Sacroiliac injury and weakness

Because the ratings turn on measured spinal motion, a physical examination recording the degrees of forward flexion and the combined range of motion of your thoracolumbar spine is central. Range of motion measurements should be rounded to the nearest five degrees. If an examiner believes your normal range differs because of age, body type, or other factors unrelated to your spinal condition, a written explanation supporting that conclusion can be considered.

Records showing muscle spasm or guarding are relevant at the 10% and 20% levels. At 20%, evidence that the spasm or guarding produces an abnormal gait or an abnormal spinal contour — such as scoliosis, reversed lordosis, or abnormal kyphosis — moves the finding to that higher level. Imaging studies, treatment notes, and surgical records can document the history and severity of your sacroiliac injury. Your own statements, and statements from people who observe you daily, can describe how pain, stiffness, or limited motion affects your ability to walk, work, and carry out everyday activities. If you have neurologic symptoms such as bowel or bladder problems, those should be documented separately for evaluation under a different diagnostic code.