TN 23 (09-20)

DI 22510.037 Pediatric Consultative Examination (CE) Report Content Guidelines for Musculoskeletal Disorders

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for pediatric musculoskeletal disorders

The guidelines in this section are in addition to the Pediatric CE report content as stated in DI 22510.035. For additional CE policy in a child’s case, also see DI 25205.015.

B. Report content specific to pediatric musculoskeletal disorders

The CE provider will use the specific requirements below to complete the CE report for a musculoskeletal disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Character, location, and radiation of pain;

b. Factors that incite and relieve the pain;

c. Symptoms of weakness, other motor loss, and/or any sensory abnormalities; and

d. Dates and results of any relevant diagnostic procedures, such as x-rays, myelography, CT scan, MRI, and radionuclide bone scan.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Any apparent abnormalities such as gait, or the need for any type of assistive device;

b. Extremities and peripheral joints:

1. Active and passive range of motion;

2. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;

3. Effusion;

4. Peri-articular swelling;

5. Pain, if any, and its distribution;

6. Tenderness;

7. Redness or heat;

8. Thickening;

9. Structural deformities;

10. Instability;

11. Grip, pinch, ability to close the fist or perform fine and gross manipulations (measured either by dynamometer or 0-5 scale);

12. Extremity strength (measured either by dynamometer or 0-5 scale);

13. Atrophy; and

14. Ability to use, and effective use of, any orthoses.

c. Spine:

1. Distribution of pain, tenderness, and sensory and/or motor loss;

2. Intensity and symmetry of deep tendon reflexes;

3. Muscle spasms, when present;

4. Active range of spinal motion;

5. When the lumbar spine is an issue, straight-leg raising (lumbar spine, both sitting and supine); and,

6. When the cervical spine is an issue, provacative test for radiculopathy, such as the Sperling test.

d. Amputated extremities:

1. Description of stump, including integrity of skin flap;

2. Tenderness; and

3. Ability to use, and effective use of, any prostheses. It is not necessary to evaluate the child’s ability to walk without the prostheses in place. If an upper extremity is involved, the CE provider should comment on the functional level of the contralateral extremity.

e. Fractures of bones of extremities or pelvis:

1. Review of imaging such as x-rays or MRI; and

2. Clinical evidence of union or non-union.

f. Soft tissue injuries/burns:

1. Nature and extent of the injury;

2. Skin sensitivity; and

3. Effect the injury has on joint motion.

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510037
DI 22510.037 - Pediatric Consultative Examination (CE) Report Content Guidelines for Musculoskeletal Disorders - 04/11/2003
Batch run: 09/25/2020
Rev:04/11/2003