Date of completion
Clinical rating system for the ankle and hindfoot
Clinician's name (or ref)
Patient's name (or ref)
Patient's d.o.b
 
Please answer the following questions.  
During the past 4 weeks......  
1 - Pain   2 - Function-activity limitations/support requirements
None   No limitations, no support
Mild Occasional   No limitation of daily activities, limitation of recreational activities, no support
Moderate, daily   Limited daily and recreational activities, cane
Severe, almost always present   Severe limitation of daily and recreational activities, walker, crutches, wheelchair, brace
     
3 - Maximum walking distance ( blocks)   4 - Walking surfaces
Greater than 6   No difficulty on any surface
4-6   Some difficulty on uneven terrain, stairs, inclines, ladders
1-3   Severe difficulty on uneven terrain, stairs, inclines, ladders
Less than 1      
     
5 - Gait abnormality   6 - Sagittal motion (flexion plus extension)
None, slight   Normal or mild restriction (30° or more)
Obvious   Moderate restriction (15°-29°)
Marked   Severe restriction (less than 15°)
     
7 - Hindfoot motion (inversion plus eversion)   8- Alignment
Normal or mild restriction (75%-100% normal)   Good, plantigrade foot, ankle-hindfoot well aligned
Moderate restriction (25%-74% normal)   Fair, plantigrade foot, some degree of ankle- hindfoot malalignment observed, no symptoms
Marked restriction (less than 25% normal)   Poor, nonplantigrade foot, severe malalignment, symptoms
     
9 - Ankle-hindfoot stability (anteroposterior, varus-valgus)  

Clinical rating system for the ankle and hindfoot is

Stable  
Definitely unstable  

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