The LEFS, short for Lower Extremity Functional Scale, rates lower-limb function out of 80 points. Two figures govern its reading and are rarely stated together: the median in healthy people is 77, and the 9-point threshold everyone teaches actually spreads from 6 to 15. The interpreter is right below.
A patient at 70 does not have the ten points to the maximum ahead of them, but the seven to the median of healthy people. The detail is below.
Figures taken from the studies listed at the end of this page, every value carrying its source where it is written. The questionnaire itself is not reproduced.
What the LEFS measures
The LEFS rates lower-limb function, from hip to toes, across twenty items with five response categories. The total is a plain sum, unweighted and without subscales, and it runs from 0 to 80. Direction to remember, the reverse of most disability scales: a high score signals better function.
Published in 1999 by Binkley et al. in 107 patients referred to twelve physiotherapy clinics, it took hold because it fits on one page and covers the whole lower limb. Its test-retest reliability reached R = 0.94 and its correlation with the physical functioning of the SF-36 0.80.
A point of sourcing, because it holds for this whole page: the maximum of 80 is written in an indexed abstract, that of the 2017 normative study. The minimum of 0 follows from the twenty five-level items and appears in a third-party database, not in a PubMed abstract. This page quotes both, saying where each comes from.
The nine points have blown apart
The LEFS is taught around a single figure, nine points, and it is the most fragile figure in everything that follows.
In Binkley, the minimal detectable change and the minimal clinically important difference are both 9 points. That is a sample coincidence, and it makes indistinguishable in practice two notions that answer different questions: one says from when you are sure the score moved, the other from when the patient notices.
The 27-study review published in 2016 blows that figure apart. Published minimal detectable changes spread from 8.1 to 15.3 points depending on reassessment interval and population, while the pooled estimate of the same review falls to 6 points. The 2025 review, entirely devoted to these two values, adds the least-said fact: twenty-four studies published a minimal detectable change, across eleven language versions, against only five for the clinically important difference, across three versions. The most-taught threshold is also the least supported.
A ceiling at 77, not at 80
This is the least-known fact about this instrument, and it changes how an end-of-rehabilitation score reads.
A 2017 study had the LEFS filled in by 1,014 visitors and staff of four hospitals, with no lower-limb surgery in the past year or scheduled. The median comes out at 77 out of 80: 78 in men, 76 in women.
The consequence is direct. A patient at 70 does not have the ten points to the theoretical maximum ahead of them, but the seven to the median of healthy people. The LEFS therefore goes insensitive at the end of rehabilitation and in athletes, that is exactly where the physiotherapist most needs a fine measure. That is why the tool at the top of this page places the score against 77, and not against 80.
| What is measured | Value | Sample |
|---|---|---|
| Score range | 0 to 80 | 20 items, 5 categories |
| Median in a healthy population | 77 | 1,014 people |
| The same, men and women | 78 and 76 | same people |
| Test-retest reliability, original | R 0.94 | 107 patients |
| Error of a point score | ± 5.3 | same patients |
| Minimal detectable change, original | 9 | same patients |
| The same, spread of published values | 8.1 to 15.3 | 27 studies |
| The same, pooled estimate | 6 | 27 studies |
| Studies publishing a detectable change | 24 | 11 language versions |
| Studies publishing an important difference | 5 | 3 language versions |
A single score that Rasch disputes
The LEFS yields one score, without subscales, and presents it as unidimensional. Two independent analyses say otherwise.
An Italian team, in 135 patients, records problems with rating scale category functioning, item fit and item redundancy. A Finnish team, in 182 foot and ankle surgery patients, finds threshold misfit in 13 of the 20 items. Both reach, separately, the same final format: fifteen items and four response categories, with no loss of responsiveness.
A 2022 COSMIN review on lower-limb fractures closes the file differently. It rates the content validity of the LEFS 'inconsistent', on very low quality evidence. Yet content validity is the property the COSMIN method holds to be the most crucial: the most used instrument of the lower limb has not established that it covers what it claims to cover.
Why this page does not display the questionnaire
The LEFS is under licence: its twenty items are not reproduced here. For French-language use, it is the Échelle fonctionnelle des membres inférieurs, produced in 2011 for the Ottawa-Carleton rehabilitation network, that must be obtained. Two caveats come with it, worth knowing before using it: it is a Canadian version, and its validation covers only content validity, not the measurement properties of the French version itself.
Three administration pitfalls
Concluding on a nine-point gain
Nine points is the original figure, in 107 patients. Depending on population and interval, the published threshold runs from 6 to 15.3. A ten-point gain does not conclude the same thing after an ankle sprain and after a knee replacement.
Aiming for 80
The median of healthy people is 77. Setting 80 as the target means asking the patient to beat half the healthy population, and being surprised at progress that slows when it is simply hitting the ceiling of the scale.
Confusing the two thresholds
The minimal detectable change says from when the measurement moved; the clinically important difference, from when the patient notices. That both are nine points in Binkley is a sample accident, not an equivalence.
Frequently asked questions
What does LEFS stand for?
LEFS stands for Lower Extremity Functional Scale. The questionnaire was published in 1999 by Binkley et al. to cover all musculoskeletal conditions of the lower limb.
How is the LEFS scored?
Twenty items with five categories, summed without weighting, for a total of 0 to 80. There is no subscale, and a high score signals better function.
How much change counts?
The most quoted figure is 9, but published values run from 6 to 15.3 points depending on population and interval. There is no single transferable threshold.
What score should be aimed for at discharge?
Not 80. The median in a healthy population is 77 out of 80, measured in 1,014 people with no recent or scheduled lower-limb surgery.
Is there a French version?
Yes, a Canadian one: the Échelle fonctionnelle des membres inférieurs, or ÉFMI, produced in 2011 for the Ottawa-Carleton rehabilitation network. No version from France has been published.
References
8 sources, PMIDs included
- Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther 1999;79(4):371-83. PMID 10201543. The original publication, in 107 patients referred to twelve physiotherapy clinics. Test-retest reliability R = 0.94, correlation of 0.80 with the physical functioning of the SF-36. It sets the figures still taught today: error of a point score of ± 5.3 points, minimal detectable change 9 points, and minimal clinically important difference 9 points as well.
- Mehta SP, Fulton A, Quach C, Thistle M, Toledo C, Evans NA. Measurement Properties of the Lower Extremity Functional Scale: A Systematic Review. J Orthop Sports Phys Ther 2016;46(3):200-16. PMID 26813750. The 27-study review that blows the single figure apart. Published minimal detectable changes spread from 8.1 to 15.3 points depending on interval and population, while the pooled estimate falls to 6 points. The same review therefore justifies both that a 6-point gain suffices and that a 15-point gain does not.
- Zhang Y, Zang Y, Martin RL. Clinically most relevant psychometric properties of the Lower Extremity Functional Scale: a systematic review. Disabil Rehabil 2025;47(8):1932-8. PMID 39136394. The 2025 review, entirely devoted to the two figures that decide. It establishes the least-said fact: 24 studies published a minimal detectable change, across eleven language versions, against only 5 for the clinically important difference, across three versions. The most-taught threshold is also the least supported. Its abstract carries no numeric value: this page draws no threshold from it.
- Dingemans SA, Kleipool SC, Mulders MAM, Winkelhagen J, Schep NWL, Goslings JC, Schepers T. Normative data for the lower extremity functional scale (LEFS). Acta Orthop 2017;88(4):422-6. PMID 28350206. The reference values in a healthy population, across 1,014 visitors and staff of four hospitals, with no lower-limb surgery in the past year or scheduled. The median is 77 out of 80, 78 in men and 76 in women. It is the only indexed abstract in this base to carry the maximum of 80.
- Bravini E, Giordano A, Sartorio F, Ferriero G, Vercelli S. Rasch analysis of the Italian Lower Extremity Functional Scale: insights on dimensionality and suggestions for an improved 15-item version. Clin Rehabil 2017;31(4):532-43. PMID 27141086. The Italian Rasch analysis, in 135 patients. It records problems with rating scale category functioning, item fit and item redundancy, and reaches after iteration a version reduced to 15 items and 4 categories which does fit the model.
- Repo JP, Tukiainen EJ, Roine RP, Sampo M, Sandelin H, Häkkinen AH. Rasch analysis of the Lower Extremity Functional Scale for foot and ankle patients. Disabil Rehabil 2019;41(24):2965-71. PMID 29987946. The Finnish Rasch analysis, in 182 foot and ankle surgery patients, which finds threshold misfit in 13 of the 20 items. After collapsing two categories and removing five items, it reaches independently the same format as the Italian team: 15 items, 4 categories.
- René F, Casimiro L, Tremblay M, Brosseau L, Lefebvre A, Beaudouin M, Belliveau V, Bergeron LP. Physiother Can 2011;63(2):242-8. PMID 22379265. The French-Canadian version, produced for the Ottawa-Carleton rehabilitation network, which serves a French- and English-speaking clientele. It proposes the title Échelle fonctionnelle des membres inférieurs, ÉFMI, and examines its content validity by parallel reverse translation and two expert committees. The title of this article is not indexed by PubMed, which returns 'Not Available': this page invents none for it.
- 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. J Patient Rep Outcomes 2022;6(1):11. PMID 35092528. The COSMIN review on lower-limb fractures, across seven studies. It rates content validity 'inconsistent', on very low quality evidence. Yet content validity is the property COSMIN holds to be the most crucial: the most used instrument of the lower limb has not shown that it covers what it claims to cover.
Page written by Anthony Baillon, physiotherapist, co-founder of Physio Learning. The questionnaire itself is by Binkley et al., 1999, and it is under licence: this page documents and interprets it, it reproduces none of its items.