Documenting the Equine Lameness Exam
The lameness exam is one of the hardest consults to document well, because it’s inherently multi-dimensional: multiple limbs, multiple gaits, flexion tests, blocks, and a diagnosis that emerges by elimination. Cram that into a paragraph and you lose the structure that makes it interpretable. This guide covers how to document an equine lameness workup so the record is as systematic as the exam itself.
Why free text fails the lameness exam
A lameness workup produces a grid of data: each limb, at walk and trot, on the straight and the circle, before and after flexion, before and after each diagnostic block. A paragraph forces that grid into a linear story, and the moment you want to compare “left fore at trot on the lunge” before and after a block, you’re hunting through prose. A structured record keeps the comparisons side by side — which is the entire point of the exam.
The AAEP lameness scale
Grade lameness on the AAEP 0–5 scale and record it consistently so it means the same thing at every recheck:
- 0 — no perceptible lameness under any circumstances.
- 1 — difficult to observe; not consistently apparent regardless of circumstances.
- 2 — difficult to observe at a walk or trotting a straight line; consistently apparent under certain circumstances (e.g. circling, inclines, hard surface).
- 3 — consistently observable at a trot under all circumstances.
- 4 — obvious at a walk.
- 5 — minimal weight bearing in motion or at rest, or a complete inability to move.
Record the grade with the circumstance — “grade 2 LF, worse on the right lunge on hard ground” carries far more than a bare number.
What to capture at each stage
History and conformation. Duration, discipline, shoeing, prior issues, and any conformational observations.
Static exam. Palpation findings, digital pulses, hoof tester response, joint effusion, and asymmetry.
Dynamic exam. Grade per limb at walk and trot, straight and on the circle (both directions), on different surfaces. Note the affected limb and phase.
Flexion tests. Which joint, duration, and the response — quantified against the baseline grade.
Diagnostic analgesia. Each block in sequence: which nerve or joint, and the percentage improvement. This is the spine of the workup — the record has to show the progression cleanly.
Imaging and assessment. Radiographs, ultrasound, or advanced imaging findings, then your localisation and working diagnosis.
Structure is the whole game
Because diagnosis comes by elimination, the value of the record is in the sequence: baseline, then how each flexion and each block changed it. A structured lameness grid preserves that sequence in a way prose simply can’t, and it makes the recheck in three weeks genuinely comparable to today.
Recording it without slowing the exam
The practical problem is that during a lameness exam your hands and attention are on the horse — you can’t stop to type after every block. Calling findings by voice as you work, then getting them organised into a structured record, keeps the documentation complete without breaking the flow of the workup.
That’s what Coggo is built for: it produces structured specialty templates — including lameness grids — not just free-text notes, so an equine workup is recorded as the grid it actually is. You dictate as you go, the same way it drafts a full SOAP note from a spoken consult, and review a clean, comparable record at the end.
If lameness exams are where your notes get thinnest, that’s the workflow worth fixing. Try Coggo free and document your next workup as a structured grid.