Completing the Shoulder and Arm DBQ: A Guide for Private Physicians

Why your completion of this form matters as much as the visit itself

VA accepts Disability Benefits Questionnaires completed by a veteran's own physician, not only by VA or contracted examiners. A completed private DBQ can support the claim without the veteran needing a separate VA-scheduled Compensation & Pension exam for that condition. But VA will only rely on a DBQ that is "adequate for rating purposes." An inadequate one doesn't simply yield a lower rating — it often gets returned, delaying the claim by months while a new exam is scheduled, typically one the veteran has no control over.

On a shoulder claim specifically, one commonly-omitted field is worth twenty percentage points. That's the case for reading the rest of this page.

Use the current version of the form

VA revises DBQs periodically and no longer prints form numbers on them — they're listed by title on VA's public DBQ page as "Shoulder and/or Arm." Check the line in the bottom-right corner of each page: the current version reads Updated on: 2025-04-15 (v25_3) and runs 14 pages. Download fresh from VA's DBQ index rather than reusing a copy saved in your practice's template library.

Don't use a date cutoff as the test — some DBQs are revised rarely and legitimately carry older dates. Compare against what VA publishes now.

The field that's worth 20 points

Under 38 C.F.R. § 4.59, an actually painful joint is entitled to at least the minimum compensable rating for that joint. The Court has held that this minimum is read within the applicable diagnostic code rather than as a floating 10% (Sowers v. McDonald, 27 Vet. App. 472 (2016), where a code assigning 0% at every level left § 4.59 with no minimum to grant).

Diagnostic Code 5201, which governs limitation of arm motion, has no 0% or 10% tier — its lowest rating is 20%. So where a shoulder's flexion and abduction both exceed 90°, the measured motion is noncompensable, and documented painful motion is the difference between a 0% and a 20% evaluation.

Concretely: record whether motion is painful, and the degree at which pain begins. "Full ROM" with the pain field blank, on a patient who reports shoulder pain, can cost that veteran 20 percentage points of a permanent monthly benefit. This is the single highest-leverage entry on the form.

(One nuance: where noncompensable motion coexists with x-ray evidence of degenerative arthritis in a major joint, VA may rate 10% under DC 5003 instead. Documenting both the pain onset point and any imaging findings lets the rater apply the correct path rather than guess.)

The legal floor: what "adequate" requires

For joint conditions, adequacy is not a matter of clinical judgment about what's worth measuring — it's dictated by 38 C.F.R. § 4.59 and reinforced by Correia v. McDonald, 28 Vet. App. 158 (2016). A compliant shoulder exam records range of motion in all of the following, where practicable:

• Active range of motion
• Passive range of motion
• Weight-bearing
• Non-weight-bearing
• The opposite shoulder, for comparison, where the condition is unilateral

Record both flexion (forward elevation) and abduction (lateral elevation) in each. DC 5201's criteria read "flexion and/or abduction," so either plane can establish the rating — but an exam that measures only one leaves the rater without the information to know which is more limiting.

Where a test genuinely cannot be performed, document why. An unexplained blank reads as an incomplete exam; a stated clinical reason reads as adequate.

Two fields that quietly decide the outcome

Dominant hand. The shoulder schedule rates the major (dominant) and minor (non-dominant) arm differently — the same limitation can be worth 40% on one side and 30% on the other. This is a single checkbox on page 1 and it is frequently filled in carelessly.

Diagnosis selection. Shoulder disability is rated under one of four codes, and three of them are not motion-based:

• DC 5200 — ankylosis of the scapulohumeral articulation. Document the position of fixation and whether abduction is possible to 60°, whether the patient can reach mouth and head.
• DC 5201 — limitation of arm motion. The ROM measurements above.
• DC 5202 — other impairment of the humerus. Turns on recurrent dislocation, malunion, fibrous union, nonunion, or loss of the humeral head, and ranges up to 80%. For recurrent dislocation the code distinguishes frequent episodes with guarding of all arm movements from infrequent episodes with guarding only at shoulder level — so document dislocation frequency and the extent of guarding specifically, not just "history of dislocations."
• DC 5203 — impairment of the clavicle or scapula. Dislocation, nonunion (with or without loose movement), or malunion.

A shoulder that repeatedly subluxates may rate considerably higher under 5202 than its range of motion would support under 5201. If your patient's pathology is instability rather than stiffness, the ROM section alone will not capture it. Complete the diagnosis and stability sections with the same care as the goniometry.

Section-by-section

Diagnosis and history. Specific and current. Include the side affected, ICD code, date of diagnosis, and relevant imaging or surgical history. The form's diagnosis list is long — rotator cuff tear, labral and SLAP lesions, impingement, glenohumeral instability, recurrent dislocation, arthroplasty, AC joint pathology — and which boxes you check shapes which diagnostic code applies.

Range of motion. Goniometer, actual degrees, not qualitative descriptions. Flexion and abduction, in each of the four testing conditions above, plus the opposite shoulder.

Pain on motion. Whether painful, and the degree at which pain begins. See above — this is the 20-point field.

Repetitive-use testing. Re-measure after at least three repetitions and record additional loss. If not possible (acute pain, safety), say so explicitly. The DeLuca line treats this as a required inquiry; silence reads as a gap, not as a clinical non-issue.

Flare-ups. Frequency, duration, severity, and an estimate of additional functional loss during a flare — in degrees where you can. "Patient reports flare-ups" without a functional estimate is treated as incomplete. If a numeric estimate genuinely can't be given, state your reasoning.

Muscle strength, stability, and ancillary findings. Grade strength 0–5. Document instability and dislocation history with the specificity DC 5202 requires. Note ankylosis, imaging results, and any brace or assistive device in regular use with its clinical necessity.

Functional impact. How the condition affects the patient's ability to perform occupational tasks.

What VA requires of you specifically

VA states these directly: all clinician information blocks at the bottom of the form must be completed, and the clinician must sign and date it. VA also reserves the right to confirm the authenticity of all DBQs, including through computer matching with other agencies. A DBQ is a verifiable federal submission, not a courtesy letter — complete it accordingly.

Common reasons a private shoulder DBQ gets returned

• Only one type of ROM recorded, or only one plane of motion
• Pain noted as a yes/no without the degree at which it begins
• No repetitive-use testing and no explanation for its absence
• Flare-ups acknowledged but not quantified
• Dislocation history noted without frequency or extent of guarding
• Dominant hand left blank or filled in incorrectly
• A superseded version of the form
• Sections left blank rather than marked not applicable with a stated reason

Scope and liability

Completing this DBQ is a clinical documentation task, not an opinion on service connection. Nothing on the Shoulder and Arm Conditions DBQ requires you to opine on whether the condition relates to military service — that is a separate nexus question, addressed if at all in a distinct medical opinion letter. Stay within what the form asks: current findings, objectively measured, consistent with the § 4.59 and Correia testing requirements.

A note on the regulatory landscape

Watch for the "Modernizing VA Disability Benefit Questionnaires Act," introduced in the U.S. House by Rep. Luttrell — if enacted it could change DBQ mechanics or requirements. This guide reflects current form and case-law requirements as of publication; verify no structural changes have taken effect before relying on it for a claim with a long timeline.