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Biomechanical assessment & patient history

PRESENTING COMPLAINT
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SITE OF PAIN / LESIONS

ACTIVITIES

FOOTWEAR / WEAR PATTERNS

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SUMMARY / IMPRESSIONS AT THIS STAGE

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Department of Podiatry, LTU, 2001 ARB & CBP

Dynamic gait analysis

OBSERVATION

LEFT

RIGHT

COMMENTS

HEAD / EYE TILT

SHOULDER DROP
ARM SWING

FRONTAL PLANE

PELVIC TILT
PATELLAR POSITION / MOVEMENT

REARFOOT MOTION / POSITION

HEEL STRIKE
MIDSTANCE
PROPULSION
BASE OF GAIT

Ref: narrow / normal / wide

ANGLE OF GAIT

Ref: 5-10 abducted

OTHER OBSERVATIONS

SAGITTAL PLANE

(eg. Abductory twist)

TORSO POSITION
ARM SWING
HEEL / LIFT TIMING
MTJ MOTION / TIMING
KNEE POSITION / MOVEMENT
OTHER OBSERVATIONS
SUMMARY / IMPRESSIONS AT THIS STAGE:
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Prone examination
REFERENCE
STJ

20 inv / 10 ev

LEFT

RIGHT

COMMENTS

ROM

0-3 inverted
Transverse plane

NEUTRAL

Sagittal plane

AXIS
POSITION
FOREFOOT POSn.

Perpendicular to rearfoot

ANKLE (KNEE

10 dorsiflexion

FLEX)

Department of Podiatry, LTU, 2001 ARB & CBP

(KNEE
EXT)

Supine examination
REFERENCE
FIRST MPJ ROM

65 dorsiflexion

FHL TEST

+ve or -ve

FIRST RAY

Equal DF and PF

ROM

Neutral

LEFT

RIGHT

COMMENTS

POSITION
MTJ

OAMTJ ROM

OAMTJ AXIAL ORIENTATION

LAMTJ

large / norm / restrict

vertical / norm / horiz
large / norm / restrict

ROM
MALLEOLAR TORSION

20-25 external

HAMSTRINGS

70-90 flexion

LIMB LENGTH DISCREPANCY ?

YES / NO

ASIS LM/MM

structural / functional

UMB - LM/MM

RIGHT: .........................

LEFT: .........................

HIP JOINT ROTATION - LEFT

HIP JOINT ROTATION - RIGHT

FLEXED

FLEXED

G. max &
piriformis

sartorius

internal

external
G. med & min. &
adductors

iliopsoas

G. max &
piriformis

sartorius

internal

external
G. med & min. &
adductors

iliopsoas

EXTENDED

EXTENDED
internal

external

internal

external

Weightbearing examination
REFERENCE

LEFT

RIGHT

COMMENTS

RCSP

2-3 everted

NCSP

0-3 inverted

TIBIAL POSITION (STJN)

0-2 inverted

NAVICULAR DROP

1cm sagittal plane

DRIFT/DROP RATIO

NAVICULAR DRIFT

1cm transverse plane

L .. R.

WHAT STOPS XS FOOT PRONATION?

CONTACT

PLANTAR FASCIA

POST. TIB. M.

STJ OSSEOUS

SUPINATION RESISTANCE TEST

EASY, NORMAL OR HARD

Department of Podiatry, LTU, 2001 ARB & CBP

Final impressions

(diagnosis / prognosis / justification )

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Management
1. INJURY (eg. pharmacological or physical therapy required)

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2. EXERCISE THERAPY

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3. ACTIVITY MODIFICATION

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4. OTHER EXTERNAL REFERRALS

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5. ORTHOSIS PRESCRIPTION
CORRECTED CALCANEAL POSITION:

LEFT

INV / EV

RIGHT:

INV / EV
STYLE:..................................................................................................................................................
(Cushioning, pressure relief, pre-formed, moulded non-cast, moulded cast or functional foot orthosis
[Root balance, modified Root, inverted, medial heel skive, DC wedge, hybrid])
MATERIAL:
COVER:

4MM POLYPROP
VINYL

EVA
3MM PORON

OTHER..............................
CAMBRELLE

EXTENSIONS:......................................................................................................................................................................................................................... HE
EL PITCH: .....................................SHELL MODIFICATIONS: .............................................................................................................................
6. FOOTWEAR: ...........................................................................................................................................................................................................
7. OTHER ADVICE: ..............................................................................................................................................................................................
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DATE OF ISSUE: .................................................................................................................................................... PAYMENT: ......................................

STUDENT: (print name)

CLINICIAN (signature)

ASSESSMENT DATE:

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Department of Podiatry, LTU, 2001 ARB & CBP