denyse
Senior Member
Posts: 740
Joined: Jun 2002
|
Wednesday September 03, 2008 9:57 AM
|
|
The doc must first document why this merits "rare case". I would refer him to the examples in 16.7d and 16.8. Although 16.7d suggests release of the flexor/extensor origins or medial or lateral epicondylitis, it also refers to a tendon rupture. My preference is to rely on the part undere 16.8a that says "impairment of due to loss of strength could be combined with other impairments, only if based on unrelated etiologic or pathomechanical causes. Otherwise, the impairment ratings based on objective anatomic findings takes precedence." It's the unrelated part that ties in the possibility. If one quickly google searches unrelated etiologic or pathomechancical causes, you will get out of the box, abnormal findings. The recent case the judge ruled on grip loss was due to a condtion like this (now I hear AA's saying this case means docs can use grip loss - yes, for that condition!). An example is a post surgical wrist that developes an abnormal fatty deposit. This challenge works when you have ROM impairment (otherwise the anatomic findings take precedence).
It's when you have no ROM loss (see example 16-72) where the case can get dicey. R/C cuffs with no ROM are tough to defend, unless you can show the following:
I don't typically like the decrease strength or pain challenge per se, as the rest of the paragraph says "that prevents effective application maximal force". Doctor just punt and say it doesn't. As a secondary challenge, look at the work restrictions, subs, patient complaints and ROM loss and reference against the motions weakened (table 16-35). For example, if one is precluded from work above shoudler, how could this not impact abduction or ER. Both require a motion from ground parallel (90 degrees) to above head (180 degree). Or how about pain with lifting - could affect flexion and IR. As I said these are back up challenges.
Lastly, ensure the measurement are taken correctly.
As such, the doctor must be explict in my he/she feels this meets rare case (#1). If ROM, then this (strength) can only be rated if there is an unrelated or pathomechanical cause (#2). Then look at the ROM loss, pain issue and it impact on effort. Lastly ensure measurement are done pursuant to 16.8b (20% variant invalidates) .
The bottom line here is that strength should be rarely used. There are cases, but I usually see no documentation like the above suggests. Unfortunately this type of impairment can rate high, so if you dispute, make sure you develope the record for the PQME (LC 4061-62) and/or trier. Consider a rating (status) conference.
|
|
