Va Form 21-0960m-2 - Ankle Conditions Disability Benefits Questionnaire Page 2
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SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
4C. LEFT ANKLE PLANTAR FLEXION
(normal endpoint is 45 degrees):
SELECT WHERE PLANTAR FLEXION ENDS
0
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
5
10
15
20
25
30
35
40
45 or greater
(extension)
4D. LEFT ANKLE PLANTAR DORSIFLEXION
(extension)
(normal endpoint is 20 degrees):
SELECT WHERE DORSIFLEXION
ENDS
0
5
10
15
20 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
NO OBJECTIVE EVIDENCE OF PAINFUL MOTION
0
5
10
15
20 or greater
(for reasons other than an
4E. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN
ankle condition, such as age, body habitus, neurologic disease),
EXPLAIN:
SECTION V- ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5A. 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 VI.
IF VETERAN IS ABLE TO PERFORM REPETITIVE-USE TESTING, MEASURE AND REPORT ROM AFTER A MINIMUM OF 3 REPETITIONS.
5B. RIGHT ANKLE POST-TEST ROM
SELECT WHERE POST-TEST PLANTAR FLEXION ENDS:
0
5
10
15
20
25
30
35
40
45 or greater
extension)
SELECT WHERE POST-TEST DORSIFLEXION (
ENDS:
0
5
10
15
20 or greater
5C. LEFT ANKLE POST-TEST ROM
SELECT WHERE POST-TEST PLANTAR FLEXION ENDS:
0
5
10
15
20
25
30
35
40
45 or greater
extension)
SELECT WHERE POST-TEST DORSIFLEXION (
ENDS:
0
5
10
15
20 or greater
SECTION VI- 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.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE ANKLE FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE ANKLE?
YES
NO
VA FORM 21-0960M-2, OCT 2012
Page 2
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