Injury to muscles that pull the arm downward.
Because the rating levels are defined by the criteria in 38 CFR § 4.56, evidence that reflects those criteria matters most. Medical records documenting the nature and extent of the muscle injury — such as operative reports, imaging, or treatment notes — help establish the severity of damage to the pectoralis major, latissimus dorsi, teres major, pectoralis minor, or rhomboids.
Physical examination findings are central. Records showing range of motion of the shoulder, strength testing of arm depression and downward scapular rotation, signs of muscle wasting or scarring, and any weakness or pain on use all speak directly to severity. If a muscle injury limits your ability to bring your arm down from overhead or swing it forward and backward, documentation of those specific functional losses is relevant.
Statements from you or people who know you describing how the injury affects work tasks, lifting, reaching, or daily activities that require arm movement can also reflect functional severity. If loss of arm use is at issue, records that address that level of impairment would be relevant to the special monthly compensation question.
Conditions that are often caused or made worse by this one. If you have any of these, they may be claimable as secondary service connection.
