APMA News - November/December 2019 - 47

Sample template for EHR use:
Pes cavus
[Insert proximal exam template if indicated**]
Cavus foot type with [associated digital deformities] is noted
[right, left, bilateral].
[see template for all associated digital deformities and insert
here].
The forefoot to rearfoot is [perpendicular, valgus] with the
apex of cavus at the [metatarsals, lesser tarsals, Chopart's
joint]. The first ray is [plantarflexed, neutral]. The lateral border of the foot is [rectus, adducted, abducted]. Midtarsal joint
motion is [limited, excessive] in the [frontal, transverse, sagittal] plane with [intact, absent] locking mechanism. Subtalar
joint motion is [measurement*, smooth, crepitus, painful,
pain free, limited, excessive] in the [frontal, transverse, sagittal] plane. Ankle joint dorsiflexion with the knee extended is
[x] degrees and with the knee flexed [x] degrees.
Manual muscle testing reveals [grade the strength of weak
muscles using 5-point scale; if no weakness document 5/5
strength]. In stance [digital deformities] [increase, decrease,
no change] [describe digital purchase]. The forefoot to rearfoot is [adducted, abducted, rectus] and RCSP is [perpendicular, inverted, everted]. In stance the foot is [medial, lateral,
rectus] relative to the leg. Coleman block test reveals [no
change to, perpendicular] RCSP.

Gait examination reveals [propulsive, apropulsive] gait with
[increased, decreased, normal] angle and base. At midstance
the foot is [pronated, pronating, neutral]. [document flexor
stabilization, extensor substitution, if present] [document
early heel off or compensation, if present***] The first ray is
[stable, unstable****] in propulsion.
*: If ROM is limited then it should be measured. If measurement is used, be certain the math is correct when you
document the neutral position. Formula: (inversion + eversion/3) - eversion = NP; if the value is positive, neutral
position is inverted, if negative, neutral position is everted
**: For example, if the examination finds 5 degrees of
forefoot valgus, but RCSP measures 10 degrees inverted,
there is another reason for the extra 5 degrees of inverted
resting stance position.
***: If limited ankle dorsiflexion was documented in static exam there must be early heel off or other compensation such as shortened stride length, medial column subluxation, lateral column breech.
****: If the first ray plantarflexes in propulsion, then it is
stable.

Sample template for EHR use:
Pes planus

[Insert proximal exam template if indicated**]

Low arch with [associated digital deformities] is noted [right,
left, bilateral]. [See template for all associated digital deformities and/or hallux valgus insert here]. The forefoot to rearfoot is
[perpendicular, varus, valgus]. In the sagittal plane the forefoot
is [neutral, dorsiflexed] at the level of [anatomic location of the
breech]. The lateral border of the foot is [rectus, adducted, abducted].

Gait examination reveals [propulsive, apropulsive] gait with
[increased, decreased, normal] angle and base. At midstance
the foot is [pronated, pronating, neutral]. [document flexor
stabilization, extensor substitution, flexor substitution if
present] [document early heel off or compensation, if present***] The first ray is [stable, unstable****] in propulsion.

Midtarsal joint motion is [limited, excessive] in the [frontal,
transverse, sagittal] plane with [intact, absent] locking
mechanism. Subtalar joint motion is [measurement*, smooth,
excessive, limited], and shows [no] planal dominance [in the
frontal, transverse plane]. There is [presence, absence] of
[pain, crepitus] with motion. Ankle joint dorsiflexion with
the knee extended is [x] degrees and with the knee flexed [x]
degrees. Manual muscle testing reveals [grade the strength of
weak muscles using 5 point scale; if no weakness document
5/5 strength]. In stance [digital deformities increase, decrease, digital purchase] the forefoot to rearfoot is [adducted, abducted, rectus] and RCSP is [perpendicular, inverted,
everted]. The foot is [medial, lateral, not] offset to the leg.
Dual limb support heel rise reveals [stable, unstable] midtarsal joint. Single limb support heel rise is [intact, absent;
right, left, bilateral].

*: If ROM is limited, then it should be measured. If measurement is used, be certain the math is correct when you
document the neutral position. Formula: (inversion + eversion/3) - eversion = NP; if the value is positive, neutral
position is inverted, if negative, neutral position is everted
**: For example, if subtalar joint ROM measures 5 degrees of pronation, but RCSP is 10 degrees everted, there
is another cause of the extra 5 degrees of everted resting
calcaneal stance.
***: If limited ankle dorsiflexion was documented in static exam there must be early heel off or other compensation such as shortened stride length, abduction, medial
column subluxation, lateral column breech.
****: If the first ray plantarflexes in propulsion, then it is
stable.
ABPM Templates continued on page 48

APMA News November/December 2019

47
APMA News - November/December 2019

Table of Contents for the Digital Edition of APMA News - November/December 2019
