The Social Security Disability Examination
This video is not authorized or endorsed by the Social Security Administration,
Disability Determination Services,
or any branch of any government.
I am Edward Harshman
and I have done Social Security disability exams
for years.
―Am I applying for disability?
—Yes.
During this time
I have seen many genuinely disabled people
with obvious problems
and expected their applications to be approved.
The purpose of this presentation
is not to help able-bodied people beat the system.
It is to help the system not beat people
who are genuinely disabled and don't know how to do things.
I offer a look at the disability system
not from an attorney not from the disability department
and not from friends who may have applied for disability
and been approved or rejected.
Many disability applicants have mental health problems.
I am sorry to say that I do not know mental health
evaluations well enough
to to be able to give meaningful advice
in this context.
Anyway, here we go.
I am going to explain about the disability examination process
When you need an attorney
The disability physical examination as it looks to you
The disability physical examination as it looks to the examining physician
Your preparation for it and what to do after it
Most of the application process centers on your application records,
not a physical exam ordered by the disability office.
The examination is, formally, a consultative examination.
It is to render an opinion only, and not to treat you.
When you need an attorney:
You don't unless there is a special reason for one.
If you were injured on the job or by a car crash
or there was some other reason
you sued because you were hurt, you do need an attorney.
You also need one if the medical proof of a medical disability
is not obvious and there is a risk that it will not be detected.
The big secret:
The disability office tells its examining doctors
to look for specific physical findings
based on what you say in your application.
The disability staff members who decide what specific physical findings
need to be looked for
are not necessarily physicians themselves.
What this means to you:
A physical finding may exist that is outside the examining doctor's
area of expertise.
You may find that the disability office will not mention this lack of expertise.
You will need to know what to do when this happens.
First, you have to learn what physical exam findings the doctor should
look for to corroborate your impairment.
Then, be prepared to tell the examining doctor about them.
Also, show these techniques to your regular doctor,
who can then use them for your benefit and take better care of you.
What the exam looks like to you
You get a letter from the disability office telling you to go to
a specified doctor and be examined.
You go there and get examined.
The doctor does not say if you are disabled or not.
You wait; later you finally get a decision.
Why the doctor does not say if you are disabled or not:
The doctor does not know!
You may have an important disability that is not detected
in the physical examination.
Mental illness and heart failure induced by exercise are examples
of disability that cannot be easily found on
a routine physical exam.
What the exam looks like to the doctor:
An unknown person arrives for an examination.
The person may be genuinely disabled and eager to cooperate, though irritated.
The person may be inventing a disability or overstating a real but small problem.
Psychiatric issues of an applicant can complicate things, for example,
impulse control disorder, violent crime history,
paranoia, narcissism, or histrionic behavior.
Make sure all medical records are sent to the disability office.
Call the office and make sure the records get there.
Remind people as needed in the medical records department of hospitals
or the secretaries of your doctors.
Do not expect the examining physician to be interested in them, however.
Do not have them sent to the examining physician too.
Inquire about the doctor you are being sent to on the Internet.
Learn about special expertise in your ailment, if any.
A well-informed examiner can be an ally.
If you are prepared for the examination and you know what needs to be looked for,
then if the examining physician
does not have special expertise, then the lack of special expertise
of the examiner will not hurt you.
Try to get a list, from the disability office,
of what the examining doctor will examine.
Depending on current policies of the disability office,
it may or may not be available.
If you can get a copy of the list, review it.
The list from the disability office of what to examine may be incomplete.
Your attorney will know what to do if it is incomplete.
If you have no attorney,
make a list of what is missing from the disability office's list
and bring your list with you.
Ask your regular doctor to help write the list of what needs to be examined.
Also, look in a good physical examination textbook.
Such a textbook is difficult reading, but can be helpful too.
Consider DeGowin an DeGowin, for example.
Used copies are not very expensive.
A bigger but easier-reading physical exam book
is written by Barbara Bates.
<i>Sapira's Bedside Guide</i> is expensive, very comprehensive,
and very difficult reading.
Be sure to find out about to detect and verify your impairment.
Never send papers or disks to the doctor.
The doctor won't want to read medical reports
or anything else except what suggests
those parts of your body that need to be examined.
But do bring a list of what should be examined,
also a list of the drugs, prescription and over-the-counter,
that you use.
When making your list of drugs, if you use marijuana or
other illegal substances,
the need for them may support your claim.
But the report is permanently on file; and if disability rules change later,
including rules about privacy, you may lose your benefits
or even go to prison.
You can ask your attorney to help you make that decision.
My personal opinion is that you should admit that
you use one or maybe more than one illegal drug,
but never admit to using a specific substance.
Then, any law enforcement won't know what it is and cannot prove that you used
marijuana or that you used cocaine
or that you used whatever it may be.
Prosecution will be much more difficult, and that may save you your freedom.
Determine if the examining doctor has a regular office
at the place you are going to be examined.
Look on the Internet or in the telephone book.
If you need driving directions to the examination,
and the doctor has a regular, listed, easily found, office,
then call the office.
If the office you are being sent to is not the examining doctor's
regular office,
then assume that the doctor works part-time there
and may not know the area.
In which case, call the disability office
for driving directions if you need them, not the doctor.
If you must cancel an appointment, call the disability office
not the doctor's office.
If you need someone to drive you to your appointment,
make sure the someone is reliable.
"Oops, sorry" will not necessarily prevent a formal no-show finding
on your claim.
This exam is important.
Pay a taxi if you need to;
don't bum a ride from an unreliable friend.
For the examination, dress as for the weight room in a gym.
Do not wear clothing that preventably covers something that needs examination.
If your knee is swollen and red, you'll have to let the redness show.
In winter, wear warm clothing over the gym clothes and plan on
removing it just before being examined.
Duck into a restroom first.
Do not use a wig, nail polish, perfume, or deodorant.
Bad hair may result from a systemic disease
that interferes with hair growth.
Don't hide the evidence.
Damaged nails suggest malnutrition or other chronic diseases.
Again, don't hide the evidence.
Perfume and deodorant cover body odor which may be medically important.
Again, don't hide the evidence.
Wear old shoes if you limp.
You will tell the doctor to examine the soles of your shoes
to corroborate the fact that you have been limping for quite a while.
Same with a cane or walker.
If you just got a new cane or a new pair of shoes,
then bring the old ones along too so their being worn out can be verified.
Also bring with you
A small and a large goniometer.
A goniometer is a measuring device to assess range of motion.
It is inexpensive online.
Bring also a cloth tape measure, as from a sewing box:
if something is swollen or shrunken you can make sure
that a formal measurement of circumference or length can be made.
Bring with you any braces, crutches, reachers, or other devices
that you normally use or that you did use but don't use now.
Do not clean them first.
If they smell bad, that proves that they have been used.
Again, don't destroy the evidence.
Try to have a witness with you in the exam room.
The witness can help give the history if you can't remember various things.
Also, if there is later a dispute as to what was examined,
the witness will support your recollection.
Special issues if the office is unlisted:
If the doctor has an ordinary office, then you arrive for the appointment
and announce yourself to the receptionist
and wait in the waiting room, just as for an ordinary doctor visit.
If the office is not where the doctor normally works,
there may be no receptionist.
If the exam is to take place at an office not that of the regular doctor's office,
then call the disability office.
Ask if there is a receptionist where the doctor will examine you.
If not, then don't arrive more than ten minutes early
or you will probably interrupt the examination of the previous claimant.
If you do arrive more than ten minutes early,
it's okay to knock on the door or press the intercom buzzer.
But if the doctor does not come out to let you in,
don't keep knocking and buzzing.
Go away, and try again ten minutes before the scheduled time.
Some people are afraid of being in a doctor's office
without a second person such as a receptionist or a family member
present.
If there will be no receptionist, then if you are afraid of the setting,
bring a witness, such as a family member or a friend,
or report your worry to the disability office.
Do not be caught by surprise.
Let's do an overview of the physical examination.
It is important to cooperate with the doctor
particularly while the history is being taken.
Here's how.
The examination:
First, a brief history is taken.
Second, the parts of your body that may be disabled are examined.
Third, after you leave, the doctor prepares a report
and sends in the examination findings.
You need to be polite, even if the doctor is rude.
Some of what looks like rudeness is persistence in
getting precise information.
Preventable vagueness suggests malingering.
You want the doctor to be cooperative, and not suspicious.
A doctor can react to your rudeness
by describing rude behavior in the report;
a judge will read it if you appeal.
Then you look to the judge like a spoiled jerk
and your appeal is more likely to be rejected.
You are under scrutiny by someone who can greatly influence
your disability claim.
Don't provoke a hostile report.
Conversely, the doctor is under your scrutiny.
Confine your retaliation to a complaint that you send to the disability office.
Don't react with hostility on the spot.
The examiner wants to know the magnitude of damage to your body,
including diagnosis,
and how badly this damage interferes with your activities.
The examiner does not care about the difficulty in learning
the right diagnosis in the first place
or about its
interpersonal consequences as you interact with people
you live with.
Do not go on and on about how you saw this doctor and that doctor
and got this MRI and that PET scan and such.
The examiner does not care.
Vagueness of history is likely when people take drugs like these:
Other drugs can cause it too:
opiates,
benzodiazepines,
selective serotonin reuptake inhibitors,
and statins.
Beta-blockers and anticonvulsants can also cause vagueness.
If you take one or more of such drugs,
then practice explaining your diagnosis and your symptoms
to a friend or relative.
Being coached on what to say, if you are being told to lie,
is fraudulent.
There is no fraud if you are simply learning to
tell the truth more effectively.
Make sure that the information you are trying to explain
gets stated clearly, or it will never get to the examining physician's report.
Use precise words, not gestures.
Say "left leg," which can be written down.
Don't point to your left leg and simply say, "leg."
You may need to practice explaining your symptoms.
When you practice giving your history, never refer to a body part
that could be left or right without saying "left" or "right."
Point to something only when you don't know the word or if
there is a rash or bruise that needs to be seen.
Remember, the doctor dictates the report with words,
not with points and gestures.
The doctor will look at you as you speak,
then look at a notepad
from time to time to write down what you say.
A gesture, visual only, while the doctor looks away from you
and cannot see it will be useless.
This difference from ordinary conversation is important.
A simple test for precision:
If you can explain your disability without using the phrase "you know"
and without pointing to distinguish left from right, then you
are probably precise enough.
If you must say "you know," then you yourself <i>don't</i> know.
Think about what you are trying to say until you do know.
The process of practicing a good history may seem difficult.
But it may make the difference between having your claim
approved and having it rejected.
Learning to explain precisely to your regular doctor
will be helpful, too.
Do not be evasive or overly wordy.
Take too much time to explain too little material,
and the doctor will simply say that you are a vague historian
and not pursue details.
Then details that might have helped you
will not be in your report at all.
If you have been in prison recently,
then mention any bottom-bunk or other activity restrictions
the prison doctors have ordered.
Have the doctor note them in the report.
Then have the prison corroborate them by sending appropriate records.
If you know the prison staff orders such restrictions
such as a bottom bunk restriction
very rarely, but the restrictions were ordered for you,
be sure to say so.
Now for the details of the examination: things that the doctor should look for
depending on the symptoms that you have.
The Physical Exam:
Expect the exam to include walking.
If the doctor contrives to walk behind you, that is normal.
Many limps and distortions of walking are best observed from behind.
The exam will include at a minimum strength and manual dexterity testing.
It will probably include other things too,
depending on the impairments to be looked for.
Physical Exam Details:
This section is the most important part
of the entire video presentation.
What pertains to you, learn thoroughly.
It may make the difference between approval and rejection
of your claim.
Also, it may help your regular doctor too
and reduce your pain and improve your life.
Headaches:
If headaches are a problem, then make sure that your doctor
looks for pain
if your head is held still and you try to tilt it back,
tilt it left and right,
and turn it left and right against resistance.
If any of these hurt and the pain is of the same kind and in the
same place as your headache pain,
then the headache is at least partially muscle-tension caused.
Neck pain:
A tight muscle in the neck can be felt.
A muscle tight on one side of the spinal column and not the other
is important.
So is an abnormal curve of the spinal column,
in the neck and elsewhere.
If you get dizzy when you tilt your head back,
then there may be a partial blockage of the basilar artery,
which is an important and unrepairable impairment.
The Adson test, which I describe later, is generally used
for shoulder examination.
But if it is positive,
it suggests compression of the subclavian artery
by the scalenus anticus muscle.
This inference, in turn, corroborates neck pain.
Sometimes, the spinal column at the base of the neck
is flexed forward abruptly.
If so, then the Adson test may be positive or the
shoulder range of motion limited.
Have the forward flexion angle at the base of the neck
measured if it is abnormal.
Also, if there is an abnormal flexion at the base of the neck,
then have shoulder flexion and abduction measured.
Shoulder muscles used in flexion and abduction
pull on the neck bones.
If that hurts, then range of motion suffers;
get the measurements into your report.
Let's begin with headaches.
Are they muscle-tension, or something else?
What about pinching of the basilar artery,
which runs up the back of the neck into the skull?
Neck pain can sometimes be corroborated
with an abnormal forward flexion of the spinal column
at the base of the neck.
I'll show you.
First, the muscle tension screening.
Look straight ahead, and hold your head still.
Push...
Push..
Push.
Don't turn.
And don't turn.
—Did any of that hurt?
—No.
If it did hurt, then there would probably be a
muscle tension component to the headaches.
Tilt your head back and look at the ceiling.
Look straight ahead.
—Any dizziness when you tilted your head back?
—No.
if there was dizziness on tilting the head back,
that would suggest basilar artery compression.
Now let's work on the nervous system.
Peripheral nerves can be checked in a physical exam like this.
Some problems with central nerve system,
including cognition or details of proprioception
and visual-spatial issues
cannot be detected in in an examination like this.
You may need to ask for a more detailed test.
Now let me show you the Adson test.
It is useful in case of a forward flexion of the base of the spinal column
which can lead to compression of the subclavian artery
when the shoulder is externally rotated.
I'm going to grab hold of your arm like this
and I am feeling the pulse and I know how intense it is.
—Now I lift your arm up here like this.
Do you feel anything weird in your arm?
—No
Okay
And I do not feel any loss of strength of the pulse.
If she <i>did</i> feel something weird or the pulse got weaker,
that would suggest a problem in the neck.
Now let me take this goniometer and I'm going to measure
the forward flexion at the base of the neck
between the top of the thoracic spinal column
and the bottom of the cervical spinal column.
Here, the angle is only 15 degrees, which is good.
If it was 60 or 70 degrees, that would corroborate
neck pain and headache pain.
I'm going to take this big goniometer and measure shoulder
flexion and extension.
Sometimes, when there is neck damage, the result includes
loss of range of motion of flexion and extension.
Right shoulder flexion: reach straight ahead
thumb up
and reach as high as you can
all right
180 degrees.
Very good.
And to the side, thumb up
and reach as high as you can
and this is 160 degrees which is also very good.
Autonomic Neuropathy:
It's easy to understand sensory and motor nerves.
When something feels weird or numb,
the sensory nerves don't work.
When muscles are paralyzed, the motor nerves don't work.
Autonomic nerves and what they do are less obvious.
Autonomic nerves manage blood pressure, heart rate,
sweating, digestion, and other things
that we don't normally have to think about.
Sometimes, the autonomic nerves don't work right;
and blood pressure can be erratic or indigestion can be a problem.
Fortunately, there is a very easy test for the autonomic nerves
that cannot be faked.
Insist that the examiner do it.
What happens to your heart rate when you take and hold a deep breath?
The heart rate should slow by about ten percent, just barely noticeable,
then return to normal as you start to breathe again.
If your heart rate does not change at all,
then your vagus nerve, an autonomic nerve,
there are several,
is not working.
The cause may simply be prescription drugs.
Many of them suppress the activity of that nerve.
If the vagus nerve works poorly, then stomach acid is low, not high,
and indigestion can occur.
If your heart rate goes down substantially,
perhaps to half its rate, or if your heart temporarily stops
and you feel faint, then there is
an obvious hemodynamic problem.
This in my experience is a rare but impressive proof of disability.
It cannot be faked and is not often found because
almost no one bothers to seek it.
Proprioception Neuropathy:
The where-are-my-hands and where-are-my-feet nerves
can malfunction too.
The examiner will make you stand with your feet together
and close your eyes.
Worse balance with closed eyes shows a proprioception problem.
Worse balance with closed eyes if someone is nearsighted
is essentially normal.
Now we're going to do a quick sensory examination
of the peripheral nervous system.
Any sensory changes, loss of sensation, numbness
in the arms or hands
uncross your legs or the legs and feet:
these feel normal?
Yes.
Okay, let's check your tendon reflexes.
Next
Biceps
sometimes the reflexes are very sluggish;
that's normal
and here
and the knees
if there are any problems, the examiner will probably test also
some other reflexes as well.
Now I'm going to check an autonomic reflex.
First, I feel for the radial pulse.
Take a deep breath and hold.
Breathe normally
What I was feeling for, and what I did find,
is that the pulse slowed down slightly, not a whole lot but slightly,
when the person takes a deep breath, then it returns to its original rate
when the person starts breathing again.
This does not always happen.
Put your heels together and your toes together
and look straight ahead
and close your eyes.
I am testing for balance.
This is the Romberg maneuver.
Open your eyes.
The balance for her did not get worse when her eyes are closed.
This is a normal finding.
Next, we're going to work on the shoulders.
Rotator cuff problems are common but a rotator cuff issue
is overdiagnosed.
Many shoulder problems exist that are not the rotator cuff.
It is possible to get considerable detail
about the shoulder,
particularly the rotator cuff, with a simple physical examination.
It will also detect some shoulder arthritis as well.
Let me show you
Shoulders:
Shoulder impairment, when it exists, is usually arthritis or
rotator cuff damage.
Sometimes, it is both.
Have the doctor examine the shoulder in enough detail
to identify the damage.
Range of motion measurements of the shoulder
show consequences of the damage, but not the damage itself.
Arthritis sometimes interferes with shoulder motion
when the doctor holds your arm and moves it in various ways.
Unless the shoulder is unstable and tends to dislocate,
rotator cuff damage without arthritis will not limit
the passive, someone else moves it, range of motion.
External rotation is the process of reaching to the side,
then moving the forearm and hand upward without moving the elbow.
If, while the doctor passively externally rotates your shoulder,
there is a catching on the shoulder blade, then you
have arthritis in your shoulder.
Have the doctor write it down.
External rotation also tests for pinching of the subclavian artery.
The Adson test calls for external rotation.
If the intensity of the pulse at the wrist becomes less
or the entire arm starts to feel prickly and numb,
then the test is positive.
This often happens with neck impairment.
Internal rotation is the process of moving your forearm down
but not moving your elbow,
as if pointing to the ground while your elbow points to the side.
If internal rotation is much more limited than external rotation,
then usually the shoulder capsule is binding, not the rotator cuff.
The rotator cuff is four muscles.
Unless swollen, stretched too far, pinched between two bones,
or otherwise mishandled
in a way that is obviously likely to be painful,
they don't generally hurt unless they are used.
Even if the muscles are damaged, they still are not likely to hurt
unless they are used.
This rule permits tensing the various rotator cuff muscles
and figuring out which one or ones hurt or are weak.
Three out of the four rotator cuff muscles can be tested
if you have your elbow at your side and bent at a right angle,
so that your hand is forward.
Testing the fourth one is more complicated.
Holding your elbow at your side and bent at a right angle,
try to swing your forearm and hand inward, toward your abdomen.
Have someone impose resistance that you cannot overcome.
This tests the subscapularis, a rotator cuff muscle.
If the movement is painful and/or weak,
then that muscles is damaged.
Holding your elbow at your side and bent at a right angle,
try to swing your forearm and hand outward, away from your abdomen.
Have someone impose resistance that you cannot overcome.
This tests the infraspinatus and the teres minor muscles,
which are two of the rotator cuff muscles.
To distinguish between the muscles,
note that the teres minor attaches to the humerus,
the upper arm bone,
a little below the infraspinatus.
So when the elbow is at the side and the teres minor is used, it
pulls the elbow toward the ribcage.
The infraspinatus, when used, does not.
Incidentally, there is a teres major muscle, which is
not part of the rotator cuff;
and it pulls the elbow toward the side and would swing
the forearm toward the abdomen.
This muscle is not part of the rotator cuff
and is very rarely damaged.
If, with the elbow at the side, swinging the forearm outward
is weak and/or painful
and pulling the elbow to the side is similarly weak and/or painful,
with the pain, if any, at the same place, same kind of pain,
the teres minor muscle is impaired.
If the outward swinging is a problem and the elbow-to-the-side is not,
then it's the infraspinatus.
Both muscles may be impaired; it's not either-or.
The supraspinatus is the most commonly impaired rotator-cuff muscle.
Unfortunately, it is also the hardest one to test.
If the muscle is completely torn, perhaps at the tendon
near the shoulder,
then there will be a habitual bumping by the pelvis of the wrist
to raise the arm up to the side.
The deltoid muscle can raise the arm if it is outward already slightly,
but the supraspinatus has to start the process.
If it cannot do so, then a bump of the pelvis
will substitute.
Feel around under your collarbone near the shoulder and you will
find a bony bump under it.
If there is tenderness below that bump and the tenderness comes and goes
as the arm is internally and externally rotated,
then the supraspinatus tendon is irritated or damaged.
The change of tenderness occurs because the supraspinatus tendon
goes behind part of the shoulderblade
and is out of reach of being pushed against, then it comes back
into range and can be pushed against.
The drop-arm test is done by having the person relax while
someone else holds the afflicted arm.
Then when the someone else suddenly drops it, the person
uses the shoulder muscles to keep it from falling.
This forces the supraspinatus to contract,
and supraspinatus pain can result.
This test is difficult to do unless the person being examined,
that's you, is willing to cooperate.
Now let's work on the shoulder range of motion.
We've already done the flexion like this
and the abduction which is to the side
now there's external rotation like this
and internal rotation like that.
Each time for her, the external and internal rotation
was 90 as it should be.
Now we're going to work on the rotator cuff tests.
First, we're going to test the subscapularis muscle.
Pull your hand toward you while I pull it away.
That's good.
—Did that hurt —No.
Now, we're going to work on the infraspinatus
and the teres minor.
Push away with your wrist, okay.
Keep your elbow toward your side, good.
—All right, did that hurt?
—No.
And another test for the teres minor:
pull your elbow toward your side while I pull it away.
Good.
The supraspinatus test.
The insertion tendon is up here.
Relax.
All right.
—Does it hurt when I push here?
—No.
—Or here —No.
If there is a difference in tenderness as I push here
depending on where the forearm is,
that suggests a problem with the supraspinatus insertion tendon.
Now we're going to do the drop arm test.
I'm going to wave your arm around
until it is completely relaxed.
Relax.
Very relaxed.
Then I'm going to let go suddenly and you stop it from falling.
It's not completely relaxed
and then I let go.
—Did that hurt?
—No.
If it did hurt, that would suggest
a supraspinatus problem.
Hands have to be tested for manual dexterity.
They also sometimes in their joints show a collagen deficiency
throughout the body.
Weak collagen is an important impairment.
Let me show you.
Hands: Many things can go wrong.
Do the forearm muscles that make the hands and fingers
do things work?
Do the muscles in the hands themselves work?
Do the joints work?
What about sensation?
Sometimes, the fingers will be deviated sideways,
away from the thumb.
If so, insist on having the deviation measured.
This condition is commonly attributed to rheumatoid arthritis.
Other conditions can cause it, too.
Whatever the cause, it is important.
Muscles that move the fingers sideways are in the hands themselves.
Muscles that bend the finger-base joints while the fingers themselves
are held straight,
the lumbricals, are also in the hands.
Finger-bend muscles and finger-straighten muscles are
generally not in the hands.
They are in the forearms.
The reason for looking at finger movements
and where the muscles are
is that sometimes muscles in the hand do not work
but those in the forearm do.
Hands can be strong but clumsy.
This can mean that motor nerves are impaired.
The muscles between bones in the back of the hands
may be sunken-looking.
This usually means motor nerves are impaired.
If they are, then other nerves may be impaired too.
I'm going to assess the right hand.
In a real examination, both hands would be assessed.
Put your right hand out like this
Bend the wrist back
Bend forward
And now to ulnar deviation, which is the angle between the metacarpal bones in the hand
and the fingers themselves.
Here, it is zero.
It should be zero.
If the fingers bend sideways toward the pinky, that suggests a collagen problem.
Now we're going to grip strength
Squeeze my fingers as hard as you can.
Good.
Now the muscles inside the hands themselves.
Move your fingers out.
All of them.
And keep them out.
Now pull them together and pinch me.
Good.
And go like this
A nice right angle.
Very good.
Now let's work on the back.
Many people have back pain that is caused by one or more bad disks.
But not all back pain is caused by disks.
Here is what the examination should include:
The back:
Back pain is hard to prove.
People often pretend to have back pain
when they apply for disability.
Corroboration of your pain is important.
If you are not as tall as previously, then the loss of height can reinforce
your claim of collapsed disks.
That's why it's important to have the height on your photo ID,
which is probably several years old by now,
compared with your real height now.
Bring an expired driver license with you if you just got a new one
less than a year ago.
Loss of height can also be due to lax muscles in the back.
If so, then the front-to-back curves can be exaggerated
and the back curvier than it should be.
These curves can and should be measured.
Insist on those measurements.
Get assistive devices: reachers, handicap-height toilet seats.
Get proficient with your reacher and bring it with you.
Not only will you corroborate your back pain by showing
a good compensation for it
during the exam, but also the reacher and the toilet
will be genuinely useful in your daily life.
When there is back pain on bending forward,
patients generally compensate by bending the knees
instead of the back
when they have to reach downward.
This habit is correctly recommended by physical therapists.
It induces knee arthritis, however.
The knee arthritis can be assessed very quickly.
Have the examiner put a hand on your knee while you sit on the exam table,
then you straighten your knee slowly.
If there is a rusty-hinge feeling in your knee,
then it has some arthritis.
Not all knee arthritis results from protecting the back.
But if there is no arthritis anywhere else,
it is highly suggestive of overuse of the knees to protect the back,
especially if you are not obese.
This finding cannot be faked.
Spondylolisthesis is the slipping forward or backward of one
spinal-column bone, vertebra,
relative to another.
Anterolisthesis is the slipping forward of the one on top, and
Posterolisthesis is the slipping backward of the one on top.
Spondylolisthesis cannot occur with intact vertebral bones
and ligaments.
Something is broken or torn.
If unstable, it is very painful.
Unstable spondylolisthesis can sometimes, but not usually,
be detected as such on physical exam.
How to detect unstable spondylolisthesis if you are lucky:
Have the examiner place his or her hand on your back
while you sit on the exam table.
While the hand remains in place, slowly lie down on the exam table.
If something moves in the spinal column, then unstable
spondylolisthesis is proved.
Unfortunately, this test does not usually work.
But try it anyway.
Spondylolisthesis is not the same as spondylolysis.
Spondylolysis is pain resulting from a fracture in the pedicle,
which in turn is part of the vertebra, the backbone.
It usually is caused by cumulative trauma,
as in a young female gymnast.
It is not likely to be caused by an industrial accident or a
motor vehicle collision, for example.
Spondylolysis is not visible on ordinary front-to-back
or side-to-side X-ray studies.
But it is visible on diagonal X-rays.
Make sure you get diagonal X-rays just in case.
Now we're going to check the lower back range of motion.
Bend forward as far as you can without hurting yourself
And without hurting yourself
Extension of the back is 35
Now bend to the left as far as you can without hurting yourself
This is 45.
Now the right.
This is 30, which is also good.
All right
and I'm now going to look for scoliosis, which is the sideways curve of the back
that's not supposed to be there.
And I feel for it and I don't find it.
Okay, turn around so that your back is toward the camera.
Now if there <i>is</i> a curve of the back, the examiner should measure the curve
in the thoracic region like this
and in the lumbar region like that.
I cannot take such measurements because there is no such scoliosis here.
Okay.
Arthritis in knee tests: Straighten your right knee slowly.
I did not feel any rusty hinge feeling when she did that.
Now the spondylolisthesis test is feeling for slippage
between the spinal column bones
as the person is moving from sitting to lying down.
Lie down slowly while I am feeling very firmly.
And the spinal column did not have any instability or shifting.
Knees:
Swelling and creaking are obvious.
Instability is in the knee is easy to sense,
with a feeling of looseness,
but is harder to trace to a particular cause.
Make sure your knees straighten all the way;
if they don't, then have the maximum amount of straightness
noted for your report.
After the knee is verified to straighten fully, or not,
the examiner should note swelling and color.
Remember the need for gym clothes?
Now you know why.
Can fluid be detected behind the kneecap?
Tapping the kneecap toward the knee itself
may make the kneecap click.
Also, fluid can slosh from above to below the kneecap and back again
if pushed by a careful examiner.
The collateral ligaments connect the thigh bone
to the lower-leg bones
at the extreme left and right of the joints.
Are they tender: do they hurt if pressed?
Are they loose: does trying to bend the knee sideways hurt
or result in some actual sideways movement?
The anterior cruciate ligament is often damaged when the knee
is hit from the side
or when a twisting pressure is placed on the knee by
turning the body and not the foot.
The Lachman and the anterior drawer test
each can test this ligament.
Anterior cruciate ligament tests:
The anterior drawer test is done by having you lie down
on the exam table,
bend the knee to a right angle, and have the examiner
pull your leg
holding just below the knee pulling away from your upper body.
If your lower leg moves, then the ligament is loose.
The Lachman test is similar,
but your knee is not bent nearly as far before
the examiner pulls your leg.
Again, if your lower leg moves, then the ligament is loose.
Either way, looseness cannot be faked.
The posterior cruciate ligament keeps the shin from moving backwards
relative to the thigh bone.
Lie on the exam table with your knee at a right angle,
then the examiner will press your shin toward your body.
If there is motion, then the posterior cruciate ligament
is loose.
The meniscus is a horseshoe-shaped piece of cartilage between
the thigh bone and the shin bone.
It often gets damaged.
So do the cartilage linings on the thigh bone and the shin bone.
These things can be tested.
To test the meniscus and the cartilage linings:
The examiner will have you lie down on the exam table,
then turn your foot inward and straighten your knee,
then bend your knee and turn your foot outward
and straighten your knee again.
The heel points to the part of the meniscus,
medial or lateral,
that is being tested.
These are called the McMurray tests,
which may be important if you read about it in your report.
Many knee problems can be seen or corroborated
by simple physical exam.
If the knees have a problem, the examiner should first
check to make sure that they straighten all the way.
Sometimes, the person being examined does not know
that they do not straighten all the way.
Is the kneecap loose?
Is there any clicking when the kneecap is pressed
or any fluid behind the kneecap?
The collateral ligaments, the edges of the knee
on the inside and the outside: do they hurt if pressed?
The knee is not supposed to bend sideways.
If it does, then obviously something's wrong.
Now let's check the anterior cruciate ligament.
This is the anterior drawer test.
Relax.
And... the examiner will pull.
The Lachman test is similar.
Relax.
And the examiner will pull
Posterior drawer test goes like this: knee to right angle
then the examiner will push.
The McMurray maneuvers test the meniscus.
First, I'll show you the medial,
and now I will show you the lateral: twist the foot the other way....
And there we are.
We are now going to do the foot problems.
Not all problems that show up in the feet, such as edema
have to do with actual foot damage.
But there are things that can go wrong with the feet themselves
including nerve or blood-vessel issues.
Feet:
Foot symptoms can result from circulation, nerves,
mechanical issues,
or more than one of these.
Circulation problems include bad arteries, bad veins or
vein valves, or bad lymph return.
Sometimes, swelling is caused by heart disease,
not problems of the feet themselves.
If the heart is weak, blood might not be pumped out of
the feet or out of the lungs.
If both feet are swollen and were not injured,
consider heart failure.
If the heart can't pump blood properly from the lungs,
then listening to the lungs with a stethoscope can show it.
If arteries in the legs and feet don't work right,
then leg exercise gets painful.
It will be difficult or impossible to feel an arterial pulse
on top of your foot.
It's supposed to be easy to find.
Also, the foot will be cool or cold
and may be reddish or bluish.
Arterial insufficiency in the feet correlates
with arterial insufficiency
in the heart, brain, and throughout the body.
Caution: if going downstairs hurts your legs and feet
more than going upstairs,
it may be spinal-column compression of the nerves
and not the arteries.
Use an X-ray of the spinal column to check for spinal stenosis.
Venous insufficiency is more obvious than
arterial insufficiency.
Veins may swell, like varicose veins.
Also, the lower legs and the feet themselves may swell.
Arterial insufficiency alone is unlikely to induce swelling.
Edema from heart or liver failure is not the fault of the arteries
or veins in your legs and feet.
When nerves become diseased, the longest nerve cells
are the first to show symptoms.
That means the feet can hurt without bad arteries or veins
and without a sprained ankle or other injury,
or they can be numb.
These are sensory nerve symptoms.
Motor nerves can deteriorate, too.
In the feet, the first ones to go bad are
the ones that keep the toes straight.
So if they become like claw toes, then motor nerves are suspect.
Foot muscles can shrink, too.
If there is no swelling,
the shrinkage of foot muscles is obvious.
Note it.
By far the most common cause of shrinkage of foot muscle
is failure of the motor nerves to those muscles.
Mechanical damage to the ankle or foot is obvious.
You will remember a bad sprain, a fracture, or other injury.
Have the examiner look for swelling or looseness.
The drawer test cannot be faked.
Here it is:
To do the drawer test:
The examiner holds your shin in place just above the ankle
and pulls your heel forward.
If something is loose, there is proof of a bad ankle.
Also, swelling and redness cannot be faked.
Calluses on the bottom of the feet corroborate a limp or
an unbalance of leg and foot muscles.
Have the examiner describe the calluses in enough detail
that another doctor
who reads the description can infer the foot defect
that makes the calluses occur.
A prescription arch support may be useful.
The examiner will first look for edema, by feeling and looking for swelling.
Any sensory problems, numbness?
There's an artery on the top of each foot, which can normally be found easily.
And in this person, it <i>is</i> found easily.
In a real examination, both feet would be examined.
Here, we're going to do only the right foot.
Draw a big circle with the right foot... ... and the other way also.
Drawer test: Hold the bottom of the shin with one hand
pull the heel forward with the other.
—Any looseness, any pain?
—No.
—Okay.
The bottom of the foot: lift it up here.
Any calluses?... ...and no calluses.
The examination is over.
Let's see what happens next.
After the exam:
If you like the examiner and would like him or her
to be your regular doctor,
don't say so right then or you will be offering a bribe.
But it's okay to ask for a business card
or find out how to reach the doctor later.
If you ask the doctor later, after the report has been sent,
then everything is fair and honest.
The first thing to do after the exam,
after leaving the office,
is to write down what was examined.
Do so <i>immediately</i> before you forget any details.
Write down what was not examined too.
If something was not examined and you think it should have been,
you may later need to remember what it is.
The reason for the list of what was not examined
is that if, later, you don't remember
whether something was examined,
then you won't falsely assume that it was.
This omission may be very important later if you need to show that the
doctor did not examine you properly.
Send the lists, what was examined and what was not,
to your attorney, if you have one.
Have your attorney get a copy of the doctor's report
from the disability office.
If you have no attorney, then get a copy
of the report for yourself.
Ask the disability office to send you one.
If you read the report and there is a discrepancy between
what was examined and what the doctor says was examined,
then tell your attorney about it, if you have one.
If you have no attorney, then what to do
is more difficult to decide.
If the discrepancy is about something irrelevant,
don't fuss about it.
Ask questions only if there is a good reason to do so.
If there is an omission, from the report and not
from the exam itself,
of something that would help you, then write to
the disability office quickly.
Be friendly, but do not await a rejection;
an appeal is a nuisance.
You will be simply reminding the disability office that
something was examined
and it was not noted in the report.
If there is an omission from the report and from the exam too,
not a discrepancy
but an important omission, of something you asked to be done,
complain in writing to the disability office.
That way, your letter of complaint will be
on file and will support
your appeal if you have to appeal.
If all goes well, your application for disability
will be approved.
If it is rejected, you need to appeal.
Policies of the disability office may change from time to time,
and I cannot give any specific advice.
But the general principles are likely to remain in force.
Here they are:
Appeals:
If your claim is rejected, you can appeal.
The disability office will explain how.
Expect that rude behavior will be noted and added to
the notes on your case,
not only with the examining physician,
but also with any
caseworkers that you are talking to.
You don't want a judge to read about it and decide
that you are spoiled
and arrogant and rule against you.
Stand up for your rights, but be polite.
If a witness was present during your examination,
and there is an issue as to
what should have been examined or what was omitted
from the report,
discuss this issue with your attorney.
If you do not have an attorney, get the discrepancy
with two witnesses, you and the other person,
into your case file.
An appeal is a nuisance for the disability staff,
not just for you.
To the staff, an appeal means meetings, paperwork, and
possible personal embarrassment
if they are caught making an error.
Your legitimate written complaints are part of
the application
and will be shown to a judge if your appeal is pushed that far.
If you have an attorney, ask about an
independent medical examination.
Your attorney can arrange one if you need one.
If you don't have an attorney, consider arranging your own
if the disability examiner did a bad job examining you
or the report was unhelpful.
Who should do your independent medical examination?
This question is important if you do not have an attorney.
Ask people who see disability reports or at least
physical examination reports
and are outside of the disability process.
A physical therapist will have seen medical notes by
various doctors and can
identify a good orthopedist for you, for example,
or maybe a neurologist if you have a stroke, and so on.
In addition to a physical therapist, you could ask a nurse
who works in a hospital.
An emergency-room nurse is ideal if you get a chance to talk
to such a nurse.
Medical records from various specialties are brought
to emergency rooms all the time,
and emergency-room nurses get to read the notes
and know who is a good physical examiner and who is not.
You want to be referred to
someone who is thorough and whose medical notes are good
and are detailed.
Credentials and status are relatively unimportant.
Credentials and status may merely make the exam more expensive.
A physician who is all buddy-buddy with
the ivory-tower set won't want to disagree with anyone.
An outsider physician, not in a hospital
and not board-certified,
is less likely to be deterred from telling the truth
to help you.
Such physicians are already not on good terms with the
ivory-tower set
and lose nothing if alienating the ivory-tower
set further.
An independent medical examination is not the same as a
second disability examination.
If, during your appeal, you are asked to get a second
physical examination by the disability office,
make sure it is not from the same doctor who
examined you before.
Otherwise, you'll get the same results.
Review the material I showed you, and good luck. Captions © 2017 Edward Harshman
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