Rating of Athletic and Daily Functional Activities: Knee-Specific Scales and Global Outcome Instruments

Tegner Activity Scale

Tegner and Lysholm developed one of the first rating scales to quantify activity levels in patients with anterior cruciate ligament (ACL) ruptures ( Table 43-1 ). The Tegner Activity Scale classifies both sports and work activities into one questionnaire using an 11-level gradient. Competitive sports make up the top three levels (levels 10-8), competitive and recreational sports categories both appear in level 7, and “other recreational sports” make up level 6 ( Table 43-2 ). Levels 5 through 1 combine work and sports together, and level 0 indicates sick leave or disability because of the knee condition. The original publication did not provide reliability, validity, or responsiveness data of this scale.

Several problems are incurred with this activity rating instrument. First, work activities are rated within the same scale as sports activities. Patients who work in heavy-labor occupations are only awarded a level 5 (out of a possible 10), but the analysis of the stress on the lower limb in some of these occupations would probably show that these knees are functioning at a level equivalent to those of competitive athletes. They should not be awarded a lower level simply because they are not athletes or did not return to highly competitive sports. Athletics and occupational activities should be measured on separate rating scales (see Chapter 41 ).

Second, this scale does not separate various sports levels according to frequency of participation or the intensity of the sport, which is determined by accounting for the forces placed on the lower extremity. For instance, only national and international elite soccer players are listed on level 10, whereas basketball is listed on a level 7. In the United States, it could be argued that competitive high school, collegiate, or professional basketball players are asked to place similar demands on the knee joint and lower extremity as elite soccer players. For patients who play or return to sports not listed on the scale, problems are incurred in trying to determine exactly which level accurately defines their sport. Third, this scale does not allow an assessment of a change in athletic participation between time periods owing to a change in lifestyle (e.g., graduated from school and no longer participates in a league). In addition, one cannot detect knee abusers in either the sport or the work levels.

Independent investigations assessed the reliability, validity and responsiveness of the Tegner scale for a variety of knee injuries. Briggs and coworkers determined its reliability, validity, and responsiveness in 122 patients with meniscus injuries. The scale was found to have adequate reliability (intraclass correlation coefficient [ICC], 0.817), content validity (no ceiling or floor effects), criterion validity with the Medical Outcomes Short Form-12 Health Survey (SF-12), and construct validity. However, only moderate effect sizes (ES) and standardized response mean (SRM) values were reported. The investigators concluded that the scale measures only moderate changes in activity levels, and noted that patients in the United States may have difficulty completing the scale because it was designed for sports commonly played in Europe.

Paxton and associates assessed the reliability and validity of this scale in 153 patients followed 2 to 5 years after an acute patellar dislocation. The scale was found to have adequate reliability (ICC, 0.92) and content validity. Briggs and colleagues found the Tegner scale had adequate reliability, validity, and responsiveness following ACL injury and reconstruction.

Ebert and associates reported that the Tegner scale was less responsive to change following articular cartilage restorative procedures in comparison with the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales of sport/recreation and quality of life. There was no strong evidence that a change in the Tegner scale was associated with patient satisfaction of the outcome of the operation. A systematic review of the use of the Tegner scale following articular cartilage repair procedures found that the majority of studies reported means values only, where nonparametric methods would be more relevant. The investigators concluded that if the instruments is used in a nonstandardized or inappropriate manner, its value as a clinical outcome measure will be compromised.

Naal and coworkers compared data from three activity rating scales (Tegner, University of California, Los Angeles [UCLA], and Marx Activity Rating Scale ) in patients who underwent total joint arthroplasty. Physical activity was assessed using the “last 7 days” version of the International Physical Activity Questionnaire (IPAQ). The Tegner scale was found to be reliable and had acceptable validity in patients undergoing total knee arthroplasty (TKA). However, this scale had lower correlation coefficients and lower completion rates than the UCLA scale and was unable to discriminate between patients who were sufficiently active (moderate and vigorous activity levels according to IPAQ classification) and those who were insufficiently active.

Hospital for Special Surgery Sports Scale

Hanley and Warren developed the Hospital for Special Surgery (HSS) knee assessment instrument for an investigation of 48 patients with ACL-deficient knees who underwent arthroscopic partial meniscectomy. The instrument includes a scale composed of four levels of various sports ranked “very stressful,” “moderately stressful,” “mildly stressful,” and “no sports activities.” Examples of sports are provided in categories A, B, and C to assist with the ratings. The advantages of this scale include the assessment of sports activities only (separately from occupations) and the attempt to sort sports participation according to the level of intensity. The problems with this scale are that ambiguous terms are used to rate the sports categories (“very stressful” may have different meanings to different patients), an assessment of reasons for change in athletics owing to non–knee-related reasons is not provided, and the detection of knee abusers is not possible. The authors did not conduct reliability, validity, or responsiveness testing of their outcome instrument.

Seto Sports Participation Survey

Seto and associates developed a sports participation survey to determine activity levels in 19 patients who had undergone ACL reconstruction. In this survey, subjects rate their activity level for 13 sports, which are divided into cutting and noncutting categories. Each sports activity receives 0 to 4 points.

• 4 = full activity with no significant signs or symptoms

• 3 = full activity with occasional or recurring mild episodes of pain, swelling, or instability

• 2 = limited activity because of moderate or severe episodes of pain, swelling, or instability

• 1 = does not participate in activity because of the injured knee

• 0 = does not participate in activity but not because of the injured knee

Patients also rate their sports participation according to frequency and duration as either competitive (6 to 7 times/week or regular participation in organized competition, 3 points), recreational (3 to 5 times/week, or 2 times/week and more than 2 hours/session, or seasonal sports 5 days or more/months, 2 points), or weekend (1 to 2 times/week for 1 hour or participation in seasonal sports ≤4 days/months, 1 point).

This scale allows the analysis of athletic participation according to frequency of play and the detection of changes in activity levels between evaluations. Knee abusers may be identified from the categories of “mild” or “moderate” symptoms occurring with activity. Because the activity level is rated per sport, reporting of data can be difficult if a population is composed of individuals who play a wide variety of sports. Reliability, validity, and responsiveness testing were not conducted on this survey.