Shoulder, Elbow, Wrist, Hip, Knee, and Ankle

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Pain, weakness, stiffness, swelling, heat and redness, instability or giving way, "locking," fatigability, lack of endurance, etc.
2. Treatment - type, dose, frequency, response, side effects.
3. If there are periods of flare-up of joint disease:

1. State their severity, frequency, and duration.
2. Name the precipitating and alleviating factors.
3. State to what extent, if any, per veteran, they result in additional limitation of motion or functional impairment during the flare-up.

4. Describe whether crutches, brace, cane, corrective shoes, etc., are needed.
5. Describe details of any surgery or injury.
6. Describe any episodes of dislocation or recurrent subluxation.
7. For inflammatory arthritis, describe any constitutional symptoms.
8. Describe the effects of the condition on the veteran's usual occupation and daily activities.
9. Dominance of extremity and means used to identify dominant extremity.
10. If there is a prosthesis, provide date of prosthetic implant and describe any complaint of pain, weakness, or limitation of motion. State whether crutches, brace, etc., are needed.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings: A detailed assessment of each affected joint is required, including joints with prostheses.

1. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance. Provide range of motion in degrees.
2. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.
3. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.
4. Describe objective evidence of painful motion, edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movement, guarding of movement, etc.
5. For weight bearing joints (hip, knee, ankle), describe gait and functional limitations on standing and walking. Describe any callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight bearing.
6. If ankylosis is present, describe the position of the bones of the joint in relationship to one another (in degrees of flexion, external rotation, etc.), and state whether the ankylosis is stable and pain free.
7. If indicated, measure the leg length from the anterior superior iliac spine to the medial malleolus.
8. For inflammatory arthritis, describe any constitutional signs.
9. Describe range of motion with prosthesis in same detail as described above for nonprosthetic joints.

D. Normal Range of Motion: All joint Range of Motion measurements must be made using a goniometer. Show each measured range of motion separately rather than as a continuum. For example, if the veteran lacks 10 degrees of full knee extension and has normal flexion, show the range of motion as extension to minus 10 degrees (or lacks 10 degrees of extension) and flexion 0 to 140 degrees.

1. Hip range of motion: (Movement of femur as it rotates in the acetabulum.)

a. Normal range of motion, using the anatomical position as zero degrees.

Flexion = 0 to 125 degrees (To gain a true picture of hip flexion, i.e., movement between the pelvis and femur in the hip joint, the opposite thigh should be extended to minimize motion between the pelvis and spine.)

Extension = 0 to 30 degrees.

Adduction = 0 to 25 degrees.

Abduction = 0 to 45 degrees.

External rotation = 0 to 60 degrees.

Internal rotation = 0 to 40 degrees.

2. Knee range of motion:

a. Normal range of motion, using the anatomical position as zero degrees.

Flexion = 0 to 140 degrees.

Extension - zero degrees = full extension. Show loss of extension by describing the degrees in which extension is not possible. (e.g., Show range of motion as extension to minus 10 degrees and flexion 0 to 140 degrees when full extension is limited by 10 degrees and full flexion is possible.)

b. Stability.

Medial and Lateral Collateral Ligaments: Varus/valgus in neutral and in 30 degrees of flexion - normal is no motion.

Anterior and Posterior Cruciate Ligaments: Anterior/posterior in 30 degrees of flexion with foot stabilized - normal is less than 5 mm. of motion (1/4 inch - Lachman's test) or in 90 degrees of flexion with foot stabilized - normal is less than 5mm. of motion (1/4 inch - anterior and posterior drawer test).

Medial and Lateral Meniscus: Perform McMurray's test.

3. Ankle range of motion:

1. Neutral position is with foot at 90 degrees to ankle. From that position, dorsiflexion is 0 to 20 degrees; plantar flexion is 0 to 45 degrees.
2. Describe any varus or valgus angulation of the os calcis in relationship to the long axis of the tibia and fibula.

4. Shoulder, elbow, forearm, and wrist range of motion:

a. Normal range of motion is measured with zero degrees the anatomical position except for 2 situations:

1. Supination and pronation of the forearm is measured with the arm against the body, the elbow flexed to 90 degrees, and the forearm in mid position (zero degrees) between supination and pronation
2. Shoulder rotation is measured with the arm abducted to 90 degrees, the elbow flexed to 90 degrees, and the forearm reflecting the midpoint (zero degrees) between internal and external rotation of the shoulder.

2. Shoulder forward flexion = zero to 180 degrees.
3. Shoulder abduction = zero to 180 degrees.
4. Shoulder external rotation = zero to 90 degrees.
5. Shoulder internal rotation = zero to 90 degrees.
6. Elbow flexion = zero to 145 degrees.
7. Forearm supination = zero to 85 degrees.
8. Forearm pronation = zero to 80 degrees.
9. Wrist dorsiflexion (extension) = zero to 70 degrees.
10. Wrist palmar flexion = zero to 80 degrees.
11. Wrist radial deviation = zero to 20 degrees
12. Wrist ulnar deviation = zero to 45 degrees.

E. Diagnostic and Clinical Tests:

1. As indicated: X-rays, including special views or weight bearing films, MRI, arthrogram, diagnostic arthroscopy.
   Note: The diagnosis of degenerative arthritis or post-traumatic arthritis of a joint requires X-ray confirmation. Once the diagnosis has been confirmed in a joint, further X-rays of that joint are not required.
2. Include results of all diagnostic and clinical tests in the examination report.

F. Diagnosis:

G. Additional Limitation of Joint Function:

Impairment of joint function is determined by actual range of joint motion as reported in the physical examination and additional limitation of joint function caused by the following factors:

• Pain, including pain on repeated use
• Fatigue
• Weakness
• Lack of endurance
• Incoordination

Do any of the above factors additionally limit joint function? If so, express the additional limitation in degrees.

Indicate if you cannot determine, without resort to mere speculation, whether any of these factors cause additional functional loss. For example, indicate if you would need to resort to mere speculation in order to express additional limitation due to repetitive use.

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Date: