“Wax and Wane Requires a Long View”: Seventh Circuit Mandates Longitudinal Analysis of Fibromyalgia Under SSR 12-2p

Case: Christine Swiecichowski v. Leland Dudek, No. 22-2011 (7th Cir. Mar. 31, 2025)

Court: United States Court of Appeals for the Seventh Circuit

Panel: Scudder, Kirsch, and Lee, Circuit Judges. Opinion by Judge Lee; dissent by Judge Kirsch.

Introduction

This Social Security disability appeal centers on how administrative law judges (ALJs) must evaluate fibromyalgia when crafting a claimant’s residual functional capacity (RFC). The Seventh Circuit vacated and remanded the denial of benefits to Christine Swiecichowski, emphasizing that fibromyalgia’s “wax and wane” nature requires ALJs to conduct a holistic, longitudinal review of the record as contemplated by Social Security Ruling (SSR) 12-2p. The court held that the ALJ’s limited reliance on snapshots of clinical findings (including repeated notations of “no acute distress”) and a passing reference to “conservative treatment” did not demonstrate the longitudinal analysis SSR 12-2p demands. The court also clarified the interplay between SSR 12-2p (fibromyalgia) and SSR 16-3p (evaluation of symptoms) at the RFC stage and reaffirmed waiver principles for arguments not raised in the district court.

The dissent would have affirmed under the highly deferential substantial-evidence standard, warning against imposing an unduly exacting requirement to cite more of the record.

Summary of the Opinion

  • The court vacated the judgment affirming the denial of disability benefits and remanded for further proceedings.
  • Holding: When evaluating fibromyalgia at the RFC stage, ALJs must perform a holistic, longitudinal review of the claimant’s symptoms consistent with SSR 12-2p’s instruction to consider “good days and bad days.” A limited set of cited visits and generalized reliance on clinical notations like “no acute distress” are insufficient to show compliance with this requirement.
  • The court recognized that clinical findings are not irrelevant in fibromyalgia cases but cautioned that ordinary normal findings (strength, reflexes, gait) are often expected with fibromyalgia and do not undermine subjective symptoms absent longitudinal context.
  • The ALJ’s cursory invocation of “conservative treatment” did not supply the missing logical bridge.
  • Waiver: Except for the SSR 12-2p/longitudinal-analysis argument, the claimant’s other appellate issues (combined-impact; state-agency opinion assessment; nurse practitioner opinion) were deemed waived because they were not presented to the district court.
  • Dissent: Judge Kirsch believed the ALJ adequately reviewed longitudinal evidence and that substantial evidence supported the decision, cautioning against demanding an unspecified quantum of citations.

Case Background

Christine Swiecichowski worked in a warehouse for over thirty years before leaving her job in 2018 due to chronic pain she attributed to fibromyalgia, depression, right upper extremity issues, and spinal disorders. The record shows a fibromyalgia diagnosis supported by a trigger-point assessment (12/18 positive points) and repeated reports of widespread pain uncorroborated by imaging or EMG—characteristic of fibromyalgia, for which objective tests other than trigger-point assessment are limited.

The ALJ found several severe impairments, including fibromyalgia, and set an RFC for light work with additional limitations. Relying on perceived inconsistencies between subjective complaints and clinical findings (e.g., “no acute distress,” normal strength/reflexes/gait), on daily activities, and on the claimant’s treatment course, the ALJ concluded she was not disabled at step five. The Appeals Council denied review; the district court affirmed.

Analysis

Precedents and Authorities Cited and Their Influence

  • SSR 12-2p (2012): The governing guidance for evaluating fibromyalgia. It sets diagnostic criteria and instructs ALJs to consider a “longitudinal record” because fibromyalgia symptoms “wax and wane,” producing “good days and bad days.” The Seventh Circuit treats this instruction as critical to RFC evaluation in fibromyalgia cases. The opinion makes clear that ALJs must demonstrate this longitudinal assessment.
  • SSR 16-3p (2017): Supersedes SSR 96-7p. Provides the two-step framework for evaluating symptoms (could the impairment reasonably produce the alleged symptoms?; if so, assess intensity, persistence, and limiting effects considering all evidence). The court reaffirmed that SSR 12-2p directs ALJs to apply SSR 16-3p at the RFC stage for fibromyalgia claims.
  • Sarchet v. Chater, 78 F.3d 305 (7th Cir. 1996); Gerstner v. Berryhill, 879 F.3d 257 (7th Cir. 2018); Vanprooyen v. Berryhill, 864 F.3d 567 (7th Cir. 2017): These cases recognize fibromyalgia’s limited objective markers and the diagnostic role of trigger-point testing. They caution against discrediting fibromyalgia because “normal” clinical findings often coexist with significant pain.
  • Wilder v. Kijakazi, 22 F.4th 644 (7th Cir. 2022): Social Security Rulings are binding on ALJs, though they lack the force of law. This reinforces the duty to follow SSR 12-2p’s longitudinal guidance.
  • Revels v. Berryhill, 874 F.3d 648 (9th Cir. 2017): The Ninth Circuit’s treatment of fibromyalgia is consonant with SSR 12-2p—patients often have normal strength, reflexes, and sensory function despite severe pain. The Seventh Circuit used Revels to illustrate why “normal” exams are not determinative against fibromyalgia.
  • Jeske v. Saul, 955 F.3d 583 (7th Cir. 2020): On appellate posture and waiver—Seventh Circuit reviews the ALJ decision directly, but arguments not raised in district court are waived on appeal. Applied here to narrow the issues.
  • Gedatus v. Saul, 994 F.3d 893 (7th Cir. 2021); Richardson v. Perales, 402 U.S. 389 (1971): Articulate the “substantial evidence” standard—low threshold but requires a logical bridge from evidence to conclusions.
  • Kastner v. Astrue, 697 F.3d 642 (7th Cir. 2012): Recites the five-step disability framework, framing where the RFC analysis (between steps three and four) fits.
  • Mandrell v. Kijakazi, 25 F.4th 514 (7th Cir. 2022): Defines RFC as the most a claimant can do on a sustained basis.
  • Burmester v. Berryhill, 920 F.3d 507 (7th Cir. 2019): Notes SSR 16-3p controls symptom evaluation for decisions issued after March 28, 2016.
  • Prill v. Kijakazi, 23 F.4th 738 (7th Cir. 2022) and Thomas v. Colvin, 745 F.3d 802 (7th Cir. 2014): Establish that “conservative treatment” can be relevant, but perfunctory reliance is improper when treatment does not control symptoms or where the nature of the condition limits treatment escalation. The court found the ALJ’s “conservative treatment” remark here too cursory.
  • Waiver authorities: Puffer v. Allstate, 675 F.3d 709 (7th Cir. 2012) (undeveloped arguments waived); Mendez v. Perla Dental, 646 F.3d 420 (7th Cir. 2011) (arguments raised first time in reply are waived).
  • Dissent’s standards: Elder v. Astrue, 529 F.3d 408 (7th Cir. 2008); Lopez v. Barnhart, 336 F.3d 535 (7th Cir. 2003); Deborah M. v. Saul, 994 F.3d 785 (7th Cir. 2021); Martin v. Kijakazi, 88 F.4th 726 (7th Cir. 2023); Beardsley v. Colvin, 758 F.3d 834 (7th Cir. 2014). These reinforce the deference owed and the requirement for a logical bridge, framing the dissent’s view that the ALJ did enough.

Legal Reasoning

1) SSR 12-2p requires a longitudinal approach at the RFC stage

The court’s central holding is interpretive and methodological: fibromyalgia’s hallmark fluctuations require ALJs to review symptom evidence over time, not to treat isolated visits as determinative. SSR 12-2p expressly directs adjudicators to “consider a longitudinal record whenever possible because the symptoms of [fibromyalgia] can wax and wane so that a person may have ‘bad days and good days.’” The Seventh Circuit emphasized that this longitudinal lens is not confined to step two (medically determinable impairment) but governs how limitations are identified and incorporated into the RFC.

Here, the ALJ cited five visits across roughly two years and concluded that clinical findings were “mixed” and that severe pain was not consistent. Yet the record contained about thirty other visits reflecting functionally limiting pain. The court did not require discussion of each entry, but it found it “unclear” that the ALJ evaluated those records “holistically over time,” as SSR 12-2p contemplates. That lack of clarity broke the logical bridge between the evidence and the RFC determination.

2) Clinical findings are relevant—but must be contextualized

The court rejected the notion that SSR 12-2p forbids consideration of physical examination findings. Clinical evidence can illuminate functional capacity (e.g., walking, strength, dexterity). Yet for fibromyalgia, “normal” findings—no acute distress, intact reflexes, normal gait, full strength—often coexist with disabling pain. The court highlighted that a note of “no acute distress” does not negate widespread tenderness and abnormal trigger-point responses, and it cited an example where the same encounter documented both “no acute distress” and “significant pain throughout” with multiple trigger points. In short, clinical findings cannot be used as a blunt instrument to contradict fibromyalgia-related pain without a longitudinal, symptom-focused analysis.

3) SSR 12-2p and SSR 16-3p work together in symptom evaluation

Once fibromyalgia is established as a medically determinable impairment (step two), SSR 16-3p guides symptom evaluation at RFC: first, whether the impairment could reasonably cause the alleged symptoms; second, the severity and persistence of those symptoms and their functional effects. For fibromyalgia, the absence of objective corroboration is expected; thus, the analysis must integrate subjective reports, medical-source statements, medication and treatment history, and activities of daily living—through a longitudinal lens.

4) “Conservative treatment” requires more than a label

The ALJ’s one-sentence observation that treatment was “conservative” carried little weight. The court distinguished decisions where detailed treatment analysis supported an inference that symptoms were not as limiting as claimed. Without explanation or record citations showing how injections, medications, or therapy controlled symptoms or were reasonable for the condition, the shorthand label did not cure the opinion’s analytical gap.

5) Waiver narrowed the appeal

Although the claimant raised multiple RFC-related challenges, only the SSR 12-2p/longitudinal analysis issue was preserved. Seventh Circuit practice requires Social Security claimants to present their objections to the district court; otherwise, they are waived on appeal. This framing underscores that the precedential value of the decision centers on the longitudinal analysis requirement rather than other potential RFC issues (combined-effect of impairments, weighing of medical opinions).

6) The dissent’s pragmatic deference

Judge Kirsch underscored the “extremely limited” nature of substantial-evidence review and viewed the ALJ’s discussion as sufficiently longitudinal, especially since the ALJ acknowledged a pattern of mixed findings and cited multiple visits over several years. The dissent also noted that many visits the majority referenced predated the amended onset date; while pre-onset evidence is relevant, the dissent cautioned against faulting the ALJ for not citing more of that period. The dissent worried the majority’s approach risks creating an undefined “threshold” of record citations.

Impact and Practical Implications

  • ALJ adjudication in fibromyalgia cases: In the Seventh Circuit, ALJs must explicitly or demonstrably conduct a longitudinal review of symptom evidence for fibromyalgia at the RFC stage. Opinions should explain how “good days and bad days” were considered and reconcile normal clinical findings with reported pain over time. A handful of citations will rarely suffice if the file shows a dense history of pain-related visits.
  • Use of “no acute distress” and similar notations: Clinicians’ shorthand observations cannot be used to undercut fibromyalgia-related pain without acknowledging that normal strength, reflexes, and gait are common in fibromyalgia. ALJs should avoid treating such notations as inherently inconsistent with severe pain.
  • “Conservative treatment” arguments: Citing treatment as conservative must be accompanied by analysis showing its significance. Where records show persistent pain despite injections, medications, or therapy, or where the condition is often not susceptible to “aggressive” interventions, a bare label is inadequate.
  • Record development and briefing: Claimants and counsel should assemble and highlight the longitudinal pain narrative, including frequency, duration, exacerbations, and functional fallout (breaks, off-task time, absenteeism). They must preserve all issues in the district court; otherwise, waiver will preclude appellate review.
  • Cross-impairment resonance: Although grounded in fibromyalgia, this reasoning may influence adjudication of other waxing/waning conditions (e.g., migraines, chronic fatigue syndrome) where normal clinical exams can coexist with substantial functional limitations.
  • Vocational consequences: A proper longitudinal review may prompt RFCs to include variability-driven limitations—additional breaks, position changes beyond the norm, off-task allowances, or absenteeism—issues often outcome-determinative at step five.
  • Judicial review: District courts reviewing ALJ decisions should look for explicit longitudinal analysis in fibromyalgia determinations and for reasoned treatment of so-called “normal” clinical findings in context.

Complex Concepts Simplified

  • Fibromyalgia: A chronic condition causing widespread pain, fatigue, sleep disturbance, and cognitive symptoms. It typically lacks objective biomarkers; diagnosis often relies on clinical judgment and trigger-point testing.
  • Trigger-point assessment: Pressure is applied to 18 standardized points; sensitivity at a sufficient number of points supports a fibromyalgia diagnosis. The Seventh Circuit recognizes this as the only accepted “test” for fibromyalgia.
  • Medically determinable impairment (MDI): An impairment established by objective medical evidence from an acceptable medical source. For fibromyalgia, SSR 12-2p sets criteria. MDI recognition at step two is distinct from whether the impairment is disabling.
  • Residual Functional Capacity (RFC): The most a claimant can do on a sustained basis despite limitations. It is determined between steps three and four and informs whether the claimant can perform past work or other work.
  • SSR 12-2p: Agency guidance specific to fibromyalgia. It directs ALJs to evaluate symptoms longitudinally because fibromyalgia fluctuates, and to integrate its effects into the RFC.
  • SSR 16-3p: Governs evaluation of symptom intensity and persistence, replacing credibility terminology. It requires consideration of objective evidence, subjective reports, medical-source statements, treatment, and daily activities.
  • Substantial evidence / Logical bridge: “Substantial evidence” is a low threshold—evidence a reasonable mind might accept. Still, the ALJ must “build an accurate and logical bridge” from evidence to conclusions, explaining why the evidence supports the RFC and the step-five outcome.
  • “Conservative treatment” rhetoric: A descriptive label (e.g., medications, injections, therapy) that can be relevant, but it must be linked to how well symptoms are controlled and what treatment escalation is medically appropriate for the condition.
  • Waiver on appeal: Even in Social Security cases where appellate courts review the ALJ’s decision directly, arguments not raised in the district court are generally not considered on appeal.

Conclusion

The Seventh Circuit’s decision crystallizes an important practice rule: in fibromyalgia cases, ALJs must take the “long view.” SSR 12-2p’s admonition to consider a “longitudinal record” is not a courtesy; it is a requirement that shapes how symptom evidence is weighed and how functional limitations are translated into the RFC. Clinical normality is not determinative against fibromyalgia, and generalized references to “conservative treatment” cannot substitute for analysis.

For claimants and counsel, the decision underscores the need to curate and explain the waxing and waning course of symptoms and to preserve all arguments in the district court. For ALJs, it signals that fibromyalgia adjudications must narrate the longitudinal symptom trajectory and explicitly reconcile fluctuating pain reports with clinical findings and daily activities. For reviewing courts, it provides a workable benchmark: remand is warranted where the opinion does not make clear that a holistic longitudinal evaluation informed the RFC.

Key takeaway: When a condition’s nature is to wax and wane, the law requires the adjudicator’s analysis to do the same—spanning the record over time to build the logical bridge that substantial-evidence review demands.