The musculoskeletal system contains a large variety of disease states that can adversely affect a person's ability to perform voluntary movement.  This system also contains disorders which can affect any joint or muscle group in the human body.  Musculoskeletal disorders usually cause symptoms of pain and decreased range of motion of the involved joints.  When evaluating disorders from this group, always keep in mind the symptom of pain as a real limiting factor in a claimant's ability to perform work activity.  However, pain must always be associated with abnormal medical findings which substantiate and support a reasonable cause for the pain.  Also try and take argumental advantage of the specific limitations caused by changes within the affected joint or muscle group.

General Evaluation

    When evaluating musculoskeletal impairments, it is important that you note the degree of joint deformity and pain.  Your evaluation should also include all relevant signs, symptoms, lab findings, a detailed description of the involved joints, range of motion (ROM), condition of surrounding muscles,  sensory or reflex loss, circulatory deficits, and any x-ray abnormalities.  All or most of this information can be found in the claimant's file.

Example  

     You have accepted a case on a 40 y/o individual who has been diagnosed as having a moderate case of rheumatoid arthritis.  The disease is affecting the joints of both the claimant's hands, with pain, stiffness and swelling.   The medical evidence supports the existence of this disorder. The claimant feels she cannot perform work using her hands due to the pain and decreased range of motion.

     The above case history is common and represents a winnable situation if you argue the claimant's specific physical limitations supported by the medical evidence.  

     Your argument should contain an in-depth analysis of the claimant's joint restrictions, including a discussion of the location, quality and factors which cause the pain and decreased range of motion (ROM).  The argument should incorporate and discuss all limitations supported by the medical evidence.   The discussion should include the claimant's description of limitations and all positive medical findings supporting the existence of the disorder.  This approach to muscular skeletal disorders is also effective in the analysis of the key medical issues in all other impairments you may encounter.  

    The following is a list of commonly seen disorders which fall into the musculoskeletal category.  Following this list, there will be a brief discussion of each disorder, pointing out any special disability criteria which should be noted.

Rheumatoid arthritis
Gout
Osteoarthritis and allied disorders
Disorders of the spine (discogenic and degenerative)
Curvature of spine
Ankylosing Spondylitis
Disorders of muscle, ligament and fascia
Osteomyelitis and other bone infections
Osteoporosis
Fractured Skull
Fractured vertebra with or without cord lesion
Fractures of upper limb
Fractures of lower limb
Fractures of all other bones
Dislocations
Sprains and strains
Soft tissue injuries
Amputations
Burns

    The above list contains most of the common diseases or injuries you will encounter as a disability representative in the area of musculoskeletal disorders.  Always keep in mind that all of these impairments should be reviewed using the general evaluation aspects as mentioned earlier in this chapter.  Here are some special considerations to note in each of the above impairments.  If the impairment is not mentioned below, evaluate it as you would any muscular skeletal disorder.

Rheumatoid arthritis (RA):

    When evaluating this disorder, note 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.  Mention any positive lab test such as the 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.   Joint deformity can be severe in this disorder but even a slight deformity can cause great functional limitations.
 

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 severe pain and limitation to a sufferer.  Osteoarthritis like its cousin RA, can cause major symptoms of 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 in this category.  Pay special attention to the x-ray findings and the physical examination which may be your only objective evidence supporting the existence of the impairment.

Back disorders:

    Spinal disorders are perhaps the most common disability claimed in the United States.  Up to forty percent of your claimants may have a back disorder as a primary or secondary allegation.  Use the general evaluation criteria such as symptoms of pain, x-ray and physical examination findings as much as possible in your argument. 

     Operations such as spinal fusion or laminectomies should be considered as objective evidence of a serious back impairment.  The more operations the claimant has undergone, 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 serious back impairment.    If  pain is alleged, try to use it as a limiting factor in sitting.  If  the claimant suffers pain while sitting, you may be able to limit him to less than sedentary work which will result in a medical vocational allowance.  Back impairments range from simple sprains to collapse of the vertebra.  Evaluation of all back disorders are the same.

    There will be occasions when a claimant alleges a back disorder without any objective findings.  These claimants insist that they are totally disabled no matter how many times they are denied.  Even these cases can be won if you can show a precipitating event (back injury) which can explain the origin of the back disorder.  You must argue the case as you would any other back disorder with an even greater emphasis on pain.   To win a case like this, there must still be a loose nexus or a medical reason for the back pain.

Ankylosing spondylitis:

    This disorder of the spine is usually seen in young men between the ages of 10 to 30 years.   This is a chronic progressive arthritic disorder which can cause significant limitations of the spine.  Again, x-rays, pain and decreased ROM on physical examination will be the most important objective findings.

Muscle, ligament and fascia:

   These disorders usually involve injuries to the muscle, ligaments or fascial 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 one of these types of cases, place some thought into how you will make it appear that the impairment has or will meet the duration requirement. Once this is done, discuss the medical findings as usual.
 

Osteomyelitis:

    This is a very serious infectious disorder of bone which can be fatal.  This disorder can cause extreme delay in the healing of fractures, joint infections and necrosis (death) of the bone tissue.  This disease is a common cause of the post fracture disorder known as a non-union.  If you encounter this disorder in a person with a fracture, the delayed healing can be grounds for an allowance.  Try to make it clear in your argument that the claimant is not expected to recover for twelve months from the date of injury.  Most fracture cases are lost because they fail to meet the duration requirement.
 

Fractures:

     Fracture cases are most often lost because they are not expected to last twelve continuous months.  Therefore, you must seek out any complications to healing such as osteomyelitis, surgeries, re-injury, etc.   Any factor which delays or complicates healing of a fracture will work in favor of an allowance determination.  Lower extremity fractures are considered to be more serious than upper extremity fractures unless there is an underlying circulatory complication or neurological damage.  Lower limb fractures obviously interfere more with ambulating, involve larger bones, take longer to heal and are therefore more susceptible to medical complications.

     Be alert to circulation problems or nerve damage secondary to a fracture in both upper and lower extremities.  A broken arm for example, may have nerve damage which could leave the claimant with only partial use of the limb.  X-ray findings and neurological deficits will supply the most relevant objective findings.  Pain and decreased ROM 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 in these disorders as well.

     Objective evidence is usually the wound itself, while subjective evidence may be pain, decreased ROM, 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 SSA.   If the amputation is caused by degenerative changes associated with vascular or neurological deficits, chances are claimant will be allowed.  Most of the cases which will come to you will be older traumatic amputations.  These cases are best argued by finding and concentrating your argument on another additional impairments which 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 leg.  In these situations you would be able to argue that the claimant would have very little chance of finding and maintaining gainful work.

     Do not be afraid to argue contra-lateral impairments in these cases.  Significant impairments on the same or opposite side of a claimant's body from the amputation will be especially limiting to the claimant's ability to function.   If the claimant has any additional impairments which can be shown to cause functional limitations to claimant's ability to work in addition to an amputation, you can win the case.