Knee Orthosis Evaluation Note (Instability Documentation)

Date of Service: [Date]

Laterality: [Right / Left / Bilateral]

Author/Credentials: [Name, credentials]

Location: [Clinic/Facility]

Visit Type: [Evaluation only / Evaluation + Fitting/Delivery]

Reason for Evaluation

[Chief complaint and referral context] (State the primary reason for evaluation such as giving way, buckling, post-operative protection, or chronic instability. Include referring clinician and orthosis category requested if applicable. Keep to 1–3 sentences.)

History and Medical Necessity

[History of present illness] (Provide a concise narrative tailored to the patient's pathway: For recent injury, include date, mechanism, and course since injury. For post-operative cases, include procedure, date, surgeon, current ROM/weight-bearing precautions, and rehab phase. For chronic instability, include duration, prior injuries/surgeries, and pattern of instability episodes.)

[Instability symptom profile] (Document patient-reported giving way, buckling, hyperextension episodes; typical triggers such as stairs, pivoting, uneven ground; frequency and associated pain/swelling. Summarize prior conservative measures tried and response.)

[Functional impact and goals] (Describe impact on ADLs, work/sport limitations, falls history, and the patient's goals. Use brief quotes only if they add clinical clarity.)

[Key dates/record clarity] (If dates or details are unknown, note the source of uncertainty and plan to obtain records. Omit if all information is available.)

Ambulatory Status

• Ambulatory status: [Ambulatory / Non-ambulatory]
• Distance and terrain: [Household / Limited community / Full community]; [Level ground only / Uneven terrain tolerated]
• Assistive device: [None / Cane / Crutches / Walker / Wheelchair]
• Weight-bearing status: [WBAT / Partial / Toe-touch / NWB] (Include only if post-operative; note source of restriction.)
• Gait observation: [Normal / Antalgic / Varus thrust / Valgus collapse / Recurvatum / Other] (Describe briefly if abnormal.)

Objective Knee Examination

[Exam limitations] (Note pain, guarding, acute swelling, post-op restrictions, immobilizer in place, or other constraints. If instability testing cannot be fully performed, state why and what alternative evidence exists. Omit if no limitations.)

Inspection/Palpation: Effusion [none / small / moderate / large]; [Alignment]; [Tenderness locations]; [Skin integrity for brace fitting]

Range of Motion: Active ROM [flexion ___° / extension ___°]; Passive ROM [flexion ___° / extension ___°]; Extension lag [absent / present ___°]; Hyperextension [absent / present ___°]; [Painful arcs if present]. (For post-op, include surgeon-ordered ROM limits.)

Strength/Neuromuscular: Quadriceps strength [0–5] [with / without extensor lag]; [Hip abductor control if relevant]; [Proprioception/balance findings if assessed]

Instability/Laxity Testing

(Use a consistent grading system across tests: 0–3+ scale or millimeters of side-to-side difference. Include endpoint quality where applicable. Compare to contralateral knee when relevant. If a test is not performed, document the reason rather than omitting.)

• Anteroposterior (ACL/PCL):
  • Lachman: [Negative / Positive, grade ___]; endpoint [firm / soft]; [comparison to contralateral]
  • Anterior drawer: [Negative / Positive, grade ___]; endpoint [firm / soft]; [comparison]
  • Posterior drawer: [Negative / Positive, grade ___]; endpoint [firm / soft]; [comparison]
  • Posterior sag: [Absent / Present]; [degree or qualitative note]
• Mediolateral (Collaterals):
  • Valgus stress 0°: [Negative / Positive, grade ___]; endpoint [firm / soft]
  • Valgus stress 30°: [Negative / Positive, grade ___]; endpoint [firm / soft]
  • Varus stress 0°: [Negative / Positive, grade ___]; endpoint [firm / soft]
  • Varus stress 30°: [Negative / Positive, grade ___]; endpoint [firm / soft]
• Rotational:
  • Pivot shift: [Negative / Trace / 1+ / 2+ / 3+]; [comparison]
  • Dial test (30°/90°): [External rotation asymmetry in degrees]; [interpretation]
  • External rotation recurvatum: [Absent / Present]; [degree if present]
• Hyperextension:
  • Recurvatum degree: [___°]; [symmetric / asymmetric vs contralateral]
  • Gait hyperextension thrust: [Absent / Mild / Moderate / Severe]
• Tests not performed: [List specific tests and reasons: pain/guarding, post-op contraindication, deferred to follow-up]

Overall instability summary: AP instability [none / mild / moderate / severe]; ML instability [none / mild / moderate / severe]; Rotational instability [none / mild / moderate / severe]; Hyperextension [none / mild / moderate / severe]

Pertinent Diagnostics

[Imaging and surgical summary] (Summarize key MRI/X-ray findings such as ligament tears, collateral injuries, or compartment OA. For post-op, note procedure performed, graft type if relevant, and precautions ordered. Do not reproduce full reports. Omit this section entirely if no relevant imaging or surgical history exists.)

Assessment

Primary diagnosis: [Diagnosis name and ICD-10 code]

Secondary diagnoses influencing brace selection: [List if applicable]

[Instability synthesis] (State instability planes involved—AP/ML/rotational/hyperextension—and severity linked to exam grades. Provide etiology context: acute injury vs post-op protection vs chronic ligamentous deficiency. Link objective findings to functional consequences and risk of further injury.)

Orthosis Recommendation

Recommended Device: [Knee immobilizer / Hinged knee brace / Functional ACL brace / Functional PCL brace / Dual-upright ACL/PCL brace / Varus-valgus unloader with hinges / Swedish-type recurvatum brace / Other]; [Prefabricated / Custom-fabricated]

Rationale: [Connect exam findings and functional needs to the chosen device and its features] (Explain why rigid or semi-rigid stabilization is required versus sleeve-style support. Specify needed features such as bilateral uprights, polycentric hinges, ROM stops, posterior tibial support for PCL, varus/valgus adjustment, rotational control, anti-migration suspension strategy. State why PT alone is insufficient at this stage if applicable.)

Custom Fabrication Justification: [Physical characteristics necessitating custom fabrication] (Include only if recommending custom-fabricated device. Document specific findings such as deformity, atypical limb shape/size, significant atrophy or edema affecting suspension. State that prefabricated alternatives were considered and found inadequate.)

Measurements and Fitting

(Include this section only if selecting, sizing, or delivering a device during this visit.)

• Measurements: Thigh circumference [___cm at ___cm above joint line]; Calf circumference [___cm at ___cm below joint line]; Knee circumference [___cm at joint line]; Limb shape [conical / cylindrical]; [atrophy / edema if present]
• Device selection: [Model/size]; [component selection]
• Fitting assessment: [Hinge alignment to knee axis]; [Suspension/migration assessment]; [Skin pressure points checked]
• Custom-fitting modifications: [Trimming / bending / molding / strap relocation / padding performed] (Document modifications requiring skilled expertise. Include only if modifications performed.)

Patient Education and Tolerance

(Include this section only when a device is delivered.)

• Training provided: [Don/doff technique]; [Strap sequence]; [ROM stop adjustments/lock use]; [Wear schedule]; [Skin checks and care]; [Red-flag symptoms]
• Patient response: [Tolerance and comfort]; [Ability to ambulate safely with brace]; [Understanding demonstrated via teach-back]
• Barriers to adherence: [Cognitive, physical, or environmental barriers and mitigation plan] (Omit if none identified.)

Plan

• Device: [Provided today / Order placed for later fitting with expected timeline]
• Rehabilitation: [PT/rehab coordination, exercises, precautions]
• Follow-up: [Timeframe]; return sooner if [falls, skin issues, worsening instability, other triggers]
• Communication: [Contact with referring clinician and recommendations conveyed] (Include only if applicable.)