knee injuries are common in young individuals and usually result in pain or some degree of loss in athletic capacities .
these sequelae can be quantified or measured using knee scores or scales , such as the international knee documentation committee ( ikdc ) subjective knee form , tegner activity scale , marx activity rating scale , kujala anterior knee pain scale , and knee injury and osteoarthritis outcome score ( koos ) .
these scores are based mainly on clinical findings , subjective complaints of the patients , or combinations of these factors . in general ,
assessments are categorized into two groups : general health and disease- or joint - specific indices . before using such an outcome measurement in a community ,
they need to be translated and culturally adapted , given that the majority of these scores reflect the characteristics of the language and the social culture of the community in which they were established .
most questionnaires in the orthopaedic literature were developed in english and therefore may reflect the anglo - saxon culture from which they derive .
many already are used as standards for the world scientific community , yet the appropriate use of these tools depends on their adaptation to different languages and cultures while maintaining cultural equivalence [ 28 , 32 ] . to avoid the potentially confusing distribution of new questionnaires
that are not comparable to those available in the literature , a rigorous adaptation process is needed , and mere translation is not sufficient .
the availability of culturally equivalent outcome measures allows for multicenter studies to be reliably conducted across different countries .
questionnaires with valid turkish versions include the koos , womac , the kujala anterior knee pain scale , and the knee outcome survey - activities for daily living scale .
first published in 1982 , the lysholm knee scale was developed to determine the functional status of patients with anterior cruciate ligament injuries of the knee .
the questionnaire also has been validated for evaluation of patients with patellofemoral pain syndrome , patellar tendinitis , meniscal injuries , and various other traumatic and degenerative chondral lesions [ 2 , 16 , 22 ] . compared with other turkish - validated knee indices ,
the womac osteoarthritis index is a validated questionnaire used to assess symptoms and physical functional disability in patients with osteoarthritis of the knee and the hip .
in contrast , the koos   was developed as an extension of the womac osteoarthritis index to evaluate short- and long - term symptoms and function in individuals with knee injuries and osteoarthritis .
these two outcome scores also require considerable time to be completed . the koos and womac require between 5 to 10 minutes to be completed .
the knee outcome survey - activities for daily living scale   preferentially focuses on daily living activities rather than the patients symptoms . however , the lysholm knee scale is more concise and therefore requires little time for the patient to complete and for the health practitioner to evaluate .
furthermore , it is not disease - specific and therefore can be used to evaluate various knee disorders [ 2 , 16 , 22 ] .
although the psychometric properties of the lysholm knee scale in relation to various knee disorders have been reported [ 25 , 13 , 16 , 22 , 30 , 33 ] , to our knowledge , only validated portuguese and german translations of the lysholm knee scale study have been published [ 31 , 38 ] .
therefore , the objectives of our study were to evaluate the ease of use , reliability , and validity of a turkish - language , culturally adapted version of the lysholm knee scale .
we translated the lysholm knee scale into turkish and culturally adapted the items in accordance with the stages recommended by guillemin .
two turkish individuals [ ekm , ao ] with a strong command of english were responsible for the literary and conceptual translation of the lysholm knee scale , including a physical therapist [ ekm ] acting as the informed translator and a teacher [ ao ] acting as the uninformed translator . both translators native language is turkish and both are fluent in english .
the translations were completed independently , and both translations then were compared and reviewed by a bilingual individual [ gk ] who highlighted any conceptual errors or inconsistencies identified in the translations .
once the primary turkish translation was established , two native english speakers [ du , da ] with a good command of turkish independently back - translated the finalized turkish translation into english .
both of these translators were unaware of the purpose of the study and had no access to the original scale .
a committee consisting of four translators [ dc , ok , gk , co ] compared the english retranslation with the initial turkish translation before approving the turkish version of the lysholm knee scale .
the lysholm knee scale is an eight - item questionnaire designed to evaluate patients after knee ligament injury .
it is scored on a 100-point scale from 0 to 100 ( worst to best symptoms , respectively ) , with 25 points attributed to pain , 15 to locking , 10 to swelling , 25 to instability , 10 to stair climbing , and 5 points each to limping , use of a support , and squatting . the kujala anterior knee pain scale developed by kujala et al .  
is comprised of 13 questions that inquire about the following factors : pain ( with walking up and down stairs , squatting , running , jumping , or prolonged sitting with the knee in flexion ) ; whether there is limping , swelling , or subluxation of the patella ; the amount of atrophy in the quadriceps muscle , flexion deficiency , and pain ; and whether a walking assist is needed .
the total score ranges from 0 to 100 , with the highest value indicating the best score .
the sf-36 consisting of eight scaled scores was used to establish a health profile , and each scale was directly transformed into a score from 0 to 100 to identify the patient s physical and mental state .
these eight sections included physical functioning , physical role functioning , bodily pain , general health perceptions , vitality , social role functioning , emotional role functioning , and mental health .
eighty patients with knee complaints were recruited from the istanbul university faculty of medicine s department of orthopedics and fulya acbadem hospital between march 2011 and january 2012 .
as the oldest and largest hospital in istanbul , istanbul medical school attracts patients from all cultures and income levels . however , high - level athletes and patients with very high incomes prefer private hospitals . therefore , to include a diverse population of patients , some patients were recruited from one of the private hospitals .
some data were excluded for the following reasons : five patients did not return for the retest assessment , two declined to complete the sf-36 , and three had received medical treatment before the retest assessment , thereby rendering the retest potentially unreliable . in total , 70 patients ( 37 males , 33 females ; mean age , 36.10    13.5  years ; range , 1772  years ) with knee complaints were included in the study ( table  1).table  1patient demographicsdemographicnumber ( % ) sex  female33 ( 47.1 )  male37 ( 52.9)education  primary school15 ( 21.4 )  high school16 ( 22.9 )  college student6 ( 8.5 )  university degree27 ( 38.5 )  master s degree4 ( 5.7 )  doctorate2 ( 2.9)dominant / nondominant side  involved right knee34 ( 48.5 )  involved left knee26 ( 37.1 )  involved both knees10 ( 14.2)diagnosis  acl injury12 ( 17.1 )  acl repair14 ( 20 )  acl and lateral meniscus lesion5 ( 7.1 )  acl and meniscus repair5 ( 7.1 )  meniscus injury4 ( 5.7 )  meniscectomy4 ( 5.7 )  patellofemoral pain syndrome20 ( 28.5 )  patellar dislocation1 ( 1.4 )  multiple ligament injury1 ( 1.4 )  osteoarthritis4 ( 5.7)acl  =  anterior cruciate ligament .
the inclusion criteria were : ( 1 ) 16  years or older ; ( 2 ) presence of a knee problem ; and ( 3 ) no treatment between the test - retest assessments .
the exclusion criteria were : ( 1 ) inability to complete the forms as a result of cognitive impairment ; ( 2 ) illiteracy or lack of understanding of turkish ; ( 3 ) had a condition that could not be stabilized after a second assessment for other ailments such as cancer , serious infection , or inflammatory disease ; and ( 4 ) the presence of neurologic or musculoskeletal disorders other than the knee condition .
the duration of patients knee symptoms in the group surveyed was 5.3    4.2  months .
patients were examined clinically by two experienced knee surgeons ( ok , ot ) . when necessary , radiography and mri were performed . before inclusion in the study group ,
participants provided written informed consent , which had been approved by the ethical committee at istanbul university ( irb study protocol : 2010/875 - 265 ) .
patients were asked to complete the turkish version of the lysholm knee scale ( appendix ) , the previously validated turkish version of the kujala anterior knee pain scale , and the turkish sf-36 .
physical therapists administered the listed questionnaires to patients in waiting rooms before their appointments with an orthopaedic surgeon .
the difficulty in understanding the question or the incompatibility with their problem was noted and the time required to complete the questionnaires was recorded .
ease of use was measured by the time it took to complete the questionnaire . additionally , we documented problems with comprehension of particular translated terms as they arose .
the test - retest reliability , which is a measure of stability or reproducibility , represents a scale s capability of providing consistent results when administered on separate occasions [ 8 , 23 ] .
the reliability of scale scores has been estimated using the internal consistency method and test - retest method across repeated administrations . to determine the test - retest reliability ,
70 patients were asked to complete the lysholm scale 3 to 14  days after the first assessment . to minimize the risk of short - term clinical change , no treatments were provided during this period .
validity is represented by the extent to which a score retains its intended meaning and interpretation . in our study ,
validity was assessed according to the following three factors : construct , convergent and divergent , and content validity .
the construct validity of the turkish lysholm knee scale was analyzed based on its correlation with the kujala anterior knee pain scale and the physical component score of the sf-36 .
correlations with the physical functioning , physical role functioning , and physical component score domains were used to assess the convergent validity .
divergent validity was evaluated using the sf-36 mental health , emotional role functioning , and mental component score domains .
it was hypothesized that the physical domains of the sf-36 would correlate more closely with disease- or joint - specific questionnaires compared with the mental domains .
content validity was assessed using the distribution and the occurrence of ceiling and floor effects .
a ceiling effect occurs when the maximum possible score of 100 is achieved , whereas a floor effect is observed when the minimum possible score of 0 is reached .
we considered scores between 90% and 100% to be maximum scores and scores between 0% and 10% were minimum scores . if more than 15% of the patients scored maximum or minimum scores , we considered these to be floor and ceiling effects , respectively .
the intraclass correlation coefficient ( icc ) was used to measure the test - retest reliability of the lysholm knee scale assessment form .
  0.811.0 was excellent , 0.610.80 was very good , 0.410.60 was good , 0.210.40 was fair , and 0.000.20 was poor ) [ 14 , 20 ] .
construct and convergent and divergent validities were evaluated with pearson s correlation coefficients , and a 95% ci was used for all correlation coefficients . a student
s paired t - test was used to detect statistically significant differences between the first and repeat tests .
all statistical analyses were performed with the statistical package for the social sciences ( spss ) 17.5 ( spss inc , chicago , il , usa ) .
floor and ceiling effects and the number of items answered were identical during the test and retest examinations .
the pilot study was conducted with 20 patients ( seven females , 13 males ; mean age , 35.00    12.5  years ; range , 1760  years ) .
some patients had difficulty answering the pain subscale items because individuals in turkey usually use minutes rather than kilometers to estimate walking distances .
however , the linguistic committee could not find a more appropriate word to replace it .
the lysholm knee scoring domains and the total score exhibited good to excellent icc values .
the paired t - test did not show any statistically significant difference between the test - retest means ( table  2 ) based on the mean test interval of 5.4    2.2  days.table  2test - retest reliability of the lysholm knee scalelysholm knee scalemean    sdreliabilitytest 1test 2p valuesintraclass correlation coefficientpain11.78    11.113.63    10.8 < 0.0010.72instability17.90    7.117.88    6.8 < 0.0010.71locking11.68    3.711.37    4.0
< 0.0010.84stair climbing6.85    3.06.71    4.2 < 0.0010.49limp3.73    1.93.76    1.4
< 0.0010.81support5.05    0.94.88    0.50.0300.50swelling7.30    4.47.50    4.4
< 0.0010.96squatting3.20    2.32.83    1.8 < 0.0010.64overall lysholm knee scale69.33    20.667.71    19.0
< 0.0010.82 test - retest reliability of the lysholm knee scale the turkish - language questionnaire showed good to excellent validity .
the correlation coefficient between the lysholm knee scale and the kujala anterior knee pain scale score was 0.78 , which is considered extremely strong ( p  <  0.001 ) .
the highest correlation was found between the lysholm knee scale and sf-36 physical function , the sf-36 bodily pain , and the lysholm knee scale and physical component score ( r  =  0.61 , r  =  0.55 , r  =  0.56 , respectively ; p  <  0.001 ) .
conversely , the lowest correlations were identified between the lysholm knee scale and the sf-36 social function , and between the lysholm knee scale and the sf-36 mental component score ( r  =  0.23 and r  =  0.14 , respectively ; p  < 
ten of 70 patients ( 14% ) scored between 90 and 100 so there was a slight ceiling effect .
there were no floor effects because none of the patients scored between 0 and 10.table  3comparison of sf-36 subscale results and overall lysholm knee scalesf-36 subscaleoverall lysholm knee scale scorecurrent studymarx et al .
sf-36 ( pf)0.61 * 0.660.570.53sf-36 ( rp)0.43 * 0.490.380.47sf-36 ( bp)0.55 * 0.570.500.55sf-36 ( gh)0.41 * 0.31sf-36 ( vt)0.380.28p value0.01sf-36 ( sf)0.240.50p value0.04sf-36 ( re)0.340.18p value0.04sf-36 ( mh)0.240.29p value0.04sf-36 ( pcs)0.57 * 0.68sf-36 ( mcs)0.140.05p value0.24 *  p  <  0.000 ; pf  =  physical functioning ; rp  =  physical role functioning ; bp  =  bodily pain ; gh  =  general health perceptions ; vt  =  vitality ; sf  =  social function ; re  =  emotional role functioning ; mh  =  mental health ; pcs  =  physical component scale ; mcs  =  mental component scale . comparison of sf-36 subscale results and overall lysholm knee scale *  p  <  0.000 ; pf  =  physical functioning ; rp  =  physical role functioning ; bp  =  bodily pain ; gh  =  general health perceptions ; vt  =  vitality ; sf  =  social function ; re  =  emotional role functioning ; mh  =  mental health ; pcs  =  physical component scale ; mcs  =  mental component scale .
the primary outcome of this study is that the turkish translation of the lysholm knee scale was shown to be easy to use , reliable , and valid .
our findings show the acceptable psychometric performance of this scale for patients with various knee disorders in the turkish population . the primary limitations of our study included the untested statistical power and small sample size .
however , previous validation studies have used similar numbers of individuals , and the sample size was large enough to reach statistical significance .
nevertheless , the turkish lysholm knee scale should be applied to larger populations to evaluate its reliability , validity , responsiveness , and minimal clinically important differences in patients with various diagnoses .
in addition , there is no ideal or universally accepted interval for requerying patients regarding their health status .
short test - retest intervals carry the risk of patients  becoming familiar with the questions  and simply answering based on memory of the first assessment .
although longer intervals can decrease this possibility , other factors need to be considered to prevent bias in such studies .
for instance , only patients with chronic , mostly degenerative disorders can be included in studies with long rescanning intervals because failing to treat an acute complaint for an extended period is unethical .
furthermore , spontaneous improvement of acute complaints may occur . even in patients with chronic disorders , spontaneous changes in complaints
can be observed . in general , the length of time between repeat administrations of a clinical outcome measure should be relatively short ( 37  days ) when the measured condition is expected to change rapidly [ 20 , 26 ] . in the literature ,
the reported intervals for retesting the lysholm knee scale usually are longer than advised periods ( table  4 ) .
we selected an interval of 3 to 14  days , similar to previous studies [ 2 , 11 , 22 , 27 , 35 ] , and thus the clinical limitations associated with this choice are acknowledged.table  4test - retest reliability , internal consistency , and validity of the lysholm knee scalelysholm knee scaletest - retest reliability ( icc)intervalcronbach s alphacorrelations with lysholm knee scale and other knee scorestegner and lysholm 0.902  weeksbengston et al .
days0.68icc  =  intraclass correlation coefficient ; aaos  =  american academy of orthopaedic surgeons ; adl  =  activities of daily living ; ikdc  =  international knee documentation committee .
test - retest reliability , internal consistency , and validity of the lysholm knee scale icc  =  intraclass correlation coefficient ; aaos  =  american academy of orthopaedic surgeons ; adl  =  activities of daily living ; ikdc  =  international knee documentation committee .
although patients found the questionnaire easy and fast to complete , some issues arose with the translation and cultural adaptation . during the translation procedures , the translators could not agree on the ideal turkish word for  instability .  whereas most of the various meanings of  instability ,  such as imbalance , lability , and variability , have a counterpart in the turkish language , knee instability does not have a perfect equivalent .
instead , patients describe their knee instability with phrases such as  giving way  ,  weakness  , or  insecurity  . the turkish term
 boalma  , which means  giving way  , was found to be the most appropriate choice and was used for  instability  and  giving way  . for cultural adaptation purposes ,
the distance unit had to be changed to metric units , similar to previous translations of the lower extremity functional scale ( lefs ) into the brazilian portuguese   and italian languages . despite miles being adapted to kilometers
, some patients still were unable to answer this question because they were unaccustomed to describing walking distance .
the test - retest indicated adequate to excellent reliability for the subscales and the turkish lysholm knee scale as a whole ( table  2 ) . in the literature ,
the test - retest reliability of the overall lysholm knee scale typically has been excellent , with the exception of bengston et al .  
kocher et al . found a reliability of 0.61 for pain and 0.67 for stair climbing subscales   ( table  4 ) . in our study , the pain subscale was 0.72 , but the stair climbing subscale showed less reliability ( 0.49 ) .
thus , these two domains ( stair climbing and support ) may lack the reproducibility necessary for scientific precision and require further refinement to improve their reliability .
cronbach s alpha coefficient for the lysholm knee scale was 0.68 in our study , which is questionable .
however , its reliability was similar to that of other studies ( table  4 ) [ 4 , 5 , 16 , 22 , 30 ] .
in some studies , the original lysholm knee scale was compared with other outcome tools using multiple scores and scales [ 4 , 5 , 16 , 22 , 30 , 33 ] .
high correlation coefficients have been reported with the fulkerson , cincinnati knee rating system , and kujala anterior knee pain scale , with the lowest correlation found with the tegner activity scale ( table  4 ) [ 16 , 30 , 33 ] . in our study , the convergent validity was assessed by comparing the lysholm knee scale with the kujala anterior knee pain scale and the sf-36 questionnaire .
the kujala anterior knee pain scale was preferred for convergent validity because the subscales , such as pain , swelling , squatting , and stair climbing , of the kujala anterior knee pain scale and lysholm knee scale are similar . the correlation coefficient between the lysholm knee scale and the kujala anterior knee pain scale score was 0.78 , which is considered good .
the correlation between the lysholm knee scale and sf-36 was variable , from fair to excellent .
this range of results is not surprising and we believe are the result of contextual differences between condition - specific questionnaires , such as the ikdc , western ontario meniscal evaluation tool ( womet ) , and cincinnati knee rating system . the strength of correlations between the sf-36 and scores of specific instruments have been limited .
this confirms that the sf-36 measures additional aspects of physical health and therefore provides a more comprehensive , but less specific , range of information about a patient s overall health than obtained with condition - specific questionnaires .
researchers have investigated the correlations between the lysholm knee scale and subscales of the sf-36 across different settings ; their results concluded poor to high correlations ( table  3 ) [ 4 , 5 , 16 , 22 , 30 ] . in our study , the correlation between the lysholm knee scale and sf-36 physical function values was higher those reported by paxton et al .   and kocher et al . , but lower than that reported by marx et al . .
the correlation between the sf-36 physical role function and bodily pain domains was similar to our results . compared with the correlations of marx et al .
, the correlations we found among the sf-36 general health perceptions , vitality , and emotional role function subdomains were superior with the lysholm knee scale .
the correlation between the sf-36 physical component score and the lysholm knee scale was higher in the study of marx et al . .
the turkish lysholm knee scale contains an adequate number of questions to reveal the functional status and pain of the patients .
it is short and easy to administer and interpret with a minimal amount of time required for clinicians , patients , or researchers . the turkish translation and culturally adapted version
are reliable and valid and can be used to assess the functional limitations of turkish patients with knee disorders .
whereas the presented translation has been validated with this preliminary study , the turkish form still should be validated in larger and more diverse populations .
lysholm diz skalasiaksama ( 5 puan )  yok5  hafif veya belirli aralklarla3  ciddi veya her zaman0destek ( 5 puan )  yok5  baston veya koltuk denei2  zerine basmak imkansz0kilitlenme ( 15 puan )  kilitlenme veya taklma hissi yok15  taklma hissi var fakat kilitlenme yok10  kilitlenme  bazen6  sk2  muayenede eklem kilitli0boalma ( dizin ne doru kaymas ) ( 25 puan )  boalma hissi hi yok25  zorlayc veya sportif aktivitelerde bazen20  zorlayc veya sportif aktivitelerde sk15  gnlk aktivitelerde bazen10  gnlk aktivitelerde sk5  her admda0merdiven kma ( 10 puan )  problem yok10  hafif problem var6  tek bacak atarak2  imkansz0melme ( 5 puan )  problem yok5  hafif problem var4  90den sonra problem var2  imkansz0ilik ( 10 puan )  yok10  zorlayc aktiviteler ile6  basit zorlanmalar ile2  devaml0ar ( 25 puan )  yok25  srekli deil , zorlayc aktiviteler srasnda hafif20  zorlayc aktiviteler srasnda belirgin0  2  kmden ( 30 dakika ) fazla yrndnde belirgin10  2  kmden ( 30 dakika ) az yrndnde belirgin5  devaml0toplam puan
 backgroundthe lysholm knee scale , first published in 1982 , is an eight - item questionnaire designed to evaluate patients after knee ligament injury . 
 however , as a tool developed in english , its use as a validated instrument has been limited to english - language populations.questions/purposesthe objectives of this study were to test the ease of use , reliability , and validity of a turkish - language , culturally adapted version of the lysholm knee scale.methodsthe lysholm knee scale was translated into turkish according to guillemin s recommendations . 
 seventy patients ( mean age , 36  years ; range , 1772  years ) with different knee complaints were included , and the scale was completed twice by each participant at 3- to 14-day intervals to assess test - retest reliability based on the interrater correlation coefficient , whereas cronbach s alpha evaluated internal consistency . 
 external validity was evaluated with correlations between the lysholm knee scale , kujala anterior knee pain scale , and sf-36 . 
 the distribution of floor and ceiling effects was determined.resultspatients completed the turkish - language lysholm questionnaire in approximately 3 minutes . 
 the test - retest reliability was 0.82 , with a cronbach s alpha coefficient of 0.68 . 
 the lysholm knee score was strongly correlated with the kujala anterior knee pain scale ( r  =  0.78 ) . 
 the turkish lysholm knee scale showed high correlations with the sf-36 physical component score ( r  =  0.61 ) and a low association with the mental component domain ( r  =  0.14).conclusionsthe turkish version of the lysholm knee scale is quickly administered , valid , and reliable , and can be used for patients with various knee disorders.level of evidencelevel iii , diagnostic study . 
 see guidelines for authors for a complete description of levels of evidence . 
Level of Evidence
Introduction
Patients and Methods
Results
Discussion
Appendix