Change in KOOS and WOMAC Scores in a Young Athletic Population With and Without Anterior Cruciate Ligament Injury

Am J Sports Med. 2018 Jun;46(7):1606-1616. doi: 10.1177/0363546518768753. Epub 2018 May 7.


Background: Several studies have examined changes in patient-reported outcome measures (PROMs) after anterior cruciate ligament (ACL) injury, but no studies to date have prospectively evaluated changes from preinjury baseline through injury and follow-up among ACL-injured patients compared to the baseline and follow-up changes of uninjured patients.

Purpose: To examine changes in PROMs over time from preinjury baseline to at least 2 years after ACL reconstruction and to compare these changes with those of an uninjured control group having similar physical activity requirements.

Study design: Cohort study; Level of evidence, 2.

Methods: The authors conducted a prospective cohort study with a nested case-control analysis at a US service academy. All incoming first year students were recruited to participate in this study. Consenting participants completed a baseline questionnaire that included the KOOS (Knee injury and Osteoarthritis Outcome Score), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and MARS (Marx Activity Rating Scale). Participants who sustained a subsequent ACL injury completed assessments at the time of surgery and at 6, 12, and 24 months after surgery. Healthy participants were recruited to repeat the baseline assessments within 1 year of graduation. Inter- and intragroup differences at these time points were evaluated with dependent and independent t tests, respectively. We also compared these results with established minimum clinically important difference (MCID) values.

Results: Of 1268 first year students entering the academy, 1005 with no previous injuries consented to participate in this study (82% male, mean ± SD age 19 ± 1 years). Of those enrolled, 30 suffered an ACL injury and met the inclusion criteria for this study. Ninety uninjured control students who met the inclusion criteria completed follow-up assessments. There were statistically significant differences across all KOOS and WOMAC subscales between ACL-injured group and uninjured group at the time of the final follow-up assessment. Four KOOS subscales (Pain, Symptoms, Sports and Recreation Function, and Knee-Related Quality of Life) and the WOMAC Stiffness subscale demonstrated >8-point differences between groups, which exceeded the established MCID for these instruments. There were no significant differences between the ACL-injured group and uninjured groups noted for the MARS ( P = .635). At the time of final follow-up, the ACL-injured group also reported significant deficits on the WOMAC Stiffness subscale ( P = .032), the MARS ( P = .030), and all KOOS subscales, with the exception of Functional Activities of Daily Living, as compared with their preinjury baseline scores. These deficits exceeded the established MCID values for 3 KOOS subscales and the MARS.

Conclusion: Patients with ACL injuries reported significant deficits on PROMs at least 2 years after surgical reconstruction in relation to preinjury baseline scores and an uninjured control group. Many of these deficits exceeded established MCID values.

Keywords: ACL injury; knee; patient-reported outcome measures; posttraumatic osteoarthritis.

MeSH terms

  • Adolescent
  • Anterior Cruciate Ligament Injuries / surgery*
  • Anterior Cruciate Ligament Reconstruction
  • Athletes
  • Case-Control Studies
  • Female
  • Humans
  • Knee Injuries / surgery
  • Knee Joint / surgery
  • Male
  • Military Personnel
  • Osteoarthritis / surgery
  • Patient Reported Outcome Measures*
  • Prospective Studies
  • Quality of Life
  • Surveys and Questionnaires
  • Young Adult