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Short Notes on Muscular Skeletal Susceptibility 2017 - Dr Mark Burgin

19/08/17. Dr. Mark Burgin BM BCh (oxon) MRCGP considers the elements that should be included in a primer for clinical negligence cases involving Muscular Skeletal Susceptibility.

I have used muscular skeletal injuries as an example to demonstrate how susceptibility can influence the management of a case by providing further evidence.

The issue of susceptibility may be raised in instructions or by a health care professional or another expert or where there appears to be inconsistencies in the case.

There is a range of opinion on susceptibility with some experts of the opinion that if susceptibility exists it is limited to rare circumstances and is generally unpredictable.

Other experts are of the opinion that weakness specific to an individual claimant can explain why differences occur.

Whether a claimant was unusually susceptible to the accident is a matter for the court so that all experts must deal with this area and present any evidence.


Vitamin D deficiency when severe causes a softening of the bones (osteo-malacia) and is suspected clinically in a patient who does expose their skin to the sun and does not take Vitamin D supplements.

The clinical signs are non specific, general aches and slow walking upstairs and unusual sensitivity to gentle palpation and is confirmed with a simple blood.

Medically there is likely to be gradations of clinical severity from almost normal to the classic presentation, the recommendations are to provide supplementation to all those at risk. (1)

An expert should address this issue by first referencing a range of opinion and then presenting the evidence for and against Vitamin D deficiency contributing to this injury and end with a statement such as.

‘Osteomalacia would be expected to increase the risk that apophysis injury may occur and would be expected to slow healing so that pain levels are high for longer and the injury takes longer to heal than normal’.

Spinal degeneration

The lumbar spine has some degeneration in most individuals by the age of thirty and 80 percent of 50 year olds have degeneration seen on a cervical spine x-ray but heredity determines most of the difference. (2) (3).

The clinical signs of degeneration are bony tenderness, sciatic or femoral nerve signs and tenderness over the large structures such as sacroiliac ligaments or pain on percussion.

Medically it is likely that spinal degeneration will weaken the structure and decrease any threshold for soft tissue damage as well as increasing the extent of this damage.

The spinal degeneration would not be expected to be accelerated or exacerbated by either the injury or the soft tissue damage due to the accident.

Once injured the individual would not be expected to recover slower than a normal person so that as time passes residual symptoms become more likely to be due to the pre-existing degeneration than the soft tissue injury.


There is a strong genetic component to posture and symptoms were previously rare in young people with a few exceptions such as typists. (4)

In recent years a phenomena reported by chiropractors (Dr James Carter, Dr. Dean Fishman) called Text Neck has been noted in children who suffer from discomfort in the neck and upper back area.

Text neck thought to occur due to the child sitting in a fixed sustained posture whilst using electronic media and postulated to speed up normal wear and tear changes.

Medically it is plausible that a person in an awkward posture might suffer increased the soft tissue damage but also possible that it might be protective.

It is likely that poor posture would slow recovery from an injury unless they receive prompt treatment from a practitioner in physical treatment registered with the HCPC, GCC or the GOsC.


Medical understanding of susceptibility has not reached the stage where it can be dealt with in disease specific primers and will remain a separate field of study.

It is not clear whether Vitamin D deficiency to an extent short of Osteomalacia would cause problems but it is more likely as severity of deficiency worsens.

Susceptibility can be used to explain issues such as low velocity impact or failure to recover and whether the expert believes or not all material evidence should be presented to the court.

A primer on susceptibility will address the legal status of susceptibility and advise experts on their duties in respect to this important area.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website

  1. NICE - Vitamin D: increasing supplement use in at-risk groups Public health guideline [PH56] Published date: November 2014

  2. Weiler 2012 Age-related changes in human cervical, thoracal and lumbar intervertebral disc exhibit a strong intra-individual correlation Eur Spine J. 2012 Aug; 21(Suppl 6): 810–818.

  3. Andersson 1998 What are the age-related changes in the spine? Baillieres Clin Rheumatol. 1998 Feb;12(1):161-73.

  4. Hansraj 2014 Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014 Nov;25:277-9.

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