DVBCQKL2 ;;ALB-CIOFO/ECF - KNEE AND LOWER LEG CONDITIONS QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;***172***;Apr 10, 1995;Build 3
;
TXT ;
;;
;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
;; disability benefits. VA will consider the information you provide on this
;; questionnaire as part of their evaluation in processing the Veteran's claim.
;;
;; 1. Diagnosis
;;
;; Does the Veteran now have or has he/she ever had a knee and/or lower leg
;; condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to knee and/or lower leg
;; conditions:
;; Diagnosis #1: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #2: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #3: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; If there are additional diagnoses that pertain to knee and/or lower leg
;; conditions, list using above format: ____
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's knee
;; and/or lower leg condition (brief summary): ________________________________
;;
;; 3. Flare-ups
;;
;; Does the Veteran report that flare-ups impact the function of the knee
;; and/or lower leg?
;; ___ Yes ___ No
;; If yes, document the Veteran's description of the impact of flare-ups in
;; his or her own words: ______________________________________________________
;;^TOF^
;; 4. Initial range of motion (ROM) measurements
;;
;; Measure ROM with a goniometer, rounding each measurement to the nearest
;; 5 degrees. During the measurements, document the point at which painful
;; motion begins, evidenced by visible behavior such as facial expression,
;; wincing, etc. Report initial measurements below.
;;
;; Following the initial assessment of ROM, perform repetitive use testing.
;; For VA purposes, repetitive use testing must be included in all joint
;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
;; serve as a representative test of the effect of repetitive use. After the
;; initial measurement, reassess ROM after 3 repetitions. Report post-test
;; measurements in section 5.
;;
;; a. Right knee flexion
;; Select where flexion ends (normal endpoint is 140 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
;;
;; b. Right knee extension
;;
;; Select where extension ends:
;; ___ 0 or any degree of hyperextension (check this box if there is no
;; limitation of extension)
;; Unable to fully extend; extension ends at:
;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___No objective evidence of painful motion
;; ___0 or any degree of hyperextension (check this box if there is no
;; limitation of extension)
;; Unable to fully extend; extension ends at:
;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;^TOF^
;; c. Left knee flexion
;; Select where flexion ends (normal endpoint is 140 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
;;
;; Select where objective evidence of painful motion begins:
;; __ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
;;
;; d. Left knee extension
;; Select where extension ends:
;; __ 0 or any degree of hyperextension (check this box if there is no
;; limitation of extension)
;; Unable to fully extend; extension ends at:
;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; __ No objective evidence of painful motion
;; __ 0 or any degree of hyperextension (check this box if there is no
;; limitation of extension)
;; Unable to fully extend; extension ends at:
;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; e. If ROM does not conform to the normal range of motion identified
;; above but is normal for this Veteran (for reasons other than a knee
;; and/or leg condition, such as age, body habitus, neurologic disease),
;; explain: ___________________________________________________________________
;;
;; 5. ROM measurements after repetitive use testing
;;
;; a. Is the Veteran able to perform repetitive-use testing with 3
;; repetitions?
;; ___ Yes ___ No
;; If unable, provide reason: __________________
;; If Veteran is unable to perform repetitive-use testing, skip to
;; section 6.
;;^TOF^
;; If Veteran is able to perform repetitive-use testing, measure and report
;; ROM after a minimum of 3 repetitions:
;;
;; b. Right knee post-test ROM
;; Select where post-test flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
;;
;; Select where post-test extension ends:
;; __ 0 or any degree of hyperextension (check this box if there is no
;; limitation of extension)
;; Unable to fully extend; extension ends at:
;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; c. Left knee post-test ROM
;; Select where post-test flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
;;
;; Select where post-test extension ends:
;; ___ 0 or any degree of hyperextension (check this box if there is no
;; limitation of extension)
;; Unable to fully extend; extension ends at:
;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; 6. Functional loss and additional limitation in ROM
;;
;; The following section addresses reasons for functional loss, if present,
;; and additional loss of ROM after repetitive-use testing, if present. The
;; VA defines functional loss as the inability to perform normal working
;; movements of the body with normal excursion, strength, speed, coordination
;; and/or endurance.
;;
;; a. Does the Veteran have additional limitation in ROM of the knee and lower
;; leg following repetitive-use testing?
;; ___ Yes ___ No
;;^TOF^
;; b. Does the Veteran have any functional loss and/or functional impairment
;; of the knee and lower leg?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment or additional
;; limitation of ROM of the knee and lower leg after repetitive use, indicate
;; the contributing factors of disability below (check all that apply and
;; indicate side affected):
;; ___ No functional loss for right lower extremity
;; ___ No functional loss for left lower extremity
;; ___ Less movement than normal ___Right ___Left ___Both
;; ___ More movement than normal ___Right ___Left ___Both
;; ___ Weakened movement ___Right ___Left ___Both
;; ___ Excess fatigability ___Right ___Left ___Both
;; ___ Incoordination, impaired ability ___Right ___Left ___Both
;; to execute skilled movements smoothly
;; ___ Pain on movement ___Right ___Left ___Both
;; ___ Swelling ___Right ___Left ___Both
;; ___ Deformity ___Right ___Left ___Both
;; ___ Atrophy of disuse ___Right ___Left ___Both
;; ___ Instability of station ___Right ___Left ___Both
;; ___ Disturbance of locomotion ___Right ___Left ___Both
;; ___ Interference with sitting, standing ___Right ___Left ___Both
;; and weight-bearing
;; ___ Other, describe: ____________________________________________________
;;
;; 7. Pain (pain on palpation)
;;
;; Does the Veteran have tenderness or pain to palpation for joint line or
;; soft tissues of either knee?
;; ___ Yes ___ No
;; If yes, side affected: ___Right ___Left ___Both
;;
;; 8. Muscle strength testing
;;
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Palpable or visible muscle contraction, but no joint movement
;; 2/5 Active movement with gravity eliminated
;; 3/5 Active movement against gravity
;; 4/5 Active movement against some resistance
;; 5/5 Normal strength
;;
;; Knee flexion:
;; Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;; Knee extension:
;; Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;;^TOF^
;; 9. Joint stability tests
;;
;; a. Anterior instability (Lachman test):
;; ___ Unable to test: ___Right ___Left ___Both
;; Right:
;; ___Normal ___1+ (0-5 millimeters)
;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
;; Left:
;; ___Normal ___1+ (0-5 millimeters)
;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
;;
;; b. Posterior instability (Posterior drawer test):
;; ___ Unable to test: ___Right ___Left ___Both
;; Right:
;; ___Normal ___1+ (0-5 millimeters)
;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
;; Left:
;; ___Normal ___1+ (0-5 millimeters)
;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
;;
;; c. Medial-lateral instability (Apply valgus/varus pressure to knee in
;; extension and 30 degrees of flexion):
;; ___ Unable to test: ___Right ___Left ___Both
;; Right:
;; ___Normal ___1+ (0-5 millimeters)
;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
;; Left:
;; ___Normal ___1+ (0-5 millimeters)
;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
;;
;; 10. Patellar subluxation/dislocation
;;
;; Is there evidence or history of recurrent patellar subluxation/dislocation?
;; ___ Yes ___ No
;; If yes, indicate severity and side affected:
;; Right: ___ None ___ Slight ___ Moderate ___ Severe
;; Left: ___ None ___ Slight ___ Moderate ___ Severe
;;
;; 11. Additional conditions
;;
;; Does the Veteran now have or has he or she ever had "shin splints" (medial
;; tibial stress syndrome), stress fractures, chronic exertional compartment
;; syndrome or any other tibial and/or fibular impairment?
;; ___ Yes ___ No
;; If yes, indicate condition and complete the appropriate sections below.
;;
;; a. ___ "Shin splints" (medial tibial stress syndrome)
;; If checked, indicate side affected: ___Right ___Left ___Both
;; Describe current symptoms: ______________________________________________
;;^TOF^
;; b. ___ Stress fracture of the lower extremity
;; If checked, indicate side affected: ___Right ___Left ___Both
;; Describe current symptoms: ______________________________________________
;;
;; c. ___ Chronic exertional compartment syndrome
;; If checked, indicate side affected: ___Right ___Left ___Both
;; Describe current symptoms: ______________________________________________
;;
;; d. ___ Evidence of acquired, traumatic genu recurvatum with weakness and
;; insecurity in weight-bearing
;; If checked, indicate side affected: ___Right ___Left ___Both
;;
;; e. ___ Leg length discrepancy (shortening of any bones of the lower
;; extremity)
;; If checked, provide length of each lower extremity in inches (to the
;; nearest 1/4 inch) or centimeters, measuring from the anterior superior
;; iliac spine to the internal malleolus of the tibia.
;; Measurements: Right leg: _________ __cm __inches
;; Left leg: __________ __cm __inches
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQKL2 13437 printed Dec 13, 2024@01:47:03 Page 2
DVBCQKL2 ;;ALB-CIOFO/ECF - KNEE AND LOWER LEG CONDITIONS QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;***172***;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+3 ;; disability benefits. VA will consider the information you provide on this
+4 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+5 ;;
+6 ;; 1. Diagnosis
+7 ;;
+8 ;; Does the Veteran now have or has he/she ever had a knee and/or lower leg
+9 ;; condition?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; If yes, provide only diagnoses that pertain to knee and/or lower leg
+13 ;; conditions:
+14 ;; Diagnosis #1: ___________________
+15 ;; ICD code: ______________________
+16 ;; Date of diagnosis: ______________
+17 ;; Side affected: ___ Right ___ Left ___ Both
+18 ;;
+19 ;; Diagnosis #2: ___________________
+20 ;; ICD code: ______________________
+21 ;; Date of diagnosis: ______________
+22 ;; Side affected: ___ Right ___ Left ___ Both
+23 ;;
+24 ;; Diagnosis #3: ___________________
+25 ;; ICD code: ______________________
+26 ;; Date of diagnosis: ______________
+27 ;; Side affected: ___ Right ___ Left ___ Both
+28 ;;
+29 ;; If there are additional diagnoses that pertain to knee and/or lower leg
+30 ;; conditions, list using above format: ____
+31 ;;
+32 ;; 2. Medical history
+33 ;;
+34 ;; a. Describe the history (including onset and course) of the Veteran's knee
+35 ;; and/or lower leg condition (brief summary): ________________________________
+36 ;;
+37 ;; 3. Flare-ups
+38 ;;
+39 ;; Does the Veteran report that flare-ups impact the function of the knee
+40 ;; and/or lower leg?
+41 ;; ___ Yes ___ No
+42 ;; If yes, document the Veteran's description of the impact of flare-ups in
+43 ;; his or her own words: ______________________________________________________
+44 ;;^TOF^
+45 ;; 4. Initial range of motion (ROM) measurements
+46 ;;
+47 ;; Measure ROM with a goniometer, rounding each measurement to the nearest
+48 ;; 5 degrees. During the measurements, document the point at which painful
+49 ;; motion begins, evidenced by visible behavior such as facial expression,
+50 ;; wincing, etc. Report initial measurements below.
+51 ;;
+52 ;; Following the initial assessment of ROM, perform repetitive use testing.
+53 ;; For VA purposes, repetitive use testing must be included in all joint
+54 ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
+55 ;; serve as a representative test of the effect of repetitive use. After the
+56 ;; initial measurement, reassess ROM after 3 repetitions. Report post-test
+57 ;; measurements in section 5.
+58 ;;
+59 ;; a. Right knee flexion
+60 ;; Select where flexion ends (normal endpoint is 140 degrees):
+61 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+62 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+63 ;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
+64 ;;
+65 ;; Select where objective evidence of painful motion begins:
+66 ;; ___ No objective evidence of painful motion
+67 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+68 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+69 ;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
+70 ;;
+71 ;; b. Right knee extension
+72 ;;
+73 ;; Select where extension ends:
+74 ;; ___ 0 or any degree of hyperextension (check this box if there is no
+75 ;; limitation of extension)
+76 ;; Unable to fully extend; extension ends at:
+77 ;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+78 ;;
+79 ;; Select where objective evidence of painful motion begins:
+80 ;; ___No objective evidence of painful motion
+81 ;; ___0 or any degree of hyperextension (check this box if there is no
+82 ;; limitation of extension)
+83 ;; Unable to fully extend; extension ends at:
+84 ;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+85 ;;^TOF^
+86 ;; c. Left knee flexion
+87 ;; Select where flexion ends (normal endpoint is 140 degrees):
+88 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+89 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+90 ;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
+91 ;;
+92 ;; Select where objective evidence of painful motion begins:
+93 ;; __ No objective evidence of painful motion
+94 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+95 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+96 ;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
+97 ;;
+98 ;; d. Left knee extension
+99 ;; Select where extension ends:
+100 ;; __ 0 or any degree of hyperextension (check this box if there is no
+101 ;; limitation of extension)
+102 ;; Unable to fully extend; extension ends at:
+103 ;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+104 ;;
+105 ;; Select where objective evidence of painful motion begins:
+106 ;; __ No objective evidence of painful motion
+107 ;; __ 0 or any degree of hyperextension (check this box if there is no
+108 ;; limitation of extension)
+109 ;; Unable to fully extend; extension ends at:
+110 ;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+111 ;;
+112 ;; e. If ROM does not conform to the normal range of motion identified
+113 ;; above but is normal for this Veteran (for reasons other than a knee
+114 ;; and/or leg condition, such as age, body habitus, neurologic disease),
+115 ;; explain: ___________________________________________________________________
+116 ;;
+117 ;; 5. ROM measurements after repetitive use testing
+118 ;;
+119 ;; a. Is the Veteran able to perform repetitive-use testing with 3
+120 ;; repetitions?
+121 ;; ___ Yes ___ No
+122 ;; If unable, provide reason: __________________
+123 ;; If Veteran is unable to perform repetitive-use testing, skip to
+124 ;; section 6.
+125 ;;^TOF^
+126 ;; If Veteran is able to perform repetitive-use testing, measure and report
+127 ;; ROM after a minimum of 3 repetitions:
+128 ;;
+129 ;; b. Right knee post-test ROM
+130 ;; Select where post-test flexion ends:
+131 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+132 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+133 ;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
+134 ;;
+135 ;; Select where post-test extension ends:
+136 ;; __ 0 or any degree of hyperextension (check this box if there is no
+137 ;; limitation of extension)
+138 ;; Unable to fully extend; extension ends at:
+139 ;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+140 ;;
+141 ;; c. Left knee post-test ROM
+142 ;; Select where post-test flexion ends:
+143 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+144 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+145 ;; __100 __105 __110 __115 __120 __125 __130 __135 __140 or greater
+146 ;;
+147 ;; Select where post-test extension ends:
+148 ;; ___ 0 or any degree of hyperextension (check this box if there is no
+149 ;; limitation of extension)
+150 ;; Unable to fully extend; extension ends at:
+151 ;; __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+152 ;;
+153 ;; 6. Functional loss and additional limitation in ROM
+154 ;;
+155 ;; The following section addresses reasons for functional loss, if present,
+156 ;; and additional loss of ROM after repetitive-use testing, if present. The
+157 ;; VA defines functional loss as the inability to perform normal working
+158 ;; movements of the body with normal excursion, strength, speed, coordination
+159 ;; and/or endurance.
+160 ;;
+161 ;; a. Does the Veteran have additional limitation in ROM of the knee and lower
+162 ;; leg following repetitive-use testing?
+163 ;; ___ Yes ___ No
+164 ;;^TOF^
+165 ;; b. Does the Veteran have any functional loss and/or functional impairment
+166 ;; of the knee and lower leg?
+167 ;; ___ Yes ___ No
+168 ;;
+169 ;; c. If the Veteran has functional loss, functional impairment or additional
+170 ;; limitation of ROM of the knee and lower leg after repetitive use, indicate
+171 ;; the contributing factors of disability below (check all that apply and
+172 ;; indicate side affected):
+173 ;; ___ No functional loss for right lower extremity
+174 ;; ___ No functional loss for left lower extremity
+175 ;; ___ Less movement than normal ___Right ___Left ___Both
+176 ;; ___ More movement than normal ___Right ___Left ___Both
+177 ;; ___ Weakened movement ___Right ___Left ___Both
+178 ;; ___ Excess fatigability ___Right ___Left ___Both
+179 ;; ___ Incoordination, impaired ability ___Right ___Left ___Both
+180 ;; to execute skilled movements smoothly
+181 ;; ___ Pain on movement ___Right ___Left ___Both
+182 ;; ___ Swelling ___Right ___Left ___Both
+183 ;; ___ Deformity ___Right ___Left ___Both
+184 ;; ___ Atrophy of disuse ___Right ___Left ___Both
+185 ;; ___ Instability of station ___Right ___Left ___Both
+186 ;; ___ Disturbance of locomotion ___Right ___Left ___Both
+187 ;; ___ Interference with sitting, standing ___Right ___Left ___Both
+188 ;; and weight-bearing
+189 ;; ___ Other, describe: ____________________________________________________
+190 ;;
+191 ;; 7. Pain (pain on palpation)
+192 ;;
+193 ;; Does the Veteran have tenderness or pain to palpation for joint line or
+194 ;; soft tissues of either knee?
+195 ;; ___ Yes ___ No
+196 ;; If yes, side affected: ___Right ___Left ___Both
+197 ;;
+198 ;; 8. Muscle strength testing
+199 ;;
+200 ;; Rate strength according to the following scale:
+201 ;; 0/5 No muscle movement
+202 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+203 ;; 2/5 Active movement with gravity eliminated
+204 ;; 3/5 Active movement against gravity
+205 ;; 4/5 Active movement against some resistance
+206 ;; 5/5 Normal strength
+207 ;;
+208 ;; Knee flexion:
+209 ;; Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+210 ;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+211 ;; Knee extension:
+212 ;; Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+213 ;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+214 ;;^TOF^
+215 ;; 9. Joint stability tests
+216 ;;
+217 ;; a. Anterior instability (Lachman test):
+218 ;; ___ Unable to test: ___Right ___Left ___Both
+219 ;; Right:
+220 ;; ___Normal ___1+ (0-5 millimeters)
+221 ;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
+222 ;; Left:
+223 ;; ___Normal ___1+ (0-5 millimeters)
+224 ;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
+225 ;;
+226 ;; b. Posterior instability (Posterior drawer test):
+227 ;; ___ Unable to test: ___Right ___Left ___Both
+228 ;; Right:
+229 ;; ___Normal ___1+ (0-5 millimeters)
+230 ;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
+231 ;; Left:
+232 ;; ___Normal ___1+ (0-5 millimeters)
+233 ;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
+234 ;;
+235 ;; c. Medial-lateral instability (Apply valgus/varus pressure to knee in
+236 ;; extension and 30 degrees of flexion):
+237 ;; ___ Unable to test: ___Right ___Left ___Both
+238 ;; Right:
+239 ;; ___Normal ___1+ (0-5 millimeters)
+240 ;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
+241 ;; Left:
+242 ;; ___Normal ___1+ (0-5 millimeters)
+243 ;; ___2+ (5-10 millimeters) ___3+ (10-15 millimeters)
+244 ;;
+245 ;; 10. Patellar subluxation/dislocation
+246 ;;
+247 ;; Is there evidence or history of recurrent patellar subluxation/dislocation?
+248 ;; ___ Yes ___ No
+249 ;; If yes, indicate severity and side affected:
+250 ;; Right: ___ None ___ Slight ___ Moderate ___ Severe
+251 ;; Left: ___ None ___ Slight ___ Moderate ___ Severe
+252 ;;
+253 ;; 11. Additional conditions
+254 ;;
+255 ;; Does the Veteran now have or has he or she ever had "shin splints" (medial
+256 ;; tibial stress syndrome), stress fractures, chronic exertional compartment
+257 ;; syndrome or any other tibial and/or fibular impairment?
+258 ;; ___ Yes ___ No
+259 ;; If yes, indicate condition and complete the appropriate sections below.
+260 ;;
+261 ;; a. ___ "Shin splints" (medial tibial stress syndrome)
+262 ;; If checked, indicate side affected: ___Right ___Left ___Both
+263 ;; Describe current symptoms: ______________________________________________
+264 ;;^TOF^
+265 ;; b. ___ Stress fracture of the lower extremity
+266 ;; If checked, indicate side affected: ___Right ___Left ___Both
+267 ;; Describe current symptoms: ______________________________________________
+268 ;;
+269 ;; c. ___ Chronic exertional compartment syndrome
+270 ;; If checked, indicate side affected: ___Right ___Left ___Both
+271 ;; Describe current symptoms: ______________________________________________
+272 ;;
+273 ;; d. ___ Evidence of acquired, traumatic genu recurvatum with weakness and
+274 ;; insecurity in weight-bearing
+275 ;; If checked, indicate side affected: ___Right ___Left ___Both
+276 ;;
+277 ;; e. ___ Leg length discrepancy (shortening of any bones of the lower
+278 ;; extremity)
+279 ;; If checked, provide length of each lower extremity in inches (to the
+280 ;; nearest 1/4 inch) or centimeters, measuring from the anterior superior
+281 ;; iliac spine to the internal malleolus of the tibia.
+282 ;; Measurements: Right leg: _________ __cm __inches
+283 ;; Left leg: __________ __cm __inches
+284 QUIT
