Date of completion
Modified Cincinnati Rating System Questionnaire
Clinician's name (or ref)
Patient's name (or ref)
Patient's d.o.b
 
This questionnaire has been designed to give your therapist information as to how your knee pain has affected your ability to manage in everyday life.  Please answer every question by placing a mark in the box that best describes your condition today.
During the past 4 weeks......  
1 - Pain Intensity   2 -Swelling
No pain, normal knee, performs 100%   No swelling
Occasional pain with strenuous sports or heavy work, knee not entirely normal, some limitations but minor and tolerable   Occasional swelling with strenuous sports or heavy work. Some limitations but minor and tolerable
Occasional pain with light recreational sports or moderate work activities, running or, heavy labour, strenuous sports   Occasional swelling with light recreational sports or moderate work ativities. Frequently brought on by vigorous activities, running, heavy labour, and strenuous sport
Pain, usually brought on by sports, light recreational activities or moderate work. Occasionally occurs with walking, standing or light work   Swelling limits sports and moderate work. Occurs infrequently with simple walking activities or light work (approx 3 times a year)
Pain is a significant problem with simple activity such as walking, relieved by rest, unable to do sports   Swelling brought on by simple walking activities and light work. Relieved by rest

Pain present all the time. Not relieved by rest

   Severe problem all the time, with simple walking activities
     
3 - Giving Way   4 - Overall activity level
No giving way   No limitation, normal knee, able to do everything including strenuous sports or heavy labour
Occasional giving way with strenuous sports or heavy work. Can participate in all sports but some guarding or limitations present   Perform sports including vigorous activities but at lower performance level: involves guarding or some limits to heavy labour
Occasional giving way with light sports or moderate work. Able to compensate but limits vigorous activities, sports, or heavy work not able to cut or twist suddenly. are conveniently positioned (e.g., on a table)   Light recreational activities possible with rare symptoms, more strenuous activities cause problems.Active but in different sports; limited to moderate work
Giving way limits sports and moderate work, occurs infrequently with walking or light work (approx 3 times per year)   No sports or recreational activities possible. Walking with rare symptoms; limited to light work
Giving way with simple walking activities and light work. Occurs once per month, requires guarding   Walking, ADL cause moderate symptoms, frequent limitations
Severe problem with simple walking activities, cannot turn or twist while walking without giving way   Walking, ADL cause severe problems, persistent symptoms
     
5 - Walking   6 - Stairs
Walking unlimited   Normal, unlimited
Slight/mild problem   Slight/mild problem
Moderate problem: smooth surface possible up to approx 800m   Moderate problems only 10-15 steps possible
Severe problem, only 2-3 blocks possible   Severe problem; requires bannister support
Severe problem; requires stick or crutches   Severe problem on 1-5 steps possible
     
7 - Running activity   8 - Jumping or Twisting
Normal, unlimited; fully competitive, strenuous   Normal, unlimited, fully competitive, strenuous
Slight mild problem; run half speed   Slight to mild problem; some guarding but port possible
Moderate problem 2-4 km   Moderate problem; gave up strenuous sports, recreational sports possible
Severe problem only 1-2 blocks possible   Severe problem; affects all sports; must constantly guard
Severe problem only a few steps   Severe problem; only light activity possible (golf, swimming)
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Modified Cincinnati Rating System is

Grading the Modified Cincinnati Rating System Questionnaire
<30
 Poor
30-54
Fair
55-79
Good
>80
Excellent

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Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.

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