TN 25 (04-19)
101.00 Musculoskeletal System (Effective Date 02/19/02)
A. Disorders of the musculoskeletal system may result from hereditary, congenital, or acquired pathologic processes. Impairments
may result from infections, 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. The provisions
of 101.02 and 101.03 notwithstanding, inflammatory arthritis is evaluated under 114.09
(see 114.0D6). We evaluate impairments with neurological causes under 111.00, as appropriate.
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 112.00 ff
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 101.05 C is an exception
to this general definition because the child has the use of only one upper extremity
due to amputation of a hand.)
(2) 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
c. What we mean by inability to perform fine and gross movements
(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.
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 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 age.
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 111.00 ff.
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 child is a newborn or
the claim can be decided favorably on the basis of the current evidence.
2. Documentation 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.
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 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
2. Response 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.
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 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.
4. Hand-held 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, spinal stenosis, arachnoiditis, or other miscellaneous conditions.
Such impingement on nerve tissue may result from a herniated nucleus pulposus, spinal
stenosis, arachnoiditis, or other miscellaneous conditions.
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 101.04.
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 101.04
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 111.00.
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 114.09
A. 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 114.09C. When there is respiratory or cardiac involvement or an associated mental
disorder, evaluation may be made under 103.00 ff, 104.00 ff, or 112.00 ff, as appropriate.
Other consequences should be evaluated according to the listing for the affected body
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
P. When 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 101.00 B2b (See DI
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 101.00 B2c.
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 101.00 B2b, which have lasted or are expected to last for at least 12
C. One hand and one lower extremity at or above the tarsal region, with inability
to ambulate effectively, as defined in 101.00 B2b;
D. Hemipelvectomy or hip disarticulation.
101.06 Fracture of the femur, tibia, pelvis, or one or more of the tarsal
A. Solid union not evident on appropriate medically acceptable imaging, and not clinically
B. Inability to ambulate effectively, as defined in 101.00 B2b, 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 101.00 M, 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 101.00 M, 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.