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Arthritis Care Res (Hoboken). 2011 November ; 63(0 11): S208–S228. doi:10.1002/acr.20632.

Measures of Knee Function:

International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form,
Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis
Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey
Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee
Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC),
Activity Rating Scale (ARS), and Tegner Activity Score (TAS)

NATALIE J. COLLINS1, DEVYANI MISRA2, DAVID T. FELSON2, KAY M. CROSSLEY1, and

EWA M. ROOS3
1Natalie J. Collins, PhD, PT, Kay M. Crossley, PhD, PT: The University of Melbourne, Melbourne,
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Victoria, Australia
2Devyani
Misra, MD, David T. Felson, MD, MPH: Boston University School of Medicine, Boston,
Massachusetts
3Ewa M. Roos, PhD, PT: University of Southern Denmark, Odense, Denmark

INTRODUCTION
Patient-reported measures of knee function are important for the comprehensive assessment
of rheumatology conditions in both clinical and research contexts. To merit inclusion in this
review, measures of knee function were required to be patient reported and assess aspects
considered important by adult patients with knee problems such as injury or osteoarthritis
(OA). Therefore, measures used in rheumatology, orthopedics, and sports medicine were
considered. Dimensions deemed to be important to patients included pain, function, quality
of life, and activity level. To identify instruments fulfilling these criteria, we utilized
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published reviews of knee instruments (1), knee OA instruments (2), and measures for use in
patellofemoral arthroplasty (3).

Based on these reviews, as well as extensive searches of more recent literature, we included
the following 9 patient-reported outcomes: Activity Rating Scale, International Knee
Documentation Committee Subjective Knee Evaluation Form, Knee Injury and
Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score Physical

© 2011, American College of Rheumatology

Address correspondence to Ewa M. Roos, PhD, PT, Research Unit for Musculoskeletal Function and Physiotherapy, Institute of
Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230, Odense M, Denmark.
[email protected].
Dr. Roos has received speaking fees (less than $10,000) from Biomet.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the
final version to be published.
 COLLINS et al. Page 2

Function Short Form, Knee Outcome Survey Activities of Daily Living Scale, Lysholm
Knee Scoring Scale, Tegner Activity Scale, Oxford Knee Score, and Western Ontario and
McMaster Universities Osteoarthritis Index (WOMAC). Although the WOMAC can be
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applied to the hip and knee, this study contains data only applicable to the knee. Measures
assessing activity level are listed separately.

Psychometric data pertaining to the reliability and responsiveness of each patient-reported

outcome are shown in Tables 1 and 2. The number of psychometric reports concerning each
instrument ranges from 2–27. A higher number of reports indicates a higher degree of
certainty in interpretation of the psychometric properties.

Psychometric properties were based on data provided in Tables 1 and 2, and interpreted
using standardized guidelines. Internal consistency was considered adequate if Cronbach’s
alpha was at least 0.7 (4), and test–retest (intra-rater) reliability was adequate if the
intraclass correlation coefficient was at least 0.8 for groups and 0.9 for individuals (5). Floor
and ceiling effects were considered to be absent if no participants scored the bottom or top
score, respectively, and acceptable if <15% of the cohort scored the bottom or top score,
respectively (6,7). We defined content validity as present when there was patient
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involvement in the development and/or selection of items (7). Measures were deemed to
have face validity if the reviewers considered that the items adequately reflected the
measured construct, or if studies reported that expert panels had made a similar assessment
(8). Construct validity was considered adequate if expected correlations were found with
existing measures that assess similar (convergent construct validity) and dissimilar
(divergent construct validity) constructs (7). As there is no gold standard measure of patient-
reported outcome, criterion validity is not applicable to this review. Effect sizes of <0.5 were
considered small, 0.5–0.8 were considered moderate, and >0.8 were considered large (9). In
this context, the minimum clinically important difference is the amount of change of a
patient-reported outcome that represents a meaningful change to the patient, while the
patient-acceptable symptom state is the least abnormal function score at which patients
would consider themselves having acceptable function (10).

INTERNATIONAL KNEE DOCUMENTATION COMMITTEE (IKDC)

SUBJECTIVE KNEE EVALUATION FORM
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Description
Purpose—To detect improvement or deterioration in symptoms, function, and sports
activities due to knee impairment (11).

Intended populations/conditions: Patients with a variety of knee conditions, including

ligament injuries, meniscal injuries, articular cartilage lesions, and patellofemoral pain (11).

Version: The IKDC was formed in 1987 to develop a standardized international

documentation system for knee conditions. The IKDC Standard Knee Evaluation Form,
which was designed for knee ligament injuries, was subsequently published in 1993 (12) and
revised in 1994 (13). The IKDC Subjective Knee Evaluation Form was developed as a
revision of the Standard Knee Evaluation Form in 1997. It has undergone subsequent minor

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revisions since its publication in 2001. The items now have the allocated scores next to each
possible response. The minimum score for each item has also been changed so that it is now
0, not 1. The scoring of the numerical rating scales for items 2 and 3 has been reversed so
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that 0 represents the highest level of symptoms and 10 represents the lowest level of
symptoms, which is in line with the scoring of the rest of the items.

Content—Three domains: 1) symptoms, including pain, stiffness, swelling, locking/

catching, and giving way; 2) sports and daily activities; and 3) current knee function and
knee function prior to knee injury (not included in the total score) (11).

Number of items—18 (7 items for symptoms, 1 item for sport participation, 9 items for
daily activities, and 1 item for current knee function).

Response options/scale—Response options vary for each item. Item 6 dichotomizes

response into yes/no; items 1, 4, 5, 7, 8, and 9 use 5-point Likert scales; and items 2, 3, and
10 use 11-point numerical rating scales.

Recall period for items—Not specified for items 1, 3, 5, 7, 8, and 9; 4 weeks for items 2,
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4, and 6. Function prior to knee injury for item 10a and current function for 10b.

Endorsements—International Cartilage Repair Society; European Society of Sports

Traumatology, Knee Surgery, and Arthroscopy; and American Orthopaedic Society for
Sports Medicine (AOSSM).

Examples of use—Conditions: knee ligament injury (anterior cruciate ligament [ACL],

posterior cruciate ligament [PCL], lateral collateral ligament [LCL], medial patello-femoral
ligament), meniscal tears, knee cartilage lesions, osteochondritis dissecans, and traumatic
knee dislocation. Interventions: ligament reconstruction (ACL, PCL, LCL, medial
patellofemoral ligament), meniscal repair, meniscectomy, microfracture, osteochondral
autografts, platelet-rich plasma injections, high tibial osteotomy, and lateral release.

Practical Application
How to obtain—The most recent revision is freely available at the AOSSM web site as
part of the IKDC Knee Forms (2000; www.sportsmed.org/tabs/research/ikdc.aspx). Multiple
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web sites have published versions of the form.

Method of administration—Patient-completed questionnaire. The form has not been

validated for administration by interview, either in person or via telephone.

Scoring—The response to each item is scored using an ordinal method (i.e., 0 for
responses that represent the highest level of symptoms or lowest level of function). The most
recent version has assigned scores for each possible response printed on the questionnaire.
Scores for each item are summed to give a total score (excluding item 10a). The total score
is calculated as (sum of items)/(maximum possible score) × 100, to give a total score of 100.
An online scoring sheet is available (www.sportsmed.org/tabs/research/ikdc.aspx) that

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provides a patient’s raw score and percentile score (relative to age- and sex-based norms).
The item regarding knee function prior to knee injury is not included in the total score.
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Missing values: The revised scoring method states that, in cases where patients have up to 2
missing values (i.e., responses have been provided for at least 16 items), the total score is
calculated as (sum of completed items)/(maximum possible sum of completed items) × 100.

Score interpretation—Possible score range 0–100, where 100 = no limitation with daily
or sporting activities and the absence of symptoms.

Normative values: Normative data are available from the general US population, stratified
for age, sex, and current/prior knee problems (14).

Respondent burden—10 minutes to complete (15). It uses simple language that is

suitable for patients.

Administrative burden—Approximately 5 minutes to score. Training is not necessary.

Manual scoring can be performed easily using the scoring instructions supplied with the
questionnaire.
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Translations/adaptations—Available in English, traditional Chinese (Taiwan, Hong

Kong), simplified Chinese (China, Singapore), French, German, Italian, Japanese, Korean,
Portuguese (Brazil), and Spanish. Cross-cultural adaptations have been conducted for the
Brazilian (16), Chinese (17), Dutch (18), Italian (15), and Thai (19) translations.

Psychometric Information
Method of development—The initial set of items was developed by the IKDC,
considering questions from the Standard Knee Evaluation Form, the MODEMS Lower Limb
Instrument, and the Activities of Daily Living and Sports Activity Scales of the Knee
Outcome Survey. Pilot testing of the initial version (n = 144) resulted in revision or deletion
of existing items and the addition of new items. Testing of the second version (n = 222)
resulted in further revisions and deletions (based on missing data), producing a final version.
Item-response theory was used to create the scoring system. Patients were not involved in
development; rather, items were selected by the IKDC, a committee of international
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orthopedic surgeons (11).

Acceptability—Missing data were relatively common in testing of the final version of the
form, with 57 of 590 patients failing to answer >3 items of 18 (11). Studies consistently
report no floor or ceiling effects (i.e., no participants scored lowest or highest score)
(11,15,16, 18,20).

Reliability—Internal consistency is adequate for patients with knee injuries and mixed
knee pathologies (Table 1). Test–retest reliability is adequate for groups of patients with
knee injuries and mixed pathologies and individuals with knee injuries. However, test–retest
reliability is slightly below adequate for individuals who fall into a broader category of knee

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pathologies. The minimal detectable change has been reported to be between 8.8 and 15.6,
and the standard error of the measure between 3.2 and 5.6.
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Validity
Face and content validity: The domains covered by the IKDC appear to represent elements
that are likely to be important to patients. However, the lack of patient contribution to the
selection and revision of items in the IKDC means that content validity cannot necessarily
be assumed.

Construct validity: There are consistent reports of high convergent and divergent construct
validity, with the IKDC more strongly correlated with the Short Form 36 (SF-36) physical
subscales and component summary than with the mental subscales and component summary
(11,16–18,20,21). Studies have shown the IKDC score to be highly correlated with the
Cincinnati Knee Rating System, pain visual analog scale, Oxford 12 Questionnaire, Western
Ontario and McMaster Universities Osteoarthritis Index, Lysholm score, and SF-36 physical
component, physical function, and bodily pain subscales (16,18,22).

Ability to detect change—In patients undergoing surgical treatment of meniscal injury,

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the IKDC shows large effect sizes at 1 year (Table 2). For patients who have had surgical
intervention for cartilage injury, the IKDC shows moderate effect sizes at 6 months and
large effect sizes at 1 year. Large effect sizes have been reported from 6–28 months
following various surgical procedures conducted in a mixed cohort of knee pathologies. The
minimum clinically important difference has been reported to be 6.3 at 6 months and 16.7 at
12 months following cartilage repair (23), and 11.5–20.5 (range 6–28 months) in those who
have undergone various surgical procedures for mixed (various) knee pathologies (24). The
patient-acceptable symptom state has not been determined.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—At face value, the domains covered by the IKDC appear to represent elements
that are likely to be important to patients. It shows adequate internal consistency and has no
floor or ceiling effects across mixed groups of patients with knee conditions. The IKDC has
been shown to be responsive to change following surgical interventions, highlighting its
usefulness in this patient population.
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Caveats and cautions—Despite demonstrating face validity, the lack of patient

contribution to item selection indicates that content validity cannot necessarily be assumed.
The relatively long recall period associated with 3 of the items may be a problem for some
patients. The use of 1 aggregate score to represent symptoms, activities, and function may
mask deficits in 1 domain. Psychometric testing is lacking for patients with knee
osteoarthritis as an isolated group, as well as responsiveness following non-surgical
management, highlighting areas for future studies.

Clinical usability—The IKDC involves minimal administrative and respondent burden,

and can be easily scored in the clinic using the online scoring sheet. However, clinicians
using the online scoring system need to keep in mind that the normative data provided are

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from a particular population, and may not be representative of their individual patient’s
population. Test–retest reliability for those with various knee pathologies suggests that the
IKDC may demonstrate inadequate reliability for the evaluation of individual patients.
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Research usability—Psychometric evaluation supports the use of the IKDC in research

for a variety of knee conditions. As some versions of the IKDC published online contain
subtle differences in the wording of instructions and items, researchers should ensure that
they utilize the version published as a component of the 2000 IKDC Knee Forms to ensure
that findings of psychometric properties still apply, and that comparisons can be made with
previous studies. Administrative and respondent burden would not limit research use,
although researchers should be diligent in checking for missing data.

KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE (KOOS)

Description
Purpose—To measure patients’ opinions about their knee and associated problems over
short- and long-term followup (1 week to decades).
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Intended populations/conditions: Young and middle-aged people with posttraumatic

osteoarthritis (OA), as well as those with injuries that may lead to posttraumatic OA (e.g.,
anterior cruciate ligament [ACL], meniscal, or chondral injury) (25).

Version: The original KOOS remains unchanged, although a short form for function has
been developed.

Content—Five domains: 1) pain frequency and severity during functional activities; 2)

symptoms such as the severity of knee stiffness and the presence of swelling, grinding or
clicking, catching, and range of motion restriction; 3) difficulty experienced during activities
of daily living (ADL); 4) difficulty experienced with sport and recreational activities; and 5)
knee-related quality of life (QOL) (25).

Number of items—42 items across 5 subscales.

Response options/scale—All items are rated on a 5-point Likert scale (0–4), specific to
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each item.

Recall period for items—Previous week for pain, symptoms, ADL, and sport/recreation
subscales. Not defined for QOL subscale.

Endorsements—International Cartilage Repair Society, American Academy of

Orthopedic Surgeons, and US Food and Drug Administration.

Examples of use—Conditions: knee ligament injury (ACL, posterior cruciate ligament

[PCL], medial collateral ligament [MCL]), meniscal tears, knee cartilage lesions, knee OA,
and osteochondritis dissecans. Interventions: ligament reconstruction (ACL, PCL, MCL),
meniscectomy, microfracture, osteochondral autografts, tibial osteotomy, total knee

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replacement (TKR), exercise (land based, aquatic), intraarticular sodium hyaluronate

injection, pharmacologic therapy, and glucosamine supplementation.
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Practical Application
How to obtain—The KOOS and associated documentation are freely available at
www.koos.nu.

Method of administration—Patient-completed, in-person questionnaire. The KOOS has

not been validated for use during an in-person or telephone interview.

Scoring—Scoring sheets (manual and computer spreadsheets) are provided on the web
site. Each item is scored from 0–4. The 5 dimensions are scored separately as the sum of all
corresponding items. A total score has not been validated and is not recommended. Scores
are then transformed to a 0–100 scale (percentage of total possible score achieved), where 0
= extreme knee problems and 100 = no knee problems (25).

Missing values: If a mark is placed outside a box, the closest box is chosen. If 2 boxes are
marked, that which indicates more severe problems is chosen. One or 2 missing values
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within a subscale are substituted with the average value for that subscale. If >2 items are
missing, the response is considered invalid and a subscale score is not calculated.

Score interpretation—0 = extreme problems and 100 = no problems.

Normative values: Population-based normative data are available, stratified by age and sex
(26).

Respondent burden—The KOOS takes 10 minutes to complete (25). It uses simple

language and similar 1-word responses for each item. The items largely reflect signs and
symptoms of their knee condition and how this affects everyday tasks, so it is not considered
that they would have an emotional impact on the individual. The knee-related QOL subscale
could be considered the most emotionally sensitive component, as it requires the individual
to reflect on how their knee affects their QOL.

Administrative burden—Approximately 5 minutes to score, using the scoring

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spreadsheet. Training is not necessary, as the components of the KOOS and the scoring
instructions are self-explanatory.

Translations/adaptations—Available in English and Swedish (original versions

developed concurrently), Austria-German, Czech, Chinese, Croatian, Danish, Dutch,
Estonian, French, German, Italian, Japanese, Latvian, Lithuanian, Norwegian, Persian,
Portuguese, Polish, Russian, Singapore English, Slovak, Slovenian, Spanish (US), Spanish
(Peru), Thai, Turkish, and Ukrainian. Cross-cultural adaptations have been conducted for the
Swedish (27,28), Chinese (29), Dutch (30), French (31), Persian (32), Portuguese (33),
Russian (Golubev; www.koos.nu), Singapore English (29), Thai (34), and Turkish (35)
translations.

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Psychometric Information
Method of development—Items were selected based on: 1) the Western Ontario and
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McMaster Universities Osteoarthritis Index (WOMAC), version 3.0; 2) a literature review;

3) an expert panel (patients referred to physical therapy for knee injuries, orthopedic
surgeons, and physical therapists from Sweden and the US); and 4) a pilot study of 2
questionnaires (1 for symptoms of ACL injury, 1 for symptoms of OA) in individuals with
posttraumatic OA. Item-response theory was not used in the development of KOOS or for
item selection (25).

Acceptability—Reported rates of missing data are low: 0.8% of items in patients who
have undergone knee arthroscopy (27) and 3.2% of items on the pain, symptoms, ADL, and
QOL subscales in patients prior to TKR (28). However, patients scheduled for TKR have
also exhibited high rates of “not applicable” or missing items (74%) on the sport/recreation
subscale (28). Studies consistently report no or acceptable floor or ceiling effects in knee
injury cohorts (27,32,36) and in patients with mild or moderate knee OA (28,29,31,33). In
those with severe OA awaiting TKR (28–31,33), there are consistent reports of floor effects
for the sport/recreation subscale (16–73.3% scored lowest score), and ceiling effects have
been reported for the pain (15–22%), sport/recreation (16%), and QOL (17%) sub-scales up
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to 12 months following TKR (28).

Reliability—For patients with knee injuries, the pain, ADL, and sport/recreation subscales
have adequate internal consistency in all reports, while the symptom and QOL subscales
have had reports of lower as well as adequate internal consistency (Table 1). In patients with
knee OA, the ADL, sport/recreation, and QOL subscales have adequate internal consistency,
while the pain and symptoms subscales have reports of lower as well as adequate internal
consistency. Test–retest reliability is adequate for group evaluation in all reports on the pain,
symptoms, and QOL subscales for patients with knee injuries, while there are reports of
lower and adequate reliability, respectively, for the ADL and sport/recreation subscales. In
knee OA, pain and ADL subscales have adequate test–retest data, while for the other
subscales, reports indicate both lower and adequate test–retest reliability. Across the 5
subscales, the minimal detectable change ranges from 6–12 for knee injuries and from 13.4–
21.1 for knee OA. The standard error of the measure is reported to be lower for knee injuries
than for OA.
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Validity
Face and content validity: As well as exhibiting face validity, the direct involvement of
patients with knee conditions in the development of the KOOS facilitates content validity
(25,28).

Construct validity: Multiple studies report that the KOOS demonstrates convergent and
divergent construct validity, with the KOOS more strongly correlated with subscales of the
Short Form 36 (SF-36) that measure similar constructs (e.g., ADL with physical function,
sport/recreation with physical function, pain with bodily pain), and less strongly with SF-36
subscales that measure mental health (25,27–30,32,33,36,37). Rasch analysis conducted
using patient data 20 weeks post–ACL reconstruction showed that only the sport/recreation

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and QOL subscales exhibited unidimensionality, not the 3 subscales that were based on the
WOMAC (38). A more recent study reported that the KOOS subscales had acceptable
dimensionality (37).
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Ability to detect change—The KOOS appears to be responsive to change in patients

with a variety of conditions that have been treated with nonsurgical and surgical
interventions (Table 2). In patients who have undergone partial meniscectomy 3 months
previously, large effect sizes are seen on all but the ADL subscale. Large effect sizes are
seen in all subscales 6 months after ACL reconstruction. Three years following autologous
chondrocyte implantation or microfracture, large effect sizes are seen for the pain, sport/
recreation, and QOL subscales, and moderate effects on the symptoms and ADL subscales.
In those with knee OA who have undergone physical therapy treatment, large effect sizes are
seen at 4 weeks on the pain, symptoms, and ADL subscales, while the sport/recreation and
QOL subscales show moderate effects. Large effect sizes are consistently reported on all
subscales 3–12 months after TKR. The minimum clinically important difference (MCID)
and patient-acceptable symptom state (PASS) have not been calculated in any patient
population.
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Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The KOOS has undergone a substantial amount of psychometric testing,
largely among populations for whom the scale was intended. Establishment of the KOOS as
a reliable and valid measure across multiple languages highlights its usefulness as a patient-
reported measure of knee function for people with knee OA and various combinations of
ACL, meniscal, and cartilage injury. The use of individual scores for each subscale, rather
than an aggregate score, enhances clinical interpretation and in research acknowledges the
impact of different interventions on different dimensions (e.g., exercise therapy is likely to
have more impact on ADL and sport/recreation, while pharmacology may impact more on
pain and symptoms) and ensures content validity in groups of different ages and functional
activity levels (e.g., the sport/recreation subscale is more important in patients with a high
physical activity level, while the ADL subscale is more important in subjects with a lower
physical activity level).

Caveats and cautions—The KOOS has not been validated for interview administration,
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meaning that it may not be appropriate for patients who are unable to read or write, or where
telephone followup is necessary. Rasch analysis suggests that only the subscales that are not
based on the WOMAC exhibit unidimensionality in patients who have undergone ACL
reconstruction. When administering the KOOS in older or less physically active individuals,
higher level components of the ADL and sport/recreation subscales may not be applicable,
and could result in missing data. It may be appropriate to leave out the sport/recreation
subscale in those with more advanced disease or disability; however, doing so omits the
ability to measure improvements seen in these more demanding functions following
treatment (28). The MCID and PASS are lacking from psychometric evaluation.

Clinical usability—The KOOS is freely available online. Administration and scoring

burden are minimal when online score sheets are utilized. Clinicians should bear in mind

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that the sport/recreation subscale may not be applicable for less physically active patients,
and may not have adequate test–retest reliability in individuals with knee injuries.
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Research usability—The KOOS fulfills desired criteria for research outcomes,

demonstrating adequate reliability for use in groups and validity when used in those with
knee injuries and knee OA. The inclusion of the 3 WOMAC subscales facilitates
comparison of findings with studies that have utilized the WOMAC as a primary measure.
The lack of reported MCID in any knee condition is a weakness.

KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE PHYSICAL

FUNCTION SHORT FORM (KOOS-PS)
Description
Purpose—Patients’ opinions about the difficulties they experience with physical activity
due to their knee problems.

Intended populations/conditions: Knee osteoarthritis (OA).

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Version: No modifications since the original publication (39).

Content—Measure of physical function derived from the activities of daily living and
sport/recreation subscales of the KOOS (39). Patients rate the degree of difficulty they have
experienced over the previous week due to their knee pain, with respect to: 1) rising from
bed, 2) putting on socks/stockings, 3) rising from sitting, 4) bending to the floor, 5) twisting/
pivoting on injured knee, 6) kneeling, and 7) squatting.

Number of items—7 items.

Response options/scale—All items are scored on a 5-point Likert scale (none, mild,
moderate, severe, extreme) scored from 0–4.

Recall period for items—Previous week.

Endorsements—Osteoarthritis Research Society International and Outcome Measures in

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Rheumatology Clinical Trials.

Examples of use—Conditions: knee OA. Interventions: total knee replacement (TKR),

intraarticular hyaluronic acid injection, and physical therapy.

Practical Application
How to obtain—The KOOS-PS and associated documentation are freely available at
www.koos.nu.

Method of administration—Patient-completed questionnaire. Has not been validated for

use during in-person or telephone interview.

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Scoring—Each question is scored from 0–4. The raw score is the sum of the 7 items. The
interval score from 0–100 is obtained using a conversion chart (39).
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Missing values: No instructions on how to handle missing values.

Score interpretation—Possible raw score range: 0–28. Scores are then transformed to a
score from 0–100, where 0 = no difficulty.

Normative values: Not available.

Respondent burden—Based on findings for the KOOS, no more than 2 minutes to

complete. Uses simple language and the same 1-word responses for each of the 7 items. As
the items relate to everyday tasks, it is not considered that they would have an emotional
impact on the individual.

Administrative burden—Less than 5 minutes to score, using the conversion table

provided (39). Training is not necessary, as the questionnaire and scoring instructions are
self-explanatory.
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Translations/adaptations—Available in English, Swedish, French, and Portuguese. Can

easily be compiled by extracting the 7 items needed from the full KOOS forms in all
languages in which the KOOS is available. Cross-cultural adaptations have been conducted
for the French (40) and Portuguese (41) translations.

Psychometric Information
Method of development—Rasch analysis was conducted on KOOS and Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC) data from individuals with knee
OA from Sweden, Canada, France, Estonia, and The Netherlands. Patient data from 13 data
sets were used (age 26–95 years, male:female ratio 1:1.4). This included community and
clinical samples, such as those who had undergone previous meniscectomy, tibial
osteotomy, or anterior cruciate ligament repair, as well as those scheduled to undergo TKR
(39).

Acceptability—Rates of missing data have not been reported. Findings of 1 study indicate
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no floor or ceiling effects when used in patients with knee OA (i.e., no patients had lowest
or highest score, respectively) (40).

Reliability—The KOOS-PS has adequate internal consistency and test–retest reliability for
groups of patients with knee OA; however, its reliability is lower than adequate for use in
individuals with knee OA (Table 1). The minimal detectable change and standard error of
the measure have not been reported.

Validity
Face and content validity: As items are taken directly from the KOOS, which has face and
content validity, this can also be assumed for the KOOS-PS.

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Construct validity: The KOOS-PS shows evidence of convergent and divergent construct
validity. Higher correlations have been shown with the Short Form 36 (SF-36) physical
function, role physical, and bodily pain sub-scales; WOMAC function subscale (excluding
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KOOS-PS items); and Osteoarthritis Knee and Hip Quality of Life questionnaire
(OAKHQOL) physical activity domain (40–42). Conversely, lower correlations have been
reported with KOOS pain, symptoms, and quality of life subscales; SF-36 mental health
subscales; mental health questionnaires (e.g., Profile of Mood States, Hospital Anxiety and
Depression Scale); and OAKHQOL social support (40–42).

Ability to detect change—In patients with knee OA, the KOOS-PS shows moderate to
large effect sizes following 4 weeks of physical therapy, and moderate effects 4 weeks after
intraarticular hyaluronic acid injection (Table 2). The KOOS-PS is also able to discriminate
groups of patients based on use of walking aids (41). The minimum clinically important
difference (MCID) and patient-acceptable symptom state have not been reported.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The KOOS-PS is one of the few knee-related patient-reported outcomes that
utilized Rasch analysis in its development. Its inclusion of only 7 items facilitates use with
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short measures of other dimensions, such as pain visual analog scales, and makes it ideal for
those for which long questionnaires may be onerous (e.g., older populations).

Caveats and cautions—The KOOS-PS was intended for use in those with knee OA, and
has only undergone psychometric testing for this patient group. The MCID has not been
reported.

Clinical usability—The minimal administration and scoring burden associated with the
KOOS-PS make it ideal for clinical use, particularly considering that the included items are
frequently asked in the standard clinical examination. However, clinicians should bear in
mind that the reliability has been shown to be less than adequate for individuals.

Research usability—Psychometric testing shows the KOOS-PS to be valid and reliable

for use in groups with knee OA, making it an ideal tool for measuring knee-related function
in research.
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KNEE OUTCOME SURVEY ACTIVITIES OF DAILY LIVING SCALE (KOS-

ADL)
Description
Purpose—To determine symptoms and functional limitation in usual daily activities
caused by various knee pathologies (43).

Intended populations/conditions: Patients undergoing physical therapy for various knee

pathologies, such as ligament/meniscal injury, osteoarthritis (OA), and patello-femoral pain
(43–45). It is applicable for patients undergoing a variety of orthopedic knee procedures and
young athletic subjects as well as older adults (46,47).

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Version: Although originally described as a single index with 17 items (43), shorter
versions have been widely used. A version using Likert-type scales is also available (48).
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Content—Single index with 2 sections pertaining to symptoms (pain, crepitus, stiffness,

swelling, instability/slipping, buckling, and weakness) and functional limitations (difficulty
walking on level surfaces, use of walking aids, limping, going up and down stairs, standing,
kneeling, squatting, sitting, and rising from a sitting position) (43,48). A separate scale has
been developed to assess sporting activities (43).

Number of items—The original version comprised 17 items (7 for symptoms, 10 for

function), but a 14-item version (6 for symptoms, 8 for function) is also used (43,48).

Response options/scale—Patients rate items using descriptive responses, which are

translated to a numerical ordinal scale for scoring. Responses for each item are scored from
0–5, with the exception of item 9 (0–3) and item 10 (0–2) in the 17-item questionnaire.

Recall period for items—1–2 days.

Endorsements—None.
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Examples of use—Conditions: anterior cruciate ligament (ACL) injury, cartilage lesions,

patellofemoral pain syndrome (PFPS), knee dislocation, and OA. Interventions: physical
therapy, knee braces, ACL reconstruction, autologous chondrocyte implantation, patellar
realignment surgery, and total knee replacement (TKR).

Practical Application
How to obtain—Presented in full as an appendix in the original publication (43).

Method of administration—Patient-completed questionnaire. It has not been validated

for interview administration (in person or via telephone).

Scoring—The total score is calculated as the sum of scores from the responses to each
item, and then transformed to a percentage score by dividing by the maximum total possible
score and multiplying by 100 (43,48).
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Missing values: While there are no instructions provided as to handling missing data, the
original publication only analyzed questionnaires with no missing data (43).

Score interpretation—Possible transformed score range 0–100, where 100 = no knee-

related symptoms or functional limitations.

Normative values: Not available.

Respondent burden—It takes approximately 5 minutes to complete the KOS-ADL

questionnaire (43). No training or assistance is required as the KOS-ADL is self-
explanatory.

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Administrative burden—The total score can be calculated in <5 minutes. No training is

required for interpretation.
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Translations/adaptations—The KOS-ADL instrument has been validated after

translation to German (49), Portuguese (50), Turkish (51), and Greek (52).

Psychometric Information
Method of development—Initial item selection was conducted by review of existing
patient-reported outcomes (e.g., Cincinnati Knee Scale, Lysholm Knee Scoring Scale, and
Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and
International Knee Documentation Committee guidelines. The list of items was modified by
12 physical therapists specialized in rehabilitation of musculoskeletal diseases of the knee
(43).

Acceptability—No floor effects have been detected (46,47). Acceptable ceiling effects
have been reported in people with a variety of knee pathologies undergoing physical therapy
and orthopedic surgeon evaluation (43,47). However, high ceiling effects have been reported
6 months after TKR (46).
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Reliability—In patients with mixed knee pathologies, the KOS-ADL has demonstrated
adequate internal consistency across multiple languages, as well as adequate test–retest
reliability for use in groups and individuals (Table 1).

Validity
Face and content validity: During development, the KOS-ADL was examined by
orthopedic surgeons and physical therapists, who thought that it adequately covered the
range of functions/painful activities performed in daily life, ensuring face validity (43).
However, since item selection did not involve patient input, this instrument may lack content
validity if the instruments from which items were drawn were not themselves derived from
patient input (43).

Construct validity: The KOS-ADL shows good correlation with other knee-specific scales,
such as the Lysholm Knee Scoring Scale (43), WOMAC subscales (46), and global
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assessment of function (43). Higher correlations with the physical than mental component
score of the Short Form 12 indicates convergent and divergent construct validity (46).

Ability to detect change—The KOS-ADL demonstrates an ability to detect change in

patients with a variety of knee disorders (Table 2). Among patients undergoing physical
therapy for various knee pathologies, small effect sizes were reported at 1 week, and large
effect sizes were reported at 4 and 8 weeks (43). Moderate effect sizes were reported among
patients with PFPS, with a minimum clinically important difference of 7.1 (45). Large effect
sizes have been reported following TKR (46). The patient-acceptable symptom state has not
been reported.

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Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The KOS-ADL scale is a reliable and valid instrument that is responsive to
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change in patients with a variety of knee conditions who are undergoing physical therapy or
orthopedic procedures.

Caveats and cautions—The lack of direct patient input into item selection means that
content validity cannot be assumed. The KOS-ADL uses more descriptive responses to each
item as compared to other patient-reported outcomes, which may be confusing or
overwhelming for some patients, particularly those with reading difficulties. By design, the
KOS-ADL does not include items pertaining to athletic activities, such as running and
jumping.

Clinical usability—The KOS-ADL is sufficiently reliable to allow use in individuals with

a variety of knee disorders.

Research usability—The KOS-ADL is reliable, valid, and appropriate for measuring

change following nonsurgical and surgical interventions in a variety of knee conditions.
However, researchers should be aware that if subjects being evaluated are highly physically
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active, this instrument is not necessarily valid. Researchers should also be consistent with
which version of the scale they are utilizing.

LYSHOLM KNEE SCORING SCALE

Description
Purpose—To evaluate outcomes of knee ligament surgery, particularly symptoms of
instability (53).

Intended populations/conditions: Patients with knee ligament injury and anteromedial,

anterolateral, combined anteromedial/anterolateral, posterolateral rotatory, or straight
posterior instability (53).

Version: First published in 1982 (53). The revised version (1985) added an item regarding
knee locking, removed items regarding pain on giving way, swelling with giving way, and
the objective measure of thigh atrophy, and also removed the reference to walking, running,
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and jumping above the sections regarding instability, pain, and swelling (54).

Content—The original scale included 8 items: 1) limp; 2) support; 3) stair climbing; 4)

squatting; 5) walking, running, and jumping; and 6) thigh atrophy (53). The revised scale
also includes 8 items: 1) limp, 2) support, 3) locking, 4) instability, 5) pain, 6) swelling, 7)
stair climbing, and 8) squatting (54).

Number of items—8 items.

Response options/scale—Individual items are scored differently, using individual

scoring scales. The revised scale modified the original scoring slightly: 1) limp (0, 3, 5), 2)
support (0, 2, 5), 3) locking (0, 2, 6, 10, 15), 4) instability (0, 5, 10, 15, 20, 25), 5) pain (0, 5,

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10, 15, 20, 25), 6) swelling (0, 2, 6, 10), 7) stair climbing (0, 2, 6, 10), and 8) squatting (0, 2,
4, 5) (54).
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Recall period for items—Not specified.

Endorsements—None.

Examples of use—Conditions: knee ligament injury (anterior cruciate ligament [ACL],

posterior cruciate ligament [PCL], medial collateral ligament [MCL], lateral collateral
ligament [LCL]), meniscal tears, knee cartilage lesions, osteochondritis dissecans, traumatic
knee dislocation, patellar instability, patellofemoral pain, and knee osteoarthritis.
Interventions: knee arthroscopy, ligament reconstruction (ACL, PCL, MCL, LCL), meniscal
repair, meniscectomy, microfracture, osteochondral autografts, high tibial osteotomy,
patellar realignment and stabilization surgery, lateral release, intraarticular hyaluronic acid
injection, and therapeutic exercise.

Practical Application
How to obtain—The revised version is freely available in the publication (54). Multiple
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web sites publish versions of the scale, although they tend to differ slightly.

Method of administration—Original and revised scales were intended for in-person

clinician administration (administered by the orthopedic surgeon with the patient’s
collaboration) (53,54), although subsequent studies have documented using the scale as a
patient-completed questionnaire (55). While significantly lower scores have been found for
questionnaires versus interview administration, suggesting interview bias (56), 1 study
reported a high level of agreement between patients and physiotherapists using a modified
version of the Lysholm scale (item for swelling removed) in patients with knee chondral
damage (57).

Scoring—Each possible response to each of the 8 items has been assigned an arbitrary
score on an increasing scale. The total score is the sum of each response to the 8 items, of a
possible score of 100. Computer scoring is not necessary.

Missing values: No instructions provided.

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Score interpretation—Possible score range: 0–100, where 100 = no symptoms or

disability. Scores are categorized as excellent (95–100), good (84–94), fair (65–83), and
poor (≤64) (54).

Normative values: Normative data are available with and without stratification by sex
(58,59).

Respondent burden—Time to complete has not been reported, but is expected to vary
depending on the administration method (i.e., patient completed versus clinician
administered). The Lysholm scale generally uses simple language in its questioning.
However, it does use some specific medical terms such as locking, catching, and weight

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bearing. Administration of this scale as it was intended (i.e., clinician administered) would
ensure adequate explanation of such terms, although this may vary between clinicians. As
the items relate to everyday tasks, it is not considered that they would have an emotional
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impact on the individual.

Administrative burden—Less than 5 minutes to score. Training is not necessary, as the

scale provides the corresponding score next to each possible response for each item.

Translations/adaptations—Published in English. Although it has been used in

international studies, no cross-cultural adaptations have been published.

Psychometric Information
Method of development—Items pertaining to limp, support, stairs, squatting, and thigh
atrophy were selected, and items for pain and swelling were adapted from the modified
Larson scoring scale (60). The authors added the item for instability, as they deemed this to
be an important component of the disability associated with ACL injury (53). The revised
scale does not report how the item for locking was selected (54). Four groups of patients
were used to compare the original scale to the modified Larson scoring scale: 1) knee
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ligament injury and anteromedial, anterolateral, and combined anteromedial/anterolateral

instability; 2) knee ligament injury and posterolateral rotatory or straight posterior
instability; 3) meniscus tears; and 4) chondromalacia patellae (53). Item-response theory
was not used in the development of the Lysholm scale.

Acceptability—Rates of missing data have not been reported. There are consistent reports
of no floor or ceiling effects (i.e., <15% of patients score the lowest or highest score,
respectively) (47,55,61–64).

Reliability—The Lysholm scale appears to have inadequate internal consistency in patients

with a variety of knee conditions (Table 1). Test–retest reliability is adequate for use in
groups with knee injuries, but is less than adequate for groups with mixed knee pathologies.
Reliability may be inadequate for use in individuals. The minimal detectable change has
been reported as between 8.9 and 10.1 for knee injuries, while the standard error of the
measure is reported to range from 3.2 to 3.6 for knee injuries and from 9.7 to 12.5 for mixed
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knee pathologies.

Validity
Face and content validity: The Lysholm scale has been reported as having face validity, as
evaluated by 5 orthopedic surgeons with sports medicine experience (47). Because the items
in the Lysholm scale are surgeon derived, content validity from the patient’s perspective
cannot be assumed.

Construct validity: Multiple studies have reported convergent construct validity for the
Lysholm score, finding significant correlations with the Hospital for Special Surgery
modified knee ligament rating system, Cincinnati Knee Ligament Score, International Knee
Documentation Committee Subjective Knee Evaluation Form, Fulkerson and Kujala scores,

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and Western Ontario and McMaster Universities Osteoarthritis Index (63–65). Two studies
have reported evidence of convergent and divergent construct validity, finding the Lysholm
score to correlate more highly with the Short Form 12 and Short Form 36 physical
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components than mental components (47,55). The Lysholm score was shown to satisfy the
Rasch model after removal of the item for swelling in patients awaiting surgery for knee
chondral damage (57).

Ability to detect change—Large effect sizes have been reported following ACL
reconstruction (6–9 months postoperative), meniscal repair (1 year postoperative), and
microfracture (1–6 years postoperative) (Table 2). Large effect sizes are also reported
following 1 month of physical therapy in a group of patients with mixed knee pathologies.
The minimum clinically important difference (MCID) and patient-acceptable symptom state
(PASS) have not been calculated in any patient population.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The Lysholm scale is a freely available measure that is able to detect change
following nonsurgical and surgical intervention. It is considered to have face validity by
orthopedic surgeons.
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Caveats and cautions—Content validity cannot be assumed, as the items included in the
Lysholm scale were surgeon derived. The Lysholm scale was developed as a clinician-
administered tool, which increases the potential for interviewer bias if the patient-reported
outcome is applied as intended. Despite this, there are inconsistencies between methods of
administration of the Lysholm scale in published studies. The MCID and PASS are lacking
in psychometric analysis.

Clinical usability—Minimal administrative and respondent burden makes the Lysholm

scale attractive for clinical use. The lack of floor and ceiling effects across different knee
conditions suggests that the Lysholm scale is useful for tracking improvement with
intervention as well as deterioration over time in patients with various knee pathologies.
However, clinicians should consider the impact of inadequate reliability in evaluation of
individuals.

Research usability—The Lysholm scale is reliable for use in research on ligament and
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meniscal injuries, chondral injuries, and patellar dislocation. It is important that researchers
consistently utilize the same scale version (54). Researchers should be aware that the
psychometric properties may change between different administration methods, ensure
consistent administration within and between studies, and be aware that clinician and patient
ratings may differ substantially. Lack of known MCID is a weakness.

OXFORD KNEE SCORE (OKS)

Description
Purpose—Brief questionnaire for patients undergoing total knee replacement (TKR) that
reflected the patient’s assessment of their knee-related health status and benefits of treatment
(66).

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Intended populations/conditions: Patients undergoing TKR.

Version: A new version was proposed on the basis that some surgeons believed that the
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scoring of the original version was nonintuitive (i.e., lower scores represented better
outcome, higher scores represented worse outcome), where the original 12 items are used
but the scoring is different (67).

Content—Single index pertaining to knee pain and function (pain severity, mobility,
limping, stairs, standing after sitting, kneeling, giving way, sleep, personal hygiene,
housework, shopping, and transport).

Number of items—12 items.

Response options/scale—Each item is followed by 5 responses (scores ranging from 1–

5), where 1 = best and 5 = worst outcomes. The modified version also has 5 responses to
each item, but the scoring is from 0–4, where 0 = worst and 4 = best outcome.

Recall period for items—Previous 4 weeks.

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Endorsements—None.

Examples of use—Conditions: cartilage defects, tibio-femoral osteoarthritis (OA),

patellofemoral OA, and rheumatoid arthritis. Interventions: autologous chondrocyte
implantation, high tibial osteotomy, unicompartmental knee replacement, and TKR.

Practical Application
How to obtain—The original version can be found in its original publication (66). The
modified version is freely available online (www.orthopaedicscore.com/scorepages/
oxford_knee_score.html) (67).

Method of administration—Patient-completed questionnaire.

Scoring—Originally, each response to each item was assigned a score from 1–5 (where 1 =
no problem and 5 = significant disability). The modified version assigns a score from 0–4
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(where 4 = no problem and 0 = significant disability). The total score is calculated as the
sum of scores from responses to all 12 items.

Missing values: No instructions provided.

Score interpretation—In the original version, the total score ranges from 12–60 (66),
while in the modified version the total score ranges from 0–48 (67). Higher scores in the
original version reflect poor outcome and lower scores reflect better outcomes. In the
modified version, this is reversed.

Normative values: Not available.

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Respondent burden—Reported to involve minimal respondent burden (66). It takes

approximately 5–10 minutes to complete the questionnaire. No training or assistance is
required since the questions are self-explanatory.
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Administrative burden—Scoring is simple and quick (66). Calculation of the total score
takes 1–5 minutes. No training is necessary.

Translations/adaptations—Translated and validated in many languages, including

Chinese (68), German (69), Japanese (70), Swedish (71), and Thai (72).

Psychometric Information
Method of development—Item generation and reduction was conducted by interviewing
patients considering TKR (66).

Acceptability—When tested in patients undergoing TKR, no missing data were reported

preoperatively, while postoperative rates of missing data remained low (5%) (66). A more
recent study reported no missing data before and 6 months after TKR (46). This study also
reported no floor or ceiling effects prior to TKR. Six months postoperatively, although there
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were no floor effects, there were ceiling effects reported (27% of patients scored the top
score).

Reliability—The OKS has adequate internal consistency across multiple languages (66,68–
72) (Table 1). The original study reported adequate test–retest reliability for use in groups
and individuals (66).

Validity
Face and content validity: Extensive input from patients in the development of the OKS
ensures content validity.

Construct validity: The OKS shows good correlation with knee-specific and general health
questionnaires, such as the Western Ontario and McMaster Universities Osteoarthritis Index,
American Knee Society Score, Knee Outcome Survey Activities of Daily Living Scale, and
pain and physical function components of the Short Form 36 and Health Assessment
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Questionnaire (66). Convergent and divergent construct validity is demonstrated by higher

correlations with the Short Form 12 physical than mental component (46). The OKS has
been shown to fit Rasch models following rescoring of some items (73), and removal of
items for limp and kneeling (74).

Ability to detect change—The OKS demonstrates good sensitivity and responsiveness to

change (Table 2). Large effect sizes have been reported 6–12 months after TKR (66,75). The
OKS has also been found to be a good predictor of revision TKR within 6 months (76). The
minimum clinically important difference (MCID) and patient-acceptable symptom state
have not been reported.

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Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The OKS is a self-administered questionnaire developed to measure outcome
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following TKR. Due to simplicity and ease of administering, it has been used widely,
especially in the UK, and is available in languages other than English. For the same reasons,
it can be used as a cost-effective screening tool in short-term (<2 years) followup of TKR
compared to physician administered instruments, such as the American Knee Society Score,
as reported by 1 study (77).

Caveats and cautions—Although simple, some items are “double barreled” and may be
confusing to patients (e.g., trouble getting in and out of a car or using public transportation).
Some response options potentially overlap with others, which may also cause confusion.
The use of an aggregate score combining pain and function may mask changes in 1 domain,
particularly given that only 1 of the 12 items relates solely to pain.

Clinical usability—Psychometric testing suggests that the OKS is sufficiently reliable for
use in individuals with knee OA. The ease of administration and scoring makes it a useful
tool for clinical use. However, clinicians should be aware that some patients may require
explanation of individual items, which could introduce interviewer bias.
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Research usability—The OKS is a knee OA–specific measure that is reliable, valid, and
responsive to change following TKR. Researchers should be aware of the different scoring
methods when interpreting findings of previous research. The lack of MCID is a weakness.

WESTERN ONTARIO AND MCMASTER UNIVERSITIES OSTEOARTHRITIS

INDEX (WOMAC)
Description
Purpose—To assess the course of disease or response to treatment in patients with knee or
hip osteoarthritis (OA) (78,79).

Intended populations/conditions: Patients with knee and hip OA (78,79).

Version: Initially developed in 1982, the WOMAC has undergone multiple revisions (most
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recent version 3.1). It is available in 5-point Likert, 100-mm visual analog scale (VAS), and
11-box numerical rating scales (80,81). Reduced versions of the WOMAC have been
validated but are not endorsed on the WOMAC web site (82–84).

Content—Three subscales: 1) pain severity during various positions or movements, 2)

severity of joint stiffness, and 3) difficulty performing daily functional activities.

Number of items—24 items.

Response options/scale—In the Likert version, each item offers 5 responses: “none”
scored as 0, “mild” as 1, “moderate” as 2, “severe” as 3, and “extreme” as 4. Alternatively,
the VAS and numerical rating scale versions permit responses to be selected on a 100-mm or

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11-box horizontal scale, respectively, with the left end marked as “none” and the right end
marked as “extreme” (78,79).
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Recall period for items—48 hours.

Endorsements—Osteoarthritis Research Society International.

Examples of use—Conditions: knee OA, chondral defects, and anterior cruciate ligament
(ACL) deficiency. Interventions: physical therapy, massage, self-management, group
education, weight loss, exercise, hydrotherapy, Tai Chi, yoga, diet, knee braces, foot
orthoses, electrotherapy (e.g., transcutaneous electrical nerve stimulation, laser, pulsed
electrical stimulation), acupuncture, pharmacotherapy (drugs, supplements), corticosteroid
injection, intraarticular hyaluronic acid injection, arthroscopy, autologous chondrocyte
implantation, ACL reconstruction, and total knee replacement (TKR).

Practical Application
How to obtain—Available from Professor Nicholas Bellamy (Australia, e-mail:
[email protected]). To obtain licensing and fee information and permission to use the
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WOMAC for clinical or research purposes a request needs to be submitted to http://

www.womac.org.

Method of administration—Self-administered or interview-administered questionnaire.

It has been validated for use in person, over the telephone, or electronically via a computer
or mobile phone (79,85–88).

Scoring—The total score for each subscale is the sum of scores for each response to each
item, and can be calculated manually or using a computer. The range for possible subscale
scores in the Likert format are: pain (0–20; 5 items each scored 0–4), stiffness (2 items, 0–
8), and physical function (17 items, 0–68). In the VAS format, the ranges for the 3 subscale
scores are: pain, 0–500; stiffness, 0–200; and physical function, 0–1,700 (78,79).

Missing values: If 2 or more pain items, both stiffness items, and 4 or more physical
function items are missing, the response should be regarded as invalid and the deficient
subscale(s) should not be used in analysis (78).
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Score interpretation—Higher scores indicate worse pain, stiffness, or physical function.

Normative values: Australian population-based normative data have been reported,

stratified by age and sex (89).

Respondent burden—5–10 minutes to complete.

Administrative burden—Approximately 5 minutes to score. Training is not necessary.

Translations/adaptations—WOMAC version 3.1 is available in >80 languages (80),

and has validated language translations for Arabic (90), Chinese (91), Finnish (92), German

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(93), Hebrew (94), Italian (95), Japanese (96), Korean (97), Moroccan (98), Singapore (99),
Spanish (100), Swedish (101,102), Thai (103), and Turkish (104,105).
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Psychometric Information
Method of development—Items were generated by survey of patients with knee or hip
OA, review of existing questionnaires (e.g., Health Assessment Questionnaire, Arthritis
Impact Measurement Scales), and input from rheumatologists and epidemiologists with
experience in clinical assessment of rheumatic diseases. Patients were also utilized in item
reduction (78).

Acceptability—The original study and subsequent studies have reported low rates of
missing data (46,78). Reports of floor and ceiling effects have differed between studies
(46,91,103,105,106). The stiffness subscale has been reported as having floor and ceiling
effects prior to intervention (46,91,105). Ceiling effects have been reported by various
studies for all subscales 6 months and 2 years after TKR (46,106).

Reliability—The stiffness and function subscales have consistently demonstrated adequate

internal consistency in knee OA (Table 1). Studies have generally reported adequate internal
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consistency for the pain subscale, although there have been reports slightly lower than
adequate. There have been mixed findings regarding adequacy of test–retest reliability in
knee OA for all subscales. Test–retest reliability for the stiffness subscale may not be
adequate for use in individuals with knee OA. One study that investigated test–retest
reliability in patients with chondral defects found that all subscales had adequate reliability
for use in groups, but only the function subscale was adequate for individual use. The
minimal detectable change and standard error of the measure vary according to condition
and subscale.

Validity
Face and content validity: Since the WOMAC was developed with extensive input from
patients with OA, as well as input from academic rheumatologists and epidemiologists
experienced in clinical assessment of rheumatologic diseases, the WOMAC can be
considered to have face and content validity.
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Construct validity: Multiple studies have shown that the WOMAC subscales demonstrate
good construct validity. Moderate to strong correlations with measures of similar constructs
(e.g., Short Form 36 [SF-36] physical subscales, pain/handicap VAS) suggest convergent
construct validity (91,94,95,98,104,105,107,108), while lower correlations with measures
such as the SF-36 mental subscales indicate divergent construct validity
(91,95,104,105,109). Although Rasch analyses have largely utilized mixed knee and hip OA
cohorts, it has been reported that there is no differential item functioning based on affected
joint (110). While 1 study found the pain subscale to demonstrate good item separation and
unidimensionality in patients with knee or hip OA (111), a subsequent study found that a
reduced pain subscale (night pain and pain on standing removed) fit the Rasch model and
provided more stable results over time and between patients with knee or hip OA and those
who have undergone joint replacement (110). The function subscale demonstrates more

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 COLLINS et al. Page 24

variability. Although found to have good item separation and unidimensionality in knee/hip
OA, function items for performing light chores, getting in/out of a car, and rising from bed
were found to be redundant (111). Similarly, Davis et al (110) suggested a 14-item function
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subscale, with items for heavy domestic duties, getting in/out of the bath, and getting on/off
the toilet removed.

Ability to detect change—The WOMAC appears to be responsive to change following

surgical and nonsurgical interventions for knee OA and chondral defects (Table 2). In
patients with knee OA, large effect sizes are consistently reported on all 3 subscales up to 2
years post-TKR. Following exercise intervention, the stiffness subscale shows small effect
sizes at 2 weeks compared to moderate to large effect sizes for the pain and function
subscales; however, these also are small at 6 months. Acupuncture has shown small to
moderate effect sizes in the short term (3 weeks), but large effect sizes after 8 weeks. Drug
intervention tends to show different patterns across 12 weeks for the 3 sub-scales. Effect
sizes for pain tend to be large initially (1 week), and become more variable at 6 weeks
(moderate to large) and 3 months (small to large). In comparison, the stiffness subscale
tends to show small to moderate effect sizes over the initial 4 weeks, becoming moderate to
large by 3 months. Similarly, effect sizes for function also gradually increase, starting at
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moderate at 2 weeks, and becoming moderate to large at 6 and 12 weeks. Following surgery
for chondral defects, large effect sizes are seen for pain and function 6 and 12 months
postoperatively, while moderate effect sizes are seen on the stiffness subscale. The
minimum clinically important difference has been calculated for TKR (up to 2 years
postoperatively; range for pain 22.9–36, range for symptoms 14.4–21.4, range for function
19–33) and nonsteroidal antiinflammatory use (4 weeks; function 9.1). The patient-
acceptable symptom state has been determined to be 31.0 (95% confidence interval 29.4–
32.9) for the function subscale in people with knee OA (112).

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The WOMAC is one of the most commonly used patient-reported outcomes
for knee OA. It is simple and quick to administer and score using guidelines provided. The
utilization of patients in development ensures content validity. In addition, the WOMAC has
undergone validated translations into multiple languages. The use of individual scores for
each subscale, rather than an aggregate score, enhances interpretation.
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Caveats and cautions—The need to obtain permission and pay licensing fees prior to
use may encourage researchers and clinicians to seek alternatives. The inclusion of tasks in
the function subscale that may not be performed regularly by all patients (e.g., stair
climbing, taking a bath) may result in missing data. Content validity is not ensured for more
physically active patients since the function scale does not include more difficult functional
tasks. Rasch analysis suggests that the function subscale contains redundant items.

Clinical usability—The variability in administration methods makes the WOMAC a good

choice for clinical use, particularly when dealing with patients with communication
difficulties. Minimal floor effects means that the pain and function subscales are able to
monitor deterioration in condition over time, while ceiling effects have only been reported

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 COLLINS et al. Page 25

following TKR. However, clinicians should consider that the stiffness subscale may not be
sufficiently reliable for use in individuals.
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Research usability—Psychometric testing indicates that the WOMAC is sufficiently

reliable and valid for use in research. The variety of validated language translations and
methods of administration is a major strength for WOMAC use in research. A body of
research supports the responsiveness to change of the WOMAC following surgical and
nonsurgical interventions. Extensive use of the WOMAC in previous research facilitates
comparison of new findings.

ACTIVITY RATING SCALE (ARS)

Descriptive
Purpose—Developed as a short, simple, knee-specific questionnaire to evaluate the
activity level of patients with various knee disorders who participate in different sports.
Intended to provide data on an athlete’s highest activity level within the past year (i.e., at a
time when they were most active) (113).
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Intended populations/conditions: Various knee conditions, including ligament, meniscus,

and chondral injury; patellofemoral pain; osteochondritis dissecans; trabecular fracture; and
iliotibial band syndrome (113).

Version: No modifications to the original version.

Content—Single index pertaining to frequency of athletic activities: 1) running, 2) cutting,

3) decelerating, and 4) pivoting.

Number of items—4 items.

Response options/scale—Each item is followed by 5 responses for the frequency of

each functional component within the past year.

Recall period for items—1 year.

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Endorsements—None.

Examples of use—Conditions: anterior cruciate ligament (ACL) injury, cartilage injury,

and knee osteoarthritis. Interventions: ACL reconstruction, autologous chondrocyte
implantation, microfracture, high tibial osteotomy, and total knee replacement.

Practical Application
How to obtain—The ARS can be found as an appendix in the original publication (113).

Method of administration—Patient-completed questionnaire. It has not been validated

for interview administration (telephone, in person).

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Scoring—Each item is scored from 0–4, where 0 = “less than 1 time a month,” 1 = “one
time in a month,” 2 = “one time in a week,” 3 = “two to three times in a week,” and 4 =
“four or more times in a week.” The total score is the sum of scores from responses to each
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of the 4 items (113).

Missing values: No specific instructions for handling missing values.

Score interpretation—The total possible score range is 0–16, where 16 = more frequent
participation.

Normative values: Not available.

Respondent burden—Approximately 1 minute to complete. Respondent burden was

intentionally minimized through the inclusion of only 4 items (113).

Administrative burden—Less than 5 minutes to score. No training is required.

Translations/adaptations—None.
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Psychometric Information
Method of development—Items were selected by literature review, expert opinion
(orthopedic surgeons who specialized in sports medicine, physical therapists, and athletic
trainers), and surveying patients with knee disorders. Item reduction involved 50 patients
with a variety of knee disorders who were physically active who rated the importance and
difficulty associated with each functional task on the preliminary list. The top 4, as agreed
by the panel of clinicians, were retained in the final version (113).

Acceptability—Information on missing data and floor/ceiling effects is not available.

Reliability—One study has evaluated the test–retest reliability of the ARS, finding
adequate reliability for use in groups and individuals (113) (Table 1). The internal
consistency has not been reported.

Validity
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Face and content validity: The use of patients with knee disorders in both item selection
and reduction ensures content validity. Final item selection also involved the opinion of
clinicians to ensure face validity (113).

Construct validity: The ARS has been reported to have moderate to strong correlation with
other knee-related scales that measure activity levels, such as the Tegner Activity Score,
Cincinnati Knee Ligament Score, and Daniel Score, suggesting good convergent construct
validity (113).

Ability to detect change—The responsiveness, minimum clinically important difference,

and patient-acceptable symptom state have not been reported (Table 2). Rasch analysis was
not performed.

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Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The ARS is a short simple measure that represents minimal administrator or
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respondent burden. As it assesses 4 common components of various sporting activities,

rather than nominating specific sports, it is generalizable across a wide range of elite and
recreational athletes. In addition, to the extent that activities such as running, stopping, and
changing direction are also needed for nonsport activities, it could be applicable to other
situations (e.g., work tasks).

Caveats and cautions—Since its focus is limited to specific activities, this scale is most
useful as an adjunct to other scales that assess other domains of knee function (114). Other
activities such as swimming and jumping cannot be evaluated by this scale. Furthermore,
since the ARS does not focus on current ability, but on baseline activity frequency perhaps
prior to injury, the validity of the instrument depends on the subject’s accurate recollection
of this frequency. The accuracy of such recollection may be influenced by the time since
injury and by the current state of activity. Lack of evidence for responsiveness to change/
sensitivity is also a limitation. The ARS should be used as an adjunct to other knee
instruments assessing symptoms and difficulty (113).
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Clinical usability—The ARS is a short activity-specific questionnaire, making it good for

clinical use. It would be suitable for patients who participate in land-based sports or
activities that do not involve jumping as a primary movement. Clinicians should consider
that the 1-year recall period may be difficult for some patients.

Research usability—The lack of psychometric data for the ARS limits its use in research.
As the scale measures the highest level of activity over the past year, without taking into
account time of injury, it may be more suited for within-subject study designs, rather than
comparing ratings between subjects.

TEGNER ACTIVITY SCORE (TAS)

Description
Purpose—To provide a standardized method of grading work and sporting activities (54).
Developed to complement the Lysholm scale, based on observations that limitations in
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function scores (Lysholm) may be masked by a decrease in activity level (54).

Intended populations/conditions: Intended for use in conjunction with the Lysholm Knee
Scoring Scale, originally in patients with anterior cruciate ligament (ACL) injury (54).

Version: Although in some circumstances it has been modified slightly to accommodate

different populations, the standard TAS remains in its original format.

Content—Graduated list of activities of daily living, recreation, and competitive sports.

The patient selects the level of participation that best describes their current level of activity.

Number of items—One item is selected from a list of 11.

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Response options/scale—A score of 10 is assigned based on the level of activity that

the patient selects. A score of 0 represents “sick leave or disability pension because of knee
problems,” whereas a score of 10 corresponds to participation in national and international
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elite competitive sports (54). Activity levels 6–10 can only be achieved if the person
participates in recreational or competitive sport.

Recall period for items—Current ability.

Endorsements—None.

Examples of use—Conditions: knee ligament injury (ACL, posterior cruciate ligament

[PCL], medial collateral ligament [MCL], lateral collateral ligament [LCL]), meniscal tears,
knee cartilage lesions, osteochondritis dissecans, traumatic knee dislocation, patellar
instability, patello-femoral pain, and knee osteoarthritis (OA). Interventions: knee
arthroscopy, ligament reconstruction (ACL, PCL, MCL, LCL), meniscal repair,
meniscectomy, microfracture, osteochondral autografts, high tibial osteotomy, patellar
realignment and stabilization surgery, lateral release, intraarticular hyaluronic acid injection,
and therapeutic exercise.
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Practical Application
How to obtain—Freely available in the original publication (54).

Method of administration—Originally established as an in-person, clinician-

administered tool (115), but has been used more recently as a patient-completed
questionnaire (55,116).

Scoring—A score of 10 is assigned based on the level of activity that the patient selects as
best representing their current activity level. Computer scoring is not necessary.

Missing values: Not applicable (single score).

Score interpretation—Possible score range: 0–10. Higher scores represent participation

in higher-level activities.
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Normative values: Normative data have been presented by sex and age group (58).

Respondent burden—Reported to take mean ± SD 3.3 ± 0.6 minutes to complete in

those who have undergone total knee replacement (117). The scale classifies work,
recreational, and sport activities in a graded activity scale, using common terminology. As
such, patients should not have difficulty selecting which level corresponds to their current
activity. Degree of difficulty (measured on a visual analog scale) has been reported to
increase with age (r = 0.25, P = 0.03) (117).

Administrative burden—Scoring time is negligible, as the score is based on a single

selected item. Training is not necessary.

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Translations/adaptations—Available in English. Although it has been used in

international studies, no cross-cultural adaptations have been published. Use in other
rheumatology populations has consisted of ankle and shoulder disorders.
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Psychometric Information
Method of development—Orthopedic surgeons selected items they believed to be
difficult for patients with ACL injury. Forty-three patients with ACL-deficient knees then
completed a questionnaire in which they graded these activities according to how difficult
they were. This formed the basis of item selection for the TAS.

Acceptability—Studies consistently report no floor or ceiling effects in those with knee

injury or OA (i.e., <15% scored lowest or highest score, respectively) (55,61,64,117).

Reliability—The TAS has adequate test–retest reliability for groups with knee injuries and
knee OA, although reliability is less than adequate for use in individuals (Table 1). For knee
injuries, the minimal detectable change is 1, while the standard error of the measure ranges
from 0.4–0.64.
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Validity
Face and content validity: At face value, the TAS covers a wide variety of activity levels
that may be applicable to patients with ACL and other knee injuries. However, as initial
activity selection was conducted by orthopedic surgeons, with patient input afterward
regarding the difficulty of these selected activities, content validity cannot necessarily be
assumed.

Construct validity: Evidence for convergent and divergent construct validity is provided by
studies that found higher correlations with the physical component of the Short Form 12
than the mental component (55,61,117). The TAS has also shown significant correlations
with the International Knee Documentation Committee Subjective Knee Evaluation Form,
Knee Society Score function score, Western Ontario and McMaster Universities
Osteoarthritis Index pain and function subscales, and Oxford Knee Score (55,61,64,117).

Ability to detect change—Following meniscal surgery, moderate effect sizes are seen 12
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months postoperatively in those with isolated meniscal lesions, and large effect sizes are
seen in those with combined lesions (Table 2). In those who have undergone ACL
reconstruction, effect sizes are reported to be moderate at 6 months and large at 9 months, 1
year, and 2 years. The minimum clinically important difference (MCID) and patient-
acceptable symptom state have not been determined.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths—The TAS is a simple freely available measure of activity level that spans
work, sporting, and recreational activities. It is one of the few patient-reported outcomes that
were developed to consider the influence of activity level on other symptoms, such as pain
alleviation when aggravating activities are avoided.

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Caveats and cautions—The TAS was originally intended and developed for patients
with ACL injury as an adjunct to the Lysholm scale, not as a stand-alone measure. The
MCID is missing from psychometric analysis. Studies suggest that TAS data need to be
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adjusted for age and sex (118).

Clinical usability—Clinicians should note that its reliability may be inadequate for use in
individuals.

Research usability—Although valid and reliable for use in groups, use of the TAS in
research may need to be applied with caution. Given its intent to measure change within
patients, the TAS may be more appropriate for within-subject repeated measures studies
rather than between-group comparisons.

Acknowledgments
Dr. Collins’s work was supported by a National Health and Medical Research Council (Australia) Health
Professional Research Training (Post-Doctoral) Fellowship. Dr. Roos’s work was supported by the Swedish
Medical Research Council.
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Table 1

Summary of reliability data*

Internal consistency (Cronbach’s

Patient cohort evaluated (ref.) α) Test–retest (ICC) MDC SEM
COLLINS et al.

Function measures
IKDC Knee injuries (ACL, meniscal, chondral) (15,20,23) 0.77–0.91 0.90–0.95† 8.8–15.6† 3.2–5.6†
Cohort of mixed knee pathologies (11,16–18,21) 0.92–0.97 0.87–0.99† 6.7 2.4–4.6†
KOOS Knee injuries (25,27,32,36) Pain: 0.84–0.91 Pain: 0.85–0.93 Pain: 6–6.1 Pain: 2.2
Symptoms: 0.25–0.75 Symptoms: 0.83–0.95 Symptoms: 5–8.5 Symptoms: 3.1
ADL: 0.94–0.96 ADL: 0.75–0.91 ADL: 7–8 ADL: 2.9
Sport/rec: 0.85–0.89 Sport/rec: 0.61–0.89 Sport/rec: 5.8–12 Sport/rec: 2.1
QOL: 0.64–0.9 QOL: 0.83–0.95 QOL: 7–7.2 QOL: 2.6
Knee OA (28–31,33) Pain: 0.65–0.94 Pain: 0.8–0.97 Pain: 13.4 Pain: 7.2–10.1
Symptoms: 0.56–0.83 Symptoms: 0.74–0.94 Symptoms: 15.5 Symptoms: 7.2–9
ADL: 0.78–0.97 ADL: 0.84–0.94 ADL: 15.4 ADL: 5.2–11.7
Sport/rec: 0.84–0.98 Sport/rec: 0.65–0.92 Sport/rec: 19.6 Sport/rec: 9–24.6
QOL: 0.71–0.85 QOL: 0.6–0.91 QOL: 21.1 QOL: 7.4–10.8
KOOS-PS Knee OA (40–42) 0.89 0.85–0.86 – –
KOS-ADL Mixed knee pathologies (43,47,49–52) 0.89–0.98 0.94–0.98 11.4 4.1
Lysholm Knee Knee injuries (ACL, meniscal, chondral; patellar dislocation) 0.65–0.73 0.88–0.97 8.9–10.1 3.2–3.6
Scoring Scale (54,55,61,63,64)
Mixed knee pathologies (43,47,119,120) 0.60–0.73 0.68–0.95 – 9.7–12.5†
OKS Knee OA (46,66,71,121) 0.87–0.93 0.91–0.94 6.1 2.2
WOMAC Chondral defects (23) Pain: 0.81–0.85 Pain: 14.4–16.2 Pain: 5.2–5.8
Symptoms: 0.75–0.86 Symptoms: 22.9–30.6 Symptoms: 8.3–11.1
Function: 0.86–0.93 Function: 10.6–15 Function: 3.8–5.4
Knee OA (42,46,91,92, 94–98,100,101,103–105,108,122,123) Pain: 0.67–0.92 Pain: 0.65–0.98 Pain: 18.8–22.4 Pain: 6.8–8.1
Symptoms: 0.7–0.94 Symptoms: 0.52–0.89 Symptoms: 27.1–29.1 Symptoms: 9.8–10.5
Function: 0.82–0.98 Function: 0.71–0.96 Function: 13.1–13.3 Function: 4.7–4.8
Activity measures

Arthritis Care Res (Hoboken). Author manuscript; available in PMC 2015 February 21.
ARS Baseline knee athletic activity for cohort of mixed knee – 0.97 – –
pathologies (113)
TAS Knee injuries (ACL, meniscal patellar dislocation) (55,61,64) n/a 0.82–0.92† 1.0 0.4–0.64

Knee OA (117) n/a 0.84 – –

*
ICC = intraclass correlation coefficient; MDC = minimal detectable change; SEM = standard error of measurement; IKDC = International Knee Documentation Committee Subjective Knee Evaluation
Form; ACL = anterior cruciate ligament; KOOS = Knee Injury and Osteoarthritis Outcome Score; ADL = activities of daily living; sport/rec = sport/recreation; QOL = quality of life; OA = osteoarthritis;
KOOS-PS = Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form; KOS-ADL = Knee Outcome Survey Activities of Daily Living Scale; OKS = Oxford Knee Score; WOMAC =
Western Ontario and McMaster Universities Osteoarthritis Index; ARS = Activity Rating Scale; TAS = Tegner Activity Scale; n/a = not applicable.
Page 38
 Large variation in time between test—retest (up to 12 months).
COLLINS et al. Page 39
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†
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Table 2

Summary of responsiveness data*

Patient cohort
evaluated ES SRM MCID
COLLINS et al.

Function measures
IKDC Knee injuries (ACL, meniscal, chondral) Meniscal repair/resection (12 m): 2.11 Meniscal repair/resection (12 m): 1.5 Chondral injuries: 6.3 (6
(20,23) Various cartilage procedures: 0.76 (6 m), 1.06 (12 m) Various cartilage procedures: 0.57 (6 m), 1.0 (12 m) m), 16.7 (12 m)
Cohort of mixed knee pathologies (22,24) Various surgical procedures (6–28 m): 1.13 Various surgical procedures: 4.4 (4–8 m), 0.94 (6–28 m) 6–28 m: 11.5 (sensitive),
20.5 (specific)
KOOS Knee injuries (25,27,36) Partial meniscectomy (3 m): 1.11 (pain), 0.93 (symp.), 0.67 (ADL), 0.9 (sport/rec), 1.15 (QOL) ACI, MF (3 y): 0.71 (pain), 0.61 (symp.), 0.75 (ADL), 0.87 (sport/rec), 0.76 –
ACLR (6 m): 0.84 (pain), 0.87 (symp.), 0.94 (ADL), 1.16 (sport/rec), 1.65 (QOL) (QOL)
ACI, MF (3 y): 0.82 (pain), 0.72 (symp.), 0.7 (ADL), 0.98 (sport/rec), 1.32 (QOL)
Knee OA (28,31,33) PT (4 w): 1.08 (pain), 0.97 (symp.), 1.07 (ADL), 0.79 (sport/rec), 0.78 (QOL) PT (4 w): 1.28 (pain), 1.02 (symp.), 1.37 (ADL), 0.83 (sport/rec), 0.87 –
TKR (3 m): 2.59 (pain), 1.63 (symp.), 2.52 (ADL), 1.31 (sport/rec), 2.8 (QOL) (QOL)
TKR (6 m): 2.28 (pain), 1.24 (symp.), 2.25 (ADL), 1.18 (sport/rec), 2.86 (QOL) TKR (3 m): 1.85 (pain), 1.45 (symp.), 1.8 (ADL), 0.89 (sport/rec), 1.93
TKR (12 m): 2.55 (pain), 1.59 (symp.), 2.56 (ADL), 1.08 (sport/rec), 3.54 (QOL) (QOL)
TKR (6 m): 1.67 (pain), 0.99 (symp.), 1.7 (ADL), 0.81 (sport/rec), 1.6
(QOL)
TKR (12 m): 2.12 (pain), 1.25 (symp.), 1.9 (ADL), 0.88 (sport/rec), 1.99
(QOL)
KOOS-PS Knee OA (40–42) PT (4 w): 0.5–0.88 PT (4 w): 0.73–1.21 –
HAI (4 w): 0.51 HAI (4 w): 0.8
TKR (6 m): 1.4
KOS-ADL Mixed knee pathologies (43,45–47) PT: 0.44 (1 w), 0.94 (4 w), 1.26 (8 w) PT (6 w): 7.1 PFPS: 7.1
PT (6 w): 0.63 TKR (6 m): 1.1
TKR (6 m): 1.3
Lysholm Knee Knee injuries (ACL, meniscal, chondral; ACLR: 1.0 (6–9 m), 1.1 (1–2 y) ACLR: 0.93 (6 m), 1.1 (9 m), 1.2 (1 y), 0.93 (2 y) –
Scoring Scale patellar dislocation) (55,61,63) Meniscal repair (1 y): 1.2 Meniscal repair (1 y): 0.97–1.13
MF (1–6 y): 1.2 MF (1–6 y): 1.1
Mixed knee pathologies (47,62,120) PT (1 m): 0.9 Variety of nonsurgical and surgical interventions (3 m): 0.9 –
OKS Knee OA (46,66) TKR (6 m): 0.9–2.19 TKR (6 m): 0.7 –
WOMAC Chondral defects (23) Various cartilage surgeries (6 m): 0.98 (pain), 0.51 (symp.), 0.88 (function) Various cartilage surgeries (6 m): 0.91 (pain), 0.40 (symp.), 0.86 (function) –
Various cartilage surgeries (12 m): 1.14 (pain), 0.72 (symp.), 1.2 (function) Various cartilage surgeries (12 m): 0.94 (pain), 0.64 (symp.), 1.13

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(function)
Knee OA (42,46,92, 96,97,100,101,105, TKR (3 m): 1.62 (pain), 1.26 (symp.), 2.02 (function) TKR (3 m): 1.14–1.58 (pain), 1.15 (symp.), 1.02–2.02 (function) NSAIDs (4 w, function):
106,108,124–128) TKR (6 m): 0.95–1.9 (pain), 0.88–1.5 (symp.), 1.01–2.2 (function) TKR (6 m): 0.95–1.8 (pain), 0.63–1.3 (symp.), 0.9–1.9 (function) 9.1 (absolute), 26
TKR (1 y): 1.8–2.4 (pain), 1.8–3.1 (function) TKR (2 y): 1.55 (pain), 1.03 (symp.), 1.32 (function) (relative)
TKR (2 y): 1.9–41 (pain), 1.3–24 (symp.), 1.7–23.9 (function) Drug (2 w): 1.09 (pain), 0.43 (symp.), 0.89 (function) TKR (6 m): 22.87 (pain),
Exercise (2 w): 0.74–0.88 (pain), 0.32–0.44 (symp.), 0.50–0.79 (function) Exercise (2 w): 0.78–1 (pain), 0.29–0.52 (symp.), 0.69–0.94 (function) 14.43 (symp.), 19.01
Exercise (6 m): 0.41 (pain), 0.28 (function) (function)
Rehabilitation (not defined): 0.52 (pain), 0.42 (symp.), 0.44 (function) TKR (12 m): 36 (pain),
Drug (2 w): 0.94 (pain), 0.46 (symp.), 0.72 (function) 33 (function)
Drug (3 w): 0.76–0.88 (pain), 0.59–0.63 (symp.), 0.75–0.77 (function)
Drug (4 w): 0.69 (pain), 0.41 (symp.), 0.56 (function)
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Patient cohort
evaluated ES SRM MCID
Drug (6 w): 0.53–0.8 (pain), 0.6–0.75 (symp.), 0.58–0.82 (function) TKR (2 y): 27.98 (pain),
Drug (8 w): 0.58 (pain), 0.53 (symp.), 0.76 (function) 21.35 (symp.), 20.84
Drug (12 w): 0.44–0.91 (pain), 0.55–0.84 (symp.), 0.58–0.81 (function) (function)
Acupuncture (3 w): 0.4 (pain), 0.52 (symp.), 0.31 (function)
Acupuncture (8 w): 1.3 (pain), 1.2 (function)
COLLINS et al.

Activity measures
ARS Baseline knee athletic activity for cohort of – – –
mixed knee pathologies
TAS Knee injuries (ACL, meniscal; patellar Various meniscal surgeries (12 m): 0.61 (isolated lesions), 0.84 (combined lesions) Various meniscal surgeries (12 m): 0.6 (isolated lesions), 0.7 (combined –
dislocation) (55,61) ACLR: 0.74 (6 m), 1.1 (9 m), 1.0 (1 y), 1.0 (2 y) lesions)
ACLR: 0.61 (6 m), 0.84 (9 m), 0.96 (1 y), 1.0 (2 y)
Knee OA – – –

*
ES = effect size; SRM = standardized response mean; MCID = minimum clinically important difference; IKDC = International Knee Documentation Committee Subjective Knee Evaluation Form; ACL = anterior cruciate ligament; KOOS = Knee Injury and Osteoarthritis
Outcome Score; symp. = symptoms; ADL = activities of daily living; sport/rec = sport/recreation; QOL = quality of life; ACLR = ACL reconstruction; ACI = autologous chondrocyte implantation; MF = microfracture; OA = osteoarthritis; PT = physical therapy; TKR = total
knee replacement; KOOS-PS = Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form; HAI = intraarticular hyaluronic acid injection; KOS-ADL = Knee Outcome Survey Activities of Daily Living Scale; PFPS = patellofemoral pain syndrome; OKS =
Oxford Knee Score; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; NSAIDs = nonsteroidal antiinflammatory drugs; ARS = Activity Rating Scale; TAS = Tegner Activity Scale.

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Summary Table for Knee Function Measures*

Scale Purpose/content Method of administration Respondent burden Administrative burden Score interpretation Reliability evidence Validity evidence Ability to detect change Strengths Cautions

Knee function
IKDC Symptoms, sport/ Patient completed 10 min 5 min; manual scoring Single score; 0–100 (100 Internal: adequate; test– Face: adequate; Responsive to change following No floor/ceiling effects No patient input in
COLLINS et al.

daily activities, using guidelines provided = no symptoms, no retest: adequate for content: cannot be surgery; MCID for cartilage development; long
function; variety of limitation with daily/ groups/individuals with assumed; construct: repair, various knee surgeries recall period;
knee conditions sport activities) knee injuries adequate missing data;
lacking psycho-
metric testing in
knee OA; aggregate
score may mask
deficits in 1
domain; multiple
versions available
KOOS Pain, symptoms, Patient completed 10 min 5 min; scoring 5 subscales; 0–100 (100 Internal, test–retest: Face: adequate; Responsive to change across a Substantial psychometric Not validated for
ADL, sport/rec, spreadsheet = no problems) variable (subscale, content: adequate; variety of knee conditions testing and cross-cultural interview
QOL; posttraumatic condition) construct: adequate following surgical and validation; individual administration;
knee OA and nonsurgical interventions; rather than aggregate applicability of
preceding MCID: NR scores sport/rec items in
conditions older/less
physically active
patients
KOOS-PS Function (ADL, Patient completed 2 min <5 min; conversion table Single score; 0–100 (100 Internal: adequate; test– Face: adequate; Responsive to change following Developed using Rasch Psychometric
sport/rec); knee OA = no difficulty) retest: adequate for content: adequate; physical therapy and hyaluronic analysis; minimal burden testing only in knee
groups; less than construct: adequate acid injection; MCID: NR OA
adequate for
individuals
KOS-ADL Symptoms, Patient completed 5 min <5 min; manual Single score; 0–100 (100 Internal: adequate; test– Face: adequate; Responsive to change across a Reliable and valid No patient input in
functional calculation = no knee- related retest: adequate content: cannot be variety of knee disorders and development;
limitations; various symptoms or functional assumed; construct: interventions (physical therapy, descriptive
knee pathologies limitations) adequate TKR); MCID for PFP responses may be
(ligament/meniscal confusing; ensure
injuries, OA, PFP) use of consistent
version; may not be
appropriate for
highly active
patients
Lysholm Limp, support, In-person clinician administration Variable depending <5 min; manual Single score; 0–100 (100 Internal: inadequate; Face: adequate; Responsive to change following Freely available; minimal No patient input in
Knee Scoring locking, instability, on administration calculation = no symptoms or test–retest: adequate content: cannot be surgery and PT; MCID: NR burden development; risk
Scale pain, swelling, method disability) only for groups with assumed; construct: of interviewer bias;
stairs, squatting; knee injuries adequate multiple versions

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knee ligament available
surgery
OKS Pain, function; Patient completed 5–10 min <5 min; manual Single score; original Internal: adequate; test– Face: adequate; Responsive to change following Reliable, valid, and Some “double-
patients undergoing calculation version 12–60 (lower retest: adequate content: adequate; TKR; MCID: NR responsive for knee OA barreled” items; use
TKR scores = better construct: adequate and TKR; cross- cultural of aggregate score;
outcomes); modified validations beware of 2
version 0–48 (higher different scoring
scores = better outcomes) methods
WOMAC Pain, stiffness; Patient- or interview- 5–10 min 5 min; manual or 3 subscales; range Internal: adequate for Face: adequate; Responsive to change following Variety of validated Licensing and fees
function; knee and administered questionnaire computer scoring depends on version stiffness and function, content: adequate; surgical and nonsurgical administration methods; required;
hip OA (validated for in-person, (Likert, VAS); lower variable for pain; test– construct: adequate interventions for knee OA and validated translations into applicability of
telephone, and electronic use) scores indicate less pain, multiple languages; function subscale
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Scale Purpose/content Method of administration Respondent burden Administrative burden Score interpretation Reliability evidence Validity evidence Ability to detect change Strengths Cautions
stiffness, and functional
retest: variable chondral defects; MCID for individual subscale items; redundant
deficits (subscale, condition) TKR and NSAID use scores; minimal floor and items in pain and
ceiling effects function subscales
(Rasch analysis)
Activity level
ARS Athletic activities; Patient completed <5 min 1 min; manual calculation Single score; 0–16 (16 = Internal: NR; test– Face: adequate; Responsiveness, MCID: NR Short and simple; adjunct Recall difficulty;
COLLINS et al.

various knee more frequent retest: adequate content: adequate; to other knee function lack of
disorders; participation) construct: adequate measures; generalizable psychometric
participation in across a variety of athletic testing
sport and similar tasks
TAS Level of sport and In-person clinician administration 3.3 min <1 min; score Single score; 0–10 Internal: N/A; test– Face: adequate; Responsive to change following Simple; spans work and More suited to
work participation; corresponds to single (higher scores = retest: adequate content: cannot be meniscal surgery and ACL sport/rec activities measure within-
knee ligament response selected participation in higher- (groups), less than assumed; construct: reconstruction; MCID: NR patient change;
injury (with level activities) adequate (individuals) adequate adjustment for age
Lysholm) and sex

*
IKDC = International Knee Documentation Committee Subjective Knee Evaluation Form; MCID = minimum clinically important difference; OA = osteoarthritis; KOOS = Knee Injury and Osteoarthritis Outcome Score; ADL = activities of daily living; sport/rec = sport/
recreation; QOL = quality of life; NR = not reported; KOOS-PS = Knee Injury and Osteoarthritis Outcome Score Physical Function Scale; KOS-ADL = Knee Outcome Survey Activities of Daily Living Scale; PFP = patellofemoral pain; TKR = total knee replacement; PT =
physical therapy; OKS = Oxford Knee Score; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; VAS = visual analog scale; NSAID = nonsteroidal antiinflammatory drug; ARS = Activity Rating Scale; TAS = Tegner Activity Score; N/A = not
applicable; ACL = anterior cruciate ligament.

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