The opinion of the court was delivered by: SHIRA SCHEINDLIN, District Judge
Luz Gonzalez appeals from a December 27, 2000 decision denying
her request for Social Security disability benefits. Gonzalez's
case was initially filed in this Court on January 10, 2000, but
was remanded to the Commissioner of Social Security for further
consideration on May 23, 2000. The Commissioner issued a final
decision again denying benefits on August 23, 2003, and Gonzalez
renewed her suit on February 2, 2005. Gonzalez now moves for
judgment on the pleadings reversing the Commissioner's decision;
the Government opposes her motion and cross-moves for judgment on
the pleadings affirming the Commissioner's decision. For the
following reasons, Gonzalez's motion is granted and the Government's motion is denied.
Luz Gonzalez is a fifty-two-year-old woman. She was born on
January 2, 1953 in the Dominican Republic, where she attended
school through the third grade.*fn1 Gonzalez does not speak
English although she has a limited ability to read and write in
English.*fn2 Gonzalez alleges that she is permanently and
totally disabled as a result of a workplace injury sustained on
November 21, 1996. At the time of her injury, Gonzalez worked as
a shipping clerk; she claims to have injured her back while
lifting a heavy box.*fn3 Following her injury, Gonzalez was
seen by a number of medical professionals and received a variety
of diagnoses and treatment recommendations.
On December 12, 1996, Gonzalez filed a claim for disability
benefits, alleging that she was permanently and totally disabled.
She stated that she was under the care of Richard Weinberg, a
chiropractor, that she was not taking any medication for her
injury, and that she was not interested in rehabilitative
services that would enable her to return to work.*fn4 On January 10,
1997, Weinberg stated that Gonzalez suffered bilateral trapezius
and SCM spasms, bilateral erector spinal spasms, L4-S1 disc
tenderness, and bilateral gluteal spasms.*fn5 Weinberg
opined that Gonzalez was totally disabled.*fn6 He noted that
the only treatment Gonzalez had received thus far was
chiropractic manipulation.*fn7
On March 5, 1997, Gonzalez was examined by Dr. Peter Graham, a
consultant for the Social Security Administration. Graham
observed that Gonzalez walked and stood normally, and that she
was able to dress and undress herself and get on and off the exam
table without a problem.*fn8 He also opined that Gonzalez
was "able to sit, stand, walk, lift, carry, handle objects, hear,
speak, and travel."*fn9 On March 18, 1997, Gonzalez stated
that she was able to care for her own personal needs but that she
had to move slowly.*fn10 On March 27, 1997, Dr. Hughes, a physician with the Social Security Administration,
completed a "Physical Residual Functional Capacity Assessment"
although he never examined Gonzalez.*fn11 He opined that
Gonzalez was able to lift fifty pounds or more frequently; that
she could stand, walk, or sit for about six hours of an eight
hour workday; that she had unlimited capacity to push and pull;
and that she had no other significant physical
limitations.*fn12 On March 28, 1997, Dr. Danza, another
physician with the Social Security Administration, reviewed the
file.*fn13
At Weinberg's request, Dr. Gondolo, a neurologist, evaluated
Gonzalez on June 9, 1997.*fn14 Dr. Gondolo noted that
Gonzalez had "5/5" strength in all four of her
extremities.*fn15 She listed her impressions as: "1
Cervical sprain and strain; 2 Rule-out cervical radiculopathy;
3 Lumbosacral sprain and strain; [and] 4 Rule-out lumbosacral
radiculopathy."*fn16
Gonzalez underwent an MRI test on February 21, 1998. Dr. Ronald Staron, the attending radiologist, listed the following
impressions: "Evidence of increased hematopoetic marrow within
the cervical spine. Disc osteophyte complex at the C5-6 level
results in spinal stenosis. Smaller disc osteophyte complexes at
the C3-4 and C4-5 levels result in mild spinal stenosis. . . .
Hemangioma in the L4 vertebral body. Mild spinal stenosis at the
L4-5 level as described, and the sagittal views demonstrate
minimal dessication of L4-5 disc."*fn17
On June 12, 1998, Weinberg reiterated his opinion that Gonzalez
was totally disabled. He also noted that she was suffering
emotional difficulties as a result of her health problems and he
referred her for psychological evaluation.*fn18 If such an
evaluation was ever made, it has not been included in the record.
On July 15, 1997, Dr. Ploski, an orthopedic surgeon who
examined Gonzalez at Weinberg's request, also recommended that
she receive a psychological evaluation.*fn19 Dr. Ploski
performed a physical examination of Gonzalez and formed an
impression of "1 Cervical derangement; 2 Low back
derangement; 3 Headaches and dizziness of unknown etiology;
[and] 4 Multiple reaction and anxiety regarding her neck and back injury."*fn21 Dr. Ploski
opined that Gonzalez was "totally disabled" as of the examination date but
he did not recommend treatment by an orthopedic sugeon.*fn22
On November 21, 1998, Gonzalez fell down the stairs of her building and
suffered injuries to her right knee and ankle.*fn23 On December 3, 1998,
she was seen by Dr. Klara Sosina, who performed a full exam. Dr. Sosina
noted "[c]ervical range of motion produced the following result: Full range
of motion in flexion and extention. Rotation to the right anf left were full.
Range of motion of the lumbosacral spine produced the following result: Full
range of motion in the flexion and extension. Lateral bending to the right and
left were full. . . . Palpation of the spine muscles resuled in: Normal Cervical
paraspinal muscles. Normal cervical interspinous space."*fn24 Dr. Sosina also
examined Gonzalez's shoulders and noted that "range of motion was full in
flextion, abduction and internal rotation. Acromio-clavicular joint was not
tender. There was no pain with shoulders and noted that "range of motion was full in flexion,
abduction and internal rotation. Acromio-clavicular joint was not
tender. There was no pain with resisted external rotation. There
was no tenderness at the rotator cuff insertion site or in the
bicipital groove."*fn25 Dr. Sosina's exam is the last exam
on record that took place before the expiration of Gonzalez's
insurance on December 31, 1998.
Subsequent to December 31, 1998, Gonzalez was seen regularly by
Dr. Sosina and Dr. Petraco for treatment of her ankle and knee
injuries.*fn26 She was prescribed a course of physical
therapy, pain medication, and eventually received arthroscopic
surgery on her knee.*fn27 Dr. Sosina's records from December
1998 until November 1999 show a steady decrease in Gonzalez's
pain coupled with an increase in range of motion.*fn28 Dr.
Petraco, a second treating physician, made similar
observations.*fn29 Neither ...