Free: How to Meet a Listing

Inside information from a former Chief Medical Consultant on what it takes to satisfy the SSA’s medical proof requirements

A revealing and practical look inside the SSA’s medical evaluation system is now available to claimants’ representatives.

These chapters from Dr. David Morton’s Medical Issues in Social Security Disability explain how the SSA interprets key Listings:

What symptoms, physical signs, laboratory test abnormalities, and regimen response are needed to qualify,
The medical data which should be included in the claimant’s file to obtain a favorable decision, and
Common issues faced by the claimant or the SSA, with a heavy focus on residual functional capacity.

The chapters are filled with nuggets about shortcomings in submitted medical records, the types of mistakes adjudicators are most likely to make, where generous allowances are provided claimants, ailments and tests frequently overlooked by treating doctors, and much more. These insider tips are extraordinary in both detail and number.

To have your free Medical Issues in Social Security Disability chapter e-mailed to you, fill in the blanks below and press Submit. The chapters available are listed below.

You may select one of the following chapters and have it e-mailed to you at no charge:

Chapter 1: Musculoskeletal System and Growth Impairments

Chapter 2: Special Senses and Speech

Chapter 3: Respiratory System

Chapter 4: Cardiovascular System

Chapter 5: Digestive System

Chapter 6: Genitourinary Impairments

Chapter 7: Hematological System

Chapter 8: Skin Disorders

Chapter 9: Endocrine System

Chapter 10: Multiple Body Systems

Chapter 11: Neurological

Chapter 12: Mental Disorders

Chapter 13: Neoplastic Diseases – Malignant

Chapter 14: Immune System

Here are the first 14 pages of an 74-page chapter:

Chapter 1

Musculoskeletal System and Growth Impairments

Contents

Part I – Adults

§1.00 Musculoskeletal System

§1.01 Category of Impairments, Musculoskeletal

§1.02 Major Dysfunction of a Joint

§1.03 Reconstructive Surgery or Arthrodesis of a Major Weight-Bearing Joint

§1.04 Disorders of the Spine

§1.05 Amputation (due to any cause)

§1.06 Fracture of Femur, Tibia, Pelvis, Tarsals

§1.07 Fracture of an Upper Extremity with Non-Union

§1.08 Soft Tissue Injury

Part II – Children

§100.00 Growth Impairments

§100.01 Category of Impairments, Growth

§100.02 Growth Impairment

§100.03 Growth Impairment

§101.00 Musculoskeletal System

§101.01 Category of Impairments, Musculoskeletal

§101.02 Major Dysfunction of a Joint

§101.03 Reconstructive Surgery or Arthrodesis of a Major Weight-Bearing Joint

§101.04 Disorders of the Spine

§101.05 Amputation (due to any cause)

§101.06 Fracture of Femur, Tibia, Pelvis, Tarsals

§101.07 Fracture of an Upper Extremity with Non-Union

§101.08 Soft Tissue Injury

Part III – Forms

§1.02F Major Dysfunction of Joints

§1.03F Reconstructive Joint Surgery

§1.04F Disorders of the Spine

§1.05F Amputation from Any Cause

§1.06F Pelvis and Lower Extremity Fractures

§1.07F Upper Extremity Fractures

§1.08F Soft Tissue Injuries

§100.02F Growth Impairments

Forms on CD Only

§1.02F(L) Major Dysfunction of Joints

§1.04F(L) Disorders of the Spine

§1.05F(L) Amputation from Any Cause

§1.06F(L) Pelvis and Lower Extremity Fractures

§1.07F(L) Upper Extremity Fractures

§1.08F(L) Soft Tissue Injuries

Form Reference:

Forms 1.02, 1.03, 1.04, 1.05, 1.06, 1.07, 1.08, and 100.02 can be used to obtain optimal information from treating physicians regarding the impairments discussed in this chapter.

General Legal Text Cross-References:

See Bohr’s Social Security Issues Annotated (James Publishing), §307, regarding specific court cases involving fibromyalgia, and §313 about other musculoskeletal impairments.

Part I – Adults

§1.00 Musculoskeletal System

[The applicable Listing of Impairments introduces each chapter and is typeset in Helvetica. Author comments follow each Listing subsection and are typeset in Times.]

SSA Listing of Impairments

A. Disorders of the musculoskeletal system may result from hereditary, congenital, or acquired pathologic processes. Impairments may result from infectious, inflammatory, or degenerative processes, traumatic or developmental events, or neoplastic, vascular, or toxic/metabolic diseases.

B. Loss of function.

1. General. Under this section, loss of function may be due to bone or joint deformity or destruction from any cause; miscellaneous disorders of the spine with or without radiculopathy or other neurological deficits; amputation; or fractures or soft tissue injuries, including burns, requiring prolonged periods of immobility or convalescence. For inflammatory arthritides that may result in loss of function because of inflammatory peripheral joint or axial arthritis or sequelae, or because of extra-articular features, see §14.00B6. Impairments with neurological causes are to be evaluated under §11.00ff.

2. How We Define Loss of Function in These Listings

Author’s Note

[Loss of function should include SSA evaluation of the claimant’s activities of daily living (ADL’s), as well as the formal medical evidence. While the SSA may provide forms for the claimant or their representative to complete, it should not be assumed that the SSA will fully develop functional capacities if not given quality information. Many claimants carelessly just write “No” or “None” in all the ADL form blanks when the SSA requests information. Or the skimpy and obscure answers are not revealing. It is in the best interest of the claimant that they or their representative give the SSA high-quality ADL information. There are numerous SSA forms eliciting information about ADL’s and functional limitations, such as the SSA-3368 Disability Report and the SSA-3369 Work History Report, in addition to specific ADL forms the SSA asks to have completed at the very beginning of the disability determination process. Every effort should be made to complete these forms with specific examples, rather than to answer “No” or in a generalization.

Legal text cross-reference: See Social Security Issues Annotated (Bohr), §204.8, regarding the impact of daily activities on credibility.]

a. General. Regardless of the cause(s) of a musculoskeletal impairment, functional loss for purposes of these listings is defined as the inability to ambulate effectively on a sustained basis for any reason, including pain associated with the underlying musculoskeletal impairment, or the inability to perform fine and gross movements effectively on a sustained basis for any reason, including pain associated with the underlying musculoskeletal impairment. The inability to ambulate effectively or the inability to perform fine and gross movements effectively must have lasted, or be expected to last, for at least 12 months. For the purposes of these criteria, consideration of the ability to perform these activities must be from a physical standpoint alone. When there is an inability to perform these activities due to a mental impairment, the criteria in §12.00ff are to be used. We will determine whether an individual can ambulate effectively or can perform fine and gross movements effectively based on the medical and other evidence in the case record, generally without developing additional evidence about the individual’s ability to perform the specific activities listed as examples in §1.00B2b(2) and §1.00B2c.

b. What We Mean by Inability to Ambulate Effectively

(1) Definition. Inability to ambulate effectively means an extreme limitation of the ability to walk; i.e., an impairment(s) that interferes very seriously with the individual’s ability to independently initiate, sustain, or complete activities. Ineffective ambulation is defined generally as having insufficient lower extremity functioning (see §1.00J) to permit independent ambulation without the use of a hand-held assistive device(s) that limits the functioning of both upper extremities. (Listing 1.05C is an exception to this general definition because the individual has the use of only one upper extremity due to amputation of a hand.)

(2) To ambulate effectively, individuals must be capable of sustaining a reasonable walking pace over a sufficient distance to be able to carry out activities of daily living. They must have the ability to travel without companion assistance to and from a place of employment or school. Therefore, examples of ineffective ambulation include, but are not limited to, the inability to walk without the use of a walker, two crutches or two canes, the inability to walk a block at a reasonable pace on rough or uneven surfaces, the inability to use standard public transportation, the inability to carry out routine ambulatory activities, such as shopping and banking, and the inability to climb a few steps at a reasonable pace with the use of a single hand rail. The ability to walk independently about one’s home without the use of assistive devices does not, in and of itself, constitute effective ambulation.

c. What we mean by inability to perform fine and gross movements effectively. Inability to perform fine and gross movements effectively means an extreme loss of function of both upper extremities; i.e., an impairment(s) that interferes very seriously with the individual’s ability to independently initiate, sustain, or complete activities. To use their upper extremities effectively, individuals must be capable of sustaining such functions as reaching, pushing, pulling, grasping, and fingering to be able to carry out activities of daily living. Therefore, examples of inability to perform fine and gross movements effectively include, but are not limited to, the inability to prepare a simple meal and feed oneself, the inability to take care of personal hygiene, the inability to sort and handle papers or files, and the inability to place files in a file cabinet at or above waist level.

d. Pain or other symptoms. Pain or other symptoms may be an important factor contributing to functional loss. In order for pain or other symptoms to be found to affect an individual’s ability to perform basic work activities, medical signs or laboratory findings must show the existence of a medically determinable impairment(s) that could reasonably be expected to produce the pain or other symptoms. The musculoskeletal listings that include pain or other symptoms among their criteria also include criteria for limitations in functioning as a result of the listed impairment, including limitations caused by pain. It is, therefore, important to evaluate the intensity and persistence of such pain or other symptoms carefully in order to determine their impact on the individual’s functioning under these listings. See also Secs. 404.1525(f) and 404.1529 of this part, and Secs. 416.925(f) and 416.929 of part 416 of this chapter [III of federal regulations].

C. Diagnosis and Evaluation

1. General. Diagnosis and evaluation of musculoskeletal impairments should be supported, as applicable, by detailed descriptions of the joints, including ranges of motion, condition of the musculature (e.g., weakness, atrophy), sensory or reflex changes, circulatory deficits, and laboratory findings, including findings on x-ray or other appropriate medically acceptable imaging. Medically acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast material, myelography, and radionuclear bone scans. “Appropriate” means that the technique used is the proper one to support the evaluation and diagnosis of the impairment.

2. Purchase of certain medically acceptable imaging. While any appropriate medically acceptable imaging is useful in establishing the diagnosis of musculoskeletal impairments, some tests, such as CAT scans and MRIs, are quite expensive, and we will not routinely purchase them. Some, such as myelograms, are invasive and may involve significant risk. We will not order such tests. However, when the results of any of these tests are part of the existing evidence in the case record we will consider them together with the other relevant evidence.

3. Consideration of electrodiagnostic procedures. Electrodiagnostic procedures may be useful in establishing the clinical diagnosis, but do not constitute alternative criteria to the requirements of listing 1.04.

D. The physical examination must include a detailed description of the rheumatological, orthopedic, neurological, and other findings appropriate to the specific impairment being evaluated. These physical findings must be determined on the basis of objective observation during the examination and not simply a report of the individual’s allegation; e.g., “He says his leg is weak, numb.” Alternative testing methods should be used to verify the abnormal findings; e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test. Because abnormal physical findings may be intermittent, their presence over a period of time must be established by a record of ongoing management and evaluation. Care must be taken to ascertain that the reported examination findings are consistent with the individual’s daily activities.

E. Examination of the Spine

Author’s Note

[See the medical forms for back impairments. It is important that the form be sent to an acceptable medical source, such as the treating orthopedic surgeon or other medical or osteopathic doctor. Forms completed by other practitioners such as chiropractors will be reviewed by the SSA but have little credibility in the disability determination. However, also see Social Security Issues Annotated (Bohr), §§203.14 and 1203.14, regarding the weight of evidence from chiropractors in various circuits.¹]

1. General. Examination of the spine should include a detailed description of gait, range of motion of the spine given quantitatively in degrees from the vertical position (zero degrees) or, for straight-leg raising from the sitting and supine position (zero degrees), any other appropriate tension signs, motor and sensory abnormalities, muscle spasm, when present, and deep tendon reflexes. Observations of the individual during the examination should be reported; e.g., how he or she gets on and off the examination table. Inability to walk on the heels or toes, to squat, or to arise from a squatting position, when appropriate, may be considered evidence of significant motor loss. However, a report of atrophy is not acceptable as evidence of significant motor loss without circumferential measurements of both thighs and lower legs, or both upper and lower arms, as appropriate, at a stated point above and below the knee or elbow given in inches or centimeters. Additionally, a report of atrophy should be accompanied by measurement of the strength of the muscle(s) in question generally based on a grading system of 0 to 5, with 0 being complete loss of strength and 5 being maximum strength. A specific description of atrophy of hand muscles is acceptable without measurements of atrophy but should include measurements of grip and pinch strength.

2. When neurological abnormalities persist. Neurological abnormalities may not completely subside after treatment or with the passage of time. Therefore, residual neurological abnormalities that persist after it has been determined clinically or by direct surgical or other observation that the ongoing or progressive condition is no longer present will not satisfy the required findings in listing 1.04. More serious neurological deficits (paraparesis, paraplegia) are to be evaluated under the criteria in §11.00ff.

F. Major joints refers to the major peripheral joints, which are the hip, knee, shoulder, elbow, wrist-hand, and ankle-foot, as opposed to other peripheral joints (e.g., the joints of the hand or forefoot) or axial joints (i.e., the joints of the spine.) The wrist and hand are considered together as one major joint, as are the ankle and foot. Since only the ankle joint, which consists of the juncture of the bones of the lower leg (tibia and fibula) with the hindfoot (tarsal bones), but not the forefoot, is crucial to weight bearing, the ankle and foot are considered separately in evaluating weight bearing.

G. Measurements of joint motion are based on the techniques described in the chapter on the extremities, spine, and pelvis in the current edition of the “Guides to the Evaluation of Permanent Impairment” published by the American Medical Association.

H. Documentation

1. General. Musculoskeletal impairments frequently improve with time or respond to treatment. Therefore, a longitudinal clinical record is generally important for the assessment of severity and expected duration of an impairment unless the claim can be decided favorably on the basis of the current evidence.

2. Documentation of medically prescribed treatment and response. Many individuals, especially those who have listing-level impairments, will have received the benefit of medically prescribed treatment. Whenever evidence of such treatment is available it must be considered.

3. When there is no record of ongoing treatment. Some individuals will not have received ongoing treatment or have an ongoing relationship with the medical community despite the existence of a severe impairment(s). In such cases, evaluation will be made on the basis of the current objective medical evidence and other available evidence, taking into consideration the individual’s medical history, symptoms, and medical source opinions. Even though an individual who does not receive treatment may not be able to show an impairment that meets the criteria of one of the musculoskeletal listings, the individual may have an impairment(s) equivalent in severity to one of the listed impairments or be disabled based on consideration of his or her residual functional capacity (RFC) and age, education and work experience.

4. Evaluation when the criteria of a musculoskeletal listing are not met. These listings are only examples of common musculoskeletal disorders that are severe enough to prevent a person from engaging in gainful activity. Therefore, in any case in which an individual has a medically determinable impairment that is not listed, an impairment that does not meet the requirements of a listing, or a combination of impairments no one of which meets the requirements of a listing, we will consider medical equivalence. (See Secs. 404.1526 and 416.926 [of federal regulations].) Individuals who have an impairment(s) with a level of severity that does not meet or equal the criteria of the musculoskeletal listings may or may not have the RFC that would enable them to engage in substantial gainful activity. Evaluation of the impairment(s) of these individuals should proceed through the final steps of the sequential evaluation process in Secs. 404.1520 and 416.920 (or, as appropriate, the steps in the medical improvement review standard in Secs. 404.1594 and 416.994) [of federal regulations].

I. Effects of Treatment

1. General. Treatments for musculoskeletal disorders may have beneficial effects or adverse side effects. Therefore, medical treatment (including surgical treatment) must be considered in terms of its effectiveness in ameliorating the signs, symptoms, and laboratory abnormalities of the disorder, and in terms of any side effects that may further limit the individual.

2. Response to treatment. Response to treatment and adverse consequences of treatment may vary widely. For example, a pain medication may relieve an individual’s pain completely, partially, or not at all. It may also result in adverse effects, e.g., drowsiness, dizziness, or disorientation, that compromise the individual’s ability to function. Therefore, each case must be considered on an individual basis, and include consideration of the effects of treatment on the individual’s ability to function.

3. Documentation. A specific description of the drugs or treatment given (including surgery), dosage, frequency of administration, and a description of the complications or response to treatment should be obtained. The effects of treatment may be temporary or long-term. As such, the finding regarding the impact of treatment must be based on a sufficient period of treatment to permit proper consideration or judgment about future functioning.

J. Orthotic, Prosthetic, or Assistive Devices

1. General. Consistent with clinical practice, individuals with musculoskeletal impairments may be examined with and without the use of any orthotic, prosthetic, or assistive devices as explained in this section.

2. Orthotic devices. Examination should be with the orthotic device in place and should include an evaluation of the individual’s maximum ability to function effectively with the orthosis. It is unnecessary to routinely evaluate the individual’s ability to function without the orthosis in place. If the individual has difficulty with, or is unable to use, the orthotic device, the medical basis for the difficulty should be documented. In such cases, if the impairment involves a lower extremity or extremities, the examination should include information on the individual’s ability to ambulate effectively without the device in place unless contraindicated by the medical judgment of a physician who has treated or examined the individual.

3. Prosthetic devices. Examination should be with the prosthetic device in place. In amputations involving a lower extremity or extremities, it is unnecessary to evaluate the individual’s ability to walk without the prosthesis in place. However, the individual’s medical ability to use a prosthesis to ambulate effectively, as defined in §1.00B2b, should be evaluated. The condition of the stump should be evaluated without the prosthesis in place.

4. Hand-held assistive devices. When an individual with an impairment involving a lower extremity or extremities uses a hand-held assistive device, such as a cane, crutch or walker, examination should be with and without the use of the assistive device unless contraindicated by the medical judgment of a physician who has treated or examined the individual. The individual’s ability to ambulate with and without the device provides information as to whether, or the extent to which, the individual is able to ambulate without assistance. The medical basis for the use of any assistive device (e.g., instability, weakness) should be documented. The requirement to use a hand-held assistive device may also impact on the individual’s functional capacity by virtue of the fact that one or both upper extremities are not available for such activities as lifting, carrying, pushing, and pulling.

K. Disorders of the spine, listed in 1.04, result in limitations because of distortion of the bony and ligamentous architecture of the spine and associated impingement on nerve roots (including the cauda equina) or spinal cord. Such impingement on nerve tissue may result from a herniated nucleus pulposus, spinal stenosis, arachnoiditis, or other miscellaneous conditions. Neurological abnormalities resulting from these disorders are to be evaluated by referral to the neurological listings in §11.00ff, as appropriate. (See also §§1.00B and E.)

1. Herniated nucleus pulposus is a disorder frequently associated with the impingement of a nerve root. Nerve root compression results in a specific neuro-anatomic distribution of symptoms and signs depending upon the nerve root(s) compromised.

2. Spinal Arachnoiditis

a. General. Spinal arachnoiditis is a condition characterized by adhesive thickening of the arachnoid which may cause intermittent ill-defined burning pain and sensory dysesthesia, and may cause neurogenic bladder or bowel incontinence when the cauda equina is involved.

b. Documentation. Although the cause of spinal arachnoiditis is not always clear, it may be associated with chronic compression or irritation of nerve roots (including the cauda equina) or the spinal cord. For example, there may be evidence of spinal stenosis, or a history of spinal trauma or meningitis. Diagnosis must be confirmed at the time of surgery by gross description, microscopic examination of biopsied tissue, or by findings on appropriate medically acceptable imaging. Arachnoiditis is sometimes used as a diagnosis when such a diagnosis is unsupported by clinical or laboratory findings. Therefore, care must be taken to ensure that the diagnosis is documented as described in listing 1.04B. Individuals with arachnoiditis, particularly when it involves the lumbosacral spine, are generally unable to sustain any given position or posture for more than a short period of time due to pain.

3. Lumbar spinal stenosis is a condition that may occur in association with degenerative processes, or as a result of a congenital anomaly or trauma, or in association with Paget’s disease of the bone. Pseudoclaudication, which may result from lumbar spinal stenosis, is manifested as pain and weakness, and may impair ambulation. Symptoms are usually bilateral, in the low back, buttocks, or thighs, although some individuals may experience only leg pain and, in a few cases, the leg pain may be unilateral. The pain generally does not follow a particular neuro-anatomical distribution, i.e., it is distinctly different from the radicular type of pain seen with a herniated intervertebral disc, is often of a dull, aching quality, which may be described as “discomfort” or an “unpleasant sensation,” or may be of even greater severity, usually in the low back and radiating into the buttocks region bilaterally. The pain is provoked by extension of the spine, as in walking or merely standing, but is reduced by leaning forward. The distance the individual has to walk before the pain comes on may vary. Pseudoclaudication differs from peripheral vascular claudication in several ways. Pedal pulses and Doppler examinations are unaffected by pseudoclaudication. Leg pain resulting from peripheral vascular claudication involves the calves, and the leg pain in vascular claudication is ordinarily more severe than any back pain that may also be present. An individual with vascular claudication will experience pain after walking the same distance time after time, and the pain will be relieved quickly when walking stops.²

4. Other miscellaneous conditions that may cause weakness of the lower extremities, sensory changes³, areflexia⁴, trophic ulceration⁵, bladder or bowel incontinence⁶, and that should be evaluated under 1.04 include, but are not limited to, osteoarthritis, degenerative disc disease, facet arthritis⁷, and vertebral fracture. Disorders such as spinal dysrhaphism⁸ (e.g., spina bifida), diastematomyelia⁹, and tethered cord syndrome¹⁰ may also cause such abnormalities. In these cases, there may be gait difficulty and deformity of the lower extremities based on neurological abnormalities, and the neurological effects are to be evaluated under the criteria in §11.00ff.

L. Abnormal curvatures of the spine. Abnormal curvatures of the spine (specifically, scoliosis, kyphosis and kyphoscoliosis) can result in impaired ambulation, but may also adversely affect functioning in body systems other than the musculoskeletal system. For example, an individual’s ability to breathe may be affected; there may be cardiac difficulties (e.g., impaired myocardial function); or there may be disfigurement resulting in withdrawal or isolation. When there is impaired ambulation, evaluation of equivalence may be made by reference to listing 14.09A. When the abnormal curvature of the spine results in symptoms related to fixation of the dorsolumbar or cervical spine, evaluation of equivalence may be made by reference to listing 14.09B. When there is respiratory or cardiac involvement or an associated mental disorder, evaluation may be made under §§3.00ff, 4.00ff, or 12.00ff, as appropriate. Other consequences should be evaluated according to the listing for the affected body system.

M. Under continuing surgical management, as used in listings 1.07 and 1.08, refers to surgical procedures and any other associated treatments related to the efforts directed toward the salvage or restoration of functional use of the affected part. It may include such factors as post-surgical procedures, surgical complications, infections, or other medical complications, related illnesses, or related treatments that delay the individual’s attainment of maximum benefit from therapy.

N. After maximum benefit from therapy has been achieved in situations involving fractures of an upper extremity (listing 1.07), or soft tissue injuries (listing 1.08), i.e., there have been no significant changes in physical findings or on appropriate medically acceptable imaging for any 6-month period after the last definitive surgical procedure or other medical intervention, evaluation must be made on the basis of the demonstrable residuals, if any. A finding that listing 1.07 or 1.08 is met must be based on a consideration of the symptoms, signs, and laboratory findings associated with recent or anticipated surgical procedures and the resulting recuperative periods, including any related medical complications, such as infections, illnesses, and therapies which impede or delay the efforts toward restoration of function. Generally, when there has been no surgical or medical intervention for 6 months after the last definitive surgical procedure, it can be concluded that maximum therapeutic benefit has been reached. Evaluation at this point must be made on the basis of the demonstrable residual limitations, if any, considering the individual’s impairment-related symptoms, signs, and laboratory findings, any residual symptoms, signs, and laboratory findings associated with such surgeries, complications, and recuperative periods, and other relevant evidence.

O. Major function of the face and head, for purposes of listing 1.08, relates to impact on any or all of the activities involving vision, hearing, speech, mastication, and the initiation of the digestive process.

P. When surgical procedures have been performed, documentation should include a copy of the operative notes and available pathology reports.

Q. Effects of obesity. Obesity is a medically determinable impairment that is often associated with disturbance of the musculoskeletal system, and disturbance of this system can be a major cause of disability in individuals with obesity. The combined effects of obesity with musculoskeletal impairments can be greater than the effects of each of the impairments considered separately. Therefore, when determining whether an individual with obesity has a listing-level impairment or combination of impairments, and when assessing a claim at other steps of the sequential evaluation process, including when assessing an individual’s residual functional capacity, adjudicators must consider any additional and cumulative effects of obesity.

§1.01 Category of Impairments, Musculoskeletal

§1.02 Major Dysfunction of a Joint(s)

Listing 1.02 Major Dysfunction of a Joint(s) (due to any cause): Characterized by gross anatomical deformity (e.g., subluxation, contracture, bony or fibrous ankylosis, instability) and chronic joint pain and stiffness with signs of limitation of motion or other abnormal motion of the affected joint(s), and findings on appropriate medically acceptable imaging of joint space narrowing, bony destruction, or ankylosis of the affected joint(s). With:

A. Involvement of one major peripheral weight-bearing joint (i.e., hip, knee, or ankle), resulting in inability to ambulate effectively, as defined in §1.00B2b; or

B. Involvement of one major peripheral joint in each upper extremity (i.e., shoulder, elbow, or wrist-hand), resulting in inability to perform fine and gross movements effectively, as defined in §1.00B2c.

§1.02.1 Author’s Discussion of Listing

§1.02.1.a General

Note: Some disorders, like rheumatoid arthritis and psoriasis, can cause both joint inflammation and joint deformity that can be present together or separately.¹¹ This listing can potentially be satisfied by joint dysfunction from any cause. However, there is an important exception in that when there is arthritis with ongoing inflammation, evaluation is done under listing 14.09. A part of listing 14.09 takes into account that there may also be joint deformity in some disorders that cause joint inflammation by using the same criteria for disabling deformity as this listing.

Rheumatoid arthritis (RA)

Rheumatoid arthritis is seen 2–3 times as frequently in females as males. Onset of RA is often gradual. Despite an enormous amount of scientific information related to RA, the cause of this disorder is still not clear. Although it is generally agreed that the immune system is involved in the RA disease process, it is not known for certain whether this is the primary cause or a secondary effect. It is known that once RA has started, the immune system plays a central role in progression of severity, and it is generally thought that T cell lymphocytes of the immune system react with normal joint tissues. Thus, RA is an autoimmune disease. The primary target for RA is the synovial membrane that surrounds and protects joints. Damage to the synovial membrane by enzymes (rheumatoid synovial collagenase) begins early, and in more advanced cases the abnormal immune process involving joint structures can affect ligaments, tendons, and bone. Dissolution damage to bone by RA is known as erosion, which can be seen on X-ray and is more serious than inflammation alone. Erosions may be of any degree of severity. Symmetry is a characteristic of RA, and means that the same joints are generally involved on both sides of the body at the same time, such as arthritis in both the right and left thumbs. However, symmetry for diagnostic purposes would not require that exactly the same joints in the right and left thumbs be involved simultaneously. In the diagnostic criteria table below, the term “juxta-articular regions” means the areas near a joint.

See the Graphics folder of the CD for Figure 1.02.1.a – 1: RA Joint Abnormalities^11a

Table 1.02.1.a – 1: American College of Rheumatology¹² 1987 - 88 Diagnostic Criteria For the Classification of Acute Arthritis of Rheumatoid Arthritis*
Criterion	Definition
1. Morning stiffness	Morning stiffness in and around the joints lasting at least 1 hr before maximal improvement
2. Arthritis of three or more joint areas	At least three joint areas simultaneously having soft tissue swelling or fluid (not bony overgrowth alone) observed by a physician (the 14 possible joint areas are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints)
3. Arthritis of hand joints	At least one joint area swollen as above in wrist, MCP, or PIP joint
4. Symmetric arthritis	Simultaneous involvement of the same joint areas (as defined in criterion 2) on both sides of the body (bilateral involvement of PIP, MCP, or MTP joints is acceptable without absolute symmetry)
5. Rheumatoid nodules	Subcutaneous nodules over bony prominences or extensor surfaces, or in juxta-articular regions, observed by a physician
6. Serum rheumatoid factor	Demonstration of abnormal amounts of serum "rheumatoid factor" by any method that has been positive in less than 5 percent of normal control subjects
7. Radiographic changes	Typical X ray changes of RA on PA view of hand and wrist, which must include erosions or unequivocal bony decalcification localized to or most marked adjacent to the involved joints (osteoarthritis changes alone do not qualify)
Abbreviations: MCP, Metacarpophalangeal; MTP, metatarsophalangeal; PA, posteroanterior (back to front); PIP, proximal interphalangeal; RA, rheumatoid arthritis.
*For classification purposes, a patient is said to have RA if he or she has satisfied at least four of the seven criteria. Criteria 1 through 4 must be present for at least 6 weeks. Patients with two clinical diagnoses are not excluded. Designation as classic, definite, or probable rheumatoid arthritis is not to be made.

Table 1.02.1.a – 2: American College of Rheumatology Classification of Global Functional Status in Rheumatoid Arthritis
Class I	Completely able to perform usual activities of daily living (self-care, vocational, and avocational)
Class II	Able to perform usual self-care and vocational activities, but limited in avocational activities
Class III	Able to perform usual self-care activities, but limited in vocational and avocational activities
Class IV	Limited in ability to perform usual self-care, vocational, and avocational activities

Treatment of rheumatoid arthritis consists of adequate rest, protection of joints from stress, physical therapy, and drugs. Surgery is sometimes done to help correct joint deformities. It should be stressed that although RA evaluated under this listing 1.02 requires gross joint deformity, such deformity is not required by listing 14.09 for the inflammatory component of rheumatoid arthritis. The common deformities of the hands seen with RA are ulnar deviation, swan neck deformities, and boutonniere deformity. Drugs used to treat RA include non-steroidal, anti-inflammatory drugs (NSAIDS) such as aspirin or ibuprofen, steroids, gold, methotrexate, etanercept, and others as appropriate. Flare-ups of activity may occur at unpredictable intervals despite treatment; the frequency, duration, and severity of these flare-ups are linked to the behavior of the disease in the individual person. With the advent of new drugs and understanding in the past several decades, progression to deforming arthritis is much less common, and a significant percentage of RA patients can maintain normal function if treatment is started early in the onset of the disease.

When has rheumatoid arthritis improved? There are no universally accepted criteria to answer this question—and none from the SSA—but numerous experts working in association with the American College of Rheumatology (ACR) have provided recommendations:¹³

Improvement of 20% or more in tender and swollen joint counts
Improvement of 20% or more in at least 3 of the following 5 ACR core set measures:

pain,
patient global assessments,
physician global assessments,
self-assessed physical disability, and
acute phase reactant.¹⁴

The authors state, “Our work suggests that this definition corresponds closely to clinicians’ impression of patient improvement since it emphasizes joint counts, and furthermore, it discriminates powerfully between active and placebo treatment, identifying few placebo treated patients as being improved.” This is an important statement, because it means that only those disability claimants or beneficiaries who are actually improved are likely to be so classified. Of course, improvement does not mean that a claimant or beneficiary fails to qualify or remain qualified under SSA’s criteria for allowance; the purpose in the ACR paper was to identify improvement criteria for clinical trials involving rheumatoid arthritis. However, meaningful improvement is an important issue for the SSA, since it influences a determination regarding the basic required 12-month duration requirement for initial applicants as well as a decision whether there is significant medical improvement in beneficiaries already receiving benefits. This issue is also important because arthritis that has an inflammatory component—like RA or psoriatic arthritis—can improve significantly in that regard. However, once gross deformity is present as in Figures 1.02.1.a – (2–4) below, it cannot be reversed by control of inflammation. In the absence of reconstructive surgery, it is unlikely that any person who validly qualifies under this listing can fail to continue to do so.

However, a University of South Florida College of Medicine study reported in the Journal of Rheumatology (May, 2007), found that rheumatologists over-estimate the degree of functional loss in rheumatoid arthritis patients they treat. The study states:

“We flunked. The very physicians deemed to be experts in rheumatoid arthritis failed to make the grade when it came to determining their patients’ functional status.

“This discrepancy is important to correct because patients can rely on these assessments for their livelihood or other necessities to perform activities of daily living.” [co-first author John D. Carter, MD, assistant professor of medicine in the USF Division of Rheumatology.]

The meaning of this study is particularly significant in view of the fact that the rheumatologists’ predictions of function were found faulty in 69% of cases by comparison to the patients’ own statements about their functions based on the Stanford Health Assessment Questionnaire-Disability Index (HAQ-DI). This questionnaire has been validated in other clinical studies. These findings illustrate what many SSA adjudicators have known for a long time: treating source opinion regarding function is no more reliable than any other professional medical opinion, if not framed by use of some standardized objective guideline. The SSA has no standardized guidelines for assessing functional limitations in RA or any other musculoskeletal disorder.

Rheumatoid arthritis produces several types of characteristic hand deformities.

In ulnar deviation, the fingers are deviated to the side (Figure 1.02.1.a – 2). The smaller bone of the forearm, or ulna, simply identifies the direction that the deformed fingers point. It would also be accurate to say the fingers deviate in the direction of the 5th, or “little,” finger, although this is not formal medical usage.

See the Graphics folder of the CD for Figure 1.02.1.a – 2: Ulnar Deviation

In swan neck deformity (Figure 1.02.1.a – 3), the metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints are fixed in a flexed position, while the proximal interphalangeal joint (PIP) is fixed in a hyperextended position. In non-medical terms, this means the deformity would have the following shape. The fact that the listing mentions ulnar deviation, but not swan neck deformity, does not meant that the latter cannot satisfy the listing. The listing gives deformity examples, not exclusionary criteria.

See the Graphics folder of the CD for Figure 1.02.1.a – 3: Swan Neck Deformity

In boutonniere deformity (Figure 1.02.1.a – 4), there is a hand joint deformity in the opposite direction as swan neck deformity.

See the Graphics folder of the CD for 1.02.1.a – 4: Boutonniere Deformity

Psoriatic arthritis

The cause of psoriatic arthritis is unknown. Like rheumatoid arthritis, psoriatic arthritis can produce joint inflammation, but occurs with equal incidence in both sexes. Psoriatic arthritis is more likely than RA to involve the hand joints nearest the fingertips (distal interphalangeal joints). It also may involve the mid-finger joints and the knuckle joints. Unlike RA, there is a tendency for involvement of joints on one side of the body (asymmetry) without involvement of the opposite side. For example, there may be arthritis in the right thumb joints but not the left thumb joints. Some patients are unaware that their joint symptoms have anything to do with their skin disorder of psoriasis. The inflammation of psoriatic arthritis produces what is typically described as a “sausage-like” swelling of the fingers. In addition to possibly involving the hand and other peripheral joints (such as the elbow or knee), psoriatic arthritis can cause inflammatory damage to the spine and sacroiliac joints of the pelvis with associated back pain and stiffness.

There are no diagnostic tests for psoriatic arthritis. Increased uric acid levels may lead to a false diagnosis of gout. Psoriatic arthritis does not usually cause the production of rheumatoid factor, although a minority of cases may have low levels of RF on testing. However, HLA-B27 antigen may be present.

About half the cases have an increased erythrocyte sedimentation rate. Antinuclear antibodies may be present in about 2 to 16% of cases. X-ray evaluation is helpful in diagnosis, in that psoriatic arthritis will tend to show asymmetric joint abnormalities, involvement of distal interphalangeal joints (DIP joints), inflammation of the sacroiliac joint (sacroiliitis), inflammation of the spine (spondylitis), ankylosis (fusion) of bone in involved joints, erosions of bone with formation of new bone, and resorption (dissolution) of bone in the distal phalanges of the hands (fingertip bones). X-ray findings in the DIP joints are sometimes referred to as having a “mouse-ear” appearance.

At least 25% of patients will develop bone destruction if only one joint is involved, but more than 60% with multiple (polyarticular) joint involvement. Bony damage can progress even if the soft-tissue inflammation is controlled. Severe finger deformities known as “arthritis mutilans” may be associated with psoriasis.¹⁵ In arthritis mutilans, bone destruction on X-rays may be described as having a “pencil-in-cup” appearance.

Most people with psoriatic arthritis have mild abnormalities, and less than 5% develop deforming arthritis. Treatment involves therapy for the skin lesions and to decrease joint inflammation. Ibuprofen may be sufficient for control in early cases of psoriatic arthritis, while psoralen with ultraviolet light (PUVA) may be used for severe skin inflammation. More severe cases may be treated with gold, or immune suppressant drugs such as methotrexate or cyclosporine.

Infectious Arthritis

Bacterial infections of joints from bacteria such as gonorrhea will resolve with antibiotic treatment, so allowance under this listing will almost always fail required duration of impairment severity. It is unusual for infectious arthritis (septic arthritis) to produce deformity severe enough to qualify under this listing. However, bone infection (osteomyelitis) in joints is a more serious matter.

Osteomyelitis most often occurs as a result of trauma producing open wounds that allows the entry of bacteria into the body, as a result of surgical procedures, or as a result of bacteria circulating in the bloodstream—a condition known as bacteremia. Osteomyelitis of joints can affect their function by means of bone destruction and joint deformity.

In weight-bearing bones, fractures through the area of infection can occur during the stage of acute infection, or later due to brittle bone. The orthopedic surgical management of osteomyelitis can actually be quite complex. Surgery may be needed to remove infected bone. In rare cases, amputation (such as of a toe) may be necessary. With modern antibiotics, acute osteomyelitis can be treated more effectively, so that chronic osteomyelitis is not as common as it was in the past. When chronic osteomyelitis does occur, it can present a difficult problem because the chronically infected bone may die and that restricts delivery of antibiotics through the bloodstream; also, secondary infection may occur in tissues near the bone that involves different organisms than those that infect the bone itself. An area of infected bone is called a sequestrum. In the treatment of chronic osteomyelitis, surgery to remove the sequestrum (sequestrectomy and curettage) along with infected soft tissues near the infection is a common requirement. Infected soft tissue removal may require reconstruction of soft tissues, such as muscle and skin grafts. The hole in the bone left by removal of the sequestrum may be packed with antibiotic beads held together with a polymethylmethacrylate (PMMG). PMMG antibiotic bead implantation may be temporary (10 days) to permanent, depending on the judgment of the surgeon. Whatever surgical antibiotic treatment is given, the patient will require prolonged systemic antibiotic therapy lasting well through surgical recovery, in order to prevent recurrent infection.

Infected bone fractures can be particularly difficult to manage in regard to healing. Such a situation might arise from an open wound and fractures occurring during an automobile accident or other trauma. For example, an infected tibial (shin-bone) fracture may require a graft of healthy bone taken from the smaller bone in the leg—the fibula. Surgical records for infected non-union of fractures or chronic osteomyelitis may refer to use of the Ilizarov technique, which involves the radical resection (removal) of infected bone and bone reconstruction. Of interest to disability determination is the fact that, on average, it takes 6 months to achieve healing with this technique and there is a high rate of associated complications.

Some surgeons use a staging system classifying osteomyelitis, developed by Cierny and Mader.¹⁶ In this staging system, physiological criteria are first used to classify the health of the patient (host).

Host Stage of Osteomyelitis

Stage A – The patient is healthy enough that a normal response to infection and surgery is expected.

Stage B – The patient’s health is compromised in some way that would be expected to impair wound healing (such as in diabetes, or other chronic diseases that suppress the immune system and the body’s ability to heal itself).

Stage C – The patient is so clinically fragile that surgery is expected to result in a worsening compared to no surgery.

The second component of staging refers to anatomical criteria, because they deal with the nature of the osteomyelitis.

Anatomical Criteria of Osteomyelitis

Type I – The infection is endosteal, that is, affects the inner bone.

Type II – The infection is confined to the surface of the bone.

Type III – There is a localized sequestrum involving the full cortical (outer) layer of bone, with cavitation of the bone.

Type IV – There are multiple osteomyelitic lesions associated with unstable bone.

The physiological and anatomical criteria can be combined in 12 different ways to classify a particular patient with osteomyelitis. For example, a patient might be classified as IIA and have a chance at curative therapy. On the other hand, a diabetic classified as BIV is more likely to receive palliative treatment only. However, it must be said that the use of the above classification criteria by orthopedists is by no means to be expected in the medical evidence of record when evaluating a disability claim. Nevertheless, it is important that the equivalent meaning be deduced from the evidence by the adjudicator, or an accurate determination is impossible. The SSA should make every effort to obtain the expert specialized opinion of the treating orthopedic surgeons regarding functional limitations, treatment, and prognosis.

Gout

Gout is a metabolic disorder associated with increased blood uric acid and sometimes deposition of urate crystals in joints—gouty arthritis. The gout can be in a primary form, caused by a defect in purine metabolism or it can be a secondary form related to drugs or other diseases. In either case, gouty arthritis is almost always amenable to effective treatment. A swollen and painful joint treated with colchicine will usually return to normal in several days. However, gout can damage bone as well as produce acute inflammation. Typically, gout produces erosions of bone at their margins while leaving the joint space intact. Because of these considerations, it would be very unusual for gout to produce the kind of deformity and functional loss required by this listing. Gout is predominantly a male disorder, and it is extremely rare for gout to occur in women under age 50.

Systemic Lupus Erythematosis (SLE)

SLE is an incurable autoimmune disease, characterized by the production of antibodies against normal tissues and the formation of damaging immune complexes, as well as other immune system abnormalities such as T cell lymphocyte dysfunction. SLE occurs 9–10 times as often in women than men, especially young women still in their reproductive years. Virtually any body system can be involved and resulting impairments must be evaluated under the appropriate listing. Susceptibility to the development of SLE depends on multiple abnormal genes. The SSA sees many lupus cases, which can produce any degree of impairment severity. It is vital to accurate disability determination that a thorough and complete physical examination be available for review, including a careful examination of the joints. Although it is unusual for joint deformities to develop in SLE, there is a type of ulnar deviation deformity seen in some cases of SLE called Jaccoud’s arthritis. Unlike the ulnar deviation associated with rheumatoid arthritis, Jaccoud’s arthritis is reversible and does not cause severe deformity-associated functional limitations. A more serious complication affecting joints is osteonecrosis (see below).

Systemic Lupus Erythematosus and Osteonecrosis

Systemic lupus erythematosus (SLE) can result in the degenerative bone condition of osteonecrosis (ON) that can affect shoulder, hip, knee, and ankle joints. ON is a condition that occurs predominantly in females with SLE, and 90% of cases occur in association with the risk factors of alcohol and tobacco use, kidney disease, and the corticosteroid drugs sometimes used to treat the SLE. ON is not rare in SLE—the incidence is reported to be somewhere between about 3% to 40% in various studies. This wide range of values may be related to differences in the types of patients seen and the type of imaging studies used. For example, MRI is more likely to show early ON changes than are plain X-rays. MRI is has about a 99% sensitivity for detecting ON.

Studies indicate that ON damage to bone can start within several months of beginning corticosteroid therapy, as has been demonstrated on MRI scanning. Joint deformity can lead to the necessity of prosthetic replacement. Of particular relevance to disability determination is the fact that X-rays won’t show the erosive bone lesions in joints characteristic of rheumatoid arthritis, and symptoms can be present before there are detectable X-ray changes. ON is suggested by the gradual onset of a deep, throbbing pain localized to bone that may be near a joint rather than in it. It is easy for the serious disorder of ON of the hip to be misdiagnosed as a much more benign trochanteric bursitis¹⁷ if there is pain in the hip area; additional confusion in diagnosis can result from the fact that ON of the hip can project pain so that it is felt in the groin. Since ON can produce significant symptoms prior to imaging studies showing any significant abnormality, it is quite likely that the SSA adjudicator—especially if the adjudicator is not a medical doctor—will fail to realize the possibility of ON or even that such a disorder exists. If a claimant with SLE has multiple joint involvement with ON, there is greater than an 80% probability that the head of the femur¹⁸ is also involved.

Some clinicians use a staging description of ON severity as seen on imaging studies:

Stage I – Plain X-rays of joint are negative. MRI or CT scanning may be distinctly abnormal. Therefore, if ON is suspected, reliance should not be placed on plain X-rays alone.
Stage II – Even plain X-rays show a combination of cysts and areas of sclerosis (increased bone density). There is no collapse of the femoral head.
Stage III – On plain X-rays and other studies the head of the femur collapses (fractures). This will produce a “crescent sign” appearance to the fracture.
Stage IV – On plain X-rays and other studies, there is additional involvement of both sides of the joint and development of arthritis.

Stages III and IV are particularly likely to qualify under the listing, and possibly Stage II.

It should be noted that although a number of drugs used to treat other disorders can induce SLE-like illness, such a condition is not true lupus and reversibility can be expected with discontinuation of the offending medication.

Scleroderma

Scleroderma means a hardening (sclero-) of the skin (-derma), and is caused by a connective tissue disease of unclear origin. Examples of connective tissue are skin, ligaments, bone, muscle, and tendons. Scleroderma is sometimes used synonymously with progressive systemic sclerosis (PSS), which is actually the systemic form of the disease that can affect a variety of organ systems in addition to skin—gastrointestinal, heart, muscles, kidneys, and lungs. There is no single diagnostic test, although auto-antibody testing and biopsy, along with physical examination, can provide important information. Scleroderma is variable in severity and progression, but incurable, and there is no effective way to arrest worsening. Additional information about scleroderma can be found in the discussion of listing 14.04. When joints are involved, there may be a non-painful swelling in the fingers, but it is also possible to have joint pain (arthralgia) and stiffness in joints that could qualify under this listing. In unusual cases, scleroderma can produce deforming arthritis mutilans (see the discussion of psoriasis above).

Polymyositis

Polymyositis is an autoimmune disorder involving connective tissue inflammation, especially muscle tissue. It can potentially affect multiple major organ systems (see discussion of listing 14.05). The disorder can be present in “overlap” syndromes that have characteristics of both scleroderma and polymyositis. Polymyositis can produce inflammation that can qualify under this listing. It can also produce joint deformity; such deformity is most often in the distal finger joints.

Reiter’s syndrome

Classic Reiter’s syndrome consists of urethritis (inflammation of the urethra), arthritis, and conjunctivitis. By these strict criteria, it is a rare disorder. However, if one includes involvement of the spine and sacroiliac joints of the pelvis (spondyloarthropathy), Reiter’s syndrome would then be defined as a more prevalent disease. The knees, ankles, and feet are the most commonly involved joints, and symptoms in these joints tend to occur early in the course of the disease along with joint stiffness. Involvement of the ankle and heel can be particularly debilitating. The inflammatory response usually doesn’t produce gross swelling in joints (except for the knee), but the persistent presence of any inflammatory swelling along with tenderness, pain, and limitation of function can satisfy the listing. If the fingers are involved in the arthritic process, the swelling may involve the entire finger to cause it to appear sausage-like, in contrast to rheumatoid arthritic swelling that tends to confine itself to the finger joint areas. Reiter’s syndrome can also affect other body systems such as the heart, but this usually occurs only as a late abnormality in about 10% of cases after the disease has been present for some years.

Reiter’s syndrome is thought to be an immune system disorder involving abnormal activity of T lymphocytes, though in some instances it might be triggered by an infection. Reiter’s syndrome is treated with non-steroidal anti-inflammatory drugs (NSAIDS) such as aspirin and ibuprofen. More potent drugs are reserved for cases that do not respond to milder medications. Poor prognostic factors include poor response to NSAIDS, onset before age 16, involvement of hip joints, elevated erythrocyte sedimentation rate (ESR) to greater than 30 mm/hr, swollen fingers or toes, and low back (lumbar) pain with limitation of motion. There is no cure but symptom severity may vary over time.

Osteoarthritis

. . . (continued in full chapter)

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