Skip to main content


Log in

Analysis of patient-reported anterior knee pain scale: implications for scale development in children and adolescents

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope



The purpose of this investigation was to estimate and document the reliability and validity of the Anterior Knee Pain Scale (AKPS) and to estimate its relative prediction accuracy of anterior knee pain in young females.


Data from a prospective, epidemiologic study to diagnose patellofemoral knee pain among female athletes (n = 499) using the Anterior Knee Pain Scale (AKPS). Data were treated in 4 phases (descriptive phase, reliability phase, scale refinement phase) and a final validation stage that was focused on an effort to test and document the validation of the AKPS short form and perform head-to-head comparisons of the 6-item short form with the original, 13-item form.


The AKPS was reduced from 13 items (αCoeff = 0.77, σSEM = 0.004) to 6 items (αCoeff = 0.78, σSEM = 0.004). Point-biserial correlations with patellofemoral pain diagnosis were comparable: r [498] = 0.70 (R 2 = 0.49, short form) and r [498] = 0.71 (R 2 = 0.51, long form), as was sensitivity: 84 % (short form) and 80 % (long form), and specificity: 89 % (short form) and 90 % (long form; AUC = 0.94 both).


The current analyses indicate that a subset of measures from the AKPS is responsive to patellofemoral pain symptoms and may support screening for related diagnoses. A simpler and quicker scale optimized for diagnostic accuracy could reduce the demand on patients, clinicians and research teams focused on the identification and management of patellofemoral pain.

Level of evidence


This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others


  1. Adirim TA, Cheng TL (2003) Overview of injuries in the young athlete. Sports Med 33(1):75–81

    Article  PubMed  Google Scholar 

  2. Barber Foss KD, Myer GD, Chen SS, Hewett TE (2012) Expected prevalence from the differential diagnosis of anterior knee pain in adolescent female athletes during preparticipation screening. J Athl Train 47(5):519–524

    PubMed Central  PubMed  Google Scholar 

  3. Blond L, Hansen L (1998) Patellofemoral pain syndrome in athletes: a 5.7-year retrospective follow-up study of 250 athletes. Acta Orthop Belg 64(4):393–400

    CAS  PubMed  Google Scholar 

  4. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR (2009) The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med 37(5):890–897

    Article  PubMed  Google Scholar 

  5. Burt CW, Overpeck MD (2001) Emergency visits for sports-related injuries. Ann Emerg Med 37(3):301–308

    Article  CAS  PubMed  Google Scholar 

  6. Calmbach WL, Hutchens M (2003) Evaluation of patients presenting with knee pain: Part I. History, physical examination, radiographs, and laboratory tests. Am Fam Physician 68(5):907–912

    PubMed  Google Scholar 

  7. Collins NJ, Crossley KM, Darnell R, Vicenzino B (2010) Predictors of short and long term outcome in patellofemoral pain syndrome: a prospective longitudinal study. BMC Musculoskelet Disord 11:11

    Article  PubMed Central  PubMed  Google Scholar 

  8. Crossley KM, Bennell KL, Cowan SM, Green S (2004) Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil 85(5):815–822

    Article  PubMed  Google Scholar 

  9. Fagan V, Delahunt E (2008) Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options. Br J Sports Med 42(10):789–795

    Article  CAS  PubMed  Google Scholar 

  10. Fairbank JC, Pynsent PB, van Poortvliet JA, Phillips H (1984) Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br 66(5):685–693

    CAS  PubMed  Google Scholar 

  11. Flandry F, Hunt JP, Terry GC, Hughston JC (1991) Analysis of subjective knee complaints using visual analog scales. Am J Sports Med 19(2):112–118

    Article  CAS  PubMed  Google Scholar 

  12. Franklin CC, Weiss JM (2012) Stopping sports injuries in kids: an overview of the last year in publications. Curr Opin Pediatr 24(1):64–67

    Article  PubMed  Google Scholar 

  13. Harrison E, Magee D, Quinney H (1996) Development of a clinical tool and patient questionnaire for evaluation of patellofemoral pain syndrome patients. Clin J Sport Med 6(3):163–170

    Article  CAS  PubMed  Google Scholar 

  14. Ingram JG, Fields SK, Yard EE, Comstock RD (2008) Epidemiology of knee injuries among boys and girls in US high school athletics. Am J Sports Med 36(6):1116–1122

    Article  PubMed  Google Scholar 

  15. 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(5):600–613

    CAS  PubMed  Google Scholar 

  16. Iversen MD, Lee B, Connell P, Andersen J, Anderson AF, Kocher MS (2010) Validity and comprehensibility of the international knee documentation committee subjective knee evaluation form in children. Scand J Med Sci Sports 20(1):e87–e95

    Article  CAS  PubMed  Google Scholar 

  17. Kettelkamp DB, Thompson C (1975) Development of a knee scoring scale. Clin Orthop Relat Res 107:93–99

    Article  PubMed  Google Scholar 

  18. Knowles SB, Marshall SW, Bowling JM, Loomis D, Millikan R, Yang J, Weaver NL, Kalsbeek W, Mueller FO (2006) A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol 164(12):1209–1221

    Article  PubMed  Google Scholar 

  19. Kocher MS, Smith JT, Iversen MD, Brustowicz K, Ogunwole O, Andersen J, Yoo WJ, McFeely ED, Anderson AF, Zurakowski D (2011) Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders. Am J Sports Med 39(5):933–939

    Article  PubMed  Google Scholar 

  20. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O (1993) Scoring of patellofemoral disorders. Arthroscopy 9(2):159–163

    Article  CAS  PubMed  Google Scholar 

  21. Larson R (1974) Rating sheet for knee function. Diseases of the knee joint. Churchill-Livingston, Edinburgh, pp 29–30

    Google Scholar 

  22. Louw QA, Manilall J, Grimmer KA (2008) Epidemiology of knee injuries among adolescents: a systematic review. Br J Sports Med 42(1):2–10

    Article  CAS  PubMed  Google Scholar 

  23. Marshall JL, Fetto JF, Botero PM (1977) Knee ligament injuries: a standardized evaluation method. Clin Orthop Relat Res 123:115–129

    PubMed  Google Scholar 

  24. McGuine T (2006) Sports injuries in high school athletes: a review of injury-risk and injury-prevention research. Clin J Sport Med 16(6):488–499

    Article  PubMed  Google Scholar 

  25. Messina DF, Farney WC, DeLee JC (1999) The incidence of injury in Texas high school basketball. A prospective study among male and female athletes. Am J Sports Med 27(3):294–299

    CAS  PubMed  Google Scholar 

  26. Myer GD, Faigenbaum AD, Foss KB, Xu Y, Khoury J, Dolan LM, McCambridge TM, Hewett TE (2013) Injury initiates unfavourable weight gain and obesity markers in youth. Br J Sports Med. doi:10.1136/bjsports-2012-091988

    PubMed Central  Google Scholar 

  27. Myer GD, Ford KR, Barber Foss KD, Goodman A, Ceasar A, Rauh MJ, Divine JG, Hewett TE (2010) The incidence and potential pathomechanics of patellofemoral pain in female athletes. Clin Biomech 25(7):700–707

    Article  Google Scholar 

  28. Myer GD, Ford KR, Di Stasi SL, Barber Foss KD, Micheli LJ, Hewett TE (2014) High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: Is PFP itself a predictor for subsequent ACL injury? Br J Sports Med. doi:10.1136/bjsports-2013-092536

    Google Scholar 

  29. Nijs J, Van Geel C, Van der Auwera C, Van de Velde B (2006) Diagnostic value of five clinical tests in patellofemoral pain syndrome. Man Ther 11(1):69–77

    Article  PubMed  Google Scholar 

  30. Nimon G, Murray D, Sandow M, Goodfellow J (1998) Natural history of anterior knee pain: a 14- to 20-year follow-up of nonoperative management. J Pediatr Orthop 18(1):118–122

    CAS  PubMed  Google Scholar 

  31. O’Donoghue DH (1955) An analysis of end results of surgical treatment of major injuries to the ligaments of the knee. J Bone Joint Surg Am 37-A(1):1–13; passim

  32. Oretorp N, Gillquist J, Liljedahl SO (1979) Long term results of surgery for non-acute anteromedial rotatory instability of the knee. Acta Orthop Scand 50(3):329–336

    Article  CAS  PubMed  Google Scholar 

  33. Ortqvist M, Roos EM, Brostrom EW, Janarv PM, Iversen MD (2012) Development of the Knee Injury and Osteoarthritis Outcome Score for children (KOOS-Child): comprehensibility and content validity. Acta Orthop 83(6):666–673

    Article  PubMed Central  PubMed  Google Scholar 

  34. Powell JW, Barber-Foss KD (2000) Sex-related injury patterns among selected high school sports. Am J Sports Med 28(3):385–391

    CAS  PubMed  Google Scholar 

  35. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

    PubMed  Google Scholar 

  36. Turba JE, Walsh WM, McLeod WD (1979) Long-term results of extensor mechanism reconstruction. A standard for evaluation. Am J Sports Med 7(2):91–94

    Article  CAS  PubMed  Google Scholar 

  37. Watson CJ, Propps M, Ratner J, Zeigler DL, Horton P, Smith SS (2005) Reliability and responsiveness of the lower extremity functional scale and the anterior knee pain scale in patients with anterior knee pain. J Orthop Sports Phys Ther 35(3):136–146

    Article  PubMed  Google Scholar 

  38. Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G (2000) Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. Am J Sports Med 28(4):480–489

    CAS  PubMed  Google Scholar 

Download references


The authors would like to thank Boone County Kentucky, School District, especially School Superintendent Randy Poe, for participation in this study. We would also like to thank Mike Blevins, Ed Massey, Dr. Brian Blavatt and the athletes of Boone County public school district for their participation in this study. All authors are independent of any commercial funder, had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. This work was supported by the National Institutes of Health/NIAMS Grants #R01-AR049735, #R01-AR05563 and #R01-AR056259.

Conflict of interest

The authors have no competing interests to declare.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Gregory D. Myer.

Additional information

This study was approved by the Cincinnati Children’s Hospital Institutional Review Board.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Myer, G.D., Barber Foss, K.D., Gupta, R. et al. Analysis of patient-reported anterior knee pain scale: implications for scale development in children and adolescents. Knee Surg Sports Traumatol Arthrosc 24, 653–660 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: