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Musculoskeletal Disorders
Home Full Impairment Discussion The musculoskeletal system contains a large variety of disease states that can adversely affect any joint or muscle group within the human body. Severe musculoskeletal disorders usually cause pain and decreased range of motion of the involved joints. When evaluating disorders of the
musculoskeletal system, you should focus on the symptom of pain
as a primary limiting factor in the claimant's ability to
perform work activity. As is true of all serious disorders, the
symptom of pain in a musculoskeletal disorder must have a loose
nexus. That is, the location and severity of the pain must be
reasonably associated with the primary diagnosis. To establish
a loose nexus, the pain must be associated with abnormal medical
findings that substantiate and support the existence and
severity of the pain. General Evaluation of MS Disorder When evaluating musculoskeletal disorders, it's important that you note any degree of joint swelling or deformity. Your evaluation should also include all relevant signs, symptoms and laboratory finding associated with the disorder. You should also make note of any decreased range of motion in the involved joints and the condition of surrounding muscle tissue. In severe musculoskeletal disorders, you may also find symptoms of sensory or reflex loss and even circulatory deficits. Make sure that you request and review all copies of the most current x-rays as well as x-ray findings at the time of onset. If a worsening of the condition can be shown to have occurred since the onset of the disorder, this evidence can be used to argue that the condition is progressive. All of the above types of medical findings should be available in the claimant's record.
A disease is considered progressive if it can be shown to worsen over time. In musculoskeletal disorders, progression of a disease is a powerful factor that can actually make it easier for you to win the case. Although Social Security would never admit it, progression of a disorder is considered to be a powerful and limiting symptom. The weight given to disease progression by Social Security depends upon the speed of the progression. If, for example, a claimant's disorder worsens over a one year period or less, this fact could have a positive influence on the outcome of the application. When progression of a disorder is emphasized in an argument, it forces Social Security to consider the claimant's current and near term residual functional capacity. Example: You have accepted a case on a 40 y/o individual who has been diagnosed with moderate rheumatoid arthritis. The disease is affecting the joints of both the claimant's hands and wrists. She is showing signs of joint pain, stiffness and swelling. She is on medication, but the symptoms are not reduced. Her medical evidence supports the existence of the disorder and the claimant feels that she can no longer perform work. X-rays taken at the time of onset show signs of joint deterioration. It is now six months later and new x-rays show a slight worsening in one affected joint. The above sample case history represents a winnable situation if you properly argue the claimant's specific physical limitations and the progressive nature of her disorder. Your argument should contain an in-depth analysis of the claimant's joint restrictions, including a discussion of the location and quality of her joint pain. Your argument should always incorporate and discuss all limitations supported by the medical evidence. This includes a discussion of the claimant's description of limitation and all positive medical findings supporting her allegation. This approach to musculoskeletal disorders is usually very affective and can also be used with most other types of impairments. The following is a list of commonly seen disorders that fall into the musculoskeletal category. Following this list, I'll provide a brief discussion of each disorder, pointing out any special disability criteria that should be noted. For a more detailed discussion of musculoskeletal disorders, see chapter 16 of the Social Security Guide.
Rheumatoid
arthritis Rheumatoid Arthritis (RA) When evaluating this disorder, note the
persistence of joint pain, swelling and tenderness of the
involved joints. Your argument will be stronger if the symptoms
have been persistent for three months or longer. Point out any
positive lab test such as a rheumatoid factor, antinuclear
antibody test, elevated sedimentation rate or membrane biopsy
results. Any one of the above tests can support the diagnosis
of rheumatoid arthritis. Also note any gross deformities of any
of the involved joints both by x-ray and on physical
examination. Joint deformity can be severe in this disorder.
But even a slight joint deformity can cause a great amount of
pain and functional limitation. Osteoarthritis (OS) This disorder is similar in symptoms and
yet significantly different in origin from rheumatoid
arthritis. Osteoarthritis is usually considered to be less
serious, although it can cause physical limitations to a
sufferer. Osteoarthritis, like its cousin RA, can also cause
severe pain and joint deformity. Usually this disorder is easy
to prove by symptoms and x-ray findings. Review this disease as
you would any other disorder in this category. Pay special
attention to the x-ray findings and the claimant's physical
examination. Use any and all objective evidence supporting the
existence and severity of the impairment.
Back disorders Spinal disorders are perhaps the most common disability claimed in the United States. Up to forty percent of your advocate caseload may contain claimants who have a back disorder as a primary or secondary diagnosis. To evaluate claimants with back disorder, use the symptom of pain, x-rays and findings within the claimant's physical examination to structure your case argument. Surgeries such as spinal fusions, disc removals, etc, are powerful sources of objective evidence and proof of a serious back impairment. The more back surgeries a claimant has, the more likely you are to win the case. It usually does not take more than two back surgeries to prove your case for a severe impairment. But being severe doesn't necessarily mean that the claimant is totally disabled. You'll still need plenty of objective evidence as ammunition in your argument for a reduced residual functional capacity. If pain is alleged, and it usually is, use it as a limiting factor in sitting. If the claimant suffers pain while sitting for less than thirty minutes, you may be able to use this to limit him to less than sedentary work. Keep in mind that most allowances for those suffering from back disorders are based on medical vocational factors. This means that you will need to use all available medical evidence to support your argument for an allowance. Occasionally, you'll get a case on a
claimant who alleges a back disorder without any objective
evidence. These claimants insist that they are totally
disabled, but lack objective evidence to prove it. Even these
cases can be won if you can show a precipitating event (back
injury) that can explain and establish a loose nexus for back
disorder. However, if there are no x-ray or laboratory tests
showing the existence of a disease state, the case will be
denied. Ankylosing spondylitis Ankylosing spondylitis is an inflammatory
disease of the spine and supporting ligaments. This condition
can cause severe pain and restrictive spinal movement. This
disorder is often seen in young men between the ages of 15 and
35 years of age. It is a chronic and progressive arthritic
disorder that can cause significant physical limitation. Again,
x-ray findings, pain and decreased range of motion on physical
examination will be the most important objective findings for
those with this disease. Muscle, ligament and fascia disorders These disorders usually involve injuries
to the muscle, ligaments or fascia layers of a joint. Seen most
often in automobile and sports injuries, these types of
impairments can be painful and extremely limiting. The problem
with most of these injuries from a disability standpoint is that
they do not usually last twelve months. If you get a case with
muscle, ligament or fascia disorders, think duration
requirement. If the case has not lasted or is not expected to
last twelve months, the case will not meet Social Security's
definition of disabled. Osteomyelitis This is a very serious infectious
disorder of bone that can be fatal. This disorder can cause an
extreme delay in the healing of fractures, joint infections and
necrosis (death) of bone tissue. This disease is a common cause
of a post fracture disorder known as a non-union. A non-union
is defined as non-healing or extremely slow healing of a
fracture site. A non-union condition can transform a fracture
case that would have been denied on duration into an allowance.
If a claimant has osteomyelitis or a non-union fracture of a
weight bearing joint, make this finding clear in your argument.
You'll need to make it clear that the claimant is not expected
to recover for twelve months due to the osteomyelitis or a
non-union fracture. Mutiple Fractures Fracture cases are most often lost because they are not expected to last twelve continuous months. However, this is slightly less true in the case of multiple fractures. Suffering multiple fractures can put extreme stress on the healing process, which may delay the overall recovery of the claimant. To win these types of claims, you must seek out any complications to healing such as osteomyelitis, stepped surgeries or re-injury. Any factor that delays or complicates healing of a fracture will work in favor of an allowance determination. Lower extremity fractures (weight bearing limbs) are considered to be more serious than upper extremity fractures. Fractures that cause circulatory compromise or neurological damage are also considered to be severely restrictive. Not only can circulatory or neurological findings cause serious complications for a fracture, it could also result in the loss of a limb. Lower limb fractures interfere more with
ambulating, involve larger bones and take longer to heal. This
makes lower extremity fractures more susceptible to medical
complication. Be alert to circulation problems or nerve damage
secondary to a fracture in both the upper and lower
extremities. A broken arm, for example, may have nerve damage
that could leave the claimant with only partial use of the
limb. X-ray findings and physical examinations showing
neurological deficits will provide the most relevant objective
findings. Pain, weakness and decreased range of motion will be
the most relevant subjective evidence.
Other fracture sites Fractures involving other sites such as
the face, skull, spine and hands must be evaluated for any
secondary deformity and/or neurological damage to the involved
site. Serious facial fractures, for example, may take multiple
surgeries to repair. Reconstruction will delay recovery, making
the condition disabling for an extended period of time. Spinal
fractures may involve complete or partial spinal nerve damage,
leaving the claimant paralyzed or with significant neurological
deficits. A skull fracture may result in brain damage which
would have to be evaluated separately under mental criteria.
The brain damage may affect the claimant's cognitive skills or
cause significant memory loss. Soft tissue injuries Soft tissue injuries such as burns and serious lacerations should be evaluated according to the extent of damage to articulating (moving) joints and muscles. It is not uncommon for a person to experience significant loss of function in hands, elbows, knees and other major joints due to traumatic injury or burns. You must be aware of any possible neurological damage as a result of serious musculoskeletal injuries as well. For example, neurological damage of a fracture site could lead to reduced function of the involved limb, resulting in a reduced residual functional capacity. Objective evidence is usually the wound itself, while subjective evidence may be pain, decreased range of motion, loss of fine motor movement, weakness and especially in the case of burns, gross disfigurement. Soft tissue injury cases are easiest to win if staged surgical procedures are required for restoration of functional use of the affected area. Keep in mind that no matter what the cause, the impairment must last or be expected to last for twelve months. Amputation: Loss of an arm or leg is not in and of itself considered to be a total disability by Social Security. If the amputation is caused by degenerative changes associated with vascular or neurological deficits, chances are the claimant will be allowed. Most of the cases of amputation you'll see as a disability advocate will be old traumatic amputations. These cases are best argued by concentrating on some other additional impairment that may act to further reduce the claimant's RFC. An example would be a claimant with a corresponding low IQ or bad vision along with the amputated arm or leg. Do not be afraid to argue contra-lateral
impairments in musculoskeletal disorders. A contra-lateral
impairment on the same or opposite side of a claimant's body,
would be especially limiting to the claimant's ability to
function. If the claimant has any additional impairments that
can be shown to cause functional limitations to his ability to
work in addition to the amputation, you'll have a better chance
of winning the case. |
