Muscle Group I Injury (Shoulder Girdle - Trapezius) C&P Exam Prep

Manual Muscle Testing (MMT) - Shoulder Group I

What it measures: Strength of trapezius, levator scapulae, and serratus anterior muscles on a 0-5 scale. Grade 5 = normal strength against full resistance; Grade 4 = reduced strength against some resistance; Grade 3 = movement against gravity only; Grade 2 = movement with gravity eliminated; Grade 1 = visible/palpable contraction only; Grade 0 = no contraction.

What to expect: The examiner will ask you to shrug your shoulders, elevate and retract the scapula, and protract/rotate the scapula upward against resistance. Both sides (right and left) will be compared. This is recorded in DBQ fields RG_4E_SHOULD_RIGHT_5_4_3_2_1_0 and RG_4E_SHOULD_LEFT_5_4_3_2_1_0.

Pain considerations: Pain during muscle testing is itself a DeLuca factor and constitutes functional loss. Under 38 CFR 4.40 and 4.45, pain on use, pain with repetition, and pain-limited motion are all compensable. Clearly state: 'That movement causes sharp/burning/aching pain in my trapezius/shoulder/neck area at [pain scale 1-10].'

Circumferential Muscle Atrophy Measurement

What it measures: Visible or measurable atrophy of the trapezius or shoulder girdle muscles compared to the unaffected side. Recorded in DBQ fields for atrophy location, normal side measurement, and atrophied side measurement.

What to expect: The examiner may use a tape measure to compare circumference of the affected shoulder/neck region against the unaffected side. The examiner will also visually inspect and palpate for loss of muscle bulk, soft or flabby muscles, or induration.

Pain considerations: Palpation of the trapezius, levator scapulae insertion points, and periscapular region may elicit pain or tenderness. Report this accurately - tenderness on palpation is an objective clinical finding.

Scar and Wound Tract Examination

What it measures: Characteristics of scars related to the muscle injury - including minimal scars, entrance/exit scars from penetrating trauma, ragged/depressed/adherent scars indicating wide damage, adhesion of scar to bone (scapula), loss of deep fascia, and other surgical scars.

What to expect: The examiner will visually inspect and palpate the wound area. DBQ fields cover: minimal scars, small/linear scars, missile track scars, ragged/depressed/adherent scars, adhesion to bone, loss of deep fascia, and other scar types. Describe all scars including size, location, and any functional limitation they cause.

Pain considerations: Adherent or keloid scars in the trapezius region can cause chronic pain and restrict neck and shoulder movement. Describe any burning, pulling, or aching pain specifically at or around scar tissue.

Endurance/Repetitive Use Testing

What it measures: Whether functional loss (weakness, pain, fatigue) increases after repetitive use of the shoulder girdle muscles. Per DeLuca v. Brown and 38 CFR 4.45, the examiner must consider whether the condition worsens after use.

What to expect: The examiner may ask you to perform a movement multiple times or ask about your functional capacity over a workday. This documents whether your symptoms are worse after sustained use. DBQ fields for fatigue (RG_4D_FATIGUE_RLB, RG_4D_FATIGUE_OCC) and weakness after use are directly relevant.

Pain considerations: Fatigue-induced pain is a legitimate DeLuca factor. Describe the sequence: initial pain level, activity that aggravates, and pain/weakness level after aggravation. Use concrete examples such as grocery shopping, driving, or desk work.

0%

No injury to Muscle Group I, or injury that is completely healed with no residual weakness, functional loss, or scar findings. Full strength (5/5) bilaterally with no pain, atrophy, or other objective findings.

From 38 CFR: Condition resolved without residual disability. No ratable findings under 38 CFR 4.73, DC 5301.

10%

Slight injury to Muscle Group I. Minimal findings such as small linear scars, mild weakness not affecting function, and no significant loss of power or endurance. The veteran may have subjective symptoms (aching, mild stiffness) without objective functional loss.

From 38 CFR: Slight injury to Group I muscles with minimal residuals. Entrance and exit scars are small or linear. Strength essentially preserved. Mild fatigue or aching with prolonged use.

20%

Moderate injury to Muscle Group I. Objective findings of muscle damage present, including some loss of muscle substance, impaired muscle tonus, moderate weakness, and demonstrable fatigue or pain on use. Scars may show some adherence or loss of deep fascia. DeLuca factors (pain, fatigue, weakness) documented after use.

From 38 CFR: Moderate injury to Group I shoulder girdle muscles with demonstrable weakness, fatigue, and pain on use. Scars may show some ragging or adherence. Loss of muscle substance present.

30%

Moderately severe injury to Muscle Group I. Significant objective findings including marked weakness, loss of power, visible or measurable atrophy, ragged or adherent scars with wide damage, impairment of coordination, uncertainty of movement, and substantially lowered fatigue threshold. Functional impairment affects occupational and daily activities.

From 38 CFR: Moderately severe injury to Group I muscles. Ragged/adherent/depressed scars indicate wide damage. Marked weakness and loss of power. Visible atrophy. Impaired coordination and significant lowering of fatigue threshold. Functional limitation substantially restricts occupational use of the affected shoulder girdle.

40%

Severe injury to Muscle Group I. Complete or near-complete loss of function of the shoulder girdle muscles. Profound weakness (MMT grade 2/5 or below), extensive atrophy, major scar adherence to scapula or bone, muscle swells and hardens abnormally in contraction, atrophy of muscle groups not in track of missile (denervation pattern), and tests of endurance show marked departure from normal. Veteran is severely limited in use of the affected extremity.

From 38 CFR: Severe injury to Group I shoulder girdle muscles with near-complete loss of use. Profound atrophy, adhesion of scar to scapula, abnormal muscle response in contraction, and denervation-pattern atrophy outside wound track. Tests of endurance show marked departure from normal. Daily and occupational function severely restricted.

Pain

How to describe it: Describe pain in specific anatomical terms: burning, aching, stabbing, or throbbing pain located over the trapezius muscle, at the trapezius insertion on the occiput, spine of scapula, or clavicle, or radiating into the neck or ipsilateral upper extremity. State the pain level on a 0-10 scale at rest, with activity, and at worst. Describe what makes it worse (overhead reaching, lifting, sustained posture, cold weather, stress) and what provides partial relief.

Example: On my worst days, the pain in my right trapezius and shoulder girdle is a 9 out of 10. I cannot lift my arm above shoulder level, I cannot turn my head without sharp pain, and the muscle seizes up into painful spasms that last hours. I am unable to dress myself or drive. I need to lie down with ice and pain medication for the rest of the day.

Examiner listens for: Specific anatomical pain location, pain at rest versus with activity, pain with palpation, pain that limits range of motion, pain that worsens with repetitive use or sustained posture, pain requiring medication or causing sleep disruption.

Avoid: Saying 'it's just a little sore sometimes' or 'I manage okay.' These statements do not accurately capture your functional loss on bad days and can anchor the examiner's assessment at a lower severity level.

Weakness and Loss of Power

How to describe it: Describe specific functional tasks you can no longer perform or struggle with due to weakness in the shoulder girdle. Quantify if possible: 'I can only lift 5 pounds overhead before my shoulder gives out' or 'I cannot hold my arm up for more than 2 minutes.' Distinguish between weakness at rest and weakness that develops after use (DeLuca fatigue).

Example: On my worst days, I have almost no strength in my right shoulder. I cannot lift a gallon of milk off a shelf at shoulder height. When I try to shrug my shoulder, I feel almost nothing - the muscle does not respond the way it should. My arm trembles when I try to hold anything above my waist.

Examiner listens for: Specific activities limited by weakness, inability to sustain resistance, weakness that develops during repetitive use, dropping objects, inability to perform overhead tasks, asymmetry between dominant and non-dominant sides.

Avoid: Saying 'I'm weak but I push through it.' The examiner needs to know the full extent of functional limitation, not your compensatory strategies.

Fatigue and Lowered Threshold of Fatigue

How to describe it: Explain that the shoulder girdle muscles fatigue far more rapidly than before the injury and much faster than the unaffected side. Give time-based examples: 'After 5 minutes of any overhead work, my trapezius is completely exhausted and I must stop for 30 minutes.' Describe how fatigue worsens as the day progresses.

Example: On a bad day, my shoulder and trapezius fatigue within minutes of any activity. By noon, even holding my arm up to type at a computer is exhausting. By evening, the muscle is completely spent and feels like dead weight. I cannot perform any upper body activities after 3 PM without severe pain and trembling weakness.

Examiner listens for: How quickly fatigue sets in compared to before injury, whether fatigue limits occupational duties, whether fatigue causes secondary symptoms like spasm or pain, how long recovery takes after fatigue onset.

Avoid: Minimizing fatigue by saying 'I just get tired like everyone else.' The DeLuca factors require the examiner to document fatigue as a specific functional loss - make it easy for them by being specific.

Impairment of Coordination and Uncertainty of Movement

How to describe it: Describe any difficulty with precise or controlled movements involving the shoulder and arm. For trapezius injuries, this may manifest as difficulty with scapular stabilization, causing poor shoulder mechanics, dropped or shaky arm movements, and inability to perform fine tasks requiring shoulder stability (e.g., writing, tool use, surgical tasks, musical instrument playing).

Example: On my worst days, I cannot reliably control my shoulder when reaching for objects. I knock things over, I miss targets, and I feel unsure whether my shoulder will hold when I reach for something. I have dropped objects because my shoulder suddenly gave way.

Examiner listens for: Observable incoordination during physical examination, patient-reported examples of fumbling or missed movements, evidence of scapular dyskinesis affecting upper extremity control.

Avoid: Failing to report coordination problems because you think they are minor. Impairment of coordination is a specific rating criterion under 38 CFR 4.73 that can increase your rating level.

Functional Impact on Daily Life and Occupation

How to describe it: Provide concrete examples of activities of daily living (ADLs) and work tasks you cannot perform or perform with difficulty. The examiner will complete fields about functional impact - give them specific language. Describe morning routine, hygiene, cooking, driving, computer work, sleep position, hobbies, and any job duties affected.

Example: On my worst days, I cannot put on a shirt without help because raising my arm to pull it over my head causes severe pain and my shoulder gives out. I cannot wash my hair properly. I cannot carry groceries. I have had to change careers because I can no longer do sustained computer work or any task requiring my right arm to be elevated. I wake up multiple times at night because any pressure on my shoulder causes intense pain.

Examiner listens for: Specific ADL limitations, occupational impairment, need for adaptive devices, whether the veteran has had to modify their job or leave employment, secondary conditions caused by compensatory movement patterns (e.g., neck or opposite shoulder pain).

Avoid: Giving vague answers like 'it affects everything.' Be specific about which activities and how. Vague statements are less persuasive in the DBQ narrative than specific, documented functional limitations.

Flare-Ups

How to describe it: Describe what triggers a flare-up (cold weather, overuse, stress, sleep position, physical activity), how long flare-ups last, how severe they are, and how they differ from your baseline symptoms. Flare-ups are recognized under M21-1 guidance as a basis for rating at the level of severity during a flare-up, not just at baseline.

Example: My flare-ups are triggered by cold weather, overhead lifting, or prolonged computer use. During a flare-up, my trapezius goes into severe spasm, my pain goes from a 4 to a 9, I cannot turn my head, and I am unable to work for 1-3 days. I have approximately 3-4 flare-ups per month that each last 2-4 days.

Examiner listens for: Frequency of flare-ups, duration, severity, triggering factors, what the veteran must do to manage them (rest, medication, ice/heat), whether flare-ups require medical care or cause missed work.

Avoid: Failing to mention flare-ups at all if the exam happens to be on a relatively good day. Your rating should reflect your full range of symptoms including worst presentations, not just how you feel on exam day.