To investigate shoulder scoring systems used in Europe and North America and how outcomes might be classified after shoulder joint replacement. All research papers published in four major journals in 2012 and 2013 were reviewed for the shoulder scoring systems used in their published papers. A method of identifying how outcomes after shoulder arthroplasty might be used to categorize patients into fair, good, very good and excellent outcomes was explored using the outcome evaluations from patients treated in our own unit. A total of 174 research articles that were published in the four journals used some form of shoulder scoring system. The outcome from shoulder arthroplasty in our unit has been evaluated using the constant score (CS) and the oxford shoulder score and these scores have been used to evaluate individual patient outcomes. CSs of < 30 = unsatisfactory; 30-39 = fair; 40-59 = good; 60-69 = very good; and 70 and over = excellent. The most popular shoulder scoring systems in North America were Simple Shoulder Test and American shoulder and elbow surgeons standard shoulder assessment form score and in Europe CS, Oxford Shoulder Score and DASH score.

Functional shoulder disabilities are frequently reported by patients with a wide variety of conditions, such as arthritis, rotator cuff disease, breast carcinoma, trauma and radiation therapy[1]. Upper limb disabilities may include pain, stiffness, decreased range of movement, lymphoedema and reduced activity tolerance. There are a myriad of scoring systems used in everyday orthopaedic practise and research, and a number of scoring systems have been developed and established to assess the function and limitations of the shoulder. None of these are ideal methods for correlating both the physician’s and the patient’s perspective[2] as some are more inclined towards the opinion of the physician while others are more centred on the patient’s self-assessment. A review of four popular journals (see below) showed that in their 2012 volumes 16 different scoring systems were commonly used to evaluate shoulder conditions. This can make it difficult to compare outcomes between studies and interventions, and makes it more problematic for practising orthopaedic surgeons to decide which of their treatment options is providing the best outcomes if the scoring systems used are different. This review aims to evaluate the evidence behind the scoring systems, and will provide some guidance as to which to rely on.

Many shoulder scoring systems are used inappropriately without being tested for their sensitivity, reproducibility and validity[3]. In order to apply any scoring system, their complete validation must be documented. Over the last 5 years the use of patient reported outcome measures (PROMs) have been promoted as they are considered to place a greater emphasis on the quality of life perceived by the patient[4]. There is therefore a need to develop questionnaires or shoulder scoring outcome measures which can address specific conditions or abnormalities of the shoulder so that they can fulfil both the patient’s and clinician’s perspective[5]. Above all, shoulder scoring systems need to be evaluated and modified for specific condition to produce a valid, sensitive and reproductive outcome.

A review was carried out of all the articles in the 2012 and 2013 volumes of four major MEDLINE/PubMed referenced journals: The Journal of Bone and Joint Surgery (Am); The Journal of Bone and Joint Surgery (Br - now called the Bone and Joint Journal); The Journal of Shoulder and Elbow Surgery; and the American Journal of Sports Medicine. That review is summarised in Figures 1 and 2 and Table 1. The CS and the ASES are those most frequently used. This may be because of their long history, and the tradition of combining both objective and subjective assessments of patients. Both have also been extensively validated. However, there is evidence that patient self-reported scoring is not only easier and cheaper, but may also be a more accurate method of assessing orthopaedic outcomes[38-40]. Other popular scoring systems include the DASH, the SST and the university of California-Los Angeles shoulder scale (UCLA). The remainder are used far less commonly, sometimes for specialised situations (i.e., the Kerlan-Jobe Orthopaedic Clinic - KJOC overhead athlete score). Different shoulder scoring systems appear to be used in different countries. In Europe the CS, DASH and the OSS appear to be the most common, while in North America, the ASES, SST, and UCLA are used to assess the shoulder most often. All of these scoring systems either test different things or features in different ways to assess shoulder function. However, one would presume some kind of inter-correlation might be found between the scoring systems used in Europe and those being performed in United States as all of them intend to evaluate the shoulder function.

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Figure 1 Number of articles that used different shoulder scoring systems during 2012 and 2013.

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Figure 2 Most popular shoulder scoring systems during 2012 and 2013. ASES: American shoulder and elbow surgeons standard shoulder assessment form; DASH: Disabilities of the arm, shoulder and hand; UCLA: University of California-Los Angeles shoulder scale.

A number of papers have evaluated whether different scoring systems are comparable. The CS is a combination of both a clinically-based and patient assessment outcome measure for patients with shoulder problems, while most other scores focus on more patient-based outcome measures. One would therefore suspect that the CS cannot be interchanged or merged with the other scoring systems which are based on self-assessment by the patients. In contrast, OSS, DASH, SST and WOSI scoring systems can be compared and interchanged to some extent. However there are confounding factors which will influence these scores. All the patient-based assessment outcome measures may be affected by personal or patient response biases. Scott et al[41] have compared the CS and OSS, and found that using the OSS gave a higher proportionate overall score for the shoulder patient than the CS and that the agreement between the scores was poor. However, other studies have revealed that OSS is more stable than CS in terms of outcome measures[18,42]. Skutek et al[43] have also shown only moderate correlation between the CS and SST. Hirschmann et al[13] suggested that CS is poor at measuring shoulder strength and should be re-evaluated for its sensitivity and reliability. Lewis[44] reviewed patients with subacromial impingement, and measured CS, DASH and the EuroQol (EQ-5D) quality of life measurement. He found that CS and DASH were both significantly improved in the intervention exercise group, but CS improved more than DASH, suggesting poor agreement between the two systems.

As the OSS and DASH are patient self-assessment measurement outcomes they could be expected to be interrelated to each other but may sometimes be used combined. Studies have reported that OSS is better to assess the surgical outcome in patients with rheumatoid arthritis as compared to the DASH and SF-36[45].

In order to check the reliability and validity of DASH and SF-6D, Slobogean et al[24] studied patients with treated proximal humeral fractures. They reported that DASH and SF-6D questionnaires were adequate in assessing psychometric properties, and suggested that these scoring systems are appropriate to assess the outcome in patients treated for proximal humeral fractures. Interestingly, van de Walter et al[46] reviewed five scoring systems-CS, -OSS, -DASH, -UCLA and a Subjective Shoulder Value following proximal humeral fractures and concluded that currently available shoulder scoring systems may not offer significant value for assessing functional improvement after such fractures.

Godfrey et al[29] conducted a study on 1077 patients suffering from shoulder instability to assess the reliability, validity, and responsiveness of the SST. They found that the SST is significantly correlated with the ASES score and both responded to change in shoulder function. However, they reported that the results were different for different age groups and different types of shoulder injury. The study conducted by van Kampen et al[16] also revealed that the SST is highly correlated with the DASH, OSS and SF-36 in terms of physical subscales; however, it did not correlate well with the CS.

Many surgical and non-surgical shoulder interventions take months to gain full benefit after shoulder treatment, so any follow up has to be measured over months and years to evaluate longer term outcomes. Our preference is to score all our patients preoperatively, then at 6 mo and 1 year if the patient continues to be followed up. For shoulder joint replacement patient’s scores are then repeated at 3, 5 and 10 years unless the patients are scored more regularly as part of a research protocol.

It has been standard practice in our unit for 20 years to use the CS to evaluate the outcome from shoulder operations and, in particular shoulder arthroplasty. Previous studies, reported in 2007[15] have highlighted the changes in the CS in normal people with increasing age and between the sexes. Table 2 shows the estimated normal CSs for age and sex.

As a practical example from our unit, in 2013 we evaluated the outcomes from all our primary anatomic and inverse (or reverse) shoulder replacements using a new Vaios shoulder replacement design[47] and the results are shown in Table 3 for anatomic shoulder arthroplasty and Table 4 for reverse shoulder arthroplasty. However these means and standard deviations are difficult to understand for most orthopaedic surgeons but they become more meaningful if they are converted into different grades of improvement.

We have therefore developed a meaningful grading system for assessing the outcomes following arthroplasty using either the CS as shown in Table 5 or the age and sex adjusted CS as shown in Table 6. These results are more meaningful than means and standard deviations and allow us to appreciate that 60% of patients achieve a good, very good or excellent result after anatomic Total Shoulder Replacement while 76% achieve a good, very good or excellent result after Inverse or Reverse shoulder replacement using the age and sex adjusted CS.

It is difficult to choose the best scoring system as a “best choice of outcome measurement tool” for patients with shoulder problems. There remains a need to develop a comprehensive outcome measurement tool that can adequately deal with both the clinician’s and the patient’s perspective. None of the scoring systems ideally fulfil this criterion. For instance, the clinically-based outcome measuring tool may not satisfy the patient, and the patient self-assessment tools may not provide the information that the clinician believes is important. Patient-based assessment tools may fall a victim to bias as the patient may under or over report symptoms: under-reporting if they wish to please the surgeon or over-reporting for secondary (or compensation related) gain. Similarly, physician-based tools may not truly reflect what the patient feels about their outcome. Therefore it makes sense to combine scoring systems when collecting data for outcome measures, and we would recommend using multiple scores, including clinically - based and patient self-assessment tools. We currently use the CS and OSS in our unit for the majority of our patients but the SST has also been proven to be a valuable outcome assessment in North America. These assessment do need to be carried out at the appropriate time and our policy in Nottingham is to always carry out a pre-operative assessment and then to carry out the first post-operative evaluation at 6 mo after surgery when the patient’s condition is reaching a plateau. The United Kingdom health service has become much more focused on using PROMs and many are moving towards using the OSS as their preferred PROM for general shoulder assessment.