History ***Total____/8 (1 pt each) 1 1 1 1 1 1 1 1 (quick mark offs)
_____ MOI/How did it happen? |
_____ When did it happen? |
_____ What happened? |
_____ Direction of forces |
_____ Sport/position |
_____ Any sounds |
_____ Location of pain |
_____ Type of pain |
_____ Rate pain level |
_____ Radiating pain |
_____ Referred pain |
_____ Overuse/acute |
_____ Movement ↑ or ↓ pain |
_____ Previous injury |
_____ Previous treatment |
_____ Length of symptoms |
_____ Sounds and sensations |
_____ Tingling/numbing |
_____ Changes in training |
_____ Age of shoes |
_____ Type of track |
_____ Other intrinsic/extrinsic factors |
_____ Medications |
|
Observation ***Total____/8 (Observation) (1 pt each) 1 1 1 1 1 1 1 1 (quick mark offs)
_____ Deformities |
_____ Symmetry of gait |
_____ Symmetry/alignment |
_____ Scars/lacerations |
_____ Skin color |
_____ Swelling |
_____ Shoe/sock removal |
_____ Shoe wear |
_____ Pain/guarding |
_____ Blisters |
_____ Callus patterns |
_____ VMO atrophy |
_____ VMO hypertrophy |
_____ Flexibility of foot/LL |
_____ Foot deformities |
Posture
_____ Pes cavus |
_____ Pes planus |
_____ Achilles t. angle |
_____ WB vs. NWB posture |
_____ Camel sign |
_____ Genu recurvatum |
_____ Genu valgus |
_____ Genu varum |
_____ Shoe creases |
_____ Shoe pattern (e.g., pronation vs. supination) |
_____ Valgus/Varus orientation of forefoot/rearfoot |
|
Palpations ***Total___/8 (Palpations) (1 pt each)
Bony Palpation - Reasons for bony palpation: AT palpates for: Total 2 points (.5 each) ______
_____ Point tenderness |
_____ Deformity |
_____ Crepitus |
_____ Symmetry |
Bony Palpations:
___ Patella |
___Fibula Head |
___ Joint line |
___ Tibial Tuberosity |
___ Tibial Plateau |
|
Soft tissue Palpation - Reasons for bony palpation: AT palpates for Total 2 points (.5 each) ____
_____Point tenderness |
____ Symmetry |
____ Spasm/tone |
____ Swelling/ warmth |
Soft Tissue Palpations
___ Patellar Tendon |
|
___ Medial Collateral Ligament |
___ Lateral Collateral Ligament |
|
|
Range of Motion ***Total____/3 (ROM)**
___ Active ROM (F, E) |
|
___ Passive ROM (F, E) |
Bi Lateral ________ 1 pt |
___ Manual muscle (F, E) |
|
Special tests ***Total_____/26 (Special Tests) ( 1 pt each)
Name: |
___ Anterior Drawer |
___Posterior Drawer |
__Lachman's |
Mechanics: |
___ |
___ |
___ |
Testing for: |
___ ACL tear/sprain |
___ PCL tear/sprain |
___ ACL tear/sprain |
Positive test: |
___ Anterior Translation |
___ Posterior Translation |
___ Anterior Trans. |
Name: |
___Valgus |
___Varus |
___Apley’s Com. |
Mechanics: |
___ |
___ |
___ |
Testing for: |
___ MCL tear/sprain |
___ LCL tear/sprain |
___ Meniscus tear |
Positive test: |
___ Hypermobility/Pain |
___ Hypermobility/Pain |
___ Pain |
|
___ 0 & 30 |
|
|