VA Form 21-0960M-2 Ankle Conditons Disability Benefits Questionnaire

OMB Approved No. 2900-0776
Respondent Burden: 30 minutes

ANKLE CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF
COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN ANKLE CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO ANKLE CONDITION(S):
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

RIGHT

RIGHT

RIGHT

LEFT

BOTH

LEFT

BOTH

LEFT

BOTH

1C. IF THERE ARE ADDITIONAL DIAGNOSES PERTAINING TO ANKLE CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S ANKLE CONDITION (brief summary):

SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE ANKLE?
YES

NO

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:

SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
4. MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, DOCUMENT THE
POINT AT WHICH PAINFUL MOTION BEGINS, EVIDENCED BY VISIBLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT INITIAL
MEASUREMENTS BELOW.
FOLLOWING THE INITIAL ASSESSMENT OF ROM, PERFORM REPETITIVE USE TESTING. FOR VA PURPOSES, REPETITIVE USE TESTING MUST BE INCLUDED
IN ALL JOINT EXAMS. THE VA HAS DETERMINED THAT 3 REPETITIONS OF ROM (at a minimum) CAN SERVE AS A REPRESENTATIVE TEST OF THE EFFECT
OF REPETITIVE USE. AFTER THE INITIAL MEASUREMENT, REASSESS ROM AFTER 3 REPETITIONS. REPORT POST-TEST MEASUREMENTS IN SECTION 5.
A. RIGHT ANKLE PLANTAR FLEXION
SELECT WHERE PLANTAR FLEXION ENDS (normal endpoint is 45 degrees):

0

5

10

15

20

25

30

35

40

45 or greater

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

B. RIGHT ANKLE DORSIFLEXION (extension)
SELECT WHERE DORSIFLEXION (extension) ENDS (normal endpoint is 20 degrees):

0

5

10

15

20 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
NO OBJECTIVE EVIDENCE OF PAINFUL MOTION

0
VA FORM
JAN 2011

5

10

15

21-0960M-2

20 or greater
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SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
C. LEFT ANKLE PLANTAR FLEXION
SELECT WHERE PLANTAR FLEXION ENDS (normal endpoint is 45 degrees):

0

5

10

15

20

25

30

35

40

45 or greater

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

D. LEFT ANKLE PLANTAR DORSIFLEXION (extension)
SELECT WHERE DORSIFLEXION (extension) ENDS (normal endpoint is 20 degrees):

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

4E. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN (for reasons other than an
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 6.
IF VETERAN IS ABLE TO PERFORM REPETITIVE-USE TESTING, MEASURE AND REPORT ROM AFTER A MINIMUM OF 3 REPETITIONS.
B. RIGHT ANKLE POST-TEST ROM
SELECT WHERE POST-TEST PLANTAR FLEXION ENDS:

0

5

10

15

20

25

30

35

40

35

40

45 or greater

SELECT WHERE POST-TEST DORSIFLEXION (extension) ENDS:

0

5

10

15

20 or greater

C. LEFT ANKLE POST-TEST ROM
SELECT WHERE POST-TEST PLANTAR FLEXION ENDS:

0

5

10

15

20

25

30

45 or greater

SELECT WHERE POST-TEST DORSIFLEXION (extension) 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, JAN 2011

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SECTION VI- FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM (Continued)
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE ANKLE AFTER REPETITIVE USE,
INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (check all that apply and indicate side affected):
No functional loss for right lower extremity attributable to claimed condition
No functional loss for left lower extremity attributable to claimed condition
Less movement than normal

Right

Left

Both

More movement than normal

Right

Left

Both

Weakened movement

Right

Left

Both

Excess fatigability
Incoordination, impaired ability to execute skilled
movements smoothly

Right

Left

Both

Right

Left

Both

Pain on movement

Right

Left

Both

Swelling

Right

Left

Both

Deformity

Right

Left

Both

Atrophy of disuse

Right

Left

Both

Instability of station

Right

Left

Both

Disturbance of locomotion

Right

Left

Both

Interference with sitting, standing and weight-bearing

Right

Left

Both

Other, describe:

SECTION VII - PAIN (PAIN ON PALPATION)
7. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN ON PALPATION OF JOINTS/SOFT TISSUE OF EITHER ANKLE?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

Right

Left

Both

SECTION VIII - MUSCLE STRENGTH TESTING
8. RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Ankle plantar flexion:

Ankle dorsiflexion:

Right

5/5

4/5

3/5

2/5

1/5

0/5

Left

5/5

4/5

3/5

2/5

1/5

0/5

Right

5/5

4/5

3/5

2/5

1/5

0/5

Left

5/5

4/5

3/5

2/5

1/5

0/5

SECTION IX - JOINT STABILITY
9A. ANTERIOR DRAWER TEST - IS THERE LAXITY COMPARED WITH OPPOSITE SIDE?
YES

NO

UNABLE TO TEST

IF YES, WHICH SIDE DEMONSTRATES LAXITY?

Right

Left

Both

9B. TALAR TILT TEST (inversion/eversion stress) - IS THERE LAXITY COMPARED WITH OPPOSITE SIDE?
YES

NO

UNABLE TO TEST

IF YES, WHICH SIDE DEMONSTRATES LAXITY?

Right

Left

Both

SECTION X - ANKYLOSIS
10. DOES THE VETERAN HAVE ANKYLOSIS OF THE ANKLE, SUBTALAR AND OR TARSAL JOINT?
YES

NO

IF YES, INDICATE SEVERITY OF ANKYLOSIS AND SIDE AFFECTED (check all that apply):
In plantar flexion, less than 30º

Right

Left

Both

In plantar flexion, between 30º and 40º

Right

Left

Both

In plantar flexion, at more than 40º

Right

Left

Both

In dorsiflexion, between 0º and 10º

Right

Left

Both

In dorsiflexion at more than 10º

Right

Left

Both

With abduction, adduction, inversion or
eversion deformity

Right

Left

Both

In good weight-bearing position

Right

Left

Both

In poor weight-bearing position

Right

Left

Both

VA FORM 21-0960M-2, JAN 2011

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SECTION XI - ADDITIONAL CONDITIONS
11. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD "SHIN SPLINTS", STRESS FRACTURES, ACHILLES TENDONITIS, ACHILLES TENDON
RUPTURE, MALUNION OF CALCANEUS (os calcis) OR TALUS (astragalus), OR HAS THE VETERAN HAD A TALECTOMY (astragalectomy)?
YES

NO

IF YES, INDICATE CONDITION AND COMPLETE THE APPROPRIATE SECTIONS BELOW:
"SHIN SPLINTS" (medial tibial stress syndrome)
Right

IF CHECKED, INDICATE SIDE AFFECTED:

Left

Both

Left

Both

Left

Both

DESCRIBE CURRENT SYMPTOMS:
STRESS FRACTURE OF THE LOWER EXTREMITY
Right

IF CHECKED, INDICATE SIDE AFFECTED:
DESCRIBE CURRENT SYMPTOMS:

ACHILLES TENDONITIS OR ACHILLES TENDON RUPTURE
IF CHECKED, INDICATE SIDE AFFECTED:

Right

DESCRIBE CURRENT SYMPTOMS:
MALUNION OF CALCANEOUS (os calcis) OR TALUS (astragalus)
IF CHECKED, INDICATE SEVERITY AND SIDE AFFECTED:
Moderate

Right

Left

Both

Marked deformity

Right

Left

Both

TALECTOMY
IF CHECKED, INDICATE SIDE AFFECTED:

Right

Left

Both

DESCRIBE CURRENT SYMPTOMS:

SECTION XII - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES
12A. HAS THE VETERAN HAD A TOTAL ANKLE JOINT REPLACEMENT?
YES

NO

IF YES, INDICATE SIDE AND SEVERITY OF RESIDUALS
Right ankle
Date of surgery:
Residuals:
None
Intermediate degrees of residual weakness, pain and/or limitation of motion
Chronic residuals consisting of severe painful motion and/or weakness
Other, describe:
Left ankle
Date of surgery:
Residuals:
None
Intermediate degrees of residual weakness, pain and/or limitation of motion
Chronic residuals consisting of severe painful motion and/or weakness
Other, describe:
12B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER ANKLE SURGERY?
YES

NO

If yes, indicate side affected:

Right

Left

Both

Date and type of surgery:
12C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER ANKLE SURGERY?
YES

NO

If yes, indicate side affected:

Right

Left

Both

If yes, describe residuals:

SECTION XIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
13A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION 1?
YES

NO

IF YES, ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN 39 SQUARE CM
(6 square inches)?
YES

NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

VA FORM 21-0960M-2, JAN 2011

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SECTION XIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
13B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?
YES

NO

IF YES, DESCRIBE (brief summary):

SECTION XIV - ASSISTIVE DEVICES
14A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES
NO IF YES, IDENTIFY ASSISTIVE DEVICE(S) USED (check all that apply and indicate frequency):
WHEELCHAIR

Frequency of use:

Occasional

Regular

BRACE(S)

Frequency of use:

Occasional

Regular

Constant

CRUTCH(ES)

Frequency of use:

Occasional

Regular

Constant

CANE(S)

Frequency of use:

Occasional

Regular

Constant

WALKER

Frequency of use:

Occasional

Regular

Constant

OTHER:

Frequency of use:

Occasional

Regular

Constant

Constant

14B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION XV - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
15. DUE TO THE VETERAN'S ANKLE CONDITION(S), IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS
OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper extremity include grasping,

manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
Yes, functioning is so diminished that amputation with prosthesis would equally serve the veteran
No

IF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:
Right lower

Left lower

FOR EACH CHECKED EXTREMITY, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE
SPECIFIC EXAMPLES (brief summary):

SECTION XVI - DIAGNOSTIC TESTING
NOTE: The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis must be confirmed by imaging studies. Once such arthritis has been documented, no
further imaging studies are required by VA, even if arthritis has worsened.
16A. HAVE IMAGING STUDIES OF THE ANKLE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, ARE THERE ABNORMAL FINDINGS?
YES

NO

IF YES, INDICATE FINDINGS:
Degenerative or traumatic arthritis
ankle:

Right

Left

Both

Right

Left

Both

Left

Both

Ankylosis
ankle:

Other. Describe:
Right

ankle:

16B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

VA FORM 21-0960M-2, JAN 2011

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SECTION XVII - FUNCTIONAL IMPACT AND REMARKS
17. DOES THE VETERAN'S ANKLE CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S ANKLE CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:

18. REMARKS (If any)

SECTION XVIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
19A. PHYSICIAN'S SIGNATURE
19D. PHYSICIAN'S PHONE AND FAX NUMBER

19B. PHYSICIAN'S PRINTED NAME
19E. PHYSICIAN'S MEDICAL LICENSE NUMBER

19C. DATE SIGNED
19F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies,
the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of
VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension,
Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain
benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us
your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The
requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.
C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.
VA FORM 21-0960M-2, JAN 2011

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