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Clinical assessment. 10 minute read.

The Lower Extremity Functional Scale (LEFS): how to score it, read the change and use it in your notes

The Lower Extremity Functional Scale (LEFS) is a 20-item questionnaire in which the patient rates how hard everyday lower limb activities are, each from 0 (extremely difficult or impossible) to 4 (no difficulty). Add up the items for a total out of 80. Higher means better function. In the original study by Binkley and colleagues, 9 points was both the minimal detectable change (MDC) and the minimal clinically important difference (MCID), so in that group a change of 9 or more could be treated as real and as meaningful to the patient. Later studies give similar values, though they differ a little between patient groups.

Below you will find how to give and score it, how to read a change, and where it goes in a SOAP note or a home exercise program (HEP) review. The last sections cover its limits. For picking measures in the first place, see the outcome measures guide.

What is the Lower Extremity Functional Scale?

Binkley and colleagues published the LEFS in Physical Therapy in 1999. They tested it in 107 patients with lower extremity musculoskeletal problems referred to 12 outpatient physical therapy clinics, and compared it with the SF-36 health survey. Test-retest reliability was excellent (R = .94). The LEFS correlated well with the SF-36 physical function subscale (r = .80) and picked up change better than the SF-36 did in that group. The authors judged it efficient to give and to score, and fit both for research and for decisions about individual patients.

That .94 is the figure in the Binkley abstract. The Shirley Ryan AbilityLab summary of the same study gives two: 0.86 for the whole sample and 0.94 for patients with more chronic conditions.

It is a region-specific measure, so it asks about the whole lower limb rather than one joint. Huynh and colleagues describe the items as covering daily activities from sitting and standing through to walking and running. In the Shirley Ryan AbilityLab Rehabilitation Measures Database it is listed as a free paper-and-pencil self-report. It takes about 5 minutes and needs no training.

Later work has mostly backed this up. Mehta and colleagues' 2016 systematic review in JOSPT took in 27 studies. Test-retest reliability was excellent, with intraclass correlation coefficients from 0.85 to 0.99, and so was responsiveness: effect sizes were consistently above 0.8. Their conclusion was that the evidence supports the LEFS as reliable and valid, and responsive to change, in a wide range of lower extremity musculoskeletal conditions.

Who is the LEFS for?

It was designed for adults with musculoskeletal problems in the lower limb, and one form does for the hip, knee, ankle or foot. In a mixed outpatient caseload that saves effort. Someone with knee osteoarthritis and someone recovering from an ankle sprain fill in the same sheet, and your team only learns one set of change values.

The Shirley Ryan AbilityLab database summarizes studies in a range of groups: people after anterior cruciate ligament (ACL) reconstruction or a hip or knee replacement, people with hip osteoarthritis or an ankle fracture, orthopedic rehabilitation inpatients and people after a stroke. In hip osteoarthritis, Pua and colleagues found the LEFS had reliability and convergent validity similar to the physical function scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). They concluded it could be used as an alternative to the WOMAC scale.

Some patients suit it less well. A very active person close to full recovery may already score at or near 80, with no room left to show progress (more on this under the limits). When the problem is only in the knee, a knee-specific questionnaire such as the Knee injury and Osteoarthritis Outcome Score (KOOS) asks about it in more detail. The measures named in the US guideline for ankle sprain, the LEFS among them, are listed on our ankle sprain page.

How to administer the LEFS

Hand the patient the standard form and let them fill it in alone. Give it out before the session starts and it will not eat into treatment time. Each item asks how much difficulty they have, or would have, with one activity today because of their lower limb problem. There are five possible answers, scored 0 to 4, with graded levels of difficulty between the two ends.

Keep the conditions the same every time: same version of the form, filled in at the same point in the visit. If someone read the questions aloud or helped with the answers, note it.

Can you copy the LEFS form?

The LEFS is listed as free in the Shirley Ryan AbilityLab database, which links to a copy of the form. That copy names the Binkley paper as its source. It carries no copyright notice and no reuse terms, and none of the other sources behind this guide gives a license for reprinting it. Free to use in the clinic does not mean free to reproduce in any format.

Translation teams have asked the developer first: Huynh and colleagues report that they obtained permission from Dr. J. M. Binkley before adapting it into Vietnamese. So this guide describes the items and does not reprint them. If you plan to put the LEFS into software or a printed product, find out who holds the rights and ask permission first, as the translation teams did.

How to score the LEFS

Add the 20 item scores. The total runs from 0 to 80: 0 means extreme difficulty with every activity on the list, 80 means no difficulty with any of them.

Higher is always better on the LEFS. Say so to colleagues who mostly use disability indexes such as the Oswestry Disability Index, where a higher score means more disability.

What if an item is left blank?

The form asks the patient to "provide an answer for each activity", and that is as far as the guidance goes. The Binkley abstract, the Shirley Ryan AbilityLab summary and the copy of the form it links to give no rule for missing items. Neither do the later papers used for this guide.

The common fix is to check the form before the patient leaves and ask about anything they skipped. If a total rests on fewer than 20 items, say so in the note. It cannot be compared directly with a full score or with the published change values.

Converting the LEFS to a percentage

The score can also be given as a percentage of maximal function: the total divided by 80, times 100. Krześniak and colleagues give this formula in their summary of the original Binkley paper. A score of 52 out of 80 becomes 65%.

If you use it, convert the change values too. The 9-point threshold is about 11% of 80. Keep the raw score next to the percentage, because every published MDC and MCID is in points.

How to interpret LEFS scores: MDC and MCID

Two questions sit behind any change in score. Is it bigger than the measure's own error? That is the MDC. Do patients tend to feel a change of that size as meaningful? That is the MCID.

Each value comes from a particular group of patients, so the table names the source.

Study Patients Published values
Binkley 1999 107 patients with lower extremity musculoskeletal problems, 12 outpatient physical therapy clinics Error around a single score of plus or minus 5.3 points; MDC 9 points; MCID 9 points (all at 90% confidence)
Pua 2009 100 adults with symptomatic hip osteoarthritis MDC 9.9 points
Abbott and Schmitt 2014 1,708 patients from 5 physical therapy clinics with musculoskeletal disorders in any body region; the LEFS values come from the 539 with a lower limb problem (Shirley Ryan AbilityLab summary) MCID 9 to 16 points. The abstract gives the range; the split into 9 for a small change, 12 for a medium one and 16 for a large one is as reported in the Shirley Ryan AbilityLab summary
Mehta 2016 Systematic review of 27 studies MDC (90% confidence) 8.1 to 15.3 points in single studies, pooled estimate 6 points; MCID 9 points

What that means in the clinic:

  1. Going by the Binkley error figure, any single LEFS score can be about 5 points out either way. A 4-point rise between two visits is inside that noise.
  2. A rise of 9 points or more clears the Binkley MDC. It also equals the MCID from Binkley and from the Mehta review, and the small-change value from Abbott and Schmitt. That makes 9 points a sound working threshold.
  3. Bigger changes mean more to patients. Abbott and Schmitt set each patient's change in score against that patient's own global rating of change at the final visit. In the Shirley Ryan AbilityLab summary of that study, 12 points lines up with "moderately better" and 16 with "quite a bit better".
  4. In hip osteoarthritis the Pua MDC is 9.9, slightly higher, so treat a change of exactly 9 points there as borderline.

The Abbott and Schmitt values describe change over a whole episode of care, judged against how the patient felt at discharge. Use them to compare the first visit with a re-evaluation, not one session with the next.

Using the LEFS in SOAP notes and HEP reviews

In common practice the LEFS is scored at the first visit, at planned re-evaluations and at discharge. Retesting every session adds little when the change you expect between sessions is smaller than the MDC.

Clinics differ on where the score goes. A common habit is to put it under subjective, because it is the patient's own report. Others list all outcome measures under objective, as our SOAP note template does. Whichever you pick, the assessment should say what the change means: the score out of 80, the baseline beside it, and the threshold you compared it with, naming the study. The SOAP notes guide covers the other sections, and the free SOAP note template has room for the score.

Goals are easier to judge in the same units. "LEFS 65/80 or higher by discharge" has a yes or no answer on the day; "improve function" never does. Add a performance test for the other half of the picture, such as the 30-second chair stand test or, for an older patient, the Timed Up and Go test.

At each HEP review the score helps you decide whether to progress the program, hold it or change it. One common approach: if two reviews in a row show no change beyond the MDC, ask the patient how much of the program they have really done before you add anything. For ways to ask, see why patients don't do their home exercises. Once they are doing it, the exercise progression guide helps you decide what to change.

Worked example: an ankle sprain re-evaluation

Ms. R is invented, and so are her scores. The doses show how a plan is written, not what to prescribe. A patient reading this should leave the choice of measures and dose to their own physio.

Ms. R, 34, right lateral ankle sprain 4 weeks ago, keen to get back to running. Re-evaluation at visit 5.

S (subjective)

  • LEFS 52/80 (38/80 at visit 1). Same form, filled in alone before the session.
  • Walking to work without pain. Stairs fine. Uneven ground still feels "wobbly". Has not tried running.
  • Home exercises done on most days.
  • No new symptoms. Denies calf pain or swelling.

O (objective)

  • Single leg stance, eyes open: 30 s on each leg, stopped there (right leg 8 s at visit 1).
  • Calf raises on both feet: 15 with no pain.

A (assessment)

  • LEFS up 14 points: past the 9-point MDC and MCID from Binkley, and between the medium (12) and large (16) values from Abbott and Schmitt. As a percentage, 65% (47.5% at visit 1).
  • Balance on a firm floor with eyes open now matches the left, which is the entry point for stage 4. The main limits now are control on uneven ground and running, which is not yet tested.

P (plan)

  • HEP moved to stage 4 of the ankle sprain program: single leg heel raise, 2 sets of 8 to 12 on each leg, 3 days a week; single leg balance with eyes closed beside the kitchen counter, 3 to 5 holds of 10 to 30 s on each leg, once a day.
  • Goals: LEFS 70/80 or higher, and 20 minutes of easy running without pain, by discharge.
  • Repeat the LEFS and single leg stance at discharge, same form, same set-up.

Once Ms. R nears 80, the LEFS has little room left to show change. From there, performance tests of her running, hopping or balance will say more than the questionnaire.

Updating the plan in PocketPhysio is quick. Swap in the stage 4 exercises, set the dose for each one and add a cue in your own words. Ms. R gets the new program as a link, by SMS or email, or in the Pocket Physio Care app, with WhatsApp as another option. Every exercise comes with its video and voice guide. At discharge her last program is still there to build on.

Limits of the LEFS

  1. A ceiling in active patients. Domzalski and colleagues studied 128 high-functioning patients after hip replacement and wrote that ceiling effects stop other scales from capturing their activities. According to the Shirley Ryan AbilityLab summary of that study, at least 88% chose "no difficulty" or "a little bit of difficulty" on every item. The same summary reports that after an ankle fracture, 14% of patients had the top score by the 24-week follow-up. Knee osteoarthritis looks different: in the Huynh study of the Vietnamese version in adults aged 45 and over, only 1 of 174 reached the maximum score.
  2. Gaps in content for some groups. Ratter and colleagues reviewed 7 studies in lower limb fractures and rated content validity as inconsistent, on very low quality evidence. The items may not cover getting about with equipment or using transportation well enough, nor self-care such as toileting and body care. They also noted that the original development did not clearly define what the LEFS sets out to measure, and did not include interviews with patients about the items.
  3. One total, several things. In the same review, studies disagreed on whether the 20 items measure a single underlying ability, and structural validity was rated insufficient.
  4. It is self-report. It tells you how the patient sees their own function across daily life, not what they can do in front of you today. Pair it with a performance test.
  5. Change values do not transfer perfectly. Each MDC and MCID comes from one kind of patient, so quote the one closest to yours.

When a falling score needs more than a new exercise

A score describes function. It does not screen for serious problems. If the LEFS drops for no clear reason or new symptoms appear, reassess the patient and repeat your red flag screening before you change the program.

Teach patients with lower limb problems to act on these without waiting for their next appointment:

  1. A calf or thigh that is newly swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
  2. A leg or foot that is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.
  3. Emergency: pain, tingling, numbness or weakness in both legs, numbness or altered feeling around your genitals or bottom, or new trouble peeing or controlling your bladder or bowels. The same applies if you lose feeling in one leg. Call emergency services or go to an emergency department straight away. These can be signs of pressure on the nerves at the base of the spine (cauda equina syndrome).
  4. Emergency: you have had a fall or an injury and now have severe hip pain, or you cannot walk or put weight on the leg. Call emergency services or go to an emergency department. This can be a sign of a broken hip (hip fracture).

After surgery, the surgeon's protocol sets the program, whatever the LEFS says.

The short version

The Lower Extremity Functional Scale is a free 20-item questionnaire for lower limb problems: each item scores 0 to 4 and the total is out of 80, with higher scores meaning better function. Check the form is complete before adding it up, because the sources for this guide gave no published rule for missing items. Treat 9 points as the working threshold for change (Binkley and colleagues); Abbott and Schmitt put medium and large changes at 12 and 16 points. Score it at the first visit, at re-evaluations and at discharge. Write the baseline and the threshold beside each score, and add a performance test once the patient nears the top of the scale.

References

  1. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Physical Therapy. 1999;79(4):371-383. doi:10.1093/ptj/79.4.371
  2. Shirley Ryan AbilityLab Rehabilitation Measures Database. Lower Extremity Functional Scale. https://www.sralab.org/rehabilitation-measures/lower-extremity-functional-scale
  3. Mehta SP, Fulton A, Quach C, Thistle M, Toledo C, Evans NA. Measurement properties of the Lower Extremity Functional Scale: a systematic review. Journal of Orthopaedic and Sports Physical Therapy. 2016;46(3):200-216. doi:10.2519/jospt.2016.6165
  4. Abbott JH, Schmitt J. Minimum important differences for the patient-specific functional scale, 4 region-specific outcome measures, and the numeric pain rating scale. Journal of Orthopaedic and Sports Physical Therapy. 2014;44(8):560-564. doi:10.2519/jospt.2014.5248
  5. Pua YH, Cowan SM, Wrigley TV, Bennell KL. The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale. Journal of Clinical Epidemiology. 2009;62(10):1103-1111. doi:10.1016/j.jclinepi.2008.11.011
  6. Ratter J, Pellekooren S, Wiertsema S, van Dongen JM, Geleijn E, de Groot V, Bloemers FW, Jansma E, Ostelo RWJG. Content validity and measurement properties of the Lower Extremity Functional Scale in patients with fractures of the lower extremities: a systematic review. Journal of Patient-Reported Outcomes. 2022;6(1):11. doi:10.1186/s41687-022-00417-2
  7. Domzalski T, Cook C, Attarian DE, Kelley SS, Bolognesi MP, Vail TP. Activity scale for arthroplasty patients after total hip arthroplasty. Journal of Arthroplasty. 2010;25(1):152-157. doi:10.1016/j.arth.2008.11.009
  8. Huynh VP, Tran TD, Sinsurin K, Jalayondeja C. Cross-cultural adaptation and psychometric properties of the Vietnamese version of the Lower Extremity Functional Scale (LEFS) in individuals with knee osteoarthritis. Journal of Patient-Reported Outcomes. 2026;10(1):117. doi:10.1186/s41687-026-01088-z
  9. Krześniak H, Truszczyńska-Baszak A, Cygańska AK. Polish translation and cultural adaptation of the Lower Extremity Functional Scale (LEFS) for adults with lower extremity complaints. Scientific Reports. 2026;16(1):655. doi:10.1038/s41598-025-28319-5

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.