Shoulder and Arm C&P Exam Prep

Shoulder Flexion (Active and Passive)

What it measures: The degree of forward elevation of the arm from 0- (arm at side) to 180- (arm fully overhead). Critical for rating under DC 5201 and functional loss under DC 5202.

What to expect: The examiner will ask you to raise your arm forward. They will use a goniometer to measure degrees. They will also passively move your arm to compare active vs. passive ROM. They will note where pain begins and where motion ends.

Pain considerations: Pain during ROM testing is a DeLuca factor. Tell the examiner exactly where in the arc pain begins (e.g., 'Pain starts at 60 degrees and becomes severe at 90 degrees'). Pain that limits motion is functionally equivalent to structural limitation under M21-1 guidance.

Shoulder Abduction (Active and Passive)

What it measures: Lateral elevation of the arm from 0- to 180-. Normal is 180-. Measured in standing and/or seated position.

What to expect: The examiner will ask you to raise your arm out to the side. Passive abduction will also be tested. The painful arc (classically 60-120-) is noted for impingement-related conditions. Both active and passive endpoints are recorded.

Pain considerations: Painful arc during abduction is a key indicator of subacromial pathology. If you experience a 'catching' or 'pinching' sensation at mid-arc, describe it precisely. This supports objective evidence of painful motion as a DeLuca functional loss factor.

Internal and External Rotation (Active and Passive)

What it measures: Rotation of the humerus at the glenohumeral joint. Internal rotation normal is approximately 60-70-; external rotation normal is approximately 60-90-.

What to expect: Tested with arm at side or at 90- abduction. Examiner measures degrees with a goniometer. Passive motion is compared to active. Pain and endpoint are documented.

Pain considerations: Loss of rotation is particularly disabling for activities of daily living. Describe specific tasks you cannot perform due to rotational limitations, such as reaching behind the back or overhead.

Repetitive Use Testing and Functional Loss After Use

What it measures: Whether ROM decreases or pain increases after repetitive use of the shoulder - a mandatory DeLuca consideration under 38 CFR 4.40 and 4.45.

What to expect: The examiner may ask you to repeat a motion several times and re-measure, or may ask you to describe what happens with sustained or repetitive use. You should proactively describe this if the examiner does not ask.

Pain considerations: Repetitive-use functional loss is one of the most underreported and under-documented aspects of shoulder exams. Under DeLuca v. Brown, the examiner is required to consider the effect of pain and fatigue on ROM after repetitive use. Accurately describe this - do not minimize.

Hawkins Impingement Test

What it measures: Detects subacromial impingement by compressing the supraspinatus tendon against the coracoacromial ligament.

What to expect: The examiner will flex your elbow to 90- and rotate your arm inward. A positive test produces pain over the anterior shoulder and is recorded as positive or negative.

Pain considerations: A positive Hawkins test is an objective clinical finding that strengthens the nexus between your symptoms and the underlying shoulder pathology.

Empty Can Test (Supraspinatus Strength)

What it measures: Assesses the integrity and strength of the supraspinatus portion of the rotator cuff.

What to expect: Arm elevated to 90- at 30- forward, thumb pointing down. The examiner applies downward pressure. Weakness or pain is a positive finding.

Pain considerations: Weakness on the Empty Can test is an objective finding of functional loss - it directly supports higher disability ratings by documenting DeLuca factor of weakness.

Crank / Apprehension and Relocation Test

What it measures: Evaluates glenohumeral joint instability and recurrent dislocation tendency - directly relevant to DC 5202 recurrent dislocation ratings.

What to expect: Arm abducted to 90-, externally rotated; examiner applies anterior force. A positive apprehension test produces fear of dislocation or pain anteriorly. Relocation test is positive if symptoms are relieved with posterior pressure.

Pain considerations: For DC 5202 recurrent dislocation, the frequency of episodes (frequent vs. infrequent) and extent of guarding (all arm movements vs. only at shoulder level) are the determinative rating factors. Accurately describe your pattern.

Lift-Off Test (Subscapularis Strength)

What it measures: Tests integrity of the subscapularis muscle and tendon - the primary internal rotator.

What to expect: Hand placed behind your back, palm facing outward. The examiner asks you to push your hand away from your back against resistance. Inability or pain is a positive finding.

Pain considerations: Subscapularis weakness is commonly associated with significant functional limitation in activities of daily living. Describe specific ADL impairments.

80%

Loss of head of humerus (flail shoulder) - major extremity. Complete loss of the humeral head resulting in a flail joint with no effective glenohumeral articulation.

From 38 CFR: DC 5202: 'Loss of head of (flail shoulder)' - rated 80% for major extremity, 70% for minor extremity. This is the highest tier under DC 5202 and reflects the most severe structural impairment of the humerus.

70%

Loss of head of humerus (flail shoulder) - minor extremity. Same structural finding as 80% level but applied to the non-dominant arm.

From 38 CFR: DC 5202: Minor extremity loss of head of humerus. Dominant hand status is recorded in the DBQ and directly affects the applicable rating percentage.

60%

Nonunion of humerus (false flail joint) - major extremity. Failure of fracture healing resulting in an abnormal motion at the fracture site, creating a false joint.

From 38 CFR: DC 5202: 'Nonunion of (false flail joint)' - 60% major, 50% minor. Imaging documentation of nonunion is critical to establishing this rating tier.

50%

Fibrous union of humerus - major extremity, OR Nonunion of humerus - minor extremity. Fibrous union involves incomplete bony healing with fibrous tissue bridging, causing pain and reduced function but more stability than a false flail joint.

From 38 CFR: DC 5202: 'Fibrous union of' - 50% major, 40% minor. Also: Nonunion minor extremity = 50%. Imaging confirmation differentiates fibrous union from nonunion.

40%

Fibrous union of humerus - minor extremity.

From 38 CFR: DC 5202: 'Fibrous union of' - 40% minor extremity. Documentation of dominant hand status is critical.

30%

Recurrent dislocation at scapulohumeral joint WITH frequent episodes AND guarding of ALL arm movements, OR Malunion of humerus with MARKED deformity - major extremity.

From 38 CFR: DC 5202: 'Recurrent dislocation of at scapulohumeral joint: With frequent episodes and guarding of all arm movements' - 30% major. Also: 'Malunion of: Marked deformity' - 30% major. Frequency of dislocation and degree of guarding are the determinative factors for the dislocation tier.

20%

Recurrent dislocation at scapulohumeral joint with INFREQUENT episodes and guarding only at shoulder level (flexion and/or abduction at 90-), OR Malunion of humerus with MODERATE deformity. Applies to both major and minor extremity at this level.

From 38 CFR: DC 5202: 'With infrequent episodes and guarding of movement only at shoulder level (flexion and/or abduction at 90-)' - 20% major and minor. Also: 'Malunion of: Moderate deformity' - 20% major and minor. This is the minimum compensable tier under DC 5202.

Pain on Motion and at Rest

How to describe it: Describe pain with a specific numeric scale (0-10), indicate exactly where in the range of motion pain begins, whether it is sharp, aching, burning, or crushing, and whether it persists after motion stops. State whether pain occurs at rest and at night.

Example: On my worst days, even resting my arm causes a 7/10 deep aching pain at the front and side of my shoulder. If I try to raise my arm, the pain spikes to 9/10 at about 45 degrees and I cannot continue. At night, the pain wakes me up when I roll onto the affected shoulder.

Examiner listens for: Location of pain (anterior, posterior, lateral shoulder), pain at beginning of motion vs. throughout arc, presence of night pain, pain at rest, relationship between activity and pain intensity.

Avoid: Saying 'it's not that bad' or 'I manage okay.' This minimizes documented severity. Accurately describe your average day and specifically your worst days.

Dislocation Episodes (Critical for DC 5202)

How to describe it: Describe the number of dislocation events per month or year, what activities trigger them (reaching, rolling over in bed, throwing), whether they self-reduce or require medical reduction, how long recovery takes, and the degree to which you guard your arm to prevent recurrence.

Example: Last year I dislocated my shoulder four times - twice while reaching overhead for something in a cabinet and twice while sleeping. Each time required a trip to urgent care for reduction. After each episode I could not use the arm for a week. Now I guard my arm constantly - I do not raise it above chest height during any activity because I am afraid of another dislocation.

Examiner listens for: Frequency of actual dislocation events, whether guarding involves ALL arm movements or only at shoulder level, whether the veteran avoids activities due to apprehension, history of surgical stabilization and outcome.

Avoid: Saying 'it pops out sometimes' without providing frequency, context, and functional impact. The distinction between frequent/all-movement-guarding (30%) and infrequent/shoulder-level-guarding (20%) is critical - be precise.

Weakness and Fatigability (DeLuca Factors)

How to describe it: Describe the inability to sustain lifting or overhead work, time limits on activity (e.g., 'I can only hold my arm up for 30 seconds before it gives out'), grip-strength impacts, and progressive weakness with repeated use.

Example: On a bad day, I cannot hold a gallon of milk at my side for more than a few seconds on the affected side. After five minutes of working with my arm raised even slightly, it begins to tremble and becomes completely unreliable. I have dropped objects I was holding because the arm just gave out without warning.

Examiner listens for: Objective weakness on special tests, stated functional limitations, ability to perform overhead work, carrying capacity, use of compensatory strategies, and descriptions that support fatigability as a DeLuca factor.

Avoid: Saying 'I'm a little weak' - give specific examples of what you cannot lift, how long you can hold a position, and when weakness becomes disabling during a typical day.

Flare-Ups

How to describe it: Describe frequency of flare-ups per month, duration, what triggers them (weather, activity, sleeping position), how severe they become, and how they affect your ability to function during the episode.

Example: I have severe flare-ups about twice a month, usually after any sustained physical activity involving my arm. During a flare, pain increases from my usual 4/10 to 9/10, I cannot use the arm for basic self-care, and the flare lasts 3-5 days. Cold weather makes flares worse and more frequent.

Examiner listens for: Frequency and duration of flare-ups, what exacerbates them, functional impact during flare periods, whether flares cause time lost from work or require rest.

Avoid: Not mentioning flare-ups at all. The DBQ specifically asks about flare-ups and they are a standalone component of rating under 38 CFR 4.40. If you have them, describe them in detail.

Incoordination and Instability

How to describe it: Describe any difficulty with precise arm movements, unexpected shoulder giving-way, inability to perform tasks requiring steady arm positioning, and apprehension during normal activities.

Example: My shoulder gives way unexpectedly during tasks like carrying a bag or reaching across my body. I have dropped trays, spilled drinks, and dropped tools at work because the shoulder suddenly loses stability with no warning. I cannot perform work tasks requiring sustained or precise arm positioning.

Examiner listens for: Positive apprehension/relocation test, stated instability during daily activities, history of subluxation or giving-way episodes short of full dislocation, compensatory behavior changes.

Avoid: Saying the shoulder 'just feels a bit loose.' Describe concrete episodes of giving-way, near-dislocations (subluxations), and how this changes your behavior and work capacity.

Functional Impact on Daily Life and Work

How to describe it: Be specific about what activities you cannot do or can only do partially. Include self-care (dressing, bathing), household tasks, driving, sleeping, and occupational tasks. Quantify limitations where possible.

Example: I cannot put on a shirt or jacket without significant difficulty and pain - it takes me 10 minutes to dress each morning using my unaffected arm and specific adaptive techniques. I cannot drive for more than 20 minutes because gripping the wheel causes pain. I sleep in a recliner because lying flat causes too much shoulder pain. I have been unable to return to my job as a warehouse worker because I cannot lift or carry as required.

Examiner listens for: Specific ADL limitations, occupational impact, compensation strategies, use of assistive devices, sleep disruption due to pain, and whether the condition causes functional impairment beyond what ROM measurements alone suggest.

Avoid: Saying 'I manage okay' or 'I've learned to work around it.' This understates disability. The examiner needs to document all functional impacts to accurately complete the DBQ.