Knowing what medical terms in medical records mean can be critical to your client’s Social Security disability claim. We recently had a case involving primarily back problems. The treating physician completed a medical source statement indicating that the claimant was experiencing pain at a level that would seriously interfere with the timely completion of job tasks. To support this, the doctor wrote, among other things, that his patient had an “abnormal gait.”
The Administrative Law Judge dismissed the doctor’s opinions, and found that the claimant was not disabled. In particular, the Judge found that the doctor could not be believed because the doctor’s own records repeatedly indicated that the patient did not have an “ataxic” gait.
We ended up appealing the case to Federal District Court, pointing out in our brief to the Court that the hearing Judge apparently did not understand the terms “ataxia” or “ataxic” gait. Ataxia is a neurological condition which describes a lack of muscle control or coordination, and usually is the result of damage to the part of the brain which controls coordination. An “antalgic gait,” on the other hand, is a limping gait adopted so as to avoid pain on weight-bearing structures. Therefore, a person can have an antalgic (abnormal) gait, and yet not have an ataxic gait.
The Court agreed, and reversed the decision of the hearing Judge on that basis.