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The
entire IKDC form, including a modems compatible demographic form and current health
assessment, subjective knee evaluation form, knee history form, surgical documentation
form, and IKDC knee examination form may be used as separate modules. Researchers who want
to remain modems compatible and use benchmarking data are required to complete the
demographic form and current health assessment. The knee history form and surgical
documentation form are provided for convenience. All researchers are required to complete
the IKDC subjective knee evaluation and knee examination forms. Scoring of the subjective
form is performed by adding the scores of each question on the form. Instructions for the
examination module are provided on the back of the form.
1. Modems
Compatible Demographic Form
3. Subjective Knee Evaluation Form
MODEMS COMPATIBLE
DEMOGRAPHIC FORM
(OPTIONAL)
Your Last
Name______________
Your Social
Security Number______________
Gender Male______ Female_____
Occupation
Today’s Date
_______I
I______
The
following is a list of common health problems. Please indicate yes or no in the first
column, and then skip to the next item. If you do have the problem, please indicate in the
second column if you receive medications or some other type of treatment for the problem.
In the last column, indicate if the problem limits any of your activities.
Yes
No
Heart
disease
High
blood pressure
Asthma
or pulmonary
disease
Diabetes
Ulcer
or stomach
disease
Bowel
disease
Kidney
disease
Liver
disease
Anemia
or other
blood
disease
Overweight
cancer
Depression
Osteoarthritis,
degenerative
arthritis
Rheumatoid
arthritis
Back
pain
Lyme
Disease
1. In general, would you say your health is:
Excellent Very Good Good Fair Poor
2. Compared to one year ago, how would you rate
your health in general now?
Much better now than 1 year ago
Somewhat better now than 1 year ago
About the same as 1 year ago
Somewhat worse now than 1 year ago
Much worse now than 1 year ago
3.
The following items are about activities you might do during a typical day. Does your
health now limit you in any of these activities?
If
so, how much?
Yes, Limited Yes,
Limited No, Not Limited
A Lot A
Little
At All
a. Vigorous activities, such as
running, lifting
heavy objects, participating in strenuous sports
b. Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or playing golf?
c. Lifting or carrying
groceries
d. Climbing several flight
of stairs
e. Climbing one flight of
stairs
f. Bending, kneeling
or stooping
g. Walking more than a
mile
h. Walking several blocks
Walking one block
i Bathing or
dressing yourself
4. During the past 4 weeks, have you had
any of the following problems with your work or other regular daily activities as a result
of your
physical health?
YES
NO
a.
Cut down on the amount of time you spent on work
or other activities
b.
Accomplished less than you would like.
c.
Were limited in the kind of work or other activities.
d.
Had difficulty performing the work or other activities
If or example, it took extra effort)
5. During the past 4 weeks, have you had
any of the following problems with your work or other regular daily activities as a result
of any emotional problems (such as feeling depressed anxious)?
YES
NO
a. Cut down on the amount of time you spent on
work or other activities
b. Accomplished less than you
would like
c. Didn’t do work
or other activities as carefully as usual
6. During the past 4 weeks, to what extent has
your physical health or emotional problems interfered with your normal
social
activities with family, friends, neighbors, or groups?
Not
at all slightly moderately quite
a bit extremely
7. How much bodily pain
have you had during the past 4 weeks?
None Very mild Mild Moderate Severe Very Severe
8. During the past 4
weeks, how did pain interfer with your normal work (including both work outside the home
and housework)?
9.These
questions are about how you feel and how things have been with you in the last 4 weeks.
For each question, please give the one answer that comesmscomes closcomes closest to the
way that you have been feeling. How much of the time during the past 4 weeks.
All of the time Most of the time A good bit of the time Some of the time A little
of the time None of the time
a. Did
you feel full of pep?
b. Have
you been very
nervous?
c. Have
you felt calm and
peaceful?
d.
Did you have a lot of
energy?
e. Have
you felt down-
hearted and blue?
f.
Did you feel worn out?
g. Have
you been a happy
person?
h. Did
you feel tired?
1
0. During the past 4 weeks, how
much10. During the past 4 weeks, how much of the time has your physical health or
emotional problems interfered with your social activities (like visiting with friends,
relatives, etc.?
11. How TRUE or FALSE is each of the following statements for
you?
Definitely Mostly
Don’t Mostly
True True Know False
a. I seem to get sick a little easier than other
people
h. I am as healthy as anybody I know
c. I expect my health to get worse
d. My health is excellent
1. Do you smoke cigarettes?
Yes No, I quit in the last six months. No, I quit more
than six months ago. No, I have never smoked.
2. Your height: _________feet __________
4. Your race (indicate all that apply) White Asian or Pacific Islander
5. How much school have you completed? Less than
high school
6. Activity level
Are you a high competitive sports person
Are
you well-trained and frequently sporting
Sporting
sometimes
Non-sporting
Your Full Name
Today’s Date
/
I
Date of Injury /
/
SYMPTOMS:
1. What is the highest level of activity
that you can perform without significant knee pain?
Very strenuous activities like jumping or pivoting
as in basketball or soccer
Strenuous activities like heavy physical work,
skiing or tennis
Moderate activities like moderate physical work,
running or jogging
Light activities like walking, housework, or yard
work
Unable to perform any of the above activities due
to knee pain
2. During the past
4 weeks, or since your
injury, how often have you had pain?
o 1 2 3 4 5 6 7 8 9
10
Never Constant
3. If you have pain, how severe is it?
o 1 2 3 4 5 7 8
9
10
No pain
Worst pain
imaginble
4. During the past 4 weeks, or since your
injury, how stiff or swollen was your knee?
Not at all Mildly
Moderately
Very
Extremely
5. What is the highest level of activity you can
perform without significant swelling in your knee?
Very
strenuous like jumping or pivoting as in basketball or soccer
Strenuous
activities like heavy physical work, skiing or tennis
Moderate
activities like moderate physical work, running or jogging
Light
activities like walking, housework, or yard work
Unable
to perform any of the above activities due to knee swelling
6. During the past 4 weeks, or since your
injury, did your knee lock or catch?
Yes
No
7. What is the highest level of activity you
can perform without significant giving way in your knee?
Very
strenuous activities like jumping or pivoting as in basketball or soccer
Strenuous
activities like heavy physical work, skiing or tennis
Moderate
activities like moderate physical work, running or jogging
Light
activities like walking, housework or yard work
Unable
to perform any of the above activities due to giving way of the knee
8. What is the highest level of activity you can
participate in on a regular basis?
Very
strenuous activities like jumping or pivoting as in basketball or soccer
Strenuous
activities like heavy physical work, skiing or tennis
Moderate
activities like moderate physical work, running or jogging
Light
activities like walking, housework or yard work
Unable
to perform any of the above activities due to knee
9. How does your knee affect your ability to:
Not difficult Minimally Moderately
Extremely Unable
at all
difficult difficult difficult to do
a. Go up stairs
b. Go down stairs
c. Kneel on the
d. Squat
e. Sit with your knee
f. Rise from a chair
g. Run straight ahead
h. Jump and land on
i. Stop and start
FUNCTION:
10. How would you rate the function of your knee on a scale of
0 to 10 with 10 being normal, excellent function and 0 being the inability to perform any
of your usual daily activities?
FUNCTION
PRIOR TO YOUR KNEE INJURY:
Cannot
perform
daily activities
No limitation
0 1 2 3 4 5 6 7 8 9 10
CURRENT
FUNCTION OF YOUR KNEE:
0 1 2
3
4
5
6
7
8
9 10
Can’t perform daily activities
No
limitation
Responses
to each item on the subjective form are scored using an ordinal method such that a score of
I is
given to responses
that represent the lowest level of
function or highest level of symptoms. For
example, item I, which is related to
the highest level of activity without significant pain is scored by assigning a score
of I to the response “Light
activities like walking, housework or yard work” and a score of 4 to the response
“Very strenuous activities like
jumping or pivoting as in basketball or soccer”. For item 2, which is related to the
frequency of pain over the last 4 weeks, the
response “Constant” is assigned a score of I and “Never” is assigned a
score of 11
The
IKDC Subjective Knee Evaluation is scored by summing the scores for the individual items
and then transforming the score to a scale
that ranges from 0 to 100. The steps
to score the IKDC Subjective Knee Evaluation are as follows:
1. Assign a score
to the individual’s response for each item, such that the lowest score represents the
lowest level of function or highest level of symptoms.
2. Calculate the raw
score by
summing the responses to all items.
3. Transform the
raw score to a 0 to 100 scale as follows:
Raw Score - Range of
Scores
IKDC
Score =
Lowest Possible Score
x
lOO
The
lowest possible score is 18 and the highest possible score is 101 and the range of
possible scores is 83. Thus if the sum of scores for the 18 items is 60 the IKDC score
would be calculated as follows:
83 x lOO
The
transformed score is interpreted as a measure of function such that higher scores
represent higher levels of function and lower levels of symptoms. A score of 100 is
interpreted to mean no limitation with activities of daily living or sports activities and
the absence of symptoms.
The
IKDC Subjective Knee Score can still be calculated if there are missing data as long as
there are responses to at least 90% of the items (i.e. responses have been provided for at
least 16 items). To calculate the raw IKDC score when there are missing data, substitute
the average score of the items that have been answered for the missing item score(s). Once
the raw IKDC score has been calculated, it is transformed to the IKDC Subjective Knee
Score as described above
Initial
Exam Date
Follow-up
Date
Months
Post-op
Involved
Knee: Right
Left
Contra lateral: Normal Nearly Normal Abnormal Severely abnormal
Onset
of Symptoms: (date)
Chief
Complaint:
Activity
at Injury: ADL
Sports
Traffic
Work
Mechanism of injury
Non-Traumatic
gradual onset
Non-Traumatic
sudden onset
Traumatic
non-contact onset
Traumatic
contact
onset
Previous Surgery:
Type
of Surgery: (check all that ap
Meniscal
surgery
Medial meniscectomy
Medial meniscal repair
Medial meniscal
transplant
Lateral meniscectomy
Lateral meniscal
repair
Lateral meniscal transplant
ACL Repair lntraarticular ACL reconstruction Extraarticular ACL reconstruction
PCL
Repair Intraarticular PCL reconstruction Posterolateral corner reconstruction
Medial
collateral ligament repair/reconstruction
Lateral
collateral ligament repair/reconstruction
Type of Graft
Patella Tendon Graft
Single Hamstring Graft
2 Bundle Hamstring Graft
4 Bundle Hamstring Graft
Extensor
Mechanism Surgery
Patella
Tendon Repair Quadriceps Tendon Repair
Patellofemoral
Surgery
Soft Tissue Realignment
Medial Imbrication
Lateral Release
Movement
of the tibial tubercle
Proximal Distal medial lateral
anterior
Trochleoplasty
Patellectomy
Osteoarthritis
Surgery
Osteotomy
Articular
Cartilage Surgery
Shaving Abrasion Drilling Microfracture
Cell therapy OATS other
Total
number of previous
surgeries_____________
Imaging Studies:
Structural (MRI)
Metabolic
(Bone Scan)
Findings:
Ligament
Meniscus
Articular
Cartilage
Bone
The
IKDC Knee Ligament Evaluation Form contains items that fall into one of seven measurement
domains. However, only the first three of these domains are graded. The seven domains
assessed by the IKDC Form are:
I.
Effusion
An
effusion is assessed by ballotting the knee. A fluid wave (less than 25 cc.) is graded
mild, easily ballotteable fluid — moderate (25-60 cc.), and a
tense knee secondary to effusion (greater than 60 cc.) is rated severe.
2.
Passive Motion Deficit
Passive
range of motion is measured with a gonimeter and recorded on the form for the index side
and opposite or normal side. Record values for hyperextension/zero point/flexion (e.g. 10
degrees of hyperextension, 150 degrees of flexion = 10/0/150. Extension is compared to
that of the normal knee.
3.
Ligament Examination
The
Lachman test, total AP translation at 70 degrees, and medial and lateral joint opening may
be assessed with manual, instrumented or stress x-ray examination. Only one should be
graded, preferably a “measured displacement”. A force of 134 N (30 Ibs). and the
maximum manual are recorded in instrumented examination of both knees. Only the measured
displacement at the standard force of 134 N is used for grading. The numerical values for
the side to side difference are rounded off, and the appropriate box is marked.
The
end point is assessed in the Lachman test. The end point affects the grading when the
index knee has 3-5 mm. more anterior laxity than the normal knee. In this case, a soft end
point results in an abnormal grade rather than a nearly normal grade.
The
70-degree posterior sag is estimated by comparing the profile of the injured knee to the
normal knee and palpating the medial femoral tibial stepoff It may be confirmed by noting
that contraction of the quadriceps pulls the tibia anteriorly.
The
external rotation tests are performed with the patient prone and the knee flexed 300 and
70*.
Equal
external rotational torque is applied to both feet and the degree of external rotation is
recorded.
The
pivot shift and reverse pivot shift are performed with the patient supine, with the hip in
10-20 degrees of abduction and the tibia in neutral rotation using either the Losee,
Noyes, or Jakob techniques. The greatest subluxation, compared to the normal knee, should
be recorded.
4.
Compartment Findings
Patellofemoral
crepitation is elicited by extension against slight resistance. Medial and lateral
compartment crepitation is elicited by extending the knee from a flexed position with a
varus and then a valgus stress (i.e., McMurray test). Grading is based on intensity and
pain.
5.
Harvest Site Pathology
Note
tenderness, irritation or numbness at the autograft harvest site.
6.
X-ray Findings
A
bilateral, double leg PA weightbearing roentgenogram at 35-45 degrees of flexion (tunnel
view) is used to evaluate narrowing of the medial and lateral joint spaces. The Merchant
view at 45 degrees is used to document patellofemoral narrowing. A mild grade indicates
minimal changes (i.e., small osteophytes, slight sclerosis or flattening of the femoral
condyle) and narrowing of the joint space which is just detectable. A moderate grade may
have those changes and joint space narrowing (e.g., a joint space of2-4 mm. side or up to
50% joint space narrowing). Severe changes include a joint space of less than 2 minor
greater than 50% joint space narrowing.
1999
Date of Index Procedure
/ /
Postoperative Diagnosis:
1.
2.
3.
Status After Procedure:
ARTICULAR CARTILAGE
STATUS:
Document the size and
location of patellar articular cartilage defects on these figures.
Articular Surface
Document tears of the
menisci or menisectomy on these figures.
Medial
Normal 1/3 Removed 2/3
Removed 3/3 Removed
Circumferential Hoop
Fibers lntact Disrupted
Remaining Meniscal Tissue:
Normal Stable tear Tear left
medial meniscectomy
medial meniscal repair
medial meniscal
transplant
medial abrade &
trephine
Normal 1/3 Removed 2/3 Removed 3/3 Removed
Circumferential Hoop
Fibers: lntact Disrupted
Remaining Meniscal
Tissue Normal Tear left in situ Unstable tear |
Procedure: |
lateral meniscectomy
lateral meniscus repair
lateral meniscal
transplant
lateral abrade &
trephine
|
|
|
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Document drill hole
placement for ligament reconstruction on these figures
Procedure:
ACL repair
lntraarticular ACL
reconstruction
Extraarticular ACL
reconstruction
PCL repair
Extraarticular PCL
reconstruction
intraarticular PCL
reconstruction
Medial collateral
ligament repair/reconstruct
Posterolateral corner
Autologous patella tendon
Hamstring tendons
Quadriceps tendon
Other
Previous Graft Harvest
Patellar Tendon
Hamstring Tendon
Quadriceps Tendon
Patient Name:
Date of Birth
Gender f m
Age: _____________
Date of examination
Generalized Laxity: tight normal lax
Alignment: obvious varus normal
obvious valgus
Patella Position: baja infera
normal alta
Patella
Subluxation/Dislocation: centered subluxable
subluxed dislocated
Range of motion (Ext/Flex): index
passive
active
Opposite passive
active
SEVEN GROUPS
FOUR
GRADES |
|
|
*GROUP |
||
A |
B |
C |
D |
GRADE |
|
Normal |
Nearly |
Abnormal |
Severely Abnormal |
A B C D |
|
I. Effusion
none
mild
moderate
severe
2. Passive motion deficit
Lack of extension
<3*
3 to 5*
6-10*
>10*
Lack of flex ion
0 –5*
6 – 15*
16 –25*
>25*
3. Ligament Examination
(manual, instrumented,
x-ray)
Lachman (25 flex) (134N)
1-2mm 3-5mm
6-10mm
>10mm
Lachman (25* flex) manual
max.
1-2
mm
3-5mm
6-10mm
>10mm
Anterior endpoint:
firm
soft
Total AP Translation (25 flex)
0-2mm
3-5mm
6-10mm
>10mm
Total AP Translation (70 flex)
0-2mm
3-5mm
6-10mm
>10mm
Posterior Drawer test (70 flex)
0-2mm
3-5mm
6-10mm
>10mm
Med joint opening (20 flex/valgus rot)
0-2mm
3-5mm
6-10mm
>10mm
Lat joint opening (20 flex/varus rot) )
0-2mm
3-5mm
6-10mm
>10mm
External Rotation Test (30 flex prone)
<5*
6-10*
11-19*
>20*
External Rotation
Test (90 flex prone) )
<5*
6-10*
11-19*
>20*
Pivot shift
equal
glide
gross
marked
Reverse pivot shift
equal
glide
gross
marked
4. Compartment Findings
Crepitus ant. Compartment
none
moderate
mild
pain
>mild pain
Crepitus med. compartment
none
moderate
mild pain
>mild pain
Crepitus lat. Compartment
none
moderate
mild pain
>mild pain
5. Harvest Site Pathology
none
mild
moderate
severe
6. X-ray Findings
Med. joint space
none
mild
moderate
severe
Lat. joint space
none
mild
moderate
severe
Patellofemoral
Ant. joint space
(sagittal)
none
mild
moderate
severe
Post. joint space
(sagittal)
none
mild moderate
severe
7. Functional Test
One leg hop (% of opposite side)
> 90%
89-76%
75-50%
<50%
**Final Evaluation
