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Cend stairs ABILITY TO RISE ON TOES (STABILITY) ( ) Able to rise on toes x 10 repetitions ( ) Able to rise on toes x 5 repetitions ( ) Able to rise on toes x 1 repetition ( ) Unable to rise on toes RUNNING ( ) Able to run as much as desired ( ) Able to run but limited ( ) Unable to run RANGE OF MOTION (To be completed by Health Care Provider) Dorsiflexion beyond neutral ( ) 40 degrees ( ) 30 degrees ( ) 20 degrees ( ) 10 degrees ( ) 5 degrees ( ) 0 degrees Plantarflexion ( ) 40 degrees ( ) 30.

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