Criteria: Most ratings are based on motion deficits; therefore, the primary tables are Figure 16-40, Pie Chart of Upper Extremity Motion Impairments Due to Lack of Flexion and Extension of Shoulder (476), Figure 16-43, Pie Chart of Upper Extremity Motion Impairments Due to Lack of Abduction and Adduction of Shoulder (477), Figure 16-46, Pie Chart of Upper Extremity Impairments Due to Lack of Internal and External Rotation of Shoulder (479); Table 16-27. If there was a distal clavicle resection or, more rarely, shoulder replacement, impairment is also based on Table 16-27. Impairment of the Upper Extremity After Arthroplasty of Specific Bones or Joints (506). If motion is normal and there are objective, consistent strength deficits, Table 16-35 Impairment of the Upper Extremity Due to Strength Deficit from Musculoskeletal Disorders Based on Manual Muscle Testing of Individual Units of Motion of the Shoulder and Elbow (510) may be used.
Guidance: The process of assessing upper extremity permanent impairment is described in Chapter 16, Upper Extremities. This is done within the context of overall directives provided in Chapter 1, Philosophy, Purpose, and Appropriate Use of the Guides, and Chapter 2, Practical Application of the Guides. There are many reasons why a rating may be higher or lower than the typical observed value; if there is an error, it is more common for the rating to higher than appropriate. Errors are higher in the context of litigation or if performed by a biased or inexperienced rater. A rating might be higher than average if the patient had marked motion or strength deficits. It could also be higher if a total shoulder replacement was performed or there were other complications. It might be lower than average if the patient had a good result from treatment, e.g., someone with a rotator cuff tear repair and now has a full range of motion and normal strength. (The goal of all interventions, including surgery, should be to restore function and minimize impairment.) It could also be lower than usual if the examiner did not consider all of the factors contributing to impairment. Typically, if the person is doing well functionally, you would expect a lower rating and a higher rating if not doing well. However, keep in mind that the focus must be on reliable information. Objective measurements are more likely to be reliable than subjective complaints, e.g., pain. However, patients may demonstrate less motion or strength than they are capable of performing. It is essential to assess the injury and its severity, determine the diagnoses (discerning those causally related to the injury versus not), assess the consistency of clinical findings that serve as the basis for the rating, and critically analyze the impairment rating to determine if it complies with standards defined in the Guides. In reviewing an impairment assessment, you need to identify the diagnoses, differentiating those that may result from the injury (e.g., a rotator cuff tear) from those that may be unrelated (e.g., arthritis). If someone has had surgery, helpful information will be derived from reviewing the operative report, including learning the diagnosis and what was done. There must be adequate time after surgery to be at maximum medical improvement; typically, this is six months to a year. The clinical findings that serve as the basis for the rating must be accurate. Most shoulder impairments are rated based on motion deficits, as explained in Section 16.4i, Shoulder Motion Impairment (474-479). Motion measurements for flexion, extension, abduction, adduction, internal rotation, and external rotation are obtained bilaterally. Figure 16-40, Pie Chart of Upper Extremity Motion Impairments Due to Lack of Flexion and Extension of Shoulder (476), Figure 16-43, Pie Chart of Upper Extremity Motion Impairments Due to Lack of Abduction and Adduction of Shoulder (477), and Figure 16-46, Pie Chart of Upper Extremity Impairments Due to Lack of Internal and External Rotation of Shoulder (479) provide impairment values for motion deficits. Impairment values are added. If the opposite extremity is normal, it should be used as the baseline. These measurements must be reliable. Therefore, it is crucial to determine if they are consistent with documentation with other health providers, including physical therapists. Sometimes limitations are secondary to pain, and other times intentional (e.g., someone could recognize that the resulting rating and associated financial award would likely be higher). In rare cases, strength loss for the shoulder is rated per Section 16.8 Strength Evaluation (507-511), as further described in Section 16.8c Manual Muscle Testing (509-511). This problematic approach is only done in the absence of motion deficits and pain and when strength measurements are reliable. According to Table 16-35, Impairment of the Upper Extremity Due to Strength Deficit from Musculoskeletal Disorders Based on Manual Muscle Testing of Individual Units of Motion of the Shoulder and Elbow (510). Section 16.7 Impairment of the Upper Extremities Due to Other Disorders (498-507) presents approaches to assessing less common upper extremity difficulties; instructions are provided in Section 16.7 to avoid duplication of impairments. If a distal clavicle arthroplasty is performed, it may be rated via Table 16-27. Impairment of the Upper Extremity After Arthroplasty of Specific Bones or Joints (506) as 10% upper extremity impairment combined with motion impairment. However, it is essential to determine that the issues with the clavicle are causally related to the injury (not prophylactically to avoid future programs), and the distal clavicle was resected (this is done by checking the operative report). Upper extremity impairment is converted to a whole person impairment by Table 16-3, Conversion of Impairment of the Upper Extremity to Impairment of the Whole Person (5th ed, p 439).
