Shoulder and Arm C&P Exam Prep

Shoulder Abduction (Active ROM)

What it measures: How far you can raise your arm out to the side away from your body. Normal is 180-. This is the single most critical measurement for DC 5200 rating thresholds.

What to expect: The examiner will ask you to raise your arm straight out to the side as far as possible without assistance from trunk lean or shoulder shrug. A goniometer may be used for precise measurement. The examiner must also test passive abduction (they move your arm) and note any difference. Testing should be performed on both shoulders.

Pain considerations: Under DeLuca v. Brown, pain on motion is itself a form of functional loss. If abduction causes pain before reaching the endpoint, the examiner should note the degree at which pain begins (not just where motion ends). Tell the examiner: 'I feel pain starting at [X] degrees and it limits how long I can hold that position.'

Shoulder Flexion (Active ROM)

What it measures: How far you can raise your arm forward in front of your body. Normal is 180-.

What to expect: You will be asked to raise your arm straight forward as far as possible. The examiner records the endpoint in degrees and whether passive flexion differs from active. Both initial and repetitive-use ROM should be noted.

Pain considerations: State specifically if pain prevents forward reaching, such as inability to put on a shirt, reach a shelf, or lift items above waist height.

Internal and External Rotation

What it measures: The rotational capacity of the shoulder joint. Normal external rotation is 90-; normal internal rotation is 70-90-. In true ankylosis the scapula and humerus move as one piece, eliminating glenohumeral rotation.

What to expect: The examiner will assess whether any glenohumeral rotation is possible or whether all apparent motion comes from scapulothoracic movement. They will compare active versus passive rotation and document degree endpoints. This directly supports or refutes the presence of ankylosis.

Pain considerations: Pain with rotation attempts should be communicated - even if some motion is technically possible, pain-limited rotation contributes to overall functional loss documentation.

Repetitive-Use Testing (Post-Exercise ROM)

What it measures: Whether your ROM decreases after repetitive use of the shoulder. This is a DeLuca factor that must be considered under Correia v. McDonald (2016) and M21-1 guidance.

What to expect: After initial ROM measurements, the examiner may ask you to perform the motion three times and re-measure. A decrease in ROM after repetition indicates additional functional loss that must be documented and factored into the rating.

Pain considerations: Fatigue, increasing pain with repetition, and weakness after sustained use are all DeLuca factors. Explicitly describe each one if present.

Weight-Bearing vs. Non-Weight-Bearing ROM (Correia Requirements)

What it measures: For the shoulder, this refers to testing with the arm loaded versus unloaded. Weight-bearing can be simulated by having the veteran hold a light weight or simply use gravity-loaded motion.

What to expect: The examiner should document both active (veteran moves arm) and passive (examiner moves arm) ROM, and note whether loaded motion differs from unloaded. Any discrepancy must be documented.

Pain considerations: If passive ROM causes sharp pain or apprehension, tell the examiner immediately. Pain-limited passive testing is medically significant and must be documented.

Shoulder Special Tests (Hawkins, Empty Can, Crank/Apprehension, Lift-Off, External Rotation Strength)

What it measures: These orthopedic tests assess for rotator cuff integrity, impingement, labral pathology, instability, and subscapularis function - important for documenting associated diagnoses that may be separately rated.

What to expect: Hawkins-Kennedy test: arm flexed to 90-, internally rotated - positive if pain. Empty Can test: arm in scapular plane, thumbs down, downward pressure - positive if weakness or pain (supraspinatus). Crank/Apprehension: arm abducted and externally rotated - positive if apprehension or pain (instability). Lift-Off: arm placed behind back, lifted off - positive if weak (subscapularis). External rotation strength test: resisted external rotation - positive if weak (infraspinatus/teres minor).

Pain considerations: Pain provoked by special tests is itself diagnostically significant - do not suppress your pain response during testing.

Muscle Atrophy Measurement (Circumferential)

What it measures: Whether the affected shoulder/arm has lost muscle mass compared to the unaffected side. Measured in centimeters at a specified anatomical location.

What to expect: The examiner may measure circumference of the upper arm at a defined location and compare bilaterally. Any atrophy suggests chronic disuse or denervation.

Pain considerations: Atrophy of disuse is a recognized sign of functional loss on the DBQ and supports the claim that pain and disability have reduced your ability to use the limb.

50%

Unfavorable ankylosis of the scapulohumeral articulation - dominant arm. The scapula and humerus move as one piece (true bony or fibrous ankylosis), with abduction limited to 25- or less from the side.

From 38 CFR: 38 CFR 4.71a DC 5200: Unfavorable, abduction limited to 25- from side - 50% dominant arm, 40% non-dominant arm. Note: The scapula and humerus move as one piece.

40%

Unfavorable ankylosis - non-dominant arm (40%), OR Intermediate ankylosis - dominant arm (40%). Intermediate position means abduction is between 25- and 60-, or the position of ankylosis is neither clearly favorable nor unfavorable.

From 38 CFR: 38 CFR 4.71a DC 5200: Intermediate between favorable and unfavorable - 40% dominant, 30% non-dominant. Unfavorable ankylosis non-dominant arm - 40%.

30%

Favorable ankylosis - dominant arm (30%), OR Intermediate ankylosis - non-dominant arm (30%). Favorable means the joint is ankylosed in a position allowing the arm to reach the mouth and head, with abduction to 60- possible.

From 38 CFR: 38 CFR 4.71a DC 5200: Favorable, abduction to 60-, can reach mouth and head - 30% dominant, 20% non-dominant. Intermediate non-dominant - 30%.

20%

Favorable ankylosis - non-dominant arm. The joint is ankylosed in a favorable position (can reach mouth and head, abduction to 60-) but this is the non-dominant arm.

From 38 CFR: 38 CFR 4.71a DC 5200: Favorable, abduction to 60-, can reach mouth and head - 20% non-dominant arm.

Ankylosis and Joint Stiffness

How to describe it: Describe the complete or near-complete loss of independent shoulder joint motion. Explain that your shoulder joint itself does not move - only your entire shoulder blade shifts when you try to raise your arm. Mention how long you have had this stiffness and whether it has worsened.

Example: On my worst days, I cannot lift my arm away from my side at all. The joint feels completely locked. Even trying to raise my arm a few inches causes severe pain, and I can feel my shoulder blade grinding and shifting rather than the actual joint moving. I cannot reach my face, comb my hair, or put on a shirt without using my other arm to assist.

Examiner listens for: Confirmation that glenohumeral joint is fixed (ankylosis), description of scapulothoracic compensation, and functional tasks that are impossible or severely limited due to joint immobility.

Avoid: Do not say 'it's just a little stiff' or 'I manage okay.' Describe the complete picture including compensatory movements, what you cannot do, and how the condition affects your daily routine. Do not minimize by comparing yourself to others.

Pain (DeLuca Factor)

How to describe it: Describe pain at rest, pain with initiation of movement, pain at specific degrees of motion, and pain after sustained or repetitive use. Include severity (0-10 scale), character (sharp, burning, aching, throbbing), location (joint, radiating down arm, into neck), and duration of pain episodes.

Example: On my worst days, the pain in my right shoulder is an 8 out of 10 even at rest. The moment I try to lift my arm even slightly, I get a sharp stabbing pain at the joint. After I try to use my arm for any task - even briefly - the pain escalates and stays elevated for hours or through the next day. I wake up at night regularly from the pain.

Examiner listens for: The DBQ asks whether pain was present during ROM testing, at what degree pain began, whether pain was present at rest, and whether it causes functional loss. The examiner documents this in the flare-up and functional loss sections.

Avoid: Do not minimize pain by saying 'I can push through it.' Report your actual experience. If pain limits how long you can do something, or prevents you from sleeping, say so. The examiner needs to hear that pain itself causes functional loss, not just ROM limitation.

Weakness (DeLuca Factor)

How to describe it: Describe inability to lift, carry, push, or pull with the affected arm. Quantify what you cannot lift (e.g., cannot lift a gallon of milk overhead, cannot carry groceries, cannot push open a heavy door). Explain whether weakness is constant or worsens with use.

Example: My right arm is so weak I cannot lift even a light object above shoulder height. I cannot carry a bag of groceries with that arm for more than a few steps before dropping it. I have completely stopped using that arm for any tasks requiring force. Even holding a plate with that arm while eating is uncomfortable.

Examiner listens for: The DBQ has specific checkboxes for weakened movement and weakness as functional loss factors. The examiner will also perform resistance testing and assess grip strength and shoulder muscle strength.

Avoid: Do not demonstrate your maximum effort during strength testing if doing so causes pain - pain-inhibited strength is medically significant. Do not say 'I manage' without explaining what accommodations you make.

Fatigability (DeLuca Factor)

How to describe it: Describe how quickly your shoulder fatigues with use, and how ROM and pain worsen after activity. Include how long you can perform a task before fatigue forces you to stop, and how long recovery takes.

Example: If I try to wash dishes or do any task that uses my shoulder for more than five minutes, the fatigue becomes overwhelming. The shoulder aches deeply and I cannot continue. It takes hours for the fatigue to resolve, and the next day my shoulder is significantly stiffer and more painful than usual.

Examiner listens for: The DBQ specifically includes fatigability as a functional loss checkbox. The examiner should ask about repetitive-use ROM change and document it. Per DeLuca, fatigability must be considered in the rating.

Avoid: Do not say 'I just take a break.' Explain the severity and duration of fatigue and its impact on your ability to work, perform self-care, or engage in normal daily activities.

Incoordination (DeLuca Factor)

How to describe it: Describe any lack of smooth, coordinated movement of the affected arm - jerky motion, inability to control fine placement of the arm, or difficulty with precise upper extremity tasks such as writing, typing, reaching for specific objects, or using tools.

Example: When I try to reach for something specific, my shoulder does not move smoothly. The motion is jerky and unpredictable. I have dropped items because I cannot control the precise positioning of my arm. I cannot reliably place my hand where I intend when my shoulder is involved.

Examiner listens for: The DBQ has a checkbox for incoordination as a functional loss factor. The examiner may observe guarding or awkward compensatory movements during the physical exam.

Avoid: If incoordination is present, report it - it is a formally recognized DeLuca factor that can independently support a higher rating level beyond ROM findings alone.

Flare-Ups (DeLuca Factor)

How to describe it: Describe the frequency, duration, triggers, and severity of flare-ups. A flare-up means a period when your shoulder is significantly worse than your baseline. Include what causes flare-ups (weather, activity, lifting, sleeping on the shoulder), what the flare looks like (increased pain, further reduced ROM, swelling, inability to use arm), and how long they last.

Example: I have severe flare-ups approximately 3-4 times per month. During a flare, my shoulder pain goes from a baseline 4/10 to 9/10, and I cannot move the arm at all for 2-3 days. Cold weather, sleeping wrong, or any attempt at overhead motion can trigger a flare. During these periods I am completely unable to work or perform self-care on the affected side.

Examiner listens for: The DBQ has dedicated fields asking about flare-up frequency, severity, and whether the examiner can document the veteran's description of flare-ups. This information directly supports higher ratings when current ROM does not reflect the worst-day picture.

Avoid: The exam captures a single snapshot in time. If you are having a relatively good day during the exam, proactively tell the examiner: 'Today is not representative of how my shoulder typically is. I need to describe what a typical day and my worst days look like.'

Functional Impact on Daily Life and Work

How to describe it: Describe specific tasks you cannot do or can no longer do because of your shoulder. Include self-care (dressing, bathing, grooming), household tasks (cooking, cleaning, yard work), vocational tasks, recreation, and sleep. Be specific and concrete.

Example: I cannot put on a button-down shirt without help. I cannot wash my hair with my right hand. I stopped driving long distances because the shoulder cramps from holding the wheel. I cannot reach overhead shelves, cannot carry a bag of groceries, and cannot perform any overhead work. I was a carpenter and had to change careers because I cannot swing a hammer or use power tools safely. I wake up 3-4 times per night from shoulder pain.

Examiner listens for: The DBQ has a dedicated section asking the examiner to document the veteran's description of functional loss. Specific, concrete examples of lost function are far more useful than general statements.

Avoid: Do not say 'I just work around it.' If you have changed how you do things, stopped doing things, or asked others for help, that IS functional loss. Every accommodation you make is evidence of disability.