Clavicle or Scapula - Impairment of C&P Exam Prep

Shoulder Flexion (Active and Passive)

What it measures: Forward elevation of the arm from neutral (0-) to maximum overhead position (normal = 180-). Assesses glenohumeral and scapulothoracic mobility, which is directly impacted by clavicle and scapula pathology.

What to expect: You will be asked to raise your arm forward as high as possible (active ROM). The examiner may then assist the movement to assess passive ROM. Testing occurs both weight-bearing (standing/sitting) and may be assessed non-weight-bearing. Perform to your actual limit - do not push through severe pain.

Pain considerations: Per DeLuca v. Brown, pain that limits motion before the anatomical endpoint must be reported and documented. State: 'I feel sharp/aching pain at approximately X degrees that prevents me from going further.' The examiner should note the degree at which pain begins, not just the endpoint.

Shoulder Abduction (Active and Passive)

What it measures: Lateral raising of the arm away from the body (normal = 180-). Especially sensitive to acromioclavicular joint and clavicle impairment affecting the shoulder girdle arc.

What to expect: You will lift your arm out to the side as high as possible. Examiner may check both active and passive abduction. Note any painful arc (often 60-120-) which is characteristic of AC joint and rotator cuff pathology secondary to clavicle impairment.

Pain considerations: If abduction causes pain specifically over the clavicle, AC joint, or scapular region, point to that exact location. This connects the ROM limitation directly to the rated condition (DC 5203).

Shoulder Internal and External Rotation

What it measures: Rotational capacity of the glenohumeral joint (normal: internal rotation ~70-, external rotation ~60-). Scapular and clavicular impairment can restrict rotation through altered shoulder mechanics.

What to expect: The examiner will place your arm at 90- abduction or at your side and ask you to rotate the forearm toward and away from your body. Both active and passive measurements are taken. Weight-bearing and non-weight-bearing positions may be tested.

Pain considerations: Rotational restriction after clavicle/scapula injury is often underreported. Describe the grinding or clicking sensation at the fracture/nonunion site during rotation if present.

Palpation for Deformity, Tenderness, and Loose Movement

What it measures: Physical examination of the clavicle and scapula to identify malunion (malaligned healed bone), nonunion (failure to heal), dislocation (persistent joint displacement), and loose movement at a fracture or nonunion site. This is the primary mechanism for rating under DC 5203.

What to expect: The examiner will press along the length of your clavicle and around your scapula to find areas of tenderness, step-off deformity, bony prominence, or abnormal mobility. They may attempt to move a suspected nonunion site to assess for 'loose movement.' This may be uncomfortable - report pain accurately.

Pain considerations: Tenderness on palpation at the fracture or nonunion site directly supports the diagnosis. Do not hold back - tell the examiner 'that spot is tender' when they press on it.

Repetitive-Use Testing (Functional ROM After Exercise)

What it measures: Whether repeated movements of the shoulder cause additional loss of motion or increased pain beyond the initial ROM measurement. Per DeLuca v. Brown, examiners must assess for functional loss from pain with use, weakness, fatigability, and incoordination.

What to expect: The examiner may ask you to perform repeated shoulder movements (e.g., three sets of flexion or abduction) and measure ROM again afterward. If they do not perform this test, proactively state how your shoulder changes with use.

Pain considerations: This is a critical and frequently overlooked element. Many veterans have near-normal ROM at rest but significant functional impairment with use. Volunteer this information if the examiner does not specifically test for it.

Muscle Strength Testing (Rotator Cuff and Shoulder Girdle)

What it measures: Strength of the deltoid, supraspinatus, infraspinatus, and subscapularis muscles, which are all affected by clavicle and scapula mechanics. Graded on the Medical Research Council (MRC) scale from 0-5.

What to expect: The examiner will apply resistance as you attempt to hold your arm in specific positions. Specific provocative tests may include the Empty Can Test (supraspinatus), the Lift-Off Test (subscapularis), and the External Rotation Resistance Test (infraspinatus). Push to your actual strength capacity - do not overperform.

Pain considerations: Weakness that is pain-limited (you stop before maximum effort due to pain) should be distinguished from true neurological weakness. Both are valid functional loss findings.

20%

Dislocation of clavicle or scapula (major or minor limb); OR Nonunion of clavicle or scapula WITH loose movement at the fracture or nonunion site (major or minor). Alternatively, rate on impairment of function of the contiguous shoulder or elbow joint if that yields a higher evaluation.

From 38 CFR: 38 CFR 4.71a DC 5203: 'Dislocation of [clavicle or scapula] - 20/20 [major/minor]'; 'Nonunion of: With loose movement - 20/20.' The alternative provision states: 'Or rate on impairment of function of contiguous joint,' meaning if shoulder ROM limitation alone would yield 20% under DC 5201, that rating applies.

10%

Nonunion of clavicle or scapula WITHOUT loose movement at the fracture site; OR Malunion of the clavicle or scapula. Alternatively, rate on impairment of function of the contiguous joint if that yields a higher evaluation.

From 38 CFR: 38 CFR 4.71a DC 5203: 'Nonunion of: Without loose movement - 10/10 [major/minor]'; 'Malunion of - 10/10.' The 'Or rate on impairment of function of contiguous joint' alternative also applies at this level.

Pain - Location, Quality, and Triggers

How to describe it: Describe exactly where the pain is: over the clavicle bone itself, at the acromioclavicular (AC) joint, near the sternoclavicular (SC) joint, around the scapula (shoulder blade), or deep in the shoulder girdle. Characterize the pain as sharp, stabbing, aching, burning, or throbbing. State what makes it worse: lifting overhead, reaching across your body, carrying weight, pushing/pulling, sleeping on that side.

Example: On my worst days, I wake up with a constant aching pain across my entire collarbone and into my shoulder blade that rates 7/10. Even lifting my arm to shoulder height causes a sharp spike to 9/10 right at the old fracture site. I cannot carry anything heavier than a cup of coffee without pain radiating down my arm, and the pain keeps me awake at night.

Examiner listens for: Specific anatomical location tied to the clavicle or scapula; pain that is provoked by shoulder movement; pain that changes with activity level; night pain that disrupts sleep; pain that has been consistent over months or years.

Avoid: Saying 'it hurts sometimes' or 'it's not that bad.' Do not minimize pain to appear stoic. Your rating depends on accurate representation of your actual impairment on a representative bad day.

Flare-Ups - Frequency, Duration, and Triggers

How to describe it: Describe episodes when your condition is significantly worse than baseline. State how often they occur (daily, weekly, monthly), how long they last (hours, days), what triggers them (physical activity, weather changes, specific movements, sleeping position), and how severe they are at their peak.

Example: I have flare-ups about 3 times per week. They're triggered by any overhead reaching or carrying anything over 5 pounds. During a flare, the pain at my collarbone fracture site spikes to 8/10 and I lose almost all ability to lift my arm. These episodes last 1-2 days and require me to rest and take additional pain medication.

Examiner listens for: Specific triggers, measurable frequency and duration, functional impact during the flare, whether flares result in incapacitation from normal activity.

Avoid: Forgetting to mention flare-ups at all, or describing them only vaguely. The examiner must document flare-up description in the DBQ to support an accurate rating.

Loose Movement or Instability at Fracture Site

How to describe it: If you can feel movement, clicking, grinding, or a sensation of instability at the site of your old fracture or dislocation, describe this clearly. Tell the examiner when it occurs and whether it's accompanied by pain, weakness, or the sensation that the shoulder 'gives out.'

Example: When I move my arm forward or try to lift something, I can feel and sometimes hear a clicking or grinding sensation right at the spot where my collarbone was fractured. My shoulder feels unstable, like something is shifting that shouldn't be. It happens every time I try to lift above shoulder level.

Examiner listens for: Any objective confirmation of loose movement, crepitus, or instability at the clavicle or scapula site - this is the specific clinical finding that determines the difference between the 10% and 20% ratings under DC 5203.

Avoid: Failing to mention clicking, grinding, or instability because you assume it is not important. This finding is the critical differentiator between rating levels under DC 5203.

Weakness, Fatigue, and Incoordination (DeLuca Factors)

How to describe it: Describe how your shoulder arm strength and endurance have changed since the injury. Mention specific tasks you can no longer perform or can only perform briefly: overhead reaching, lifting, pushing, pulling, carrying. Describe how quickly your arm fatigues compared to before the injury.

Example: My arm becomes weak and starts shaking after less than a minute of holding it overhead. Tasks I used to do without thinking - reaching a shelf, carrying groceries, throwing a ball - now cause my shoulder to give out and ache for hours afterward. I can no longer perform my job duties that require lifting or overhead work.

Examiner listens for: Observable weakness during strength testing, functional loss beyond what ROM measurements alone capture, occupational and daily life impairment.

Avoid: Only describing pain and ignoring weakness or fatigue. VA raters use all DeLuca factors - pain, fatigue, weakness, and incoordination - to capture total functional loss.

Visible Deformity

How to describe it: If you have a visible bump, ridge, asymmetry, or abnormal contour over your collarbone or shoulder blade, point it out to the examiner and describe when it appeared (immediately after injury, or over time). Explain whether it has grown, stayed the same, or changed in shape.

Example: Since my clavicle fracture healed crooked, there is a noticeable bump on my right collarbone that you can see and feel. My right shoulder sits lower than my left and the deformity is permanent. It is visible in all shirts and causes me embarrassment in addition to pain.

Examiner listens for: Objective physical finding of malunion deformity; asymmetry; relationship between the deformity and reported functional limitation.

Avoid: Not pointing out a visible deformity because you assume the examiner will see it. Be proactive - say 'I have a visible deformity here' and show them.

Impact on Daily Activities and Employment

How to describe it: Describe specifically which activities of daily living (ADLs) are affected: dressing, bathing, cooking, driving, sleeping, household chores. For employment, describe your job duties and which ones you can no longer perform or perform only with difficulty or accommodation.

Example: I cannot dress myself without pain - putting on a shirt, fastening my seatbelt, or reaching behind my back all cause sharp pain at my collarbone. At work, I can no longer stock shelves, carry boxes, or work with my arms above my head. My employer has had to reassign my duties and I was passed over for promotion because of my physical limitations.

Examiner listens for: Concrete, specific examples of impairment. The DBQ requires the examiner to document the functional impact of the condition - give them rich, accurate detail.

Avoid: Saying 'I manage okay' or 'I just push through it.' The examiner needs to know your honest, full impairment picture - not the impression you want to give a healthcare provider who is trying to help you manage.