Chapter 16 Lower Limb

Author-Editors of the Musculoskeletal Chapters 15, 16, and 17 

Publication Date: September 12, 2024

J. Mark Melhorn, MD, FAAOS, FABOS, FACOEM, FACS, FAAHS, FASSH, FIAIME

Co-chair, AMA Guides Editorial Panel
Clinical Associate Professor, Department of Orthopaedics, University of Kansas School of Medicine – Wichita
The Hand Center at Mid-America Orthopedics 
Wichita, KS

Barry Gelinas, MD, DC, FIAIME

Advisor, AMA Guides Editorial Panel
Edmonton, AB, Canada

Subcommittee Upper Limb (Authors)

Barry Gelinas, MD, DC, FIAIME
Advisor, AMA Guides Editorial Panel
Edmonton, AB, Canada

Eric A.K. Mayer MD
North American Spine Society (NASS)
Dell Medical School at the University of Texas
Texas Spine & Scoliosis
Austin, TX

Gary W. Pushkin MD, FAAOS, FIAIME
Cohen & Pushkin MD PA
Baltimore, MD

J. Mark Melhorn, MD, FAAOS, FABOS, FACOEM, FACS, FAAHS, FASSH, FIAIME
Co-chair, AMA Guides Editorial Panel
Clinical Associate Professor, Department of Orthopaedics, University of Kansas School of Medicine – Wichita
The Hand Center at Mid-America Orthopedics
Wichita, KS

Les Kertay PhD, ABPP, FAIME
Ridgeside, TN

Noah Raizman, MD, MFA, FAAOS, FASSH
The Centers for Advanced Orthopaedics
Washington, DC

Steven P. Feinberg, MD, MS, MPH
Adjunct Clinical Professor
Stanford Anesthesiology, Perioperative and Pain Medicine Department
Stanford University - School of Medicine
Stanford, CA
 

Subcommittee Lower Limb (Authors)

Barry Gelinas, MD, DC, FIAIME
Advisor, AMA Guides Editorial Panel
Edmonton, AB, Canada

Christopher R. Brigham, MD
Hilton Head Island, SC

Charles F. Xeller MD, FIAIME
Houston, TX

Charles N. Brooks, MD
Bellevue, WA

Diana Kraemer, MD, FIAIME
Seattle, WA

Douglas W. Martin, MD, FACOEM, FAAFP, FIAIME
Co-chair, AMA Guides Editorial Panel
CNOS Occupational Medicine
Dakota Dunes, SD

J. Mark Melhorn, MD, FAAOS, FABOS, FACOEM, FACS, FAAHS, FASSH, FIAIME
Co-chair, AMA Guides Editorial Panel
Clinical Associate Professor, Department of Orthopaedics, University of Kansas School of Medicine – Wichita
The Hand Center at Mid-America Orthopedics
Wichita, KS

James Underhill, PsyD, MP, FIAIME
Austin, TX

Naomi Shields, MD, FAAOS
Tru Ortho
San Antonio, TX

Subcommittee Spine & Pelvis (Authors)

Barry Gelinas, MD, DC, FIAIME
Advisor, AMA Guides Editorial Panel
Edmonton, AB, Canada

C. Timothy Floyd, MD
Boise, ID

David Bauer, MD
Orthopedic Independent Medical Exams
Richardson, TX

Eugene J Carragee, MD, FAAOS
Professor, Emeritus
Department of Orthopaedic Surgery
Stanford University School of Medicine
Stanford, CA

Marjorie Eskay-Auerbach, MD, JD
Spine Care and Forensic Medicine, PLLC
Tucson, AZ

J. Mark Melhorn, MD, FAAOS, FABOS, FACOEM, FACS, FAAHS, FASSH, FIAIME
Co-chair, AMA Guides Editorial Panel
Clinical Associate Professor, Department of Orthopaedics, University of Kansas School of Medicine – Wichita
The Hand Center at Mid-America Orthopedics
Wichita, KS

Patrick R. Luers MD
Loudon, TN

Randall D. Lea, MD, MPH
Navarre, FL

Subcommittee International

Charl Els, MBChB, FCPsych[SA], MMedPsych (cum laude), Dip.ABAM, MROCC, DESS, ACBOM, FIAIME
Assistant Registrar: Continuing Competence
College of Physicians and Surgeons of Alberta
Edmonton, Alberta, CAN
(moderator)

Subcommittee PROMs

Dan Bruns, PsyD, FAPA
Health Psychology Associates
Greeley, CO
(moderator)

Alex Bruns, MS
Health Psychology Associates
Greeley, CO

Barry Nierenberg, PhD
College of Psychology, Nova Southeastern University
Miami, FL

Kathryn L. Mueller, MD, MPH
University of Colorado School of Medicine, APA and ACOEM
Aurora, CO

Maija Broox Bruzas, PhD
Health Psychology Associates
Greeley, CO

Stephen R. Gillaspy, PhD
American Psychological Association
Oklahoma City, OK

Ravi Prasad, PhD
University of California, Davis School of Medicine
Sacramento, CA

Robert L. Glueckauf, PhD
Dept. of Behavioral Sciences and Social Medicine
College of Medicine, Florida State University
Tallahassee, FL

AMA Guides Panel Members 2023 - 2024

Douglas W. Martin MD, FACOEM, FAAFP, FIAIME
Co-chair
CNOS Occupational Medicine
Dakota Dunes, SD

J. Mark Melhorn, MD, ,FAAOS, FABOS, FACOEM, FACS, FAAHS, FASSH FIAIME
Co-chair
Clinical Associate Professor, Department of Orthopaedics, University of Kansas School of Medicine – Wichita
The Hand Center at Mid-America Orthopedics
Wichita, KS

Steven P. Feinberg, MD, MS, MPH
Adjunct Clinical Professor
Stanford Anesthesiology, Perioperative and Pain Medicine Department
Stanford University - School of Medicine
Stanford, CA

David Gloss, MD
Charleston Area Medical Center
Charleston, West Virginia

Rita Livingston, MD, MPH
Live-Well Medical Consultants, LLC
Savannah, Georgia

Idalia Massa-Carroll, PhD
Colorado Psychological Services
Arvada, Colorado

E. Kano Mayer, MD
Seton Spine & Scoliosis Center
Austin, Texas

Gayla Poling, PhD
National Institute on Deafness and Other Communication Disorders
Bethesda, Maryland

Jeffrey Keller, MD*
American College of Correctional Physicians
Idaho Falls, Idaho

Marilyn Price, MD
Massachusetts General Hospital
Boston, Massachusetts

Noah Raizman, MD
The Centers for Advanced Orthopaedics
Washington, District of Columbia

Michael Saffir, MD
Orthopaedic Specialty Group
Bethany, Connecticut

Robert Sataloff, MD
Drexel University College of Medicine
Philadelphia, Pennsylvania

Advisors to the AMA Guides Editorial Panel (2023 – 2024)

Hon. Shannon Bishop, JD*
Louisiana Office of Workers' Compensation
Harahan, Louisiana

Christopher R. Brigham, MD, MMS
Brigham and Associates, Inc.
Charleston, South Carolina

Barry Gelinas, MD, DC
International Academy of Independent Medical Evaluators
Edmonton, Alberta

Abbie Hudgens, MPA*
Tennessee Bureau of Workers' Compensation
Nashville, Tennessee

Les Kertay, PhD, ABPP
Axiom Medical Consulting, LLC
Chattanooga, Tennessee

Hon. David Langham, JD
Florida Compensation Claims
Tallahassee, Florida

Robert Snyder, MD 
Tennessee Bureau of Workers’ Compensation
Nashville, TN 

* Former member, who was active during 2024 content creation
Former Panel Members (2019 – 2022) 

Helene Fearon, PT
Fearon Physical Therapy, Inc.
Phoenix, Arizona

Robert Goldberg, DO
Beth Israel Hospital & Medical Center
New York, New York

Lylas Mogk, MD
Henry Ford Health System
Detroit, Michigan

Jan Towers, PhD, RN
Frederick Community Health Care for Homeless Clinic and Federally Qualified Health Center
Biglerville, Pennsylvania

Contributors (Reviewers)

For transparency, accountability and acknowledgement of contributions, reviewer’s names and affiliations are listed below in alphabetical order.

Alexis Rojas, PhD
University of Florida College of Medicine
Jacksonville, FL

Amy Lemley, JD
Foulston Siefkin LLP
Wichita, KS

Annette S. Kluck, PhD
The University of Mississippi
Oxford, MS

Arjena Valis Palacios Reese, MS
Nova Southeastern University
Miami, FL

Arthur E. Rhodes, MD
Devaughn James Injury Lawyers
Wichita, KS

Azadeh Farokhi, MD, MPH, MOH
Washington State Labor & Industries
Tumwater, WA

Barbara Ward-Zimmerman, PhD
Society for Health Psychology
Glastonbury, CT

Barry Gelinas, MD, DC
Advisor, AMA Guides Editorial Panel
Edmonton, CA

Behrooz Broukhim, MD
North Hollywood, CA

Ben Young, MD
Mid-American Orthopedics
Wichita, KS

Bill Townsley II, JD
Flesson, Gooing, Coulson & Kitch LLI
Wichita, KS

Brian Filips, JD
James H. Brown & Associates
Edmonton, Alberta, CAN

Brian S. Wilson, DC, MHA
Director of Medical and Health Services Research, Office of Chief Medical Officer
Ohio Bureau of Workers’ Compensation
Columbus, OH

Bruce Boyer, BA Psy
Western Washington University
Bellingham, WA

Christopher R. Brigham, MD, MMS
Brigham and Associates, Inc.
Charleston, South Carolina

Chris Wong, MD
Orthopaedic Associates of South Broward
Hollywood, CA

Christopher Kauffman, MD
North American Spine Society
Nashville, TN

Clifford K H Lau, MD, FAAOS
Honolulu, HI

D’anna Sydow, MS
Nova Southeastern University
Miami, FL

David Huculak, JD
James H. Brown & Associates
Edmonton, Alberta, CAN

David Hufford, MD
Mid-America Orthopedics 
Wichita, KS

David Linklater, MD
WCB Alberta
Edmonton, Alberta, CAN

Descatha Alexis, MD, PhD
Univ Angers Inserm/CHU Angers/Hofstra Northwell
Angers, France

Dong-Sik Park, MD
Korean Academy of Independent Medical Examiners
Seoul, South Korea

Doug Shepherd, MD
Utah Labor Commission Industrial Accidents
Layton, UT

Charl Els, MBChB, FCPsych[SA], MMedPsych(cum laude), Dip.ABAM, MROCC, DESS, ACBOM, FIAIME
Assistant Registrar: Continuing Competence
College of Physicians and Surgeons of Alberta
Edmonton, Alberta, CAN

Edward D. Heath Jr, JD
Law Office of Edward D. Heath, Jr.
Wichita, KS

Emily Jayne Ross, PhD
University of Miami Miller School of Medicine
Miami, FL

Geert Lammens, MD
Geert Lammens Medische Expertises
Ghent, Belgium

Glenn Pfefer MD, FAAOS
Professor Cedars-Sinai, Orthopaedics
Los Angeles, CA

Harold Hoffman, MD
Occupational Medicine, University of Alberta 
Edmonton, Alberta, CAN

Harvey Hanel
North Dakota Workforce Safety & Insurance
Bismarck, ND

Ian Blair Fries, MD
Bone, Spine & Hand Surgery, Chartered
Brick, NJ

Jennifer H. Christian, MD, MPH
Alliance for Bridging Health & Work
Wayland, MA

Jessica Flori, PhD
University of Connecticut School of Medicine
Farmington, CT

John Babb, MS
Mid-America Orthopedics 
Wichita, KS

John Hopkins, MD, PhD
Preventative Medicine Research Center
Dallas, TX

Jolene F. Rohde 
North Dakota Workforce Safety & Insurance
Bismarck, ND

Jon Morgan, DPM
Mid-America Orthopedics
Wichita, KS

Jonathan Voegeli, JD
Slape & Howard, Chtd
Wichita, KS

Jorgia Wilson, MS
Nova Southeastern University
Fort Lauderdale, FL

Joshua Paredes, BS
Florida State University
Tallahassee, FL

Hon. Bruce Moore, JD
Kansas Department of Labor
Division of Workers Compensation
Salina, KS

Julia M. Iannucci, PsyD
Nova Southeastern University
Miami, FL

Justin Strickland, MD
Mid-America Orthopedics
Wichita, KS

Kara Jackson Schroeder, MS
Nova Southeastern University
Miami, FL

Kelly Griffin, MA, MS
Nova Southeastern University
Fort Lauderdale, FL

Lawrence T. Donovan, DO
Naples, FL

Lora L. Black, PhD, MPH
The Ohio State University Wexner Medical Center
Columbus, OH

Mark S. Williams
The Hartford
Portland, ME

Maryana Kravtsenyuk, MD, MSc, FRCPC
University of Toronto, University of Alberta
Northern Ontario School of Medicine
Toronto, ON, CAN

Merita Ismajli Marku, MD
Skopje, North Macedonia

Michel Daigle, MD, FAAOS, FRCS, AOQ, ASSH
St-Bruno, QC, CAN

Michael Snyder, JD
Snider & Seiwert, LLC Law Firm
Wichita, KS

Michelle M. Langer, PhD
Northwestern University
Chicago, IL

Morgan Young, DC
Washington State Department of Labor and Industries 
Tacoma, WA

Nan E. Rothrock, PhD
Northwestern University
Chicago, IL

Nina Lucas, MD, CCFP
Halifax, Nova Scotia, CAN

Noelle Mastrili, PhD
Rosalind Franklin University of Medicine and Science
North Chicago, IL

Olivia L. Campbell, PsyD
Spalding University, School of Professional Psychology
Louisville, KY

Pat Do, MD
Mid-America Orthopedics 
Wichita, KS

Patrick A. Turner, JD
Devaughn James Injury Lawyers 
Wichita, KS

Phil Slape, JD
Slape & Howard, Chtd.
Wichita, KS

Philo F. Willetts, Jr., MD
Westerly, RI

Quentin Durand-Moreau, MD, Med
University of Alberta – Division of Preventative Medicine
Edmonton, Alberta, CAN

Raymond Earl Peeples Jr., MD 
Peeples Medical Legal Consulting LLC
Little Rock, AK

Richard Strain, MD
Broward Health Medical Center
Ft. Lauderdale, FL

Ron Wilcox, DC 
Morgan Young Washington
Tumwater, WA

Ryan W. Livermore, MD
Mid-America Orthopedics 
Wichita, KS

Sang-Gu Lee, MD
Naeun Hospital Spine Center
Korean Academy of Independent Medical Examiners
Seoul, South Korea

Scott S. Porter, PhD
Saible Neuropsychology, LLC
Petersburg, FL

Sebastian Straube, BM BcH, MA (Oxon), DPhil
University of Alberta, Department of Medicine
Edmonton, Alberta, CAN

Shawn Uraine, MD
IAIME
Loma Linda, CA

Stanley G. Andeell, JD
Foulston Siefkin LLP
Wichita, KS

Steven Howell, MD
Kansas Orthopaedic Center
Wichita, KS

Sydney Black, PsyD
Spalding University, School of Professional Psychology, St Elizabeth Physicians 
Louisville, KY

Talaib Rajwani, MD, PhD
Edmonton, Alberta, CAN

Tarun Bhargava, MD
Mid-America Orthopedics 
Wichita, KS

Timothy E. Doerr, MD
Idaho Medical Exams
Eagle, ID

Tom Mayer, MD
Pride 
Dallas, TX

Victoria Cho, MD
WCB Alberta
Edmonton, Alberta, CAN

William J. Sullivan, MD
Aurora, CO

X. J. Ethan Moses, MD, MPH, FACOEM
Colorado Division of Worker’s Compensation
Denver, CO

William Messamore, MD
Kansas Orthopaedic Center
Wichita, KS

Provided Public Comments
Abby Cheng
Adi Renbaum
Amanda Trimpey
American Academy of Physical Medicine and Rehabilitation (AAPM&R)
American Psychological Association
Ashley Maleki
Benjamin Eric Kaplan
Bill Gallagher
Brian M Shelley
Brian Shelley
Caswell Nkuna
Catherine Jeakle Hill
Chaim Rogozinski
Chris Patton
Chris Stewart
Christopher John Standaert
Dan Bruns
David Bauer
Diana Kraemer
Dorian Kenleigh
Elaine Leighton
Emmy Ho
Ernst van den Doel
Eva Pacheco
Frank Salvi
Geert Pieter Lammens
Glen Seidman
Glen Seidman
James B. Talmage (TBWC)
James L. Williams (IAIME)
Jeffrey Scott
Jim Steihl
Joanne Willer
John Hopkins
Jolene Rohde
Jonathan Dunne
Josh Kerr
Kavitha Moturi
Keith L. Blankenship
Kevin Park
Leslie Narramore
Maria Buscemi
Martha Luevano
Matthew Gold
Michael Hisey
Millie Suk 
Mohammad Eman
Pam Vanderbilt
Patrick Luers
Patti Vaughn
Prakash Jayabalan
Rahul Bhala
Rebecca Bowen
Richard Rozenswiag 
Rick Wickstrom
Salim Esmail
Sarah Cartagena
Stephen Mandel
Steve Johnson
Tiffany Knowlton
Timothy R Lubenow MD
Tom Stanley
Travis Colt
Vikki Stefans
William Brady
William F Hefley, Jr
William Gallagher

Registered Attendees for Public Web Access
Barrie Ross
Barry Markman
Bill Gallagher
Brian M Shelley
Cary Ginter
Chris Voegele
David Bauer
David Hufford
DC Schainholz
Diana Kraemer
Eva Pacheco
Gary Pushkin
James Underhill
John Hopkins
Jolene Rohde
Kathryn Mueller
Manijeh Berenji
Matthew Gold
Naomi Shields
Sanjeev Batra
Sarah White
Tsun Ming Cheng

Non-Registered Attendees for Public Web Access
The panel extends its gratitude to all individuals and organizations who provided comments during the public access period as non-registered attendees.
 

Table 16-19: DBI Table Toe(s)/Foot/Ankle Impairment

Table 16-20: DBI Table Knee Impairment

Table 16-21: DBI Table Hip Impairment

Table 16-23f: DBI Table Toe(s) Digital Nerve Sensory Impairment

Table 16-23h: DBI Table Sensory-Only Peripheral Nerve Impairment

Table 16-23i: DBI Table Peripheral Nerve and Entrapment Neuropathy Impairment

Table 16-23j: DBI Table 16-23j Lumbosacral Plexus Impairment

Table 16-25: Amputation Impairment Lower Limb

Table 16-26: DBI Table Vascular Impairment

Table 16-27: DBI Table CRPS Impairment

Table 16-19: DBI Table Toe(s)/Foot/Ankle Impairment

• 16-19-00 Confirmed Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-19-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-19-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-19-03 Soft Tissue Disease or Event Healed Minor or Nail Deformity (ie, abrasion, bite, bruise, burn, contusion, laceration, puncture wound, diabetic foot)*
• 16-19-04 Soft Tissue Disease or Event Healed Nonsuperficial (such as diabetic foot)*
• 16-19-05 Sprain, Strain, Specific Traumatic Event, Tendonitis, Tendinosis, Nonspecific Tendonitis of Foot, Ankle
• 16-19-06 Great Toe sprain, strain, contusion, crush, specific traumatic injury affecting toe motion*
• 16-19-07 Lesser Toe(s) sprain, strain, contusion, crush, specific traumatic injury all other tendons affecting toe motion*
• 16-19-08 Great Toe and/or Lesser Toes Interphalangeal Joint (IP) Joint instability/ligamentous laxity*
• 16-19-09 Great Toe and/or Lesser Metatarsophalangeal (MTP) Joint instability/ligamentous laxity Toes*
• 16-19-10 Anterior Tibial Tendon Strain, tendonitis, tendinosis, calcific tendonitis, history of tendon rupture
• 16-19-11 Posterior Tibial Tendon Strain, tendonitis, tendinosis, calcific tendonitis, history of tendon rupture
• 16-19-12 Achilles Tendon Strain, tendonitis, tendinosis, calcific tendonitis, history oftendon rupture
• 16-19-13 Peroneal Tendon (longus and/or brevis Strain, tendonitis, tendinosis, calcific tendonitis, history of tendon rupture
• 16-19-14 All other not listed Tendons Strain, tendonitis, tendinosis, calcific tendonitis, history of tendon rupture
• 16-19-15 Ankle Joint Instability or Ligamentosus Laxity
• 16-19-16 Phalanx Fracture (Greater or Lesser Toes)*
• 16-19-17 Great Toe Metatarsal Fracture
• 16-19-18 Lesser Toe(s) Metatarsal(s) Fracture*
• 16-19-19 Sesamoid(s) Fracture*
• 16-19-20 Tarsometatarsal Fracture and/or Dislocation (Lisfranc)
• 16-19-21 Midfoot – Cavus Foot (High Arch)128
• 16-19-22 Midfoot – Rocker Bottom (pes planus or convex pes valgus)
• 16-19-23 Navicular - Cuboid (Transverse Tarsal / Chopart) Fracture
• 16-19-24 Calcaneus Fracture
• 16-19-25 Talus Fracture
• 16-19-26 Tibia Articular – Pilon/Plafond Fracture (Intraarticular)
• 16-19-27 Ankle Fracture (malleolar, bimalleolar, trimalleolar)
• 16-19-28 Tibia Extra-articular Fracture
• 16-19-29 Osteochondral Defect Ankle
• 16-19-30 Interphalangeal Joint Arthritis
• 16-19-31 Greater (First) Metatarsophalangeal Joint Arthritis
• 16-19-32 Lesser Metatarsophalangeal Joint Arthritis
• 16-19-33 Avascular Necrosis Talus
• 16-19-34 Talonavicular Arthritis
• 16-19-35 Subtalar Arthritis
• 16-19-36 Calcaneocuboid Arthritis
• 16-19-37 Pan-Talar Arthritis (Tibial-talar, Talar-calcaneal, Talar-navicular)
• 16-19-38 Ankle Arthritis (Tibiotalar Joint)
• 16-19-39 Great Toe IP or Lesser Toe(s) DIP and PIP Joint Arthrodesis*
• 16-19-40 Great Toe MTP Joint Arthrodesis
• 16-19-41 Lesser Toe(s) MTP Arthrodesis (Each Toe)*
• 16-19-42 Subtalar Arthrodesis
• 16-19-43 Tibiotalocalcaneal Arthrodesis (Fusion of Tibiotalar and Subtalar)
• 16-19-44 Pantalar Arthrodesis (Tibiotalar, Subtalar, Talonavicular)
• 16-19-45 Ankle Arthrodesis
• 16-19-46 Double or Triple Arthrodesis (Subtalar, Talonavicular, Calcaneocuboid)
• 16-19-47 Ankle Arthroplasty (Total Ankle Replacement)
• 16-19-48 Great Toe Stiffness Interphalangeal (IP) Joint
• 16-19-49 Lesser Toe(s) Stiffness Distal Interphalangeal (DIP) and/or Proximal Interphalangeal (PIP) Joint*
• 16-19-50 Great Toe Stiffness Metatarsophalangeal (MTP) Joint
• 16-19-51 Lesser Toe(s) Stiffness Metatarsophalangeal (MTP) Joint*
• 16-19-52 Hindfoot Stiffness (Talus and Calcaneus)
• 16-19-53 Ankle Stiffness (Tibia – Talar Joint)

Table 16-20: DBI Table Knee Impairment

• 16-20-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-20-01 Incongruent Clinical Presentation with Residual Symptoms
• 16-20-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-20-03 Soft Tissue Disease or Event Healed Minor (ie, abrasion, bite, bruise, burn, contusion, laceration, puncture wound)*
• 16-20-04 Soft Tissue Disease or Event Healed Nonsuperficial
• 16-20-05 Bursitis, plica, contusion, or other soft tissue lesion (suprapatellar, prepatellar, infrapatellar, pes anserine, semimembranosus-tibial collateral ligament, gastrocnemius-semimembranosus, popliteus, etc)
• 16-20-06 Prepatellar Bursitis (Housemaid's Knee, Plica suprapatellar, medial, lateral, or infrapatellar)133
• 16-20-07 Strain, tendonitis, ruptured tendon, traumatic event, tendonitis, tendinosis, nonspecific tendonitis knee, contusion/crush injury
• 16-20-08 Myositis Ossificans (hypertrophic ossification)
• 16-20-09 Meniscal Injury
• 16-20-10 Anterior Cruciate Ligament (ACL) Injury
• 16-20-11 Posterior Cruciate Ligament (PCL) Injury
• 16-20-12 Anterior and Posterior Cruciate Ligament (ACL and PCL) Injury
• 16-20-13 Medial Collateral Ligament (MCL) Injury
• 16-20-14 Lateral Collateral Ligament (Posterolateral Corner) Injury
• 16-20-15 Cruciate and collateral ligament injury
• 16-20-16 Cruciate, collateral ligament and meniscal injury
• 16-20-17 Patellar Subluxation or Dislocation
• 16-20-18 Patellectomy
• 16-20-19 Osteochondral Fracture Knee
• 16-20-20 Osteochondritis Dissecans Knee
• 16-20-21 Arthritis primary knee joint
• 16-20-22 Arthritis Patellofemoral Arthritis
• 16-20-23 Knee Angulation (Femoral Shaft)
• 16-20-24 Knee Instability
• 16-20-25 Knee Stiffness
• 16-20-26 Tibial Osteotomy
• 16-20-27 Total Knee Replacement (TKA) or Unicompartmental knee arthroplasty (UKA)
• 16-20-28 Knee Arthrodesis (joint ankylosis, fusion)
• 16-20-29 Fracture Femoral Shaft Without ROM Loss
• 16-20-30 Fracture Supracondylar or Intercondylar
• 16-20-31 Fracture Patellar Without ROM Loss
• 16-20-32 Fracture Tibial Plateau
• 16-20-33 Fracture Proximal Tibial Shaft

Table 16-21: DBI Table Hip Impairment

• 16-21-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-21-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-21-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-21-03 Soft Tissue Disease or Event Healed Minor (ie, abrasion, bite, bruise, burn, contusion, laceration, puncture wound)*
• 16-21-04 Soft Tissue Disease or Event Healed Nonsuperficial*
• 16-21-05 Hip Bursitis or Impingement Syndrome
• 16-21-06 Hip Strain, tendonitis, tendinosis, nonspecific tendonitis, tendon rupture
• 16-21-07 Hip Myositis Ossificans
• 16-21-08 Hip Instability (Hip Dislocation)
• 16-21-09 Hip Avascular Necrosis
• 16-21-10 Hip Acetabular Labral Tear
• 16-21-11 Hip Stiffness (Fractures Femoral Shaft, Neck, Intertrochanteric, Subtrochanteric, Acetabular, Fracture Malunion)
• 16-21-12 Hip Degenerative Conditions (not otherwise listed)
• 16-21-13 Hip Arthritis (Arthrosis)
• 16-21-14 Hip Total Hip Arthroplasty (Hip Replacement)
• 16-21-15 Hip Arthrodesis
• 16-21-16 Femoral Osteotomy*
• 16-21-17 Hip Osteochondral Fracture
• 16-21-18 Hip Osteochondritis Dissecans
• 16-21-19 Femoral Fractures Shaft Without ROM Loss (ie Femur Fracture)
• 16-21-20 Femoral Fractures Neck, Intertrochanteric, Subtrochanteric Without ROM Loss
• 16-21-21 Hip Fracture Acetabular Without ROM loss

Table 16-23f: DBI Table Toe(s) Digital Nerve Sensory Impairment

• 16-23f-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-23f-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-23f-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-23f-03 Great Toe Transverse Digital Nerve Loss Distal to MTP joint
• 16-23f-04 Great Toe Longitudinal Digital Nerve Loss Distal to MTP
• 16-23f-05 Lessor Toe(s) Transverse Digital Nerve Loss Distal to MTP Joint
• 16-23f-06 Great or Lessor Toe(s) Longitudinal Digital Nerve Loss Distal to MTP

• 16.23g Toe(s) (Digital) Neuroma Assessment and Impairment Rating

Table 16-23h: DBI Table Sensory-Only Peripheral Nerve Impairment

• 16-23h-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-23h-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-23h-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-23h-03 Lateral Femoral Cutaneous
• 16-23h-04 Sural
• 16-23h-05 Saphenous

Table 16-23i: DBI Table Peripheral Nerve and Entrapment Neuropathy Impairment

• 16-23i-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-23i-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-23i-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• Motor Nerves
• 16-23i-01 Obturator
• 16-23i-02 Superior Gluteal
• 16-23i-03 Inferior Gluteal
• Mixed Nerves
• 16-23i-04 Femoral
• 16-23i-05 Sciatic
• 16-23i-06 Common Peroneal
• 16-23i-07 Tibial
• 16-23i-08 Medial Plantar or Lateral Plantar
• 16-23i-09 Superficial Peroneal
• 16-23i-10 Diabetic Neuropathy

Table 16-23j: DBI Table 16-23j Lumbosacral Plexus Impairment

• 16-23j-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-23j-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-23j-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-23j-03 Lumbosacral (T12 through S4)
• 16-23j-04 Lumbar Plexus (L1 through L4)
• 16-23j-06 Sacral Plexus (L5 through S4)

Table 16-25: Amputation Impairment Lower Limb

• 16.25d Toe(s) Amputations: Details and Associated Conditions
• 16.25e Foot/Ankle Amputations and Associated Conditions
• 16.25f Knee and Hip Amputation and Associated Conditions

Table 16-26: DBI Table Vascular Impairment

• 16-26-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-26-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-26-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-26-03 Vascular Condition of Digits/Foot*
• 16-26-04 Vascular Condition of Lower Limb*

Table 16-27: DBI Table CRPS Impairment

• 16-27-00 Accurate Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
• 16-27-01 Incongruent Clinical Presentation With Residual Symptoms
• 16-27-02 Incongruent Clinical Presentation With Reported Nonspecific Pain (Primary Pain)
• 16-27-03 Complex Regional Pain Syndrome (CRPS)

Table 16-01g Lower Limb Evaluation Record

Table 16-16a Impairment Values Conversion for Toe(s)/Foot/Ankle, Lower Limb to Whole Person

Table 16-16b Impairment Values Conversion for Lower Limb to Whole Person

Table 16-16d Combined Values Chart

What's New for 2024

Publication Date: September 12, 2024
Evaluators familiar with the 2008 Guides will notice significant changes in the latest update. The grade modifiers have been replaced to address the feedback from multiple stakeholders, who found that these modifiers introduced an undesirable bias, reducing the fairness and equity of impairment values across various jurisdictions. Specifically, the grade modifiers, which used terms like "mild," "moderate," or "severe," lacked specificity and resulted in wide ranges of impairment values for similar functional losses. This led to reduced interrater and intrarater reliability, and a decline in accuracy, consistency, and reproducibility.

In place of the grade modifiers, the 2024 edition introduces specific individual elements (SIEs) of the clinical history, physical examination, and relevant clinical studies. Additionally, key elements have been replaced with specific diagnostic rows in the diagnosis-based impairment (DBI) tables, leading to more fair and equitable impairment values.

Evaluators are already familiar with the criteria in the diagnostic row, which are based on the traditional three components: clinical history, physical examination, and relevant clinical studies. As a result, all evaluators possess the skills necessary to match the objectively verified anatomical findings to the criteria in each diagnostic row.

The SIEs for clinical history include current clinical presentation; mechanism of injury; reported functional loss; functional outcome surveys; the impact of no treatment, appropriate treatment, or inappropriate treatment; and any preexisting impairments, diseases, conditions, illnesses, comorbidities, psychosocial factors, and considerations for the natural history of the diagnosis.

For physical examination, the SIEs cover traditional assessments such as appearance, sensory function, motor strength, and vascular supply.

The SIEs for relevant clinical studies include radiographs, MRI, CT scans, nerve studies, vascular studies, and laboratory tests.

By using specific individual elements (SIEs), evaluators can apply objectively verifiable criteria to confirm appropriate impairment values based on the International Classification of Functioning, Disability, and Health classes defined in the diagnostic rows. This approach ensures that impairment values are fair and equitable, accurately reflecting the individual's condition at the time of maximum medical improvement and the improvements provided by treatments.

The diagnostic rows list the necessary SIEs to determine the impairment value, enhancing the quality of impairment rating reports. Evaluators can now document the diagnosis and the SIEs present at maximum medical improvement (MMI) to determine the impairment rating. This method allows for easier review by both professional and nonprofessional evaluators, ensuring consistency and fairness across multiple jurisdictions.

What's New for Diagnoses

The diagnosis-based impairment (DBI) tables have been expanded to encompass a wider range of diagnoses, including new conditions, treatments, and medical advancements that were unavailable in 2008. This update ensures that the DBI tables are more comprehensive and up-to-date, allowing evaluators to consider a wider range of conditions and their respective treatments. As a result, impairment ratings are more accurate and reflective of current medical practices, improving the overall fairness and reliability of impairment evaluations.

Consistency

All three musculoskeletal chapters follow the same format and approach in the DBI tables. Sections and tables are specifically numbered to facilitate easy identification of the diagnostic row in the evaluator's report, establishing the specific individual elements of the clinical history (CH), physical examination (PE), and relevant clinical studies (CS) used to match the diagnostic row criteria.

The DBI tables include specific instructions to minimize the need to reference multiple sections or tables, eliminating the need to use grade modifier tables and reducing the need to "flip back and forth in the book” during an impairment evaluation. This streamlines the process, reduces errors, and improves the accuracy of impairment ratings. Clear guidance for adding or combining impairment values at different level is often incorporated into the DBI tables.

Vignettes

The 2008 vignettes have been updated to align with the 2024 method, reducing the need for additional training and enhancing reliability and consistency. Furthermore, new vignettes featuring complex clinical presentations (real-world examples) have been added to illustrate the 2024 method.

Getting Started

While the evaluator is encouraged to thoroughly read the entire chapter, valuable insights and detailed explanations are provided to support the instructions in the DBI tables. This comprehensive review ensures a deep understanding of the methodology and the rationale behind the updated approach, facilitating a more accurate and consistent application of the impairment evaluation process. Familiarity with the entire chapter will enhance the evaluator's ability to effectively use the DBI tables and apply the 2024 method to a wide range of clinical scenarios.

On behalf of the Guides Panel, we would like to thank the panel members, the five musculoskeletal subcommittees, contributors and reviewers, those who provided public comments, web access attendees, and the AMA Guides staff for their support in this update as listed in the Acknowledgments Section.

For over 50 years, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) have been the trusted source for physicians, patients, and regulators, providing fair, equitable, and consistent impairment rating guidance and tools. The aim of the AMA Guides is to offer an authoritative and equitable framework for impairment ratings, ensuring that all parties receive accurate and unbiased evaluations.

In June 2019, the AMA established the AMA Guides Editorial Panel (Guides Panel) to create a transparent process involving a broad spectrum of professionals to determine whether, when, and how the Guides should be revised. The Guides Panel periodically publishes a set of editorial priorities to inform the broader stakeholder community of the Panel's primary focus. Relevant stakeholders are invited to develop proposals for enhancements to the AMA Guides based on advances in medical science.

In response to stakeholder requests, the Guides Panel created a musculoskeletal subcommittee in August 2022 to address the three musculoskeletal chapters: upper limb, lower limb, and spine and pelvis. The subcommittee engaged professional healthcare organizations to contribute materials and expertise to these chapters.

The musculoskeletal subcommittee subsequently developed three primary goals:

1. Revise the evaluation method and steps for conducting an impairment rating.

2. Enhance the diagnosis-based impairment tables by incorporating specific individual elements of the clinical history, physical examination, and relevant clinical studies.

3. Assess the impact to stakeholders in transitioning from the 2008 to the 2024 methodology.

These goals aim to improve the accuracy and consistency of impairment ratings, ensuring they reflect current medical knowledge and practices.

To achieve these goals, the Guides Panel appointed J. Mark Melhorn, MD, and Barry Gelinas, MD, DC, as the musculoskeletal chapter author-editors. The musculoskeletal editors developed five subcommittees for the upper limb, lower limb, spine and pelvis, PROMIS (Patient-Reported Outcomes Measurement Information System), and international contributors. These subcommittees worked collaboratively to ensure the comprehensive and accurate revision of the musculoskeletal chapters.

The musculoskeletal author-editors started with the Guides 2008 as the foundation. Materials were updated and provided to the subcommittees. Routine interactions with the subcommittees, contributors, and public comments were completed using the current best science applied to the RAND/UCLA Appropriateness Method (Delphi) at each step in Figure 1 and Figure 2. This approach establishes a foundation for future updates.

Understanding and evaluating impairment is an ongoing process, especially as medical science progresses at an exponential rate. A study in 2011 estimated that the doubling time of medical knowledge was 50 years in 1950, 7 years in 1980, and 3.5 years in 2010. By 2020, it was projected to be just 73 days. This means that what medical students learn in their first 3 years will constitute only 6% of what is known a decade later.¹

Another perspective on this challenge is provided by a 2021 article, which forecasted that in the next 100 years, we will experience 20,000 years' worth of progress.²

To incorporate the latest scientific advancements and ensure transparency in the development process, the Guides Panel has adopted several enhancements to the 2024 AMA Guides for the musculoskeletal chapters (Chapter 15 Upper Limb, Chapter 16 Lower Limb, and Chapter 17 Spine and Pelvis).

On behalf of the Guides Panel, we would like to thank the panel members, the five musculoskeletal subcommittees, contributors and reviewers, those who provided public comments, web access attendees, and the AMA Guides staff for their support in this update.

Douglas W. Martin, MD, FACOEM, FAAFP, FIAIME

Co-chair, AMA Guides Editorial Panel

CNOS Occupational Medicine

Dakota Dunes, SD

J. Mark Melhorn, MD, FAAOS, FABOS, FACOEM, FACS, FAAHS, FASSH, FIAIME

Co-chair, AMA Guides Editorial Panel

Clinical Associate Professor

Department of Orthopaedics

University of Kansas School of Medicine – Wichita

The Hand Center at Mid-American Orthopedics

Wichita, KS

Introduction to the Musculoskeletal Chapters 15, 16, and 17

The 2024 musculoskeletal chapters offer a valid and reproducible framework for evaluating functional deficits, utilizing the latest evidence-based science and incorporating recent scientific and medical advancements.

A musculoskeletal impairment rating at maximum medical improvement (MMI) is based on a confirmed and clinically relevant diagnosis (DX) and the impact of this diagnosis on the individual's functional abilities. Confirmation of the DX is based upon professional knowledge, judgment, and experience. At the time of the ratings evaluation, the DX is confirmed using the traditional three components of clinical history (CH), physical examination (PE), and relevant clinical studies (CS). The three components of a DX are based on objectively verified anatomic and/or physiological findings that are consistent with the natural history of the condition. The natural history of the condition is sometimes referred to as the natural history of the injury or disease and refers to the progression of a disease process in an individual over time after taking into consideration any natural aging-related changes; the impact of no treatment, appropriate treatment, or inappropriate treatment; and any preexisting impairment, diseases, conditions, illnesses, comorbidities, and/or psychosocial factors.

Evidence-Based Approach

One of the few constants in life and healthcare is change. The science of impairment evaluation has advanced significantly, with a strong emphasis on evidence-based approaches. This focus ensures that impairment assessments are grounded in the latest research and best practices, leading to more accurate, consistent, and reliable evaluations.³

With advancement comes change.

1. We acknowledge that people and organizations often resist change due to a preference for the familiar and a fear of the unknown. This phenomenon is known as inertia. Established routines and methods provide a sense of stability and predictability, making the prospect of change unsettling.

2. A second concern can be that new methods usually require learning and training.

3. Finally, resource allocation is necessary to implement changes.⁴

Despite the challenges, transitioning to the AMA Guides 2024 evidence-based approach, which utilizes the current best science in impairment evaluation, is essential for improving accuracy, consistency, reliability, and fairness, while also enhancing ease of use. Consequently, the benefits far outweigh the difficulties, leading to more accurate impairment ratings and greater credibility in the field.

In 2023, the musculoskeletal author-editors, with the support of the Guides Panel, undertook a research study to better understand the impact of transitioning from the 2008 to the 2024 updated methodology and to address the first two concerns listed above. Using clinical data from the 2008 vignettes, an analysis comparing the 2008 and 2024 methodologies was conducted. The study reported several conclusions:

1. The 2024 method reduced the time required to complete the evaluation, thereby enhancing ease of use and reducing learning or training time.

2. Impairment value accuracy was improved, resulting in fairer and more equitable evaluations.

3. Consistency, reliability, and reproducibility were enhanced, improving both interrater and intrarater performance.

The full details of the study are available at Journal of Occupational and Environmental Medicine.⁵

A second study was designed to address the third concern of resource allocation. In the realm of impairment values, resource allocation encompasses two aspects: the cost of training and the impact on financial awards. The first study indicated that training costs should be reduced with the 2024 edition. The financial awards cost relates to any potential changes in impairment values based on diagnosis. This study compared all 31 upper limb clinical vignettes from 2008 and repeated the ratings using the 2024 updated methodology and enhanced diagnosis-based impairment tables. The study reported several conclusions:

1. The two expert evaluators obtained the same impairment value 100% of the time across two separate evaluations, demonstrating intrarater and interrater reliability.

2. Six digit impairment vignettes provided the following averages: 10.8% digital impairment using 2008, and 11.0% digital impairment using 2024.

3. For the 31 upper limb impairment vignettes, the average using 2008 was 14.19%; using 2024, 14.23%.

4. When the 31 upper limb impairment values were converted to whole person, the whole person impairment (WPI) values where then averaged using 2008, resulting in 8.52% WPI; using 2024, 8.65% WPI.

5. When 6 digit impairment values, 8 hand impairment values, 31 upper limb impairment values, and the 31 whole person impairment values were average, 2008 yielded 11.0% and 2024 yielded 11.1% (composite whole person impairment).

The final conclusion above suggests that the transition from the 2008 to the 2024 methodology will result in no significant change in financial awards if strictly based on impairment values. Impairment ratings and impairment rating reports produced using the AMA Guides are used extensively in the United States and internationally as critical inputs for determining fair compensation for individuals with work-related injuries. Importantly, the determination of appropriate compensation falls within the jurisdiction of state governments, not physicians. As such, the impairment rating provided by a physician is often only one input into a complex disability and compensation calculation.

It is crucial to understand that the AMA Guides address impairment rather than disability. Impairment refers to the loss of function due to a medical condition, as assessed by medical professionals using the Guides. In contrast, disability encompasses the broader impact of an impairment on an individual's ability to perform work and daily activities. Disability determination falls under the purview of the appropriate jurisdictional entity, such as state or federal agencies, which may incorporate additional factors beyond medical impairment when deciding on the final financial award.

J. Mark Melhorn, MD, FAAOS, FABOS, FACOEM, FACS, FAAHS, FASSH FIAIME

Author-Editor Musculoskeletal Chapters
Co-Chair, AMA Guides Editorial Panel
Clinical Associate Professor, Department of Orthopaedics, University of Kansas School of Medicine – Wichita
The Hand Center at Mid-America Orthopedics
Wichita, KS

Barry Gelinas, MD, DC, FIAIME
Author-Editor Musculoskeletal Chapters
Advisor, AMA Guides Editorial Panel
Edmonton, AB, Canada