A. Disorders of the musculoskeletal system may result from
hereditary, congenital, or acquired pathologic processes. Impairments may result from infectious, inflammatory, or degenerative
processes, traumatic or developmental events, or neoplastic, vascular, or toxic/metabolic diseases.
B. Loss of function.
1. General. Under this section, loss of function
may be due to bone or joint deformity or destruction from any cause; miscellaneous disorders of the spine with or without
radiculopathy or other neurological deficits; amputation; or fractures or soft tissue injuries, including burns, requiring
prolonged periods of immobility or convalescence. For inflammatory arthritides that result in loss of function because of
inflammatory peripheral joint or axial arthritis or sequelae, or because of extra-articular features, see 114.00E. Impairments
with neurological causes are to be evaluated under 111.00ff.
2. How we define loss
of function in these listings.
a. General. Regardless of the cause(s) of a musculoskeletal
impairment, functional loss for purposes of these listings is defined as the inability to ambulate effectively on a sustained
basis for any reason, including pain associated with the underlying musculoskeletal impairment, or the inability to perform
fine and gross movements effectively on a sustained basis for any reason, including pain associated with the underlying musculoskeletal
The inability to ambulate effectively or the inability to perform fine and gross movements effectively
must have lasted, or be expected to last, for at least 12 months. For the purposes of these criteria, consideration of
the ability to perform these activities must be from a physical standpoint alone. When there is an inability to perform these
activities due to a mental impairment, the criteria in 112.00ff are to be used. We will determine whether a child can ambulate
effectively or can perform fine and gross movements effectively based on the medical and other evidence in the case record,
generally without developing additional evidence about the child's ability to perform the specific activities listed as
examples in 101.00B2b(2) and (3) and 101.00B2c(2) and (3).
b. What we mean by inability
to ambulate effectively.
(1) Definition. Inability to ambulate effectively means
an extreme limitation of the ability to walk; i.e., an impairment that interferes very seriously with the child's ability
to independently initiate, sustain, or complete activities. Ineffective ambulation is defined generally as having insufficient
lower extremity functioning (see 101.00J) to permit independent ambulation without the use of a hand-held assistive device(s)
that limits the functioning of both upper extremities. (Listing 101.05C is an exception to this general definition because
the child has the use of only one upper extremity due to amputation of a hand.)
How we assess inability to ambulate effectively for children too young to be expected to walk independently. For children
who are too young to be expected to walk independently, consideration of function must be based on assessment of limitations
in the ability to perform comparable age-appropriate activities with the lower extremities, given normal developmental expectations.
For such children, an extreme level of limitation means skills or performance at no greater than one-half of age-appropriate
expectations based on an overall developmental assessment rather than on one or two isolated skills.
(3) How we assess inability to ambulate effectively for older children. Older children, who would be expected
to be able to walk when compared to other children the same age who do not have impairments, must be capable of sustaining
a reasonable walking pace over a sufficient distance to be able to carry out age-appropriate activities. They must have the
ability to travel age-appropriately without extraordinary assistance to and from school or a place of employment.
Therefore, examples of ineffective ambulation for older children include, but are not limited to, the inability to walk
without the use of a walker, two crutches or two canes, the inability to walk a block at a reasonable pace on rough or uneven
surfaces, the inability to use standard public transportation, the inability to carry out age-appropriate school activities
independently, and the inability to climb a few steps at a reasonable pace with the use of a single hand rail. The ability
to walk independently about the child's home or a short distance at school without the use of assistive devices does not,
in and of itself, constitute effective ambulation.
c. What we mean by inability to
perform fine and gross movements effectively.
(1) Definition. Inability to
perform fine and gross movements effectively means an extreme loss of function of both upper extremities; i.e., an impairment
that interferes very seriously with the child's ability to independently initiate, sustain, or complete activities. To
use their upper extremities effectively, a child must be capable of sustaining such functions as reaching, pushing, pulling,
grasping, and fingering in an age-appropriate manner to be able to carry out age-appropriate activities.
(2) How we assess inability to perform fine and gross movements in very young children. For very young children,
we consider limitations in the ability to perform comparable age-appropriate activities involving the upper extremities compared
to the ability of children the same age who do not have impairments. For such children, an extreme level of limitation means
skills or performance at no greater than one-half of age-appropriate expectations based on an overall developmental assessment.
(3) How we assess inability to perform fine and gross movements in older children.
For older children, examples of inability to perform fine and gross movements effectively include, but are not limited to,
the inability to prepare a simple meal and feed oneself, the inability to take care of personal hygiene, or the inability
to sort and handle papers or files, depending upon which activities are age-appropriate.
Pain or other symptoms. Pain or other symptoms may be an important factor contributing to functional loss. In order for pain
or other symptoms to be found to affect a child's ability to function in an age-appropriate manner or to perform basic
work activities, medical signs or laboratory findings must show the existence of a medically determinable impairment(s) that
could reasonably be expected to produce the pain or other symptoms.
The musculoskeletal listings that include
pain or other symptoms among their criteria also include criteria for limitations in functioning as a result of the listed
impairment, including limitations caused by pain. It is, therefore, important to evaluate the intensity and persistence of
such pain or other symptoms carefully in order to determine their impact on the child's functioning under these listings.
See also §§ 404.1525(f) and 404.1529 of this part, and §§ 416.925(f) and 416.929 of
part 416 of this chapter.
C. Diagnosis and evaluation.
1. General. Diagnosis and evaluation of musculoskeletal impairments should be supported, as applicable,
by detailed descriptions of the joints, including ranges of motion, condition of the musculature (e.g., weakness, atrophy),
sensory or reflex changes, circulatory deficits, and laboratory findings, including findings on x-ray or other appropriate
medically acceptable imaging. Medically acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial
tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast material, myelography, and radionuclear
bone scans. "Appropriate" means that the technique used is the proper one to support the evaluation and diagnosis
of the impairment.
2. Purchase of certain medically acceptable imaging. While any
appropriate medically acceptable imaging is useful in establishing the diagnosis of musculoskeletal impairments, some tests,
such as CAT scans and MRIs, are quite expensive, and we will not routinely purchase them. Some, such as myelograms, are invasive
and may involve significant risk. We will not order such tests. However, when the results of any of these tests are part of
the existing evidence in the case record we will consider them together with the other relevant evidence.
3. Consideration of electrodiagnostic procedures. Electrodiagnostic procedures may be useful in establishing
the clinical diagnosis, but do not constitute alternative criteria to the requirements of 101.04.
D. The physical examination must include a detailed description of the rheumatological, orthopedic, neurological,
and other findings appropriate to the specific impairment being evaluated. These physical findings must be determined on the
basis of objective observation during the examination and not simply a report of the child's allegation; e.g., "He
says his leg is weak, numb."
Alternative testing methods should be used to verify the abnormal findings;
e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test. Because abnormal physical findings
may be intermittent, their presence over a period of time must be established by a record of ongoing management and evaluation.
Care must be taken to ascertain that the reported examination findings are consistent with the child's age and activities.
E. Examination of the spine.
1. General. Examination
of the spine should include a detailed description of gait, range of motion of the spine given quantitatively in degrees from
the vertical position (zero degrees) or, for straight-leg raising from the sitting and supine position (zero degrees),
any other appropriate tension signs, motor and sensory abnormalities, muscle spasm, when present, and deep tendon reflexes.
Observations of the child during the examination should be reported; e.g., how he or she gets on and off the examination table.
Inability to walk on the heels or toes, to squat, or to arise from a squatting position, when appropriate, may
be considered evidence of significant motor loss. However, a report of atrophy is not acceptable as evidence of significant
motor loss without circumferential measurements of both thighs and lower legs, or both upper and lower arms, as appropriate,
at a stated point above and below the knee or elbow given in inches or centimeters. Additionally, a report of atrophy should
be accompanied by measurement of the strength of the muscle(s) in question generally based on a grading system of 0 to 5,
with 0 being complete loss of strength and 5 being maximum strength. A specific description of atrophy of hand muscles is
acceptable without measurements of atrophy but should include measurements of grip and pinch strength. However, because of
the unreliability of such measurement in younger children, these data are not applicable to children under 5 years of
2. When neurological abnormalities persist. Neurological abnormalities may not
completely subside after treatment or with the passage of time. Therefore, residual neurological abnormalities that persist
after it has been determined clinically or by direct surgical or other observation that the ongoing or progressive condition
is no longer present will not satisfy the required findings in 101.04. More serious neurological deficits (paraparesis, paraplegia)
are to be evaluated under the criteria in 111.00ff.
F. Major joints refers to the
major peripheral joints, which are the hip, knee, shoulder, elbow, wrist-hand, and ankle-foot, as opposed to other peripheral
joints (e.g., the joints of the hand or forefoot) or axial joints (i.e., the joints of the spine.) The wrist and hand are
considered together as one major joint, as are the ankle and foot. Since only the ankle joint, which consists of the juncture
of the bones of the lower leg (tibia and fibula) with the hindfoot (tarsal bones), but not the forefoot, is crucial to weight
bearing, the ankle and foot are considered separately in evaluating weight bearing.
Measurements of joint motion are based on the techniques described in the chapter on the extremities, spine, and pelvis in
the current edition of the "Guides to the Evaluation of Permanent Impairment" published by the American Medical
Musculoskeletal impairments frequently improve with time or respond to treatment. Therefore, a longitudinal clinical record
is generally important for the assessment of severity and expected duration of an impairment unless the child is a newborn
or the claim can be decided favorably on the basis of the current evidence.
of medically prescribed treatment and response. Many children, especially those who have listing-level impairments, will have
received the benefit of medically prescribed treatment. Whenever evidence of such treatment is available it must be considered.
3. When there is no record of ongoing treatment. Some children will not have received ongoing
treatment or have an ongoing relationship with the medical community despite the existence of a severe impairment(s). In such
cases, evaluation will be made on the basis of the current objective medical evidence and other available evidence, taking
into consideration the child's medical history, symptoms, and medical source opinions. Even though a child who does not
receive treatment may not be able to show an impairment that meets the criteria of one of the musculoskeletal listings, the
child may have an impairment(s) that is either medically or, in the case of a claim for benefits under part 416 of this
chapter, functionally equivalent in severity to one of the listed impairments.
Evaluation when the criteria of a musculoskeletal listing are not met. These listings are only examples of common musculoskeletal
disorders that are severe enough to find a child disabled. Therefore, in any case in which a child has a medically determinable
impairment that is not listed, an impairment that does not meet the requirements of a listing, or a combination of impairments
no one of which meets the requirements of a listing, we will consider whether the child's impairment(s) is medically or,
in the case of a claim for benefits under part 416 of this chapter, functionally equivalent in severity to the criteria
of a listing. (See §§ 404.1526, 416.926, and 416.926a.)
Individuals with claims for benefits under
part 404, who have an impairment(s) with a level of severity that does not meet or equal the criteria of the musculoskeletal
listings may or may not have the RFC that would enable them to engage in substantial gainful activity. Evaluation of the impairment(s)
of these individuals should proceed through the final steps of the sequential evaluation process in § 404.1520 (or,
as appropriate, the steps in the medical improvement review standard in § 404.1594).
I. Effects of treatment.
1. General. Treatments for musculoskeletal
disorders may have beneficial effects or adverse side effects. Therefore, medical treatment (including surgical treatment)
must be considered in terms of its effectiveness in ameliorating the signs, symptoms, and laboratory abnormalities of the
disorder, and in terms of any side effects that may further limit the child.
to treatment. Response to treatment and adverse consequences of treatment may vary widely. For example, a pain medication
may relieve a child's pain completely, partially, or not at all. It may also result in adverse effects, e.g., drowsiness,
dizziness, or disorientation, that compromise the child's ability to function. Therefore, each case must be considered
on an individual basis, and include consideration of the effects of treatment on the child's ability to function.
3. Documentation. A specific description of the drugs or treatment given (including surgery),
dosage, frequency of administration, and a description of the complications or response to treatment should be obtained. The
effects of treatment may be temporary or long-term. As such, the finding regarding the impact of treatment must be based on
a sufficient period of treatment to permit proper consideration or judgment about future functioning.
J. Orthotic, prosthetic, or assistive devices.
1. General. Consistent
with clinical practice, children with musculoskeletal impairments may be examined with and without the use of any orthotic,
prosthetic, or assistive devices as explained in this section.
2. Orthotic devices.
Examination should be with the orthotic device in place and should include an evaluation of the child's maximum ability
to function effectively with the orthosis. It is unnecessary to routinely evaluate the child's ability to function without
the orthosis in place. If the child has difficulty with, or is unable to use, the orthotic device, the medical basis for the
difficulty should be documented. In such cases, if the impairment involves a lower extremity or extremities, the examination
should include information on the child's ability to ambulate effectively without the device in place unless contraindicated
by the medical judgment of a physician who has treated or examined the child.
Prosthetic devices. Examination should be with the prosthetic device in place. In amputations involving a lower extremity
or extremities, it is unnecessary to evaluate the child's ability to walk without the prosthesis in place. However, the
child's medical ability to use a prosthesis to ambulate effectively, as defined in 101.00B2b, should be evaluated. The
condition of the stump should be evaluated without the prosthesis in place.
assistive devices. When a child with an impairment involving a lower extremity or extremities uses a hand-held assistive device,
such as a cane, crutch or walker, examination should be with and without the use of the assistive device unless contraindicated
by the medical judgment of a physician who has treated or examined the child. The child's ability to ambulate with and
without the device provides information as to whether, or the extent to which, the child is able to ambulate without assistance.
The medical basis for the use of any assistive device (e.g., instability, weakness) should be documented. The requirement
to use a hand-held assistive device may also impact on the child's functional capacity by virtue of the fact that one
or both upper extremities are not available for such activities as lifting, carrying, pushing, and pulling.
K. Disorders of the spine, listed in 101.04, result in limitations because of distortion of the bony and ligamentous
architecture of the spine and associated impingement on nerve roots (including the cauda equina) or spinal cord. Such impingement
on nerve tissue may result from a herniated nucleus pulposus or other miscellaneous conditions. Neurological abnormalities
resulting from these disorders are to be evaluated by referral to the neurological listings in 111.00ff, as appropriate. (See
also 101.00B and E.)
1. Herniated nucleus pulposus is a disorder frequently associated
with the impingement of a nerve root, but occurs infrequently in children. Nerve root compression results in a specific neuro-anatomic
distribution of symptoms and signs depending upon the nerve root(s) compromised.
Other miscellaneous conditions that may cause weakness of the lower extremities, sensory changes, areflexia, trophic ulceration,
bladder or bowel incontinence, and that should be evaluated under 101.04 include, but are not limited to, lysosomal disorders,
metabolic disorders, vertebral osteomyelitis, vertebral fractures and achondroplasia. Disorders such as spinal dysrhaphism,
(e.g., spina bifida) diastematomyelia, and tethered cord syndrome may also cause such abnormalities. In these cases, there
may be gait difficulty and deformity of the lower extremities based on neurological abnormalities, and the neurological effects
are to be evaluated under the criteria in 111.00ff.
L. Abnormal curvatures of the
spine. Abnormal curvatures of the spine (specifically, scoliosis, kyphosis and kyphoscoliosis) can result in impaired ambulation,
but may also adversely affect functioning in body systems other than the musculoskeletal system. For example, a child's
ability to breathe may be affected; there may be cardiac difficulties (e.g., impaired myocardial function); or there may be
disfigurement resulting in withdrawal or isolation. When there is impaired ambulation, evaluation of equivalence may be made
by reference to 114.09A.
When the abnormal curvature of the spine results in symptoms related to fixation of the
dorsolumbar or cervical spine, evaluation of equivalence may be made by reference to 114.09B. When there is respiratory or
cardiac involvement or an associated mental disorder, evaluation may be made under 103.00ff, 104.00ff, or 112.00ff, as appropriate.
Other consequences should be evaluated according to the listing for the affected body system.
M. Under continuing surgical management, as used in 101.07 and 101.08, refers to surgical procedures and any
other associated treatments related to the efforts directed toward the salvage or restoration of functional use of the affected
part. It may include such factors as post-surgical procedures, surgical complications, infections, or other medical complications,
related illnesses, or related treatments that delay the child's attainment of maximum benefit from therapy. When burns
are not under continuing surgical management, see 108.00F.
N. After maximum benefit
from therapy has been achieved in situations involving fractures of an upper extremity (101.07), or soft tissue injuries (101.08),
i.e., there have been no significant changes in physical findings or on appropriate medically acceptable imaging for any 6-month
period after the last definitive surgical procedure or other medical intervention, evaluation must be made on the basis of
the demonstrable residuals, if any. A finding that 101.07 or 101.08 is met must be based on a consideration of the symptoms,
signs, and laboratory findings associated with recent or anticipated surgical procedures and the resulting recuperative periods,
including any related medical complications, such as infections, illnesses, and therapies which impede or delay the efforts
toward restoration of function.
Generally, when there has been no surgical or medical intervention for 6 months
after the last definitive surgical procedure, it can be concluded that maximum therapeutic benefit has been reached. Evaluation
at this point must be made on the basis of the demonstrable residual limitations, if any, considering the child's impairment-related
symptoms, signs, and laboratory findings, any residual symptoms, signs, and laboratory findings associated with such surgeries,
complications, and recuperative periods, and other relevant evidence.
O. Major function
of the face and head, for purposes of listing 101.08, relates to impact on any or all of the activities involving vision,
hearing, speech, mastication, and the initiation of the digestive process.
surgical procedures have been performed, documentation should include a copy of the operative notes and available pathology
101.01 Category of Impairments, Musculoskeletal
101.02 Major dysfunction of a joint(s) (due to any cause): Characterized by gross anatomical deformity
(e.g., subluxation, contracture, bony or fibrous ankylosis, instability) and chronic joint pain and stiffness with signs of
limitation of motion or other abnormal motion of the affected joint(s), and findings on appropriate medically acceptable imaging
of joint space narrowing, bony destruction, or ankylosis of the affected joint(s). With:
A. Involvement of one major peripheral weight-bearing joint (i.e., hip, knee, or ankle), resulting in inability
to ambulate effectively, as defined in 101.00B2b;
B. Involvement of one major peripheral joint in each upper extremity (i.e., shoulder, elbow, or wrist-hand),
resulting in inability to perform fine and gross movements effectively, as defined in 101.00B2c.
101.03 Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint, with inability
to ambulate effectively, as defined in 101.00B2b, and return to effective ambulation did not occur, or is not expected to
occur, within 12 months of onset.
101.04 Disorders of the spine (e.g., lysosomal disorders, metabolic disorders, vertebral osteomyelitis,
vertebral fracture, achondroplasia) resulting in compromise of a nerve root (including the cauda equina) or the spinal cord,
with evidence of nerve root compression characterized by neuro-anatomic distribution of pain, limitation of motion of the
spine, motor loss (atrophy with associated muscle weakness or muscle weakness) accompanied by sensory or reflex loss and,
if there is involvement of the lower back, positive straight-leg raising test (sitting and supine).
101.05 Amputation (due to any cause).
A. Both hands;
B. One or both lower extremities at or above the tarsal region, with
stump complications resulting in medical inability to use a prosthetic device to ambulate effectively, as defined in 101.00B2b,
which have lasted or are expected to last for at least 12 months;
C. One hand and one lower extremity at or above the tarsal region, with inability to ambulate effectively, as
defined in 101.00B2b;
or hip disarticulation.
101.06 Fracture of the femur, tibia, pelvis, or one or more of the tarsal bones. With:
A. Solid union not evident on appropriate medically acceptable imaging, and not clinically
B. Inability to ambulate
effectively, as defined in 101.00B2b, and return to effective ambulation did not occur or is not expected to occur within
12 months of onset.
101.07 Fracture of an upper extremity with nonunion of a fracture of the shaft of the humerus, radius,
or ulna, under continuing surgical management, as defined in 101.00M, directed toward restoration of functional use of the
extremity, and such function was not restored or expected to be restored within 12 months of onset.
101.08 Soft tissue injury (e.g., burns) of an upper or lower extremity, trunk, or face and head,
under continuing surgical management, as defined in 101.00M, directed toward the salvage or restoration of major function,
and such major function was not restored or expected to be restored within 12 months of onset. Major function of the
face and head is described in 101.00O.