Clin Rheumatol (2013) 32:91–98
DOI 10.1007/s10067-012-2095-0
ORIGINAL ARTICLE
Cross-cultural adaptation and validation of the Spanish
version of the Cumberland Ankle Instability Tool (CAIT):
an instrument to assess unilateral chronic ankle instability
David Cruz-Díaz & Fidel Hita-Contreras &
Rafael Lomas-Vega & M. C. Osuna-Pérez &
Antonio Martínez-Amat
Received: 27 July 2012 / Revised: 7 September 2012 / Accepted: 15 September 2012 / Published online: 9 October 2012
# Clinical Rheumatology 2012
Abstract The Cumberland Ankle Instability Tool (CAIT) is a
valid instrument to determine the presence of chronic ankle
instability (CAI) and to assess its severity. Self-report test is
very useful for researchers and clinical practice, and CAI is a
widespread tool. Nevertheless, there is lack of measurement
instruments validated into Spanish, which represents a major
difficulty for research dealing with a Spanish-speaking popu-
lation. The questionnaire was cross-culturally adapted into
Spanish. The psychometric properties tested in the Spanish
version of the CAIT were measured for internal consistency,
test–retest reliability, construct validity, criterion validity, and
responsiveness in 108 participants who were recruited from
several fitness centers. The Spanish version of the CAIT had
high internal consistency (Cronbach's α00.766) and reliabil-
ity (intraclass correlation coefficient00.979, 95 % confidence
interval (CI)00.958–0.990). Correlation with the 36-item
Short-Form Health Survey (SF-36) physical component sum-
mary score (rho00.241, p00.012) was greater than the SF-36
mental component summary score (rho0−0.162, p00.094).
The construct validity shows three different factors in the
questionnaire and good responsiveness with a mean change
of −2.43 (95 % CI0−3.12 to 1.73, p<0.0001) and a size effect
of Cohen's d01.07. The Spanish version of the CAIT has been
D. Cruz-Díaz : F. Hita-Contreras : R. Lomas-Vega :
M. C. Osuna-Pérez : A. Martínez-Amat (*)
Department of Health Sciences, Faculty of Health Sciences,
University of Jaén,
23071 Jaén, Spain
e-mail: amamat@ujaen.es
F. Hita-Contreras : A. Martínez-Amat
Institute of Biopathology and Regenerative Medicine (IBIMER),
Departmento de Anatomía y Embriología, Facultad de Medicina,
University of Granada,
18071 Granada, Spain
shown to be a valid and reliable instrument for measuring
chronic ankle instability and constitutes a useful instrument
for the measurement of CAI in the clinical setting in Spain.
Keywords Ankle instability . CAIT . Cross-cultural
adaptation . Spanish version
Introduction
Ankle sprain is one of the most common injuries occurring not
only in sport [1], but in everyday activities [2]. It is estimated
that one ankle sprain occurs per 10,000 population everyday
[3]. One of the most important problems is the great recurrence
rate of ankle injuries, which has been reported to be as high as
80 % [4]. Changes in the proprioceptive system of the ankle
joint complex, together with muscular weakness, subtalar joint
instability, and ligamentous laxity have been identified as
contributing factors to chronic ankle instability (CAI) [5–8].
Self-reported outcome instruments have become a valu-
able tool for clinical practice and research due to the impor-
tance of monitoring the effectiveness of treatment, the basis
of evidence-based health care. Hiller et al. developed the
Cumberland Ankle Instability Tool (CAIT) [9], a discrimi-
native questionnaire that can identify patients with CAI and
measure the severity of functional ankle instability. It is a
valid and reliable instrument, and compared to others, such
as the ankle instability instrument [10], it is widely
employed. The CAIT was originally developed in English
with a high content validity based on qualitative techniques
(focus group data) and a complete literature review. This
questionnaire is independent of reference to the other leg
with a particular multiple answer option for each item,
increasing the precision of the instrument.
92 Clin Rheumatol (2013) 32:91–98

Currently, a Spanish version of the chronic ankle instability
questionnaire is not available. Therefore, we have chosen to
cross-culturally translate it and determine its measurement
properties according to the guidelines described by Guillemin
et al. and Beaton et al. [11, 12], which are widely accepted and
used for the translation and adaptation of outcome measures.
Culturally adapting a health questionnaire, rather than devel-
oping a new one, is preferred, as it is more economical and
faster, and it may facilitate future comparisons among popu-
lations [13, 14]. Therefore, the aim of the present study was to
determine the measurement properties of the Spanish version
of the CAIT.
Materials and methods
The Cumberland Ankle Instability Tool
The original version of CAIT comprises nine items designed
to evaluate several aspects of chronic ankle instability
(Appendix 1). The items look into the degree of difficulty
in performing different physical activities due to the CAI of
the affected ankle. The total score of the nine items ranges
from 0 (severe instability) to 30 (normal stability). The
psychometric properties of the original version showed that
CAIT can discriminate between stable and unstable ankles
and classify them according to severity of the instability.
The test–retest reliability was excellent (intraclass correla-
tion coefficient (ICC) 2.100.96) and internal consistency
was acceptable (α00.83) [9].
cultural differences and still preserve the equivalence
with the original version. Therefore, the term “the ball
of my foot” was translated as “pulpejo del pie” which
means “the fleshy part of the foot” when literally trans-
lated into English and “roll over” was translated as
“torcer” which means “to sprain” in the literal translation
into English. After these considerations, the psychometric
properties of the final Spanish version of the CAIT were
assessed.
Study population
The final Spanish version of the CAIT was administered to
108 native Spanish speakers (58 males and 50 females) over
18 years old. The subjects were recruited by invitation from
five Spanish sport centers. Inclusion criteria were:
1. Previous history of unilateral ankle sprain with at least a
2-month record before the start of the study
2. No other lower limb injuries 6 months before the enrollment
process (e.g., fracture, talipes equinovarus, and surgery)
3. Patients who did not meet the above criteria or were unable
to read the questionnaire were excluded from the study
A subgroup of 32 participants filled out the Spanish
version of the CAIT 1 week later for retesting. Character-
istics of the sample are described in Table 1. The study was
approved by the University of Jaén's Human Ethics Com-
mittee and a written informed consent was gained from all

Cross-cultural adaptation Table 1 Description of the sample of study and the subsample of test–
retest group
The process of the cross-cultural adaptation and validation of
the Spanish version of the CAIT was performed according to Variables Sample N0108 Retest group N032
the guidelines proposed by Guillermine et al. [11] and Bea- Age 30.22 8.78 25.84 2.89
ton et al. [12]. Working independently, two bilingual experts Height 1.71 0.08 1.71 0.07
translated the English CAIT into Spanish (Appendix 2). The Weight 68.08 1064 69.69 9.68
translators met with two clinical experts in the field (one of
BMI 23.19 2.61 23.70 2.03
them was a medical doctor and the other was a physiother-
CAIT score 24.83 2.99 26.34 1.52
apist) to ensure that the phrasing of each test item was
Gender
clinically appropriate. The two versions were compared in
Male 58 53.70 % 20 62.50 %
a meeting between the two translators and a single consensus
Female 50 46.30 % 12 37.50 %
version was developed.
Ankle
Back-translation from Spanish into English was per-
Left 40 37.04 % 11 34.38 %
formed independently by two other professional bilingual
Right 68 62.96 % 21 65.63 %
translators who were blinded to the original English
version of the CAIT. The two back-translated versions Quantitative variables were expressed as means and SD. Categorical
were compared and a single consensus version was de- variables are expressed as frequencies and percentages
veloped. Some modifications were performed to address BMI body mass index, CAIT Cumberland Ankle Instability Tool
Clin Rheumatol (2013) 32:91–98 93

participants prior to commencing data collection. To assess the post-measurement data, was used to determine the magni-
sensitivity to change, 63 of the 108 participants accepted to tude of the effect.
participate in a 4-week proprioceptive training program
(three sessions a week) focused on the improvement of
lower limb postural control, active force restoration and Results
ankle strength, and coordination.
The mean CAIT score and standard deviation (SD) of the total
Analysis of psychometric properties sample (n0108), the test–retest subsample (n032) and the
proprioceptive intervention subsample (n063) were 24.83, SD
Five psychometric properties of the Spanish version of the 2.99; 26.34, SD 1.52; and 22.65, SD 1.84, respectively
CAIT were analyzed: internal consistency, test–retest reli- (Table 1).
ability, criterion validity, construct validity, and sensitivity
to change. This process was carried out on 108 subjects with Internal consistency
ankle injury. Test–retest reliability was assessed on a sub-
sample of 32 subjects and sensitivity to change was assessed The Cronbach's α for the score of the Spanish version of
on a subsample of 63 subjects. the CAIT in the first measurement was 0.766, providing
Internal consistency of the Spanish version of the CAIT high internal consistency. In the item analysis, no im-
was assessed by Cronbach's α coefficient. The CAIT score provement was observed every time that one particular
of the first measurement was used for this analysis. An item was deleted from the scale, except for numbers 5
instrument is considered internally consistent when the and 6, showing a very slight increase when they were
items are at least moderately correlated with each other omitted (Table 2).
and each item is correlated with the total score (α00.70 to
0.95) [15, 16]. Test–retest reliability
Intraclass correlation coefficient was used to determine test–
retest reliability. It is considered poor when ICC is <0.40, To determine test–retest reliability, CAIT was administered
moderate between 0.40 and 0.75, substantial between 0.75 to a subgroup of 32 subjects 1 week after the first time. ICC
and 0.90, and excellent when >0.90 [17]. value was 0.979 (95 % CI00.958–0.99, p<0.001) and can
The generic 36-item Short-Form Health Survey (SF-36) be considered as excellent.
questionnaire was used to assess the criterion validity of
the Spanish CAIT. SF-36 is a multipurpose, short-form Construct validity
health survey with only 36 questions, which is widely
used to survey health-related quality of life. SF-36 is a To evaluate the construct validity, exploratory factor anal-
questionnaire used to obtain a measure of health status ysis was used. The Kaiser–Meyer–Olkin score, a measure
and has demonstrated validity across all ages. It provides of sampling adequacy, was 0.781, and the suitability of
two summary measures: physical health and mental health the sample for the exploratory factor analysis was
[18, 19]. The Spanish version of the SF-36 was translated
and validated in the Spanish population by Alonso et al. Table 2 Internal consistency
in 1995 [20].
Construct validity was assessed by exploratory factorial Corrected item: Cronbach's α if item
total correlation was deleted
analysis with the scores of the first CAIT. According to
Kline's criteria, a sample of 108 subjects is enough to Item 1 0.600 0.716
perform this analysis [21]. Item 2 0.619 0.713
Sensitivity to change is defined as the ability of a measure Item 3 0.409 0.749
(or instrument) to reflect underlying change over time [22]. Item 4 0.583 0.725
After the 4-week specific proprioceptive training program, the Item 5 −0.073 0.792
CAIT questionnaire was filled out again by the 63 subjects Item 6 0.209 0.776
who accepted to participate in this program. The analysis of Item 7 0.498 0.740
the results was carried out using Student's t test for paired Item 8 0.629 0.721
samples. Cohen's d for paired samples, defined as the differ- Item 9 0.508 0.738
ence between two means divided by the standard deviation of
94 Clin Rheumatol (2013) 32:91–98

Table 3 Total variance explained through exploratory factor analysis

Component Initial eigenvalues Extraction sums of squared loadings Rotation sums of squared loadings

Total % variance Cumulative, % Total % variance Cumulative, % Total % variance Cumulative, %

1 3.495 38.834 38.834 3.495 38.834 38.834 2.601 28.904 28.904

2 1.266 14.063 52.897 1.266 14.063 52.897 1.829 20.319 49.222
3 1.216 13.507 66.404 1.216 13.507 66.404 1.546 17.182 66.404
4 0.801 8.905 75.309
5 0.653 7.254 82.563
6 0.466 5.182 87.745
7 0.418 4.642 92.388
8 0.368 4.091 96.478
9 0.317 3.522 100.000

Extraction method (principal component analysis) was used

demonstrated by the Bartlett test of specificity (p<0.001). Sensitivity to change

The total variance explained is 66.404 % (Table 3).
Component matrix identified three factors. Seven items
loaded to the first factor, whereas items 5 and 6 produced
independent factors (Table 4).
Criterion validity
The baseline and final mean scores were 22.65 (SD01.84)
and 25.08 (SD02.27), respectively. The mean change was
−2.43 (95 % CI0−3.12 to 1.73, p<0.0001). In the magni-
tude of the effect size estimation, Cohen's d was 1.07, which
can be considered as a high effect size [23].

The Spearman correlation coefficient between SF-36

and the Spanish CAIT components was used to assess Discussion
criterion validity. The Spanish version of the CAIT
presented a low but statistically significant Spearman Ankle sprain is one of the most common injuries not
correlation with the physical component summary only in physical exercise practice, but also in normal
(rho 00.241, p 00.012) and no statistical relationship everyday activities. As a consequence of this damage,
with the mental component summary (rho 0−0.162, p0 residual symptoms in ankle joint are not uncommon.
0.094). Frequently patients with previous history of ankle sprain
reported feelings of ankle joint instability and episodes
of “giving way” [24]. Once ankle sprain occurs, recur-
Table 4 Component matrix
rent twists of this ankle, weakness, and pain usually
Component complicate the development of some activities with au-
tonomy and security [25, 26]. These symptoms can
1 2 3
persist for prolonged periods if not properly treated,
Item 8 0.796 −0.199 −0.055 leading to chronic ankle instability. An appropriate ther-
Item 1 0.730 0.268 −0.249 apeutic approach is essential for the prevention and
Item 9 0.719 −0.351 −0.195 management of the adverse effects associated with ankle
Item 4 0.701 −0.044 0.334 sprain. This negative impact involves not only physical,
Item 2 0.692 0.460 −0.096 but also socioeconomic consequences for the patient
Item 7 0.632 0.365 −0.327
[27]. For these reasons, there is an increasing number
Item 3 0.579 −0.378 0.399
of studies about the diagnosis, treatment, and prevention
Item 5 −0.149 0.731 0.342
of the ankle joint complex sprain and its consequences.
Until now, there has been no specific method to assess
Item 6 0.288 0.085 0.781
the chronic ankle instability in Spanish. Therefore, our
Extraction method (principal component analysis) objective was to perform the Spanish cross-cultural
Clin Rheumatol (2013) 32:91–98
adaptation and validation of the CAIT, thus providing a
valid and simple tool to discriminate and measure the sever-
ity of functional ankle instability for Spanish-speaking clini-
cians and researchers [9].
The adaptation of a questionnaire to another language is
not only a translation of the original into another language: it
is a thorough process, and transcultural differences must be
considered. The translation of the English CAIT into Span-
ish and the back-translation adequately corresponded with
the original version. No modifications were included, the
meaning of the items was preserved, and there was complete
consensus about the final version. Nevertheless, significant
findings were observed in the analysis of the psychometric
properties of the instrument.
The Cronbach's α of the questionnaire ranged from 0.70
to 0.95, which is a very good internal consistency [15]. In
the original version of the CAIT, the Cronbach’s α was 0.83
[9], similar to that obtained in the present study.
Test–retest reliability of the Spanish version of the CAIT
was 0.979 with a 95 % CI between 0.958 and 0.990 (p<
0.001), slightly superior to the value of the English version
(0.96). Both results are considered excellent and show a
high level of reliability [15, 17]. These data confirm that
the Spanish version of the CAIT can be considered as a
reliable and stable instrument for the assessment of chronic
ankle instability.
In the evaluation of the construct validity, the explor-
atory factorial analysis showed three components that
explained 66.40 % of the total variance. From the
whole nine items, seven loaded in the same factor,
and items 5 and 6 produced independent factors. The
Cronbach’s α was slightly increased when items 5 and
6 were deleted. No factorial analysis was performed in
the original version of the CAIT, and therefore, no
comparison can be made. The Spanish version of the
CAIT is the first in assessing its internal structure,
establishing a one-dimensional component with two
equally important aspects (items 5 and 6). A possible
explanation to this might be that all the items in the
questionnaire are related to usual and daily activities
(running, practicing sports, and walking down stairs),
while items 5 and 6 refer to unusual activities such as
feeling unstable when standing on one leg (item 5) or
when hopping from side to side (item 6). These unusual
instability situations may be perceived in a different
way by the patient.
Criterion validity was assessed using the Spearman cor-
relation coefficient between the SF-36 summary compo-
nents and the Spanish version of the CAIT. Our results
showed a stronger correlation with the physical than with
95
the mental component of the SF-36. This agrees with other
studies which suggested that physical function and pain
dimensions of SF-36 seem to be most relevant on outpa-
tients with musculoskeletal conditions [28].
Sensitivity to change, also called longitudinal construct
validity [29], is considered an integral part of the analysis of
the questionnaire's validity. In the present study, results
show how the patients improve the overall scores in the
CAIT due to the 4-week specific proprioceptive training
program. This points at the questionnaire's ability to deter-
mine changes in the patient's status. Functional instability of
the ankle can be identified in those with a CAIT score lower
than 27. According to the questionnaire, a patient with a low
score will experience difficulties not only in sports perfor-
mance or demanding activities, but also in daily life activ-
ities such as walking or standing upright. This should be
considered when evaluating the responsiveness of the ques-
tionnaire, where it is understandable that worse scores at
baseline obtained a bigger improvement than those with
better initial results.
Good psychometric properties and the capacity to
identify subtle changes in a patient's status over time
make the Spanish version of the CAIT a useful tool in
chronic ankle instability management. It is a fast and
easily applicable instrument that will allow clinicians to
assess the effectiveness of treatment, providing immediate
feedback on the patient's ankle status and enabling the
development of therapeutic strategies. The Spanish CAIT
can also provide Spanish researchers a valid tool for
research on ankle instability, a very usual health problem
in the Spanish population.
Conclusions
The Spanish version of the CAIT has been shown to be a
valid and reliable instrument for measuring chronic ankle
instability. Acceptability was high and time for completion
was short, thus making CAIT a useful instrument to measure
CAI in the clinical setting in Spain.
Acknowledgments The authors wish to express their gratitude to
Medicarim Centro Company for their logistic support, Mr. Agustín
Pérez-Barroso for his help with technical and practical issues in this
study, Dr. Valentín Rocandio-Cilveti for his collaboration in the theoret-
ical framework of this study, and every athlete who kindly agreed to take
part in this research.
Disclosures Cross-cultural adaptation to spanish speaker population
of CAIT.
96 Clin Rheumatol (2013) 32:91–98

Appendix 1. Cumberland Ankle Instability Tool

Please tick the statement that best describes your ankles.

Note: The scoring scale is on the right. The scoring system is not visible on the subject's version
Clin Rheumatol (2013) 32:91–98 97

Appendix 2. Spanish version of the CAIT

Por favor, marque en cada pregunta la ÚNICA afirmación

que describa mejor sus tobillos

NOTA. La escala de puntuación está en la derecha. El sistema de puntuación no está visible en la versión del participante
98
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