Injury to muscles that stabilize the shoulder joint.
Because the severity levels are defined in § 4.56, evidence that reflects the specific criteria in that section carries the most weight. Medical records documenting how the injury occurred, which muscles were affected, and findings on physical examination help establish the diagnosis and degree of damage. Records showing muscle weakness, reduced range of motion at the shoulder, pain with abduction or rotation, and any signs of muscle atrophy or scarring are directly relevant to separating one severity level from another.
Imaging studies, surgical or operative reports, and notes from treating providers describing the functional condition of the shoulder over time all help show severity. Statements from you or people who know you — describing difficulty lifting, reaching, or performing work tasks that require strong shoulder movements — can show how the injury affects daily function. If the injury is to your dominant arm, documentation confirming which arm is dominant supports the correct rating percentage being applied. VA may also consider whether loss of use of the extremity is present, which could relate to eligibility for special monthly compensation under 38 CFR § 3.350.
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.
