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Date of completion
IDKC Score
Date of completion
2014-10-20

IKDC SUBJECTIVE KNEE EVALUATION FORM

Patient's name (or ref
 
Clinician Diagnosis                   
Patient's d.o.b
Type of surgery: 
Surgery date   
 

INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities.

Answer every question by ticking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can.
 

Symptoms - These questions should be answered thinking of your knee symptoms during the last week.

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?
Never 0 1 2 3 4 5 6 7 8 9 10 Constant
3. If you have pain, how severe is it?
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Pain
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 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 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
 
Sports activities
 
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 giving way of the knee
9. How does your knee affect your ability to:
a. Go up stairs No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
b. Go down stairs No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
c. Kneel on the front of your knee No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
d. Squat No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
e. Sit with your knee bent No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
f. Rise from a chair No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
 g. Run straight ahead No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
 h. Jump and land on your involved leg No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
 i. Stop and start quickly No difficulty Minimal difficulty Moderate difficulty Extreme difficulty Unable to do
 
Function, and activity of daily living - The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee.
 
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 knee injury
Can not perform ADL 0 1 2 3 4 5 6 7 8 9 10 No limitation of ADL
Current function of your knee:
Can not perform ADL 0 1 2 3 4 5 6 7 8 9 10 No limitation of ADL

 

Thank you very much for completing all the questions in this questionnaire.

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IKDC Score is

A group of knee surgeons from Europe and America met in 1987 and founded the International Knee Documentation Committee. A common terminology and an evaluation form were created. This form is the standard form for use in all publications on results of treatment of knee ligament injuries.

IKDC COMMITTEE:

AOSSM: Anderson, A., Bergfeld, J., Boland, A. Dye, S., Feagin, J., Harner, C. Mohtadi, N. Richmond, J. Shelbourne, D., Terry, G.

ESSKA: Staubli, H., Hefti, F., Hoher, J., Jacob, R., Mueller, W., Neyret, P.

APOSSM: Chan, K., Kurosaka, M.

Reference for Score: IKDC 2000 forms