Measson MV, Ithurburn MP, Rambaud AJM.

Intra-rater Reliability of a Qualitative

Landing Scale for the Single-Hop Test: A Pilot Study. IJSPT. 2022;17(3):493-500.

Original Research

Intra-rater Reliability of a Qualitative Landing Scale for the Single-

Hop Test: A Pilot Study
a
Maxime V. Measson 1, Matthew P. Ithurburn 2, Alexandre JM. Rambaud 3
1Externat Saint Michel, Institut de Formation en Masso-Kinésithérapie de Saint Etienne, Saint Etienne, France, 2 Department of Physical Therapy and
Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, 3 Externat Saint Michel, Institut de Formation en Masso-
Kinésithérapie de Saint Etienne; Department of Clinical and Exercise Physiology, Sports Medicine Unity, University Hospital of Saint Etienne, Faculty of
Medicine; SFMKS Lab, Société Française des Masseurs-kinésithérapeutes du Sport
Keywords: movement quality, landing error scoring system, hop tests, return to sport
https://doi.org/10.26603/001c.33066

International Journal of Sports Physical Therapy

Vol. 17, Issue 3, 2022

Background
The test battery classically used for return-to-sport (RTS) decision-making after anterior
cruciate ligament (ACL) reconstruction (ACLR) may not be sufficient, as it does not
include a qualitative analysis of movement. Therefore, the Landing Error Scoring System
(LESS) scale was adapted to a primary functional test in the typical RTS test battery: the
single leg hop for distance (SHD).

Hypothesis/ Purpose
The aim of this study was to determine the intra-rater reliability of the LESS scale
adapted to the SHD (SHD-LESS scale) in healthy young athletes.

Study Design
Reliability analysis

Methods
Nineteen healthy individuals (14 men, 5 women; mean age: 22.4 years) participated in the
study. Participants performed the SHD tasks on both limbs (dominant and non-dominant)
using a standardized protocol in two sessions that were one week apart (single reviewer;
2-dimensional video). Intra-class correlation coefficients (ICC2,1) were used to measure
the reproducibility of the scale in the dominant (dom) and non-dominant (nondom)
limbs. Additionally, limb data (dom and nondom) were pooled and evaluated collectively
with intra-class correlation coefficients. The Kappa coefficient was used to assess the
reproducibility of each individual item of SHD-LESS scale.

Results
The intra-rater reliability was good (ICCdom = 0.77; ICCnondom = 0.87; ICCpooled = 0.87) for
the overall SHD-LESS scale scores. Agreement of SHD-LESS individual items ranged from
62% to 100%. Dorsiflexion at initial contact (97% agreement; kappa value=0.79) and knee
valgus after landing (88% agreement; kappa value=0.65) had excellent agreement and
kappa values.

Conclusion
The newly-adapted SHD-LESS scale showed good intra-rater reliability overall. Further
studies should evaluate the impact of using the SHD-LESS scale within the RTS test
battery on outcomes in patients after ACLR.

a Corresponding author:
Alexandre J.M. Rambaud
Department of Clinical and Exercise Physiology, Sports Medicine Unity,
University Hospital of Saint Etienne, Faculty of Medicine, Saint-Etienne, France
[email protected]
 Intra-rater Reliability of a Qualitative Landing Scale for the Single-Hop Test: A Pilot Study

Level of Evidence
3

INTRODUCTION to the SHD (SHD-LESS) in healthy young athletes. The hy-

pothesis of this study was that the reproducibility of the
After an anterior cruciate ligament (ACL) injury, the aim SHD-LESS would be good or excellent (ICC > 0.75).
of ACL reconstruction is to restore functional stability of
the knee. Following surgery, a primary end goal of rehabil- METHODS
itation is to prepare the patient to resume sports-related
STUDY DESIGN
activities, defined in a recent consensus statement on re-
turn-to-sport (RTS) as being a part of a continuum: return- This study was an intra-rater reliability study and followed
to-participation, return-to-sport, and return-to-perfor- the “Guidelines for Reporting Reliability and Agreement
mance.1 During late-stage rehabilitation, sport-specific Studies” (GRRAS) and “Quality Appraisal of Reliability
tasks such as pivoting and rapid change of directions are Studies” (QAREL)13,14 during the planning and implemen-
typically resumed. To start the transition toward RTS at tation of this study. Prior to the study, a declaration of con-
the completion of rehabilitation, clinical practice guidelines formity for the protection of data has been made (MR4 -
recommend that athletes complete a RTS testing battery in 2214186v0) to CNIL (Commission Nationale de l’Informa-
order to evaluate readiness for the return to the field with- tique et des Libertés). All subjects signed written informed
out restriction and with the lowest possible risk of reinjury.2 consent prior to participating in any study-related proce-
However, recent meta-analysis data demonstrated that the dures.
ACL reinjury rate (ipsilateral and contralateral) in athletes
under 25 years of age following RTS was 23%,3 suggesting PARTICIPANTS
that currently-used RTS testing may not be comprehensive
and may be insufficient to identify those at risk of poor out- Nineteen healthy young individuals (14 men and 5 women;
comes or reinjury. While RTS testing batteries often include age: 22.4 ± 0.25 years; height: 175.0 ± 1.5 cm; weight: 68.2 ±
measures of muscle strength and knee-related functional 2.0 kg) were recruited between February and May 2019 and
performance, such as one-leg hop for distance tests,2 a key participated in the study. The inclusion criteria specified
measure missing from most testing batteries used in RTS that participants were non-professional athletes, partici-
decision-making is the assessment of movement patterns or pated in a cutting/pivoting sport (soccer, basketball, hand-
movement quality.4 ball, rugby, budo…) with a minimum frequency of two train-
One-leg hop for distance tests, such as the single leg ing sessions/week and one match or game/week, and were
hop for distance (SHD), are the most commonly-used lower between 18 and 25 years old. All participants were enrolled
limb functional tests after ACLR.5 The SHD remains the and tested during their sports season. Exclusion criteria
most used test because it is simple and does not require were a history of knee injury (ACL or other ligaments of the
any equipment. In addition, the SHD allows for the evalu- knee joint) or a history of lower limb musculoskeletal injury
ation of the ability of the knee to absorb load during land- less than three months prior to enrollment and testing.
ing.6 The Limb symmetry Index of SHD, a ratio of the per-
formance of the operated limb to the healthy limb, is widely TESTING PROCEDURES
used in return to sport test batteries.2 But SHD perfor-
mance/distance symmetry analysis (LSI of SHD) has previ- Participants completed the SHD task (Figure 1) in two ses-
ously been questioned due to the potential risk of masking sions separated by six to 10 days. The general protocol con-
information about poor or altered movement strategies to sisted of four consistent steps: 1) introduction to the testing
achieve symmetric distance.7,8 For this reason, we sought session and tasks, 2) warm-up, 3) test set-up, and 4) task
to combine the objective measurement of distance with a performance and data collection. Following a standardized
qualitative analysis of landing. warm-up program,15 study participants were shown a video
The Landing Error Scoring System (LESS) was originally demonstration of the correct SHD technique with the fol-
developed for a double-leg landing task by Padua and col- lowing instructions: 1) begin standing on a lower limb be-
leagues,9 and has a good interrater and intra-rater relia- hind the start line with arms crossed over the chest; 2) at-
bility (.95 and .96 respectively).10 Recent work by O’Con- tempt to jump as far forward as possible; and 3) land on the
nor11 has adapted this scale for a single-leg drop-landing same lower limb while keeping the arms crossed to avoid
task. However, in the scientific literature, no previous work upper extremity momentum assisting in jump performance
has utilized a quality of movement scoring system with the (described previously16). Participants were informed that
most commonly performed functional performance task in the test would be invalidated if they lost balance (inability
the RTS test battery: the SHD.12 Additionally, because the to maintain balance upon jump landing for at least 3 sec-
SHD assesses unilateral characteristics of the lower limb, its onds) or could not control the landing. Participants were
use as the functional task of interest may be better suited then allowed to ask questions to clarify their understanding
for an assessment of movement quality in those with unilat- of what was required in order to correctly perform the SHD
eral injuries compared to a bilateral jump-landing-rebound and were provided three practice trials. Following practice
task (such as the original LESS).11 The aim of this study was trials, participants performed three trials on both the domi-
to evaluate the intra-rater reliability of the LESS adapted nant limb and the non-dominant limb, as described by Reid

International Journal of Sports Physical Therapy

 Intra-rater Reliability of a Qualitative Landing Scale for the Single-Hop Test: A Pilot Study

Table 1. Single leg hop for distance – landing error scoring system (SHD-LESS) scale.

Score
1. Forward Trunk Flexion at IC Yes = 0
Error: flexion < 5°. No = 1
2. Knee Flexion at IC Yes = 0
Error: flexion <5°. No = 1
3. Ankle Dorsiflexion at IC Yes = 0
Sagittal Error: the landing is not done with the heel. No = 1
View 4. Forward Trunk Flexion Displacement Yes = 0
Error: Trunk DOES NOT flex more than at IC No = 1
5. Knee Flexion Displacement Yes = 0
Error: <30° more flexion after IC; F(IC)-F(displacement). No = 1
6. Ankle Dorsiflexion Displacement Yes = 0
Error: Heel DOES NOT touch the ground No = 1
7. Knee Valgus at IC
Yes = 2
Error: the vertical line passing through the center of the patella is medial to or passes
No = 0
through the big toe.
8. Lateral Trunk Flexion at IC Yes = 1
Error: the trunk is tilted by more than 10°. No = 0
9. Knee Valgus Displacement
Yes = 2
A. Error: the vertical line through the big toe is outside/lateral or on the axis of the
Frontal No = 0
patella on the key frame.
View if not,
If not,
Yes = 1
B. Error: the vertical line through the big toe is outside or on the axis of the patella
No = 0
among all images between the IC and after displacement.
10. Contralateral Pelvic Drop Displacement Yes = 1
Error: Contralateral pelvic drops below ipsilateral pelvic. No = 0
11. Tibial Rotation Displacement Yes = 1
Error: there is tibial rotation (more than 2°, included). No = 0
12. Distance covered > 64% height Yes = 0
Error: the distance is less than 64% of the subject size. No = 1
Others 13. Overall impression Excellent=0
Error if the movement performed by the subject is "rigid/poor" at the hip, knee and Average=1
ipsilateral ankle. Poor=2
OVERALL SCORE (0-16)

IC: initial contact; Displacement: Maximal flexion knee

et al.17 The dominant limb was defined as “the primary foot

used to kick a ball”.

SHD-LESS SCALE

An adapted LESS scale was created to evaluate the SHD

landing: the SHD-LESS scale (Table 1). The adapted SHD-
LESS scale was developed using the same procedures as
the single-leg drop-landing LESS scale recently described
by O’Connor.11 All items on the O’Connor LESS scale for
falling and landing on one leg were analyzed for their ap-
plicability to the SHD assessment. As a result of this analy-
sis, the items (items 1, 2, 3, 8 and 9) were modified to be rel-
evant to the SHD task (Table 1).
In addition, two items have been added to the SHD-LESS. Figure 1. Single leg hop for distance (SHD) task and
The first item added (item 12; Table 1) included an evalu- 2D camera configuration.
ation of the jump performance (distance, cm). In complet-
ing the SHD, participants were instructed to jump as far
as possible, and this external focus allowed participants to possible that participants could purposefully jump a shorter
concentrate on the jumping performance and not the ex- distance to improve the overall landing movement quality
plicit execution of the movement/landing. Because it was which might affect the results,18 the jump distance criterion

International Journal of Sports Physical Therapy

 Intra-rater Reliability of a Qualitative Landing Scale for the Single-Hop Test: A Pilot Study

Table 2. Intra-rater reliability of qualitative (Landing Error Scoring System scale adapted to the single leg hop
for distance (SHD): SHD-LESS score) and quantitative (jump distance) measures between sessions 1 and 2. Data
are shown as ICC value (95% confidence interval); ICC: intraclass correlation coefficient; dom: dominant lower
limb; nondom: non-dominant lower limb.

Qualitative: Quality of landing score Quantitative: Jump Performance

Test: SHD (SHD-LESS score) Test: SHD (jump distance)

ICCdom 0.77 (0.46 - 0.91) 0.90 (0.73 - 0.96)

ICCnondom 0.87 (0.67 - 0.95) 0.94 (0.83 - 0.98)
ICCpooled 0.87 (0.75 - 0.93) 0.92 (0.85 - 0.96)

was defined as a minimum distance equal to 64% of the par- Session 1 and Session 2. ICC2,1 values were interpreted as
ticipant’s height.19 If the participant was unable to achieve poor (<0.50), moderate (0.50-0.74), good (0.75-0.89), or ex-
this distance, a penalty of one point was imposed (Table cellent (0.90-1.00), according to Portney and Watkins.21
1). The second item added (item 13; Table 1) included an SHD distance was compared between Sessions 1 and 2
overall impression of movement quality during the SHD with statistical adapted tests to the distribution of variables
landing. This item is the same as that of item 16 of the (paired simple t test or Wilcoxon test). Statistical signifi-
original double-leg landing LESS described by Padua and cance was set at p < 0.05. To determine intra-rater relia-
colleagues.9 Overall landing quality were evaluated as ex- bility of each individual item of the SHD-LESS scale, kappa
cellent (0 points), average (1 point), or poor (2 points). coefficients were calculated. The kappa-values were inter-
preted as follows values ≤ 0 as indicating no agreement
TWO-DIMENSIONAL VIDEO ANALYSIS and 0.01–0.20 as very poor agreement, 0.21–0.40 as poor
agreement, 0.41– 0.60 as moderate agreement, 0.61–0.80 as
As described by Everard et al., two cameras were used to strong agreement, and 0.81–1.00 as near perfect agreement
film the jumps from the front and the side.10 Prior to com- and =1, perfect agreement.22 Statistical analyses were per-
pleting the video evaluation and scoring, each SHD test formed using JASP (JASP Team [2018] Version 0.9.2.0) and R
video was verified to include the necessary scoring informa- software (version 3.4.4 [2018–03–15]).
tion (angles, distances, and key images). The cameras were
placed on a tripod perpendicular to the frontal and sagit-
RESULTS
tal plane, at a height of 60 cm and a distance of 3m (Figure
1). The video recordings were analyzed using Kinovea (Ki-
The final sample included 17 participants that completed
novea, www.kinovea.org, version 0.8.15).
the SHD. Two outliers were excluded from analyses for the
Markers were placed on the great trochanter, the lateral
SHD test (SHD performance/distance difference between
epicondyle of the knee, the lateral malleolus, the center of
Sessions 1 and 2 >2.5 SD). For the overall SHD-LESS scale
the patella (estimation of the center of the knee; equidis-
scores, intra-rater reliability ICC values were between 0.77
tant from the epicondyles of the femur), and the center of
and 0.87 (Table 2).
the line passing through the two malleoli (estimation of the
For individual items within the SHD-LESS scale, kappa
center of the ankle joint).
coefficients ranged from very low to almost perfect, de-
The video evaluations were scored by a single rater (AR;
pending on the individual item evaluated (Table 3). For
physiotherapist with 20 years of experience). After collect-
jumping performance (quantitative measure), intra-rater
ing all data, analyses were performed first for Session 1 and
reliability of jumping performance ranged from 0.90 to 0.94,
then Session 2, consecutively. The video evaluation to score
depending on the lower limb (dominant vs. non-dominant
the SHD-LESS was completed in two parts. First, the eval-
vs. pooled) (Table 3). No statistical differences were found
uation of the jumping performance (item 12; distance) was
between Sessions 1 and 2 for the of quality of landing scores
performed, and this defined the trial that would be evalu-
(pdom=0.41 ; pnondom=0.07 ; ppooled=0.05) or for SHD jump
ated for qualitative performance (the trial with the furthest
distance (pdom=0.55 ; pnondom=0.53 ; ppooled=0.73).
distance among the 3 trials). Using this trial, the remaining
items from the SHD-LESS were scored (items 1-11; 13).
DISCUSSION
STATISTICAL ANALYSIS MAIN RESULTS (OVERALL SHD-LESS SCORES)

In order to determine intra-rater reliability of the scale, The aim of this study was to determine the intra-rater re-
the overall score of the SHD-LESS was compared between liability of using an adapted version of the LESS scale for a
Session 1 and Session 2 individually for each lower limb new task, the SHD. For the overall scores on the SHD-LESS
(dominant and non-dominant) using intraclass correlation scale, we found good intra-rater reliability (ICC=0.77 and
coefficients (ICC2,1) with statistical adapted tests to the dis- ICC=0.87 for the dominant and non-dominant limb, respec-
tribution of variables (Pearson test or Spearman test). Fol- tively).21 Regarding the reproducibility of this newly-devel-
lowing research by Van Melick and al.,20 the dominant and oped SHD-LESS scale, there are no previous studies with
non-dominant limbs were pooled and evaluated between

International Journal of Sports Physical Therapy

 Intra-rater Reliability of a Qualitative Landing Scale for the Single-Hop Test: A Pilot Study

Table 3. Percent agreement and Kappa coefficients for SHD-LESS (Landing Error Scoring System scale adapted to
the single leg hop for distance) individual items.

SHD-LESS
Items Item description % Agreement Kappa value Interpretation
Forward Trunk Flexion at IC
1 94% NC NC
(degrees)
Knee Flexion at IC
2 100% NC NC
(degrees)
Dorsiflexion at IC
3 97% 0.79 Strong
(position)
Forward Trunk Flexion Displacement
4 79% 0.34 Poor
(degrees)
Knee Flexion after Landing
5 97% 0.00 Very poor
(degrees)
Ankle Dorsiflexion after Landing
6 71% 0.12 Very poor
(position)
Knee Valgus at IC
7 88% - 0.06 Disagreement
(position)
Lateral Trunk Flexion at IC
8 71% 0.30 Poor
(degrees)
Knee Valgus after Landing
9 88% 0.65 Strong
(position)
Contralateral Pelvic Drop after Landing
10 65% 0.02 Very poor
(position)
Tibial Rotation Displacement
11 62% 0.24 Poor
(degrees)
Distance Covered > 64% Height
12 97% 0.84 Almost perfect
(Distance)
13 General observation 76% 0.42 Moderate

IC: Initial Contact.

which to compare our results. In addition, we observed dif- scales. While overall scores for the SHD-LESS demonstrated
ferences in ICC values between the dominant and non-dom- good reliability, only three items (dorsiflexion of the ankle,
inant lower limbs. The dominant limb was defined as the knee flexion displacement, and knee valgus displacement)
primary foot used to kick a ball. However, unilateral tasks showed Kappa values interpreted as strong on the 13 items
were evaluated in the current study, and it may have not for this scale. Interpretation of the Kappa scores for some
been necessary to differentiate dominant and non-domi- items does not seem possible, because no errors were found
nant limbs. The data could have been pooled initially.20 in the video analyses for some items (not allowing for cal-
When analyzing the pooled data, good intra-rater reliability culation of the Kappa score). These items may have less
was found (ICCpooled = 0.87), utilizing a larger sample size relevance for a healthy population, but could be of great
(17 subjects with 2 legs; n=34). relevance for individuals following ACL reconstruction.24,25
Thus, future studies should evaluate the reliability (overall
SECONDARY OUTCOMES (INDIVIDUAL ITEM ANALYSES) and individual item assessment) of the SHD-LESS in pa-
tients following ACL reconstruction.
In this study, percentage of agreement for individual SHD- To ensure that subjects performed a reasonably similar
LESS items ranged from 62% to 100%. For tibial rotation task between the two sessions, jumping performance on the
(item 11), the rater (AR) of the study achieved only 62% SHD (quantified as hop distance) has been investigated and
agreement. Because tibial rotation is a transverse plane an excellent agreement for jump performance (distance;
variable, it is likely that evaluating this item may be partic- item 12; Table 2) on the SHD task has been obtained. These
ularly difficult with cameras only in the sagittal and frontal findings are consistent with previous work examining the
planes, and may be inappropriate for a 2D assessment of reliability of the SHD for jump performance (distance),
movement. In calculating percent agreement values, Cohen which found excellent reliability (ICC=0.92).17 While the
suggests the possibility that there is the potential for false jump distances between the two sessions were highly cor-
agreement when raters make random guesses, and Cohen’s related, recent research has shown that individuals follow-
kappa was developed to account for this concern.23 For in- ing ACL reconstruction with similar distance performance
dividual item assessment of the SHD-LESS, the Kappa co- on the SHD and other dynamic tasks use varying movement
efficients ranged from very poor to almost perfect for both strategies to accomplish the tasks.26,27 Thus, the landing

International Journal of Sports Physical Therapy

 Intra-rater Reliability of a Qualitative Landing Scale for the Single-Hop Test: A Pilot Study

movement strategies used with similar distance jumps be- recovering from ACLR or how ready for return to sport they
tween the 2 trials could not be really identical, which may are.
affect the reliability of the qualitative landing assess-
ment.26,27 STUDY LIMITATIONS

FURTHER APPLICATIONS The current study, although pilot in nature, is not without
important limitations. First, the 2D video analysis time was
The overall scores for the SHD-LESS scale demonstrated particularly long to complete the scale scoring for each task
good reliability and may be an important component in fu- (30 minutes for one limb). This may limit the clinical ap-
ture ACL reconstruction RTS testing batteries. The SHD- plication of these scales in a real-time setting. Secondly,
LESS scale contributes to an objective RTS evaluation, with the current study included only a young population (20-25
an analysis of the quality of landing during the test most years old), with more males than females, which does not
frequently used in the decision to RTS (i.e., the SHD).12 The reflect or apply to the general population. Finally, items of
SHD may also be the most relevant sport-related task to this newly-developed SHD-LESS scale were not previously
evaluate for quality of movement in individuals following validated, due to the pilot nature of this study. Future re-
ACLR. Specifically, unilateral tasks may be more relevant search should refine and validate these individual items for
than bilateral tasks for qualitative assessment, because of eventual applications in patient populations (such as those
the possibility of compensation on the healthy lower limb post-ACL reconstruction) for which movement quality as-
during a bilateral landing task like the drop vertical jump sessment may be a critical part of a multifactorial func-
(DVJ).28 Additionally, the single-leg hop tests described tional assessment.
originally by Noyes et al.29 have been used extensively and Finally, it would be interesting to evaluate inter-rater re-
previously evaluated for intra- and inter-rater reproducibil- producibility as well as to establish a cut-off score to reduce
ity.17,30 These functional tests therefore provide clinicians the risk of (re)injury, especially after ACL reconstruction.
with important information in the follow-up and serial test-
ing of their ACLR patients. CONCLUSION
The single-leg drop landing task is also incorporated in
RTS testing batteries following ACL reconstruction,31 and
The newly-adapted SHD-LESS scale showed good intra-
is associated with other important elements such as psy-
rater reliability, and could be used alongside the evaluation
chological factors and social-contextual factors.32 Also, a
of SHD performance in RTS testing following ACL recon-
single-leg drop landing task may be more biomechanically-
struction. Further studies should evaluate the inter and in-
demanding26 compared to SHD and only appropriate in
tra-rater reliability of the SHD-LESS in individuals follow-
late-stage rehabilitation. The SHD is often performed ear-
ing ACL reconstruction as well as the impact of using the
lier in rehabilitation following ACL reconstruction (approx-
SHD-LESS scale within the RTS test battery on outcomes.
imately 3 months) to assist with return to running, and thus
may have greater utility during early-to-mid rehabilitation
progression.33,34
Single-leg distance jump tests appear to have low sen-
CONFLICTS OF INTEREST
sitivity in predicting injury-free return to sport, but high
specificity,35 and providing an objective assessment of the The authors declare that they have no conflicts of interest.
patient’s functional abilities after ACLR. It should be noted
that functional tests, although providing valuable informa-
Submitted: April 27, 2021 CDT, Accepted: January 23, 2022 CDT
tion, do not, on their own, indicate how well the patient is

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 Intra-rater Reliability of a Qualitative Landing Scale for the Single-Hop Test: A Pilot Study

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