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International Knee Documentation Committee

Subjective Knee Evaluation Form

Instructions for completion of this questionnaire:

 Answer each question based on your condition within the past week.
 Please answer EVERY question with ONE answer to the best of your ability.

PATIENT NAME:

DATE OF BIRTH:

DATE:

BODY PART:

How would you rate your knee today as a percentage of normal (0%
to 100%), with 100% being normal?

HHSM 04.2020 01
 IKDC SUBJECTIVE KNEE EVALUATION FORM

SYMPTOMS Grade symptoms at the highest activity level at which you think you could function without significant
symptoms, even if you are not actually performing activities at this level.

1. What is the highest level of activity that you can perform without significant knee pain?
4 Very strenuous activities like jumping or pivoting as in basketball or soccer
3 Strenuous activities like heavy physical work, skiing or tennis
2 Moderate activities like moderate physical work, running or jogging
1 Light activities like walking, housework or yard work
0 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?
10 9 8 7 6 5 4 3 2 1 0
Never            Constant

3. If you have pain, how severe is it?

10 9 8 7 6 5 4 3 2 1 0
No pain            Worst pain
imaginable
4. During the past 4 weeks, or since your injury, how stiff or swollen was your knee?
4 Not at all
3 Mildly
2 Moderately
1 Very
0 Extremely

5. What is the highest level of activity you can perform without significant swelling in your knee?
4 Very strenuous activities like jumping or pivoting as in basketball or soccer
3 Strenuous activities like heavy physical work, skiing or tennis
2 Moderate activities like moderate physical work, running or jogging
1 Light activities like walking, housework, or yard work
0 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? 0 Yes 1 No

7. What is the highest level of activity you can perform without significant giving way in your knee?

4 Very strenuous activities like jumping or pivoting as in basketball or soccer

3 Strenuous activities like heavy physical work, skiing or tennis
2 Moderate activities like moderate physical work, running or jogging
1 Light activities like walking, housework or yard work
0 Unable to perform any of the above activities due to giving way of the knee

OFFICE USE:

HHSM 04.2020 Symptom Score: _____ 02

 Page 2 – IKDC SUBJECTIVE KNEE EVALUATION FORM

SPORTS ACTIVITIES:

8. What is the highest level of activity you can participate in on a regular basis?

4Very strenuous activities like jumping or pivoting as in basketball or soccer

3Strenuous activities like heavy physical work, skiing or tennis
2Moderate activities like moderate physical work, running or jogging

1Light activities like walking, housework or yard work

0Unable to perform any of the above activities due to knee

9. How does your knee affect your ability to:

Not
Minimally Moderately Extremely Unable to
difficult
difficult Difficult difficult do
at all
a. Go up stairs 4 3 2 1 0
b. Go down stairs 4 3 2 1 0
c. Kneel on the front of your knee 4 3 2 1 0
d. Squat 4 3 2 1 0
e. Sit with your knee bent 4 3 2 1 0
f. Rise from a chair 4 3 2 1 0
g. Run straight ahead 4 3 2 1 0
h. Jump and land on your involved leg 4 3 2 1 0
i. Stop and start quickly 4 3 2 1 0

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 which may include sports?

FUNCTION PRIOR TO YOUR KNEE INJURY:

Couldn’t No limitation in
0 1 2 3 4 5 6 7 8 9 10
perform daily
           daily activities
activities
activities
CURRENT FUNCTION OF YOUR KNEE:

Couldn’t 0 1 2 3 4 5 6 7 8 9 10 No limitation in
perform daily            daily activities
activities
activities

OFFICE USE:
Activity Score: ______

HHSM 04.2020 03
 Tegner Activity Scale
The instrument scores a person's activity level between 0 and 10 where 0 is 'on sick leave/disability' and 10 is
'participation in competitive sports such as soccer at a “national elite” level. Please select the most appropriate
activity level from the list below for both before your injury and your current activity level.

Activity Level Before Injury Current Activity Level

Level 10 Competitive sports- soccer, football, rugby (national elite)

Level 9 Competitive sports- soccer, football, rugby (lower divisions), ice hockey, wrestling,
gymnastics, basketball

Level 8 Competitive sports- racquetball or bandy, squash or badminton, track and field
athletics (jumping, etc.), down-hill skiing

Level 7 Competitive sports- tennis, running, motorcars speedway, handball

Recreational sports- soccer, football, rugby, bandy, ice hockey, basketball, squash,
racquetball, running

Level 6 Recreational sports- tennis and badminton, handball, racquetball, down-hill skiing,
jogging at least 5 times per week

Level 5 Work- heavy labor (construction, etc.)

Competitive sports- cycling, cross-country skiing,
Recreational sports- jogging on uneven ground at least twice weekly

Level 4 Work - moderately heavy labor (e.g. truck driving, etc.)

Level 3 Work - light labor (nursing, etc.)

Level 2 Work - light labor

Walking on uneven ground possible, but impossible to back pack or hike

Level 1 Work - sedentary (secretarial, etc.)

Level 0 Sick leave or disability pension because of knee problems

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For staff use ONLY:

SCORING:

Scored from 4 to 0, with 4 being ‘no difficulty’ and 0 being ‘unable to do’. Simply add the
score for each item and divide by the maximum possible score which is 87. This value is
then multiplied by 100 to get a percentage.

Note: the response to item 10a “function prior to knee injury” is not included in overall
score. The response to item 6 “did your knee lock” yes=0, no=1.

IKDC score= (sum of items/87)x100

IKDC score= _________%

A higher score = a higher level of physical function (100% = full function)

Tegner Activity Scale

Before Injury Activity Level=______
Current Activity Level=__________

SANE (Single Assessment Numeric Evaluation):

____________%

STATISTICAL DATA:

IKDC: MDC - (minimal detectable change): 13 pts

MCID – (minimal clinically important difference): 12 pts

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