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ORIGINAL ARTICLES

A standardized method for the


assessment of shoulder function
Research Committee, American Shoulder and Elbow Surgeons
Robin R. Richards, MD, FRCS(C), Chairman, Kai-Nan An, PhD,
Louis U. Bigliani, MD, Richard J. Friedman, MD, FRCS(C),
Gary M. Gartsman, MD, Anthony G. Gristina, MD,
Joseph P. Iannotti, MD, PhD, Van C. Mow, PhD, John A. Sidles, PhD, and
Joseph D. Zuckerman, MD, Rosemont, III.

The American Shoulder and Elbow Surgeons have adopted a standardized form
for assessment of the shoulder. The form has a patient self-evaluation section
and a physician assessment section . The patient self-evaluation section of the
form contains visual analog scales for pain and instability and an activities of
daily living questionnaire. The activities of daily living questionnaire is marked
on a four-point ordinal scale that can be converted to a cumulative activities of
daily living index. The patient can complete the self-evaluation portion of the
questionnaire in the absence of a physician. The physician assessment section
includes an area to collect demographic information and assesses range of
motion, specific physical signs, strength, and stability. A shoulder score can be
derived from the visual analogue scale score for pain (50%) and the cumulative
activities of daily living score (50%). It is hoped that adoption of this instrument
to measure shoulder function will facilitate communication between investigators,
stimulate multicenter studies, and encourage validity testing of this and other
available instruments to measure shoulder function and outcome.
(J SHOULDER ELBOW SURG 7994;3:347-52)

The

American Shoulder and Elbow Surgeons


adopted a standardized form for the assessment of shoulder function at their annual closed
meeting held October 31 to November 2, 1993,
in Williamsburg, Virginia. This form was developed by the Research Committee of the
American Shoulder and Elbow Surgeons
(ASES), which recommended its use to the Executive Committee. The Executive Committee
agreed with the concept and content of the form,
and the form was adopted by the membership.

From the Research Committee, Amer icon Shoulder and Elbow Surgeons, Rosemont, III.
Reprint requests: Amer ican Shoulder and Elbow Surgeon s,
6300 North River Rd., Suite 727, Rosemont, IL 60018-4226.
Copyright 1994 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/94/$3.00 + 0 3211/59628

Most clinicians agree that a standardized


method of assessing musculoskeletal function
facilitates communication between investigators, permits and encourages multicenter trials
to be performed, and allows the communication
of useful and relevant outcome data to physicians, healthcare administrators, and the general public." 11 The ASES Standardized Shoulder
Assessment Form was developed during a 3year time period. The concept of the form was
discussed at the ASES closed meeting held in
Chicago in 1990. It was believed that any proposed form should be reviewed by the membership before adoption. The key attributes of
any proposed form identified by the membership as being desirable were (1) ease of use;
(2) a method of assessing activities of daily living (ADLs); and (3) inclusion of a patient selfevaluation section.

347

348 Richards et al.

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November/December 7994

SHOULDER ASSESSMENT FORM


AMERICAN SHOUlDER AND ElBOW SURGEONS

Name:
Age:

Date

I Hand dominance:

L Ambi

Sex:

Diagnosis:

Initial Assess? Y

Procedure /Date:

Followup :

M'

Figure 1 Demographic info rmatio n.

All forms that existed at that time were reviewed by the Research Committee. 1,3,4,7.9, 12 A
draft form was presented to the membership at
the closed meeting held in Seattle, Washington,
in September 1991. The membership was encouraged to use the form and to offer constructive criticism. More than 70 suggestions for
change and improvement were made after distribution of the first ' draft. The suggested
changes were reviewed by a subcommittee of
the Research Committee in the summer of 1992.
The form was revised and redistributed after the
ASES closed meeting held in Vail, Colorado, in
September 1992 .
Another 15 suggestions were made, and most
were incorporated into the form that was
adopted by the membersh ip. It is the belief of
the Research Committee and the American
Shoulder and Elbow Surgeons that the shoulder
assessment form represents a state-of-the-art
assessment tool for patients with shoulder disorders. The form consists of a physician assessment section and a patient self-evaluation
section. The patient self-evaluation section can
be completed in approximately 3 minutes. The
presence of a physician or paramedical worker
is not required for the completion of the patient
self -evaluation portion of the form . Forms are
available from the ASES office in Chicago and
are also available on diskette (WordPerfect 5.1
WordPerfect Corp., Orem, Utoh), because it is
recognized that individual investigators may
wish to customize the form for their use. The
addition of other questions or specific maneuvers on physical examination is encouraged according to the distinctive needs of individuals
and groups working with specific subsets of patients. The ASES standardized shoulder assessment form is offered as a baseline measure of
shoulder function applicable to all patients regardless of diagnosis.

DEMOGRAPHIC INFORMATION
The patient's name, age, hand dominance,
sex, diagnosis, and procedure are noted (Figure 1). Spaces are available to note the date of
the assessment and the date of procedure, if an
operative procedure has been performed. An
annotation is also present to ind icate whether
the patient is being seen for the first time and,
if not, what the length of follow-up is. It is antic ipated that many clinicians will wish to "customize" this portion of the form according to
their needs and the format of patient demographic information at their parent institution.

PATIENT SELF-EVALUATION
The patient self-evaluation form is divided
into three sections.
Pain. The first section concerns pain (Figure 2). The patients are asked to identify
whether they are having pain in the shoulder
and are asked to record the location of their
pain on the pain dioqrom." Patients are asked
whether they have pain at night and whether
they take pain medication. The next question
identifies the use of a nonnarcotic analgesic.
Another question identifies the use of na rcotic
med ication . The patient is asked to record the
number of pills required each day. The severity
of pain is graded on a 10 cm visual analog scale
that ranges from 0 (no pa in at all) to 10 (pa in
as bad as it can be)." 13, ,.
Instability. The patient is asked to identify
whether he or she experiences symptoms of instability (Figure 3). The sensation of instability
experienced by the patient is assessed quantitat ively according to a visual analog scale. A
higher score is given, if the shoulder feels very
unstable.
Activities of daily living. Ten activities of
daily living are assessed on a four-point ordinal
scale (Figure 4).2 The patients are asked to cir-

J. Shoulder Elbow Surg.


Volume 3, Number 6

Richards et al.

349

PATIENTSEU-EVALUATION
Are you havlng pain In your ahouldfJI7 (circle oomIct

No

Mark where your pain is

00 you have pain In your shoulder at nlgh!?

Yes

No

00 you take pain medication (aspirin, AdvII, Tylenol tc.)?

Yes

No

00 you take narootlc pain medication (oodelne

Yes

Of

atronger)?

How many plUs do you take each day (average)?

No
pills

How bad Is your pain today (mark line)?


01

No pain at all

,10

Pain as bad as It can be

Figure 2 Patient self-evaluation : pain questionnaire. (Advil, WhitehallRobins lnc., Madison, N .J.; Tylenol, McNeil Consumer, Pleasantville, N .J.)

Does your shoulder feel uns1able (as " It Is going to dislocate?)

Yes

No

Very stable

Figure 3 Patient self-eval uatio n: instabili ty q uestionnai re.

cle 0, if they are unable to do the activity, 1, if


they find it very difficult to do the activity, 2, if
they find it somewhat difficult to do the activity,
and 3, if they find no difficulty in performing the
activity. Each shoulder is assessed separateJy.
Because 10 questions are asked the maximum
score is 30. The 10 questions include activities
that are heavily dependant on a range of shoulder motion that is free from pain. The patients
are also asked to identify their normal work and
sporting activities. The cumulative activities of
daily living score is derived by totaling the
scores awarded for each of the individual activities.

PHYSICIAN ASSESSMENT
The physician assessment portion of the form
consists of the following sections.
Range of motion. Total (combined glenohumeral and scapulothoracic) shoulder motion is measured, because the ability to differentiate glenohumeral from scapulothoracic rno-

tion is not consistent (Figure 5). Both active and


passive motion for both shoulders is recorded.
The use of a goniometer is preferred. Forward
elevation is measured as the maximum armtrunk angle viewed from any direction. External
rotation is measured with the arm comfortably
at the side and .c lso with the arm at 90 of abduction. Internal rotation is measured by noting
the highest segment of spinal anatomy reached
with the thumb. Cross-body adduction is measured by measuring the distance of the antecubital fossa from the opposite acromion.
Signs. Signs are graded 0 if not present, 1
if mild, 2 if moderate, and 3 if severe (Figure 6). Signs that a re assessed include supraspinatus or greater tuberosity tenderness, acromioclavicular joint tenderness, and biceps
tendon tenderness or biceps tendon rupture. If
tendon tenderness is present in other locations,
the examiner is asked to note the location. Impingement is assessed in three ways: (1) passive
forward elevation of the shoulder in slight in-

350

Richards et

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November/December 1994

Cirde the number in the box that indicates your ability to do the following aetMties:
VfKY dilli<:ult to do ; 2 Somewhat difficult; 3 Not diffICUlt

o Unable to do ; 1

RIGHT ARM

ACTIVITY

LEFT AR M

1. Put on a coat

0 1 2 3

2. Sleep on your painful 01' affected side

0 t 2 3

0 t 2 3

o
o
o
o
o

1 2 3

o
o
o
o

1 2 3

0 1 2 3

3. Wash back/do up bra in back


4. Manage toUelling
5. Comb hair
6. Reach a high shelf
7. Uft 10 Ibs. above shoulder

10. Do usu al sport Ust:

1 2 3
1 2 3

0 1 2 3

8. Throw a ball overhand


9. Do usual work Ust:

1 2 3

I
I

1 2 3

0 1 2 3

1 2 3

1 2 3
1 2 3
1 2 3
1 2 3

o
o
o

1 2 3
1 2 3
1 2 3

Figure 4 Patient self-evaluation: activity of daily living questionnaire.

PHYSICIAN ASSESSMENT
RIGHT

RANGE OF MOTION
T_ should """"'"

AaMl

~~ed

FOI'Ward elevation

p......,.

LEFT

p......,.

AaMl

0IlQI0)

(Mulmum _

Extemal rotation lMn comlof1aIlIy at Iidol


Extemal rotation lMn at f1t1' abduction)
Inlernal rotation

(ItgI.- _ _ _

Crossbody adduction

onuomy . - wOIl lllumb)

.. _

........-)

Figure 5 Physician assessment: range of motion.

SIGNS
o

none ; 1 mUd; 2 moderate; 3 MV.'"

SIGN

Right

Left

AC joint tenderness

o
o

Biceps tendon tenderness (01' rupture)

0 123

o
o
o

0 1 2 3

0 123

Supraspinatus/greater tuberosity tenderness

Other tenderness Ust

1 2 3
1 2 3

1 2 3
1 2 3
1 2 3

Subacromial crepitus

Scars location

Impingement I (PuoIw torwonl


Impingement II

....._

In oIg/It .........

(Puoivo _ _ .."

Imp ingement III ff1t1' ...... _ _ . _

f1t1' Oodonl

-"" ...)

Atrophy location:

Deformity : describe

Figure 6 Physician assessment : signs .

ternal rotation; (2) passive internal rotation at


90 of flexion; and (3) at 90 of active abduction
(the classic painful are).
The presence or absence of subacromial

crepitus is noted as are the presence or absence


of scars, atrophy, and deformity. The examiner
is asked to record the exact location of scars,
atrophy, or deformity, if they do exist.

J. Shoulder Elbow Surg.


Volume 3, Number 6

Richards et al.

351

STRENGTH
(record MAC grade)

o - no oonlrllClion; 1 llid<or; 2 ........-. wilh grw.iIy oIminaleel


3 - ........-. ogainol grJIviy; 4 - Il'IOemOnI aoM* IClfTMl .-anco; 5 - nonNII ~.
Right
Testing affected by pain?

Forward elevation
Abduction
External rotation
Internal rotation

(Arm comIot1obIy

o.

aIdo )

(Arm comIot1obIy .. aIdo)

left

012345

012345

o
o

o
o

1 2 3 4 5
1 234 5

012345

1 234 5
1 234 5

012345

Figure 7 Physician assessment : strength.

Strength. Strength is graded according to


the Medical Research Council grade (Figure 7).
The examiner is asked to note whether pain may
be influencing the assessment. Strength is measured in forward elevation, abduction, external
rotation with the arm comfortably at the side,
and internal rototion with the arm comfortably
at the side.
Instability. Instability is graded 0, if absent,
1, if mild (0 to 1 cm translation), 2, if moderate
(1 to 2 cm translation or translates to the glenoid
rim), 3, if severe (greater than 2 cm translation
or over rim of glenoid) (Figure 8). The presence
of absence of anterior translation, posterior
translation, inferior translation, and anterior
apprehension are all noted and graded. The
examiner is asked to note whether the previously mentioned maneuvers reproduce the patient's symptoms and whether the patients hove
voluntary instabil ity, a positive relocation test,
or generalized ligamentous laxity. Space is
present for recording other physical findings.
The examiner is asked to sign the form .
SHOULDER SCORE INDEX
The information obtained from the patient
self-evaluation form can be used to derive
shoulder score. Equal we ight is given to degree
of pain experienced by the patient and the cumulative ADL score. The shoulder score is de rived by the following formula: (10 - Visual
analog scale pain score) x 5 = + (5/3) x
Cumulative ADL score . For example, if the visual analog scale pain score is 6, and the cumulative ADL score is 22, the shoulder function
index is: ([10 - 6] x 5 = 20) + (5/3 x 22 =
37) = 57 (out of a possible 100).
It is hoped that use of this form will encouroge
commun ication between investigators. The form

INSTABIUlY
o - none; t mild (0 - 1 em tr811SlalJon)
2 moderate (1 2 em translation Ot Iran sletos 10 gleno id rlm)

3 - severe (> 2 an translation or over rim of glenoid)


Anterior translation

o 1 2 3

o 1 2 3

Posterior translation

o 1 2 3

o 1 2 3

Inferlot Iransletion (ouicus sign)

o 1 2 3

o 1 23

Antetlor apprehension

o 1 2 3

o 1 2 3

Reptoduces symptOtnS?

Voluntary Inslability?

Reloce tlon test positMI?

Generalized ligamentous laxity?

Other physical findings:

Examiner's name:
Date

Figure 8 Physician assessment : insta bility.

has been found acceptable to the membership


of the American Shoulder and Elbow Surgeons.
It is the membership's hope that adoption of this
form will encourage its use and its comparison
with other measures of outcome. The Research
Committee also recognizes that communication
between specialty groups is impo rtant. Use of
a standardized evaluation instrument such as
the SF 36 as a general health outcome measure
is encouraged at this time, because it is a measure of general heolth status that most health
care workers and administrators will know.
Testing of the various outcome measures that
are available is to be encouraged, and it is the
Research Committee's hope that this will occur
and will allow further evolution and refine out-

352

Richards et

01.

outcome measurement
shoulder.

1. Shoulder Elbow Surg.


November/December 7994

instruments

for

the

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Matsen FA III, Fu FH, Hawkins RJ, edi to rs. The shoulde r:
a balan ce of mob ility and sta bility. Rosemont : American
A cademy of Orthopaedic Surgeons, 1993:501- 18.

The authors acknowledge the support, encouragement, and counsel of American Soc iety of Shoulder and Elbow Surgeons past presidents Frederick
A. Matsen III, MD, Richard J. Hawkins, MD, FRCS(C),
Robert J. Neviaser, MD, Russell F. Warren, MD, and
president Harvard Ellman, MD.

8. Me lzack R. The McGill pain questionna ire: major properties and scori ng method . Pain 1975; 1:277-99.

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