TN 3 (04-21)
DI 34121.013 Musculoskeletal Listings from 09/29/16 to 04/01/21
1.00 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 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. The provisions
of 1.02 and 1.03 notwithstanding, inflammatory arthritis is evaluated under 14.09
(see 14.09D6). Impairments with neurological causes are to be evaluated under 11.00.
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 12.00 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 1.05 C 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.
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 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.
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 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 11.00.
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.
2. 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 be considered.
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 work experience.
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
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 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 individual.
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
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.
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 1.04
B. 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 11.00.
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, 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
14.09 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 14.09C. When there is respiratory or cardiac involvement or an associated mental
disorder, evaluation may be made under 3.00, 4.00, or 12.00, as appropriate. Other
consequences should be evaluated according to the listing for the affected body system.
M. Under 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 8.00 F.
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 X 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
P. When surgical procedures have been performed, documentation should include a copy of the operative notes and available pathology
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
1.01 Category of Impairments, Musculoskeletal
1.02 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 1.00 B2b;
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 1.00 B2c.
1.03 Reconstructive surgery or surgical arthrodesis of a major weight-bearing
joint, with inability to ambulate effectively, as defined in 1.00 B2b, and return to effective
ambulation did not occur, or is not expected to occur, within 12 months of onset.
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:
A. 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 in 1.00
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 1.00 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 1.00 B2b;
D. Hemipelvectomy or hip disarticulation.
1.06 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 1.00 B2b, 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 1.00 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.
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 1.00 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 1.00 O.