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First published on October 11, 2005, doi:10.1177/0363546505280214
This version was published on January 1, 2006
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The American Journal of Sports Medicine 34:128-135 (2006)
© 2006 American Orthopaedic Society for Sports Medicine

The International Knee Documentation Committee Subjective Knee Evaluation Form

Normative Data

Allen F. Anderson, MD*,{dagger}, James J. Irrgang, PhD, PT, ATC{ddagger}, Mininder S. Kocher, MD, MPH§, Barton J. Mann, PhD||, John J. Harrast, MA Members of the International Knee Documentation Committee

From the {dagger} Tennessee Orthopaedic Alliance, Nashville, Tennessee, the {ddagger} {ddagger}University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania, § §Children’s Hospital, Boston and Harvard Medical School, Boston, Massachusetts, the || American Orthopaedic Society for Sports Medicine, Rosemont, Illinois, and Data Harbor Incorporated, Chicago, Illinois

* Address correspondence to Allen F. Anderson, MD, Tennessee Orthopaedic Alliance, 4230 Harding Road, 10th Floor, Nashville, TN 37205 (e-mail: andersonaf{at}tnortho.com).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The International Knee Documentation Committee Subjective Knee Evaluation Form may be used to measure symptoms, function, and sports activity for people with a variety of knee disorders, including ligamentous and meniscal injuries, osteoarthritis, and patellofemoral dysfunction. To date, normative data have not been established for this valid, reliable, and responsive outcomes instrument.

Purpose: To provide clinicians and researchers with normative data to facilitate the interpretation of results on the International Knee Documentation Committee Subjective Knee Evaluation Form.

Study Design: Cross-sectional survey.

Methods: The Subjective Knee Evaluation Form was mailed to 600 people in each of 8 age/gender categories (18–24 years, 25–34 years, 35–50 years, and 51–65 years for both male subjects and female subjects). Participants were drawn from a panel of 550 000 households (1 300 000 subjects) representative of noninstitutionalized persons in the United States and were matched to data from the United States Census Bureau on geographical region, market size, income, and household size.

Results: Complete data were available for 5246 knees. Twenty-eight percent of respondents reported an injury, weakness, or other problem with one or both knees. Normative data were determined for respondents as a whole and for the subset of respondents with no history of knee problems. Mean scores were determined for men aged 18 to 24 years (89 ± 18), 25 to 34 years (89 ± 16), 35 to 50 years (85 ± 19), and 51 to 55 years (77 ± 23); mean scores were also determined for women aged 18 to 24 years (86 ± 19), 25 to 34 years (86 ± 19), 35 to 50 years (80 ± 23), and 51 to 65 years (71 ± 26). Scores were higher for the subset of respondents with no history of current or prior knee problems.

Conclusion: Scores on the International Knee Documentation Committee Subjective Knee Evaluation Form vary by age, gender, and history of knee problems. The normative data collected in this article will allow clinicians to interpret how patients with knee injuries are functioning relative to their age- and gender-matched peers and will enable researchers to determine the clinical outcomes of treatment.

Key Words: International Knee Documentation Committee (IKDC) • normative data • knee outcomes instrument


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Clinicians and researchers have used numerous knee outcomes scales to evaluate the results of treatment.4,6–9,13–16,18–21,25–27 Unfortunately, the differences in these scales are sufficiently great to preclude predicting results from one scale based on another, and the inconsistency among the scales creates an impediment to progress in the field.1,3,7,15,17,23,24 The International Knee Documentation Committee (IKDC) was therefore established to unify the assessment of outcomes by developing a standardized international knee form. The original IKDC form, published in 1993 and revised in 1994, included only the minimum essential criteria necessary to evaluate results.2 The committee envisioned a second, more comprehensive form that would allow for valid scientific analysis of knee function. The new IKDC Subjective Knee Evaluation Form (Subjective Knee Form), published in 2000, was well tested and found to be an instrument that was valid, reliable,10,11 and responsive (Irrgang JJ, Anderson AF, Boland AL, et al, unpublished data, 2004) and that could be used to assess symptoms, function, and sports activity in patients with a variety of knee disorders, including ligamentous and meniscal injuries, patellofemoral pain, and osteoarthritis.10,11 More recently, it has also been shown to be significantly associated with patient satisfaction after ACL reconstruction.12

The next step in standardization of the IKDC Subjective Knee Form was collection of normative data. The primary purpose of this study was to provide clinicians and researchers with normative data that would place scores, changes in scores, and scores from male or female patients of different ages within the context of normal population values. Normative comparison facilitates the interpretation of results on the IKDC form for patient management decisions and for comparison between groups of patients by demonstrating how close patients come to the normal range of functioning.

In this cross-sectional study, the IKDC Subjective Knee Form was administered to a random sample in the United States to establish population norms. It was hypothesized that there would be no differences in scores between male and female respondents. The score was, however, expected to demonstrate an inverse relationship with age. A secondary purpose of this study was to provide additional evidence for construct validity of the Subjective Knee Form score by examining for differences in scores between respondents with and without a history of knee problems. It was hypothesized that people experiencing knee problems would score lower than those without knee problems.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The IKDC Subjective Knee Form consists of 18 questions in the domains of symptoms, functioning during activity of daily living and sports, current function of the knee, and participation in work and sports (see Appendix, available in the online version of this article at www.ajsm.org/cgi/content/full/34/1/128/DC1).

Procedure
Potential participants were mailed a version of the IKDC form that was modified to assess the function of both the left and right knees. For example, question 1 on the form is, "What is the highest level of activity that you can perform without significant knee pain?" In the survey, this question was separated into 2 parts: "What is the highest level of activity that you can perform without significant right knee pain?" and "What is the highest level of activity that you can perform without significant left knee pain?" References to knee injuries in questions 2, 4, and 6 were also removed. For example, in question 2 ("During the past 4 weeks, or since your injury, how often have you had pain?"), the phrase "or since your knee injury" was deleted because it was expected that many respondents would not have suffered a knee injury. In addition, survey participants were asked several questions, not on the form, that were related to their current experience of knee injury/weakness/other problems, current treatment for knee problems, and history of knee surgery.

Sampling Method
The participants were drawn from a panel that was recruited and maintained by NFO Worldgroup (Toledo, Ohio), a marketing research firm. NFO Worldgroup’s panel is a sample of 550 000 households (1 300 000 subjects) that is matched to data from the US Census Bureau on geographical region, market size, age, income, and household size. The sample for this study was developed as a stratified, random sample that was representative of the age, gender, marital status, household income, household size, and race of the panel as a whole. The goal was to collect data from approximately 300 men and 300 women within 4 general age categories (18–24 years, 25–34 years, 35–50 years, and 51–65 years). The target sample size was determined to achieve a 95% confidence interval (95% CI) and a ± 5% error rate for each of the 8 age/gender categories. Forms were mailed to 4800 people, representing 9600 possible knee assessments. The number of respondents by gender and age groups are reported in Table 1Go. There was no incentive for participation, and there was no attempt to remind or follow up with people who had not returned a completed form.


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  		TABLE 1 Number of Respondents by Age and Gender
 
Data Management and Analysis
A score on the Subjective Knee Form can be calculated when there are responses to at least 90% of the items (ie, when responses have been provided for at least 16 items). In the original scoring instructions for the Subjective Knee Form, missing values are replaced by the average score of the items that have been answered.11 However, this method could slightly overestimate or underestimate the score, depending on the maximum value of the missing items (2, 5, or 11 points). In the present study, therefore, the score was calculated as follows:


Formula

This method of scoring the IKDC Subjective Knee Form is more accurate than the original method.

Analysis
Descriptive statistics, including means, percentiles, 95% CIs, SDs, ranges, and percentages of ceiling and floor scores within each age and gender categories were calculated. A 2-way analysis of covariance (ANCOVA) with post hoc testing was used to identify differences in the Subjective Knee Form score by gender and age categories (18–24 years, 25–34 years, 35–50 years, and 51–65 years). These age categories were chosen to represent populations based on expected levels of physical activity, physical ability, and general health. An ANCOVA was also used to determine if respondents with a current injury, weakness, or other knee problems, or respondents currently receiving treatment for knee problems, had lower scores on the IKDC form than did respondents who did not have knee problems.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The IKDC Subjective Knee Forms were returned by 2670 participants (response rate, 56%). Of these people, 2625 participants (98%) completed at least 90% of the items (the criterion for scoring the forms) for their right knee, and 2621 participants (98%) met the scoring criterion for their left knee. Sufficiently complete data on 5246 knees were therefore available for computation of the Subjective Knee Form score. Fifty-two percent of all respondents were women. The response rates for each age and gender group were as follows: between 18 and 24 years, 44% for men, 47% for women; between 25 and 34 years, 48% for men, 57% for women; between 35 and 50 years, 58% for men, 63% for women; and between 51 and 65 years, 64% for men, 64% for women.

The difference in the overall response rates of 54% for men and 58% for women was statistically significant (Fisher exact test, P < .01). In addition, there were significant differences in response rates by age category. Response rates were significantly higher (Fisher exact test, P < .01) for older age groups (the highest response rate of 64% was found in participants aged 51–65 years) versus younger age groups (the lowest response rate of 46% was found in participants aged 18–24 years) in every comparison.

The mean age of respondents was 39 years (SD, 14 years; range, 18–65 years). Fifty-eight percent were currently married, 29% had never been married, 9% were divorced, 2% were widowed, and 2% were separated.

Twenty-eight percent of respondents indicated they were currently experiencing an injury, weakness, or other problem with one or both knees. Ten percent indicated they were currently receiving treatment for one or both knees (eg, seeing a doctor, physical therapist, or other health care provider; taking medications; or performing exercises for a knee problem). Nine percent reported prior knee surgery. Of these respondents, 89% had surgery more than 1 year before this study. The most common surgeries reported were nonspecified arthroscopic surgery (20% of all surgeries) and ligament surgery (14% of all surgeries). The frequency of knee problems, nonsurgical treatments, and surgeries are presented in Table 2Go.


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  		TABLE 2 Respondents Who Reported a History of Knee Problems, Nonsurgical Treatments, and Surgeries
 
The mean scores for the IKDC Subjective Knee Form as well as 95% CIs, SDs, medians, and sample sizes for each age/gender group are reported for all respondents in Table 3Go. The same information, without the respondents who had a current knee problem, current treatment, or history of knee surgery, is provided in Table 4Go. These tables also provide scores from the IKDC form at 5-percentile increments for each age/gender category. Figures 1Go and 2Go present these data in graphical format.


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  		TABLE 3 IKDC Subjective Knee Evaluation Form Percentiles and Descriptive Statistics by Gender and Agea
 

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  		TABLE 4 IKDC Subjective Knee Evaluation Form Percentiles and Descriptive Statistics by Sex and Age (Respondents With Knee Problems, Treatments, and Surgery Excluded)a
 

Figure 1
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  		Figure 1. Subjective Knee Evaluation Form score percentiles for men in the United States. IKDC, International Knee Documentation Committee.

 

Figure 2
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  		Figure 2. Subjective Knee Evaluation Form score percentiles for women in the United States. IKDC, International Knee Documentation Committee.

 
The mean score on the IKDC Subjective Knee Form for the entire sample was 82 (SD, 22; range, 2–100). Twenty-six percent of respondents scored 100, the highest possible result. Men scored significantly higher than women (84.4 vs 80.1, respectively; P < .0001), even though men were 5 months older, on average, than women (39.6 years vs 39.1 years, respectively).

As expected, there was a significant negative correlation between age and Subjective Knee Form score (r5246 = –0.25, P < .0001), which provides support for the construct validity of the form. One-way ANOVA confirmed that there was a statistically significant between-groups effect for age (F4,5241 = 89.26, P < .0001). However, Scheffe post hoc analyses indicated that age differences did not emerge until the group of 35- to 50-year-old respondents. The youngest age groups did not differ from each other, but the means in each of these groups were statistically higher than those of the 2 oldest age groups (35–50 years and 51–65 years). The mean for the age group of 35- to 50-year-old respondents was significantly higher than that of the 51-to 65-year-old respondents. This finding held when the data for men and women were analyzed separately.

As an assessment of the validity of the IKDC Subjective Knee Form, scores were compared between respondents who reported problems in their right knee, their left knee, both knees, or neither knee. Scores were compared separately for right and for left knees. Age was used as a categorical covariate in these analyses because differences in scores might be an artifact of age. An ANCOVA revealed, as expected, that patients who reported current problems in the target knee or both knees had lower scores than did patients who had no reported current knee problems or who only reported problems in the opposite knee. Similar analyses were performed, with current nonsurgical treatments for knee problems and history of knee surgery as the independent variables. In all comparisons, the scores on the Subjective Knee Form were significantly lower for respondents who reported treatment or surgery on the target knee, compared to those who reported no treatment or surgery and those with treatment or surgery on the opposite knee only. Means and SDs for each group as well as details of these analyses can be found in Table 5Go.


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  		TABLE 5 Right and Left Knee IKDC Scores by Current Knee Problems, Current Treatments, and History of Knee Surgerya
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The primary purpose of this study was to establish normative data for the scores on the IKDC Subjective Knee Form within a representative population-based sample. The data (Tables 3Go and 4Go, Figures 1Go and 2Go) provide a valuable point of reference that allows researchers to determine knee performance at baseline and provides a standard to evaluate the significance of treatment within the clinical context of normal age- and gender-adjusted values.

The normative data can be used to convert a patient’s Subjective Knee Form score to the percentile for that patient’s age/gender category if he or she is between 18 and 65 years of age. For example, using Table 3Go, a 40-year-old woman who scores an 82 has a percentile ranking of 40, indicating that her score is greater than 40% of all women between the ages of 35 and 50 years.

Alternatively, the normative data can be used to convert a patient’s score on the Subjective Knee Form to a standard score (z), which relates the patient’s result to the population mean and standard deviation for the patient’s age and gender. The standard score for a patient can be calculated as follows:


Formula

For example, the standard score for a 20-year-old man who scores a 70 on the Subjective Knee Fo]rm would be


Formula

Consequently, his score would be 1.09 SDs below the population mean for men between 18 and 24 years of age. In another example, a 52-year-old woman who scores an 80 on the Subjective Knee Form has a standard score of .35, indicating that her result is .35 of an SD above the population mean for women aged between 51 and 65 years. Converting a patient’s result on the IKDC Subjective Knee Form to a standard score provides a mechanism to "adjust" the results based on the patient’s age and gender, permitting a more valid comparison among persons or cohorts who differ in terms of age and gender. In addition to providing a benchmark, these data may also serve as starting points for determining sample size requirements in studies using the IKDC form.

Age and gender are both statistically significant factors in understanding Subjective Knee Form scores. As expected, an age-related decrease in scores was observed. However, the finding that these differences did not appear until after the age of 35 years suggests that either the Subjective Knee Form has limited sensitivity to distinguish between people with relatively high levels of function related to the knee or that there are, in fact, few actual differences in function related to the knee within the population through early adulthood. These data indicate that studies including patients between 18 and 34 years of age do not need to adjust Subjective Knee Form scores for age differences. However, the differences in scores for subjects in groups younger than 35 years, compared to those in groups 35 years and older, indicate that studies using the IKDC Subjective Knee Form should adjust the score for age in both men and women when evaluating patients across these age levels.

Surprisingly, women had lower scores at most percentiles and lower mean scores than men when comparing the same age groups (Table 3Go). This finding, in addition to the overall difference in mean scores between men and women and the age-related decrease in scores, indicates that results from male and female patients should be referenced to the same gender cohorts in clinical studies using the IKDC Subjective Knee Form.

A secondary purpose of this study was to provide additional evidence for construct validity of the Subjective Knee Form score by examining for differences in the scores between respondents with and without a history of knee problems. As expected, respondents who reported current problems, treatment, or past surgery of one or both knees had lower scores compared to respondents who had no current problems, treatment, or prior surgery. Respondents with a current unilateral knee problem, current treatment, or history of knee surgery also had lower scores for the involved knee compared to the noninvolved knee. These results indicate that the IKDC Subjective Knee Form is able to differentiate patients with greater knee symptoms and lower levels of function, which lends further support for interpretation of the Subjective Knee Form score as a measure of symptoms and function during activities of daily living and sports.

Normative data were provided for both the respondents as a whole and the subset of respondents who reported no history of knee problems because the scores were higher for the subset of respondents with no history of current or prior knee problems. The reference population for the data in Table 3Go was the US population at large, including respondents who reported current knee problems, treatment, or a history of knee surgery. The data in Table 4Go represent the US population that does not have a current knee problem or a history of knee surgery. When using these normative data, researchers and clinicians should carefully consider the population to which they would like to compare their results, and they should specify which population was used.

Despite a cross-sectional design, the present study has limitations. The panel methodology used in this study typically results in a 60% or higher response rate with a single-wave mailing. The response rate in this study was only 56%. Even so, the sample size met the margin of error set a priori (95% CI with a ± 5% error rate) and ensured acceptable sample representation within the 8 age/gender categories. Although not optimal, the low response rate was probably not a significant weakness because response bias effects are minimized if the response rate exceeds 50%.5,22 Another limitation of this study was the failure to establish normative data for the population group younger than 18 years.

In summary, the IKDC Subjective Knee Form, a well-standardized outcomes instrument, is a valuable measure of symptoms, function, and sports activity. The normative data described in the present study enhance the value of this form by providing age- and gender-adjusted values so clinicians and researchers can assess how patients are functioning at baseline and can determine the outcomes of treatment more precisely. Consequently, the results of studies based on scores from the IKDC Subjective Knee Form are placed in a firmer context, and decisions are more likely to lead to improved patient care.

The IKDC Subjective Knee Evaluation Form, available in English, French, German, Italian, Japanese, and Spanish, may be downloaded from the Internet at http://www.sportsmed.org/research/index.asp.


   ACKNOWLEDGMENTS
 
This study would not have been possible without a grant from the Orthopaedic Research and Education Foundation and the AOSSM. Members of the IKDC are as follows: A Anderson, N Amendola, A Boland, J Feagin, J, Fulkerson, C Harner, S Howell, J Irrgang, M Kocher, J Richmond, D Shelbourne (from the AOSSM); H Staubli, N Friedrich, F Hefti, J Hoher, R Jacob, W Mueller, P Neyret (from the ESSKA); K Chan, M Kurosaka (from the APOSSM).


   FOOTNOTES
 
One or more authors has declared a potential conflict of interest: James Irrgang received funding from the AOSSM to perform psychometric analysis of the IKDC form as reported in a manuscript previously published in the AJSM (29: 600-613, 2001).


   REFERENCES
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 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
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