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

DC 5301 musculoskeletal 38 CFR 4.73

DBQ Overview

Interview + Physical
Form Name
Muscle_Injuries
Form Code
Muscle_Injuries
Page Count
12
Examiner Type
Orthopedic Surgeon, Physiatrist, or appropriate clinician
Estimated Duration
30-60 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To evaluate the nature, severity, and functional impact of a service-connected or potentially service-connected injury to Muscle Group I, which includes the extrinsic muscles of the shoulder girdle - specifically the trapezius, levator scapulae, and serratus anterior. The examiner will document objective findings and functional loss to support a disability rating under 38 CFR 4.73, Diagnostic Code 5301.

What the examiner evaluates:

  • Identification of the injured muscle group (Group I: trapezius, levator scapulae, serratus anterior)
  • Nature of the original injury (wound track, scar characteristics, missile/shrapnel evidence)
  • Current scar findings including minimal scars, entrance/exit scars, ragged adherent scars, loss of deep fascia
  • Muscle findings: loss of substance, soft/flabby muscles, impaired muscle tonus, induration or atrophy, adaptive contraction of opposing muscles, abnormal swelling/hardening during contraction
  • Functional loss indicators: weakness, loss of power, fatigue, lowered threshold of fatigue, impairment of coordination, uncertainty of movement
  • Shoulder strength testing (manual muscle testing 0-5 scale, both right and left)
  • Range of motion of the shoulder and cervical spine as applicable
  • Presence of visible or measurable muscle atrophy with circumferential measurements
  • Assistive device usage (wheelchair, walker, crutches, canes, braces)
  • Impact on activities of daily living and occupational function
  • History, onset, course of the condition
  • Retained foreign bodies (shell fragments, shrapnel) if applicable by X-ray evidence
  • Any neoplasms, residuals, or complications of the muscle injury

Exam will typically be conducted in-person at a VA medical facility, contractor clinic (QTC, LHI, VES), or occasionally via telehealth for records-only review. You have the right to request an in-person examination. Bring all relevant medical records, buddy statements, and a written summary of your symptoms. Most states permit recording of the exam - check your state law and notify the examiner beforehand if you intend to record.

Typical duration: 30-60 minutes

Manual Muscle Testing (MMT) - Shoulder Group I

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.

Key thresholds:

  • Grade 5/5 bilateral — Likely supports 0% or minimal rating if no other findings
  • Grade 4/5 — Some functional loss; supports moderate rating
  • Grade 3/5 — Significant functional loss; supports higher rating tier
  • Grade 2/5 or below — Severe functional loss; supports maximum or near-maximum rating

Tips:

  • Do not exaggerate weakness - demonstrate your true maximum effort
  • Perform the test at your actual current capacity, not what you could do on a good day
  • Inform the examiner if pain or fatigue limits your ability to sustain resistance
  • Ask to repeat the test if you were not at your worst (e.g., after prolonged activity that morning)
  • Report any increase in pain or symptom worsening after the testing itself

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

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.

Key thresholds:

  • Measurable asymmetry present — Documents objective atrophy supporting moderate-to-severe rating
  • No measurable atrophy — Does not preclude rating if functional loss from weakness, fatigue, or pain is documented

Tips:

  • Point out any visible winging of the scapula (sign of serratus anterior weakness)
  • Mention any history of documented atrophy in treatment records
  • Note if atrophy is not visible because the condition is bilateral or compensatory hypertrophy occurred in adjacent muscles
  • Request the examiner note findings in writing even if subtle

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

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.

Key thresholds:

  • Ragged, depressed, adherent scars indicating wide damage — Supports higher severity rating tier
  • Adhesion of scar to scapula or long bone — Objective finding supporting moderate-to-severe rating
  • Minimal/linear scars only — Lower severity scar finding; functional loss from other factors still evaluated

Tips:

  • Know the location of all scars on your shoulder, neck, and upper back related to this condition
  • If scars are adherent or tender, demonstrate this to the examiner by showing restricted movement caused by the scar
  • Mention any surgical scars from procedures to treat this muscle injury
  • Note if scars cause pain, numbness, or restricted movement in daily activities

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

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.

Key thresholds:

  • Symptoms worsen after repetitive use — Supports higher rating; per DeLuca, examiner must note this
  • No change after repetitive use — May support lower rating tier

Tips:

  • Before the exam, engage in your normal morning activities so symptoms reflect typical use patterns
  • Tell the examiner: 'By the end of the day, or after using my arm repeatedly, my shoulder becomes significantly weaker and more painful'
  • Describe specific examples: 'After 20 minutes of overhead work my trapezius fatigues completely and I must stop'
  • Ask the examiner to document the DeLuca factors even if they do not test repetitive use directly

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.

Estimate

Rating Criteria Breakdown

40% Severe injury to Muscle Group I. Complete or near-complete l ...

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.

Key Symptoms

  • Profound weakness (MMT 2/5 or below)
  • Extensive measurable atrophy
  • Adhesion of scar to scapula or long bone
  • Muscles swell and harden abnormally in contraction
  • Atrophy of muscle groups outside the wound track (denervation)
  • Tests of endurance markedly abnormal compared to normal side
  • Inability to perform overhead activities
  • Severe functional impairment of upper extremity use
  • Soft, flabby muscles in wound area

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.

30% Moderately severe injury to Muscle Group I. Significant obje ...

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.

Key Symptoms

  • Marked weakness (MMT grade 3/5 or less)
  • Loss of power in shoulder girdle
  • Visible or measurable atrophy of trapezius or related muscles
  • Ragged, depressed, adherent scars indicating wide damage
  • Impairment of coordination
  • Uncertainty of movement
  • Significantly lowered fatigue threshold
  • Adaptive contraction of opposing muscle groups
  • Functional limitation in overhead activities, lifting, carrying

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.

20% Moderate injury to Muscle Group I. Objective findings of mus ...

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.

Key Symptoms

  • Moderate weakness on MMT (grade 4/5 or 3+/5)
  • Some loss of muscle substance
  • Impaired muscle tonus on palpation
  • Lowered threshold of fatigue
  • Fatigue and/or pain with use
  • Moderate scar findings (some adherence or track)
  • Some loss of deep fascia

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.

10% Slight injury to Muscle Group I. Minimal findings such as sm ...

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.

Key Symptoms

  • Mild aching or tenderness in trapezius area
  • Minimal or linear entry/exit scars
  • Slight subjective weakness
  • No measurable atrophy
  • Full or near-full strength on MMT
  • No significant loss of power

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.

0% No injury to Muscle Group I, or injury that is completely he ...

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.

Key Symptoms

  • No weakness
  • No fatigue
  • No pain on use
  • Full range of motion
  • No scar findings
  • No atrophy

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

How to Describe Your Symptoms

Pain

How to describe:

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.

Worst-day 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.”

What the 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.

Understatements to 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:

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).

Worst-day 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.”

What the 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.

Understatements to 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:

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.

Worst-day 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.”

What the 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.

Understatements to 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:

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).

Worst-day 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.”

What the examiner listens for:

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

Understatements to 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:

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.

Worst-day 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.”

What the 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).

Understatements to 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:

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.

Worst-day 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.”

What the 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.

Understatements to 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.

Common Mistakes to Avoid

Prep Checklist

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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, accurate C&P examination that evaluates all DeLuca factors including pain, fatigue, weakness, incoordination, and flare-ups - not just static range of motion or strength at rest.
  • You have the right to request an in-person C&P examination rather than a records-only review if your condition has significant functional findings that require physical examination.
  • You have the right to review the completed DBQ and challenge an inadequate examination through a Notice of Disagreement, Supplemental Claim, or request for a new examination.
  • You have the right to submit your own medical evidence (independent medical opinions, private treatment records, buddy statements) to supplement or challenge the C&P examiner's findings.
  • In most states, you have the right to record your C&P examination. Check your state's one-party or two-party consent law before recording, and notify the examiner at the start of the exam.
  • Under 38 CFR 4.40 and 4.45 (DeLuca v. Brown), you have the right to have pain, fatigue, weakness, and incoordination - including effects after repetitive use - considered as sources of functional loss, not just measured range of motion or strength.
  • You have the right to the benefit of the doubt under 38 USC 5107(b). When evidence is in approximate balance, the VA must resolve the question in your favor.
  • You have the right to a new examination if your condition has significantly worsened since the last rating decision, or if the prior examination was inadequate.
  • You have the right to have your symptoms rated based on your worst-day presentation and the full range of your condition, not just how you present on the specific day of the examination.
  • You have the right to be treated with dignity and respect during the examination. You may bring a representative, VSO, family member, or support person to accompany you, though they may need to remain in the waiting area during the physical examination depending on facility policy.

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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.