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C&P Exam Prep: Clavicle or Scapula - Impairment of
DBQ Overview
Interview + Physical- Form Name
- Shoulder_and_or_Arm
- Form Code
- Shoulder_and_or_Arm
- Page Count
- 14
- Examiner Type
- Physician or Physician Assistant
- Estimated Duration
- 30-45 minutes
- Exam Format
- Interview + Physical
What to Expect During Your Exam
Exam Overview
To document the current severity of clavicle or scapula impairment, including any dislocation, nonunion, or malunion of these bones, and to assess resulting functional limitation of the shoulder girdle and contiguous joints. The examiner will also evaluate whether the condition can be rated on impairment of function of a contiguous joint (shoulder or elbow) if that yields a higher evaluation.
What the examiner evaluates:
- Type of bony impairment: dislocation, nonunion (with or without loose movement), or malunion of clavicle or scapula
- Presence and degree of loose movement at the fracture or nonunion site
- Visible or palpable deformity of the clavicle or scapula
- Active and passive range of motion of the glenohumeral (shoulder) joint and acromioclavicular joint
- Pain with motion, at rest, and with repetitive use (DeLuca factors)
- Strength testing of the rotator cuff and shoulder girdle muscles
- Functional loss due to pain, fatigue, weakness, and incoordination
- Any flare-ups, their frequency, duration, and severity
- Surgical history related to the clavicle or scapula
- Assistive device use
- Impact on occupational and daily activities
- Whether the condition should be rated under DC 5203 or alternatively on impairment of function of a contiguous joint (DC 5201, 5202, 5200, or elbow codes)
Exam typically conducted at a VA Medical Center, VAMC community-based outpatient clinic (CBOC), or contracted examiner facility (QTC, LHI, VES). In-person examination is standard for musculoskeletal conditions. Bring any imaging (X-rays, CT scans, MRI) related to the clavicle or scapula. You have the right to request that the exam be recorded in most states.
Typical duration: 30-45 minutes
Shoulder Flexion (Active and Passive)
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.
Key thresholds:
- Limited to 90- or less (arm at shoulder level) — 20% under DC 5201 if rated on contiguous joint function
- Limited to 90-180- — 10% under DC 5201 if motion is mildly limited
- Pain with motion before reaching normal endpoint — May support higher effective rating via DeLuca factors even if measured ROM appears near-normal
Tips:
- Perform active ROM first, then passive - report pain at the exact degree it begins
- Tell the examiner if today's motion is better or worse than your typical day
- If motion worsens after repetition, state this before the exam ends
- Report any crepitus (grinding/clicking) you feel during movement
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)
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.
Key thresholds:
- Abduction limited to 90- (shoulder level) — 10-20% range depending on rating method used
- Painful arc between 60- and 120- — Supports functional loss finding; examiner should document as DeLuca factor
Tips:
- Report if there is a painful arc at mid-range even if you can complete full abduction with effort
- Describe the quality of pain (sharp, burning, aching) and its exact location (over clavicle, AC joint, top of shoulder, etc.)
- Mention if you compensate by hiking your shoulder or leaning your body
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
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.
Key thresholds:
- External rotation limited to 30- or less — Significant functional loss; supports higher rating if contiguous joint function is used
- Internal rotation - inability to reach lumbar spine or above — Documents ADL limitations (hygiene, dressing)
Tips:
- Tell the examiner which daily activities require rotation and how the limitation affects you
- Mention difficulty fastening a bra, tucking in a shirt, reaching behind your back, or combing hair
- Note whether pain or stiffness limits rotation even before the physical endpoint
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
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.
Key thresholds:
- Dislocation confirmed (clavicle or scapula) — 20% (major or minor)
- Nonunion WITH loose movement — 20% (major or minor)
- Nonunion WITHOUT loose movement — 10% (major or minor)
- Malunion confirmed — 10% (major or minor)
- Contiguous joint (shoulder) function more severely impaired — Rate under DC 5200, 5201, 5202 instead - potentially higher rating
Tips:
- Point to the exact location of your clavicle or scapula that was fractured, dislocated, or surgically repaired
- Describe any visible bump, ridge, or step-off deformity you can see or feel yourself
- Tell the examiner if you feel movement or clicking at the fracture site when you move your arm
- If you have imaging showing the nonunion or malunion, bring it and mention it explicitly
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)
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.
Key thresholds:
- Motion decreases after repetition by 10- or more — Supports finding of functional loss greater than initial ROM suggests
- Pain intensity increases with use — Must be documented as a DeLuca factor for accurate rating
Tips:
- Tell the examiner: 'After using my arm for [X minutes/repetitions], I lose another [X degrees] of motion and the pain becomes [description]'
- Describe the fatigue and weakness that sets in after sustained shoulder use
- Give a concrete daily example: 'After washing dishes for 5 minutes, I cannot lift my arm above my shoulder'
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)
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.
Key thresholds:
- Strength grade 3/5 or less (movement against gravity only) — Documents significant weakness as a DeLuca functional loss factor
- Positive Empty Can or Lift-Off test — Supports rotator cuff involvement secondary to scapular/clavicle impairment
Tips:
- Report if your arm gives way suddenly or if you drop objects
- Mention if your shoulder fatigues rapidly during overhead tasks
- Describe specific tasks you can no longer do due to weakness: 'I cannot lift a gallon of milk above my shoulder'
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.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 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. |
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. |
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. |
20% Dislocation of clavicle or scapula (major or minor limb); OR ...
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.
Key Symptoms
- Persistent dislocation of the clavicle (sternoclavicular or acromioclavicular) or scapula
- Nonunion of a clavicle or scapula fracture confirmed on imaging
- Palpable loose or abnormal movement at the fracture/nonunion site
- Significant shoulder girdle instability or clicking with arm movement
- Pain and functional limitation consistent with 20% under contiguous joint DCs (e.g., shoulder motion limited to 90- or above)
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 th ...
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.
Key Symptoms
- Healed but malaligned clavicle or scapula fracture (malunion) with visible or palpable deformity
- Nonunion confirmed on imaging but without demonstrable loose movement on exam
- Chronic aching pain at the malunion site, especially with overhead activity
- Mild to moderate limitation of shoulder motion attributable to the malunion
- Cosmetic deformity (bump or ridge over clavicle) with functional impact
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.
How to Describe Your Symptoms
Pain - Location, Quality, and Triggers
How to describe:
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.
Worst-day 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.”
What the 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.
Understatements to 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:
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.
Worst-day 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.”
What the examiner listens for:
Specific triggers, measurable frequency and duration, functional impact during the flare, whether flares result in incapacitation from normal activity.
Understatements to 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:
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.'
Worst-day 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.”
What the 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.
Understatements to 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:
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.
Worst-day 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.”
What the examiner listens for:
Observable weakness during strength testing, functional loss beyond what ROM measurements alone capture, occupational and daily life impairment.
Understatements to 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:
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.
Worst-day 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.”
What the examiner listens for:
Objective physical finding of malunion deformity; asymmetry; relationship between the deformity and reported functional limitation.
Understatements to 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:
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.
Worst-day 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.”
What the 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.
Understatements to 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.
Common Mistakes to Avoid
Failing to mention that the nonunion site has loose movement
The difference between a 10% and 20% rating under DC 5203 for nonunion is entirely based on whether there is loose movement. If the veteran does not describe this symptom, the examiner may not specifically test for it.
Instead: Before the exam, identify whether you feel any clicking, shifting, or instability at the fracture/nonunion site. During the exam, proactively say: 'I feel movement/instability at the site of my old fracture when I move my arm.'
Impact: 10% vs. 20%
Performing at 'best-day' capacity during ROM testing
Many veterans unconsciously push through pain during the exam to appear capable. ROM measured at best-day effort may not reflect true disability and can result in a lower rating.
Instead: Tell the examiner if today is a better or worse day than usual. Stop movement at the point where pain begins and say: 'I feel pain here at X degrees.' Per M21-1 guidance, the examiner should capture your representative level of impairment, not your maximum possible effort on a good day.
Impact: Any level
Not mentioning that contiguous joint (shoulder) function may be rated separately or alternatively
DC 5203 explicitly allows rating on 'impairment of function of contiguous joint.' If shoulder ROM is limited to 90- or less due to clavicle/scapula impairment, the veteran may qualify for 20% under DC 5201 - potentially higher than the DC 5203 rate alone.
Instead: If your shoulder motion is significantly limited, make sure to fully document all ROM limitations during the exam. Bring up the alternative rating to your VSO before the exam and ensure the examiner documents all shoulder motion measurements.
Impact: 10% vs. 20%
Not reporting functional loss beyond ROM measurements (DeLuca factors)
ROM measurements during a brief exam may appear less limited than the veteran's actual functional state because pain, fatigue, and weakness with use are not captured by a single static measurement.
Instead: Proactively describe: (1) how much pain increases with repeated use, (2) how quickly fatigue sets in, (3) whether weakness causes the arm to give way, and (4) whether ROM degrades after activity. If the examiner does not perform repetitive-use testing, state: 'My motion worsens significantly after repetitive use.'
Impact: Any level
Minimizing or not reporting flare-ups
Flare-up frequency and severity are required DBQ fields and directly inform the rating decision. Veterans who do not volunteer this information may receive an incomplete evaluation.
Instead: Prepare a written summary of your flare-up pattern before the exam: how often they occur, what triggers them, how long they last, and how severe they are. Have this ready to share with the examiner.
Impact: Any level
Not bringing imaging or medical records documenting the fracture, nonunion, malunion, or dislocation
DC 5203 requires objective evidence of the specific type of bony impairment (dislocation, nonunion, malunion). Without imaging, the examiner may be unable to confirm the diagnosis.
Instead: Request copies of all relevant X-rays, CT scans, and MRI reports from your treating providers. Bring them to the exam and hand-deliver them to the examiner. Confirm VA has uploaded them to your file before the exam date.
Impact: Any level
Prep Checklist
Before Your Exam
Day Of
During the Exam
After the Exam
Your Rights During a C&P Exam
- You have the right to a thorough, in-person examination conducted by a qualified physician or physician assistant for musculoskeletal conditions.
- You have the right to have the examiner review your entire claims file before conducting the examination.
- You have the right to describe your symptoms in your own words, including worst-day presentation and flare-up patterns, not just how you feel on the day of the exam.
- You have the right to report pain at the exact degree it begins during ROM testing - the examiner must document this, not just the endpoint of motion.
- Under DeLuca v. Brown, 8 Vet. App. 202 (1995), the examiner must assess and document pain on movement, weakened movement, excess fatigability, and incoordination as sources of functional loss - not just static ROM measurements.
- You have the right to request that the examination be recorded in most U.S. states. Contact your VSO or state veterans affairs office to confirm the applicable rules in your state.
- You have the right to challenge an inadequate C&P examination by submitting a personal statement, requesting a new exam, or appealing the rating decision if the exam did not address required elements.
- You have the right to have your condition rated under the most favorable diagnostic code - DC 5203 must be compared with the alternative provision to rate on impairment of function of the contiguous joint, and the higher evaluation applies.
- You have the right to submit additional evidence (imaging, treatment records, buddy statements) at any time before or after the exam to support your claim.
- You have the right to a free copy of your completed DBQ and claims file through VBMS or a FOIA request.
Related Conditions
- Scapulohumeral Articulation, Ankylosis of Direct complication. Clavicle or scapula impairment can progress to complete ankylosis of the scapulohumeral joint, rated under DC 5200 at 30 50%. If the shoulder joint is completely fused, DC 5200 applies instead of or in addition to DC 5203.
- Shoulder - Limitation of Motion Alternative rating pathway. DC 5203 explicitly permits rating on 'impairment of function of contiguous joint.' If limitation of shoulder abduction or flexion to 90 or less is present, DC 5201 may yield a higher rating (20%) than DC 5203 for malunion or nonunion without loose movement (10%). Raters must compare both and assign the higher evaluation.
- Shoulder - Recurrent Dislocation or Subluxation Overlapping pathology. Clavicle dislocation or acromioclavicular separation can cause or contribute to glenohumeral instability, potentially separately ratable under DC 5202 if manifestations are distinct and non duplicative per M21 1, Part V, Subpart iii, 1.B.1.
- Acromioclavicular Joint Osteoarthritis Common secondary condition. Malunion or chronic dislocation of the clavicle frequently causes post traumatic arthritis at the acromioclavicular joint, separately ratable under DC 5003 (degenerative/post traumatic arthritis) if there is objective evidence of arthritis on X ray and limitation of motion.
- Post-Traumatic Arthritis - Shoulder Secondary condition. Clavicle or scapula fractures with malunion frequently cause post traumatic arthritis of the glenohumeral or acromioclavicular joints, potentially ratable separately under DC 5003 if X ray findings confirm arthritis and limitation of motion is present.
- Rotator Cuff Tear Associated injury. Clavicle and scapula fractures, especially those involving the AC joint, are frequently accompanied by rotator cuff tears. If a rotator cuff tear is separately diagnosed and produces distinct symptomatology, it may be separately ratable and should be claimed concurrently.
- Elbow - Other Impairment (Flail Joint) Alternative contiguous joint rating. DC 5203 also permits rating on impairment of function of the elbow as the contiguous joint. In severe cases of clavicle/scapula impairment affecting elbow function, DC 5209 (60/50%) could potentially apply.
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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.