Is your patient disabled due to major Joint Dysfunction?

Comprehensive Reporting for Social Security Disability Evaluation Purposes
“Major joint dysfunction” is disabling under the Social Security regulations, if certain criteria are met. (20 CFR Pt. 404, Subpt. P, App. 1, 1.02)

Major joint dysfunction must be characterized by gross anatomical deformity (such as subluxation, contracture, bony or fibrous ankylosis, instability, etc.) and chronic joint pain and stiffness, with signs of limitation of motion or other abnormal motion of the affected joints. Imaging must show joint space narrowing, bony destruction, or ankylosis of the affected joint.

It must involve one major peripheral weight bearing joint (hip, knee or ankle), resulting in inability to ambulate effectively (see Medical-Legal Journal, Vol. 23, p.4); or involve one major peripheral joint in each upper extremity (shoulder, elbow or wrist-hand), resulting in an inability to perform fine and gross movements effectively.

Social Security defines ability to perform fine and gross movements effectively as: ability to sustain reaching, pushing, pulling, grasping, and fingering functions so as to carry out activities of daily living, such as preparing a simple meal and feeding oneself, personal hygiene, sorting and handling papers or files, and placing files in a file cabinet at or above waist level.

As with other “Listings,” your patient may be regarded disabled if his/her condition “equals” the Listing, that is, results in impairment of equal severity, even if it does not “meet” the Listing.

Medical Findings Needed
Your patient’s joint dysfunction may be described/diagnosed as osteoarthritis (i.e., degenerative or hypertrophic), rheumatoid arthritis or inflammatory arthritis.

Detailed findings on examination and medically acceptable diagnostic imaging are critical to enable proper evaluation of the degree of impairment. These include: 1) detailed descriptions of the joints; 2) measurements of joint motion (no subjective component) with strict adherence to the “Guides to the Evaluation of Permanent Impairment” published by the AMA and carefully positioning the patient to avoid substituted motion from distal joints; and 3) patient’s pain and perceived dysfunction should be recorded and correlated with the measurements.

Despite Social Security’s inherent skepticism concerning limitations of joint motions which are difficult to measure objectively, testing of minor motions and/or the ability of one joint to glide on another may correlate with subjective complaints of stiffness and indicate that the joint is not functioning properly.

Medically acceptable imaging includes, but is not limited to, x-rays, CAT scans and MRI’s which properly support the diagnosed impairment.

Some Challenges and Suggestions
Joints pose varying difficulties in detecting motion limitations and effusion. The hip joint is so deep, effusion cannot be appreciated on examination unless it is substantial. Also, hip joint function may be difficult to isolate and range of motion limitations difficult to accurately measure, due to the patient’s capability to move the joint grossly and compensate with segments on either side of the joint. Careful observation, a thorough review of the patient’s symptoms (especially thigh, groin and buttock pain aggravated by walking and relieved by rest), palpation and multiple range of motion studies should help detect arthritis in the hip, as well as the degeneration shown by AP and lateral x-rays.

Gross anatomical deformities (subluxation, contracture, bony or fibrous ankylosis, etc.) should be readily apparent, but additional testing will probably be needed to evaluate their effect on functional capability and performance.

A Proposed Format for Medical Reports
If your patient suffers with inflammatory arthritis, a comprehensive medical statement for Social Security disability evaluation purposes should include the following:

  • Your patient’s name, Social Security number and diagnosis;
  • Whether your patient has any of the following:
    o History of joint pain, swelling and tenderness
    o Morning stiffness
    o Synovial inflammation
    o Limitation of motion in joints
    o Rheumatoid nodules
    o Serum rheumatoid factor
    o Radiographic changes typical of inflammatory arthritis
    o Inability to ambulate effectively
    o Inability to perform fine and gross movements effectively.
  • Identify all joints with inflammation on most recent examination, considering each hand, wrist, elbow, shoulder, hip, knee, ankle, and foot; as well as the spine and any other symptomatic joints.
  • Is your patient on long term steroid therapy?
    o If so, list significant side effects from steroid use.
  • State the degree of involvement (none, mild, moderate or severe) of all extra-articular manifestations of inflammatory arthritis as to the eyes, lungs, heart, digestive system, kidneys, skin, and all other body parts or systems affected.
  • As to these constitutional symptoms
    o Fatigue
    o Fever
    o Malaise, or
    o Weight loss,
    state degree, whether mild, significant, severe or none.
  • As to the following abilities, state your patient’s limitations:
    o Standing at one time: none, 15 minutes, 30 minutes, 1 hour, 2 hrs or 4 hrs;
    o Sitting at one time: none, 15 minutes, 30 minutes, 1 hour, 2 hrs or 4 hrs;
    o Work in one day: none, 1 hour, 2 hours, 4 hours, 6 hours, or 8 hours;
    o Occasionally lift: none, 5 pounds, 10 pounds, 20 pounds, 50 pounds;
    o Frequently lift: none, 5 pounds, 10 pounds, 20 pounds, 50 pounds;
    o As to each of the following activities, state extent to which your patient could engage in a work setting, whether never, occasionally, frequently or constantly: bend; stoop; fine manipulation with left hand; fine manipulation with right hand; gross manipulation with left hand; gross manipulation with right hand; raise left arm over shoulder level; raise right arm over shoulder level.
  • Please add comments on your observations and opinion as to your patient’s limited capacity for work due to inflammatory arthritis, either to explain your responses to the above or to elaborate on limitations not covered in your responses to the above, noting the bases for your opinions.

These questions should also be used to describe the limitations affecting lupus patients.

Since you are the treating physician, your medical opinion is a critical component of the judge’s decision on whether your patient is disabled for Social Security purposes.

This article was prepared by Arthur W. Stevens III and Peter E. Yeager

Authors acknowledge National Organization of Social Security Claims Representatives, Social Security Practice Guide, Vol. 4, §§ 29.04 and 29.05 (2002).