Most allegations of disability involving musculoskeletal disorders are associated with arthritis. Examples of types of arthritis and diseases that can cause arthritis include the following:

• AIDS • ankylosing spondylitis • autoimmune diseases, such as systemic lupus erythematosus • cancer • infections—bacterial, fungal, or viral • inflammatory bowel diseases, such as ulcerative colitis and regional enteritis (Crohn’s disease) • metabolic diseases, such as gout and pseudogout • osteoarthritis • psoriasis • Reiter’s syndrome, and • rheumatoid arthritis. To the extent that inflammation of soft tissues in joints or the spine is involved, evaluation would be done under the Immune System Listings 14.09 and 114.09. Some musculoskeletal disorders, such as rheumatoid arthritis of joints and ankylosing spondylitis of the spine, can produce both soft tissue inflammation and bony damage. It may be necessary to evaluate such disorders under more than one of the SSA’s listings.

2. T raumatic Damage Most traumatic damage the SSA sees comes from automobile, motorcycle, and industrial accidents. Major trauma may fracture multiple bones, including the spine, rupture organs, amputate limbs, tear away skin and muscle, damage joints, crush or sever the spinal cord with resulting paralysis, or fracture the skull with permanent brain injury

3. Back Pain Most back pain is caused by age-related degenerative processes like degenerative disc disease and arthritis. Other, less common, causes of back pain include inflammatory diseases (ankylosing spondylitis) and cancer (such as breast or prostate cancer) that has spread to the spine. Medical judgment must be used in evaluating each case in regard to severity and chances for improvement.

4. A mputations Amputations can result from trauma itself, or be required as surgery to remove a limb that has been too badly damaged to repair after trauma. Most amputations the SSA sees, however, result from surgery to remove a diseased leg to which adequate blood flow cannot be restored—usually as a consequence of diabetes. Atherosclerosis can also lead to a diseased leg requiring amputation. In these instances, however, modern surgical techniques can often restore blood flow sufficiently to avoid amputation.

5. Other Diseases Several genetic diseases, such as muscular dystrophy, affect muscle strength. Inflammatory muscle diseases, such as polymyositis, can cause muscle weakness but are discussed in Chapter 29. Neurological disorders such as strokes, cerebral palsy, and polio can also cause muscle weakness and are discussed in Chapter 26. Muscle strength also may be decreased by chronic use of drugs such as steroids and alcohol— an added factor in severity that must be considered in all cases.

6. Loss of Function Loss of function is vitally important in determining the extent of disability caused by musculoskeletal disorders. Although a physical examination and x-rays must reveal objective abnormalities, your inability to function, particularly due to pain, fatigue, or other symptoms, is equally as important. Of course, saying that you’re feeling pain or other symptoms if you don’t also have physical abnormalities that would reasonably explain such symptoms may be given little credibility in a disability determination. The SSA needs evidence from your treating doctor to support your disability claim. Unfortunately, a treating doctor’s records often do not contain sufficient details about alleged musculoskeletal disorders for the SSA to make an accurate disability determination.

Loss of function may be due to bone or joint deformity or destruction from any cause; miscellaneous disorders of the spine with or without neurological deficits; amputation; or fractures or soft tissue injuries including burns that require prolonged periods of immobility or convalescence.

a. Pain or Other Symptoms Pain or other symptoms may be an important factor contributing to functional loss. The musculoskeletal listings that include pain or other symptoms among their criteria also include criteria for limitations caused by pain.

b. How the SSA Defines Loss of Function Regardless of the cause of a musculoskeletal impairment, functional loss refers to an (1) inability to walk effectively on a sustained basis, or (2) inability to perform fine and gross movements effectively on a sustained basis. The SSA will consider whether your daily activities are consistent with your doctor’s exam findings, or with a consultative examination. In children, function should always be looked at in terms of what is appropriate for the child’s age. In older teenagers, age-appropriate function can be similar to that of an adult.

7. Diagnosis and Evaluation Diagnosis and evaluation of your musculoskeletal impairments should be appropriately supported by detailed descriptions of your joints, including ranges of motion. Additionally, the report on the condition of your muscles should discuss the presence of any weakness or atrophy. Any abnormal sensation or reflexes, decreased circulation, and laboratory findings should be described. Findings on your x.rays or other appropriate imaging may be used in making a disability determination. Medically acceptable imaging includes: . plain x.ray imaging . computerized axial tomography (CAT scan) . magnetic resonance imaging (MRI) . myelography, and . radionuclear bone scans. The SSA tries to avoid buying expensive tests for you such as MRIs, and will never purchase invasive tests such as myelography. However, such tests can be extremely useful when provided by your treating doctor. Also, if you�fve had any surgical procedures done, be sure your documentation includes a copy of the operative notes and any available pathology reports.

8. Orthotic, Prosthetic, or Assistive Devices If you use an orthosis, the SSA will want your medical exam data to include an evaluation of your maximum ability to function with the orthosis in place. Normally, the SSA will not require that you be evaluated for ability to function without your orthosis. However, if you state that you cannot use an orthosis, the SSA will want the reason documented and your ability to function without it evaluated by a doctor who actually examines you. An exception would be made if the doctor submits a reasonable medical explanation of why you cannot be evaluated without your orthosis.

If you use a prosthesis, the SSA will want you to have a medical exam with the prosthetic device in place. Of course, if you have an amputation, the SSA will not require an evaluation of your ability to walk without a leg prosthesis. However, the SSA will require that the condition of the stump be described. This is important, because some claimants have ulcers, infection, or other problems that can cause short- or long-term problems in wearing the prosthesis. If you use a hand.held assistive device such as a cane, crutch, or walker, you will be examined both with and without the device unless this goes against the medical judgment of a doctor who has treated or examined you. Your ability to walk with and without the device provides information about how well you can ambulate without assistance. The SSA tries to document the medical basis, such as instability of a joint or muscle weakness, to explain why you use an assistive device. The requirements are similar for evaluating children with orthotic, prosthetic, or other devices, except that the evaluation must be done based on age-appropriate expectations for the particular child.

C. Specific Listings and Residual Functional Capacity The listings that follow are in the federal regulations. I have interpreted and commented on them for greater ease of understanding while explaining their requirements. It is impossible to discuss here all of the medical possibilities related to every kind of disorder, and you may need help from your treating doctor to more fully understand how your particular impairment relates to these listings. The discussion of residual functional capacity does not apply to children.

1. L isting 1.02: Major Dysfunction of a Joint (Adults) This listing relates to severe functional loss caused by any type of joint dysfunction, regardless of the specific medical diagnosis. For example, the problem could have been caused by trauma or by any of the many types of arthritis. Trauma resulting from industrial, automobile, and motorcycle accidents accounts for most of the traumatic cases the SSA sees. Severe traumatic bone fracture into a joint space is often followed by post-traumatic degenerative arthritis after the fracture is healed. Inflammatory processes, such as rheumatoid and psoriatic arthritis, can eventually lead to bone destruction and joint deformity if not adequately controlled with treatment. So, by the time gross deformity of a joint is present, there usually has been a joint disorder present for quite some time. a. L isting Level Severity First, the listing requires you to have an obvious (gross) deformity. Possible examples of such deformity are subluxation, contracture, ankylosis, and instability. You must also have a history of chronic joint pain and stiffness, as well as loss of motion or some other kind of abnormal movement. In addition, some type of imaging technique, such as x-rays, must verify the presence of arthritic changes such as joint space narrowing. A particular percentage of joint space narrowing or other abnormality is not required. Once it’s been established that your condition meets the requirements above, your condition must be shown to satisfy A or B, below.

A Involvement of one hip, knee, or ankle joint that results in extreme limitation in your ability to walk. You must be unable to sustain a reasonable walking pace over a sufficient distance to carry out your activities of daily living. You should be unable to travel without a companion’s assistance to and from your job or school. More specifically, some examples of ineffective ambulation given by the SSA include your inability to: • walk without the use of a walker • walk without the use of two crutches or two canes • walk a block at a reasonable pace on rough or uneven surfaces • use standard public transportation • carry out ordinary activities involving walking, such as shopping and banking, and • climb a few steps at a reasonable pace with the use of a single handrail. The listing does not require complete inability to walk in all circumstances. For example, if you can walk about your home without the help of a person or an assistive device, that does not, by itself, mean you cannot qualify under the listing. The requirement is that you have serious difficulty in starting, sustaining, or completing activities. Also, using only one crutch or cane would not necessarily restrict you from qualifying under the listing, provided that your functional limitations are severe enough. In addition, the SSA recognizes that people who cannot walk effectively might be able to stand without assistive devices. Therefore, your ability to stand without assistance would not disqualify you under the listing. B Involvement of one major joint in each upper extremity that results in extreme limitation in your ability to perform fine and gross movements. Major joints are the shoulder, elbow, or hand/wrist.

b. R esidual Functional Capacity In analyzing residual functional capacity, the SSA divides your body in two, analyzing your upper extremities separately from your lower extremities.

i. Upper Extremity Dysfunction The SSA needs information regarding how well you can use your upper extremities—specifically, whether you’re able to push, pull, lift, carry, and grasp objects and do small movements with your fingers (fine manipulations). Note that the use of an assistive device such as a cane ties up the use of an arm and hand. So, if you require a cane to walk, the SSA cannot refer you to jobs requiring that you lift and carry with both arms while walking.

ii. Lower Extremity Dysfunction In evaluating your RFC, the SSA must determine how long you can stand and walk on arthritic joints. Let the SSA know if the arthritis is severe enough that you can’t stand or walk most of a workday—and have your treating doctor provide supporting statements. For the SSA to claim that you can perform light, medium, or heavy work, you must be able to walk or stand six to eight hours a day. Significant arthritis in a major joint of a lower extremity would prevent such standing or walking. Even if your hands and arms are unaffected by the arthritis, you’ll be restricted to sedentary work. If you are older and have a limited education, these restrictions may mean that you’ll be awarded benefits on the basis of the RFC. If you had an arthritic hip, knee, or ankle joint replaced with an artificial one, see the RFC comments under Listing 1.03.

2. L isting 101.02: Major Dysfunction of a Joint (Children) First, the listing requires that the child have an obvious (gross) deformity. Possible examples of such deformity are subluxation, contracture, ankylosis, and instability. The child must also have a history of chronic joint pain and stiffness, as well as loss of motion or some other kind of abnormal movement. In addition, some type of imaging technique, such as xrays, must verify the presence of arthritic changes like joint space narrowing. The child doesn’t need to have any specific percentage of joint space narrowing or other abnormality. Second, once it’s been established that the child’s condition meets the requirements above, the condition must also be shown to satisfy A or B, below.

A Involvement of one hip, knee, or ankle joint that results in extreme limitation in the child’s ability to walk. The child must be unable to sustain a reasonable walking pace over a sufficient distance to be able to carry out age-appropriate activities of daily living. For children who are too young to be expected to walk independently, the SSA considers their function in terms of how well they can perform age-appropriate activities with their lower extremities. 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. Older children would not have the ability to travel without a companion�s assistance to and from a job or school. More specific examples of ineffective ambulation given by the SSA include the older child�fs inability to: . walk without the use of a walker . walk without the use of two crutches or two canes . walk a block at a reasonable, age-appropriate pace on rough or uneven surfaces . use standard public transportation . carry out ordinary age-appropriate activities involving walking, such as shopping and school activities, or . climb a few steps at a reasonable pace with the use of a single handrail. The listing does not require that the child be completely unable to walk in all circumstances. For example, the child�s ability to walk about its home (or short distances at school) without the help of a person or an assistive device does not, in and of itself, mean the child cannot qualify under the listing. The requirement is that the child have serious difficulty in starting, sustaining, or completing activities. Nor would the use of only one crutch or cane necessarily restrict the child from qualifying under the listing, provided that his functional limitations are severe enough. Also, the SSA recognizes that people who cannot walk effectively might nevertheless be able to stand without assistive devices. Therefore, the child’s ability to stand without assistance would not disqualify him or her under the listing.

B Involvement of one major joint in each upper extremity that results in extreme limitation in the child�fs age-appropriate ability to perform fine and gross moFor an older child to use his upper extremities effectively in carrying out age-appropriate activities of daily living, the child must be able to perform age-appropriate functions like reaching, pushing, pulling, grasping, and fingering. Therefore, in older children, examples of inability to effectively perform fine and gross movements include inability to prepare simple meals and feed themselves, inability to take care of personal hygiene, and inability to sort and handle papers or files (depending on which activities are age appropriate). To qualify under part B, it is not necessary that the child be totally unable to use his upper extremities. The requirement is that they have serious difficulty in starting, sustaining, or completing age-appropriate activities.vements. Major joints are the shoulder, elbow, or hand/wrist. For very young children, the SSA will look at how limited they are in their ability to perform age.appropriate activities involving the upper extremities. Determinations of extreme limitation in such children are made by comparison with the limitations for persistent motor dysfunction for infants and young children described in Listing 110.07A.

3. L isting 1.03: Reconstructive Surgery on a Hip, Knee, or Ankle (Including Surgical Arthrodesis of a Joint) (Adults) Reconstructive surgery usually involves placing an artificial joint into a person. An alternative procedure is surgical arthrodesis—fusing an arthritic joint with healthy, living bone to relieve pain and make it more stable. In most cases, reconstructive surgery is successful. Patients are able to put at least partial weight on the joint and walk within a few days, and to put full weight on the joint soon after that. Certainly, walking usually occurs within a year of surgery. Only in cases of surgical failure—such as a loose artificial joint or infection of the bone—is the patient likely to remain unable to walk. Even then, a second operation usually corrects the problem. Your surgeon may try to help you by reporting to the SSA that “recovery will require a year” in the absence of any documented complications. However, the SSA is likely to disregard this kind of statement if the surgeon cannot provide evidence to back it up.

a. L isting Level Severity To qualify, you’ll need to show that reconstructive surgery failed on your hip, knee, or ankle and that you’ll be unable to walk effectively on the joint for at least 12 months. See the discussion under Listing 1.02A regarding how the SSA decides whether walking is ineffective.

b. R esidual Functional Capacity If you had an arthritic hip, knee, or ankle joint replaced with an artificial one, you will still have some limitations. You should not be expected to work in a setting where you�fd be walking on grossly uneven surfaces or climbing or using leg controls more than occasionally. Similarly, you should probably be restricted to no more than light lifting, up to 20 pounds. If your artificial joint has problems or you have had artificial joint replacements in multiple major weight.bearing joints, your RFC rating should not be higher than sedentary work. However, the SSA has no official policies in regard to how much a person with a prosthetic joint can lift and carry. Of course, if you are restricted to sedentary work because of an inability to walk over two hours daily, you wouldn�ft have to lift over ten pounds anyway. If you have a solid arthrodesis in a joint, the SSA could give you an RFC for as high as medium work. Remember that an arthrodesis, unlike a prosthesis, will fix a joint so that it cannot bend. This can limit you from certain kinds of work-related activities. For example, a fused knee joint will prevent use of leg controls with that leg. It will also rule out various activities such as squatting, kneeling, and climbing anything more than a slight incline.

4. L isting 101.03: Reconstructive Surgery on a Hip, Knee, or Ankle (Including Surgical Arthrodesis of a Joint) (Children)

a. L isting Level Severity Failure of reconstructive surgery of the child’s hip, knee, or ankle with an inability to walk effectively on the joint expected to last at least 12 months. See the discussion under Listing 101.02 regarding how the SSA decides whether walking is ineffective in a child.

5. L isting 1.04: Disorders of the Spine (Adults) This listing deals with various spinal disorders common in adults, such as:
• herniated nucleus pulposis (HNP) • spinal arachnoiditis • spinal stenosis • osteoarthritis • degenerative disc disease • facet arthritis, and • vertebral fracture. (Note that inflammatory disorders involving the spine, known as spondyloarthropathies, are evaluated under Listing 14.09. Examples of disorders that can cause spondyloarthropathy are ankylosing spondylitis and Reiter’s syndrome.) The SSA requires that your spinal exam include testing your reflexes, sensation, and muscle strength. Additionally, your exam should test your ability to squat and arise, walk on your heels and toes, and bend your back. The presence or absence of muscle spasms in your back should be noted, as this is an objective finding that lends credibility to lower back pain complaints. Weakness, as well as reflexes and sensation, must rationally relate to the nerve root that is compressed. (Specific nerves supply specific muscles and carry sensation from specific areas of skin.) If you have muscle atrophy, there must be measurements of your muscles, documenting the degree to which they have actually gotten smaller. Weakness should be graded on a scale of zero to five. The examining doctor will be asked to add any other relevant observations about you, such as your ability to get on and off an examining table and whether you need help putting on your socks and shoes, or slacks or trousers. The SSA will also evaluate the restrictions on your daily activities. If your treating doctor’s records are incomplete or not current, the SSA will send you for a consultative examination.

A person in really severe pain tries to obtain relief. The SSA will look at how often you go to the doctor for your pain, what your doctor says about the pain, and the medical records showing your history of severe pain. If you have transportation or money problems that limit your ability to obtain the best treatment, make that clear to the SSA. Be aware that the SSA may check such an assertion with your treating doctor. The SSA will look at the types of treatments your doctor has administered or recommended to treat the pain, and at how you responded. The treatments may help indicate the degree of your pain—at least as your doctor has understood it—and show how well you responded. Possible pain treatments include pain relievers, muscle relaxants, physical therapy, braces, epidural steroid injections, transcutaneous electrical nerve stimulators (TENS), biofeedback, psychotherapy, spinal cord electrical stimulators, treatment in special pain clinics, and treatment with radio-frequency fields to damaged pain fibers in the facet joints that connect vertebrae. (See Chapter 5 for more information about pain and other symptoms.) If you have prominent neurological abnormalities, evaluation should also be done under the appropriate neurological listing.

a. L isting Level Severity Once a disorder has been documented, your condition must satisfy either A, B, or C, below. A Evidence of pressure on your spinal nerve root or spinal cord, as evidenced by: • pain • loss of motion in the spine muscle weakness • decreased deep tendon reflexes and sensation, and • an abnormal straight-leg-raising test, if the lower back is involved. This part of the listing is quite difficult to satisfy, as most cases of back pain are not associated with significant neurological abnormalities. B Spinal arachnoiditis, as evidenced by: • confirmation of the disorder by a pathology report of a biopsy, an operative note confirming arachnoiditis, or an appropriate imaging test (myelography, CT scan, or MRI) • severe burning pain, or other abnormal and painful sensation (dyesthesia), and • pain severe enough to require changing your position or posture more than once every two hours. C Lumbar spinal stenosis resulting in pseudoclaudication, as evidenced by: • an appropriate imaging test (myelography, CT scan, or MRI), and • chronic nonradicular pain and weakness that results in your being unable to walk effectively. To read about how the SSA defines being unable to walk effectively, see the discussion under Listing 1.02A.

b. Residual Functional Capacity Most of the work-related limitations for back impairments are for pain caused by sitting or standing for prolonged periods, as well as lifting and bending. The majority of disability claimants the SSA sees for back pain have some osteoarthritis of the spine or degeneration of the intervertebral discs, or have had a single back surgery. They are usually assigned an RFC for medium or light work with occasional bending. They may be granted disability, especially if they are over age 55, have a limited education, and cannot return to their prior work. You should receive an RFC rating for no more than medium work, even lower if you suffer any of the following impairments: • lumbar fusion (bending should be restricted to occasional) • cervical fusion (overhead work should be restricted to occasional) scoliosis of the thoracic or lumbar spine with at least 40º of scoliotic curve • at least 50% compression fracture of a vertebral body • significant spondylolisthesis associated with chronic pain • significant osteoporosis of the spine • significant degenerative disc disease in the cervical or lumbar spine with associated chronic pain • chronic pain after a lumbar or cervical laminectomy, or • significant degenerative arthritis of the spine with associated chronic pain. Some claimants with multiple back surgeries or other severe back problems have so much pain that they cannot do even sedentary work, even though they don’t have severe neurological abnormalities.

6. L isting 101.04: Disorders of the Spine (Children) Arthritis and degenerative disc disease do not occur as often in children as adults. It’s rare, for example, to see a herniated nucleus pulposis or spinal stenosis in a child. Nor is arachnoiditis seen as often in children as in adults. Traumatic fractures may be seen in children as well as adults. However, there are other spinal disorders that the SSA mentions with regard to children, such as: • infection of the spine (vertebral osteomyelitis) • metabolic disorders that weaken the spine • developmental disorders resulting in incomplete or abnormal formation of the spine, or • disorders of spinal curvature (scoliosis, kyphosis, kyphoscoliosis) that may appear alone or in association with some other disorder.

a. L isting Level Severity Actually, a spinal disorder of any cause can qualify under the listing, provided that it produces the required abnormalities. The same kinds of physical examination abnormalities are required as for adults (see adult Listing 1.04A), taking into account the child’s age. If the child has prominent neurological abnormalities, evaluation should also be done under the appropriate neurological lis7. L isting 1.05: Amputation (Adults) Trauma, diabetes mellitus, and atherosclerosis are the most common causes of lower-extremity amputations in adults. Most upper-extremity amputations are related to trauma, such as industrial accidents. However, the cause of the amputation is irrelevant—it is the functional result that matters to SSA. This fact is reflected in the requirements of the listing.ting.

a. L isting Level Severity Once the fact of your amputation has been documented, you must show that your condition satisfies A, B, C or D below. A Amputation of both hands. B Amputation of one or both lower extremities at or above the ankle and an inability to walk effectively, as described in Listing 1.02A. C Amputation of one hand and one lower extremity at or above the ankle, along with an inability to walk effectively, as described in Listing 1.02A.

b. R esidual Functional Capacity Few disability applicants have problems severe enough to qualify for this listing level. But many have some degree of damage to the legs that requires an RFC. These are evaluated case by case, but some of the frequently used RFCs are as follows: • sedentary work for an above-the-knee amputation when you can walk effectively on an artificial leg, or • medium work for a below-the-knee amputation when you can walk effectively on an artificial leg.

8. L isting 101.05: Amputation (Children) In children, the cause of most upper- and lowerextremity amputations is trauma. In some cases, amputation of a limb may be necessary to treat a cancerous tumor, such as an osteosarcoma. Amputations are also done, though rarely, to treat an irreversibly deformed limb. However, the cause of the amputation is irrelevant—it is the functional result that matters to the SSA. This fact is reflected in the requirements of the listing.

9. L isting 1.06: Fracture of the Femur, Tibia, Tarsal Bone, or Pelvis (Adults) The SSA frequently sees applicants with recently broken bones, but many are denied benefits because the breaks are expected to heal well within 12 months. This is true even for people with multiple fractures from automobile or motorcycle accidents. Only in rare cases where an applicant has a history of fractures not healing would the SSA predict that the current fractures would not heal within 12 months. In general, for you to be granted disability on this basis, your fracture would have to remain unhealed for least six months and be likely to remain unhealed for a total of at least 12 months. Lack of healing for six months is not an SSA policy—but as a matter of medical fact, no doctor can reliably assert that the required 12-month duration will be satisfied without first seeing at least six months of failed healing. If your doctor states to the SSA that your fracture will not heal within 12 months, your doctor must provide supporting evidence. A simple letter stating that recovery from your fracture will require at least 12 months, without convincing medical reasons, will be almost useless.

a. L isting Level Severity In addition to documentation of the fracture, your condition must qualify under both A and B, below. A Solid union of your fracture is not evident on appropriate medically acceptable imaging and the fracture is not clinically solid. To satisfy the listing, an x.ray or other imaging test such as an MRI must confirm the failure of your fracture to heal. The x.ray must show that the space of the fracture line is still visible with little or no healing bony callus having formed across it. If the fracture is in a bone that can be evaluated on physical examination, then a doctor must feel or see movement evidence that the bone portions haven�ft reunited. Some healing of the fracture won�ft disqualify you as long as a solid union has not occurred. B An inability to ambulate effectively, with no expectation that you�fll regain your ability to walk effectively within 12 months of onset. The ability to walk effectively is described in Listing 1.02A.

b. R esidual Functional Capacity The extent of your RFC depends on the severity and location of your fractures. That means that the analysis must be highly individualized. The fractures that are most likely to heal poorly are those involving multiple bone fragments, fractures into joint spaces, and fractures complicated by infection. Fractures that occur into joint spaces of the lower extremities may result in post-traumatic arthritis that remains as a permanent impairment after the fracture has healed. Such arthritis in a knee, hip, or ankle can greatly reduce your ability to stand or walk for long periods, or to use leg controls. If you can’t stand or walk for at least six to eight hours daily, your RFC is reduced to sedentary work and your chances of receiving a medical-vocational allowance are greatly increased.

10. L isting 101.06: Fracture of the Femur, Tibia, Tarsal Bone, or Pelvis (Children)

a. L isting Level Severity In addition to documentation of the fracture, the child’s condition must qualify under both A and B, below. A Solid union of the child�fs fracture is not evident on appropriate medically acceptable imaging and the fracture is not clinically solid. To satisfy the listing, an x.ray or other imaging test such as an MRI must confirm the failure of the fracture to heal. The x.ray must show that the space of the fracture line is still visible with little or no healing bony callus having formed across it. If the fracture is in a bone that can be evaluated on physical examination, then a doctor must feel or see movement evidence that the bone portions have failed to reunite. Some healing of the fracture won�ft disqualify the child as long as it hasn�ft healed into a solid union. B An inability to ambulate effectively, with no expectation that the child will regain the ability to walk effectively within 12 months of onset. The ability to walk effectively is described in Listing 101.02A.

11. L isting 1.07: Fractures of an Upper Extremity (Adults) The SSA frequently sees applicants with broken bones, but many are denied because the breaks are expected to heal well within 12 months. This is true even for people with multiple fractures from automobile or motorcycle accidents. Only in rare cases where an applicant has a history of fractures not healing would the SSA predict that the current fractures would not heal within 12 months.

12. L isting 101.07: Fractures of an Upper Extremity (Children)

13. L isting 1.08: Soft Tissue Injuries of an Upper or Lower Extremity, Trunk, or Face (Adults)

Allowances are made under this listing not merely because of the injury itself, but because of the limiting effects of treatment and possible complications. Severe burns are a good example of an impairment that might be evaluated under this listing. A finding that the listing is met is based on a consideration of the symptoms, signs, and laboratory findings associated with recent or anticipated surgical procedures and the resulting recuperative periods. Included in this consideration should be any related medical complications, such as infections, illnesses, and therapies that impede or delay the efforts toward restoration of function in your upper extremity.

14. L isting 101.08: Soft Tissue Injuries of an Upper or Lower Extremity, Trunk, or Face (Children)
See comments under adult Listing 1.08.

15. L isting 100.02: Growth Impairment Related to Known Cause (Children)

Growth impairments linked to a definite medical cause include skeletal abnormalities like dwarfism, infections before birth, fetal alcohol poisoning, genetic abnormalities, diabetes, hypothyroidism, severe heart disease, sickle cell anemia, malnutrition, cystic fibrosis, kidney failure, or other severe chronic diseases. Children who are small because their parents are small are not considered to have a growth impairment.

16. L isting 100.03: Growth Impairment of Unknown Cause (Children)
Only children with growth impairments not related to some known medical disorder are evaluated under this listing. Part A is similar to part A in Listing 100.02, except that a greater fall in percentile ranking for height is required. Part B requires x-ray verification that the age of the child’s bones is far below that normally expected for her age. This should be done by a doctor experienced in interpreting such x-rays—a radiologist. If the child’s epiphyses (bone growth centers) are “closed,” then they are no longer active and the child’s growth has stopped. Such closure of the epiphyses is normal as a person becomes an adult and growth stops. In older children when the epiphyses have already closed at the time of disability determination, bone age determination can’t be done and this listing cannot be used. If several height measurements are not available when the child applies for disability, the SSA will hold the claim