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 assess-
ment of shoulder function at their annual closed
meeting held October 31 to November 2, 1993,
in Williamsburg, Virginia. This form was de-
veloped by the Research Committee of the
American Shoulder and Elbow Surgeons
(ASES), which recommended its use to the Ex-
ecutive 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 El-
bow 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 investiga-
tors, permits and encourages multicenter trials
to be performed, and allows the communication
of useful and relevant outcome data to physi-
cians, healthcare administrators, and the gen-
eral public." 11 The ASES Standardized Shoulder
Assessment Form was developed during a 3-
year time period. The concept of the form was
discussed at the ASES closed meeting held in
Chicago in 1990. It was believed that any pro-
posed form should be reviewed by the mem-
bership before adoption. The key attributes of
any proposed form identified by the member-
ship as being desirable were (1) ease of use;
(2) a method of assessing activities of daily liv-
ing (ADLs); and (3) inclusion of a patient self-
evaluation section.
347
348 Richards et al.
SHOULDER ASSESSMENT FORM
AMERICAN SHOUlDER AND ElBOW SURGEONS
Name:
Age: I Hand dominance:
Diagnosis:
Procedure /Date:
Figure 1 Demographic info rmatio n.
All forms that existed at that time were re-
viewed 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 en-
couraged to use the form and to offer construc-
tive criticism. More than 70 suggestions for
change and improvement were made after dis-
tribution 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 dis-
orders. The form consists of a physician as-
sessment 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 maneu-
vers on physical examination is encouraged ac-
cording to the distinctive needs of individuals
and groups working with specific subsets of pa-
tients. The ASES standardized shoulder assess-
ment form is offered as a baseline measure of
shoulder function applicable to all patients re-
gardless of diagnosis.
J. Shoulder Elbow Surg.
November/December 7994
Date
R L Ambi Sex: M F
Initial Assess? Y N
Follow·up : M' Y
DEMOGRAPHIC INFORMATION
The patient's name, age, hand dominance,
sex, diagnosis, and procedure are noted (Fig-
ure 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 an-
tic ipated that many clinicians will wish to "cus-
tomize" this portion of the form according to
their needs and the format of patient demo-
graphic information at their parent institution.
PATIENT SELF-EVALUATION
The patient self-evaluation form is divided
into three sections.
Pain. The first section concerns pain (Fig-
ure 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 in-
stability (Figure 3). The sensation of instability
experienced by the patient is assessed quanti-
tat 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. Richards et al. 349
Volume 3, Number 6

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 Of atronger)? Yes No
How many plUs do you take each day (average)? pills
How bad Is your pain today (mark line)?
01 I I I I ,10
No pain at all Pain as bad as It can be

Figure 2 Patient self-evaluation : pain questionnaire. (Advil, Whitehall-

Robins lnc., Madison, N .J.; Tylenol, McNeil Consumer, Pleasantville, N .J.)

Does your shoulder feel uns1able (as " It Is going to dislocate?) I Yes I 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 shoul-
der 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 ac-
tivities.
PHYSICIAN ASSESSMENT
The physician assessment portion of the form
consists of the following sections.
Range of motion. Total (combined gle-
nohumeral and scapulothoracic) shoulder mo-
tion is measured, because the ability to differ-
entiate 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 arm-
trunk 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 ab-
duction. Internal rotation is measured by noting
the highest segment of spinal anatomy reached
with the thumb. Cross-body adduction is mea-
sured by measuring the distance of the ante-
cubital fossa from the opposite acromion.
Signs. Signs are graded 0 if not present, 1
if mild, 2 if moderate, and 3 if severe (Fig-
ure 6). Signs that a re assessed include supra-
spinatus or greater tuberosity tenderness, ac-
romioclavicular 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. Im-
pingement is assessed in three ways: (1) passive
forward elevation of the shoulder in slight in-
350 Richards et 01. 1. Shoulder Elbow Surg.
November/December 1994

Cirde the number in the box that indicates your ability to do the following aetMties:
o • Unable to do ; 1 • VfKY dilli<:ult to do ; 2 • Somewhat difficult; 3 • Not diffICUlt

ACTIVITY RIGHT ARM LEFT AR M

1. Put on a coat 0 1 2 3 o 1 2 3

2. Sleep on your painful 01' affected side 0 t 2 3 0 t 2 3

3. Wash back/do up bra in back o 1 2 3 o 1 2 3

4. Manage toUelling o 1 2 3 o 1 2 3

5. Comb hair o 1 2 3 o 1 2 3

6. Reach a high shelf o 1 2 3 o 1 2 3

7. Uft 10 Ibs. above shoulder o 1 2 3 0 1 2 3

8. Throw a ball overhand 0 1 2 3 o 1 2 3

9. Do usual work· Ust: I o 1 2 3 o 1 2 3

10. Do usu al sport· Ust: I 0 1 2 3 o 1 2 3

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

PHYSICIAN ASSESSMENT
RANGE OF MOTION RIGHT LEFT
T_ should« """"'" p......,. p......,.
AaMl AaMl
~~ed

FOI'Ward elevation (Mulmum _ 0IlQI0)

Extemal rotation lMn comlof1aIlIy at Iidol

Extemal rotation lMn at f1t1' abduction)
Inlernal rotation (ItgI.- _ _ _ onuomy . - wOIl lllumb)
Cross·body adduction ~ _ .. _ ........-)

Figure 5 Physician assessment: range of motion.

SIGNS
o• none ; 1 • mUd; 2 • moderate; 3 • MV.'"

SIGN Right Left

Supraspinatus/greater tuberosity tenderness o 1 2 3 o 1 2 3
AC joint tenderness o 1 2 3 o 1 2 3
Biceps tendon tenderness (01' rupture) 0 123 o 1 2 3
Other tenderness · Ust 0 1 2 3 0 123
Impingement I (PuoIw torwonl ....._ In oIg/It ......... _ I Y N y N
Impingement II (Puoivo _ _ .." f1t1' Oodonl Y N Y N
Imp ingement III ff1t1' ...... _ _ . _ -"" ...) y N y N
Subacromial crepitus y N y N
Scars • location y N y N
Atrophy· location: y N Y N
Deformity : describe y N Y N

Figure 6 Physician assessment : signs .

ternal rotation; (2) passive internal rotation at crepitus is noted as are the presence or absence
90° of flexion; and (3) at 90° of active abduction of scars, atrophy, and deformity. The examiner
(the classic painful are). is asked to record the exact location of scars,
The presence or absence of subacromial atrophy, or deformity, if they do exist.
J. Shoulder Elbow Surg. Richards et al. 351
Volume 3, Number 6

STRENGTH
(record MAC grade)

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

3 - ........-. ogainol grJIviy; 4 - Il'IO¥emOnI aoM* IClfTMl .-anco; 5 - nonNII ~.

Right left
Testing affected by pain? y N Y N
Forward elevation 012345 012345
Abduction o 1 2 3 4 5 o 1 234 5
External rotation (Arm comIot1obIy o. aIdo ) o 1 234 5 o 1 234 5
Internal rotation (Arm comIot1obIy .. aIdo) 012345 012345

Figure 7 Physician assessment : strength.

Strength. Strength is graded according to INSTABIUlY

the Medical Research Council grade (Figure 7). o - none; t • mild (0 - 1 em tr811SlalJon)
The examiner is asked to note whether pain may 2 • moderate (1 • 2 em translation Ot Iran sletos 10 gleno id rlm)
3 - severe (> 2 an translation or over rim of glenoid)
be influencing the assessment. Strength is mea- Anterior translation o 1 2 3 o 1 2 3
sured in forward elevation, abduction, external Posterior translation o 1 2 3 o 1 2 3

rotation with the arm comfortably at the side, Inferlot Iransletion (ouicus sign) o 1 2 3 o 1 23

Antetlor apprehension o 1 2 3 o 1 2 3
and internal rototion with the arm comfortably
Reptoduces symptOtnS? Y N Y N
at the side.
Voluntary Inslability? Y N Y N
Instability. Instability is graded 0, if absent, Reloce tlon test positMI? Y N Y N
1, if mild (0 to 1 cm translation), 2, if moderate Generalized ligamentous laxity? Y N

(1 to 2 cm translation or translates to the glenoid Other physical findings:

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's name:
examiner is asked to note whether the previ-
ously mentioned maneuvers reproduce the pa- Date

tient'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 cu-
mulative 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 vi-
sual analog scale pain score is 6, and the cu-
mulative 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
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 mea-
sure 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 instruments for the
shoulder.
The authors acknowledge the support, encour-
agement, and counsel of American Soc iety of Shoul-
der 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.
REFERENCES
1. Altc hek DW, Warren RF, W ickiewicz TL, et 01. Arthro-
scop ic acrom ioplasty: technique and results. J Bone
Joint Surg [Am] 1990;72A 1198-207 .
2. Bruett TL, Overs RP. A critical review of 12 ADL scales.
Phys Ther 1969;49 :857-62.
3. Constant CR, Murley AHG. A clinical method of func-
tional assessment of the shoulder . Clin Orthap 1987;
214 :160-4.
4. Ellman H, Han ker G , Bayer M . Repair of the rot ator cuff:
end-result study of facto rs influencing reconstructio n.
J Bone Joint Surg [A m] 1986;68A 1136-44.
5. Gerber C. Integrated scoring systems for the functional
assessment of the shoulder. In: Matsen FA III, Fu FH,
Hawkins RJ, ed itors. The shoulder: a ba lance of mob ility
and stability. Rosemont : American Academy of Ortho-
paed ic Surgeons, 1993:531-50.
1. Shoulder Elbow Surg.
November/December 7994
6. Huskisson EC. The measuremen t of pa in. J Rheum
1982;9 :768-9.
7. Lippitt SB, Harryman DT II, Matsen FA 1111. A practical
tool for evaluation function : the simple shoulder test. In:
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.
8. Me lzack R. The McGill pain questionna ire: major prop-
erties and scori ng method . Pain 1975; 1:277-99.
9. Nee r CS II. An terior ocromioplasty for the chroni c im-
pingement synd rome in the shoulder : a preliminary re-
port . J Bon e Joint Surg [Am] 1972;54A41-50.
10. Ransford AO, Cairns D, Mooney V. The pa in drowing
as an aid to the psychologic evaluation of patients with
low back pain. Spine 1976; 1:127-34 .
11. Richards RR. The history : how effective is it in making the
diagnosis. In: Matsen FA III, Fu FH, Hawkins RJ, editors.
The shoulder: a balance of mob ility and stability.
Rosemont : Ameri can Academy of Orthopaedic Sur-
geons, 1993 :32 1-30.
12. Rowe CR, Patel D, Southmayd WW. The Bankart pro -
cedure: a long-term end -result study. J Bone Joint Surg
[AmI 1978;60A 1- 16.
13. Scott J, Huskisson EC. Graphic representation of pain.
Pain 1976;2 :175-84.
14. Sriwatanakui K, Kelvie W, Lasagna L, et 01. Studies w ith
different types of visual analog scales for measurement
of pain. Cl in Pharmacal Ther 1983;34 :234-9 .