Evidence Checklist: Rotator Cuff Tear

Orthopedic evaluation with shoulder range of motion and rotator cuff testingCritical

Examination documenting shoulder flexion, abduction, internal and external rotation in degrees, rotator cuff muscle testing (strength and pain), and special tests (drop arm, empty can, Gerber lift-off).

Nexus opinion linking rotator cuff tear to service ("at least as likely as not")Critical

A medical opinion connecting your rotator cuff tear to in-service injury, repetitive overhead duties, heavy lifting, or a fall during military service.

MRI confirming rotator cuff tear (partial or full thickness)Critical

MRI documenting the tear type (partial vs. full thickness), which tendons are involved (supraspinatus, infraspinatus, subscapularis, teres minor), tear size, and degree of muscle atrophy or retraction.

Surgical records (if rotator cuff repair was performed)

Operative reports from arthroscopic or open rotator cuff repair, including tear size, repair technique, and any additional procedures (acromioplasty, biceps tenodesis).

Documentation of dominant vs. non-dominant armCritical

Medical records specifying which shoulder is affected and which arm is dominant. The major extremity receives a higher rating.

Buddy statement from spouse, family, or fellow service member

A written statement from someone who can describe observable symptoms and how your condition affects daily life.

Personal statement describing symptoms and functional impact

Your own written account of how this condition affects your daily activities, work, and relationships. Describe your worst days.

Completed DBQ Shoulder and Arm ConditionsCritical

Standardized form capturing shoulder range of motion in all planes, rotator cuff findings, pain, and functional limitations.

Service treatment records (STRs)Critical

Military medical records showing in-service treatment, complaints, or injuries related to this condition.