Knee Flexion Angle Measurement Using Virtual Assessment Tools: Correct Procedure and Potential Pitfalls

Virtual patient assessment will inevitably require smartphone technology to remotely measure knee range of motion. We conducted an experiment to analyze the impact of observer position relative to the flexed knee on the perceived angle measured using an electronic application (Dr. Goniometer) for iPhone. Two observers measured the apparent knee flexion angle from 7 different positions at 3 different heights relative to the center of the knee joint. Intraclass correlations were calculated to evaluate the intraobserver and interobserver variability using two-way mixed-effects models. The intraclass correlation for interobserver variability was excellent at 0.804 (95% confidence interval 0.663-0.889). When the observer was greater than 15° from the knee perpendicular, the true angle of knee flexion (90°) was not observed in any of the measurements. This was the case when observed from both proximal (range 95°-121°) and distal (range 92°-108°) directions. Ideally the camera lens should be perpendicular to the long axis of the lower limb in the proximal-distal direction and at the same height. However, if the camera lens is within 15° of the perpendicular, then at 90° of true flexion, the perceived angle will not be greater than 95° in 94% of cases.