Listing 1.19 in 2026: Pathologic Fractures Due to Any Cause SSDI Claims Under Paragraph A Three Pathologic Fractures on Three Separate Occasions Within a 12-Month Period and Paragraph B Inability to Use an Upper Extremity or Documented Medical Need for a Walker, Bilateral Canes, Bilateral Crutches, or a Wheeled and Seated Mobility Device

If you've broken the same bone twice, or three bones in a year without a real accident to explain any of them, your body's telling you something. In SSA's Blue Book that story lives in Listing 1.19. It's the rule for pathologic fractures, meaning fractures that happen from disease rather than trauma. And it's one of the shortest musculoskeletal listings on the books, which fools a lot of claimants into thinking it's easy. It isn't. The bar for Paragraph A is precise, and the bar for Paragraph B is a hard functional threshold that mirrors the rest of section 1.00.

This guide walks you through the verbatim text of Listing 1.19, what SSA means by a pathologic fracture, how the three-fracture rule works, what qualifies under Paragraph B for both hand loss and assistive devices, and how adjudicators handle common underlying diseases like osteoporosis, multiple myeloma, Paget disease, chronic corticosteroid osteopenia, and osteogenesis imperfecta. It closes with two worked examples so you can see how the pieces fit.

The Verbatim Text of Listing 1.19

SSA's Listing 1.19 in 2026 reads as follows under 20 CFR Part 404, Subpart P, Appendix 1:

Both A and B must be met. A single miserable fracture won't cut it, and three fractures without the functional loss won't either. The claim rises or falls on that pairing.

What SSA Means by "Pathologic"

A pathologic fracture is a break that happens because the underlying bone is diseased, not because a person took a hard hit. SSA doesn't require you to prove the mechanism in words. What it requires is medical documentation showing that the bone failed under a load that would not fracture a healthy bone.

The classic clinical signal is a low-energy fracture. Someone standing up from a chair and snapping a vertebra. Someone lifting a grocery bag and cracking a rib. A patient rolling in bed and fracturing a humerus. If the imaging and history show the bone gave way from ordinary daily activity or from the disease process itself, that's pathologic.

SSA's own guidance in section 1.00B2 tells adjudicators to look for the underlying disorder in your treatment notes. The disorder is often listed explicitly. Bone metastases from breast, prostate, lung, kidney, or thyroid cancer. Multiple myeloma with lytic lesions. Paget disease of bone. Severe osteoporosis with T-scores at or below negative 2.5 on DEXA. Osteogenesis imperfecta, all types. Chronic glucocorticoid therapy at doses that thin cortical bone. Renal osteodystrophy. Osteomalacia from vitamin D deficiency or hypophosphatemia. And rare disorders like hypophosphatasia and fibrous dysplasia.

The Three-Fracture Rule Under Paragraph A

Paragraph A is a counting rule. You need three fractures. On three separate occasions. Within a rolling 12-month window. Let's break each of those pieces down because SSA takes them literally.

What Counts as a Fracture

Any bone. Vertebral compression fractures count, and they count each level. If your DEXA report and MRI show new T7 and T9 compression fractures on the same imaging study but the T7 was noted on a prior scan and T9 is new, only T9 is new. If both are new on the same day, that's one fracture event, not two.

Stress fractures caused by pathologic bone count. Insufficiency fractures of the pelvis and sacrum count when the bone is diseased. A hip fracture from a rise-from-sitting motion counts. A rib fracture from coughing counts if the ribs are lytic. What does not count is a fracture from clear high-energy trauma such as a car collision or a fall from a ladder.

What "Separate Occasions" Means

Three separate calendar events. Not three fractures found on one imaging session. If you go to the ER after a fall and imaging shows fractures at three vertebral levels sustained in that fall, that's one occasion. But if a scan in March shows a new L2, then June shows a new T11, then October shows a new L4, that's three occasions.

Some claim adjudicators try to argue that two vertebral fractures spotted on the same MRI are two occasions. They aren't, and SSA's own training materials say so. You need three temporally distinct events.

The 12-Month Window

The 12 months are a rolling window, not a calendar year. If your fractures happened in July 2024, February 2025, and June 2025, you meet the rule as of June 2025 because those three events fell within 12 months. You do not need all three inside a single January-to-December year.

Paragraph B: The Functional Test

Paragraph B has two paths and you only need one. Path B1 is upper extremity loss. Path B2 is a bilateral assistive device.

B1: Upper Extremity Fine and Gross Movement Loss (1.00E4)

Section 1.00E4 tells you what SSA wants to see. Inability to use one upper extremity to independently initiate, sustain, and complete work-related activities involving fine and gross movements. That's a functional standard, not an imaging finding. Your doctor's notes need to say something like this. The claimant cannot open a jar, cannot lift a gallon of milk to countertop height, cannot type a full sentence without pain that stops the activity, cannot grip a tool through a full shift, cannot fasten buttons or hold a pen for a full sentence.

Under Listing 1.19, only one upper extremity has to fail this test. That is different from Listing 1.18, which requires bilateral upper extremity loss under Paragraph C4. So a pathologic humeral fracture that heals with chronic pain and limited shoulder function on the dominant side can satisfy B1 by itself.

B2: Bilateral Assistive Device or Both-Hands Wheelchair

The other path is the same one you see across most of section 1.00. Under 1.00C6a there needs to be a documented medical need. A prescription, a PT note, or a treating physician letter that says the device is required because of the impairment and is expected to be needed for at least 12 months.

Under 1.00C6d(i) the qualifying devices are a walker, bilateral canes, or bilateral crutches. Both hands on the device. A single cane doesn't count. A rollator with a seat does count as a walker because a rollator is a wheeled walker with brakes and a rest platform. Under 1.00C6d(ii)(A) a wheeled and seated mobility device such as a manual wheelchair, powered wheelchair, or scooter counts only if operating it requires the use of both hands.

If you have a manual wheelchair you self-propel with two hands, that meets B2. If you have a power chair you drive with a right-hand joystick, that does not meet B2 because only one hand is used.

The Underlying Diseases That Drive Listing 1.19 Claims

Severe Osteoporosis

Postmenopausal osteoporosis and secondary osteoporosis from hypogonadism, celiac disease, or long-term steroid therapy are the largest single group. DEXA T-scores at or below negative 2.5 at hip or spine set the diagnosis. FRAX 10-year major osteoporotic fracture risk above 20 percent supports it. Vertebral compression fractures often stack up over months in patients with T-scores at negative 3 or lower, and adjudicators are used to seeing this pattern.

Treatment records should show bisphosphonates such as alendronate, risedronate, or zoledronic acid, or anabolic therapies such as teriparatide, abaloparatide, or romosozumab. Failure to fracture-heal despite adherent therapy is not required, but continued fracturing despite therapy strengthens the case.

Multiple Myeloma and Metastatic Bone Disease

Myeloma routinely causes lytic vertebral, rib, and long-bone fractures. If you have a myeloma diagnosis and three fracture events in 12 months with either a upper-extremity functional loss or a walker prescribed, Listing 1.19 pairs with the medical evidence you already have from your oncologist. SSA also runs myeloma claims through Listing 13.07 (lymphoma) and 13.09 (leukemia), but many light-chain and progressive myeloma cases end up allowed on the musculoskeletal side.

Bone metastases follow the same pattern. Breast cancer with mixed lytic-blastic lesions in ribs and spine. Prostate cancer with predominantly blastic lesions that still fracture under load. Kidney and thyroid cancers with vascular osteolytic lesions. Any of these can produce three-in-12 with poor healing.

Paget Disease of Bone

Paget disease creates enlarged, disorganized bone that is mechanically weak. Femurs, tibias, and pelvis are common sites. Elevated alkaline phosphatase in the absence of liver disease and characteristic imaging (thickened cortex, coarse trabeculae, expanded bone) support the diagnosis. Bisphosphonate response is usually good, but many patients still fracture during flare periods.

Chronic Corticosteroid Therapy

Patients on prednisone at 7.5 mg daily or more for three months or longer are at accelerated fracture risk. Rheumatoid arthritis, lupus, giant cell arteritis, and transplant recipients often fall in this group. Steroid-induced osteoporosis presents earlier and at higher T-scores than postmenopausal osteoporosis, so the DEXA number alone can understate the risk. When these patients start fracturing, they fracture fast.

Osteogenesis Imperfecta

OI is congenital. Types I through IX vary in severity, but adults with OI who reach working age typically have Type I or Type IV. Adult OI patients often have 30 or more lifetime fractures. Meeting three in 12 months is common during pregnancy-related bone loss, after starting a new job with more physical demand, or during periods off bisphosphonates.

Renal Osteodystrophy and CKD-MBD

Chronic kidney disease-mineral bone disorder produces mixed lesions of high-turnover and low-turnover bone. Dialysis patients fracture the hip, pelvis, ribs, and vertebrae at rates well above the general population. If your nephrologist has documented adynamic bone disease or hyperparathyroid bone disease on bone biopsy or PTH/alkaline phosphatase patterns, Listing 1.19 applies.

How SSA Adjudicates a Listing 1.19 File

Adjudicators at the DDS level get your medical records, run them through the sequential evaluation, and check the listings. For Listing 1.19 they'll pull imaging reports and pathology to confirm each fracture. They'll look at your ED notes to verify the mechanism. They'll count events across 12 months. Then they'll check Paragraph B either through your treating provider's functional notes or through the assistive device documentation.

Common file weaknesses that sink claims include:

• Only two documented fracture events, with a third suspected but never imaged
• Multiple new vertebral compression fractures found on a single MRI, treated as one occasion by the adjudicator
• Upper extremity limitation described in vague terms without specific work-related tasks
• A single cane instead of bilateral canes
• A power wheelchair operated with one hand
• Absence of a treating provider prescription for the assistive device

Every one of these gaps is fixable if you catch it before the file closes. Get a fresh spine MRI dated after your last known fracture. Ask your PT to write a functional statement matching 1.00E4 language. Ask your primary or your ortho to write a device prescription that says "medically necessary for at least 12 months, bilateral, due to pathologic fracture risk and gait instability."

How Listing 1.19 Interacts With Other Rules

Listing 1.18 Abnormality of a Major Joint

If a pathologic fracture involves a major joint (hip, knee, shoulder, elbow, wrist, or ankle) and produces chronic joint dysfunction, you can pursue both 1.18 and 1.19. Adjudicators can allow on either. See our Listing 1.18 breakdown for the joint-specific criteria.

Listing 1.22 Non-Healing Complex Fracture

A pathologic fracture that fails to unite can independently meet Listing 1.22. If any of your three fractures did not heal within nine months or required revision surgery, review the Listing 1.22 rule.

Listing 13.07 Multiple Myeloma

Myeloma patients with progressive disease despite therapy meet Listing 13.07 directly, which is usually a faster path. Pursue both listings together. SSA can allow on whichever fits the record.

Medical Vocational Grid

If Paragraph B can't be met but you have real functional loss, SSA moves to the residual functional capacity evaluation and the medical vocational grid. A 55-year-old worker with high school education and a history of light unskilled work can grid at rule 202.06 if RFC is limited to sedentary due to fracture pain and instability. A 60-year-old at the same profile grids at 201.06 automatically.

Worked Example: Maria, 52, Cambridge MA, Multiple Myeloma

Worked Example: Kevin, 61, Fort Lauderdale FL, Steroid-Induced Osteoporosis

The Common Rejections and How to Beat Them

Three failure patterns explain most Listing 1.19 denials.

Only Two Documented Fractures

Symptomatic fractures often go unimaged because a patient waits it out. A rib that hurt for six weeks and then stopped hurting might be a healed pathologic fracture, but if there's no CT and no chest x-ray showing it, adjudicators won't count it. If you have a suspected fracture in your history, get imaging now. A CT chest, a bone scan, or a whole-body MRI can retrospectively confirm old fractures at healed or partially healed states.

Same-Day Fractures Counted as One Occasion

If your only three fractures were all found on one MRI session but they clearly happened at different times based on differing stages of healing on the scan, ask the radiologist to note the different acuity of each fracture in an addendum. Fresh edema on T2 sequence for one level, healing marrow reaction on another level, and a chronic wedge deformity on a third can support three separate occasions.

Weak Upper Extremity Functional Documentation

"Right shoulder pain limits function" is not enough. What SSA wants is the specific work-related activity language from 1.00E4. Ask your treating provider or your OT to state clearly whether you can independently initiate, sustain, and complete work-related activities involving fine and gross movements of the affected upper extremity.

Frequently Asked Questions