Osteoarthritis, knee surgery, manipulatory ability, and errors in range of motion. Includes medical opinion form.

By Dr. David A. Morton

Excerpted from Medical Issues in Social Security Disability

In all joints, osteoarthritis is the most common arthritis seen by the SSA. If the only abnormality is a joint space narrowing of less than 20 or 30%, it would not be particularly impressive in the absence of significant pain or other abnormalities. The same is true of less than 20 or 30% loss of joint motion where that is the only abnormality other than minor X-ray changes. However, individuals vary in symptomatology and judgment must be applied on that basis as long as credibility is not lost by an allegation of severity that is not reasonably believable on any basis, including individual variation in symptoms. Further into the spectrum of non-severity, a claimant with only a 10% loss of joint space and 10% loss in range of motion in a non-deformed joint with no soft tissue damage would have difficulty convincing a medically knowledgeable SSA adjudicator that they have significant functional limitations. See Social Security Ruling (SSR) 96-7p for a detailed discussion by the SSA regarding credibility. In real life, most adjudicators do not have time to write up the lengthy reasons for credibility decisions that SSA wants documented on paper. However, failure of the adjudicator to do this paperwork provides a basis, on appeal, to question whether credibility was adequately considered.

 

Lower Extremity Joint Dysfunction

Arthritis of weight-bearing joints may produce limitations in walking, standing, climbing, kneeling, crawling, squatting, and in use of leg controls. It is difficult to give specific examples of RFCs based on lower extremity joint dysfunction because of the large number of pathological and functional conditions that are possible.

 

Medically Required Hand-Held Assistive Device

The SSA’s position on this issue in regard to the ability to perform sedentary work is relevant to any cause of severe lower extremity dysfunction, particularly since the listing generally requires that both upper extremities be tied up in use of assistive devices for ambulation. Individuals restricted to sedentary work and using one arm with an assistive device may or may not be a medical-vocational allowance:

“To find that a hand-held assistive device is medically required, there must be medical documentation establishing the need for a hand-held assistive device to aid in walking or standing, and describing the circumstances for which it is needed (i.e., whether all the time, periodically, or only in certain situations; distance and terrain; and any other relevant information). The adjudicator must always consider the particular facts of a case. For example, if a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not ordinarily be significantly eroded.
“Since most unskilled sedentary work requires only occasional lifting and carrying of light objects such as ledgers and files and a maximum lifting capacity for only 10 pounds, an individual who uses a medically required hand-held assistive device in one hand may still have the ability to perform the minimal lifting and carrying requirements of many sedentary unskilled occupations with the other hand. (Bilateral manual dexterity is needed when sitting but is not generally necessary when performing the standing and walking requirements of sedentary work.) For example, an individual who must use a hand-held assistive device to aid in walking or standing because of an impairment that affects one lower extremity (e.g., an unstable knee), or to reduce pain when walking, who is limited to sedentary work because of the impairment affecting the lower extremity, and who has no other functional limitations or restrictions may still have the ability to make an adjustment to sedentary work that exists in significant numbers. On the other hand, the occupational base for an individual who must use such a device for balance because of significant involvement of both lower extremities (e.g., because of a neurological impairment) may be significantly eroded.
In these situations, too, it may be especially useful to consult a vocational resource in order to make a judgment regarding the individual’s ability to make an adjustment to other work.” (26)

Knee Surgery for Osteoarthritis and Projected Ratings

The SSA frequently sees cases of osteoarthritis (OA) of the knee treated with arthroscopic lavage and debridement in an attempt to improve pain and function. In lavage, torn pieces of cartilage and other debris are washed out of the joint, and debridement involves smoothing of joint surfaces. In undiscriminated cases of OA, multiple sources of evidence suggest that such procedures do little good, providing pain relief in less than half of patients. Because of unpredictable outcomes, such surgery on the osteoarthritic knee remains a topic of controversy. Some authorities think that better discrimination of the cases most likely to respond would lead to better success. For example, patients with unstable meniscal cartilage tears are likely to have improvement, while those with malalignment problems of the knee and severe OA of the medial compartment are not as likely to have good results. Obesity is not a factor. Based on these considerations, the SSA should not deny a claim based on the presumption of improvement when OA of the knee is involved, and the claimant is still recovering from arthroscopic debridement and/or lavage. Such cases should be diaried at least 3 months, and then an assessment of improvement made.

 

Upper Extremity Joint Dysfunction

Deformities produce possible limitations in use of the hands and arms: gripping, pushing, pulling, hand controls, and fine manipulations. Involvement of the shoulder can limit the capacity for overhead work, a requirement in many types of jobs. Unfortunately, not as much success has been possible replacing the small joints of the hand and wrist as has been achieved in restoring function in the hip and lower extremity joints. Even if there are prosthetic restorations, very significant loss of function is likely to remain—particularly lack of fine manipulatory ability. Also, strong grip strength necessary for lifting and carrying 50 or more lbs. is usually not present after prosthetic joint replacement in the hands.

Unfortunately, most treating or other examining doctors do not measure grip strength objectively with a hand ergometer, but this information should be obtained whenever possible. Measurements are still subjective to the extent of being effort-dependent by the claimant, but the observing doctor can judge whether a sincere effort is made by the claimant during testing. Alternatively, it is important to obtain detailed information about the types of daily activities the claimant carries out in use of the hands—specifically, what they can lift and manipulate and whether limitations are imposed by weakness, pain, or both. It is a mistake to evaluate the degree of impairment of arthritis without paying close attention to limiting pain and other symptoms in individual claimants. In fact, pain can be more limiting than a deformity itself.

The importance of a careful physical examination of the hands cannot be over-emphasized. If the claimant cannot walk 6–8 hours daily, the RFC cannot exceed sedentary work. In these instances, inability to perform fine manipulations usually eliminates the sedentary jobs that the SSA can cite for denial and will often result in a medical-vocational allowance even in young, educated claimants. Most treating and other examining doctors do little, if anything, to objectively determine a claimant’s manipulatory ability. It is helpful if the physician can provide observational data regarding the claimant’s ability to pick up coins, handle shirt buttons, and oppose fingertips to the thumb. It is also important to elicit manipulatory information from the claimant—any examples they can relate to ability or inability to use their hands in regard to manipulation. Impairment of fine manipulation is to be expected in significant hand deformity of all types. For example, note how the fingertips turn up in boutonniere deformity—this would obviously impair fingertip manipulation such as picking up small objects like coins, or handling small parts as might occur in electronic parts assembly.

It is possible that some soft-tissue abnormality that cannot be seen on X-ray films could be visualized with other imaging techniques, such as magnetic resonance imaging (MRI) of the shoulder, or arthrography. However, it would not be reasonably cost-effective for the SSA to purchase large numbers of MRI’s on joints with LOM and absence of other abnormalities on physical examination and X-rays just to look for unlikely abnormalities that might influence the residual functional capacity.

Many people with RA, SLE, scleroderma, and other autoimmune diseases have increased discomfort and dysfunction of hand usage with exposure to cold. The SSA is particularly likely to over-look such a RFC restriction, but it can make the difference between medical-vocational allowance or denial in some claims. Such an environmental restriction also restrains the SSA from rigidly applying the Medical-Vocational Rules in 20 CFR, Part 404, Subpart P, Appendix 2.

 

Problems with Range of Motion

A serious source of errors in medical evidence in arthritis claims concerns the range of motion (ROM) of joints reported by doctors. Many claimants allege “arthritis” as a disabling impairment, yet the SSA must purchase large numbers of consultative examinations because the treating physician has too little information and cannot—or will not—provide the evidence needed. Moreover, it is not unusual for treating doctors and consultative examination doctors to report LOM in joints and give a diagnosis of arthritis when there are no deformities, soft tissue abnormalities, or joint inflammation detectable on physical examination. In these cases, the only way the SSA can evaluate the LOM reported is to have X-rays performed. Yet in a significant number of such cases, the X-rays turn out to be normal or minimally abnormal. In other cases, but less commonly, a normal joint ROM is reported but is difficult to believe when severe abnormalities are present on X-rays. ROM reported by doctors is probably the most unreliable kind of medical evidence that the SSA obtains. One can only presume that such “errors” are based on sloppy or non-existent physical examination, but such false or contradictory medical “evidence” is a common problem for adjudicators.

MAJOR DYSFUNCTION OF JOINTS
TREATING PHYSICIAN
DATA SHEET

Short form


FOR REPRESENTATIVE USE ONLY


REPRESENTATIVE’S NAME AND ADDRESS REPRESENTATIVE’S TELEPHONE:

REPRESENTATIVE’S EMAIL:

 

PHYSICIAN’S NAME AND ADDRESS PHYSICIAN’S TELEPHONE:

PHYSICIAN’S EMAIL:

 

PATIENT’S TELEPHONE:

PATIENT’S NAME AND ADDRESS

PATIENT’S EMAIL:

PATIENT’S SSN:

 

LEVEL OF ADJUDICATION:

[ ] Initial DDS    [ ] Recon DDS

[ ] Initial CDR    [ ] Hearing Officer

[ ] Administrative Law Judge    [ ] Appeals Council

[ ] Federal District Court    [ ] Federal Appeals Court
TYPE OF CLAIM:

Title 2    [ ] DIB/DWB   [ ] CDB

Title 16  [ ] DI    [ ] DC

 


Dear Dr.

We are pursuing the Social Security disability claim for the above-named individual (the “patient”). We understand how valuable your time is, and this data sheet has been designed to allow you to provide medical information in an efficient and organized way. As a treating physician, your records and medical judgment are vital in arguing for a fair disability determination for the patient before the Social Security Administration (SSA). If you receive multiple data sheets, please disregard repetitive questions.
Your medical specialty please:

Note 1: This document will not have legal validity for Social Security disability determination purposes unless completed by a licensed medical doctor or osteopath.

Note 2: This document only concerns joint dysfunction. Other impairments and limitations resulting from a combination of impairments should be considered separately.

Note 3: Age, degree of general physical conditioning, sex, body habitus (i.e., natural body build, physique, constitution, size, and weight), insofar as they are unrelated to the patient’s medical disorder and symptoms, should not be considered when assessing the functional severity of the impairment.

“Occasionally” means very little up to 1/3 of an 8 hour workday.

“Frequently” means 1/3 to 2/3 of an 8 hour workday.

I. What is the medical impairment (rheumatoid arthritis, traumatic arthritis, osteoarthritis, etc.) causing joint dysfunction?

 

II. Is there a history of chronic joint pain and stiffness?

[ ] Yes    [ ] No    [ ] Unknown
If Yes, when did the patient first complain to you of such symptoms?
Response of pain and stiffness to treatment:

[ ] Complete symptomatic relief

[ ] Partial symptomatic relief

[ ] No symptomatic relief

 

III. In the affected joints, is there significant limitation of motion?

[ ] Yes    [ ] No   [ ] Unknown


IV. Does the patient have gross anatomical deformity of any joint?

[ ] Yes    [ ] No    [ ] Unknown
If Yes, please check all that apply.
A. Hands/Wrist
[ ] Ulnar deviation                 [ ] One or    [ ] both hands?

[ ] Swan-neck deformity        [ ] One or    [ ] both hands?

[ ] Boutonniere deformity       [ ] One or    [ ] both hands?

[ ] Contracture                      [ ] One or    [ ] both hands?

[ ] Bony or fibrous ankylosis    [ ] One or    [ ] both hands?

[ ] Instability                          [ ] One or    [ ] both hands?

[ ] Other (please specify)        [ ] One or    [ ] both hands?
B. Elbows
[ ] Contracture                       [ ] Left      [ ] Right

[ ] Bony or fibrous ankylosis     [ ] Left      [ ] Right

[ ] Instability                           [ ] Left      [ ] Right

[ ] Other (please specify)         [ ] Left      [ ] Right
C. Shoulders

[ ] Contracture                       [ ] Left      [ ] Right

[ ] Bony or fibrous ankylosis     [ ] Left      [ ] Right

[ ] Instability                           [ ] Left      [ ] Right

[ ] Other (please specify)         [ ] Left      [ ] Right
D. Hips

[ ] Contracture                       [ ] Left      [ ] Right

[ ] Bony or fibrous ankylosis     [ ] Left      [ ] Right

[ ] Instability                           [ ] Left      [ ] Right

[ ] Other (please specify)         [ ] Left      [ ] Right
E. Knees

[ ] Contracture                       [ ] Left      [ ] Right

[ ] Bony or fibrous ankylosis     [ ] Left      [ ] Right

[ ] Instability                           [ ] Left      [ ] Right

[ ] Other (please specify)         [ ] Left      [ ] Right
F. Ankles

[ ] Contracture                       [ ] Left      [ ] Right

[ ] Bony or fibrous ankylosis     [ ] Left      [ ] Right

[ ] Instability                           [ ] Left      [ ] Right

[ ] Other (please specify)         [ ] Left      [ ] Right
G. Are there imaging studies for involved joints?

[ ] Yes    [ ] No    [ ] Unknown
If Yes, please provide the following information.
1. Joint involved: _____________________________________

[ ] Left    [ ] Right
Imaging used                         Imaging abnormalities
[ ] Plain x-ray                         [ ] Joint space narrowing

(state % narrowing ________)

[ ] CT                                    [ ] Bony ankylosis      [ ] Fibrous ankylosis

[ ] MRI                                   [ ] Bone destruction

[ ] Other (describe below)

 

2. Joint involved: _____________________________________

[ ] Left    [ ] Right
Imaging used                         Imaging abnormalities
[ ] Plain x-ray                         [ ] Joint space narrowing

(state % narrowing ________)

[ ] CT                                    [ ] Bony ankylosis      [ ] Fibrous ankylosis

[ ] MRI                                   [ ] Bone destruction

[ ] Other (describe below)

 

3. Joint involved: _____________________________________

[ ] Left    [ ] Right
Imaging used                         Imaging abnormalities
[ ] Plain x-ray                         [ ] Joint space narrowing

(state % narrowing ________)

[ ] CT                                    [ ] Bony ankylosis      [ ] Fibrous ankylosis

[ ] MRI                                   [ ] Bone destruction

[ ] Other (describe below)

 

V. The patient’s current limitations and capacities

Note 1: The limiting effects of pain or other symptoms should be included in assessment of functional loss.

Note 2: If the patient uses any type of orthotic or prosthetic device, questions pertain to function while using such devices.

A. Lower extremity function (adults and children)

1. Can the patient ambulate without the use of a hand-held assistive device that limits the functioning of both upper extremities?

[ ] Yes     [ ] No     [ ] Unknown
2. Can the patient sustain a reasonable walking pace over a sufficient distance to be able to carry out activities of daily living?

[ ] Yes     [ ] No     [ ] Unknown

For example:

Does the patient have the ability to travel without companion assistance to and from work or school?

[ ] Yes     [ ] No     [ ] Unknown
Does the patient require bilateral upper limb assistive devices, such as two crutches, two canes, or a walker?

[ ] Yes     [ ] No     [ ] Unknown
Is the patient able to walk one block at a reasonable pace on rough or uneven surfaces?

[ ] Yes     [ ] No     [ ] Unknown
Is the patient able to use standard public transportation?

[ ] Yes     [ ] No     [ ] Unknown
Is the patient able to carry out routine ambulatory activities, such as shopping and banking?

[ ] Yes     [ ] No     [ ] Unknown
Is the patient able to climb a few steps at a reasonable pace using a single handrail?

[ ] Yes     [ ] No     [ ] Unknown
Other marked limitation (please specify)

 

B. Upper extremity function (adults and children)

Does the patient have an extreme loss of function in both upper extremities, to the extent that the ability to perform fine and gross movements seriously interferes with the ability to independently initiate, sustain, or complete activities?

[ ] Yes     [ ] No     [ ] Unknown

For example:

Is the patient able to prepare a meal and feed himself or herself?

[ ] Yes     [ ] No     [ ] Unknown
Is the patient able to take care of personal hygiene?

[ ] Yes     [ ] No     [ ] Unknown
Is the patient able to sort and handle papers or files?

[ ] Yes     [ ] No     [ ] Unknown
Is the patient able to place files in a file cabinet at or above waist level?

[ ] Yes     [ ] No     [ ] Unknown
Other marked limitation (please specify)
C. Specific residual functional capacities and limitations (work-related functions for adults only)

Note: The following questions apply only to patients at least 18 years of age. For children, please see Section VI.

1. Does the patient have the ability to stand and/or walk 6 – 8 hours daily on a long-term basis?

[ ] Yes     [ ] No     [ ] Unknown
If No, how long can the patient stand and/or walk (with normal breaks) in a 6 – 8 hour work day?
2. What maximum weight can the patient lift and/or carry occasionally (cumulatively not continuously)?

[ ] Unknown

[ ] Less than 10 lbs.

[ ] 10 lbs.

[ ] 20 lbs.

[ ] 50 lbs.

[ ] 100 lbs.

[ ] Other (lbs.)
3. What weight can the patient lift and/or carry frequently (cumulatively not continuously)?

[ ] Unknown

[ ] Less than 10 lbs.

[ ] 10 lbs.

[ ] 20 lbs.

[ ] 50 lbs. or more

[ ] Other (lbs.)

4. Work environment temperature restrictions
Would the patient’s exertional capacities for lifting and carrying (as described in 2 and 3 above) be further reduced by work in extremely hot or cold environments?

[ ] Yes    [ ] No    [ ] Unknown
5. Specific types of function
a. Can the following activities be performed?

 

Pushing or pulling:

Right arm: [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Left arm:   [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

 

Climbing:

Smooth inclines:  [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Rough inclines:    [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Ladders:             [ ] never    [ ] occasionally    [ ] frequently    [ ] unknownn

Poles:                 [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Stairs:                [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Overhead work:

Right arm: [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Left arm:   [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

 

Hand controls:

Right arm: [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Left arm:   [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown
Leg controls: (repetitive force must be applied with leg)

Right arm: [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Left arm:   [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Squatting:  [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Kneeling:   [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Crawling:   [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown

Crouching: [ ] never    [ ] occasionally    [ ] frequently    [ ] unknown
6. Does the claimant have impairment in balance as a result of lower extremity disease, injury, or reconstructive surgery?

[ ] Yes    [ ] No    [ ] Unknown
7. Fine manipulatory ability
Does the patient have limitations in the ability to perform fine manipulations (precise, coordinated, reasonably rapid use of the fingers)?

[ ] Yes    [ ] No    [ ] Unknown

 

If Yes, please answer the following questions.
a. Can the patient perform finger-thumb apposition at a normal speed?

[ ] Yes    [ ] No    [ ] Unknown
b. In regard to hand function, could the patient perform the following activities at normal pace?

 

Handle coins, including picking up coins from a flat surface?

Right hand: [ ] Yes    [ ] No    [ ] Unknown

Left hand:  [ ] Yes    [ ] No    [ ] Unknown

 

Handle small parts, as in electronic assembly?

Right hand: [ ] Yes    [ ] No    [ ] Unknown

Left hand:   [ ] Yes    [ ] No    [ ] Unknown

 

Use a screwdriver, including positioning small screws in holes?

Right hand: [ ] Yes    [ ] No    [ ] Unknown

Left hand:   [ ] Yes    [ ] No    [ ] Unknown

 

Manipulate cloth and sewing thread?

[ ] Yes    [ ] No    [ ] Unknown

 

VI. For children under age 18 only.

Note: The limiting effects of pain or other symptoms should be included in assessment of functional loss.

Are the child’s limitations described in Section V, A and B above abnormal for the child’s age?

[ ] Yes    [ ] No    [ ] Unknown

 

If you have other information regarding limitations in age-appropriate abilities, including developmental or other types of testing, please attach copies or discuss the results here.

 

VII. Additional Physician Comments

 

 

Physician’s Name (print or type):

Physician’s Signature (no name stamps):

Date:

 


David A. Morton has degrees in both psychology (B.A.) and medicine (M.D.). For 14 years he was a consultant for Disability Determination for Social Security Administration in Arkansas, and he was the Chief Medical Consultant during the last 8 years of that time. In his capacity of Chief Medical Consultant, he hired, trained, supervised and evaluated the work of both medical doctors (M.D.’s), and clinical psychologists (Ph.D.’s) in the medical determination of mental disability claims. He also supervised medical disability determinations of physical disorders, and personally made more than 50,000 determinations of both physical and mental disorders in both adults and children in every specialty of medicine pertaining to disability. Dr. Morton is the author of Medical Issues in Social Security Disability, from which this article is excerpted.