Va Form 21-0960m-12 - Shoulder And Arm Conditions Disability Benefits Questionnaire Page 4
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6SECTION X - SPECIFIC TESTS FOR ROTATOR CUFF CONDITIONS
(Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation indicates
10A. HAWKINS' IMPINGEMENT TEST
a positive test; may signify rotator cuff tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
IF POSITIVE, SIDE AFFECTED:
Right
Left
Both
(Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner.
10B. EMPTY-CAN TEST
Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
IF POSITIVE, SIDE AFFECTED:
Right
Left
Both
(Patient holds arms at side with elbow flexed 90 degrees. Patient externally rotates against resistance.
10C. EXTERNAL ROTATION/INFRASPINATUS STRENGTH TEST
Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
IF POSITIVE, SIDE AFFECTED:
Right
Left
Both
(Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may
10D. LIFT-OFF SUBSCAPULARIS TEST
indicate subscapularis tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
IF POSITIVE, SIDE AFFECTED:
Right
Left
Both
SECTION XI - HISTORY AND SPECIFIC TESTS FOR INSTABILITY/DISLOCATION/LABRAL PATHOLOGY
(clicking, catching, etc.)
11A. IS THERE A HISTORY OF MECHANICAL SYMPTOMS
?
YES
NO
IF YES, SIDE AFFECTED:
Right
Left
Both
(subluxation)
(scapulohumeral)
11B. IS THERE A HISTORY OF RECURRENT DISLOCATION
OF THE GLENOHUMERAL
JOINT?
YES
NO
(check all that apply):
IF YES, INDICATE FREQUENCY, SEVERITY AND SIDE AFFECTED
INFREQUENT EPISODES
Right
Left
Both
FREQUENT EPISODES
Right
Left
Both
GUARDING OF MOVEMENT ONLY AT
Right
Left
Both
SHOULDER LEVEL
GUARDING OF ALL ARM MOVEMENTS
Right
Left
Both
(With patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of
11C. CRANK APPREHENSION AND RELOCATION TEST
instability with further external rotation may indicate shoulder instability)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
IF POSITIVE, SIDE AFFECTED:
Right
Left
Both
SECTION XII - HISTORY AND SPECIFIC TESTS FOR CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT
AND STERNOCLAVICULAR JOINT CONDITIONS
12A. DOES THE VETERAN HAVE AN AC JOINT CONDITION OR ANY OTHER IMPAIRMENT OF THE CLAVICLE OR SCAPULA?
YES
NO
IF YES, INDICATE SEVERITY AND SIDE AFFECTED:
MALUNION OF CLAVICLE OR SCAPULA
Right
Left
Both
NONUNION OF CLAVICLE OR SCAPULA
Right
Left
Both
WITHOUT LOOSE MOVEMENT
NONUNION OF CLAVICLE OR SCAPULA
Right
Left
Both
WITH LOOSE MOVEMENT
DISLOCATION (ACROMIOCLAVICULAR SEPARATION
Right
Left
Both
OR STERNOCLAVICULAR DISLOCATION)
(Describe)
Right
Left
Both
OTHER
12B. IS THERE TENDERNESS ON PALPATION OF THE AC JOINT?
YES
NO
IF YES, INDICATE SIDE:
Right
Left
Both
(Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint
12C. CROSS-BODY ADDUCTION TEST
pathology)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
IF POSITIVE, SIDE AFFECTED:
Right
Left
Both
Page 4
VA FORM 21-0960M-12, OCT 2012
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