DI 34121.003 Musculoskeletal Listings From 01/06/86 To 10/24/99
1.00 MUSCULOSKELETAL SYSTEM
A. Loss of function may be due to amputation or deformity. Pain may be an important factor in causing
functional loss, but it must be associated with relevant abnormal signs or laboratory
findings. Evaluations of musculoskeletal impairments should be supported where applicable
by detailed descriptions of the joints, including ranges of motion, condition of the
musculature, sensory or reflex changes, circulatory deficits, and X-ray abnormalities.
B. Disorders of the spine, associated with vertebrogenic disorders as in 1.05C, result in impairment because
of distortion of the bony and ligamentous architecture of the spine or impingement
of a herniated nucleus pulposus or bulging annulus on a nerve root. Impairment caused
by such abnormalities usually improves with time or responds to treatment. Appropriate
abnormal physical findings must be shown to persist on repeated examinations despite
therapy for a reasonable presumption to be made that severe impairment will last for
a continuous period of 12 months. This may occur in cases with unsuccessful prior
Evaluation of the impairment caused by disorders of the spine requires that a clinical
diagnosis of the entity to be evaluated first must be established on the basis of
adequate history, physical examination, and roentgenograms. The specific findings
stated in 1.05C represent the level required for that impairment; these findings,
by themselves, are not intended to represent the basis for establishing the clinical
diagnosis. Furthermore, while neurological examination findings are required, they
are not to be interpreted as a basis for evaluating the magnitude of any neurological
impairment. Neurological impairments are to be evaluated under11.00-11.19.
The history must include a detailed description of the character, location, and radiation
of pain; mechanical factors which incite and relieve pain; prescribed treatment, including
type, dose, and frequency of analgesic; and typical daily activities. Care must be
taken to ascertain that the reported examination findings are consistent with the
individual's daily activities.
There must be a detailed description of the orthopedic and neurologic examination
findings. The findings should include a description of gait, limitation of movement
of the spine given quantitatively in degrees from the vertical position, motor and
sensory abnormalities, muscle spasm, 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 examining table. Inability to walk on heels or toes, to squat, or to arise
from a squatting position, where 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
upper or lower arms) at a stated point above and below the knee or elbow given in
inches or centimeters. A specific description of atrophy of hand muscles is acceptable
without measurements of atrophy, but should include measurements of grip strength.
These physical examination findings must be determined on the basis of objective observations
during the examination and not simply a report of the individual's allegation, e.g.,
he says his leg is weak, numb, etc. Alternative testing methods should be used to
verify the objectivity of the abnormal findings, e.g., a seated straight-leg raising
test in addition to a supine straight-leg raising test. Since abnormal findings may
be intermittent, their continuous presence over a period of time must be established
by a record of ongoing treatment. Neurological abnormalities may not completely subside
after surgical or nonsurgical treatment, or with the passage of time. Residual neurological
abnormalities, which persist after it has been determined clinically or by direct
surgical or other observation that the ongoing or progressive condition is no longer
present, cannot be considered to satisfy the required findings in 1.05C.
Where surgical procedures have been performed, documentation should include a copy
of the operative note and available pathology reports.
Electrodiagnostic procedures and myelography may be useful in establishing the clinical
diagnosis, but do not constitute alternative criteria to the requirements in 1.05C.
C. After maximum benefit from surgical therapy has been achieved in situations involving fractures of an upper extremity (see 1.12),
or soft tissue injuries of a lower or upper extremity (see 1.13), i.e., there have
been no significant changes in physical findings or X-ray findings for any 6-month
period after the last definitive surgical procedure, evaluation should be made on
the basis of demonstrable residuals.
D. Major joints as used herein refer to hip, knee, ankle, shoulder, elbow, or wrist and hand. (Wrist
and hand are considered together as one major joint.)
E. The measurements of joint motion are based on the techniques described in the “Joint Motion Method of Measuring and
Recording,” published by the American Academy of Orthopedic Surgeons in 1965, or the
“Guides to the Evaluation of Permanent Impairment — The Extremities and Back” (Chapter
I); American Medical Association, 1971.
1.01 Category of Impairments, Musculoskeletal
1.02 Active rheumatoid arthritis and other inflammatory arthritis.
With both A and B:
A. History of persistent joint pain, swelling, and tenderness involving multiple major
joints (see 1.00D) and with signs of joint inflammation (swelling and tenderness)
on current physical examination despite prescribed therapy for at least 3 months,
resulting in significant restriction of function of the affected joints, and clinical
activity expected to last at least 12 months; and
B. Corroboration of diagnosis at some point in time by either:
1. Positive serologic test for rheumatoid factor; or
2. Antinuclear antibodies; or
3. Elevated sedimentation rate; or
4. Characteristic histologic changes in biopsy of synovial membrane or subcutaneous
nodule (obtained independent of Social Security disability evaluation).
1.03 Arthritis of a major weight-bearing joint (due to any cause):
With history of persistent joint pain and stiffness with signs of marked limitation
of motion or abnormal motion of the affected joint on current physical examination.
A. Gross anatomical deformity of hip or knee (e.g., subluxation, contracture, bony
or fibrous ankylosis, instability) supported by X-ray evidence of either significant
joint space narrowing or significant bony destruction and markedly limiting ability
to walk and stand; or
B. Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint
and return to full weight-bearing status did not occur, or is not expected to occur,
within 12 months of onset.
1.04 Arthritis of one major joint in each of the upper extremities (due to any cause) :
With history of persistent joint pain and stiffness, signs of marked limitation of
motion of the affected joints on current physical examination, and X-ray evidence
of either significant joint space narrowing or significant bony destruction. With:
A. Abduction and forward flexion (elevation) of both arms at the shoulders, including
scapular motion, restricted to less than 90 degrees; or
B. Gross anatomical deformity (e.g., subluxation, contracture, bony or fibrous ankylosis,
instability, ulnar deviation) and enlargement or effusion of the affected joints.
1.05 Disorders of the spine:
A. Arthritis manifested by ankylosis or fixation of the cervical or dorsolumbar spine
at 30° or more of flexion measured from the neutral position, with X-ray evidence
1. Calcification of the anterior and lateral ligaments; or
2. Bilateral ankylosis of the sacroiliac joints with abnormal apophyseal articulations;
B. Osteoporosis, generalized (established by X-ray) manifested by pain and limitation
of back motion and paravertebral muscle spasm with X-ray evidence of either:
1. Compression fracture of a vertebral body with loss of at least 50 percent of the
estimated height of the vertebral body prior to the compression fracture, with no
intervening direct traumatic episode; or
2. Multiple fractures of vertebrae with no intervening direct traumatic episode; or
C. Other vertebrogenic disorders (e.g., herniated nucleus pulposus, spinal stenosis)
with the following persisting for at least 3 months despite prescribed therapy and
expected to last 12 months. With both 1 and 2:
1. Pain, muscle spasm, and significant limitation of motion in the spine; and
2. Appropriate radicular distribution of significant motor loss with muscle weakness
and sensory and reflex loss.
1.08 Osteomyelitis or septic arthritis (established by X-ray):
A. Located in the pelvis, vertebra, femur, tibia, or a major joint of an upper or
lower extremity, with persistent activity or occurrence of at least two episodes of
acute activity within a 5-month period prior to adjudication, manifested by local
inflammatory, and systemic signs and laboratory findings (e.g., heat, redness, swelling,
leucocytosis, or increased sedimentation rate) and expected to last at least 12 months
despite prescribed therapy; or
B. Multiple localizations and systemic manifestations as in A above.
1.09 Amputation or anatomical deformity of (i.e., loss of major function due to degenerative changes associated with vascular
or neurological deficits, traumatic loss of muscle mass or tendons and X-ray evidence
of bony ankylosis at an unfavorable angle, joint subluxation or instability):
A. Both hands; or
B. Both feet; or
C. One hand and one foot.
1.10 Amputation of one lower extremity (at or above the tarsal region):
A. Hemipelvectomy or hip disarticulation; or
B. Amputation at or above the tarsal region due to peripheral vascular disease or
diabetes mellitus; or
C. Inability to use a prosthesis effectively, without obligatory assistive devices,
due to one of the following:
1. Vascular disease; or
2. Neurological complications (e.g., loss of position sense); or
3. Stump too short or stump complications persistent, or are expected to persist,
for at least 12 months from onset; or
4. Disorder of contralateral lower extremity which markedly limits ability to walk
1.11 Fracture of the femur, tibia, tarsal bone, or pelvis with solid union not evident on X-ray and not clinically solid, when such determination
is feasible, and return to full weight-bearing status did not occur or is not expected
to occur within 12 months of onset.
1.12 Fractures of an upper extremity with nonunion of a fracture of the shaft of the humerus, radius, or ulna under continuing
surgical management directed toward restoration of functional use of the extremity
and such function was not restored or expected to be restored within 12 months after
1.13 Soft tissue injuries of an upper or lower extremity requiring a series of staged surgical procedures within 12 months after onset for
salvage and/or restoration of major function of the extremity, and such major function
was not restored or expected to be restored within 12 months after onset.