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Oregon WCD Form 4841: Lower Extremity Range of Motion

For most Oregon lower extremity injuries, Bulletin 239 asks examiners to complete this WCD form with the closing examination report. It records active range of motion in degrees for both hips, knees and ankles and for each toe at the IP and MP joints, against norms printed on the form. The insurer or the Workers' Compensation Division then rates permanent impairment from the reported findings.

Who completes it

The examining physician completes the measurements for the injured side and the opposite side, then prints name and title, signs and dates it. Attending physicians and medical arbiters perform these exams.

Submitting and payment

How to submit it
Return the form with the closing or impairment exam report to the insurer or self-insured employer.
Who pays
The insurer pays the lesser of the billed amount or the OAR 436-009-0040 physician fee schedule amount, and the worker cannot be billed for an accepted claim.

Good to know

  • Norms include hip flexion 100 and extension 30 degrees, knee flexion 150 degrees, ankle dorsiflexion 20 and plantar flexion 40 degrees, eversion 20 and inversion 30 degrees.
  • Measure the contralateral joint unless it has a history of injury or disease, and state in the report whether such a history exists.
  • The lower extremity covers the femoral head to the toes but not the pelvic bones; amputation levels, instability and length discrepancy are reported in the narrative.
  • If a joint is ankylosed, report the plane of motion and the angle of fixation in degrees from the neutral zero position.

Get the official form

Download the current version from the source each time; forms change without notice.

Lower Extremity Range of Motion

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What joints are on Oregon Form 4841?

Hips (flexion, extension, abduction, adduction, internal and external rotation), knees (flexion and extension), ankles (dorsiflexion, plantar flexion, inversion and eversion), the great toe at the IP and MP joints, and the second through fifth toes at the MP joint, on both the right and left sides.

Should the narrative report repeat the Form 4841 numbers?

Bulletin 239 says to complete Form 4841 together with the closing examination report. The report itself still needs the other findings the bulletin lists, such as amputation level, ligament laxity grades, chondromalacia, strength loss, walking or standing limits, apportionment and the medically stationary date.