Letting patients know about shoulder arthroplasty outcomes - emphasizing function rather than "score"

As pointed out in a prior post: Nobody with Shoulder Arthritis Comes In Asking For An ASES score of 80...Guess What They Do Ask For, surgeons frequently express arthroplasty outcomes as a number: for example, the ASES, SANE, VAS, SAS, or SSV score. While these numbers are of value in clinical research, they have little meaning to the patient considering shoulder joint replacement, who would rather know which of their lost functions they are likely to regain after surgery.

A recent paper, "Anatomic shoulder arthroplasty: a single surgeon’s consecutive series of four hundred and fifty eight patients" [1], shows how this can be done. The authors tracked patients having an anatomic total shoulder for cuff-intact arthritis performed by one surgeon using a basic technique: preoperative planning with plain films, subscapularis peel, conservative non-corrective glenoid reaming, an all-polyethylene glenoid component with an ingrowth central peg, and a standard-length humeral component, carried out under general anesthesia. Preoperative CT scans, nerve blocks, augmented glenoid components, structural bone grafting, navigation, and patient-specific instrumentation were not used.

A prospectively collected database identified 523 shoulders for inclusion. Sixty-five (12%) had less than two years of follow-up, 19 of them because the patient had died. That left 458 shoulders: mean age 64 years, 62% male, mean follow-up 6.7 years. Two hundred eight had five or more years of follow-up; 116 had ten or more.

Each patient's shoulder function was characterized before and sequentially after surgery by asking them to answer "yes" or "no" indicating whether or not they could perform each of the 12 functions of the Simple Shoulder Test (SST).

The mean number of "yes" answers on the SST increased from 3.3 to 9.2 of 12, a change of 5.9 points, or about 3.7 times the minimal clinically important difference (MCID) of 1.6. The mean percent of maximal possible improvement (%MPI) was 71%.

These are the data useful in clinical research.

For the patients, the item-level results are the more useful ones.

SST items before surgery (red) and at final follow-up (blue) [1].

Before surgery, only 8% could sleep comfortably; afterward, 86%. Twenty-one percent could tuck in a shirt; afterward, 81%. Twenty-nine percent could put a hand behind the head; afterward, 91%. Those are gains of 78, 60, and 62 percentage points in the three functions patients often name when they describe what the arthritis has taken from them.

All twelve functions improved (p < 0.0001 for each). The highest final rates were for comfort at rest (97%) and placing a coin on a shelf at shoulder height (94%). The lowest were for overhand throwing (44%) and lifting eight pounds overhead (57%); both were still substantial improvements from preoperative rates of 3% and 9%.

Two of the largest gains, tucking in a shirt and hand behind head, depend on the internal and external rotation that are hardest to recover after a reverse total shoulder. Lopez and colleagues found that internal rotation dysfunction and anterior shoulder pain were more common after reverse than after anatomic arthroplasty for osteoarthritis, differences that standard outcome instruments may not capture [2].

This information is useful in our discussions with patients considering shoulder joint replacement.

Other findings from the study are also of interest to prospective patients.

Durability

The mean SST reached 9.3 by two years and stayed there: at no later time point did it fall by as much as the MCID of 1.6. The number of shoulders at risk declined over time, as it must in any long series: 422 at two years, 311 at four, 257 at six, 182 at eight, and 116 at ten. Patel and colleagues found 97% survivorship at ten years, with SST improving from 4 to 8 [3]. In 202 patients aged 60 or under, Neyton and colleagues reported improvement in the Constant score from 37.5 to 73.3, although survivorship of their total shoulders declined more steeply after ten years [4].

Twelve shoulders (2.6%) had a reoperation: seven within the first two years, four between two and five years, and one between five and ten years. Six were for subscapularis failure, two for stiffness, one for infection, one for hematoma, and one for glenoid loosening; one was converted to a reverse at an outside hospital for reasons that were not determined.

Of note, glenoid loosening—the failure mode often cited as a reason to avoid an anatomic total shoulder—accounted for only one reoperation in this series.

Predictive factors

In multivariable regression (n = 389, R² = 0.16), better final SST was predicted by higher preoperative SST, male sex, higher preoperative optimism, no prior shoulder surgery, and no tobacco use. Age, BMI, VAS pain score, and a history of depression or anxiety were not significant predictors. Greater change in SST was predicted by lower preoperative SST (R² = 0.32): the patients with the least function had the most to gain. Two of the five predictors of the final result can be addressed before the incision: tobacco use and the patient’s expectation of benefit. However, it should also be noted that the model explains only 16% of the variance in final SST, so most of what determines how a given patient ends up is not captured by these variables.

Glenoid type

The Walch classification was available for 349 shoulders (76%): A1 16, A2 146, B1 28, B2 100, B3 52, D 7. Glenoid morphology did not significantly affect final SST (p = 0.40), SST change (p = 0.41), or %MPI (p = 0.20). Shoulders with B2 glenoids had the highest final SST of any subgroup (9.7) and the highest %MPI (75%). B2 and B3 glenoids combined (n = 152) compared with concentric A-type glenoids (n = 162) as follows: final SST 9.5 versus 9.1 (p = 0.18), change +6.5 versus +6.0 (p = 0.09), and %MPI 73% versus 67% (p = 0.05).

Two of the 152 shoulders with eccentric glenoids (1.3%) had a reoperation, compared with seven of the 162 with concentric glenoids (4.3%; p = 0.31).

This finding is of interest because B2 and B3 morphology is often used as a reason to choose a reverse, an augment, or a graft [5]; a matched-cohort analysis, however, found no difference in clinical outcomes, complications, or revision rates between anatomic and reverse arthroplasty for these glenoids [6].

What this study does and does not show prospective patients

It shows that in 458 consecutive shoulders operated on by one surgeon with a standard, non-augmented, all-polyethylene glenoid, patient-reported comfort and function improved by more than three times the MCID, improved in each of the twelve functions measured, reached a plateau at two years, and did not decline by as much as the MCID in the shoulders followed beyond ten years.

The limitations include:

These outcomes were observed in the practice of an individual experienced surgeon using a consistent method and may not be generalizable to other practices.

The study does not compare outcomes of anatomic and reverse shoulder arthroplasty for cuff-intact arthritis.

The study did not assess serial radiographs for the presence of radiolucencies.

The study did not show that glenoid morphology does not matter, only that no difference was detected in this series.

There was loss to follow-up: 65 shoulders were excluded for lack of two-year data. Nineteen of those patients had died; the status of the other 46 is not known.

Finally, reoperation may be an insensitive endpoint in patients who are elderly, medically unfit, or content to live with a painful shoulder.

The Bottom Line

Our primary responsibility is to our patients. They make decisions about having surgery based largely on the information provided by the surgeon. This information needs to be presented objectively and in terms that are easily comprehensible. Sharing data on what functions past patients could perform before and after a defined surgical procedure is one such approach. The data will be most relevant if they come from the practice of the operating surgeon because the surgeon is the method.

Building a better way to inform our patients

Marsh Wren

Union Bay Natural Area

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References

1.         Schiffman C, Chin E, Whitson A, Hsu J, Matsen FA III. Anatomic shoulder arthroplasty: a single surgeon’s consecutive series of four hundred and fifty eight patients. Int Orthop. Published online September 10, 2026. doi:10.1007/s00264-026-07017-5

2.         Lopez R, Goltz D, Cox R, Yao JJ, Boufadel P, Lazarus M, Ramsey M, Namdari S. Comparison of anterior shoulder pain and internal rotation dysfunction after anatomic and reverse shoulder arthroplasty for osteoarthritis. J Shoulder Elbow Surg. 2025;34:2130-2137. doi:10.1016/j.jse.2024.12.027

3.         Patel AV, White CA, Schroen CA, Cirino CM, Ranson WA, Shukla DR, Galatz LM, Parsons BO, Flatow EL, Cagle PJ. Anatomic total shoulder arthroplasty: long-term clinical, radiographic, and patient-reported outcomes. J Am Acad Orthop Surg. 2026;34(16):e2226-e2232. doi:10.5435/JAAOS-D-25-01121. PMID 41812257

4.         Neyton L, Kirsch JM, Collotte P, Collin P, Gossing L, Chelli M, Walch G. Mid- to long-term follow-up of shoulder arthroplasty for primary glenohumeral osteoarthritis in patients aged 60 or under. J Shoulder Elbow Surg. 2019;28(9):1666-1673. doi:10.1016/j.jse.2019.03.006. PMID 31202630

5.         Aleisawi H, Kruse C, Nucci N, Alturki N, Abdel Khalik H, Athwal GS, Khan M. Outcomes of anatomic versus reverse shoulder arthroplasty for B2 & B3 glenoids with an intact rotator cuff: an updated systematic review and proportional meta-analysis. Shoulder Elbow. Published online July 17, 2025. doi:10.1177/17585732251359590. PMID 40689354

6.         Polisetty TS, Swanson DP, Hart PJ, Cannon DJ, Glass EA, Jawa A, Levy JC, Kirsch JM. Anatomic and reverse shoulder arthroplasty for management of type B2 and B3 glenoids: a matched-cohort analysis. J Shoulder Elbow Surg. 2023;32(8):1629-1637. doi:10.1016/j.jse.2023.02.125. PMID 36935078

Shoulder motion, function and satisfaction after arthroplasty

A recent article, Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty, pointed out that satisfaction after shoulder arthroplasty - can be associated with scores on patient-reported outcome measures (PROMs). (See Patient satisfaction after shoulder arthroplasty - anticipation and informing). In turn, PROMs are dependent upon restoring lost shoulder range of motion (ROM). The authors questioned whether there was a threshold in postoperative active ROM beyond which additional improvement in motion was not associated with additional improvement in the PROMs that primarily measured function (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES] score, and the Shoulder Pain and Disability Index [SPADI]). (Of note, other outcome measures, such as the Shoulder Arthroplasty Smart Score, primarily measure motion (70% of the total score) attributing only 10% of the points to function).

They included 4,459 TSAs (1,802 aTSAs, 2,657 rTSAs) with minimum 2-year follow-up. Indeed they found thresholds in postoperative ROM that were associated with no further improvement in the standard PROMs.

The "S" shapes of these curves are interesting. See for example the figures below plotting the patient's Simple Shoulder Test (SST) responses against active flexion and active external rotation. 

At the left side of these curves, improvement in motion has little effect on the number of SST functions the shoulder could perform. In the middle, there is a steep improvement in function with increasing range. At the right hand of the "S", the curve flattens out so that further improvements in range are not strongly associated with increased function. For the SST the inflection points (thresholds) were 153 degrees for active flexion, 50 degrees of active external rotation, and active internal rotation to L2. Similar thresholds were found for other function-based outcome measures, including the ASES score and the SPADI.

Subjective satisfaction was assessed by asking patients to rate their shoulder as being  “worse”, “unchanged”, “better”, or “much better” compared to before surgery. Among shoulders that achieved all ROM thresholds, 93% of patients rated their shoulder as “much better” compared to before surgery.

It is interesting to view these results in the light of data presented in Practical Evaluation and Management of the Shoulder. The authors of that book characterized elevation in terms of the angle of elevation

and the plane of elevation.

They learned that - rather than being confined to "abduction" and "flexion" - different functions were performed in different planes and with different angles of elevation.

It can be seen that the average maximum angle of elevation for eight normal subjects was 148 degrees, and that this range was not necessary for most of the activities of daily living.

Of course the ability to perform functions does not only depend on elevation angle and plane, but also on the rotation of the arm as shown below.

Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty is an important article in that it can help guide motion goals for arthroplasty surgery and postoperative rehabilitation. It suggests that a shoulder that has active elevation to 180, external rotation to 90 and internal rotation to T7 may not be more functional or satisfactory than one has 153 degrees of active flexion, 50 degrees of active external rotation, and active internal rotation to L2. 

Comment to shoulderarthritis@uw.edu

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link). 

How much should it cost to evaluate the shoulder?

Characterizing the comfort, function, and range of motion of the shoulder before and sequentially after treatment are the cornerstones clinical shoulder practice. As is the case for most types of measurement, greater accuracy, precision, and detail can be purchased with more money. The amount of accuracy, precision, and detail needed depends on questions that need to be answered.

For example, the authors of Test-retest reliability of isometric shoulder muscle strength during abduction and rotation tasks measured using the Biodex dynamometer found that shoulder muscle strength in abduction and rotation measured with the pricey Biodex dynamometer (see this link) are reproducible and correlate with the strength assessment of the Constant Score; under what circumstances is the increased cost worth it?  Furthermore, the Constant Score itself requires the costs of travel and a clinic visit (see this Constant–Murley Score: systematic review and standardized evaluation in different shoulder pathologies).

By contrast, validated mail-in questionnaires assessing shoulder comfort and function avoid the costs of equipment, travel and an office visit and provide information on the patient's ability to perform individual shoulder functions before and sequentially after treatment (see Shoulder joint replacement arthroplasty - what outcomes do patients care about?). 

As another example, the ranges of shoulder motion can be measured using an expensive artificial intelligence-based image recognition detectable sensor (see Comparative accuracy of a shoulder range motion measurement sensor and Vicon 3D motion capture for shoulder abduction in frozen shoulder); in what circumstances is the information gained worth the cost?

 Even the use of a simple goniometer by clinical staff requires travel and an office visit. 

Travel and visit costs for clinical followup can be avoided by the use of telehealth, as emphasized by the authors of Validation of an on-screen application-based measurement of shoulder range of motion (ROM) over telehealth medium who sought to investigate the accuracy and reliability shoulder range of motion measurement through telehealth in 24 healthy volunteers and 16 symptomatic patients with shoulder range of motion (ROM) deficits. The shoulder ROM was first examined physically using the goniometer in the clinic and then over Zoom. Comparison of the two methods showed only minor mean differences for the healthy volunteers and the patients. They concluded that the telehealth method of measuring shoulder ROM was accurate and reliable when compared to the clinical goniometer method.

Even simpler and more accessible than telemedicine is asking the patient, family, or friend to email photos of the arm in selected positions to follow ranges of motion in the treatment of conditions such as frozen shoulder and during joint replacement rehabilitation. 

Patients can be sent the figures below, asking them to position the arm as far in the indicated direction as possible. By keeping the photos on file the surgeon can monitor patient progress. The advantage of this system is that the patient need not be connected in real-time via telehealth, but can send in the photos at whatever time works for them.

Here are a few examples:

 

This approach can demonstrate active range 

assisted range

and the relative contributions of glenohumeral to scapulothoracic motion.

While this approach to following shoulder motion during treatment may not be as accurate as direct in-person measurements, it provides a cost effective method for monitoring the progress of shoulder range of motion achieved by physical therapy and surgery. Again, because photographs can be sent at a time convenient to the patient and viewed at a time convenient for the surgeon, this simple approach is easily accessible at both ends of the communication. If problems are identified, an in-person evaluation can be arranged. 

You can support cutting edge shoulder research and education that are leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

How does the shoulder work? Videos from the late Doug Harryman

 Our late fellow, Doug Harryman, produced many wonderfully educational videos.

In recognition of him and his many critical contributions to our understanding of the shoulder, we present a two part video that he produced and narrated on the mechanics of the shoulder. Click on these links: Part I and Part II
Sit back watch, learn, and remember him.

More about Doug Harryman can be found at this link and at this link.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

Assessing shoulder function: subjective, objective or both?

Relationship Between Patient-Reported Assessment of Shoulder Function and Objective Range-of Motion Measurements

These authors asked three questions:

(1) How does subjective patient assessment of shoulder function correlate with objectively measured active shoulder range of motion? 

(2) What is the difference in active motion between shoulders that can and those that cannot be used to perform each of the functions of the Simple Shoulder Test (SST see this link)? and

(3) Does the relationship between subjective and objective assessment of shoulder function differ between male and female patients?

In 74 male and 30 female patients with osteoarthritis they analyzed the relationship between the SST patient self-assessments of shoulder function  and objective range-of-motion measurements recorded by the observer-independent Kinect motion capture system

For both female and male patients, they found a poor correlation between objective measurements of active abduction and the total SST scores of osteoarthritic shoulders (square symbols). The relationships between active abduction and total SST score were closer for the contralateral shoulders (diamond symbols).

For all shoulders combined there was essentially no difference in these relationships for female (square symbols) and male (diamond symbols). 

They found a significant difference in active abduction between the osteoarthritic shoulders that allowed and those that did not allow the patient to perform the individual SST functions for only 4 of the 12 functions in the female group and 5 of 12 in the male group because of the highly variable relationship between self-assessed function and active abduction. 

In contrast, when the contralateral shoulders were assessed, this difference was found to be significant for 10 of the 12 functions in the female group and all 12 of the functions in the male group. 

Comment: One of the challenges in the measurement of passive and active shoulder motion is that these "objective" measurements have been shown to be observer-dependent. This study used an observer-independent method for measuring the range of active shoulder motion. 

The key finding in this study was that the active range of motion correlated poorly with the patients' self-assessed function of their osteoarthritic shoulders, meaning that the shoulder function was dependent on characteristics of the shoulder and the patient other than the active range of motion.

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