C&P Exam for Scapulohumeral articulation, ankylosis of (DC 5200)

Diagnostic code: 5200Condition: Scapulohumeral articulation, ankylosis ofRegulation: 38 CFR § 4.71aDBQ: DBQ MUSC Shoulder and Arm

Which form the examiner uses

For scapulohumeral articulation, ankylosis of (DC 5200), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

This DBQ evaluates shoulder and arm conditions including range of motion, ankylosis, rotator cuff, instability, clavicle/scapula and humerus impairment, and surgical procedures.

How DC 5200 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-V, XI, and XIV-XVI of this form. Section V is the condition-specific section for this code. Sections VI-X and XII-XIII cover unrelated conditions on this DBQ and are skipped.

DIAGNOSIS (Section I)
  • List the claimed conditions that pertain to this questionnaire
  • The Veteran does not have a current diagnosis associated with any claimed conditions listed above.
  • Shoulder strain – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Shoulder impingement syndrome – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Bicipital tendonitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Bicipital tendon tear – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Rotator cuff tendonitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Rotator cuff tear – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Labral tear, including SLAP (superior labral anterior-posterior lesion) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Subacromial/subdeltoid bursitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Glenohumeral joint osteoarthritis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Acromioclavicular joint osteoarthritis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Ankylosis of glenohumeral articulations (shoulder joint) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Glenohumeral joint instability – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Glenohumeral joint dislocation/recurrent dislocation – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Shoulder joint replacement (total shoulder arthroplasty/hemiarthroplasty) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Acromioclavicular joint separation – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Degenerative arthritis, other than posttraumatic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Arthritis, gonorrheal – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Arthritis, pneumococcic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Arthritis, streptococcic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Arthritis, syphilitic – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Arthritis, rheumatoid (multi-joints) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Post-traumatic arthritis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Arthritis, typhoid – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Other specified forms of arthropathy (excluding gout) (specify) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Osteoporosis, residuals of – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Osteomalacia, residuals of – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Bones, neoplasm, benign – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Osteitis deformans – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Gout – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Bursitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Myositis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Heterotopic ossification – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Tendinopathy (select one if known): Tendinitis / Tendinosis / Tenosynovitis – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Inflammatory other types (specify) – Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Other (specify) – Other diagnosis #1: Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • Other (specify) – Other diagnosis #2: Side affected (Right/Left/Both), ICD Code, Date of diagnosis
  • If there are additional diagnoses that pertain to shoulder and/or arm conditions, list using above format
MEDICAL HISTORY (Section II)
  • 2A. Describe the history (including onset and course) of the Veteran's shoulder and/or arm condition (brief summary)
  • 2B. Does the Veteran report flare-ups of the shoulder and/or arm? Yes / No
  • If yes, document the Veteran's description of the flare-ups he or she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he or she experiences during a flare-up of symptoms
  • 2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time? Yes / No
  • If yes, document the Veteran's description of functional loss or functional impairment in his/her own words
RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)
  • 3A. Initial ROM measurements: All normal / Abnormal or outside of normal range / Unable to test / Not indicated
  • If 'Unable to test' or 'Not indicated' please explain
  • If ROM is outside of 'normal' range, but is normal for the Veteran (for reason other than a shoulder/arm condition, such as age, body habitus, neurologic disease), please describe
  • If abnormal, does the range of motion itself contribute to a functional loss? Yes / No (if yes, please explain)
  • Can testing be performed? Yes / No; If no, provide an explanation
  • If this is the unclaimed joint, is it: Damaged / Undamaged
  • Active Range of Motion – Flexion endpoint (180 degrees)
  • Active Range of Motion – Abduction endpoint (180 degrees)
  • Active Range of Motion – Internal rotation endpoint (90 degrees)
  • Active Range of Motion – External rotation endpoint (90 degrees)
  • If noted on examination, which ROM exhibited pain (select all that apply): Flexion / Abduction / Internal Rotation / External Rotation
  • If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe – Flexion degree endpoint (if different than above)
  • If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other – Abduction degree endpoint (if different than above)
  • If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other – Internal rotation degree endpoint (if different than above)
  • If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other – External rotation degree endpoint (if different than above)
  • Passive Range of Motion – Flexion endpoint (180 degrees) / Same as active ROM
  • Passive Range of Motion – Abduction endpoint (180 degrees) / Same as active ROM
  • Passive Range of Motion – Internal rotation endpoint (90 degrees) / Same as active ROM
  • Passive Range of Motion – External rotation endpoint (90 degrees) / Same as active ROM
  • If noted on examination, which ROM exhibited pain? (select all that apply): Flexion / Abduction / Internal Rotation / External Rotation
  • Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – Flexion degree endpoint (if different than above)
  • Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – Abduction degree endpoint (if different than above)
  • Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – Internal Rotation degree endpoint (if different than above)
  • Passive ROM limitation attributable to pain, weakness, fatigability, incoordination, or other – External rotation degree endpoint (if different than above)
  • Is there evidence of pain? Yes / No; If yes check all that apply: weight-bearing / nonweight-bearing / active motion / passive motion / on rest/non-movement / causes functional loss / does not result in/cause functional loss
  • Comments
  • Is there objective evidence of crepitus? Yes / No
  • Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, to include the glenohumeral joint, humerus, clavicle, scapula, acromioclavicular joint, or sternoclavicular joint? Yes / No; If yes, please explain. Include location, severity, and relationship to condition(s).
  • 3B. Is the Veteran able to perform repetitive-use testing with at least three repetitions? Yes / No; If no, please explain
  • Is there additional loss of function or range of motion after three repetitions? Yes / No
  • After three repetitions – Flexion endpoint (180 degrees)
  • After three repetitions – Abduction endpoint (180 degrees)
  • After three repetitions – Internal rotation endpoint (90 degrees)
  • After three repetitions – External rotation endpoint (90 degrees)
  • Select factors that cause this functional loss: Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
  • 3C. Is the Veteran being examined immediately after repeated use over time? Yes / No
  • Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time? Yes / No
  • Select factors that cause this functional loss (repeated use over time): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
  • Estimate range of motion immediately after repeated use over time – Flexion endpoint (180 degrees)
  • Estimate range of motion immediately after repeated use over time – Abduction endpoint (180 degrees)
  • Estimate range of motion immediately after repeated use over time – Internal rotation endpoint (90 degrees)
  • Estimate range of motion immediately after repeated use over time – External rotation endpoint (90 degrees)
  • Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
  • 3D. Is the examination being conducted during a flare-up? Yes / No
  • Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups? Yes / No
  • Select factors that cause this functional loss (flare-ups): Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other / N/A
  • Estimate range of motion during flare-ups – Flexion endpoint (180 degrees)
  • Estimate range of motion during flare-ups – Abduction endpoint (180 degrees)
  • Estimate range of motion during flare-ups – Internal rotation endpoint (90 degrees)
  • Estimate range of motion during flare-ups – External rotation endpoint (90 degrees)
  • Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence.)
  • 3E. In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None / Interference with standing / Disturbance of locomotion / Less movement than normal / Weakened movement / Instability of station / Interference with sitting / Swelling / Deformity / More movement than normal / Atrophy of disuse / Other, describe
  • Please describe additional contributing factors of disability
MUSCLE ATROPHY (Section IV)
  • 4A. Does the Veteran have muscle atrophy? Yes / No
  • 4B. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section? Yes / No; If no, provide rationale
  • 4C. Right upper extremity – specify location of measurement
  • Circumference of more normal side (cm)
  • Circumference of atrophied side (cm)
  • 4C. Left upper extremity – specify location of measurement
  • Circumference of more normal side (cm)
  • Circumference of atrophied side (cm)
ANKYLOSIS (Section V)
  • 5A. Is there ankylosis of the scapulohumeral (glenohumeral) articulation (shoulder joint) - (i.e., the scapula and humerus move as one piece)? Yes / No
  • If yes, indicate the severity of ankylosis: Ankylosis in abduction up to 60 degrees; can reach mouth and head (favorable ankylosis)
  • Ankylosis in abduction between favorable and unfavorable (intermediate ankylosis)
  • Ankylosis in abduction at 25 degrees or less from side (unfavorable ankylosis)
  • 5B. Indicate angle of ankylosis in degrees of abduction
  • 5C. If ankylosed, is there involvement of Muscle Group I (trapezius, levator scapulae, serratus magnus) and II (pectoralis major II (costosternal), latissimus dorsi and teres major, pectoralis minor; rhomboid)? Yes / No; If yes, complete the Muscle Injuries questionnaire.
ROTATOR CUFF CONDITIONS (Section VI)
  • Hawkins' Impingement Test: Positive / Negative / Unable to test / N/A
  • Empty Can Test: Positive / Negative / Unable to test / N/A
  • External rotation/infraspinatus strength test: Positive / Negative / Unable to test / N/A
  • Lift-off subscapularis test: Positive / Negative / Unable to test / N/A
  • 6B. If unable to test, is a rotator cuff condition suspected? Yes / No; If yes, please describe
SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY (Section VII)
  • 7A. Crank Apprehension and Relocation Test: Positive / Negative / Unable to test / N/A
  • 7B. If unable to test, is shoulder instability, dislocation or labral pathology suspected? Yes / No; If yes, please describe
  • 7C. Is there shoulder instability, dislocation or labral pathology? Yes / No
  • 7D. Does the Veteran have mechanical symptoms (clicking, catching, etc.)? Yes / No
  • 7E. Are there current residuals of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint? Yes / No; If yes, check all that apply: Infrequent episodes and guarding of movement only at shoulder level (flexion and/or abduction at 90°) / Frequent episodes and guarding of all arm movements
  • Affects range of motion? Yes / No
CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT AND STERNOCLAVICULAR JOINT CONDITIONS (Section VIII)
  • 8A. Cross-body adduction test: Positive / Negative / Unable to test / N/A
  • 8B. If unable to test, is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition suspected? Yes / No; If yes, please describe
  • 8C. Is there a clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition or other impairment? Yes / No; If yes, indicate severity: Malunion of clavicle or scapula / Nonunion of clavicle or scapula without loose movement / Nonunion of clavicle or scapula with loose movement / Dislocation (acromioclavicular separation or sternoclavicular dislocation) / Other (describe)
  • 8D. Does the clavicle or scapula condition affect range of motion of the shoulder (glenohumeral joint)? Yes / No
CONDITIONS OR IMPAIRMENTS OF THE HUMERUS (Section IX)
  • 9A. Does the Veteran have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus? Yes / No; If yes, check all that apply: Loss of head (flail shoulder) / Nonunion (false flail shoulder) / Fibrous union
  • 9B. Does the Veteran have malunion of the humerus with moderate or marked deformity? Yes / No; If yes, indicate severity: Moderate deformity / Marked deformity
  • 9C. Does the humerus condition affect range of motion of the shoulder (glenohumeral joint)? Yes / No
SURGICAL PROCEDURES (Section X)
  • 10A. No surgery
  • Total shoulder joint replacement – Date of surgery
  • Residuals: None / Intermediate degrees of residual weakness, pain, or limitation of motion / Chronic residuals consisting of severe painful motion or weakness / Other residuals, describe
  • Arthroscopic or other shoulder surgery – Date of Surgery / Type of Surgery
  • Describe residuals
OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section XI)
  • 11A. Does the Veteran have any other pertinent physical findings, complications, signs, or symptoms related to any conditions listed in the diagnosis section above? Yes / No; If yes, describe (brief summary)
  • 11B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section? Yes / No; If yes, also complete the appropriate dermatological questionnaire.
  • 11C. Comments, if any
ASSISTIVE DEVICES (Section XII)
  • 12A. Does the Veteran use any assistive devices? Yes / No
  • Brace – Frequency of use: Occasional / Regular / Constant
  • Other, describe – Frequency of use: Occasional / Regular / Constant
  • 12B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition
REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XIII)
  • 13A. Due to the Veteran's shoulder or arm condition(s), is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well-served by an amputation with prosthesis (functions of the upper extremity include grasping, manipulation, etc.)? Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran / No
  • If yes, indicate extremities for which this applies: Right upper / Left upper
  • 13B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function, and provide specific examples (brief summary)
DIAGNOSTIC TESTING (Section XIV)
  • 14A. Have imaging studies been performed in conjunction with this examination? Yes / No
  • 14B. If yes, is degenerative or post-traumatic arthritis documented? Yes / No; If yes, indicate side: Right / Left / Both
  • 14C. If yes, provide type of test or procedure, date and results (brief summary)
  • 14D. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes / No; If yes, provide type of test or procedure, date and results (brief summary)
  • 14E. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition(s)
FUNCTIONAL IMPACT (Section XV)
  • 15A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? Yes / No
  • If yes, describe the functional impact of each condition, providing one or more examples
REMARKS (Section XVI)
  • 16A. Remarks (if any - please identify the section to which the remark pertains when appropriate)

Rating Levels for DC 5200

The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

What the Board discussed in granted decisions for DC 5200

The themes below were extracted by clustering 500 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

  1. 40% Benefit of the doubt doctrine applied or noted as applicable
    The Board cited the statutory or regulatory benefit of the doubt standard, noted its consideration, or applied it in favor of the Veteran when evidence was in approximate balance.
    198 of 500 sample sentences
  2. 22% Benefit of the doubt doctrine found inapplicable, preponderance against claim
    The Board found that the preponderance of evidence weighed against the claim, rendering the benefit of the doubt doctrine inapplicable and resulting in denial.
    112 of 500 sample sentences
  3. 16% Evidence found in equipoise, higher rating or service connection warranted
    The Board determined that the lay and medical evidence was in relative equipoise or approximate balance on a material question, resolving doubt in the Veteran's favor to grant a higher rating or service connection.
    80 of 500 sample sentences
  4. 11% Medical nexus opinion recorded as at least as likely as not
    A VA or private examiner opined that a current disability was at least as likely as not incurred in, caused by, or related to the Veteran's active military service or a service-connected condition.
    56 of 500 sample sentences
  5. 4% Objective range of motion or functional loss findings cited in support of higher rating
    The Board noted specific clinical findings of limited range of motion, pain on use, or functional impairment as supporting a higher disability rating under the applicable diagnostic code.
    18 of 500 sample sentences
  6. 2% Diagnostic Code 5200 or shoulder ankylosis criteria cited in rating analysis
    The Board referenced Diagnostic Code 5200 or the specific criteria for scapulohumeral ankylosis in evaluating whether the evidence supported a particular disability rating.
    10 of 500 sample sentences
  7. 2% Lay statements of continuity of symptoms or severity recorded
    The Board noted the Veteran's competent lay assertions regarding onset, continuity, or severity of symptoms as credible and material to the rating or service connection determination.
    10 of 500 sample sentences
  8. 2% Probative weight assigned to specific medical evidence or opinion
    The Board assigned preponderant or significant probative weight to a particular VA or private medical opinion, examination report, or treatment record in resolving the claim.
    10 of 500 sample sentences
  9. 1% Evidence of record found to support specific percentage disability rating
    The Board found that the totality of lay and medical evidence supported a specific schedular disability rating under the applicable diagnostic code for the period on appeal.
    6 of 500 sample sentences
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Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.