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 may result in loss of function because
of inflammatory peripheral joint or axial arthritis or sequelae, or because of extra-articular features, see 14.00B6. Impairments
with neurological causes are to be evaluated under 11.00ff.
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
impairment. 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 12.00ff are to be used. We will determine whether an individual 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 individual's ability to perform the specific activities listed as examples
in 1.00B2b(2) and 1.00B2c.
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(s) that interferes very seriously with the individual's ability to independently initiate,
sustain, or complete activities. Ineffective ambulation is defined generally as having insufficient lower extremity functioning
(see 1.00J) to permit independent ambulation without the use of a hand-held assistive device(s) that limits the functioning
of both upper extremities. (Listing 1.05C is an exception to this general definition because the individual has the use
of only one upper extremity due to amputation of a hand.)
(2) To ambulate effectively,
individuals must be capable of sustaining a reasonable walking pace over a sufficient distance to be able to carry out activities
of daily living. They must have the ability to travel without companion assistance to and from a place of employment or school.
Therefore, examples of ineffective ambulation 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 routine ambulatory activities, such as shopping and banking,
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 one's home 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. Inability
to perform fine and gross movements effectively means an extreme loss of function of both upper extremities; i.e., an impairment(s)
that interferes very seriously with the individual's ability to independently initiate, sustain, or complete activities.
To use their upper extremities effectively, individuals must be capable of sustaining such functions as reaching, pushing,
pulling, grasping, and fingering to be able to carry out activities of daily living. Therefore, 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, the inability to sort and handle papers or files, and the inability to place
files in a file cabinet at or above waist level.
d. 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 an individual's ability 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
individual'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 chapte
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
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.
Consideration of electrodiagnostic procedures. Electrodiagnostic procedures may be useful in establishing the clinical diagnosis,
but do not constitute alternative criteria to the requirements of 1.04.
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 individual'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 individual's daily activities.
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 individual 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.
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 1.04. More serious
neurological deficits (paraparesis, paraplegia) are to be evaluated under the criteria in 11.00ff.
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
G. 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 Association.
1. General. 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 claim can be decided favorably on the basis of the current evidence.
Documentation of medically prescribed treatment and response. Many individuals, 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
3. When there is no record of ongoing treatment. Some individuals
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 individual's medical history, symptoms, and medical source opinions.
Even though an individual who does not receive treatment may not be able to show an impairment that meets the criteria of
one of the musculoskeletal listings, the individual may have an impairment(s) equivalent in severity to one of the listed
impairments or be disabled based on consideration of his or her residual functional capacity (RFC) and age, education and
4. 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 prevent a person from
engaging in gainful activity. Therefore, in any case in which an individual 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 medical equivalence. (See §§ 404.1526 and 416.926.) Individuals
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
and 416.920 (or, as appropriate, the steps in the medical improvement review standard in §§ 404.1594 and 416.994).
I. Effects of treatment.
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 individual.
2. Response to treatment. Response to treatment and adverse consequences of treatment may
vary widely. For example, a pain medication may relieve an individual's pain completely, partially, or not at all. It
may also result in adverse effects, e.g., drowsiness, dizziness, or disorientation, that compromise the individual's ability
to function. Therefore, each case must be considered on an individual basis, and include consideration of the effects of treatment
on the individual'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, individuals 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 individual's maximum ability to function effectively with the orthosis. It is unnecessary to routinely evaluate
the individual's ability to function without the orthosis in place. If the individual 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 individual'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
3. 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 individual's ability
to walk without the prosthesis in place. However, the individual's medical ability to use a prosthesis to ambulate effectively,
as defined in 1.00B2b, should be evaluated. The condition of the stump should be evaluated without the prosthesis in place.
4. Hand-held assistive devices. When an individual 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 individual. The individual's ability to ambulate with and without the device provides information as to whether, or
the extent to which, the individual 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 individual'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 1.04, 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, spinal stenosis, arachnoiditis, or other miscellaneous conditions. Neurological abnormalities
resulting from these disorders are to be evaluated by referral to the neurological listings in 11.00ff, as appropriate. (See
also 1.00B and E.)
1. Herniated nucleus pulposus is a disorder frequently associated
with the impingement of a nerve root. Nerve root compression results in a specific neuro-anatomic distribution of symptoms
and signs depending upon the nerve root(s) compromised.
2. Spinal arachnoiditis.
a. General. Spinal arachnoiditis is a condition characterized by adhesive thickening of
the arachnoid which may cause intermittent ill-defined burning pain and sensory dysesthesia, and may cause neurogenic bladder
or bowel incontinence when the cauda equina is involved.
b. Documentation. Although
the cause of spinal arachnoiditis is not always clear, it may be associated with chronic compression or irritation of nerve
roots (including the cauda equina) or the spinal cord. For example, there may be evidence of spinal stenosis, or a history
of spinal trauma or meningitis. Diagnosis must be confirmed at the time of surgery by gross description, microscopic examination
of biopsied tissue, or by findings on appropriate medically acceptable imaging. Arachnoiditis is sometimes used as a diagnosis
when such a diagnosis is unsupported by clinical or laboratory findings. Therefore, care must be taken to ensure that the
diagnosis is documented as described in 1.04B. Individuals with arachnoiditis, particularly when it involves the lumbosacral
spine, are generally unable to sustain any given position or posture for more than a short period of time due to pain.
3. Lumbar spinal stenosis is a condition that may occur in association with degenerative
processes, or as a result of a congenital anomaly or trauma, or in association with Paget's disease of the bone. Pseudoclaudication,
which may result from lumbar spinal stenosis, is manifested as pain and weakness, and may impair ambulation. Symptoms are
usually bilateral, in the low back, buttocks, or thighs, although some individuals may experience only leg pain and, in a
few cases, the leg pain may be unilateral. The pain generally does not follow a particular neuro-anatomical distribution,
i.e., it is distinctly different from the radicular type of pain seen with a herniated intervertebral disc, is often of a
dull, aching quality, which may be described as "discomfort" or an "unpleasant sensation," or may be of
even greater severity, usually in the low back and radiating into the buttocks region bilaterally. The pain is provoked by
extension of the spine, as in walking or merely standing, but is reduced by leaning forward. The distance the individual has
to walk before the pain comes on may vary. Pseudoclaudication differs from peripheral vascular claudication in several ways.
Pedal pulses and Doppler examinations are unaffected by pseudoclaudication. Leg pain resulting from peripheral vascular claudication
involves the calves, and the leg pain in vascular claudication is ordinarily more severe than any back pain that may also
be present. An individual with vascular claudication will experience pain after walking the same distance time after time,
and the pain will be relieved quickly when walking stops.
4. 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 1.04 include, but are not limited to,
osteoarthritis, degenerative disc disease, facet arthritis, and vertebral fracture. 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 11.00ff.
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, an individual'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 14.09A. 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 14.09B. When there is respiratory or cardiac involvement
or an associated mental disorder, evaluation may be made under 3.00ff, 4.00ff, or 12.00ff, as appropriate. Other consequences
should be evaluated according to the listing for the affected body system.
continuing surgical management, as used in 1.07 and 1.08, 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 individual's attainment of maximum benefit from therapy. When burns are not under
continuing surgical management, see 8.00F.
N. After maximum benefit from therapy
has been achieved in situations involving fractures of an upper extremity (1.07), or soft tissue injuries (1.08), 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 1.07 or 1.08 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 individual'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 1.08, relates to impact on any or all of the activities involving vision, hearing,
speech, mastication, and the initiation of the digestive process.
P. When surgical
procedures have been performed, documentation should include a copy of the operative notes and available pathology reports.
Q. Effects of obesity. Obesity is a medically determinable impairment that is often associated
with disturbance of the musculoskeletal system, and disturbance of this system can be a major cause of disability in individuals
with obesity. The combined effects of obesity with musculoskeletal impairments can be greater than the effects of each of
the impairments considered separately. Therefore, when determining whether an individual with obesity has a listing-level
impairment or combination of impairments, and when assessing a claim at other steps of the sequential evaluation process,
including when assessing an individual's residual functional capacity, adjudicators must consider any additional and cumulative
effects of obesity.
1.01 Category of Impairments, Musculoskeletal
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:
of one major peripheral weight-bearing joint (i.e., hip, knee, or ankle), resulting in inability to ambulate effectively,
as defined in 1.00B2b;
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 1.00B2c.
surgery or surgical arthrodesis of a major weight- bearing joint, with inability to ambulate effectively,
as defined in 1.00B2b, and return to effective ambulation did not occur, or is not expected to occur, within 12 months
1.04 Disorders of the spine (e.g., herniated nucleus pulposus, spinal arachnoiditis,
spinal stenosis, osteoarthritis, degenerative disc disease, facet arthritis, vertebral fracture), 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);
B. Spinal arachnoiditis, confirmed by an operative note or pathology report of tissue biopsy,
or by appropriate medically acceptable imaging, manifested by severe burning or painful dysesthesia, resulting in the need
for changes in position or posture more than once every 2 hours;
C. Lumbar spinal stenosis resulting in pseudoclaudication, established by findings on appropriate medically acceptable
imaging, manifested by chronic nonradicular pain and weakness, and resulting in inability to ambulate effectively, as defined
1.05 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 1.00B2b, which have lasted or are expected to
last for at least 12 months;
One hand and one lower extremity at or above the tarsal region, with inability to ambulate effectively, as defined in 1.00B2b;
D. Hemipelvectomy or hip disarticulation.
1.06 Fracture of the femur, tibia, pelvis, or one or more of the tarsal bones.
A. Solid union not evident on appropriate medically acceptable imaging and
not clinically solid;
B. Inability to
ambulate effectively, as defined in 1.00B2b, and return to effective ambulation did not occur or is not expected to occur
within 12 months of onset.
1.07 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 1.00M, 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.
1.08 Soft tissue injury (e.g., burns) of
an upper or lower extremity, trunk, or face and head, under continuing surgical management, as defined in 1.00M, 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 1.00.