Received: 3 December 2017 Revised: 4 June 2018
DOI: 10.1002/pri.1765
RESEARCH ARTICLE
Measurement of knee joint range of motion with a digital
goniometer: A reliability study
Melanie Svensson1,2
1
Hela Kroppen Fysioterapi och Friskvård AB,
Stockholm, Sweden
2
Department of Molecular Medicine and
Surgery, Sports Trauma Research Center,
Karolinska Institutet, Stockholm, Sweden
Correspondence
Melanie Svensson, MSc, RPT, Hela Kroppen
Fysioterapi och Friskvård AB, Kapellgränd 13,
Stockholm, Sweden.
Email: melanie.svensson@aleris.se
Physiother Res Int. 2019;24:e1765.
https://doi.org/10.1002/pri.1765
Accepted: 11 July 2018
| Veronika Lind1 | Marita Löfgren Harringe1,2
Abstract
Objectives: Measurements of joint range of motion (ROM) are part of a physical
therapist's daily work. Activities of daily living and exercises can be complicated to
perform when ROM is limited, and depending on the demands in daily living, the knee
joint requires different ROM. In sports, a few degrees in ROM may make the
difference between getting injured or not. The goals for physical therapists are to help
the patients to regain full ROM, mobility, strength, and function after sustaining an
injury. To measure joints with the manual universal goniometer is considered time‐
consuming and difficult with respect to repeated measurements. Recently, a new
digital instrument for measuring ROM was developed—EasyAngle. A first objective
of the study was to investigate the reliability of EA for measuring knee joint angles,
considering intrarater and interrater reliability. A second objective was to investigate
if there were any differences in the intrarater reliability between a novice and an
experienced assessor.
Method: Passive knee angles were measured in fixed positions for 40 knee joints
(20 subjects). Two registered physical therapists, one novice and one experienced,
conducted the measurements. Both registered physical therapists were blinded to
the measurements throughout the study.
Results: The results showed very good intrarater (intraclass correlation coefficient
[ICC] 0,997–0,998, standard error of mean 1.15–1.48, smallest detectable difference
[SDD] 3.19–4.09, limits of agreement −3.36–3.04, −4.66—4.09) and interrater reliabil-
ity (ICC 0.994, standard error of mean 2.11, SDD 5.85, limits of agreement −4.75–6.95)
for measurements of knee joint ROM. No statistical difference between a novice and
an experienced assessor was detected (p = 0.86).
Conclusion: The results of the present study showed very good ICC values for both
intrarater and interrater reliability measuring knee joint ROM with EasyAngle.
Relatively high SDD values were seen for both assessors and may indicate a problem
monitoring small differences between measurements. Further studies are recom-
mended to increase the generalizability of the results.
KEY W ORDS
evaluation, lower extremity, physical therapists, reproducibility of results
wileyonlinelibrary.com/journal/pri Copyright © 2018 John Wiley & Sons, Ltd. 1 of 7
2 of 7
1 | I N T RO D U CT I O N
Measurements of joint range of motion (ROM) are part of a physical
therapists' daily work, especially for physical therapists working in pri-
mary health care and orthopaedics. The goals for physical therapists
are to help patients regain full ROM, mobility, strength, and function
after sustaining an injury. ROM is measured to discover limitations in
joint movement and to evaluate the patient's progress in an interven-
tion or rehabilitation program (Akizuki, Yamaguchi, Morita, & Ohashi,
2016; Gogia, Braatz, Rose, & Norton, 1987). Thus, it is of great impor-
tance that measurements are precise with respect to reliability and
validity in order to make the physical therapists' work as precise as
possible (Akizuki et al., 2016).
A common treated and measured joint is the knee joint (Akizuki
et al., 2016; Gogia et al., 1987). Shelbourne, Freeman, and Gray
(2012) studied individuals who had undergone anterior cruciate liga-
ment reconstruction and found that a loss of knee extension with 3
to 5° compared with the opposite knee adversely affected the subjec-
tive and objective results after surgery. A limited ROM was also asso-
ciated with lower quadriceps muscle strength and more often
associated with radiographic osteoarthritis (Lohmander, Östenberg,
Englund, & Roos, 2004). Depending on the demands of daily living,
the knee joint requires different ROM (Moritz, 2007). In sports, a
few degrees in ROM may make the difference between getting injured
or not. Bradley and Portas (2007) studied football players and con-
cluded that players with smaller ROM in the hip and knee before the
season suffered more muscle ruptures of the hamstring muscle during
season, compared with players with good mobility in the hip and knee.
Over the years, the most common tool for measuring ROM has
been the universal goniometer (UG; full‐circle manual goniometer;
Gajdosik & Bohannon, 1987; Russell, Jull, & Wootton, 2003). The
advantage with the UG is its low cost, but both hands are needed to
perform the measurements, which makes it difficult to stabilize other
body segments (Gajdosik & Bohannon, 1987). Numerous studies have
found the UG to have generally good intrarater and interrater reliability,
and most of those studies have found the intrarater reliability to be bet-
ter than the interrater reliability (Boone et al., 1978; Brosseau et al.,
2001; Jakobsen, Christensen, Christensen, Olsen, & Bandholm, 2010;
Peters et al., 2011; Piriyaprasarth & Morris, 2007; Rothstein, Miller, &
Roettger, 1983; Watkins, Riddle, & Lamb, 1991). The majority of the
studies have also shown better reliability for knee flexion than knee
extension (Brosseau et al., 1997; Brosseau et al., 2001; Rothstein
et al., 1983; Watkins et al., 1991). Even if the UG shows good intrarater
and interrater reliability, it has a measurement error of 5° for measure-
ments of the lower extremity (Boone et al., 1978). Alternative types of
goniometers with various technologies fluid‐based (Rheault, Miller,
Nothnagel, Straessle, & Urban, 1988), parallelogram (Brosseau et al.,
1997; Brosseau et al., 2001), applications for the smartphone (Gogia
et al., 1987; Milani et al., 2014; Ockendon & Gilbert, 2012), digital pho-
tography (Naylor et al., 2011; Verhaegen, Ganseman, Arnout,
Vandenneucker, & Bellemans, 2010), digital inclinometer (Cleffken,
van Breukelen, Brink, van Mameren, & Damink, 2007), Orthoranger
(Clapper & Wolf, 1988), and internet‐based goniometers (Russell
et al., 2003) have been evaluated for measurements of the knee joint,
and each of the different goniometers has its own benefits.
SVENSSON ET AL.
Recently, a new instrument for measuring joint ROM was devel-
oped—EasyAngle (EA). EA was developed with the purpose to digitize
angle measurements to optimize the reliability. It may be held by one
hand during measurements, leaving one hand free to stabilize a body
part during measurements, and five measurements may be saved
on the display. The hypothesis is that measurements with the new
developed digital goniometer will be reliable, easy, and fast to use.
A first objective of the study was to investigate the reliability of
EA for measuring knee joint angles, considering intrarater and
interrater reliability. A second objective was to investigate if there
were any differences in the intrarater reliability between a novice
and an experienced assessor.
2 | METHODS
2.1 | Study design
A methodological study, designed according to Guidelines for
reporting Reliability and Agreement Studies (Kottner et al., 2011),
investigating the intrarater and interrater reliability of a digital goniom-
eter was conducted. The study was designed in accordance with the
ethical guidelines from the Helsinki declaration of ethical principles
(World Medical Association. WMA Declaration of Helsinki ‐ Ethical
Principles for Medical Research Involving Human Subjects, 1964)
and approved by the local ethical board in Stockholm (Dnr2017‐
1981/31). Written and oral information was provided to the subjects,
and the subjects were informed that they, at any time, could leave the
study without explaining the reason. Written consent was retrieved
from all subjects before participating in the study.
2.2 | Subjects
Twenty healthy, male (7) and female (13) subjects, between the ages
of 21 and 66, were included in the study. The subjects were recruited
with a convenience sampling strategy and consisted of colleagues,
friends, and gym visitors. Demographic data were collected before
measurements (m[SD] = age 39 [15.6], height 172.2 [8.2] cm, mean
weight 70.2 [11.4] kg, and physical activity 6 [3.2] hr per week), and
questions regarding previous and current knee injuries were
answered. Knee joint instability, ligament injuries, meniscal tear inju-
ries, patellar tendinosis, osteoarthritis, and undefined pain were
reported by nine of the included subjects. Both the right and left knee
were measured at one occasion, resulting in a total of 80 measure-
ments for each assessor.
2.3 | Assessors
Two registered physical therapists (RPT), RPT1 and RPT2, with
different experience of measuring joint angles conducted the mea-
surements. RPT1 was considered the novice RPT and had worked as
a physical therapist for less than a year with no experience of measur-
ing with EA, and RPT2, the experienced RPT, had worked as a physical
therapist for 8 years and had experience of measuring with EA from a
previous study and from clinical work. Before conducting the
SVENSSON ET AL.
measurements, RPT1, the novice assessor, were familiarized with
EA and practiced measuring ROM on three different subjects for
half a day.
2.4 | EA
EA is a handheld digital goniometer with a display attached in the mid-
dle of a hard plastic ruler and provided with a position sensor, always
aware of its position in space. An algorithm minimizing disturbing
angular components like rotation is incorporated in the digital device.
This algorithm also makes the goniometer less affected by body shape
of the patient and how the physical therapist handles EA. To measure
knee joint ROM, EA is lined up with the lateral side of femur, between
trochanter major and the middle of the lateral joint space of the knee,
and thereafter between the middle of the lateral joint space of the
knee and the lateral malleoli (Rheault et al., 1988). The goniometer
then compares the first position with the second position, and the
angular difference between the two positions represents the knee
joint ROM. The measurement values are given in degrees with an
interval of one degree. The display saves the last five measurements.
Two EAs were used in the present study. At the start of the study they
were calibrated by measuring a 90° angle.
2.5 | Procedure
The first 10 subjects were measured firstly by RPT1 followed by RPT2,
and thereafter, the remaining 10 subjects were measured firstly by
RPT2 followed by RPT1. The right knee joint was always measured
first by the two assessors. The test leader randomly placed the knees
of the subjects in different angles and marked the reference points on
the subjects with removable crosses. RPT1 measured the right and left
knee angle once and then left the room to give the digital goniometer
with the saved measurements blinded to the test leader who
FIGURE 1 EasyAngle pointing towards the
reference points lateral joint space and
trochanter major
3 of 7
registered them in a protocol. Although the test leader registered
RPT1's measurements, RPT2 measured the same right and left knee
angle and then gave the digital goniometer to the test leader. This
was repeated twice for each subject. The subjects were lying supine
on a bench with the arms along the body, wearing underwear or shorts
(Figure 1). Time consumption for each subject was estimated to
15 min. Small knee extension angles were avoided due to the blinding
of the measurements. The display reports saved angles but not direc-
tions once saved. That is, whether it is a knee hyperextension or flex-
ion. When uncovering the display, the test leader would therefore not
be able to understand whether there was an extension defect or a
hyperextension that was measured. During real‐time measurements,
before saving the data, an arrow is seen on the display indicating a
hyperextension. Angles ranging from 14 to 131° were used.
2.6 | Statistical analysis
Thirty‐five measurements are required to get a reliability coefficient of
0.80 with a significant level of 5% (Eliasziw, Young, Woodbury, &
Fryday‐Field, 1994). Intraclass correlation coefficient (ICC) 3.1 was
calculated for intrarater and interrater reliability. The ICC values were
interpreted according to the classification of Altman (1991),
ICC < 0.20 = poor, 0.21–0.40 = fair, 0.41–0.60 = moderate, 0.61–
0.80 = good, and 0.81–1.0 = very good. A 95% confidence interval
was calculated for the true difference to check if there were any sys-
tematic differences between the measurements (Bruton, Conway, &
Holgate, 2000). Smallest detectable difference (SDD) and the standard
error of mean (SEM) were calculated for intrarater and interrater reli-
ability. There are no existing cut‐off points for SDD and SEM, but
the closer to zero, the better the value. To test the presence of any
systematic and significant difference between the two assessors, an
independent t test was conducted. The significant level was set at
p < 0.05. Moreover, the correlation for interrater reliability was
4 of 7 SVENSSON ET AL.

presented in a scatter‐plot. SPSS version 24 and Excel 2017 version

15.30 were used.

3 | RESULTS

According to the classification of Altman (1991), the results showed

very good intrarater (ICC 0.997–0.998) and interrater reliability (ICC
0.994) regarding measurements of knee joint ROM (Table 1). No dif-
ferences between a novice and an experienced assessor were
detected (p = 0.86).
Hereunder Bland Altman plots are presented to give an alterna-
tive and supporting way of evaluating the reliability (Figures 2–4).
Figure 5 illustrates the correlation between the measurements from
RPT1 and RPT2. FIGURE 2 Bland–Altman plot for intra‐rater reliability, RPT1:
The two goniometers that were used during the procedure The outer lines represent 95% limits of agreement. The middle line
showed consistency at the start of the study. However, when all sub- represents the mean of the differences between measurement one
jects were measured, a difference of two degrees was noticed and measurement two

between the goniometers.

4 | DISCUSSION

The results of the present study showed very good ICC values for
both intrarater and interrater reliability measuring knee joint ROM,
according to the classification of Altman (1991). The limits of agree-
ment in the Bland Altman plots indicate a small spread of the values
for intrarater reliability as well as for interrater reliability. No statistical
significance was found between the novice and the experienced
assessor. Although the ICC values were very good, the SDD values
were relatively high and may indicate a problem monitoring small
differences.
The methods and statistical analyses vary a lot between studies.
The results of the present study demonstrate similar results as a study
by Rothstein et al. (1983), Watkins et al. (1991), Peters et al. (2011), FIGURE 3 Bland–Altman plot for intrarater reliability, RPT2:
and Jakobsen et al. (2010) where high intrarater and interrater reliabil- The outer lines represent 95% limits of agreement. The middle line
represents the mean of the differences between measurement one
ity were found for measurements of passive knee flexion with the UG.
and measurement two
EA shows a higher ICC value for interrater reliability compared with
visual estimation (0.83), evaluated by Watkins et al. (1991). EA should
therefore be preferred prior to visual estimation when measuring pas- the reliability of an inclinometer, EA seems to be a more reliable mea-
sive knee flexion. Jakobsen et al. (2010) found that the tester experi- surement tool with lower SDD and SEM values. This is also evident
ence does not appear to influence the degree of reliability when comparing the SEM values from the present study to Boone et al.
measuring with the UG, which, according to the present study, seems (1978), who evaluated the reliability of the UG, suggesting that EA is
to be the fact for EA as well. Comparing the results from the present preferable for measurements of the knee joint ROM.
study to Verhaegen et al. (2010), who evaluated the intrarater reliabil- The subjects were measured in fixed positions, and therefore, the
ity of digital photography, and Cleffken et al. (2007), who evaluated variations within the individuals could be excluded in the present

TABLE 1 The results of intrarater reliability and interrater reliability

Mean value first Mean value second

measurement (°) (SD) measurement (°) (SD) ICC3.1 (95% CI) SEM SDD LoA

Intrarater reliability RPT1 61.0 (27.2) 61.2 (27.3) 0.998 (0.997–0.999) 1.15 3.19 −3.36–3.04
Intrarater reliability RPT2 59.9 (27.5) 60.5 (27.4) 0.997 (0.995–0.998) 1.48 4.09 −4.66–4.09
Interrater reliability 0.994 (0.989–0.997) 2.11 5.85 −4.75–6.95

Note. The ICC value is based on the first measurement from the two assessors.
SD, standard deviation; ICC, intraclass correlation; CI, confidential interval; SEM, standard error of mean; SDD, smallest detectable difference; LoA, limits of
agreement.
SVENSSON ET AL.
FIGURE 4 Bland–Altman plot for interrater
reliability: The outer lines represent 95% limits
of agreement. The middle line represents the
mean of the difference between RPT1 and
RPT2
FIGURE 5 Scatter plot: Correlation between the first measurements
from RPT1 and RPT2
study. If, instead, maximal flexion would have been measured, there
might have been problems because of the stretch effect, which can
occur when measuring maximal flexion several times. A reasonably
even distribution between men and women and a wide range in age
for the included subjects in the present study makes the results gener-
alizable for a larger population. Both assessors were blinded for their
own and each other's measurements, which limited the possibility
for the assessors to affect the results. To minimize the risk of system-
atic errors, the two assessors took turns to start measuring. The study
was designed according to Guidelines for reporting Reliability and
Agreement Studies with the aim of creating a study with a low risk
of bias (Kottner et al., 2011). The results of the present study were
evaluated in multiple ways, which strengthens the results of the study.
There could have been some benefits with fixating the subjects during
the measurements to exclude the risk of motions between the mea-
surements, but when measuring joint ROM in clinic, there is no or little
time to fixate the patient before collecting measurements. Therefore,
5 of 7
the study group agreed upon not fixating the subjects with belts or
likewise. Common reference points that have been used in previous
studies are trochanter major, the lateral epicondyle of femur and caput
fibula, and the lateral malleoli (Clarkson Hazel, 2000). In the present
study, the middle of the lateral joint space was used to facilitate the
measurements and to avoid the rotation of the lower leg that occurs
during knee extension. A third part marked out the reference points
on the subjects to make the method as standardized and replicable
as possible. This may have influenced the results of the reliability.
The two goniometers that were used for conducting the measure-
ments showed consistency at the start of the study. However, when
all subjects were measured, a difference of 2° was noticed between
the goniometers. It is unclear if the two goniometers showed different
number of degrees during the study or not, but when looking at the
results, no systematic differences could be seen between the two
assessors. However, a relatively high SDD was found, which may be
caused by the difference of 2°between the two goniometers or indi-
cate a problem monitoring small differences between measurements.
This has to be further investigated. To increase the reliability, it is
often recommended to use the mean of two or more rater rating
(Perkins, Wyatt, & Bartko, 2000). The ICC values in the present study
were calculated from single measurements, and therefore, the results
are not likely overestimated. The digital goniometer seems to be effec-
tive and may simplify the physical therapists' work. EA is used by only
one hand, which, according to the two assessors, is beneficial com-
pared with the UG where both hands are needed to conduct measure-
ments. That makes the procedure using EA less time‐consuming and
easier to handle compared with UG.
To strengthen the reliability of EA, more studies must be con-
ducted. It is important to evaluate the validity of EA, preferably com-
pared with X‐ray. EA is promoted to be useful for all joints of the
body, and therefore, more reliability and validity studies for several
joints need to be performed. It is also important to evaluate the reli-
ability of EA on different populations, for example, children, subjects
with injuries like anterior cruciate ligament injury and osteoarthritis
6 of 7
or patients that have undergone, total knee or hip arthroplasty. Only a
few knee extension angles were measured in the present study. In
previous studies measurements of knee extension have shown lower
reliability compared with measurements of knee flexion with different
measurement instruments (Brosseau et al., 1997; Clapper & Wolf,
1988; Piriyaprasarth & Morris, 2007; Watkins et al., 1991). It would
therefore be of value to investigate the reliability of EA during mea-
surements of knee extension angles.
In the present study EA showed very good intrarater and
interrater reliability. The digital goniometer seems to be effective
and may simplify the physical therapists' work. No statistical differ-
ences between a novice and an experienced assessor could be seen.
The present study may therefore be a first step towards considering
EA as an alternative measurement tool for physical therapists, novice
or experienced.
CONF LICT OF INT E RE ST
The authors declare no conflict of interest.
ORCID
Melanie Svensson https://orcid.org/0000-0003-0576-3237
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How to cite this article: Svensson M, Lind V, Löfgren
Harringe M. Measurement of knee joint range of motion with
a digital goniometer: A reliability study. Physiother Res Int.
2019;24:e1765. https://doi.org/10.1002/pri.1765