Guide for Aviation Medical ExaminersVersion 09/30/2026
Section 13
ITEMS 42-43. Musculoskeletal
13 pagesPages 276–288
| CHECK EACH ITEM IN APPROPRIATE COLUMN | Normal | Abnormal |
|---|---|---|
| 42. Upper and lower extremities (Strength and range of motion) | ||
| 43. Spine, other musculoskeletal |
I. Code of Federal Regulations
All Classes: 14 CFR 67.113 (b)(c), 67.213 (b)(c), and 67.313 (b)(c)
(b) No other organic, functional, or structural disease, defect, or limitation that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved finds -
Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or
May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.
No medication or other treatment that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the medication or other treatment involved, finds -
Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or
May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.
II. Examination Techniques
Standard examination procedures should be used to make a gross evaluation of the integrity of the applicant's musculoskeletal system. The AME should note:
Pain - neuralgia, myalgia, paresthesia, and related circulatory and neurological findings
Weakness - local or generalized; degree and amount of functional loss
Paralysis - atrophy, contractures, and related dysfunctions
Motion coordination, tremors, loss or restriction of joint motions, and performance degradation
Deformity - extent and cause
Amputation - level, stump healing, and phantom pain
Prostheses - comfort and ability to use effectively
III. Aerospace Medical Disposition
The following is a table that lists the most common conditions of aeromedical significance, and course of action that should be taken by the AME as defined by the protocol and disposition in the table. Medical certificates must not be issued to an applicant with medical conditions that require deferral, or for any condition not listed in the table that may result in sudden or subtle incapacitation without consulting the AMCD or the RFS. Medical documentation must be submitted for any condition in order to support an issuance of an airman medical certificate.
ITEM 42. Upper and Lower Extremities NEUROPATHY (Peripheral Neuropathy) All Classes
(Updated 01/25/2023)
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| A. NeuropathyWithout functional limitations | If the AME can determine the condition is:• Under control;• Medications are acceptable; and• The individual has no symptoms that would interfere with flight duties: |  ISSUEAnnotate this information in Block 60.If no AME explanation, the pilot may be asked to provide documentation. |
| B. NeuropathyWith weakness/ numbnessORFunctional limitations | Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the neuropathy (including etiology if known); current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment and plan (prognosis); and follow-up.2. It must specifically include a description of any weakness, numbness, or functional limitations.3. Lab already performed for this condition.4. Any other testing or imaging deemed clinically necessary by the treating physician.Note: If the neuropathy is due to an underlying condition such as diabetes - see that section. |  DEFERSubmit the information to the FAA for a possible Special Issuance Annotate (elements or findings) in Block 60.If not addressed in the progress note, the AME should describe any functional limitations that could affect the pilot's ability to operation aircraft controls. |
OSTEOMYELITIS (BONE INFECTION)
- All Classes
- Updated 08/26/2026
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| A. Single episode fully resolved | If the AME can determine the condition has fully resolved with no residual sequelae which would interfere with flight duties: |  ISSUESummarize findings in Item 60. |
| B. All others• Currently on antibiotics• 2 or more lifetime episodes• Chronic or recurrent infection• Functional limitation or required amputation | Submit the following for FAA review:1. A current, detailed Clinical Progress Note generated from a clinic visit with an infectious disease specialist or treating physician no more than 90 days before the AME exam.It should include a summary of the history of the condition or diagnosis; current medications, dosages, and side effects (if any); clinical exam findings; results of any testing performed; diagnosis; assessment and plan (prognosis); and follow-up.2. It must specifically include:• Etiology or any underlying cause with frequency of episodes (chronic or recurrent) and likelihood to reoccur.• Any functional limitations. |  DEFERSubmit the information to the FAA for a possible Special Issuance.Summarize findings in Item 60.If not addressed in the progress note, the AME should describe any functional limitations that could affect the pilot's ability to operate aircraft controls. |
- UPPER AND LOWER EXTREMITIES
- All Classes
- (Updated 08/26/2026)
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| Amputations | Submit a current, detailed Clinical Progress Note to include functional status (degree of impairment as measured by strength, range of motion, pain), medications with side effects (if any), and all pertinent medical reports | If applicant has a SODA issued on the basis of the amputation - IssueOtherwise - Requires FAA Decision After review of all medical data, the FAA may authorize a special medical flight test |
| Atrophy of any muscles that is progressive,Deformities, either congenital or acquiredORLimitation of motion of a major joint, that are sufficient to interfere with the performance of pilot duties | Submit a current, detailed Clinical Progress Note to include functional status (degree of impairment as measured by strength, range of motion, pain), medications with side effects (if any), and all pertinent medical reports | Requires FAA Decision |
| Neuralgia | See Item 46. Neurologic, Other Conditions - Neuralgia (Trigeminal Neuralgia, Post Herpetic Neuralgia) Disposition Table | See disposition table |
| Sciatica, if sufficient to interfere with function or is likely to become incapacitating | Submit a current, detailed Clinical Progress Note to include functional status (degree of impairment as measured by strength, range of motion, pain), medications with side effects (if any), and all pertinent medical reports | Requires FAA Decision |
| Tremor | See Item 46. Neurologic, Extrapyramidal, Hereditary, and Degenerative Diseases of the Nervous System- Tremor Disposition Table | See disposition table |
- Item 43. Spine, Other Musculoskeletal
- ARTHRITIS
- All Classes
- (Updated 04/29/2026)
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| A. Osteoarthritis | • Well controlled, no persistent daily symptoms;• No functional limitations; and• Treatment is NSAIDS or antiinflammatory medication only. |  ISSUESummarize this History, annotate Block 60. |
| B. Osteoarthritis on additional medicationORAutoimmune arthritis | See CACI worksheetThis will require a current, detailed clinical progress noteand Hydroxychloroquine (HCQ)/ Chloroquine (CQ) Status Summary (Plaquenil/Aralen) if taking plaquenil. | Follow the CACI - Arthritis WorksheetAnnotate Block 60. |
| C. All others• Complications*;• Symptomatic; or• Underlying cause with complications or systemic disease, etc. | Submit the following to the FAA for review:☐ A current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and follow-up. ☐ It should note if there are any functional limitations. ☐ Operative notes (if applicable); and ☐ Copies of imaging reports and lab (if already performed by treating physician) |  DEFERSubmit the information to the FAA for a possible Special Issuance.Follow up Issuance Will be per the airman’s authorization letter. |
*Complications include:
Joint deformity or decreased range of motion or strength that would impair flight duties
Systemic disease
CACI - Arthritis Worksheet (Updated 04/29/2026)
To determine the applicant’s eligibility for certification, the AME must review a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician or specialist no more than 90 days prior to the AME exam. If the applicant meets ALL the acceptable certification criteria listed below, the AME can issue. Applicants for first- or second- class must provide this information annually; applicants for third-class must provide the information with each required exam.
| AME MUST REVIEW | ACCEPTABLE CERTIFICATION CRITERIA |
|---|---|
| Treating physician finds the condition stable on current regimen and no changes recommended | [ ] Yes |
| Symptoms | [ ] None or mild to moderate symptoms with no significant limitations to range of motion, lifestyle, or activities |
| Cause of Arthritis*Osteoarthritis - see Arthritis Disposition Table CACI may not be required. | Acceptable causes are limited to: [ ] Osteoarthritis* and/or [ ] Autoimmune to include only the following: rheumatoid (limited to joint), psoriatic, or ankylosing spondylitis |
| Acceptable MedicationsKEY:Interleukin Inhibitors (IL)Janus Associated Kinase Inhibitor (JAK)Monoclonal Antibody, Anti-CD20 (CD20)Phosphodiesterase-4 Enzyme Inhibitor (PDE4)Selective T-Cell Costimulation Blocker (T-Cell)Tumor necrosis factor inhibitors (TNF) | [ ] One or more of the following with or without routine NSAID use:• Oral steroid prednisone 20 mg/day equivalent or less (see steroid conversion calculator)• NSAID (routine use)• azathioprine (Imuran)• methotrexate (Trexall)• sulfasalazine (Azulfidine)• Hydroxychloroquine (HCQ)/Chloroquine (Plaquenil/Aralen) see status report requirement below**• Any singe medication listed below after a 2-week ground trial and:▪ No post-dose observation time: o PDE4: apremilast (Otezla) o JAK: baricitinib (Olumiant); tofacitinib (Xeljanz); upadacitinib (Rinvoq)▪ 4-hour post-dose observation time: o TNF: adalimumab (Humira and all biosimilars), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) o IL: anakinra (Kineret), guselkumab (Tremfya), ixekizumab (Taltz), risankizumab (Skyrizi), sarilumab (Kevzara), secukinumab (Cosentyx), tocilizumab (Actemra), ustekinumab (Stelara)▪ Other post-dose observation time: o 72-hour rituximab (Rituxan) 72-hour - CD20 o 24 hours: infliximab (Inflect, Remicade, Renflexis) - TNF o 24 hours: abatacept (Orencia) – T-Cell |
| ** STATUS SUMMARY is required if Hydroxychloroquine (HCQ)/Chloroquine (CQ) (Plaquenil/Aralen) is used. | [ ] Hydroxychloroquine (HCQ)/ Chloroquine (CQ) Status Summary (Plaquenil/Aralen) is favorable and no concerns OR [ ] N/A (NOT taking hydroxychloroquine/chloroquine [Plaquenil/Aralen]) |
AME MUST NOTE in Block 60 one of the following:
[ ] CACI qualified arthritis. (Documents do not need to be submitted to the FAA.) [ ] Has current OR previous SI/AASI but now CACI qualified arthritis. [ ] NOT CACI qualified arthritis. I have deferred. (Submit supporting documents.)
- CEREBRAL PALSY
- All Classes
- (Updated 01/25/2023)
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| A. Any history | Submit the following for FAA review:1. A current, detailed neurological evaluation, in accordance with the FAA Specifications for Neurologic Evaluation, generated from a clinic visit with the treating neurologist no more than 90 days before the AME exam.2. It must include and evaluation of items such as balance, strength, range of motion limitations and pain. It must describe any functional deficits or limitations for both large and small muscle groups as well as dexterity to operate an aircraft.3. All school/academic records: Educational accommodations, Individual Education Plan (IEP) such as a "504" plan, educational support services provided, educational assessments and testing associated with IEP or individualized accommodations, neuropsychological assessments and testing, educational transcripts, and, if available, chief pilot reports.Note: In some cases, additional information such as brain imaging (MRI/CT) or neurocognitive testing may be required after review of the above items.Physical limitations associated with CP may require a Medical Flight Test (MFT). If a MFT is required, please state which FSDO the individual would prefer to use. |  DEFERSubmit the information to the FAA for a possible Special Issuance. |
- COLLAGEN DISEASE
- All Classes
- (Updated 03/29/2023)
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| Acute Polymyositis; Dermatomyositis; Lupus Erythematosus; or Polyarteritis Nodosa | Submit a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and followup. | Requires FAA Decision |
- GOUT AND PSEUDOGOUT
- All Classes
- (Updated 04/29/2015)
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| Gout PseudogoutWell controlled | Interview and examination reveal:☐ No persistent symptoms or functional impairment.☐ Med combinations of NSAIDS, uric acid reducers (allopurinol, etc.), or uric acid excreters (probenecid) with no aeromedically significant side effects. |  ISSUE Note findings in Block 60. |
| Gout PseudogoutFunctional impairment Joint deformity Kidney stones, recurrent Meds other than above Not controlled Persistent symptoms | Submit a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and followup. It should also address:☐ Severity and frequency of exacerbations to include interval between and date of most recent flare; ☐ Extent of renal involvement; and ☐ Extent of joint deformity or functional impairment and if it would impair operation of aircraft controls. |  DEFER Submit records to the FAA for decisionFollow up - per SI/AASI |
- SPINE, OTHER MUSCULOSKELETAL
- All Classes
- (Updated 03/29/2023)
| DISEASE/CONDITION | EVALUATION DATA | DISPOSITION |
|---|---|---|
| Active disease of bones and jointsIf due to a specific condition – See those pagesIf due to arthritis – See the Arthritis page | Submit a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and follow-up.Include functional status (degree of impairment as measured by strength, range of motion, pain). | Requires FAA Decision |
| Ankylosis, curvature, or other marked deformity of the spinal column sufficient to interfere with the performance of pilot duties | Submit a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and follow-up.Include functional status (degree of impairment as measured by strength, range of motion, pain). | Requires FAA Decision |
| Intervertebral Disc Surgery | See note | See note |
| Musculoskeletal effects of:Muscular DystrophyOrMyopathies | Submit a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and follow-up. | Requires FAA Decision |
| Include functional status (degree of impairment as measured by strength, range of motion, pain). | ||
| Musculoskeletal effect of Myasthenia Gravis | See Myasthenia Gravis Disposition Table | See disposition table |
| Other disturbances of musculoskeletal function, acquired or congenital, sufficient to interfere with the performance of pilot duties or likely to progress to that degree | Submit a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and follow-up.Include functional status (degree of impairment as measured by strength, range of motion, pain). | Requires FAA Decision |
| Symptomatic herniation of intervertebral disc | Submit a current, detailed Clinical Progress Note generated from a clinic visit with the treating physician no more than 90 days before the AME exam. It must include a detailed summary of the history of the condition; current medications, dosage, and side effects (if any); physical exam findings; results of any testing performed; diagnosis; assessment; plan (prognosis); and follow-up.Include functional status (degree of impairment as measured by strength, range of motion, pain). | Requires FAA Decision |
Note: A history of intervertebral disc surgery is not disqualifying. If the applicant is asymptomatic, has completely recovered from surgery, is taking no medication, and has suffered no neurological deficit, the AME should confirm these facts in a brief statement in Block 60. The AME may then issue any class of medical certificate, providing that the individual meets all the medical standards for that class.
The paraplegic whose paralysis is not the result of a progressive disease process is considered in much the same manner as an amputee. The AME should defer issuance and may advise the applicant to request a Medical Flight Test. Other neuromuscular conditions are covered in more detail in Item 46.