Beyond the Surface: Understanding Soft Tissue Conditions and Disability Claims

Welcome to Season 5, Episode 38 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Beyond the Surface: Understanding Soft Tissue Conditions and Disability Claims."

Most people think proving a soft tissue injury should be simple - pain is pain, right? But in Long-Term Disability claims, carriers see it differently. Conditions like chronic back strains, tendonitis, or shoulder injuries often don’t appear on MRIs or X-rays, and insurers are quick to assume they’ll heal on their own. That assumption can turn a legitimate medical issue into an uphill battle for benefits. In this episode of Winning Isn’t Easy, disability law expert Nancy L. Cavey unpacks why soft tissue claims are some of the most misunderstood - and most denied - in disability law. You’ll learn how carriers evaluate these “invisible” injuries, what they look for in your medical records, and how they use recovery timelines and vague evidence to deny claims. Nancy walks through what you need to know: how soft tissue disorders actually affect the body, how insurers assess your functional capacity, and why detailed documentation - from therapy notes to functional assessments - can make or break your case. You’ll also learn how working closely with your doctor and attorney can strengthen your claim and ensure your records clearly show how pain limits your ability to work. By the end, you’ll understand why soft tissue claims require more than a diagnosis - they demand strategy, persistence, and proof that connects your pain to your work limitations. Winning Isn’t Easy, but with the right evidence and approach, you can turn a “soft” tissue claim into a strong case for the benefits you deserve.

In this episode, we'll cover the following topics:

One - What Are Soft Tissue Disorders?

Two - How Long-Term Disability Carriers View Claims for Soft Tissue Conditions

Three - What Medical Treatment Does a Long-Term Disability Carrier Expect?

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals. 

Transcript

Nancy Cavey [00:00:00]:
 Foreign Nancy Cavey, National Risk and Individual Disability Attorney welcome to Winning isn't Easy. Now, before we get started, I've got to give you that legal disclaimer. This podcast is not legal advice. The Florida Bar association says I have to tell you that. And now that I've done that, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers and plans play, and what you need to know to get the disability benefits you deserve. So off we go now. Today I'm going to dive into the complexity of soft tissue conditions and how they're evaluated by disability carriers and plans. When it comes to soft tissue conditions, disability carriers or plans don't just want to know that you're injured or that you have some sort of ongoing generative condition.
 
 Nancy Cavey [00:00:57]:
 They want a complete picture of how your medical condition impacts your ability to perform, your own occupation and your level of physical functioning, your residual functional capacity and ultimately at the own occupation stage, why it is you can't do another occupation. I will tell you that soft tissue injuries like chronic back strains, tendinitis, persistent shoulder problems often don't show up on traditional imaging. And and disability insurance carriers or plans are often quick to assume that they'll heal on their own. And that assumption can put your claim at risk even when your pain and limitations are real, rather and severe. So in today's episode, I'm going to break it down into three parts. I'm going to talk about what soft tissue disorders are, how they affect the body, and why they're often underestimated by disability carriers or plans. Then I'm going to go through how long term disability carriers or plans evaluate these conditions, what they look for in your medical records, how they assess your functional limitations, and what can make or break your claim. And finally, I'm going to tackle the role of treatment and medical documentation, from physical therapy and medication to surgeries and functional assessments, and why working with an attorney and a doctor as a team is often essential to securing benefits for soft tissue conditions.
 
 Nancy Cavey [00:02:10]:
 My goal is that at the end of this episode, you're going to understand why getting disability benefits for soft tissue conditions is about far more than having an injury or a progressive medical condition. It's about clearly documenting your limitations, understanding what disability carriers or plans are looking for, not only in terms of the policy or plan, but your medical records, and building a strategy that maximizes your chances of success. So I'm going to specifically talk about three things. Number one, what are soft tissue disorders? Two, how do long term disability carriers view these types of claims? And 3 what does the disability carrier plan expect in your medical records and in the terms of of your medical treatment? Got it. Let's take a break for a moment before we get into this episode.
 
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 Nancy Cavey [00:03:33]:
 Welcome back to Winning Isn't Easy. What Are Soft Tissue Disorders? Now, I think it's important for you to understand what soft tissue disorders are and why there are can be very complex Soft tissue disorders involve damage or inflammation to muscles, tendons or ligaments. The tissues that support, connect and allow movement in our bodies. Unlike broken bones or torn organs, soft tissue injuries often don't show obvious structural damage on X rays, making them difficult for insurers to evaluate. Yet the impact on daily functioning can be substantial. Now, these conditions can develop in a variety of ways. Trauma such as a fall sports accident or even a car accident can cause immediate injury. Repetitive stress or overuse, like long hours at a computer, intense workouts or weekend sports like pickleball can lead to chronic inflammation or even tearing ligaments and tendons over time.
 
 Nancy Cavey [00:04:28]:
 And even seemingly minor injuries, if not addressed properly, can evolve into long term problems that interfere with work and daily life. So let's talk about common examples of software tissue conditions. They include sprains and strains. So ligamentous and muscle injuries often occur in the ankles, wrists, knees and back. Tendonitis. It's an inflammation of a tendon due to repetitive motion, such as tennis elbow or rotator cuff injuries as a result of pitching. That can be bursitis, which is inflammation of the fluid filled sacs that cushion the joints and prevent friction, often affecting the shoulder, the elbow or the hip. Then there's chronic back injuries, injuries to the back muscles and ligaments that persist beyond the typical healing period, and they limit mobility, strength and endurance.
 
 Nancy Cavey [00:05:14]:
 I will tell you, based on my years of experience, that the difficulty for policyholders arises because soft tissue disorders don't always look severe to outsiders. You might be able to walk or lift light objects, but you still experience debilitating pain when performing repetitive motions or maintaining positions that required by a person's occupation. So the tasks that were once simple, like gripping a tool, lifting a box, standing for long periods, or even sitting at a desk, can become impossible. Now, insurance carriers or plans, often prioritize objective evidence such as here's the X ray, the broken bone, here's the X ray or CT scan that shows the herniated disc or damage to the vertebral structure. Here's nerve damage as documented by an EMG and nerve conduction study test. Now, you don't always see that in the case of subjective medical conditions or like chronic soft tissue injuries, claimants have to document this not only in the terms of what caused it, here's an objective basis for the diagnosis, but the ways in which it impacts their ability to work. I want you to understand the medical and functional implications of soft tissue disorders because it's essential for you in your claim. I want you to understand the difference between like a temporary sprain and a chronic debilitating condition.
 
 Nancy Cavey [00:06:27]:
 And that can mean the difference between a deny claim or successful award. Now, many times the path to benefits is going to begin with those diagnostic studies that establish the basis of the underlying medical condition. But we also want to establish the severity and persistence of this condition through careful medical documentation, functional assessments and a clear narrative in your medical records of how this condition impacts your abilities on a daily basis. Got it. Let's take a break. Let's talk about how long term disability carriers view claims for ultimately soft tissue conditions or post operative conditions that present with normal exam findings. Now, soft tissue conditions can be particularly challenging to prove in long term disability claims. Insurers or plans often assume that these injuries will heal within weeks.
 
 Nancy Cavey [00:07:30]:
 And if you don't meet the elimination period, which is a waiting period before benefits begin, they may initially deny your coverage. So normally there might be a six month elimination period. So it could be 30 days, 60 days, 90 days. And they're looking to see whether your medical condition is one that should heal within that timeframe based on their medical duration guidelines. And they may say, well, according to the guidelines, this soft tissue back strain should have healed 60 days and our elimination period is 90 days. So too bad, so sad you don't satisfy the elimination period. Now obviously many people who have soft tissue injuries such as an ankle sprain or a back sprain, can recover quickly and never be eligible for benefits. And I'm not talking to that type of case.
 
 Nancy Cavey [00:08:14]:
 I'm talking about a situation where the injury persists beyond the typical 90 day elimination period. But I will tell you that in my experience, a disability carrier plan is going be looking after that 90 day elimination period at your medical records. They want to determine the nature of the injury, the treatments that were provided, your response to the treatment they want to look at whether your condition is really severe enough to prevent you performing the material duties of your own occupation and eventually any occupation. So what are they looking for? Well, first they're looking for evidence of severe soft tissue conditions impacting muscles, ligaments or tendons. They are also looking for surgeries that have been recommended or would repair the damage to tissues. They're looking for documentation of extensive tissue damage through MRIs, operative reports, or other imaging. They're looking for medical notes that illustrate the severity and expected duration of the condition. And they are looking for clear evidence that the condition prevents the performance of essential job duties.
 
 Nancy Cavey [00:09:13]:
 Let me tell you about a case that I had involving a firefighter who liked to kite board. And he had a severe groin strain and hernia as a result of kite. Worty underwent surgery but had persistent pain, soft tissue, swelling. His claim was denied, and we fought long and hard to get his benefits by trying to establish in the medical records the severity and expected duration of his symptoms. We documented in progress notes, physical therapy notes, and surgical documentation why he couldn't perform the essential job duties of a firefighter. That included documenting restrictions on lifting, pulling, pushing, stooping, bending, sitting, using hands and arms, and repetitive motions. To do that, we had a functional capacity evaluation to document objectively the functional restrictions and limitations. We took that to the attending physician, treating physician and asked the doctor to endorse the FCE findings and to complete a residual functional capacity form.
 
 Nancy Cavey [00:10:15]:
 We wanted to do that to provide a more precise assessment of his limitations. We also have done the same thing in other types of cases where the person has persistent soft tissue findings after, for example, undergoing back surgery. So the back surgery may have dealt with the radicular pains, but the person still has issues with swelling or stiffness or other symptoms that impact their ability to sit, that impact their need to alternate sitting and standing that may require them to elevate their legs or to ice or to heat. So what we're trying to do is to work backwards, if you will, and in that particular case, document that the person had surgery. And yes, they had a partial recovery, but no, they didn't have a complete recovery because they continue to have soft tissue issues. Swelling, spasm. We wanted to make sure that the doctor documented the spasm. We wanted the functional capacity evaluator to corroborate the spasm and other soft tissue findings.
 
 Nancy Cavey [00:11:16]:
 We wanted that FCE provider to document objectively the difficulty sitting, standing, walking, the level of discomfort, and how that person had to stop. Gave their great effort during the FCE but couldn't complete all of the tasks of the FCE despite giving a great effort. Those are the kinds of things that you want to do in these types of cases. Now I will tell you the game changes when there's a transition from your own occupation to any occupation. Policies will vary in their definition of any occupation, but generally in my view, what you have to prove is that you can't even do a sedentary job involving sitting most of the day and performing, you know, basically manual tasks. They'll often argue that that you can perform these sedentary tasks even if you have having post surgical issues. So let's say for example you have bilateral carpal tunnel in both wrists. You undergo surgery, the tingling and numbness is gone, but you have problems with swelling and stiffness and with repetitive use of your wrists and fingers, your just pain blows up again.
 
 Nancy Cavey [00:12:22]:
 What we want to be able to document is the post surgical wrist complications that prevent things like gripping, twisting or lifting and the impact that it has when you're using both hands. So again, a functional capacity evaluation can help document these sorts of issues. You can see that navigating the process without strategy, without the assistance of an experienced attorney, a physician and a great FCE provider can really result in a claim denial or termination and an unsuccessful appeal. The goal here is to collect and organize medical records to frame the narrative of symptoms and functionality in line with the policy terms, develop the necessary medical documentation in terms of objective testing, in terms of documentation of the symptoms, and to get that functional capacity evaluation and of course have that all cooperated in the medical records and in the residual functional capacity forms and the endorsement of the fce. So it's teamwork that's going to increase the likelihood of approval and it positions you in a strong appeal if benefits are denied or terminated. Got it? Let's take a break.
 
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 Nancy Cavey [00:14:22]:
 Welcome back to Winning Isn't Easy. What medical treatment does a long term disability carrier expect in a soft tissue disability claim? Now I will tell you that medical treatment plays a central role in any long term disability claim. Insurance carriers and Disability plans are going to use the treatment you receive to gauge whether your condition truly prevents you from doing your own occupation or any occupation. I will tell you that in soft tissue cases, this is going to face intense scrutiny. Carriers are often going to downplay the functional limitations caused by slow healing injuries, assuming that most soft tissue injuries resolve quickly with conservative care. However, I'll tell you that chronic injuries, soft tissue injuries, can persist beyond the elimination period and require more thorough documentation of ongoing disability. The first line of attack, by the way, is going to be the disability carrier plan, saying that based on your medical records, you do not meet the elimination period. And this is a period that can be 30 days, 60 days, 90 days.
 
 Nancy Cavey [00:15:23]:
 I've even seen them as long as a year. And in that time frame, you have to meet the definition of disability as defined by the terms of the policy of the plan, and you're not getting paid in that timeframe. Disability carriers think it's an easy win to deny benefits in a soft tissue case during the elimination period. But if you make it past then, then the question becomes, well, are you still disabled? As that term is defined by the policy of the plan. What they're going to be looking for is treatment, and they're going to be looking for diagnostic studies. So let's start out with the diagnostic studies they're going to be looking for. Well, is there an X ray, is there an mri, is there a CT scan, is there an MRI arthrogram that document an injury or a disabling medical condition? Okay, so we see that. What's the physical exam findings? Are these physical exam findings consistent with the diagnosis and the objective medical tests? And sometimes the tests aren't positive, they're negative.
 
 Nancy Cavey [00:16:26]:
 But that doesn't mean that you're not disabled. It means that we have to go about proving this case a bit differently. So they're going to look at the physical exam findings. They're also going to be looking at what treatment was recommended for your chronic soft tissue condition. As we know, the treatment legitimately is going to start out conservatively with things like physical therapy, medication like muscle relaxers or injections to relieve the pain and inflammation. If these interventions fail, additional steps can include a referral to a specialist pain management physician or even a surgeon. One of the things that I like to do is to look at what the nature of the person's soft tissue injury or medical condition is. Is it a bursitis? Is it an inflammation? What is it? What would we expect to see on exam findings? What is the duration guidelines? That the carriers say are applicable to this case, and at what point should they recover? What typically do physicians or medical providers see when the condition has not healed in the time that's reasonably expected? And what type of diagnostic studies are ordered to determine why there is these ongoing soft tissue injuries or conditions? Is it an mri? Is it going to be diagnostic studies like MRI orthograms? Is it going to be perhaps injections that are diagnostic in nature to kind of tease out what the medical condition is? Or is it going to be physical therapy? Is it going to be inflammatory medication or other pain medication or injections? But.
 
 Nancy Cavey [00:18:03]:
 But as the condition persists, they're going to be looking to that referral to that specialist, the pain management provider, or the surgeon. And what they want to see is that your treatment is appropriate in terms of the type of treatment, the frequency and intensity of treatment. If they think that your care is insufficient, they're going to argue that your condition isn't severe enough to meet the policy's definition of disability. So support from your physician is crucial. And oftentimes we have to get not only detailed APS forms and RFC forms, but there are times when we want to get a functional capacity evaluation, which is an objective measure of the impact of the person's capabilities, and explain via a letter from the doctor that they're endorsing the RFC or the FCE and that the reason why we're not seeing. They're not seeing a progression in the improvement, but rather a chronic condition is X, Y, or Z. We want your physician to explain why that is. We want them to address the lack of progression in improvement, the lack of response, why there's been a lack of response or an incomplete response, why this condition has lasted longer than typical, and what they anticipate your future treatment to be.
 
 Nancy Cavey [00:19:22]:
 And I think that taking the extra step in getting this explanation is the difference between a deny claim or a successful one. The other thing that I think is really crucial is that if your physician isn't going to play ball with you, that you, and preferably your lawyer, identify a specialist in this area who would be willing to do an independent medical examination and address those very questions. We lawyers know doctors in our geographic area who are willing to do IMEs are willing to listen to policyholders like yourself to take that good history, to do a thorough exam, to recommend studies, to analyze your records, and answer the questions that disability carriers or plans often ask and which are the basis of a claim denial or termination. So remember, you need to be proactive, but if you're in a situation where your benefits have been denied or terminated, there really is a specific strategy that, in my view needs to be implemented so clearly. When this condition persists either beyond the elimination period or beyond the duration guidelines the disability carriers or plans use, having professional assistance is going to be crucial. And I've outlined for you exactly what needs to be done. But you need to remember that you only have 180 days in which to file an appeal, and that appeal is the trial of your case. You can't add anything new once that appeal process is completed.
 
 Nancy Cavey [00:20:47]:
 So in our office, we do appeals that are 25 to 60 pages long. We address the medical basis for the denial and of course argue the applicable law. But we're taking a comprehensive approach and getting documentation from the physician, having our clients undergo the FCEs or getting IMEs and taking the necessary steps to rebut, element by element, the basis of the disability carrier's denial of your soft tissue condition. So you can see that navigating chronic soft tissue injuries requires professional guidance, and it's essential to the success of one of these claims. Thank you for tuning into this week's episode of Winning Isn't Easy. If you found this episode helpful, please take a moment to like our page, leave a review, share it with your family and friends, and subscribe to this podcast. Join us next week for another insightful discussion. An episode of Winning Isn't Easy.
 
 Nancy Cavey [00:21:46]:
 Thanks for listening.