ARM IMPAIRMENT OF

K. PARAKKAL · 2026 · Case ID: A26027302

MIXED

Summary

The Veteran, who served in the U.S. Marine Corps from November 2018 to September 2023, appeals the denial of an increased disability rating for service-connected right shoulder strain and the denial of service connection for rhabdomyolysis. The Board reviewed the evidence concerning the Veteran's right shoulder strain, noting that the July 2024 and February 2025 VA examinations did not show limitation of motion midway between the side and shoulder level, which is required for a higher rating under Diagnostic Code 5201. While pain and weakness were noted, the Board found these were already compensated and did not meet criteria for higher ratings under other codes. For rhabdomyolysis, the Veteran reported an in-service incident during a strenuous physical fitness challenge that led to rhabdomyolysis and acute kidney failure. Conflicting medical evidence existed: a March 2026 VA opinion stated the condition resolved without rationale, while a December 2025 private chiropractor's opinion found residuals of rhabdomyolysis, including tremors and cramping, and opined it was at least as likely as not related to service and permanent. The Board found the private opinion more probative due to its objective findings and rationale. Service connection for rhabdomyolysis was granted, with the Board acknowledging residual functional impairment despite stable kidney function. The appeal for an increased rating for right shoulder strain was denied.

Rationale

July 2024 VA exam showed flexion to 120 degrees, abduction to 90 degrees.; February 2025 VA exam showed flexion to 180 degrees, abduction to 180 degrees with pain.; Neither examination showed limitation midway (45 degrees) required for higher rating.; Painful motion already compensated; no ankylosis or humerus impairment.

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

5201

Docket No.

251024-602375

Full Decision Text

Citation Nr: A26027302
Decision Date: 03/26/26 Archive Date: 03/26/26

DOCKET NO. 251024-602375
DATE: March 26, 2026

ORDER

Entitlement to an increased evaluation in excess of 20 percent disabling for service-connected right shoulder strain is denied.

Entitlement to service connection for rhabdomyolysis is granted.

FINDINGS OF FACT

1. Throughout the rating period on appeal, right shoulder strain did not manifest as right arm limitation of motion midway between side and shoulder level (flexion and/or abduction limited to 45 degrees).

2. The Veteran's currently diagnosed rhabdomyolysis is related to active service and productive of functional impairment to include bilateral shoulder muscle pain and weakness.

CONCLUSIONS OF LAW

1. The criteria for entitlement to an increased evaluation in excess of 20 percent disabling for service-connected right shoulder strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201.

2. The criteria for service connection for rhabdomyolysis have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service with the U.S. Marine Corps from November 2018 to September 2023.

This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2025 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (Agency of Original Jurisdiction (AOJ)).

In October 2025, the Veteran filed a Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), selecting the Evidence Submission docket. The Veteran submitted additional evidence in support of her claim within the prescribed 90-day window.

1. Entitlement to an increased evaluation in excess of 20 percent disabling for service-connected right shoulder strain.

Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from disability. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4.

When a question arises as to which of two ratings applies under a Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3.

The Veteran's entire history is to be considered when assigning disability rating. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); 38 C.F.R. § 4.1. The Board should consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the period of claim on appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999).

For disabilities of the musculoskeletal system, the disability is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. § 4.40.

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.").

In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court specified additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170.

In addition, assignment of a disability rating should consider limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. See DeLuca, 8 Vet. App. 202. Specifically, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court stated that flare-ups must be considered in providing an estimate of additional functional loss based on range of motion.

In Mitchell, 25 Vet. App. at 43, the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Mitchell, 25 Vet. App. at 38 (quoting 38 C.F.R. § 4.40).

Service-connected right shoulder strain is assigned a 20 percent disability rating under Diagnostic Code 5201, limitation of motion of the arm.

Disabilities of the Shoulder and Arm are rated under Diagnostic Codes 5200 through 5203. Normal ranges of upper extremity motion are defined by VA regulation as follows: forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71, Plate I.

Diagnostic Code 5201, limitation of motion of the arm, provides that limitation of motion of the arm at the shoulder level (flexion and/or abduction limited to 90 degrees) is rated 20 percent for the major shoulder. Limitation of motion of the arm midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees) is rated 30 percent for the major shoulder. Limitation of motion of the arm to 25 degrees from the side is rated 40 percent for the major shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5201.

Here, the evidence of record includes a July 2024 VA examination of the right, non-dominant, shoulder
Diagnostic Code 5201, limitation of motion of the arm, provides that limitation of motion of the arm at the shoulder level (flexion and/or abduction limited to 90 degrees) is rated 20 percent for the major shoulder. Limitation of motion of the arm midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees) is rated 30 percent for the major shoulder. Limitation of motion of the arm to 25 degrees from the side is rated 40 percent for the major shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5201.

Here, the evidence of record includes a July 2024 VA examination of the right, non-dominant, shoulder. During the examination, the Veteran reported that her right shoulder disability had worsened since service, with muscle spasms particularly at an elevated position, which makes it difficult for her to hold her child, to work out, and to hike. The Veteran reported moderate flare ups occurring twice a month that last more than an hour, and are precipitated by working out and are alleviated by taking ibuprofen. On active range of motion testing, the Veteran right shoulder flexion was to 120 degrees and abduction was to 90 degrees. Passive range of motion yielded the same results. Pain was evident on weight-bearing, active motion, passive motion and did not result in functional loss. On repetitive use testing, right shoulder flexion was to 110 degrees and abduction to 80 degrees, with pain. Repeated use over time testing was not conducted but the VA examiner opined that pain would significantly limit functional ability with repeated use over time. The VA examiner estimated that repeated use over time for the right shoulder would yield flexion to 100 degrees with abduction to 70 degrees. There was no crepitus, muscle atrophy, ankylosis, impairment of the humorous, or impairment of the clavicle or scapula.

The Veteran was also afforded a February 2025 VA examination of the bilateral shoulders. During the examination, the Veteran reported she has bilateral shoulder pain and weakness that radiates to her elbows, which limits her ability to care for her baby. The Veteran did not report flare-ups but reported functional loss with limitation in reaching, carrying, pushing, pulling and lifting moderate objects from mid-chest and above. On initial range of motion testing, the Veteran had normal range of motion results. Active range of motion testing also showed flexion to 180 degrees and abduction to 180 degrees, with pain on flexion and abduction. Passive range of motion yielded the same results. Pain was evident on weight-bearing, active motion, passive motion which resulted in functional loss. The evidence did not suggest that additional loss of function or range of motion would occur with repeated use. There was no crepitus, muscle atrophy, ankylosis, impairment of the humorous, or impairment of the clavicle or scapula.

Based on the above, the Board finds that throughout the entire period on appeal, right shoulder strain did not manifest as right arm limitation of motion midway between side and shoulder level (flexion and/or abduction limited to 45 degrees), as required for a higher 30 percent evaluation under Diagnostic Code 5201. The July 2024 VA examination showed, at worst, that estimated repeated use over time for the right shoulder would yield flexion to 100 degrees with abduction to 70 degrees. At no point during the pendency of the appeal did the Veteran exhibit right arm limitation of motion midway between side and shoulder level (flexion and/or abduction limited to 45 degrees). And while the VA examinations show painful motion and weakness of the right shoulder, the Board notes that the Veteran has already been compensated for painful motion of the right shoulder in the assignment of her initial disability rating. 38 C.F.R. § 4.59, 4.40; Mitchell, 25 Vet. App. at 38.

The Board has considered whether the Veteran is entitled to a higher rating under other diagnostic codes evaluating the shoulder and arm. A rating in excess of 20 percent is available under Diagnostic Code 5200 (ankylosis of scapulohumeral articulation) and Diagnostic Code 5202 (humerus impairment). Here, the medical evidence does not show that the Veteran has any humerus impairments or ankylosis of her right shoulder joint. Ankylosis is the immobilization of a joint due to disease, injury, or surgical procedure, usually the fixation of a joint. The evidence does not exhibit and the Veteran does not contend that her right shoulder joint has ever exhibited being stuck or fixed in abduction or flexion. Therefore, assignment of a rating under those diagnostic codes is not warranted in this matter.

shoulder and arm. A rating in excess of 20 percent is available under Diagnostic Code 5200 (ankylosis of scapulohumeral articulation) and Diagnostic Code 5202 (humerus impairment). Here, the medical evidence does not show that the Veteran has any humerus impairments or ankylosis of her right shoulder joint. Ankylosis is the immobilization of a joint due to disease, injury, or surgical procedure, usually the fixation of a joint. The evidence does not exhibit and the Veteran does not contend that her right shoulder joint has ever exhibited being stuck or fixed in abduction or flexion. Therefore, assignment of a rating under those diagnostic codes is not warranted in this matter.

Accordingly, the Board finds a rating in excess of 20 percent disabling for service-connected right shoulder strain is not warranted. Because the most persuasive evidence of record is against the claim, the benefit of the doubt doctrine is not for application and the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

The Board notes that Diagnostic Code 5201 does not contemplate the ameliorative effects of medication. The Court has held that in assigning a disability rating, VA may not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56 (2012). More recently, the Court stated that the "the Board [is] obligated to discount the beneficial effects of the medication taken for each disability and evaluate the baseline severity of those disabilities" and held that "Jones applies in the evaluation of musculoskeletal disabilities where the relevant [diagnostic code] does not reference medication as a factor in evaluation." Ingram v. Shinseki, 2025 U.S. App. Vet. Claims LEXIS 327, *15-19 (March 12, 2025).

The Board notes, however, that neither Jones nor Ingram address how the Board is to discount the beneficial effects of medication, particularly when used as treatment for musculoskeletal symptoms and where examiners do not reasonably have the ability to assess range of motion both with and without use of medication. Remanding this appeal to order an addendum medical opinion based on Jones and Ingram, and in the lens of the rating criteria under § 4.71a, would almost certainly require an examiner to engage in medical speculation and would result in a medical opinion that lacks the degree of certainty to ascertain, even under the benefit-of-the-doubt standard, the impact of the ameliorative effects of medication on the severity of a veteran's musculoskeletal disability in terms of range of motion. See, e.g., Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2005) (medical opinions that are speculative have "little probative value"). Therefore, the Board does not wish to further delay adjudication of the Veteran's appeal to engage in likely unfruitful further development pursuant to Jones and Ingram.

2. Entitlement to service connection for rhabdomyolysis.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996).

Congress specifically limits entitlement for service-connected disease or injury to cases which result in a disability; thus, without proof of a present disability, there can be no claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

The Federal Circuit held that where pain causes functional impairment, a "disability" for VA compensation purposes can exist, even if there is no underlying diagnosis or pathology. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). The Federal Circuit explained that a "disability" under 38 U.S.C. § 1110 refers to the functional impairment in earning capacity, not the underlying cause of said disability. Id. at 1363. The Federal Circuit also noted that 38 C.F.R. § 4.10 defines the term "functional impairment" as the inability of the body or a part of it "'to function under the ordinary conditions of daily life including employment.'" Id.

Notwithstanding, the Federal Circuit in Saunders limited its holding by stating that a claimant's report of "subjective" pain in and of itself will not establish a current disability. Id. at 1367. In other words, a claimant cannot demonstrate service connection simply by asserting subjective pain. Id. Rather, a claimant will need to show that his or her pain reaches the level of functional impairment of earning capacity. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. The Court's holding in Saunders is supported by the public policy behind veterans' compensation - i.e., to compensate veterans whose ability to earn a living is impaired as a result of their military service. Id.

In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran.

The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of evidence for and against the claim. See 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the claimant prevails.

The Board is bound by favorable findings made by the AOJ: service treatment records show the Veteran was hospitalized for diagnosed rhabdomyolysis in November 2019. 38 C.F.R. § 3.104(c). Thus, the Board must determine if the Veteran has a current diagnosis of rhabdomyolysis that was caused by service, to include the November 2019 hospitalization.

Here, the Veteran was afforded a July 2024 VA Muscle Injuries examination which showed that the Veteran had a diagnosis of rhabdomyolysis, as of November 2019, which affected both sides of Group I (extrinsic muscles of shoulder girdle) and Group IV (shoulder girdle muscles) muscles. During the examination, the Veteran reported that while in service, she participated in a MURPH challenge without proper training, which involved a one-mile run, 100 pull-ups, 200 push-ups, 300 squats and another one-mile run. She reported that her arm muscles broke down as a direct result and she was in pain, where two days after she couldn't move her arms. The Veteran was referred to Fort Belvoir with a diagnosis of acute kidney failure on admission, and was on IV fluids for two days with monitoring of her kidney. On discharge, the Veteran had soreness, back pain and struggled to extend her arms. She reported that since separation, her disability has worsened and has chronic back pain and she cannot do activities she once enjoyed, like hiking.

A July 2024 VA Kidney Conditions examination also showed a diagnosis of rhabdomyolysis, and the Veteran reported the same history within the July 2024 VA Muscles Injury examination.

In February 2025, the Veteran was afforded an additional VA Muscle Injuries examination which showed that the Veteran had a diagnosis of rhabdomyolysis, as of November 2019, which affected both sides of Group I, Group II, Group III, Group IV, Group V and Group VI shoulder girdle and arm muscles. The VA examiner also found that rhabdomyolysis affected both sides of Group VII, Group VIII and Group IX forearm and hand muscles; Group XIII, Group XIV, Group XV, Group XVI, Group XVII, Group XVIII pelvic girdle and thigh; and Group XIX, Group XX, Group XXI, Group XXII, Group XXIII torso and neck muscles. During the examination, the Veteran similarly reported that while in service, she participated in an extreme physical fitness challenge without proper training, which involved a one-mile run, 100 pull-ups, 200 push-ups, 300 squats and another one-mile run. She reported that after the challenge, she couldn't move her arms. Two days later the Veteran was referred to Fort Belvoir with a diagnosis of rhabdomyolysis and acute kidney failure, and was on IV fluids for two days with monitoring of her kidney. She reported that today, her she has severe bilateral shoulder pain and weakness that radiates to her elbows, which limits her ability to provide care for her baby. It was noted that rhabdomyolysis did impact her ability to work. It was noted that she was limited in reaching, carrying, pulling, and lifting moderate objects from mid-chest and above due to residua weakness in shoulders following rhabdomyolysis. The VA examiner noted that labs were not ordered with the examination because her rhabdomyolysis was stable for years, with the last comprehensive metabolic panel (CBP) showing stable and baseline kidney function.

In March 2025, the AOJ requested a clarifying medical opinion to determine whether rhabdomyolysis was an acute condition that has now resolved.

Within a March 2026 VA medical opinion, the VA examiner indicated that the Veteran's rhabdomyolysis had resolved. A rationale was not provided.

Within a December 2025 private opinion, the private chiropractor found that the Veteran suffered from residuals of rhabdomyolysis, which she was diagnosed with during active duty. The Veteran reported that she has tremors and cramping in her arms, and thus, the chiropractor diagnosed the Veteran with tremors in arms from rhabdomyolysis, which persisted since service. The chiropractor opined that it was at least as likely as not that the condition was directly and causally related to the Veteran's military service, and that it was a permanent condition.

In sum, there is conflicting evidence regarding whether the Veteran's rhabdomyolysis is productive of disability with the February 2025 VA examiner and the December 2025 chiropractor noting functional impairment while the March 2026 examiner noted a resolution of the condition. Notably, the March 2026 VA examiner did not provide a rationale for the conclusion that rhabdomyolysis had resolved. The Board accords more probative value to the February and December 2025 examination reports which are accompanied by objective findings and a rationale in comparison to the March 2026 addendum opinion which is conclusory.

The Board finds that while the Veteran's kidney function is apparently stable, she continues to have residual functional impairment, including bilateral shoulder muscle pain and weakness as a result of her rhabdomyolysis. Service connection is granted.

K. Parakkal

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. Woodarek

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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