The Independent Orthopedic Examination

• Author: Samuel D. Hodge, Jr./Jack E. Hubbard
• Profession: Skilled litigator, is chair of the department of legal studies at Temple University/Professor of Neurology at the University of Minnesota
• Pages: 673-734

The Independent

Orthopedic

Examination

Noubar Didizian, Samuel D. Hodge Jr., and Jack E. Hubbard

A person might be an

expert in any field of

knowledge or a master

of many material skills

and accomplishments.

But without inner

cleanliness, his brain

is a desert waste.

Sri Sathya Sai Baba

15

Introduction

Personal injury and disability claims involve monetary payments, either from the per-

son at fault or from an insurance company. Those responsible for paying the damages

incurred in an incident of trauma usually want to make sure that the claimed injuries are

legitimate before expending large sums of money. Also, responsible parties may wish to

ascertain if the injuries are as significant as the claimant maintains. Therefore, a medi-

cal examination from a physician other than the person’s health care provider may be

required. This process, known as an independent medical evaluation (IME), is very com-

mon in personal injury matters.1

Few things, however, create more derisive comments by the plaintiff’s bar in a personal

injury context than the IME. Counsel doesn’t object to the notion that the defense or

insurance carrier has the right to have the client examined in a medical/legal context. The

rules of court and statutory schemes clearly provide for such examinations, so it would

be difficult to maintain that position. Rather, counsel considers it an affront that these

examinations are labeled “independent” since they are paid for by the insurance carrier

and the physicians selected are frequently used on multiple occasions by the defense.

Nevertheless, these same attorneys will refer their clients to certain physicians for treat-

ment and think nothing of it.

The purpose of this chapter is not to debate the merits of this issue. Rather, it is

designed to educate attorneys on how the orthopedic examination is conducted and

to explain the individual parts of the evaluation, which encompasses the axial skeleton

(spine) and the four extremities. The reader is introduced to the basics of the orthopedic

IME, both from a theoretical and practical approach. Written descriptions of the IME are

supplemented through the use of photographs and drawings that reinforce the concepts

presented.

Who Should Conduct the IME

It must be noted at the start that an orthopedic surgeon is not the only choice to perform

an IME. In fact, depending upon the problem, other types of specialists may be more

suitable. This section provides an overview of the disciplines that can be chosen for the

examination depending upon the problem.2

674 ◆ CHAPTER 15

Physical Medicine and Rehabilitation (Physiatry)

Physical medicine and rehabilitation, also called physiatry, is that branch of medicine that

focuses on the prevention, diagnosis, and treatment of disorders of the musculoskeletal,

cardiovascular, and pulmonary systems that produce impairment and functional disability.

Physiatry is one of the 24 medical specialties certified by the American Board of Medi-

cal Specialties. Physiatrists concentrate on nonsurgical solutions and restoration of bodily

function for individuals who have simple mobility difficulties or more comprehensive

cognitive issues. Physiatrists are also responsible for coordinating long-term rehabilita-

tion for people with complicated medical issues such as spinal cord trauma, cancer, stroke,

neurological disorders, brain injuries, or amputations, and the major goal of treatment is

to restore one’s quality of life.

Physiatry came into existence in the 1930s and expanded dramatically after World

War II as many veterans returned with serious disabilities. Physiatrists focused on helping

these individuals restore function and deal with chronic pain.

Physiatrists must complete four years of medical school followed by a similar period

for residency training with time devoted to developing clinical skills and training in the

specialty. Further study is needed to subspecialize in musculoskeletal rehabilitation, pedi-

atrics, traumatic brain injuries, spinal cord injuries, or sports medicine.

Orthopedics

Orthopedic (also spelled orthopaedic) surgery is that branch of medicine that specializes in

the diagnosis, correction, care, treatment, rehabilitation, and prevention of injuries and

diseases of the musculoskeletal system. That includes the bones, joints, ligaments, tendons,

and muscles. Conditions can be acute, chronic, traumatic, and/or recurrent. In addition to

mechanical considerations, orthopedists are concerned with pathology, genetics, and the

intrinsic, extrinsic, and biomechanical factors of this body system. Orthopedic surgeons

use both surgical and nonsurgical techniques in their arsenal of treatment options.

The word orthopedic was coined from two Greek words: ortho, meaning straight, and

paedia, meaning children, as historically the field was dedicated to the treatment of skel-

etal deformities in children.

As with physiatry, many of the developments in orthopedic surgery resulted from

experiences during wartime. For example, during World War II intramedullary rods to

treat fractures of the femur and tibia were found to be effective, and external fixation of

fractures was refined during the Vietnam War.

Orthopedic surgeons undertake between five and seven years of advanced training,

and some also spend additional years serving in a fellowship to refine their specialization.

Many orthopedic surgeons prefer to practice general orthopedics, whereas some special-

ize in a specific area of the body such as the feet, hands, shoulders, spine, hips, or knees.

Some also choose specialized areas of care such as sports medicine or trauma medicine.

Neurosurgery

Neurosurgery is the division of medicine that specializes in surgically treating disorders

of the nervous system, including the brain, spinal cord, nerve roots, and nerves. A vast

majority of individuals think of neurosurgeons only as brain surgeons; however, they treat

much more than the brain. Many neurosurgeons are also spine specialists. Although this

type of physician generally treats patients with brain and spinal cord disorders, their prac-

tice focus may be further subdivided into disk herniations, hydrocephalus, head trauma

with hemorrhages and/or fractures, brain tumors, pituitary tumors, cerebral aneurysms,

subarachnoid hemorrhages, spinal stenosis, epilepsy, strokes, and Parkinson’s disease.

Neurosurgeons use both surgical and nonsurgical techniques, with focus on prevention,

evaluation, diagnosis, treatment, critical care, and rehabilitation of neurological disorders.

In the 1960s, the operating microscope was introduced into the operating room and

revolutionized the practice of neurosurgery. This tool allows neurosurgeons to clearly

visualize the minutest details of the body, thereby enhancing the already technically deli-

cate surgery while preserving and not traumatizing surrounding tissue.

THE INDEPENDENT ORTHOPEDIC EXAMINATION ◆675

Neurosurgeons undergo one of the longest education and training time frames of any

of the surgical specialties, owing to the complexity of the nervous system and delicate

surgical techniques they must perform. Neurosurgeons attend a minimum of five years of

advanced postgraduate training, with some programs extending up to eight years. Some

neurosurgeons opt to undertake an additional fellowship in their area of study, adding

several years to their training.

It is important to realize that both neurosurgeons and orthopedic surgeons are con-

sidered spine specialists and perform surgery to this area. Neurosurgeons and orthopedic

surgeons are skilled in taking care of disk herniations, disk degenerations, spinal stenosis,

fractures of the spine, spondylolisthesis (slippage of the spine), scoliosis, and bone tumors.

Only neurosurgeons, however, have been trained to perform procedures inside the lining

of the spinal canal or the dura. Therefore, neurosurgeons treat and diagnose disorders

such as spinal cord tumors, arachnoid cysts, syringomyelia, tethered spinal cord, spina

bifida, and nerve root tumors.

Neurology

Neurologists specialize in diagnosing, medically treating, and managing disorders of the

brain, spinal cord, nerves, muscles, and pain. Common neurological conditions treated

include headaches, neck and back pain, stupor and coma, dementia, Alzheimer’s disease,

seizures and epilepsy, sleep disorders, cerebral palsy, tumors, Parkinson’s disease, multiple

sclerosis, spinal cord disorders, and maladies of the muscles and neuromuscular junctions.

Neurological examinations test muscle strength and movement, balance, coordination,

ambulation, reflexes, sensation, vision, memory, speech, language, and other cognitive

abilities. These physicians also determine what area of the brain and/or nervous system

may be affected. Although neurologists can recommend surgery, they themselves use only

nonsurgical techniques.

Prominent neurologists include Alois Alzheimer, a German physician who first

observed the symptoms of Alzheimer’s disease in 1906; and Joseph Babinski, a French

neurologist who described the pathological sign of plantar flexion known as the Babinski

sign. Mortiz Heinrich Romberg, a German neurologist, discovered the Romberg sign in his

original account of the effects of syphilis. This sign was noted to include a loss of sense

of position, unsteadiness, or falling with the eyes closed.

Neurologists attend at least one year of postgraduate study in either internal medicine

or medicine/surgery and at least three years of specialty resident training. They often

subspecialize by completing a fellowship in various neurological diseases such as epilepsy,

stroke, multiple sclerosis, and neuromuscular disorders.

The Medical Evaluation

Medical students learn how to conduct medical evaluations during their second year of

medical school. They start as neophytes, and the learning curve continues throughout

their medical career. Over the years of practice, however, a physician becomes more

proficient and develops a personal style and approach to a subject evaluation. It is this

unique interaction with subjects that separates the medical field from other professions.

In general the medical evaluation includes several components by which the physician

is able to come to a diagnosis of the subject’s difficulty. The components of a thorough

medical evaluation include

• the taking of a history which includes the history of present illness, past medical

history, family history, medication history, and social history

• hands-on physical examination

• review of diagnostic studies, if available

• an analysis of any available medical records

• clinical opinion as to diagnosis and treatment

Likewise, the Independent Medical Evaluation approach to the claimant should be in the

same objective manner of taking a detailed medical history (with focus on the claimed