Validity and Reliability of the Hindi Versions of the Lysholm Knee Scoring Scale and Tegner Activity Scale

Study patients

A prospective cohort of 100 consecutive patients presenting with knee-related complaints (for example, ligament injuries, meniscal pathology, patellofemoral disorders, and cartilage lesions) was enrolled at a sports injury clinic of one of the largest tertiary care referral centers in North India, which receives patients from approximately nine to ten states and therefore serves a clinically and geographically diverse population.

• Inclusion criteria: Patients aged 18–70 years, fluent and literate in Hindi, presenting with primary knee-related complaints

• Exclusion criteria: Age <18 or >70 years; active joint infection; inflammatory or advanced post-traumatic arthritis; cognitive, neurological, or psychiatric impairment precluding completion of self-report forms; or receipt of major therapeutic interventions during the 14-day test-retest interval.

Sample size determination

Sample size requirements were estimated using the approach for reliability studies recommended by Terwee et al., which advises a minimum of 50 participants for adequate assessment of reliability and measurement error ^[6]. Enrolling 100 patients exceeded this threshold twofold, providing adequate precision for the primary criterion validity, reliability, and internal consistency analyses. The study was not designed to yield diagnosis-specific estimates.

Lysholm and Tegner scales

• Lysholm scale: An eight-item questionnaire evaluating limping (5 points), support or crutches (5 points), locking (15 points), instability (25 points), pain (25 points), swelling (10 points), stair climbing (10 points), and squatting (5 points). Total scores range from 0 to 100, with higher scores reflecting superior knee function (91–100 = excellent, 84–90 = good, 65–83 = fair, <65 = poor)

• Tegner scale: A single-item, 11-level rating scale (0–10) quantifying physical activity levels from daily living or sedentary work (level 0–1) up to elite competitive sports (level 10).

Translation and cultural adaptation procedure

Permission was obtained from the original developers before translation. Standard forward-backward translation protocols were implemented ^[7,8]:

1. Forward translation: Two independent translations from English into Hindi were generated by a bilingual orthopedic surgeon and a professional translator

2. Synthesis: The translations were synthesized into a single preliminary Hindi draft following consensus discussion

3. Back-translation: Blinded back-translation into English was conducted by an independent native English speaker and a professional translator

4. Expert committee review: An expert panel (orthopedic surgeons, language experts, and clinical methodologists) reviewed all versions to resolve semantic, idiomatic, and conceptual discrepancies, with disagreements resolved through open discussion until consensus was reached. Assigned point values next to response items were removed from patient-facing forms to prevent response bias

5. Cultural modification: Sports listed on Tegner activity levels 7–10 were culturally adapted. Inaccessible or uncommonly played sports (for example, bandy and ice hockey) were removed, and sports widely played in India (for example, kabaddi, kho-kho, field hockey, and cricket) were integrated at equivalent physical demand levels. The adapted scale was designated the Hindi-adjusted Tegner scale

6. Pre-testing: The draft was pretested on 30 patients. Although three participants sought clarification on the term “giving way” (instability), misinterpretation remained below the 15% threshold; minor phrasing adjustments were made to ensure maximal clarity.

Comparator instrument

The validated Hindi version of the IKDC-SKF served as the primary benchmark for criterion validity. The IKDC-SKF yields an overall transformed score ranging from 0 to 100, calculated from 18 of its 19 items; the two remaining items, present overall knee function (Item 10a) and present level of sports activity (Item 10b), both rated on a 0–10 scale, are scored separately and were used here for item-specific comparison with the Tegner scale ^[9].

Data collection

Patients completed the questionnaires digitally via Google Forms in waiting areas.

• Baseline (T_{1}): Completion of the Hindi Lysholm scale (present symptoms), Hindi-adjusted Tegner scale (pre-injury, present, and expected post-treatment levels), and Hindi IKDC-SKF

• Intraday reliability (T_{2}): Completion of a second administration on the same day after physician consultation to evaluate short-term repeatability

• Interday test-retest reliability (T_{3}): Re-administration via digital link at 14 days post-baseline, during which no clinical interventions occurred.

The order in which the Hindi Lysholm, Hindi-adjusted Tegner, and Hindi IKDC-SKF were presented was randomized at each time point to minimize order and recall effects between instruments. Completion time was systematically tracked. Floor and ceiling effects were calculated as the proportion of participants achieving the absolute minimum (0) or maximum possible scores.

Statistical analysis

Analyses were performed using Statistical Package for the Social Sciences Version 25.0 (IBM Corp., Armonk, NY, USA).

• Criterion validity: Evaluated using Pearson correlation coefficients (r) between present Lysholm and Tegner scores and IKDC-SKF total and item-specific scores. Values of r > 0.7 denoted strong correlation, 0.5–0.7 moderate, and <0.5 weak

• Reliability: Intraclass correlation coefficients (ICC) (^[2,1], two-way random-effects model, absolute agreement) assessed intraday and interday test-retest reliability. ICC values were classified as poor (<0.50), moderate (0.50–0.75), good (>0.75–0.90), or excellent (>0.90)

• Measurement error: Standard error of measurement (SEM) (= standard deviation × √(1−ICC), using the intraday ICC) and minimal detectable change at 90% confidence (MDC90 = SEM × 1.645 × √2) were computed ^[10]

• Internal consistency: Assessed for the multi-item Lysholm scale using Cronbach alpha (α), with values between 0.70 and 0.95 considered acceptable ^[6].

A two-tailed P < 0.05 was considered statistically significant for all analyses. All questionnaires were scored by an investigator blinded to the results of the comparator instrument to reduce the risk of assessment bias.

Patient demographic and clinical characteristics

The baseline characteristics of the study cohort (n = 100) are summarized in Table 1. The overall mean age was 39.6 ± 13.2 years (range, 18–68 years), with a mean duration from injury to assessment of 3.5 ± 2.0 months.

Feasibility and administration

Missing data rates were negligible (<1% across all items). Mean completion time was 4 min (range, 2–6 min) for the Hindi Lysholm scale and 3 min (range, 2–5 min) for the Hindi-adjusted Tegner scale, demonstrating excellent feasibility in outpatient settings.

Floor and ceiling effects

Neither the Lysholm total score nor the Tegner activity scores demonstrated significant overall floor or ceiling effects (>15% threshold) (Table 2). Individual Lysholm items exhibited expected ceiling effects due to discrete single-item capping (for example, support item: 72% ceiling), reinforcing that overall sum scores rather than sub-item scores should be used for functional tracking. Item-level ceiling effects may nonetheless limit sensitivity to change at the item level (Limitations).

Validity

The Hindi Lysholm scale showed a strong, statistically significant correlation with the Hindi IKDC-SKF (r = 0.87, P < 0.001). The Hindi-adjusted Tegner scale demonstrated a moderate overall correlation with the Hindi IKDC-SKF (r = 0.58, P < 0.001) and higher specific correlations with IKDC-SKF activity-related items (Item 10b: r = 0.61; Item 10a: r = 0.64; both P < 0.001) (Table 3, Figure 2).

Reliability and measurement error

The Hindi Lysholm scale demonstrated excellent intraday (ICC = 0.93) and 14-day interday test-retest reliability (ICC = 0.97). The Hindi-adjusted Tegner scale demonstrated moderate intraday (ICC = 0.75) and interday test-retest reliability (ICC = 0.88) (Table 4, Figure 3).

For the Lysholm total score, SEM was 5.1 points, and MDC90 was 11.9 points. For the adjusted Tegner present score, SEM was 0.81 levels, and MDC90 was 1.89 levels.

Internal consistency

Cronbach alpha for the Hindi Lysholm total score was 0.72 (95% confidence interval [CI], 0.63–0.80) at baseline, 0.74 (95% CI, 0.65–0.81) at intraday re-test, and 0.70 (95% CI, 0.60–0.78) at 14-day test-retest. All point estimates met the pre-defined threshold (0.70–0.95), indicating acceptable, although borderline, scale homogeneity; the lower confidence limits fell below 0.70.

Limitations

The findings should be interpreted in light of the following limitations, which also define priorities for future work.

1. Sample size, setting, and generalizability: The sample comprised 100 consecutive patients recruited at a single sports injury clinic. Although this exceeds the minimum generally recommended for reliability analysis, it may be insufficient to establish psychometric performance across clinical subgroups. The clinic forms part of one of the largest tertiary care referral centers in North India, which receives patients from approximately nine to ten states and therefore draws a clinically and socioeconomically diverse population. This broad catchment mitigates, but does not eliminate, the risk of selection bias associated with consecutive recruitment from a specialist clinic and the limited geographical representation of a single-site sample, and patients from every Hindi-speaking region of India may still not be represented. The translated scales have not yet been validated in an independent cohort or across multiple centres, and their reproducibility and broader applicability therefore remain to be confirmed.

2. Linguistic diversity and literacy: Standard Hindi was used, and regional dialects and variations in vocabulary across northern and central India may influence comprehension and responses. The multi-state catchment of the study center is likely to have exposed the translated instruments to a range of dialects and sociocultural backgrounds, and pretesting identified few comprehension difficulties, but dialect was not recorded, and dialect-specific performance was not analyzed. Only Hindi-literate patients were included, so the findings may not extend to illiterate individuals, who may require interviewer-administered questionnaires.

3. Cultural adaptation of the Tegner scale: Although the listed sports were adapted to Indian contexts, the cultural relevance of every activity level was not independently established across different communities, although the multi-state catchment of the study centre provided some diversity of background within the sample. Replacing selected sports with Indian sports may affect direct comparability with the original scale and with previously published international studies, and measurement equivalence between the original English Tegner scale and the Hindi-adjusted version was not formally tested.

4. Criterion and construct validity: The Hindi IKDC-SKF served as the primary comparator, but it is not an independent gold standard for all aspects of knee function and activity. Correlations between the Lysholm and IKDC-SKF scores may partly reflect overlapping symptom and functional domains, and the moderate correlation of the Hindi-adjusted Tegner scale with the IKDC-SKF total score (r = 0.58) reflects, at least in part, the distinct constructs measured. Construct validity was assessed primarily through correlation with the IKDC-SKF, and a comprehensive set of pre-specified construct-validity hypotheses was not reported.

5. Responsiveness and longitudinal validation: The ability of either scale to detect clinically meaningful change after treatment or rehabilitation was not evaluated, and it remains unestablished how reliably score changes reflect recovery after procedures, such as anterior cruciate ligament (ACL) reconstruction. This initial validation was cross-sectional in design.

6. Population characteristics and eligibility criteria: Participants presented with a broad range of knee-related complaints, reflecting the case mix of a tertiary referral center. This enhances the clinical diversity of the cohort but may influence score distributions and psychometric estimates, and separate validity and reliability estimates were not reported for individual conditions, such as ligament injuries, meniscal pathology, and patellofemoral disorders. Measurement invariance across age groups, sexes, educational levels, and diagnoses was not examined. Patients younger than 18 or older than 70 years and those with cognitive, neurological, or psychiatric impairment were excluded, which limits applicability to adolescent, older, and medically complex populations.

7. Self-report and mode of administration: Self-reported scores may be affected by expectations, pain perception, social desirability, and patients’ understanding of the questions. The Tegner scale includes pre-injury activity levels, which are subject to retrospective recall bias, particularly when assessment occurs months after injury. Questionnaires were completed through Google Forms, and equivalence with paper-based or interviewer-administered formats was not established.

8. Reliability design: The intraday retest followed physician consultation on the same day, which could have influenced patients’ understanding of, or responses to, the questions. For the 14-day interval, major interventions were excluded, but the stability of symptoms and activity levels between assessments was not formally documented. The consistently high coefficients are reassuring in this regard, although these conditions should be tightly specified in future work.

9. Internal consistency, measurement error, and item-level effects: Cronbach alpha was assessed only for the multi-item Lysholm scale, as internal-consistency analysis is not ordinarily applicable to the single-item Tegner scale. Alpha values for the Lysholm scale ranged from 0.70 to 0.74, with CIs extending below 0.70, indicating acceptable but borderline internal consistency. The MDC90 values of 11.9 points for the Lysholm scale and 1.89 levels for the Tegner scale imply that smaller changes cannot be distinguished confidently from measurement error. Although overall scores showed no significant floor or ceiling effects, individual Lysholm items did show ceiling effects, which may limit their sensitivity to change.

Future multicenter studies that include patients from diverse regions, dialects, literacy levels, and diagnoses are warranted. Such studies should incorporate pre-specified construct-validity hypotheses, formal equivalence testing against the original Tegner scale, evaluation of measurement invariance, and longitudinal assessment of responsiveness after interventions, such as ACL reconstruction. Despite these limitations, the present findings provide a sound initial psychometric foundation for the use of these instruments in Hindi-speaking patients.

Conflict of Interest:

Nil

Source of Support:

Nil

Consent

The authors confirm that informed consent was obtained from the patient for publication of this article

How to Cite this Article

Raj S, Sen AK, Kumar R, Yadav A, Gopavaram UKR, Kumar SR. Validity and Reliability of the Hindi Versions of the Lysholm Knee Scoring Scale and Tegner Activity Scale. Journal of Orthopaedic Case Reports 2026 November;16(11):524-531. doi: 10.13107/jocr.2026.v16.i11.8542.