the musculoskeletal system roman a. goy md medical officer odp/office of medical assistance...

The Musculoskeletal System The Musculoskeletal System

Roman A. Goy MD

Medical Officer

ODP/Office of Medical Assistance

September 1, 2015[This presentation has not been approved by ODP to convey policy.]

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Disability Evaluation Under Social Security

1.00 Musculoskeletal System - Adult

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Disability Evaluation Under Social Security

1.00 Musculoskeletal System – Adult

1.02 Major Dysfunction Peripheral Joints

1.03 Reconstructive Surgery

1.04 Disorders of the Spine

1.05 Amputation

1.06 Fracture of major lower extremity bones

1.07 Fracture of upper extremity bones

1.08 Soft tissue injury (burns)

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1.02 - 1.02 - Major dysfunction of a jointMajor dysfunction of a joint

A) One major peripheral weight bearing joint -

Resulting in inability to ambulate effectively.

B) One major peripheral joint in each upper extremity –

Resulting in inability to perform fine & gross movements effectively.

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Disorders of the MS System Disorders of the MS System 1.00

Inability to ambulate:

•The inability to ambulate effectively

•on a sustained basis for any reason,

•including pain associated with the underlying musculoskeletal impairment.

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Disorders of the MS System Disorders of the MS System 1.00

Effective ambulation requires being:

•Capable of sustaining a

• Reasonable walking pace • Over a sufficient distance • To carry out activities of daily living.

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Effective AmbulationEffective Ambulation

Important:

The ability to walk independently at home without use of assistive devices does not, in and of itself, constitute effective ambulation

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Examples of Effective AmbulationExamples of Effective Ambulation

Able to travel to and from work or school without companion assistance

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Ineffective AmbulationIneffective Ambulation

Is an extreme limitation of the ability to walk

i.e. to independently initiate, sustain, or complete activities.

Generally defined as…

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Definition of Ineffective AmbulationDefinition of Ineffective Ambulation

• Insufficient lower extremity functioning

to permit independent ambulation

• without the use of a hand-held assistive device(s) that limits the functioning of both upper extremities

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Examples of Ineffective AmbulationExamples of Ineffective Ambulation

Inability to walk without use of a

walker

Inability to walk without use of two

crutches or two canes

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Inability to use standard public transportation

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Inability to carry out routine ambulatory activities such as

•SHOPPING

•BANKING

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Inability of climb a few steps at a reasonable pace with use of a single hand rail

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Inability to walk a block

at a reasonable pace

on rough or uneven surfaces

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1.02 - 1.02 - Major dysfunction of a jointMajor dysfunction of a joint

Characterized by:

Gross anatomical deformity (subluxation, contracture, ankylosis, instability)

Chronic pain & stiffnessSigns of limitation of motionJoint space narrowing, bony destruction, or ankylosis on appropriate imaging

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Major dysfunction of a joint(s) due to Major dysfunction of a joint(s) due to any cause any cause Listing 1.02

Shoulder

Elbow

Wrist-hand

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Inability to perform fine and gross Inability to perform fine and gross movements effectivelymovements effectively

Means an extreme loss of function of both upper extremities.

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Loss of Function – Upper Loss of Function – Upper ExtremitiesExtremities

Extreme loss of function of both upper extremities,

i.e., inability to initiate, sustain, or complete activities, such as:

•Reach, push, pull, grasp, and finger to complete ADLs.•Prepare meals and feed oneself.•Take care of personal hygiene.•Sort and handle papers and files.•Place files in a cabinet at waist or higher level.

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1.03 – 1.03 – Reconstructive surgery of a Reconstructive surgery of a jointjoint

Major weight-bearing joint

Inability to ambulate effectively

Within 12 months of onset

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Reconstructive surgery or surgical Reconstructive surgery or surgical arthrodesis of a major weight bearing joint arthrodesis of a major weight bearing joint

1.031.03

Talus fracture dislocation•s/p ORIF and ankle fusion

•with inability to ambulate effectively•for 12 months from onset

21Meets Listing 1.03

Reconstructive surgery or surgical Reconstructive surgery or surgical arthrodesis of a major weight bearing joint arthrodesis of a major weight bearing joint

1.031.03

Osteoarthritis of the knee•s/p total knee replacement•With complications infection, failure of revision•And inability to ambulate effectively, •For 12 months from onset

22Meets Listing 1.03

Reconstructive Surgery - ArthroplastiesReconstructive Surgery - Arthroplasties

• Joint replacements (arthroplasties) generally have a >95% success rate

• Most provide improvement of function within 1 month

• Do not assume work-related functional limitations merely because a claimant has a prosthetic joint

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Normal Spine, Disc & NervesNormal Spine, Disc & Nerves

Lumbar spine

•Vertebral bodies•Intervertebral discs•Facet joints•Foramen

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1.04 - Disorders of the Spine1.04 - Disorders of the Spine

• Normal disc• Degenerated disc• Bulging disc• Herniated disc• Thinning disc or narrowed disc

• Disc degeneration with osteophyte formation

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Herniated lumbar disc can cause a •Compressed spinal nerve, or •Compressed thecal sac compression

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Facet joint arthritis can cause:

•Low back pain•Impingement of nerve roots leaving foramen•Radiculopathy (pain radiating down thighs and legs with sensory loss and motor loss)

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• Lumbar spinal stenosis—the lumbar canal is smaller on the right

• Compressing the neural canal (pressure on nerve roots, cauda equina

• Causing low back pain, motor and sensory loss

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• Cauda equina (horse’s tail) is the nerve roots which come off the end of the spinal cord

• Nerve roots to rectum, anus, bladder (damage causes loss urine and bowel control)

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Similar, But Confusing TermsSimilar, But Confusing Terms

Spondylitis

• Autoimmune disorder (ankylosing s.)• Causes inflammation between the vertebrae

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Spondylosis

• Degenerative osteoarthritis of the spine• Changes in the cartilage, disk, and bone

Spondylolysis

• Fracture of a pars interarticularis vertebra• Usually affects 5th lumbar vertebrae

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Courtesy American Academy of Orthopedic Surgeons

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Spondylolisthesis

• Slippage of one vertebrae on another (usually lumbar)

• Graded from I – IV (depending upon %)

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Bulging disc

• Disc “bulges” from its “normal” anatomic position

• Does not necessarily cause symptoms• Often temporary

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Protruding disk

• More than a “bulge”, but less than herniation• May cause intermittent symptoms depending upon location

• Usually resolves spontaneously or with conservative management

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Herniated disc

• Gelatinous material in center of disc pushes out through fibrous outer layer

• Think hockeypuck sized jelly doughnut

• Most resolve (heal) spontaneously or with conservative management

• More common in cervical and lumbar spines

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Intervertebral Disc HerniationIntervertebral Disc Herniation

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Spinal canal stenosis

• Narrowing of the spinal canal through which the spinal cord or cauda equina passes

• Touching vs. impingement• Impingement of the cord is neurosurg emergency

• Trauma• Posterior disc herniation in C-spine

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Spinal canal stenosis

• Spinal stenosis of the cauda equina (below L3) much more common• Often degenerative in nature• May be due to trauma

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Foraminal Stenosis

•Foramina are the bony opening of the vertebrae through which the peripheral nerves pass

•May be due to

• Degenerative spine disease• Osteophytes/spurs (also degenerative)• Trauma

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Sensory DermatomesSensory Dermatomes

Correlation between the nerve roots coming out of the spine and the areas of innervation

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• Neuroanatomic distribution of pain

• L5 nerve root compression causes pain and paresthesias (numbness tingling) along lateral thigh, anterolateral leg, top of foot between 1st & 2nd toes

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Motor MyotomesMotor Myotomes

Correlation between the nerve roots and the areas of motor innervation

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Some Causes of Arachnoiditis

Infection e.g. Meningitis Myelographic Dyes

(Especially Oil Based Myodil (pantopaque)

Epidural Steroid InjectionDepo-MedrolChemonucleosis with

chymopapainSubarachnoid Hemorrhage

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1.04 Disorders of the Spine1.04 Disorders of the Spine

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1.04 – 1.04 – Disorders of the spineDisorders of the spine

E.g. herniated disk, arachnoiditis, stenosis,

osteoarthritis, DJD, facet arthritis, fracture

Compromise of a nerve root or cord

WITH

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1.04 1.04 AA – – Disorders of the spineDisorders of the spine

Nerve root compression

Neuroanatomical distribution of pain

Limitation of motion of spine

Motor loss (atrophy or weakness)

Sensory of reflex loss

SLR if Lumbar (sitting & standing)

OR

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1.04 1.04 BB – – Disorders of the spineDisorders of the spine

Spinal arachnoiditis

Confirmed by operative or path report or AMAI

Severe burning or dysthesias

Need to change position every 2 hours

OR

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1.04 1.04 CC – – Disorders of the spineDisorders of the spine

Lumbar spinal stenosis

Resulting in pseudoclaudication

Established by AMAI

Chronic non-radicular pain & weakiness

Inability to ambulate effectively

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1.05 – 1.05 – AmputationAmputation

A) Both hands or

B) 1 or both extremities at or above tarsalsInability to use prosthesis to ambulate effectively due to stump complications

At least 12 months or

D) 1 hand & 1 lower extremity w/ ITAE or

D) Hemipelvectomy or hip disarticulation

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Prognosis after AmputationPrognosis after Amputation

Over 90% expected to be successful after 4- 6 months

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Prognosis after AmputationPrognosis after Amputation

Normal Steps (barring complications):

• Healing of the stump• Fitting of the prosthesis• Learning to use the prosthesis

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Orthotic, Prosthetic, Orthotic, Prosthetic, or Assistive Devicesor Assistive Devices

• Must be medically necessary

• Assess function rather than presume inability based on amputation or use of an assistive device

• New lightweight/energy storing materials decrease exertion associated with walking

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Natural Foot

Energy Storing Foot

Origin of Photographs Unknown

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1.05D Hemipelvectomy/hip 1.05D Hemipelvectomy/hip disarticulationdisarticulation

• Hemipelvectomy

• Hip disarticulation

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Prosthesis for Above the Knee Amputation

Origin of Photograph Unknown

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1.05D - Hemipelvectomy/Disarticulation1.05D - Hemipelvectomy/Disarticulation

• Prosthesis

• Requires walker or two crutches to walk

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Types of FracturesTypes of Fractures

• Simple: clean break of bone with no open wound

• Comminuted: Bone is broken into small fragments (more serious)

• Compound (Open): external wound leading to the break of a bone

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Treatment of FracturesTreatment of Fractures

Reduction: realignment and repositioning of a fx

• Closed reduction: manipulation without incision

• Open reduction: manipulation where incision is necessary

• Internal Fixation: repair may require the placement of rods, screws, plates, or other hardware

What is ORIF ?

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Non-union of a FractureNon-union of a Fracture

• Bones will usually repair within 2 months

• Complications can delay healing and may result in bone deformities

• Duration then is very case specific

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Ankle subluxationAnkle subluxation

• Bones are shifted out of place

• Ankle after open reduction and internal fixation (ORIF)

• Restored back to normal anatomical relationship

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Open Dislocation of ankleOpen Dislocation of ankle

• Talus bone out of ankle joint.

• After ORIF of ankle—now talus is located in the joint anatomically (normal)

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Medically acceptable image—X-ray Medically acceptable image—X-ray ankleankle• Normal ankle joint space—note joint space between tibia and talus

• Note narrowing of joint space between tibia and talus of ankle

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Limitation of MotionLimitation of Motion

Normal ankle joint range of motion:

•20 degrees extension• •60 degrees flexion

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Range of MotionRange of Motion

Measurement of Joint Motion(except for the spine)

Use AMA Guides to the Evaluation of Permanent Impairment

for technique & normal values6th edition

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1.06 – 1.06 – Non union lower extremityNon union lower extremity

Fracture femur, tibia, pelvis, or tarsal bones

WITH

A) No clinically solid union & on AMAI

AND

B) ITAE for at least 12 months

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1.06 Fracture of femur 1.06 Fracture of femur

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The FootThe Foot

Tarsals

Metatarsals

Phalanges

Calcaneus or Heel bone

Arch includes tarsals & metatarsals

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1.07 – 1.07 – Nonunion of an upper Nonunion of an upper extremityextremity

Fracture of the shaft of the humerus, radius or ulna

Nonunion

Under continuous surgical management towards

restoration of functional use

Such function not restored within 12 months of onset

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1.07 – 1.07 – Nonunion of an upper Nonunion of an upper extremityextremity

Under continuous surgical management:

Surgical procedures and associated treatments directed toward the salvage or restoration of functional use of the affected part, including post-surgical procedures, surgical complications, infections, or other medical complications, related illnesses, or related treatments

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1.08 – 1.08 – Soft tissue injury (Burns)Soft tissue injury (Burns)

Extremities or face and head

Under continuous surgical management towards

restoration of major function

Such function not restored within 12 months of onset

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1.00 - Major function face and head1.00 - Major function face and head

For purposes of listing 1.08, relates to impact on any or all activities of:

•Vision•Hearing•Speech•Mastication•Initiation of digestive process

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Diagnosis & EvaluationDiagnosis & Evaluation

Should be supported by:

Applicable detailed description

(ROM, musculature, sensory & reflexes, etc.)

Laboratory findings (x-rays, CT, MRI, bone scans, etc.)

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Medical ExaminationMedical Examination

• Chief Complaint• Past Medical History• Social History• Family History• Review of Systems• Examination• Lab results• Medications• Diagnosis• Treatment Plan

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• Must Relate

• Be Based on Objective Observation

• Supported by Alternative Testing Methods

• Over Time if Intermittent

• Consistent with daily activities


Subjective

Objective

Assessment

Plan

Note: Not “his leg is numb”

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• Must Relate

• Be Based on Objective Observation

• Supported by Alternative Testing Methods

• Over Time if Intermittent

• Consistent with daily activities


Note:

Observations are important: on/off table

Atrophy requires measurements in legs and arms, not hands

Strength grading 0 to 5***

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AnatomyAnatomy

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Peripheral Joints & Spine

The Upper ExtremityThe Upper Extremity

• Upper arm – humerus

• Forearm – radius (thumb side) & ulna

• Wrist bones – carpals

• Palm and back of hand – metacarpals

• Fingers – phalanges

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The Lower ExtremityThe Lower Extremity

Thigh - femur

Hip Joint (femoral

head)Knee cap -

patella

Shin - tibiaFibula

Ankle - tarsals

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The SpineThe Spine

Cervical

Thoracic spine(T1 – T12)

Lumbar spine(L1 – L5)

Sacrum (S1–S5)

Coccyx

Anterior Left Lateral

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The PelvisThe Pelvis

Ilium (part of the pelvis) – lay term for hips

Iliac crest

Acetabulum(hip fits here)

Sacrum

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JointsJoints

• Movable joints are held together with ligaments

• Contain synovial fluid for lubrication

• Pelvis joints flex slightly, but no true movement

• Some joints have no movement at all

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LigamentsLigaments

• Bind bones together

• Flexible, but do not stretch

• Can deteriorate w/ age, etc.

• They can tear or fray

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TendonsTendons

• Similar to ligaments, but…

• Attach muscles to bones

• Can deteriorate w/ age, etc.

• Can also tear

:

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CartilageCartilage

• Fibrous connective tissue found throughout the body• Joints• Nose

• Ears

• Usually found at ends of long bones to provide smooth surface for articulation

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Normal knee X-ray Normal knee X-ray

femur,

tibia, and

patella

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Dislocation of knee joint Dislocation of knee joint

• X-ray knee located

• X-ray knee dislocated

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Major dysfunction of joint KneeMajor dysfunction of joint Knee

• X-ray right knee with normal joint space

• X-ray right knee with decreased joint space, especially medially

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Major dysfunction of joint KneeMajor dysfunction of joint Knee

• Knee joint osteoarthritis with joint space narrowing

• After total knee replacement

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Major Dysfunction of the Hip JointMajor Dysfunction of the Hip Joint

Normal hip joint

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http://www.njsrlaserspine.com/Portals/16887/images/fibromyalgia_s7.jpg

* Pain* Pain91

* Pain* Pain

•May be an important contributor to functional loss

•Must be associated with medical signs or laboratory findings that could reasonably be expected to produce the pain or other symptom

•Intensity of pain may vary from mild to severe

•We must evaluate the intensity and persistence of the symptom(s)

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Chronic Pain - What is it?Chronic Pain - What is it?

• Pain that continues beyond the point of expected tissue healing

• Sometimes, there is no clearly identifiable pain generator that explains the pain.

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Chronic Pain – ExamplesChronic Pain – Examples

• Chronic low back pain

• Fibromyalgia (SSR 14-1p)

• Chronic Fatigue Syndrome (SSR 14-1p)

• Complex Regional Pain Syndrome (CRPS, aka Reflex Sympathetic Dystrophy – RSD; SSR 03-2p)

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Common Causes of Chronic Back Common Causes of Chronic Back PainPain

• Osteoarthritis • Osteophytes or spurs• Degenerative Disk Disease• Nerve root or cord involvement- e.g. sciatica• Ankylosing spondylitis (14.00)

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Other Examples of Diagnoses & Other Examples of Diagnoses & Conditions Related to Pain Conditions Related to Pain

• Bursitis – Trochanteric, etc.• Spina Bifida (myelomeningocele)• Scoliosis• Sacroillitis• Compression fractures• Plantar fasciitis

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Chronic Pain – MedicationChronic Pain – Medication

Patients have variable tolerance to medication side effects.

Use or non-use of medication, per se, does not validate or invalidate pain symptoms

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Chronic Pain - Putting it all Chronic Pain - Putting it all TogetherTogether

• Establish a MDI based on signs, symptoms and lab findings

• Evaluate for consistency of the MER, both internally, and with ADLs and third party reports

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OsteoarthritisOsteoarthritis

• Most common cause of joint dysfunction

• Begins as a disintegration of cartilage

• Usually has an inflammatory component

• When cartilage wears away, the bone is exposed, leading to pain with movement

• Excess weight, smoking, injury, and physical strain predispose, but not required

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Documentation of ArthritisDocumentation of Arthritis

• “Objective” findings (ROM, gait & station, strength testing)

• Imaging studies are necessary

There may be a poor correlation between findings and symptoms

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Examination of the SpineExamination of the Spine

• Gait

• Range of motion (ROM)?

• Motor and sensory abnormalities

• Muscle spasm

• Deep tendon reflexes (DTRs)

• Straight leg raising (SLR)

• Give way test

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SLR Sitting and SupineSLR Sitting and Supine

SLR in sitting position is a confirmatory test

•A Positive test

• Aggravates or produces radicular pain symptoms• Low back pain is not considered a positive test

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SLR Sitting and SupineSLR Sitting and Supine

• Combining both sitting and supine tests is considered a clinical validation sign

• Results must be concordant (both + or -)• Angle of positivity should be approximately =

• Test must be + on same side as pathology, but may be + on opposite side as well

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Supine Straight Leg RaisingSupine Straight Leg Raising

Courtesy Wikipedia.org

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Lasegue TestLasegue Test

Courtesy Medscape.com

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Observations During Observations During the Spinal Examination the Spinal Examination

• On and off the examination table

• Arising from a squatting position

• Atrophy with limb measurements

• Strength (0 to 5, or dynamometer)

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Non-organic Findings of the SpineNon-organic Findings of the Spine (Waddell’s Signs or Clinical Validation Signs)

• .

•

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Waddell’s Signs

• Unrelated tenderness • superficial or non-anatomic

• Simulation tests• axial compression or pseudo rotation

• Distraction test e.g. SLR

• Regional disturbances• dysfunction, weakness, or sensory

• Overreaction

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Axial Compression &Pseudorotation

Photo courtesy of: http://revue.medhyg.ch/art/Images/22913_2.gif

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Clinical Validation Signs Clinical Validation Signs (aka Waddell’s Signs)(aka Waddell’s Signs)• Interpretation

• Three or more positive signs indicate symptom exaggeration/magnification

• Does not equate to malingering

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Examination of knee for instabilityExamination of knee for instability

Two tests:

Pulling the tibia forward with respect to the knee shows instability of knee

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Other Medical SignsOther Medical Signs

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Clinical Instruments:Clinical Instruments:DynamometerDynamometer

• Measures grip or pinch strength

• Measurements of other muscle groups usually done by physical therapist or physiatrist

Photo courtesy of Pro-Med Products, Inc.

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Clinical Instruments:Clinical Instruments:GoniometerGoniometer

• Protractor with arms for measuring joint movement


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Clinical Instruments:Clinical Instruments:InclinometerInclinometer

• More precise

than goniometer


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Laboratory Studies –Laboratory Studies –ImagingImaging

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Laboratory Studies – Laboratory Studies – ElectrodiagnosticElectrodiagnostic

• Nerve conduction• Measures electrical impulse velocity along a nerve

• Electromyography (EMGs)• Records activity of skeletal muscles

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ReminderReminder: Rheumatoid and : Rheumatoid and Inflammatory Arthritis Are Evaluated Inflammatory Arthritis Are Evaluated Under the Immune System ListingUnder the Immune System Listing

• Includes not just rheumatoid arthritis, but all forms of inflammatory arthritis.

• Functional consequences of joint inflammation are more important than specific diagnosis.

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More information?More information?

Office of Learning on the Intranet

• Click on “Entry Level Training”

• Click on “Disability Examiner”

• Click on “Disability Examiner Basic Training Course”

• Double-click “Unit 4” folder• Musculoskeletal is the first body system

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Other Other IntraIntranet Resourcesnet Resources

• Digital Library (intranet homepage)

• Click on “Medical”• Select an online reference

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Internet Resourcesnet Resources

• National Library of Medicine (www.nlm.nih.gov)

• National Institutes of Health (www.nih.gov)

• CDC (www.cdc.gov)

• Mayo Clinic, Johns Hopkins, Cleveland Clinic

• Major Professional Society web sites

• WebMD, Medscape, eMedicine (careful!)

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Article ResourcesArticle Resources

• PubMed (www.ncbi.nlm.nih.gov)

• Google (http://scholar.google.com)

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Traditional (paper) ResourcesTraditional (paper) Resources

• AMA, Guides to the Evaluation of Permanent Impairment, 6th edition

• Presley Reed, MD, The Medical Disability Advisor, 5th edition• www.mdguidelines.com

• Both available in electronic format

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Questions?

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the musculoskeletal system roman a. goy md medical officer odp/office of medical assistance...

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