroscopy with
arthroscopic bankart repair. Thereafter, Mr. Frederick
engaged in several months of physical/occupational therapy
(R. at 390-584), yet he continued to report pain in his left
shoulder, left hand, wrists, neck, and knees. An arthrogram
and MRI of his left shoulder revealed post-operative changes
and mild tendinopathy of the supraspinatus. (R. at 373).
Thereafter, Dr. McPherron performed a manipulation of Mr.
Frederick's left shoulder, after which, Mr. Frederick
continued to experience pain, numbness, and tingling. (R. at
second half of 2012, Mr. Frederick sought treatment from
orthopedists Dr. Adelbert Mencias and Dr. Todd Graham because
he continued to experience pain. Dr. Mencias performed a left
cubital tunnel release and right wrist steroid injections for
Mr. Frederick's cubital tunnel syndrome. (R. at 585-92,
2013, Mr. Frederick sought treatment from general
practitioner, Dr. Walter Fritz. (R. at 697-98, 741-44,
762-66, 769-78, 799-803). Records indicate that Mr. Frederick
was prescribed a host of medications including Lyrica, Mobic,
Hydrocodone, Restoril, Zanaflex, Ultram, Wellbutrin, and
Norco. The pain medication caused Mr. Frederick to feel
distracted and “in a fog” to the point where he
avoided driving. (R. at 297-303).
Fritz referred Mr. Frederick to board certified
anesthesiologist, Dr. Barry Ring, for pain management. (R. at
705-40). In February 2013, Dr. Ring reviewed Mr.
Frederick's various laboratory results and examined Mr.
Frederick. The examination indicated that Mr. Frederick
tested positive for pain in his shoulders, knees, left hand,
and back. Dr. Ring reported that an MRI showed a disc bulge
in Mr. Frederick's neck and that a left wrist brace was
prescribed. Dr. Ring required Mr. Frederick to be off of work
until further evaluation. An April nerve conduction study
revealed bilateral ulnar neuropathies at the elbows and
bilateral low cervical radiculopathies. Mr. Frederick
underwent trigger point cervical steroid injections. As of
July, Mr. Frederick was still reporting little relief from
Fritz's medical records show that Mr. Frederick continued
to experience pain and stiffness in his neck with radiation
to both shoulders, along with pain in his knees, wrists, and
left hand. He documented that Mr. Frederick suffered from a
decreased range of motion in his neck and left shoulder, and
a decreased grip strength in his left hand. From early 2013
through late 2015, Dr. Fritz consistently opined that future
employment was unlikely for Mr. Frederick as he was
“completely disabled.” Dr. Fritz completed
physical residual functional capacity
(“RFC”)assessments in October 2013, January 2015,
and August 2015 (R. at 741-44, 762-65, 799-803) revealing
that Mr. Frederick suffered from dizziness, fatigue, and pain
in his shoulders, arms, hands, knees, and neck which limited
his ability so much so that he was rendered disabled.
early 2014, neurosurgeon, Dr. Michel Malek reviewed Mr.
Frederick's MRIs. (R. 745-51). Dr. Malek found that the
cervical MRI confirmed evidence of herniation consistent with
Mr. Frederick's symptoms. The lumbar spine MRI showed
slight desiccation and retrolisthesis, and evidence of an
annular tear on the right at ¶ 5-S1. An EMG/nerve study
showed chronic L5-S1 radiculopathy. Surgery to the lumber and
cervical spine was an option but Dr. Malek wanted Mr.
Frederick to get a second opinion. Dr. Malek opined that Mr.
Frederick needed to remain off work, subject to later
physical consultative examiners opined that Mr. Frederick was
capable of performing at least sedentary work with
restrictions (R. at 691-93, 791-97), non-examining state
agents opined that Mr. Frederick was capable of performing
light work with restrictions (R. 142-62), and an independent
medical expert (“ME”) testified that Mr.
Frederick was capable of performing light work with
restrictions. (R. at 66-70).
reviewing the record, the ALJ concluded that Mr. Frederick
was capable of performing a limited range of light work. In
making this determination, the ALJ gave Drs. Fritz and
Malek's opinions “little weight” because the
ALJ believed that they were inconsistent with the record
evidence. (R. at 27, 31). In determining the type of work Mr.
Frederick could perform, the ALJ rested on the vocational
expert's testimony that based strictly on the (relevant)
hypothetical posed to him,  Mr. Frederick would not be able
to perform his past work, but could perform unskilled work as
a parking lot attendant, school crossing guard, and office
helper. Accordingly, the ALJ found at step five that Mr.
Frederick was not disabled.
STANDARD OF REVIEW
the Appeals Council denied review, the Court evaluates the
ALJ's decision as the final word of the Commissioner of
Social Security. Schomas v. Colvin, 732 F.3d 702,
707 (7th Cir. 2013). This Court will affirm the
Commissioner's findings of fact and denial of disability
benefits if they are supported by substantial evidence.
Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008).
Substantial evidence consists of “such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion.” Richardson v. Perales,
402 U.S. 389, 401 (1971). This evidence must be “more
than a scintilla but may be less than a preponderance.”
Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir.
2007). Thus, even if “reasonable minds could