Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 24, Issue 9, pp 2973–2982 | Cite as

A novel patient-reported outcome measure for anterior cruciate ligament injury: evaluating the reliability, validity, and responsiveness of Japanese anterior cruciate ligament questionnaire 25

  • Masashi NagaoEmail author
  • Tokuhide Doi
  • Yoshitomo Saita
  • Yohei Kobayashi
  • Mitsuaki Kubota
  • Haruka Kaneko
  • Yuji Takazawa
  • Muneaki Ishijima
  • Hisashi Kurosawa
  • Kazuo Kaneko
  • Masahiko Nozawa
  • Hiroshi Ikeda
  • Sung-Gon Kim



Despite objectively good results, up to 70 % of individuals may not return to their pre-injury level of sports activity after anterior cruciate ligament (ACL) reconstruction surgery. Although psychological responses have been shown to affect outcomes after ACL injury, an appropriate means of measuring their effects, in addition to functional status, has not been determined. The purpose of this study was to develop a patient-reported questionnaire for measuring psychological factors associated with outcomes after ACL injury and to evaluate its reliability, validity, and responsiveness.


After item analysis based on the results of two pilot studies and a short relevance assessment, 25 questionnaire items were selected for the Japanese Anterior Cruciate Ligament Injury Questionnaire 25 (JACL-25) and assessed for validity, reliability, and responsiveness in subjects with ACL injury.


The JACL-25 had no floor or ceiling effects and no confounding factors. A Cronbach’s alpha coefficient of 0.981 and a Guttman split-half coefficient of 0.983 indicated excellent reliability. Large standardized response means (1.30–1.62) and effect sizes (0.96–1.51) from the preoperative to postoperative period indicated good responsiveness. Construct structures were created, and these items were separated into three domains. Strong correlations between the JACL-25 and the International Knee Documentation Committee Subjective Knee Form (r s = −0.86), Lysholm Score (r s = −0.73), and Tegner Activity Scale (r s = −0.65) indicated good concurrent validity of the JACL-25.


The present study demonstrated that the JACL-25 was valid, reliable, and responsive enough to evaluate psychological factors associated with outcomes in individuals with ACL injuries.

Level of evidence

Diagnostic study, Level III.


Anterior cruciate ligament injury Questionnaires Validation study JACL-25 


Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

167_2015_3595_MOESM1_ESM.doc (128 kb)
Supplementary material 1 (DOC 127 kb)
167_2015_3595_MOESM2_ESM.docx (28 kb)
Supplementary material 2 (DOCX 28.1 kb)


  1. 1.
    Akai M, Doi T, Fujino K, Iwaya T, Kurosawa H, Nasu T (2005) An outcome measure for Japanese people with knee osteoarthritis. J Rheumatol 32:1524–1532PubMedGoogle Scholar
  2. 2.
    Akaike H (1973) Information theory and an extension of the maximum likelihood principle. In: Petrov BN, Csaki F (eds) Second international symposium on information theory. Akademiai Kiado, Budapest, pp 267–281Google Scholar
  3. 3.
    Anthoine E, Moret L, Regnault A, Sebille V, Hardouin JB (2014) Sample size used to validate a scale: a review of publications on newly-developed patient reported outcomes measures. Health Qual Life Outcomes 12:176CrossRefPubMedGoogle Scholar
  4. 4.
    Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45:596–606CrossRefPubMedGoogle Scholar
  5. 5.
    Chmielewski TL, Zeppieri G Jr, Lentz TA, Tillman SM, Moser MW, Indelicato PA, George SZ (2011) Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther 91:1355–1366CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Cohen J (2013) Statistical power analysis for the behavioral sciences. Academic Press Inc, LondonGoogle Scholar
  7. 7.
    Cronbach LJ (1951) Coefficient alpha and the internal structure of tests. Psychometrika 16:297–334CrossRefGoogle Scholar
  8. 8.
    Doi T, Akai M, Endo N, Fujino K, Iwaya T (2013) Dynamic change and influence of osteoporotic back pain with vertebral fracture on related activities and social participation: evaluating reliability and validity of a newly developed outcome measure. J Bone Miner Metab 31:663–673CrossRefPubMedGoogle Scholar
  9. 9.
    Everhart JS, Best TM, Flanigan DC (2015) Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 23:752–762CrossRefPubMedGoogle Scholar
  10. 10.
    Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD (2001) Development and validation of the International Knee Documentation Committee Subjective Knee form. Am J Sports Med 29:600–613PubMedGoogle Scholar
  11. 11.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kim SG, Kurosawa H, Sakuraba K, Ikeda H, Takazawa S (2006) The effect of initial graft tension on postoperative clinical outcome in anterior cruciate ligament reconstruction with semitendinosus tendon. Arch Orthop Trauma Surg 126:260–264CrossRefPubMedGoogle Scholar
  13. 13.
    Kim SG, Kurosawa H, Sakuraba K, Ikeda H, Takazawa S, Takazawa Y (2005) Development and application of an inside-to-out drill bit for anterior cruciate ligament reconstruction. Arthroscopy 21:1012PubMedGoogle Scholar
  14. 14.
    Kocher, Steadman JR, Briggs K, Zurakowski D, Sterett WI, Hawkins RJ (2002) Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction. J Bone Joint Surg Am 84-A:1560–1572PubMedGoogle Scholar
  15. 15.
    Kowalchuk DA, Harner CD, Fu FH, Irrgang JJ (2009) Prediction of patient-reported outcome after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 25:457–463CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kvist J, Osterberg A, Gauffin H, Tagesson S, Webster K, Ardern C (2013) Translation and measurement properties of the Swedish version of ACL-Return to Sports after Injury questionnaire. Scand J Med Sci Sports 23:568–575PubMedGoogle Scholar
  17. 17.
    Kvist J, Ek A, Sporrstedt K, Good L (2005) Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 13:393–397CrossRefPubMedGoogle Scholar
  18. 18.
    Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW (2007) The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 30:77–94CrossRefPubMedGoogle Scholar
  19. 19.
    Lentz TA, Zeppieri G Jr, George SZ, Tillman SM, Moser MW, Farmer KW, Chmielewski TL (2015) Comparison of physical impairment, functional, and psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after ACL reconstruction. Am J Sports Med 43:345–353CrossRefPubMedGoogle Scholar
  20. 20.
    Lethem J, Slade PD, Troup JD, Bentley G (1983) Outline of a fear-avoidance model of exaggerated pain perception-I. Behav Res Ther 21:401–408CrossRefPubMedGoogle Scholar
  21. 21.
    Magnussen RA, Granan LP, Dunn WR, Amendola A, Andrish JT, Brophy R, Carey JL, Flanigan D, Huston LJ, Jones M, Kaeding CC, McCarty EC, Marx RG, Matava MJ, Parker RD, Vidal A, Wolcott M, Wolf BR, Wright RW, Spindler KP, Engebretsen L (2010) Cross-cultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surg Sports Traumatol Arthrosc 18:98–105CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, Bouter LM, de Vet HC (2010) The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res 19:539–549CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Sakamoto Y (1992) Categorical data analysis by AIC. Kluwer Academic Publishers, DordrechtGoogle Scholar
  24. 24.
    Hoshino YA, Doi T, Akai M, Tobimatsu Y, Iwaya T (2012) Development of a screening tool for risk of locomotive syndrome in the elderly: the 25-question Geriatric Locomotive Function Scale. J Orthop Sci 17:163–172CrossRefPubMedGoogle Scholar
  25. 25.
    Shirado O, Doi T, Akai M, Fujino K, Hoshino Y, Iwaya T (2007) An outcome measure for Japanese people with chronic low back pain: an introduction and validation study of Japan low back pain evaluation questionnaire. Spine (Phila Pa 1976) 32:3052–3059Google Scholar
  26. 26.
    Spindler KP, Wright RW (2008) Clinical practice. Anterior cruciate ligament tear. N Engl J Med 359:2135–2142CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49PubMedGoogle Scholar
  28. 28.
    Thomee P, Wahrborg P, Borjesson M, Thomee R, Eriksson BI, Karlsson J (2006) A new instrument for measuring self-efficacy in patients with an anterior cruciate ligament injury. Scand J Med Sci Sports 16:181–187CrossRefPubMedGoogle Scholar
  29. 29.
    Tjong VK, Murnaghan ML, Nyhof-Young JM, Ogilvie-Harris DJ (2014) A qualitative investigation of the decision to return to sport after anterior cruciate ligament reconstruction: to play or not to play. Am J Sports Med 42:336–342CrossRefPubMedGoogle Scholar
  30. 30.
    Wagenmakers E, Farrell S (2004) AIC model selection using Akaike weights. Psychon Bull Rev 11:192–196CrossRefPubMedGoogle Scholar
  31. 31.
    Webster KE, Feller JA, Lambros C (2008) Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport 9:9–15CrossRefPubMedGoogle Scholar
  32. 32.
    Woby SR, Roach NK, Urmston M, Watson PJ (2005) Psychometric properties of the TSK-11: a shortened version of the Tampa scale for kinesophobia. Pain 117:137–144CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  • Masashi Nagao
    • 1
    Email author
  • Tokuhide Doi
    • 2
  • Yoshitomo Saita
    • 3
  • Yohei Kobayashi
    • 3
  • Mitsuaki Kubota
    • 3
  • Haruka Kaneko
    • 3
  • Yuji Takazawa
    • 3
  • Muneaki Ishijima
    • 3
  • Hisashi Kurosawa
    • 4
  • Kazuo Kaneko
    • 3
  • Masahiko Nozawa
    • 1
  • Hiroshi Ikeda
    • 3
  • Sung-Gon Kim
    • 1
  1. 1.Department of Orthopedic SurgeryJuntendo University Nerima HospitalTokyoJapan
  2. 2.Hakucho Geriatric Healthcare FacilityTokyoJapan
  3. 3.Department of Orthopedic SurgeryJuntendo University HospitalTokyoJapan
  4. 4.Department of Orthopedic SurgeryJuntendo Tokyo Koto Geriatric Medical CenterTokyoJapan

Personalised recommendations