Musculoskeletal

Shoulder Condition C&P Exam Guide

Associated DBQ Form: DBQ Shoulder and Arm

What to Expect During Your Exam

The shoulder C&P exam takes about 30-45 minutes and includes a physical examination with range of motion testing.

The exam includes:
1. Medical history review
2. Range of motion testing (flexion, abduction, rotation)
3. Strength testing
4. Special tests for impingement and rotator cuff
5. Review of imaging studies

Questions the Examiner May Ask

  • 1 How did you injure your shoulder?
  • 2 Which shoulder is affected?
  • 3 Is this your dominant arm?
  • 4 Can you raise your arm overhead?
  • 5 Do you have pain reaching behind your back?
  • 6 Does your shoulder feel weak?
  • 7 Do you have difficulty sleeping on that side?
  • 8 Have you had any shoulder surgeries?
  • 9 What activities are limited by your shoulder condition?

Documentation to Bring

  • Service treatment records documenting shoulder injury
  • Current imaging (X-rays, MRI)
  • Surgical records if applicable
  • Physical therapy records
  • Documentation of treatments (injections, etc.)

How to Prepare

Before your exam:

1. **Document your injury** - When and how did it happen?

2. **Know which shoulder** - Is it your dominant or non-dominant arm? (ratings differ)

3. **List functional limitations** - Reaching overhead, behind back, lifting

4. **Track pain patterns** - When is it worst? What movements cause pain?

5. **Note sleep impact** - Many shoulder conditions make sleeping difficult

Helpful Tips

- Dominant arm gets a higher rating than non-dominant for the same limitation
- Stop range of motion when pain begins
- Mention if repetitive movement increases pain
- Describe specific activities you can't do (reaching overhead, carrying)
- If you've had surgery, explain what was done and current symptoms
- Mention if shoulder pain affects your sleep
- Report any weakness or instability

Common Mistakes to Avoid

- Claiming inability to raise arm when records show otherwise
- Inconsistency between stated limitations and observed behavior
- No documented in-service shoulder injury
- Refusing to attempt range of motion testing

How VA Rates This Condition

Shoulder conditions are rated under 38 CFR § 4.71a:

**Limitation of Arm Motion (DC 5201):**

Major (dominant) / Minor arm:
- 20% / 20%: At shoulder level (90°)
- 30% / 20%: Midway between side and shoulder level
- 40% / 30%: Limited to 25° from side

**Impairment of Humerus (DC 5202):**
- Ratings range from 20% to 80% depending on severity

**Impairment of Clavicle/Scapula (DC 5203):**
- 10%: Malunion or nonunion without loose movement
- 20%: Nonunion with loose movement or dislocation

**Note:** The higher rating is given for the dominant (major) arm.