Routine: DVBCQKL2

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

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQKL2   13437     printed  Apr 23, 2025@18:01:32                                                                                                                                                                                                   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

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