Range Of Joint Motion Evaluation Chart Page 2
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211. Shoulder (Abduction – Adduction)
12. Shoulder (Flexion – Extension)
Left
Left
O
O
O
O
Adduction 30
Abduction 150
Extension 50
Flexion 150
Degrees
Degrees
Degrees
Degrees
Right
Right
O
O
O
O
Adduction 30
Abduction 150
Extension 50
Flexion 150
Degrees
Degrees
Degrees
Degrees
13. Elbow
14. Forearm (Pronation – Supination)
Left
Left
O
O
O
O
Extension 0
Flexion 150
Pronation 80
Supination 80
Degrees
Degrees
Degrees
Degrees
Right
Right
O
O
O
O
Extension 0
Flexion 150
Pronation 80
Supination 80
Degrees
Degrees
Degrees
Degrees
15. Ankle
16. Ankle (Flexion – Extension)
Left
Left
O
O
O
O
Inversion 30
Eversion 20
Plantar 40
Dorsal 20
Degrees
Degrees
Degrees
Degrees
Right
Right
O
O
O
O
Inversion 30
Eversion 20
Plantar 40
Dorsal 20
Degrees
Degrees
Degrees
Degrees
17. Wrist (radial, ulnar)
18. Wrist
Left
Left
O
O
O
O
Radial 20
Ulnar 30
Extension 60
Flexion 60
Degrees
Degrees
Degrees
Degrees
Right
Right
O
O
O
O
Radial 20
Ulnar 30
Extension 60
Flexion 60
Degrees
Degrees
Degrees
Degrees
19. Thumb (MP Joint)
20. Thumb (IP Joint)
Left
Right
Left
Right
O
O
O
O
Flexion 60
Flexion 60
Flexion 80
Flexion 80
Degrees
Degrees
Degrees
Degrees
DATE OF EXAMINATION
EXAMINING PHYSICIAN’S SIGNATURE
DATE OF REPORT
DSHS 13-585A (REV. 03/2014)
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