What Is RFC?
If your joint problems are not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Subjective Symptoms Must Be Credible
Individuals vary in symptomatology, and your subjective symptoms should be taken into account. But you must be credible. It is important that you do not lose your credibility by alleging symptoms that are so severe that they are not believable in light of the objective medical evidence. For example, if you have only a 10% loss of joint space and 10% loss in range of motion and your joint is not deformed and has no soft tissue damage, you will have difficulty convincing a medically knowledgeable Social Security Administration adjudicator that you have significant functional limitations.
Joint space narrowing of less than 20% or 30% similarly would not result in a finding of significant limitations unless you also have significant pain or other abnormalities. The same is true of less than 20% or 30% loss of joint motion with no other abnormalities other than minor X-ray changes.
Lower Extremity Joint Dysfunction
Arthritis of weight-bearing joints (ankles, knees, and hips) may produce limitations in walking, standing, climbing, kneeling, crawling, squatting, and in use of leg controls. All of these limitations may result in a lower RFC, but it is difficult to give specific examples based on lower extremity joint dysfunction because of the large number of pathological and functional conditions that are possible.
Medically Required Hand-Held Assistive Devices
To meet the listing you must need a hand-held assistive device for walking that requires both arms, such as a walker. But suppose you need a device that requires only one arm, like a cane?
To find that a hand-held assistive device is medically required, you need medical documentation establishing the need for a hand-held assistive device to aid in walking or standing, and describing the circumstances for which it is needed (i.e., whether all the time, periodically, or only in certain situations; distance and terrain; and any other relevant information). If you need a hand-held assistive device only for prolonged walking, walking on uneven terrain, or ascending or descending slopes, you will ordinarily be able to do sedentary work.
Since most unskilled sedentary work requires only occasional lifting and carrying of light objects such as ledgers and files and a maximum lifting capacity for only 10 pounds, if you use a medically required hand-held assistive device in one hand, you may still have the ability to perform the minimal lifting and carrying requirements of many sedentary unskilled occupations with the other hand. (Bilateral manual dexterity is needed when sitting but is not generally necessary when performing the standing and walking requirements of sedentary work.)
For example, if you must use a hand-held assistive device to aid in walking or standing because of an impairment that affects one lower extremity (e.g., an unstable knee), or to reduce pain when walking, and you are limited to sedentary work because of the impairment affecting the lower extremity, and you have no other functional limitations or restrictions, you may still have the ability to perform sedentary work that exists in significant numbers. On the other hand, if you must use a hand held assistive device for balance because of significant involvement of both lower extremities (e.g., because of a neurological impairment), your occupational base may be significantly eroded.
Knee Surgery for Osteoarthritis and Projected Ratings
If you have osteoarthritis of the knee, you may have undergone or be considering arthroscopic lavage and debridement (see Figure 9 below). Osteoarthritis of the knee is often treated with arthroscopic lavage and debridement in an attempt to improve pain and function. In lavage, torn pieces of cartilage and other debris are washed out of the joint, and debridement involves smoothing of joint surfaces. Because of unpredictable outcomes, such surgery on the osteoarthritic knee is controversial. Evidence suggests that these procedures fail to provide pain relief in many cases. For example, patients with unstable meniscal cartilage tears are likely to improve after surgery, while patients with malalignment problems of the knee and severe OA of the medial compartment are not as likely to have good results.
Based on these considerations, the Social Security Administration should wait at least 3 months to assess the effects of the surgery on your ability to work. The Social Security Administration should not consider and deny your claim before then based on the presumption that your knee will improve.
Upper Extremity Joint Dysfunction
Joint deformities may produce limitations in use of the hands and arms: gripping, pushing, pulling, hand controls, and fine manipulations. Involvement of the shoulder can limit the capacity for overhead work, a requirement in many types of jobs. Unfortunately, doctors have not had as much success replacing the small joints of the hand and wrist as they have achieved in restoring function in the hip and lower extremity joints. Even with prosthetic restorations, very significant loss of function is likely to remain—particularly lack of fine manipulatory ability. Also, strong grip strength necessary for lifting and carrying 50 or more lbs. is usually not present after prosthetic joint replacement in the hands.
Unfortunately, most treating or other examining doctors do not measure grip strength objectively with a hand ergometer, but the Social Security Administration should obtain this information whenever possible. Measurements are still subjective because they depend on a claimant’s effort, but the observing doctor can judge whether you have made a sincere effort during testing.
If you have a joint deformity in the upper extremities, it is important to obtain detailed information about the types of daily activities you carry out in use of your hands—specifically, what you can lift and manipulate and whether limitations are imposed by weakness, pain, or both. It is a mistake to evaluate the degree of impairment of arthritis without paying close attention to limiting pain and other symptoms in individual claimants. In fact, pain can be more limiting than a deformity itself.
The importance of a careful physical examination of the hands cannot be over-emphasized. If you cannot walk 6 to 8 hours daily, your RFC cannot exceed sedentary work. In these instances, inability to perform fine manipulations usually eliminates the sedentary jobs that the Social Security Administration can cite for denial and will often result in allowance of your claim.
It is helpful if your doctor can provide observational data regarding your ability to pick up coins, handle shirt buttons, and oppose fingertips to the thumb. It is also important for you to provide specific examples of your ability or inability to use your hands in regard to manipulation. For example, can you pick up small objects like coins, or handle small parts as might occur in electronic parts assembly?
Many people with rheumatoid arthritis, lupus, scleroderma, and other autoimmune diseases have increased discomfort and dysfunction of hand usage with exposure to cold. The Social Security Administration is particularly likely to overlook such a RFC restriction, but it can make the difference between allowance or denial in some claims.
Problems with Range of Motion
A serious source of errors in medical evidence in arthritis claims concerns the range of motion of joints reported by doctors. Many claimants allege “arthritis” as a disabling impairment. The Social Security Administration sends many claimants to doctors for consultative examinations because the treating physician has too little information and cannot—or will not—provide the evidence needed. Moreover, it is not unusual for treating doctors and consultative examination doctors to report loss of motion in joints and give a diagnosis of arthritis when there are no joint deformities, soft tissue abnormalities, or joint inflammation detectable on physical examination. In these cases, the only way the Social Security Administration can evaluate the loss of motion reported is to have X-rays performed. Yet in a significant number of such cases, the X-rays turn out to be normal or minimally abnormal. In other cases, but less commonly, a normal joint range of motion is reported but is difficult to believe when severe abnormalities are present on X-rays. Range of motion reported by doctors is probably the most unreliable kind of medical evidence that the Social Security Administration obtains. One can only presume that such “errors” are based on sloppy or non-existent physical examination, but such false or contradictory medical “evidence” is a common problem for adjudicators.
Your Doctor’s Medical Opinion Can Help You Qualify for Social Security Disability Benefits
The Social Security Administration’s job is to determine if you are disabled, a legal conclusion based on your age, education and work experience and medical evidence. Your doctor’s role is to provide the Social Security Administration with information concerning the degree of your medical impairment. Your doctor’s description of your capacity for work is called a medical source statement and the Social Security Administration’s conclusion about your work capacity is called a residual functional capacity assessment. Residual functional capacity is what you can still do despite your limitations. The Social Security Administration asks that medical source statements include a statement about what you can still do despite your impairments.
The Social Security Administration must consider your treating doctor’s opinion and, under appropriate circumstances, give it controlling weight.
The Social Security Administration evaluates the weight to be given your doctor’s opinion by considering:
- The nature and extent of the treatment relationship between you and your doctor.
- How well your doctor knows you.
- The number of times your doctor has seen you.
- Whether your doctor has obtained a detailed picture over time of your impairment.
- Your doctor’s specialization.
- The kinds and extent of examinations and testing performed by or ordered by your doctor.
- The quality of your doctor’s explanation of your impairment.
- The degree to which your doctor’s opinion is supported by relevant evidence, particularly medically acceptable clinical and laboratory diagnostic techniques.
- How consistent your doctor’s opinion is with other evidence.
When to Ask Your Doctor for an Opinion
If your application for Social Security disability benefits has been denied and you have appealed, you should get a medical source statement (your doctor’s opinion about what you can still do) from your doctor to use as evidence at the hearing.
When is the best time to request an opinion from your doctor? Many disability attorneys wait until they have reviewed the file and the hearing is scheduled before requesting an opinion from the treating doctor. This has two advantages.
- First, by waiting until your attorney has fully reviewed the file, he or she will be able to refine the theory of why you cannot work and will be better able to seek support for this theory from the treating doctor.
- Second, the report will be fresh at the time of the hearing.
But this approach also has some disadvantages.
- When there is a long time between the time your attorney first sees you and the time of the hearing, a lot of things can happen. You can improve and go back to work. Your lawyer can still seek evidence that you were disabled for a certain length of time. But then your lawyer will be asking the doctor to describe your ability to work at some time in the past, something that not all doctors are good at.
- You might change doctors, or worse yet, stop seeing doctors altogether because your medical insurance has run out. When your attorney writes to a doctor who has not seen you recently, your attorney runs the risk that the doctor will be reluctant to complete the form. Doctors seem much more willing to provide opinions about current patients than about patients whom they have not seen for a long time.
Here is an alternative. Suggest that your attorney request your doctor to complete a medical opinion form on the day you retain your attorney. This will provide a snapshot description of your residual functional capacity (RFC) early in the case. If you improve and return to work, the description of your RFC provides a basis for showing that you were disabled for a specific period. If you change doctors, your attorney can get an opinion from the new doctor, too. If you stop seeing doctors, at least your attorney has one treating doctor opinion and can present your testimony at the hearing to establish that you have not improved.
If you continue seeing the doctor but it has been a long time since the doctor’s opinion was obtained, just before the hearing your attorney can send the doctor a copy of the form completed earlier, along with a blank form and a cover letter asking the doctor to complete a new form if your condition has changed significantly. If not, your attorney can ask the doctor to send a one-line letter that says there have been no significant changes since the date the earlier form was completed.
There are times, though, that your attorney needs to consider not requesting a report early in the case.
- First, depending on the impairment, if you have not been disabled for twelve months, it is usually better that your attorney wait until the twelve-month duration requirement is met.
- Second, if you just began seeing a new doctor, it is usually best to wait until the doctor is more familiar with your condition before requesting an opinion.
- Third, if there are competing diagnoses or other diagnostic uncertainties, it is usually best that your attorney wait until the medical issues are resolved before requesting an opinion.
- Fourth, a really difficult judgment is involved if your medical history has many ups and downs, e.g., several acute phases, perhaps including hospitalizations, followed by significant improvement. Your attorney needs to request an opinion at a time when the treating doctor will have the best longitudinal perspective on your impairment.
Medical Opinion Forms
Medical opinion forms can be great time savers for both your attorney and your doctor, but they must be used with care. Forms may not be appropriate at all in complex cases; and they need to be supplemented in many cases so that all issues are addressed. The best forms are clear and complete but not too long.