IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION

JAMIE S.,1

Plaintiff,

v. 

KILOLO KIJAKAZI, 

Acting Commissioner of Social Security,2

Defendant.

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No. 20 C 3373 

Magistrate Judge Beth W. Jantz 

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 Jamie S.’s application for Disability 

Insurance Benefits (“DIB”). 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 [dkt. 20, Pl.’s Mot.] is granted, and the Commissioner’s cross-motion for 

summary judgment [dkt. 25, Def.’s Mot.] is denied. The Commissioner’s decision is reversed, 

and this matter is remanded for further proceedings consistent with this Memorandum Opinion 

and Order. 

1

 In accordance with Internal Operating Procedure 22, Privacy in Social Security Opinions, the 

Court refers to Plaintiff by his first name and the first initial of his last name.

2

 Pursuant to Federal Rule of Civil Procedure 25(d), Kilolo Kijakazi has been substituted for her

predecessor.

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BACKGROUND

I. Procedural History

On August 8, 2017, Plaintiff filed a claim for DIB, alleging disability since August 1, 

2017, due to spine disorders and carpal tunnel syndrome (“CTS”). [Dkt. 17-4, R. 280-81; R. 90-

91.] Plaintiff’s claim was denied initially and again upon reconsideration. [R. 100, 112.] 

Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”), which was initially

held on October 16, 2018, and continued to February 28, 2019, in order to give additional time 

for Plaintiff to submit medical evidence. [R. 40-89.] Plaintiff personally appeared and was 

represented by counsel at both hearings and testified with the assistance of an interpreter at the 

second hearing. [R. 42, 45-68, 78.] Vocational expert (“VE”) Cheryl R. Hoiseth also testified at 

the second hearing. [R. 69-74.] On April 17, 2019, the ALJ denied Plaintiff’s claim for benefits, 

finding him not disabled under the Social Security Act. [R. 21-33.] The Social Security 

Administration Appeals Council denied Plaintiff’s request for review, leaving the ALJ’s decision 

as the final decision of the Commissioner. [R. 1-3.] 

II. The ALJ’s Decision

The ALJ analyzed Plaintiff’s claim in accordance with the Social Security

Administration’s five-step sequential evaluation process. [R. 21-33.] The ALJ found at step one 

that Plaintiff had not engaged in substantial gainful activity since his alleged onset date of 

August 1, 2017. [R. 24.] At step two, the ALJ concluded that Plaintiff had the following severe 

impairments: spine disorders and carpal tunnel syndrome. [R. 24.] The ALJ concluded at step 

three that his impairments, alone or in combination, do not meet or medically equal one of the 

Social Security Administration’s listings of impairments (a “Listing”). [R. 24-25.] Before step 

four, the ALJ determined that Plaintiff retained the residual functional capacity (“RFC”) to 

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perform medium work with the following additional limitations: he can only occasionally climb 

ladders, ropes, or scaffolds; he can only occasionally stoop or crawl; he must avoid concentrated 

exposure to vibration; he can frequently use the lower left extremity for operating foot controls; 

he can frequently handle or finger bilaterally and reach overhead; he can be off task no more 

than 15% of a workday; he can understand English at least 30% of a workday; and he needs oral 

instructions. [R. 25-31.] At step four, the ALJ concluded that Plaintiff would not be able to 

perform his past relevant work. [R. 31-32.] At step five, based upon the VE’s testimony and 

Plaintiff’s age, education, work experience, and RFC, the ALJ concluded that Plaintiff could 

perform jobs existing in significant numbers in the national economy, leading to a finding that he 

is not disabled under the Social Security Act. [R. 32-33.] 

DISCUSSION

I. Judicial Review

 Under the Social Security Act, a person is disabled if he is unable “to engage in any 

substantial gainful activity by reason of any medically determinable physical or mental 

impairment which can be expected to result in death or which has lasted or can be expected to 

last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). To 

determine disability within the meaning of the Social Security Act, the ALJ conducts a five-step 

inquiry, asking whether: (1) the claimant has performed any substantial gainful activity during 

the period for which he claims disability; (2) the claimant has a severe impairment or 

combination of impairments; (3) the claimant’s impairment meets or equals any listed 

impairment; (4) the claimant retains the RFC to perform his past relevant work; and (5) the 

claimant is able to perform any other work existing in significant numbers in the national 

economy. 20 C.F.R. § 416.920(a). “A finding of disability requires an affirmative answer at 

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either step three or step five.” Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 352 (7th Cir. 

2005). “The claimant bears the burden of proof at steps one through four, after which 

at step five the burden shifts to the Commissioner.” Id. 

Because the Appeals Council denied review, the ALJ’s decision became the final 

decision of the Commissioner and is reviewable by this Court. 42 U.S.C. § 405(g); Cullinan v. 

Berryhill, 878 F.3d 598, 603 (7th Cir. 2017). The Court plays an “extremely limited” role in 

reviewing the ALJ’s decision. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008). Judicial 

review of the ALJ’s decision is limited to determining whether it adequately discusses the issues 

and is based upon substantial evidence and the proper legal criteria. Villano v. Astrue, 556 F.3d 

558, 561-62 (7th Cir. 2009). “Substantial evidence” is “such relevant evidence as a reasonable 

mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148, 

1154 (2019) (internal quotation omitted). “To determine whether substantial evidence exists, the 

court reviews the record as a whole but does not attempt to substitute its judgment for the ALJ’s 

by reweighing the evidence, resolving material conflicts, or reconsidering facts or the credibility 

of witnesses.” Beardsley v. Colvin, 758 F.3d 834, 836-37 (7th Cir. 2014). While this review is 

deferential, “it is not intended to be a rubber-stamp” on the ALJ’s decision. Stephens v. 

Berryhill, 888 F.3d 323, 327 (7th Cir. 2018). The Court will reverse the ALJ’s finding “if it is 

not supported by substantial evidence or if it is the result of an error of law.” Id. at 327. 

The ALJ has a basic obligation both to develop a full and fair record and to “build an 

accurate and logical bridge between the evidence and the result [so as] to afford the claimant 

meaningful judicial review of the administrative findings.” Beardsley, 758 F.3d at 837. 

Although the ALJ is not required to mention every piece of evidence in the record, the ALJ’s 

analysis “must provide some glimpse into the reasoning behind her decision to deny benefits.” 

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Zurawski v. Halter, 245 F.3d 881, 889 (7th Cir. 2001); accord Craft v. Astrue, 539 F.3d 668, 673 

(7th Cir. 2008). The ALJ “must explain [the ALJ’s] analysis of the evidence with enough detail 

and clarity to permit meaningful appellate review.” Scrogham v. Colvin, 765 F.3d 685, 695 

(7th Cir. 2014) (quoting Briscoe, 425 F.3d at 351). Thus, even if reasonable minds could differ 

as to whether the claimant is disabled, courts will affirm a decision if the ALJ's opinion is 

adequately explained and supported by substantial evidence. Elder, 529 F.3d at 413. 

II. Analysis 

Plaintiff argues that (1) the ALJ erred in crafting the RFC and at step 5 by failing to 

adequately support her findings, including by the ALJ affording great deference to only a 

selective review of a functional capacity evaluation (“FCE”), (2) the ALJ’s determination that 

Plaintiff could communicate in English is flawed, and (3) the ALJ’s subjective symptom 

assessment is not supported by substantial evidence. [Dkt. 20, Pl.’s Mem. at 5-15; dkt. 28, Pl.’s 

Reply at 1-9.] The Commissioner argues in opposition that the ALJ reasonably assessed 

Plaintiff’s subjective statements and the opinion evidence, the ALJ reasonably determined that 

Plaintiff could communicate in English, and the VE’s testimony at step 5 about jobs Plaintiff 

could perform was consistent with the Dictionary of Occupational Titles (“DOT”). [Dkt. 26, 

Def.’s Mem. at 2-16.] After reviewing the record and the briefs submitted by the parties, the 

Court agrees with Plaintiff that the ALJ failed to adequately support her RFC finding with 

substantial evidence, including by selectively relying on the FCE. Because this failure alone 

warrants remand, the Court does not reach Plaintiff’s additional arguments.

In determining Plaintiff’s RFC, the ALJ found that Plaintiff could perform medium work 

except that he can only occasionally climb ladders, ropes, or scaffolds; occasionally stoop or 

crawl; no more than frequently use the lower left extremity for operating foot controls; no more 

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than frequently handle or finger bilaterally and reach overhead; must avoid concentrated 

exposure to vibration; can be off task no more than 15% of a workday; can understand English at 

least 30% of a workday; and needs oral instructions. [R. 25.] Plaintiff argues—and the Court 

agrees—that the ALJ failed to build a “logical bridge” between the evidence and these RFC 

limitations. [Pl.’s Mem. at 5-9.] Beardsley, 758 F.3d at 837. Since the ALJ’s analysis was 

deficient, the Court is unable to evaluate whether substantial evidence supports the ALJ’s 

conclusions and ultimate RFC determination, and remand is thus warranted. 

While evaluating Plaintiff’s subjective symptoms, the ALJ gave a lengthy summary of 

the medical evidence in the record—which was voluminous, totaling over 1800 pages in this 

case, [see R. 444-2323]—and later briefly discussed her takeaways from that evidence, but did 

not explain how her conclusions were supported by the record or translated into the RFC. 

[See R. 26-31.] In her discussion, the ALJ first cited parts of two specific records without any 

analysis of them: the FCE’s conclusion in September 2018 that Plaintiff could not perform his 

past relevant work at a heavy exertional level but could work at a medium exertional level, and 

the internal medicine consultative examination findings in November 2017 of no edema, nonantalgic gait, normal grip strength, normal ability to grasp and manipulate objects in both hands, 

normal range of motion in the cervical and lumbar spine, and ability to walk 50 feet without 

support. [R. 30; see R. 951-64 (FCE), 863-66 (consultative exam).] The ALJ then made several 

general observations about the treatment record: 

After having CTS and neck surgeries, physical therapy helped improve his 

symptoms. Physical exams did not consistently revealed [sic] deficits. He did not 

consistently report having symptoms to providers. Some imaging revealed only 

mild deficits. He refused treatment, including injections and physical therapy, 

suggesting that his symptoms were not as severe as alleged.

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[R. 30.] Immediately after that discussion, in a new paragraph, the ALJ outlined the above RFC

and explained as follows: “The exertional, postural, environmental, and off-task limitations 

accommodate his spine disorder issues and pain. The manipulative and off-task limitations 

accommodate his CTS issues and pain. The language limitation accommodates his limited 

abilities in understanding English. The record does not support further limitations.” [R. 30-31.]

This discussion raises more questions than it answers about how the ALJ viewed the

medical evidence in crafting the RFC here. The ALJ had an obligation to “include a narrative 

discussion describing how the evidence supports each conclusion, citing specific medical facts 

(e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).” 

SSR 96-8p, 1996 WL 374184, at *7; see also Mark J. v. Saul, No. 18 C 8479, 2020 WL 374676, 

at *5 (N.D. Ill. Jan. 23, 2020) (ALJ must build a logical bridge between record and RFC 

assessment and merely summarizing medical evidence is not sufficient). The terse sentences

following the RFC that broadly connect parts of the RFC to Plaintiff’s spine disorder issues, CTS 

issues, and pain explain nothing about how severe those conditions are or why those limitations 

are appropriate to address the conditions. [See R. 31.] And the bare citations to the FCE and an 

internal medicine consultative examination, without any elucidation as to how they support the 

RFC, are similarly unhelpful and incomplete. [See R. 30.]

That leaves just the block-quoted five sentences above representing the ALJ’s takeaways 

from the medical evidence, which have no citations to the medical records (or even to the ALJ’s 

earlier summary of those records) and are vague. For example, the ALJ stated that “[p]hysical 

exams did not consistently reveal[] deficits” and that Plaintiff “did not consistently report 

symptoms to providers,” but there are no specifics about what deficits the ALJ did not see in 

which physical exams, what is meant by “consistently,” or to which “providers.” [R. 30.] 

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Without any context or further detail, the Court is unable to review (1) whether these statements 

about the evidence are accurate or (2) how the ALJ used this evidence to inform her crafting of 

the RFC. Similarly, the ALJ concluded that “[s]ome imaging revealed only mild deficits.” 

[R. 30.] Again, the Court is left to wonder what is meant by “some”—as it seems to imply also 

that at least some other imaging revealed more than mild deficits—and ultimately how the mild 

deficit findings factored into the ALJ’s RFC. The remaining two sentences—explaining that 

Plaintiff’s symptoms improved after CTS and neck surgeries with physical therapy and that 

Plaintiff refused injections and physical therapy—are at least more specific, but these statements 

are still not supported with citation to the record, and more importantly, remain untethered to the 

RFC.

Further, although the Court is unable to trace the ALJ’s reasoning from the evidence to 

her conclusions here with any particularity, even a review of the ALJ’s own summary of the 

medical evidence raises questions about her conclusions and whether she engaged in

impermissible “cherry-pick[ing]” of the record to come up with those conclusions, as Plaintiff

also asserts. [Pl.’s Mem. at 5-6.] See Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir. 2014) 

(“The ALJ must confront the evidence that does not support [her] conclusion and explain why 

that evidence was rejected.”). For example, as to Plaintiff’s purported refusal of injections and 

physical therapy, the ALJ noted earlier in her decision that Plaintiff participated in physical 

therapy for his back condition until November 2017 when he reported he stopped because his 

pain had decreased and that Plaintiff refused epidural injections due to possible complications

(i.e., side effects) in June 2018. [R. 27-29.] But then the ALJ acknowledged that Plaintiff did 

later opt for transforaminal injections in January 2019 in order to treat his lumbar degenerative 

disk disease. [R. 30.] And, similarly, the ALJ noted that Plaintiff did engage in physical therapy

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after November 2017: Plaintiff went to physical therapy for his CTS after his left carpal tunnel 

release surgery in February 2018, and Plaintiff was referred to physical therapy for his back in 

January 2019. [R. 28-30.] When it came to assessing Plaintiff’s subjective symptoms and 

determining the RFC, the ALJ acknowledged none of this nuance, instead broadly concluding 

that Plaintiff’s sometimes refusal of treatment was a reason his symptoms were not as severe as 

he alleged. [R. 31.] 

The ALJ’s conclusion that “[p]hysical exams did not consistently reveal[] deficits” also is 

puzzling in light of the evidence that the ALJ summarized. [R. 30.] Just to name a few of the 

deficiencies, there are numerous reports in the ALJ’s own recitation of the medical evidence of 

Plaintiff having edemas, decreased strength in his extremities, positive left straight leg raise tests 

and Faber’s tests, decreased range of motion in the spine, and gait issues. [See R. 26-30.] 

Ultimately, it appears that the record evidence is considerably more mixed than the ALJ’s bare 

conclusions would suggest, and the ALJ erred in not explaining her reasoning in adopting her 

ultimate conclusions. See Moore, 743 F.3d at 1123; Amanda M. v. Kijakazi, No. 3:20-cv-50272, 

2022 WL 1773780, at *3 (N.D. Ill. June 1, 2022).

Next, the ALJ turned to the opinion evidence after she laid out the RFC, but her 

evaluation of the medical opinions was also deficient. As Plaintiff’s application for benefits was 

filed after March 17, 2017, the evaluation of medical opinion evidence is governed by 20 C.F.R. 

§ 404.1520c. Under § 404.1520c(a), the ALJ “will not defer or give any specific evidentiary 

weight, including controlling weight,” to any medical opinion. Instead, the ALJ considers a 

variety of factors in assessing medical opinions, but the “most important factors”—and the only 

factors that the ALJ is required to discuss in her decision—are supportability and consistency. 

20 C.F.R. § 404.1520c(b)(2). But the ALJ did not adequately address these factors with respect 

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to the state agency physicians’ prior administrative medical findings or the examining source’s 

FCE.

As to the prior administrative medical findings, state agency physicians concluded

initially and upon reconsideration in December 2017 and March 2018, respectively, that Plaintiff 

could perform light work with the following additional limitations: he had unlimited ability to 

balance, kneel, crouch, and manipulate objects; he could only frequently climb ladders, ropes, 

and scaffolds; he could only occasionally stoop or crawl; and he had to avoid concentrated 

exposure to vibration. [R. 95-97, 107-09.] The ALJ acknowledged that the state agency medical 

consultants opined that Plaintiff “should be limited to light work with postural and 

environmental limitations to account for his back, neck, and CTS symptoms,” but the ALJ never 

identified what those postural and environmental limitations were in her decision. [R. 31.] The 

ALJ found the state agency medical opinions “persuasive to the extent that postural and 

environmental limitations are justified to accommodate his spine disorders and CTS, but they are 

inconsistent with [Plaintiff's] improvement after his surgeries, including his reports to providers, 

deficits noted during physical exams, and [Plaintiff's] refusal of treatment.” [Id.] Here, the ALJ

did indeed impose some—but not all—of the postural and environmental limitations that the 

state agency physicians thought were warranted, but it is not clear (because of her lack of 

specificity) whether she did this because she was adopting those doctors’ opinions or not (or at 

least adopting them in part, i.e., the portions that limited Plaintiff to occasional stooping or 

crawling and avoiding concentrated exposure to vibration). [See R. 31, 95-97, 107-09.] And the 

ALJ found Plaintiff less limited overall than the stage agency physicians had, concluding that he 

could perform medium work rather than light work. [R. 31.] The ALJ’s perfunctory and unclear 

attempts to consider the supportability and consistency of the state agency physicians’ opinions, 

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by simply citing unspecified reports to providers, physical exam findings, and refusal of 

treatment without detail, are plainly inadequate because the ALJ gives no indication as to what 

portions of the record on which she was relying and thus gives the Court no ability to trace her 

actual reasoning. [See R. 31.] To the extent that the ALJ is citing those reasons with reference 

to her earlier conclusions about the record, as just discussed above, those conclusions are 

similarly unexplained and deficient. [See R. 30.]

Turning to the FCE, the ALJ focused only on the evaluation’s conclusions about what 

Plaintiff could lift and carry, finding them “generally persuasive.” [R. 31.] The ALJ concluded 

that the FCE opinion showed that although Plaintiff could not return to his previous work, “his 

treatment and reports of improvement to providers shows that he was capable of working.” [Id.] 

Further, as to the lifting and carrying specifically, the ALJ determined that “the record 

demonstrates that [Plaintiff] is capable of lifting and carrying more weight than [the opinion 

provided] based on [Plaintiff's] lack of consistent reports of symptoms to providers and 

consistent deficits demonstrated during exams and imaging.” [Id.] Thus, the ALJ explained, the

FCE opinion is “consistent with [Plaintiff] experiencing improvement with surgery and physical 

therapy, but the record shows that [Plaintiff] is capable of slightly more than what [the FCE 

opinion determined].” [Id.] Once again, the ALJ’s discussion does not address the consistency 

and supportability of the FCE’s opinion with any specificity, and the ALJ relies on the same 

underdeveloped reasoning as before to find that Plaintiff can do “slightly more” than the opinion 

includes. [Id.] This is another error.

Moreover, Plaintiff is correct that the ALJ failed to address any limitations that the FCE 

opined were necessary beyond lifting and carrying restrictions. [Pl.’s Mem. at 6; Pl.’s Reply at 

6-7.] In particular, the ALJ did not discuss whether she found the FCE’s postural limitations 

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warranted: that Plaintiff can occasionally reach forward sustained, must avoid reaching 

overhead sustained, avoid bending, occasionally repetitive squat and avoid sustained squatting, 

occasionally kneel, avoid crawling, occasionally climb stairs, occasionally climb ladders, 

occasionally walk, avoid bilateral grasp occasionally, and occasionally grip. [R. 952-53.] 

Again, as with the state agency physicians’ opinions, the ALJ included some of these limitations

in the ultimate RFC (e.g., Plaintiff can occasionally climb stairs and ladders) but also left out

several (e.g., Plaintiff should avoid crawling or bending and only occasionally grip objects). 

[See R. 30-31.] Without any explanation given, the Court cannot evaluate what role this

significant portion of the FCE played in the ALJ’s RFC determination of Plaintiff’s postural 

limitations.

Last, as Plaintiff points out and the Commissioner admits, [Pl.’s Mem. at 5-6; 

Def.’s Mem. at 9], the ALJ misidentified the medical professional who performed the FCE as 

Dr. John Song, M.D., instead of physical therapist Christina Smith. This would be a relatively 

trivial mistake had the ALJ given other well-supported reasons for partially adopting the FCE by

finding Plaintiff “capable of slightly more than [ ] opined,” [R. 31], but here the misidentification 

casts further doubt as to whether the ALJ adequately considered the FCE.

3

3

 Plaintiff argues in her opening brief that because the FCE was completed by a physical 

therapist, it should not even be considered opinion evidence, citing to the former regulations 

concerning opinion evidence, which required that opinions be from “acceptable medical 

sources.” See 20 C.F.R. § 404.1527(f). [Pl.’s Mem. at 5-6.] In her reply, Plaintiff presses that

same argument now under the current regulations. [Pl.’s Reply at 6.] The Court, however, notes 

that the regulations in effect now no longer refer to “acceptable medical sources” but rather 

simply “medical sources,” which has a broader definition under which a physical therapist would 

seem to qualify because he or she is licensed by a State. 20 C.F.R. § 404.1520c; see 20 C.F.R. 

§ 404.1502(d) (“Medical source means an individual who is licensed as a healthcare worker by a 

State and working within the scope of practice permitted under State or Federal law. . .”). 

Regardless, this issue can be addressed and litigated if/as appropriate on remand.

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Overall, the ALJ’s decision lacks sufficient analysis for the Court to determine how the 

ALJ credited the medical opinions and, in general, what led the ALJ to impose the particular

RFC limitations. It is the ALJ’s responsibility to adequately explain her reasoning in order for 

the Court to be able to review whether the decision is supported by substantial evidence. 

See Scrogham, 765 F.3d at 695. Because the ALJ did not fulfill that obligation here, the Court 

must remand the case for further consideration. See, e.g., Darlene M. v. Kijakazi, No. 19 CV 

6389, 2021 WL 3773291, at *6 (N.D. Ill. Aug. 25, 2021). 

CONCLUSION

 For the foregoing reasons, Plaintiff’s motion for summary judgment [dkt. 20] is granted, 

and the Commissioner’s motion for summary judgment [dkt. 25] is denied. The Commissioner’s 

decision is reversed, and this matter is remanded for further proceedings consistent with this 

Memorandum Opinion and Order. 

SO ORDERED. 

Date: 9/12/2022 

BETH W. JANTZ

United States Magistrate Judge

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