SHOULDER IMPAIRMENT OF

S. HENEKS · 2026 · Case ID: A26039898

DENIED

Summary

The veteran, who served for training in July-September 1980 and June-October 1981, appeals the denial of an increased disability rating for his service-connected left shoulder degenerative joint disease with glenohumeral joint instability. The veteran sought a rating higher than the 20 percent currently assigned. An August 2021 VA examination diagnosed left shoulder degenerative joint disease and glenohumeral joint instability, noting pain with flexion, abduction, and internal rotation, and weakness causing functional loss. Range of motion was limited to 60 degrees flexion and abduction, and 20 degrees rotation, with pain on motion. The examiner estimated further loss of motion after repeated use, but could not conduct rotator cuff or instability tests due to suspected pathology. The Board reviewed the evidence under the current rating criteria, which assigns a 20 percent rating for shoulder flexion/abduction limited to 45 degrees from the side, and a 30 percent rating for limitation to 25 degrees. The Board found the evidence did not support a limitation to 25 degrees, even considering pain and functional loss from repeated use. The Board found the VA examiner's analysis adequate and the veteran's reported functional loss did not meet the criteria for a higher rating. Therefore, the Board denied the increased rating claim.

Rationale

Veteran sought increased rating for left shoulder disability.; VA exam showed limitation of motion to 60 degrees flexion/abduction, 20 degrees rotation.; Evidence did not support limitation to 25 degrees for higher rating.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

211117-198086

Full Decision Text

Citation Nr: A26039898
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 211117-198086
DATE: April 29, 2026

ORDER

Entitlement to a rating in excess of 20 percent for left shoulder degenerative joint disease with glenohumeral joint instability is denied.

FINDING OF FACT

Throughout the appeal period, the left shoulder disability did not more nearly approximate limitation of motion to 25 degrees from the side.

CONCLUSION OF LAW

Throughout the appeal period, the criteria for a rating higher than 20 percent for left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, DCs 5003-5201.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty for training from July to September 1980 and from June to October 1981. He achieved Veteran status after receiving an injury that resulted in a grant of service connection while on inactive duty for training on April 25, 1982. 38 U.S.C. § 101(24); 38 C.F.R. § 3.1(d).

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2021 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In that rating decision, the RO denied a disability rating in excess of 20 percent for the service-connected left shoulder degenerative joint disease with glenohumeral joint instability.

In November 2021, the Veteran appealed the September 2021 rating decision to the Board by submitting a VA Form 10182 Decision Review Request: Board Appeal (notice of disagreement or NOD). The Veteran selected the Hearing docket.

The Veteran withdrew his hearing request in June 2025. Therefore, in considering this claim, the Board may review the evidence that was of record when the RO decided the claim as well as the evidence submitted by the Veteran or his representative within 90 days following receipt of the hearing withdrawal. 38 C.F.R. § 20.302(b).

If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in its decision on the claim on appeal. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider in this decision, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Increased Rating

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10.

Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3.

In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991).

St
rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3.

Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007).

Entitlement to a rating in excess of 20 percent for left shoulder disability.

The Veteran filed an increased rating claim for his service-connected left shoulder disability in July 2021.

The Veteran underwent a VA shoulder examination in August 2021. He was diagnosed with left shoulder degenerative joint disease and glenohumeral joint instability. The Veteran is right hand dominant. He reported current symptoms of worsened pain and decreased range of motion. He did not report flare-ups. In addition, the Veteran reported functional loss due requiring assistance to get dressed and disturbed sleep due to pain.

Range of motion testing revealed flexion to 60 degrees, abduction to 60 degrees, and internal and external rotation to 20 degrees. Pain was noted with flexion, abduction, and internal rotation. There was evidence of pain with weight-bearing and active motion causing functional loss. The examiner indicated weakness caused functional loss. There was objective evidence of crepitus and localized tenderness and pain on palpitation. Passive range of motion was not conducted as the examiner determined it was medically unadvisable. There was no additional functional loss after observed repetitive use. Repeated use over time resulted in additional functional loss.

Based on procured evidence including lay statements, the examiner estimated range of motion for flexion was 45 degrees, abduction to 45 degrees, and internal and external rotation to 10 degrees. The factors included in assessing the functional loss were fatigability, lack of endurance, pain, and weakness. The Veteran was not being examined during a flare-up and did not report flare-ups. The left shoulder was not manifested by muscle atrophy or ankylosis. However, the examiner was unable to conduct rotator cuff testing because a rotator cuff condition was suspected. The examiner was also unable to conduct the Crank Apprehension and Relocation Test. The examiner suspected shoulder instability, dislocation, or labral pathology based on crepitus, clicking, and catching. The Cross-body Adduction test was positive, but the clavicle and scapula were not suspected as impaired. There was no indication of a humerus condition and the Veteran has not had a surgery on the left shoulder. No assistive devices were used. Functional impact was described as the Veteran being unable to reach overhead, needs assistance dressing, and is unable to lift and carry objects.

The left shoulder disability has been rated pursuant to 38 C.F.R. § 4.71a, DC 5003-5201 (limitation of motion).

The Board notes that the Veteran is right-handed based on the VA examination reports. Therefore, his right arm is considered the dominant arm, such that the criteria for rating minor upper extremities will be applied. 38 C.F.R. § 4.69.

The normal range of motion of the shoulder is 0 to 180 degrees of flexion (forward elevation), 0 degrees to 180 degrees of abduction, 0 degrees to 90 degrees of external rotation, and 0 degrees to 90 degrees of internal rotation. 38 C.F.R. § 4.71, Plate I.

Limitation of motion of the arm at the shoulder is rated under DC 5201. The Board notes that the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). As the Veteran filed his claim in July 2021, the revised criteria apply. Under Diagnostic Code 5201, for the minor side, a 20 percent rating is warranted for limitation of motion of the arm at
, and 0 degrees to 90 degrees of internal rotation. 38 C.F.R. § 4.71, Plate I.

Limitation of motion of the arm at the shoulder is rated under DC 5201. The Board notes that the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). As the Veteran filed his claim in July 2021, the revised criteria apply. Under Diagnostic Code 5201, for the minor side, a 20 percent rating is warranted for limitation of motion of the arm at the shoulder level (flexion and/or abduction limited to 90 degrees) or midway between side and shoulder level (flexion and/or abduction limited to 45 degrees). A 30 percent rating is warranted for flexion and/or abduction limited to 25 degrees from the side.

The Board also notes other diagnostic codes relating to the shoulder including DC 5200 (ankylosis of scapulohumeral articulation), DC 5202 (humerus), and DC 5203 (a malunion of the clavicle or scapula or a nonunion of the clavicle or scapula without loose movement). However, those disabilities have not been shown on examination or by the evidence of record. Therefore, the Board finds that application of those diagnostic codes is not warranted.

After a review of the evidence of record, the Board finds that a rating in excess of 20 percent disabling is not warranted.

Turning to DC 5201, throughout the period on appeal, the Veteran's left shoulder disability has been manifested by range of motion limited to, at worst, 45 degrees flexion and 45 degrees abduction. This degree of limitation was estimated to occur following repeated use over time. Accordingly, even taking into consideration further loss of function following repeated use over time, the evidence does not show that Veteran's limitation of motion has been restricted to 25 degrees from the side and the left shoulder disability has not been shown to more nearly approximate the rating criteria for a higher 30 percent evaluation.

The Board recognizes the July 2025 Brief, in which the Veteran's representative asserted that the August 2021 VA examiner only estimated the range of motion after repeated use over time and that the severity of the condition may be worse if there were an actual examination after repeated use over time. However, the August 2021 VA examiner did consider the effects of fatigability, lack of endurance, pain, and weakness following repeated use over time. The examiner further considered the Veteran's lay statements as to these effects in providing an estimated further loss of motion analysis in that report. Additionally, the Veteran's own reporting of functional loss describes being unable to reach overhead, not similar to being unable to flexion or abduction limited to 25 degrees. The Board does not find any inadequacy in the examiner's medical analysis.

Therefore, the Board finds no basis for assigning a higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca v. Brown, 8 Vet. App. at 204-7. In this regard, the assigned 20 percent rating has been based upon painful motion. As demonstrated by the competent medical evidence of record, the 20 percent rating assigned during this period adequately compensates the Veteran for the extent of functional loss resulting from pain. Therefore, it follows that even when considering functional loss due to factors such as pain, the right shoulder disability was not manifested by symptomatology approximating a higher 30 percent rating.

The probative evidence of record does not support a rating in excess of 20 percent and the claim is denied.

S. HENEKS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Robinson, C. B.

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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