Expanding role of VISA-P in patellofemoral pain assessment-case for caution and context

Abstract

The VISA-P originally developed to assess patellar tendinopathy severity, is increasingly being applied to patellofemoral pain (PFP) assessment. This editorial examines the expanding role of VISA-P within the context of existing patient-reported outcome measures (PROMs) for PFP, such as the Kujala Anterior Knee Pain Scale and the Knee injury and Osteoarthritis Outcome Score for Patellofemoral Pain and Osteoarthritis. While VISA-P offers advantages in brevity, readability, and temporal stability, its original design targeting athletic populations with patellar tendinopathy limits its specificity and comparability when applied broadly to heterogeneous PFP populations. Moreover, VISA-P currently lacks validated diagnostic thresholds to guide clinical decision-making. Although the recent validation of VISA-P in Spanish-speaking populations enhances accessibility, caution is advised in its widespread adoption without clear delineation of its role relative to other PROMs. The editorial argues for careful contextual use of VISA-P, emphasizing the need for tools that balance specificity, efficiency, and universality to capture the complex spectrum of PFP across diverse populations.

Key Words: Patellofemoral pain; Patient-reported outcome measure; VISA-P; Knee; Athletic

Core Tip: The future of patient-reported outcome measures in patellofemoral pain (PFP) must balance specificity, efficiency, and universality. VISA-P may serve a niche-young, athletic, sport-homogenous groups-but broader utility demands either revision or combination with tools that capture the complexity of PFP across diverse demographics.

INTRODUCTION

The validation of the VISA-P for patellofemoral pain (PFP), represents an evolving trend in the search for pragmatic patient-reported outcome measures (PROMs). It was initially developed as a severity index for patellar tendinopathy by Visentini et al[1] in 1998, the VISA-P’s role in the management of PFP has yet to be established.

PROMS IN PFP: FILLING A GAP OR CROWDING THE FIELD?

PFP remains a pervasive condition, affecting physically active individuals, particularly runners[2,3]. The burden it imposes extends beyond mere physical limitations-it encroaches on psychological well-being, quality of life, and long-term joint health[4,5]. In this context, PROMs serve as critical adjuncts, helping clinicians appreciate the broader impact of disease burden on patients. Yet, despite the prevalence of PFP, there are 40 existing PROMs for anterior knee pain[4] and yet none have been universally accepted for the assessment of PFP.

Tools such as the Kujala Anterior Knee Pain Scale (KPS), introduced in 1993[6], and the Knee injury and Osteoarthritis Outcome Score for Patellofemoral Pain and Osteoarthritis (KOOS-PF), developed in 2014[7], have sought to fill this role. The Kujala scale, while specifically targeting anterior knee pain syndromes, is more global and was first described in 1993. More recently introduced in 2014, KOOS-PF, blends symptoms of osteoarthritis with patellofemoral-specific pathology, making it less applicable for young, active populations with isolated PFP, and independently stated to have the best content validity[8].

The VISA-P, with its relative brevity (approximately 4 minutes completion time), readability, and temporal stability, eases usability for patients. Comparable to the KOOS-PF, VISA-P has been validated in Spanish, enhancing accessibility and cultural reach[9].

Cross-cultural validation of PROMs is essential to ensure accurate assessment of PFP in Spanish-speaking populations, where direct translations may fail to capture cultural nuances in pain perception and functional limitation[10]. Instruments like the Spanish-adapted KOOS and Oxford Hip Score have undergone rigorous linguistic and psychometric validation, demonstrating reliable performance in clinical and research settings across Spain and Latin America[11,12]. VISA-P’s validation in Spanish increases its utility in the global content. Such culturally adapted PROMs enhance the interpretability of patient outcomes and support equitable, patient-centred care in orthopaedics.

Crucially, the question arises: Does VISA-P offer genuine advancement in PFP assessment, or does it merely add another measure without resolving core limitations?

VISA-P FOR PFP: STRENGTHS AND STRUCTURAL LIMITATIONS

The principal strength of VISA-P lies in its concise structure, grounded in assessing functional impairments relevant to athletic populations. Compared to KOOS-PF (approximately 4: 30 minutes) and Kujala (approximately 5 minutes), its efficiency is an advantage. Furthermore, temporal stability-a key psychometric asset-outperforms some existing tools, making it suitable for tracking clinical progression over time.

The original design of VISA-P targets patellar tendinopathy, not PFP. Its questions emphasize sport-specific functional tasks and pain during high-load activities. While there is overlap with athletic PFP, the instrument lacks specificity in capturing the broader spectrum of PFP presentations, especially in less active or sedentary individuals.

Among athletes, its comparability across individuals is compromised. As the authors themselves concede, VISA-P should not be used to compare individuals unless they are engaged in the same sport at the same intensity. This confines its use in large-scale studies or clinical audits where heterogeneity of activity levels is inevitable.

DIAGNOSTIC UTILITY VS. SEVERITY MONITORING

Another critical consideration is whether VISA-P offers diagnostic clarity or merely quantifies severity and impact. At present, there is no clear evidence or consensus regarding cut-off scores for intervention or stratification. While the scale may support longitudinal monitoring, it does not yet facilitate treatment thresholds or clinical decision-making-a missed opportunity in an area where effective interventions remain limited.

Further studies may allow the development of cut-off thresholds to help guide management options including early physiotherapy, activity modification, or surgical referral for refractory cases.

CONCLUSION

In conclusion, while the validation of VISA-P for Spanish-speaking populations with PFP is a welcome development, its role must be more clearly delineated. Without a definitive advantage over existing PROMs like KOOS-PF and KPS, particularly in non-homogenous populations, its widespread adoption could risk fragmenting outcome data, limiting cross-study comparability, and confusing interpretation for clinicians.

The future of PROMs in PFP must balance specificity, efficiency, and universality. VISA-P may serve a niche-young, athletic, sport-homogenous groups-but broader utility demands either revision or combination with tools that capture the complexity of PFP across diverse demographics. Until such time, it remains a valuable, but context-bound, instrument in the clinician's toolkit.