Listing 1.22 Non-Healing or Complex Fracture of the Femur, Tibia, Pelvis, or Talocrural Bones in 2026: How SSA Decides Non-Union and Mal-Union Claims Under Paragraph A Imaging and Paragraph B 12-Month Limitation With a Documented Medical Need for a Walker, Bilateral Canes, or Bilateral Crutches

By Anthony Albert, Benefits Research Director, Disability Exchange · Updated June 30, 2026 · SSA Blue Book Section 1.00 Musculoskeletal (Adult)

If you broke your femur, tibia, pelvis, or ankle in a serious crash, fall, or workplace accident and the bone has not healed the way it should, you may meet Listing 1.22. SSA wrote 1.22 in the 2021 musculoskeletal revision specifically for non-unions, delayed unions, and complex mal-unions in the major weight-bearing lower extremity bones. It is not a soft listing. The imaging has to say what SSA wants it to say, and you have to need a walker or two canes to get around for at least 12 months.

This guide walks both paragraphs of 1.22 with the verbatim text. We cover what SSA means by "solid union not evident on imaging," what counts as a documented medical need under 1.00C6a, why the 4-month proximity rule under 1.00C7c controls timing, and how the talocrural bones (the ankle joint complex of tibia, fibula, and talus) fit the listing. Two worked Massachusetts and Florida cases close the file.

If you have a fracture that has not healed and you are filing or appealing an SSDI claim, the goal is a file that hits both paragraphs of 1.22 with the right vocabulary in the right places. See If You Qualify.

What 1.22 Actually Says

Here is the verbatim text of Listing 1.22 from the SSA Blue Book Section 1.00 Musculoskeletal (Adult), revised effective April 2, 2021:

This is a tight two-part AND test. Paragraph A is the bone test. Paragraph B is the function test. You need both. A claimant with a non-united femur fracture who walks on a single cane will not meet 1.22 because Paragraph B requires bilateral assistance. A claimant who uses a walker but whose latest CT shows solid bridging callus across the fracture line will not meet 1.22 because Paragraph A is missing.

Listing 1.22 is narrow on anatomy too. It applies only to the femur, tibia, pelvis, and talocrural bones. The talocrural bones are the tibial plafond, the medial malleolus, the fibular distal segment, and the talus. A non-healing fracture of the fibular shaft alone is not enough. A non-healing fracture of the tibial plateau or pilon is. A non-healing humerus fracture, scaphoid non-union, or vertebral compression fracture is filed under a different listing or proceeds through Step 5 RFC.

For other major joint problems that do not fit 1.22, see our deep dive on Listing 1.18 abnormality of a major joint.

Paragraph A: Solid Union Not Evident on Imaging and Not Clinically Solid

Paragraph A is the radiology paragraph. SSA wants two things: imaging that does not show solid union, and a clinical exam that does not feel solid union. Both. The "not clinically solid" piece is sometimes overlooked. A treating orthopedic note that says "the fracture site is tender to palpation and there is movement at the fracture line on stress" carries real weight in DDS decisions.

What "Solid Union Not Evident on Imaging" Means

The orthopedic literature defines non-union as a fracture that has shown no radiographic progress toward healing across three consecutive months or any failure to heal by nine months. SSA does not use those exact thresholds in 1.22, but DDS examiners are trained to look for the same imaging features. The strongest Paragraph A files describe:

• Persistent fracture line visible on plain X-ray or CT across the cortex.
• Lack of bridging callus across the fracture site at six months or later.
• Hypertrophic non-union with "elephant foot" callus that does not bridge.
• Atrophic non-union with rounded, sclerotic, non-reactive bone ends.
• Mal-union with angulation exceeding 10 degrees in any plane that interferes with limb mechanics.
• Pseudarthrosis (false joint) at the fracture site.

1.00C3 defines what imaging SSA accepts. Plain radiographs are sufficient for fracture assessment. CT is preferred when fine bony detail is needed (tibial plateau, pilon, pelvic ring, talus). MRI is helpful for marrow signal and soft tissue, but it is not the primary imaging for fracture healing. Bone scan and SPECT/CT can document increased uptake at a non-union site and are persuasive add-ons.

The 1.00C7c 4-Month Proximity Rule

Section 1.00C7c controls timing. SSA wants imaging done within four months before or four months after the period under consideration for the Paragraph B finding. A 2024 CT that showed non-union does not anchor a 2026 hearing unless the treating orthopedist documents that the non-union persists. Update the imaging 60 to 90 days before the hearing if your case is older than four months.

What "Not Clinically Solid" Means

The clinical exam piece of Paragraph A is the orthopedic surgeon's hands-on assessment. The provider tests for tenderness at the fracture site, motion at the fracture line under stress, and limb shortening or rotational deformity. A note that says "tenderness over the mid-shaft tibia, palpable step-off, gross motion with varus stress" is a strong Paragraph A anchor.

If the bone is in an external fixator, an Ilizarov frame, or a recent revision plate, the clinical "not solid" finding is essentially given. The harder cases are the ones where the patient is past the hardware stage and the surgeon has labeled the fracture "healed" prematurely. Get a second opinion before the hearing if the imaging tells a different story than the chart note.

Paragraph B: 12-Month Limitation With a Documented Medical Need for a Bilateral Assistive Device

Paragraph B has two pieces. The duration test under 20 CFR 404.1509 (at least 12 months) and the assistive device test under 1.00C6a and 1.00C6d(i) or 1.00C6d(ii)(A). Both have to be in the record.

1.00C6a Documented Medical Need

Section 1.00C6a defines documented medical need as evidence from a medical source supporting medical need for an assistive device for a continuous period of at least 12 months. The evidence has to describe the circumstances under which you need the device, such as which activities require it. A single prescription is not enough. The file needs the longitudinal record. Physical therapy gait evaluations, follow-up orthopedic visits, and occupational therapy home assessments that describe the device in use across multiple months are the strongest anchors.

1.00C6d(i) Walker, Bilateral Canes, Bilateral Crutches

The standard Paragraph B path is the bilateral assistive device test. SSA wants documentation that you require either a walker (standard, rollator, or platform), bilateral canes (two canes used together), or bilateral crutches (axillary, forearm, or platform forearm). A single cane is not enough. A unilateral knee brace is not enough. The bilateral requirement reflects SSA's view that a person who can ambulate with a single cane retains the upper extremity function to perform some work-related activities at sedentary or light.

1.00C6d(ii)(A) Wheeled and Seated Mobility Involving Both Hands

If you use a manual wheelchair that you propel with both hands, you also satisfy this prong. The chair has to be the primary means of mobility, not an occasional accommodation for long distances. Documentation should describe the chair use at home as well as outside the home. If you use a power wheelchair or a scooter, that does not satisfy the "both hands" requirement of 1.00C6d(ii)(A) and you need to file under a different listing or proceed to Step 5.

12-Month Duration

SSA needs the limitation to last at least 12 months. Non-unions and complex mal-unions almost always satisfy this clinically. The question for DDS is whether the record documents the limitation across that span. Three months of post-operative limitation does not satisfy 1.22 even if the bone is clearly not healed. The treating orthopedist has to project that the limitation will continue for at least 12 months from onset, or the file has to show that it already has. After a second revision surgery that fails to achieve union, the 12-month projection is reasonable.

Anatomy: What Counts as a Talocrural Bone

The talocrural joint is the ankle joint. The talocrural bones SSA references in 1.22 are the distal tibia (including the tibial plafond and the medial malleolus), the distal fibula (including the lateral malleolus), and the talus. A pilon fracture (high-energy distal tibia) is one of the most common 1.22 anchors because pilon non-unions are notoriously hard to fix.

What does not count as a talocrural bone for 1.22: the calcaneus (heel), the navicular, the cuboid, the cuneiforms, and the metatarsals. A non-healing calcaneal fracture is filed under a different framework and goes through Step 5 RFC analysis.

Common Causes Behind a 1.22 Non-Union

Knowing why the bone did not heal helps you build a stronger file. Common causes include:

• High-energy mechanism. Motor vehicle crashes, falls from height, and motorcycle crashes produce more comminution, more soft tissue stripping, and more vascular disruption. Pilon fractures, segmental tibial fractures, and pelvic ring injuries from high-energy mechanisms have non-union rates above 10 percent in the orthopedic literature.
• Open fracture (Gustilo-Anderson III). Open fractures, especially Gustilo-Anderson IIIB and IIIC, carry non-union rates approaching 20 percent in the tibia.
• Smoking. Tobacco use roughly doubles non-union risk and is documented in essentially every orthopedic chart. SSA examiners do not deny on this basis, but the surgeon should chart smoking cessation counseling because it strengthens the "I have done everything reasonable" narrative.
• Diabetes mellitus. Poorly controlled diabetes impairs bone healing through vascular and cellular mechanisms. A claimant with HbA1c above 8 and a non-union has a clinically plausible story.
• NSAID use. Long-term NSAID use, especially during the first six weeks of healing, can interfere with osteogenesis. Many post-fracture patients are on prescription NSAIDs for pain and the chart should document this.
• Infection. Post-operative deep infection (osteomyelitis) is one of the most common causes of non-union after open fractures. Infected non-unions require staged revision and bone grafting. If your file includes positive cultures or prolonged IV antibiotics, this is a strong anchor.
• Inadequate fixation. Hardware failure, plate breakage, or intramedullary nail breakage at the fracture site signals that mechanical stability was not achieved. Revision surgery is then required.

Surgical Treatment Picture in 2026

SSA does not deny non-union claims because surgery is available. The agency knows that revision surgery for non-union is a high-stakes operation with a multi-month recovery and a real failure rate. The orthopedic literature reports that revision surgery for established non-union of the femur or tibia achieves union in 70 to 85 percent of cases on the first revision. That means 15 to 30 percent fail the first revision and require a second.

The standard 2026 revision techniques include:

• Exchange intramedullary nailing. The most common revision for diaphyseal tibial or femoral non-union. The original nail is removed, the canal is reamed (which stimulates osteogenic activity and delivers autograft), and a larger-diameter nail is inserted.
• Plate fixation with autograft. Iliac crest bone graft is the gold standard for biology. Reamer-Irrigator-Aspirator (RIA) graft from the femur is an alternative.
• BMP-2 (Infuse). Recombinant human bone morphogenetic protein-2. FDA-approved for open tibial fractures with intramedullary nailing. Used off-label for non-union revisions.
• Ilizarov or hexapod external fixator. For infected non-unions, malalignment, and bone loss. The fixator distracts and compresses to stimulate bone regeneration. Treatment times of 6 to 12 months are common.
• Masquelet induced membrane technique. For segmental bone loss. A cement spacer is placed at the first stage to induce a vascularized membrane. Six to eight weeks later the spacer is removed and autograft is placed inside the membrane.
• Free vascularized fibular graft. For large segmental defects, especially after tumor resection or severe trauma.
• Bone stimulator. External low-intensity pulsed ultrasound (LIPUS) or PEMF (pulsed electromagnetic field). Modest evidence base. Often used as an adjunct.

A treating orthopedist who has tried two revision surgeries plus a bone stimulator plus BMP-2 and still has a non-united tibia is making the case for you. Document the failures. List every prior surgery in chronological order in the brief and tie each one to a post-operative imaging study.

Pelvis Non-Union: The Hardest Anatomy

Pelvic ring non-unions are rare but devastating. The pelvis bears axial load through the sacroiliac joints and any disruption of that ring impairs ambulation. SSA recognizes pelvic ring non-union under 1.22 if the imaging confirms the lack of union and the claimant requires bilateral assistance.

Common pelvic anatomies that fit 1.22 include:

• Vertical shear pelvic fracture with persistent superior displacement of the hemipelvis.
• Open book pelvic injury with widened pubic symphysis that did not heal after ORIF.
• Sacral non-union after Denis Zone II or III sacral fracture.
• Acetabular non-union after both-column or T-type acetabular fracture.

The imaging here is CT with reformatted coronal and sagittal images. Plain pelvic films are inadequate. SPECT/CT is helpful for documenting metabolically active non-union.

How DDS Reads a Non-Union File

DDS examiners get a stack of records. They look for three things in a 1.22 file. First, an imaging report that uses the words non-union, delayed union, or persistent fracture line. Second, an orthopedic note that describes the clinical exam as "not clinically solid" or describes pain and motion at the fracture site. Third, a documented prescription, gait evaluation, or PT note showing bilateral assistive device use across at least three encounters spanning at least four months.

If any of those three is missing, the file gets routed to Step 5 RFC. SSR 96-9p then controls the sedentary erosion analysis. A claimant who needs bilateral canes to ambulate has a profoundly eroded sedentary base. SSR 96-9p says that the occupational base for sedentary work is significantly eroded by the need for a hand-held assistive device for balance or ambulation. The Grid Rules at 201.06, 201.10, and 201.14 then often direct a finding of disabled at advanced age (55 and older) and even at closely approaching advanced age (50 to 54) with the right vocational profile.

Worked Example: Patrick, 59, Worcester, Massachusetts

Patrick was driving home from his welding shift on Interstate 290 in January 2024 when a box truck rear-ended him at highway speed. He sustained a closed comminuted mid-shaft femoral fracture and an open Gustilo-Anderson IIIA distal tibial pilon fracture. The femur was fixed with a reamed intramedullary nail. The pilon was managed in a staged fashion with external fixation followed by definitive ORIF six weeks later.

At six months the femur showed delayed union. At 12 months CT showed a persistent fracture line at the mid-shaft femur with hypertrophic callus that did not bridge. The pilon was worse. CT at 12 months showed an atrophic non-union of the distal tibia with screw loosening at the medial plate.

Patrick had revision surgery on the femur in March 2025 (exchange nailing with reaming and autograft from the contralateral iliac crest). The femur went on to union by November 2025. The pilon required a Masquelet technique in May 2025 with cement spacer placement, followed by bone grafting in July 2025. At hearing in May 2026, CT showed early bridging callus across the pilon but no solid union. The treating orthopedist documented tenderness at the pilon fracture site and refused to clear Patrick for weight-bearing without bilateral forearm crutches.

Patrick used bilateral forearm crutches at home and a four-wheeled rollator outside the home from March 2024 onward, a span of more than two years at hearing. Three separate PT evaluations and a home OT assessment in October 2024 documented the device need across the period. The orthopedic medical source statement on HA-1152 said: "Solid union of the distal tibia is not evident on imaging and is not clinically solid. The patient has required a walker or bilateral forearm crutches continuously since the date of injury and will require them for at least another 12 months."

The ALJ found Listing 1.22 met at the hearing. The decision quoted Paragraph A and Paragraph B verbatim and referenced 1.00C6a and 1.00C7c. Patrick was approved with an onset date of January 2024. Back pay covered 29 months.

Worked Example: Elena, 52, Jacksonville, Florida

Elena fell from a 14-foot stepladder while painting an exterior cornice in July 2024. She sustained a Tile C vertically unstable pelvic ring injury (right sacral fracture, disrupted symphysis pubis, and an associated right superior and inferior pubic rami fracture). She had emergent pelvic ORIF with symphyseal plate and bilateral iliosacral screws.

At six months CT showed persistent diastasis at the symphysis, screw loosening at the right ilium, and a non-united right sacral fracture with sclerotic edges. The orthopedic trauma surgeon scheduled a revision but Elena's diabetes was uncontrolled (HbA1c 10.4) and the revision was delayed until endocrine optimization. The revision happened in December 2025 with iliosacral screw exchange and posterior pelvic plating with iliac crest autograft.

At hearing in June 2026, CT showed the right sacral fracture still not united, with active bone scan uptake. The pubic symphysis was now stable. The trauma surgeon documented that Elena could not weight-bear without bilateral platform forearm crutches and used a manual wheelchair propelled with both hands for distances greater than 50 feet inside her home. Two PT discharges and one home health OT evaluation across 2024 and 2025 documented the bilateral device need.

The ALJ found Listing 1.22 met. The decision noted that the sacral non-union satisfied Paragraph A (the imaging clearly showed lack of union and the surgeon's exam clearly showed instability) and that the bilateral platform forearm crutch use plus the both-hands wheelchair use both satisfied Paragraph B under 1.00C6d(i) and 1.00C6d(ii)(A). Onset was set at the date of the fall, July 2024. Back pay covered 23 months.

For a parallel motor vehicle accident case under a different musculoskeletal listing, see our deep dive on Listing 1.15 nerve root compromise.

State Pages for Filing and Appeals

Filing and appeal procedures vary by DDS. If you are in Massachusetts, see our Massachusetts SSDI page. If you are in Florida, see our Florida SSDI page. Other state pages: Texas, California, New York, Pennsylvania, Ohio.

What to Get on the Medical Source Statement

The HA-1152 medical source statement is the single most important document for a 1.22 claim at the hearing level. The orthopedic surgeon or treating physician should sign a statement that includes all of the following:

• The anatomical location of the fracture (femur, tibia, pelvis, talus, medial malleolus, lateral malleolus, tibial plafond).
• The date of the original injury.
• The dates of all surgical interventions, including the type of fixation and any revision or grafting procedures.
• A statement that solid union is not evident on the most recent imaging, with the date and modality of that imaging.
• A statement that the fracture is not clinically solid on examination, with the specific findings (tenderness, motion at the fracture site, deformity).
• A description of the assistive device the patient requires (walker, bilateral canes, bilateral crutches, or both-hands wheelchair) with the dates of prescription and the circumstances of use.
• A statement that the limitation has lasted at least 12 months or is expected to last at least 12 months.

If the surgeon does not write the statement in those terms, the file can still win, but the ALJ has to do more interpretation. Give the ALJ less to interpret.

Step 5 RFC Fallback if 1.22 Does Not Quite Fit

If the imaging shows partial bridging callus and the surgeon will not call it a non-union, you fall to Step 5 RFC analysis. SSR 96-9p says the occupational base for sedentary work is significantly eroded by the need for a hand-held assistive device for balance or ambulation. SSR 83-10 says a less than full range of sedentary work supports a finding of disabled when the vocational profile includes advanced age, limited education, and an unskilled or semi-skilled work history. The Grid Rules at 201.06, 201.10, and 201.14 then often direct a disabled finding for claimants 55 and older with the right vocational profile.

For claimants under 55 with a sedentary RFC, the file has to show specific limitations that prevent the residual occupational base from being intact. Need for a sit-stand option, need to raise the leg, need for unscheduled breaks to weight-shift, and inability to tolerate prolonged static positions are the standard ones for lower extremity non-unions.

Frequently Asked Questions

If you have a non-healing femur, tibia, pelvis, or talocrural fracture, the work is now medical documentation. Get the imaging current. Get the orthopedic medical source statement on HA-1152. Get the PT and OT notes documenting bilateral device use across at least four months. Then file with all four pieces aligned.

See If You Qualify