Current Concepts

Analysis of Evidence-Based Medicine for Shoulder Instability

Kevin D. Plancher, M.D., and Sheryl L. Lipnick, D.O.

Abstract: Clinical research has become a major influencing factor in the determination of treatment
choice in our society. Outcome data have been requested by third-party payers, patients, and
administrators alike. Currently, there are over 10 different scoring systems that have been used to
evaluate the efficacy of treatment for shoulder instability. Some of these scoring systems are based
on the specific condition of shoulder instability; however, other systems are broadly based to
incorporate a spectrum of shoulder conditions. This review summarizes the process of proper
development and testing of the scoring systems, discusses their role in clinical research with respect
to shoulder instability, and explains the dichotomy of postoperative recurrence of instability and high
shoulder scores. The Shoulder Rating Questionnaire (SRQ), Melbourne Instability Shoulder Score
(MISS), Western Ontario Shoulder Instability Index (WOSI), Oxford Instability Score (OIS), and
Simple Shoulder Test were shown to be reliable for patients with instability. The SRQ, MISS, WOSI,
OIS, and American Shoulder and Elbow Surgeons score have all been shown to be largely
responsive. There are 2 shoulder scoring systems, the WOSI and the MISS, that we recommend be
used to evaluate shoulder instability. The SRQ and OIS were found to be less responsive for patients
with instability compared with patients with other shoulder dysfunctions. Other scoring systems lack
inter-rater reliability, validity, and/or responsiveness for patients in the instability population. The
optimal scoring system for patients with upper extremity problems other than those with shoulder
instability has yet to be determined; however, the American Shoulder and Elbow Surgeons score may
be considered, because this instrument has been proven to be valid, reliable, and responsive. Key
Words: Shoulder—Scoring systems—Outcome measurements—Validity—Melbourne Instability
Shoulder Score (MISS)—Western Ontario Shoulder Instability Index (WOSI).

A n increasing number of outcome measurement

systems have been designed to report on the
effectiveness of treatment for shoulder pathologies.
These scoring systems need to be valid, reliable, and
responsive, with high intraobserver agreement. More
emphasis on outcome data has been requested by not
From the Orthopaedic Foundation for Active Lifestyles (K.D.P.,
S.L.L.), Cos Cob, Connecticut; Plancher Orthopaedics & Sports
Medicine (K.D.P., S.L.L.), New York, New York; and Albert Ein-
stein College of Medicine (K.D.P.), New York, New York, U.S.A.
The authors report no conflict of interest.
Address correspondence and reprint requests to Kevin D.
Plancher, M.D., Orthopaedic Foundation for Active Lifestyles, 31
River Rd, Cos Cob, CT 06807, U.S.A. E-mail: kplancher@
plancherortho.com
© 2009 by the Arthroscopy Association of North America
0749-8063/09/2508-0928$36.00/0
doi:10.1016/j.arthro.2009.03.017
only patients but also administrators and third-party
payers. Quality-of-life measures have become the
standard means of assessing the results of health care
interventions.1 There is a need in the orthopaedic
community for well-designed outcome studies that
measure the improvement of health status and quality
of life of patients. Using the appropriate instrument is
essential if outcome measures are to be valid and
clinically meaningful. Recently, the patient’s percep-
tions have assumed greater importance in outcome
measurements. Failure to account for these factors has
been a major limitation in previous shoulder scoring
systems.
When one is evaluating a shoulder scoring system,
the different forms of treatment must be compared
along with the results. Adequate outcome data to
support the treatment strategies must be evaluated.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 8 (August), 2009: pp 897-908 897
898 PLANCHER AND LIPNICK
The scoring system should account for the confound-
ing factors that may affect the outcomes.
An article was recently published on measuring
arthroscopic outcome.2 The authors discussed how
measures of symptoms, activities, and function may
be specific to region/joint, disease, or injury. General
outcome measures are usually less responsive to
change in the patient’s status compared with more
specific outcome measures, which focus primarily on
the condition or population of interest to increase
responsiveness. Region-specific measures have the
advantage of being appropriate for a wide variety of
injuries, whereas more specific measures may be more
relevant to patients and clinicians. The authors further
stated that a measure must be validated for a specific
purpose such as the evaluation of a population of
subjects with a specific condition. Not surprisingly,
there has been a recent trend in the orthopaedic liter-
ature to evaluate region-specific scoring systems for
acceptable psychometric parameters (validity, respon-
siveness, and reliability) for injury-specific patholo-
gies.3,4
A review of the numerous knee injury–measuring
outcomes currently in use was recently published in
The Journal of the American Academy of Orthopae-
dic Surgeons.5 The author noted that there has been
a shift from clinician-based outcomes tools to the
development and validation of patient-reported out-
comes measures. He concluded that a general health
outcomes measure should be used in conjunction
with one or more disease- or condition-specific rat-
ing scales.
Nagi6 developed a disablement scheme in 1965 to
further describe functionality and the consequences of
pathology. The term “disablement” refers to the con-
sequences that a disease, injury, or congenital abnor-
mality may have on human functionality at many
different levels. Nagi’s disablement scheme character-
izes the transition of active pathology to impairment,
which is an anatomic or physiologic abnormality or
loss. Impairment then leads to functional limitation
and, finally, to disability.
The orthopaedic literature has traditionally focused
on measures of impairment, which include range of
motion, strength, stability, and pain. In the past clini-
cians determined the various outcome priorities with-
out accounting for patient preferences. A standard,
universally accepted shoulder scoring system for as-
sessing the functional state of a normal, diseased, or
postoperative shoulder does not exist. This is one of
the most important factors preventing progress in clin-
ical orthopaedics. As Kirkley and Griffin7 stated in
their article on disease-specific quality-of-life mea-
surement tools, “Nowhere are there more insensitive,
unreliable, unvalidated measurement tools than in the
orthopaedic literature.”
According to Gerber,8 the more commonly used
systems have major deficiencies when applied to in-
stability populations. One common deficiency is an
insufficient number of items in the evaluation. Some
response options are not mutually exclusive. In addi-
tion, some scoring systems rely on only part of the
tool to be used to generate a score. Other grading
systems use poorly defined techniques for performing
examinations. Different authors weigh items arbi-
trarily. Lastly, there is inadequate consultation with
patients in the item-generation process, leading to
diminished comprehensiveness.
Leggin and Iannotti9 evaluated shoulder outcome
measurements in 1999, concluding that the goal of any
treatment intervention should be to improve the pa-
tient’s pain, function, and satisfaction. They urged for
the creation of a patient self-assessment tool that mea-
sures outcome for the general population of shoulder
patients in conjunction with a scale designed for the
athletic population. In addition, the level of improve-
ment in impairments such as range-of-motion and
strength impairments should be compared with the
patient’s assessment of outcome.
The solution to these problems involves a multifac-
torial approach. Knowledge of strengths and weak-
nesses of the traditionally used systems may serve as
a guide for future improvements. There needs to be
more awareness of appropriate methods by which
these instruments should be developed and tested.
Traditional systems need to be thoroughly evaluated
to recognize deficiencies. Clinicians should be made
aware of the newer systems supported by psychomet-
ric testing data.
INSTRUMENT DEVELOPMENT
AND TESTING
A proper quality-of-life tool requires a formal de-
velopment process and extensive instrument testing.
The approach to this methodology is described by
Guyatt and colleagues10 and is divided into 2 phases
with a total of 9 steps. The first phase, the develop-
ment process, involves 4 steps. The first step specifies
measurement goals. The next step is item generation.
This is both expert and patient based. The third step
involves item reduction. The fourth step is question-
naire formatting. This often involves the visual analog
 SHOULDER INSTABILITY
scale (VAS) and Likert scale. The first phase is out-
lined below in detail.
Development
Specifying Measurement Goals: Specific mea-
surement goals must first be identified. The population
must be adequately described, and the appropriate
sampling of this population must be considered. Usu-
ally, this involves an evaluative instrument that de-
tects important changes over time in health status.
Sampling instruments can also be discriminative or
predictive. Discriminative instruments differentiate
between patients with different levels of health at one
time, whereas predictive instruments predict the pa-
tient’s future health status. For the purpose of this
article, the instrument should evaluate the quality of
life for patients with symptomatic instability of the
shoulder. Patients with problems that will prevent
reliable completion of interviews or questionnaires,
such as language barriers or psychiatric disorders,
must be excluded. Patients who have other disorders
that may contribute to shoulder dysfunction or other
major illnesses that would influence their quality of
life should also be excluded.
Item Generation: Item generation is a critical step
in the overall development process of a measurement
tool. Domains that represent overall health include
physical symptoms, sports and recreation, work, life-
style, and emotions. Item generation involves 3 steps:
(1) a thorough review of the literature, including mod-
ifications of similar disease-specific quality-of-life
outcome measures; (2) interviews with colleagues and
experienced clinicians to identify issues involved with
treating patients with the condition of interest (in this
case, shoulder instability); and (3) interviews with
patients with the condition of interest.
Item Reduction: To make a tool practical and
reasonable in length, items must be eliminated.
Focus groups can be very helpful in the item-reduc-
tion phase to identify questions that contain the
most importance and frequency. Patients can identify
items that have the greatest relevance to their experience
based on the importance to their overall health. Items can
also be compared with one another to eliminate those
that measure a similar concept.
Question Formatting: Response systems need to
be able to detect minimal but clinically significant
changes within each subject. Two commonly used
systems are the simple VAS and the Likert scale. The
VAS consists of a 10-cm line on which patients can
mark their response for each item. Patients respond by
placing a mark on the line estimating the amount of
899
that item they are experiencing. The Likert scale has 7
options for which patients indicate agreement with
each statement. For example, terms such as excellent,
very good, good, moderate, poor, very poor, and ex-
tremely poor are used. Ideally, the questionnaire
should be at an eighth-grade reading level or less. The
questions should be as short as possible and worded in
a positive manner for ease of interpretation.
Testing
The second phase of the methodology used to for-
mulate a proper quality-of-life tool, as originally de-
scribed by Guyatt and colleagues,10 is discussed in the
following sections. This phase involves rigorous in-
strument testing and includes 5 components: (1) pre-
testing, (2) reliability, (3) responsiveness, (4) valida-
tion, and (5) interpretability.
Pretesting: The pretesting phase identifies any
problems that might arise with the set of items in the
questionnaire. The clarity of the wording is fully eval-
uated. Subjects are given the questionnaire and asked
to give their interpretation of each item, as well as to
identify unclear questions or the need for the addition
of any questions that were omitted.
Reliability: Reliability is the extent to which a
system is consistent and free from error. This involves
both testing and retesting. Repeat administration of a
measurement tool is performed in stable subjects and
should produce the same results. The instrument
should be measured initially and then again after an
interval long enough that the subject will have forgot-
ten the previous responses but short enough that the
responses will not have changed. The ideal time for
retesting has not yet been determined. Reliability is
important for discriminative tools, and intrarater and
inter-rater reliability should be established. The intra-
class correlation coefficient (ICC) is a statistical test of
agreement between repeated measures and evaluates
the ratio of between-subject variance to total variance.
Values range from ⫺1 to ⫹1, with 0 indicating ran-
dom correlation. Although the degree of reliability is
not concrete, acceptable test-retest reliability is gen-
erally considered to have an ICC of 0.70 or greater.11
Internal consistency (IC), as measured by the Cohen ␬
statistic, is another measure of reliability. This mea-
sures how well individual items “hang” together. The
acceptable IC as measured by the Cronbach ␣ is
greater than 0.60, where an ␣ of 1.0 represents perfect
IC.12 Other authors, however, have suggested that
acceptable scores should be greater than 0.70.13
900 PLANCHER AND LIPNICK
Responsiveness: Responsiveness refers to the abil-
ity of a tool to measure change over time. There are a
variety of methods that have been proposed to mea-
sure the responsiveness of a tool, including the re-
sponsiveness index, standardized response mean
(SRM), relative efficiency, and effect size. The SRM
is calculated by the following formula: (Mean post-
operative scale ⫺ Mean preoperative scale)/SD of
change in scale. The effect size is calculated by the
following formula: (Mean postoperative scale ⫺
Mean preoperative scale)/SD of preoperative scale.
Small effects are considered greater than or equal to
0.20, moderate effects are considered greater than or
equal to 0.50, and large effects are considered greater
than or equal to 0.80.14 The most frequently used
formula, the SRM, is the method that best correlates
with the power of a test and is most relevant to
designing clinical trials.15 A highly responsive scale
has the very important benefit of requiring fewer sub-
jects in clinical trials to show a statistically significant
difference between treatment groups.
Validation: Validity discusses the extent to which
an instrument measures what it is intended to measure.
There are various types of validity. Criterion validity
is a way to show that the results of the new scale
correlate to an external “gold standard.” Content va-
lidity is shown when the scale measures all important
aspects of the condition to be examined. It addresses
floor and ceiling effects. Construct validity refers to
whether there is a correlation with other measures as
could be predicted if an instrument is measuring what
it is supposed to measure. Construct validation is the
major category for health-related quality-of-life in-
struments. An extra component to validity is the sen-
sitivity to change or responsiveness.
Currently, there is no shoulder scoring system avail-
able for instability or other conditions that has been
established as the gold standard. Thus the validation
process requires the use of multiple types of validity
for verification. The scoring systems that will be re-
viewed in this article have been compared with other
shoulder scoring systems, the Short Form (SF)–12,
and the SF-36. Although some of these systems may
have been validated for a combination of various types
of shoulder dysfunction, many have not been vali-
dated specifically for the subgroup of instability. Al-
though the SF-36 is a known standard for health status
measurement, it was not originally developed to be
used specifically in relation to outcomes of surgical
treatment.
Interpretability: Interpretability relies on placing
the magnitude of a change seen with a measurement
tool in a context for physicians. The minimal impor-
tant difference (MID) is the smallest difference in
score that patients perceive as beneficial and that
would mandate a change in management. The MID
can help to judge the magnitude of benefit from dif-
ferent treatments, assist in calculating the sample size
for clinical trials, and help to determine the proportion
of patients who will benefit from a given treatment.
SCORING SYSTEMS
When creating a shoulder scoring system, patient
input and feedback should be emphasized. The popu-
lation for whom the tool is being designed should be
adequately defined. The purpose of the instrument
should be discriminative, evaluative, or predictive.
Discriminative systems will differentiate between pa-
tients with different levels of a condition, whereas
evaluative systems will determine the effectiveness of
the treatment. Predictive systems will classify individ-
uals against an external criterion. Self-administered
scoring systems show less observer bias and are easier
to use.
Overall, common guidelines and criteria for treat-
ment need to be developed. Identification of effective
treatments for similar conditions needs to be facili-
tated and comparative prospective studies encouraged.
There is a great need for a validated measuring sys-
tem. This system should be simple, effective, and
strongly weighted toward functional outcome. It
should satisfy the development testing criteria and be
self (patient)–administered.
Various scoring systems for functional assessment
of the shoulder have been reported.16,17 Unfortunately,
these scores concentrated on range of motion, pain,
functional limitation, or strength while the primary
complaint in the patient with shoulder instability, and
sometimes the only complaint, is apprehension or
avoidance of activity. Because most instruments have
not focused on apprehension, dichotomy has occurred
in many recent studies between postoperative recur-
rence of instability and reporting of high shoulder
scores.
The scoring systems that address instability, in no
particular order, include the Rowe/modified Rowe
score; the American Shoulder and Elbow Surgeons
(ASES) score; the Shoulder Rating Questionnaire
(SRQ); the Melbourne Instability Shoulder Score
(MISS); the Disabilities of the Arm, Shoulder and
Hand (DASH) score; the Western Ontario Shoulder
Instability Index (WOSI); the Oxford Instability Score
(OIS); the Constant-Murley (CM) score; the Athletic
 SHOULDER INSTABILITY 901

TABLE 1. Characteristics of Shoulder Scoring Systems

Scoring System No. of Questions Total Score Pain Stability Function ROM Strength Satisfaction S/O

ASES self-report 11 100 50 0 50 0 0 0 S

ASORS 6 100 10 10 60 10 10 0 S/O
CM 7 100 15 0 20 40 25 0 S/O
DASH 30 100 13 0 80 0 7 0 S
MISS 24 100 15 33 52 0 0 0 S
OIS 12 60 10 10 40 0 0 0 S
Rowe 3 100 0 50 30 20 0 0 S/O
SRQ 21 100 40 0 60* 0 0 Separate S
SST 12 12 2 0 7 3 0 0 S
UCLA 5 35 10 0 10 5 5 5 S/O
WOSI 21 21 4 2 11 2 2 0 S

Abbreviations: ROM, range of motion; S, subjective; O, objective.

*Includes 15 points for global assessment.

Shoulder Outcome Rating Scale (ASORS); the Uni-
versity of California, Los Angeles (UCLA) score; and
the Simple Shoulder Test (SST). Of these, the WOSI
and the MISS are rigorously designed and evaluated
but not widely used. The more commonly used sys-
tems are also reviewed but have major deficiencies
when applied to instability populations. The reader
therefore should be cautious when making conclu-
sions that could alter clinical decisions, because some
scoring systems used may not be evaluating subjects
adequately. The various characteristics of the different
systems are summarized in Table 1.
Rowe Score
The Rowe score was initially described in 1978 as
a method to assess the outcome of treatment for an-
terior shoulder instability after Bankart repair.18 There
are a total of 100 points: 50 points for stability, 20
points for range of motion, and 30 points for function.
There are, however, a number of problems associated
with the scoring system. No published reports exist on
development or testing. The test includes double-bar-
rel questions, where subjects must consider more than
one question at the same time. The assignment of
weighting is not supported. The measurement for ap-
prehension is not clearly defined. The type of range of
motion, whether active versus passive, is not speci-
fied. In addition, loss of external rotation, which can
be crucial for the overhead athlete, is allocated only a
small percentage of the overall score. The scoring
system combines 2 items of subjective evaluation with
1 physical examination, leading to a total score com-
posed of separate attributes. Lastly, there is no specific
evaluation of pain.
Modified Rowe Score
Jobe et al.19 made additions to the Rowe score,
which resulted in the modified Rowe scale. The new
scoring system took into consideration the ability to
throw, the return to prior level of competition, and a
pain scale. There are still a total of 100 points, with 10
points for pain, 30 points for stability, 10 points for
range of motion, and 50 points for function. Similar
problems exist for both the Rowe and modified Rowe
scales. There are no published reports on development
or testing of the modified Rowe scale. There are
double-barrel questions, weighting is not supported,
the measurement for apprehension is not clearly de-
fined, and the scoring system combines 2 items of
subjective evaluation with 1 physical examination.
The main disadvantage of the new scoring system is
the increased value given to athletic activities. This
change decreases the sensitivity to the effect of treat-
ment for nonathletic patients.
ASES Score
The ASES score was developed by the ASES Re-
search Committee and published by Richards et al.20
in 1994. There is a self-reporting section with a 100-
point score index. There is 1 question with respect to
pain, which is marked on a 10-cm VAS and multiplied
by 5 and is worth a total of 50 points. The pain score,
unfortunately, is not specific to any particular activity.
The section on activities of daily living is composed of
10 questions and is also worth 50 points. However,
there are only 4 Likert categories, giving the tool a
high likelihood of poor responsiveness. The system
has been found to be reliable, valid, and responsive by
902 PLANCHER AND LIPNICK
subsequent testing but not by the original develop-
ers.21 There is no rationale for weighting items, no
“satisfaction” category, and no description on how
items were selected. The physical assessment portion
of the test, which is not scored, evaluates the follow-
ing clinical components: range of motion, manual
motor testing, tenderness to palpation, crepitus, im-
pingement, apprehension, relocation test, general lax-
ity, and voluntary instability.
Michener et al.21 examined the psychometric prop-
erties of the ASES patient self-reporting section in the
Journal of Shoulder and Elbow Surgery in 2002. They
made calculations based on data from 63 patients with
various shoulder dysfunctions who underwent physi-
cal therapy for operative and nonoperative diagnoses.
They concluded that the ASES system is a reliable,
valid, and responsive outcome tool, which can be used
as an evaluative and discriminative tool. The concern
is the amount of responsiveness that the ASES system
has for instability patients.
Kocher et al.12 reviewed the ASES scoring system
in The Journal of Bone and Joint Surgery, American
Edition, in 2005 and found that there is reliability,
validity, and responsiveness of the ASES subjective
shoulder scale in a heterogeneous population of pa-
tients with instability, rotator cuff disease, and gleno-
humeral osteoarthritis. There were a total of 455 pa-
tients with instability, 474 patients with rotator cuff
disease, and 137 patients with glenohumeral osteoar-
thritis. They concluded that the ASES scale shows
overall acceptable psychometric performance for out-
comes assessment in all subgroups. They cautioned,
however, that the ASES may not be an optimal out-
come measure. Although the reliability is acceptable,
it may not be precise enough to be used on an indi-
vidual basis. The minimal difference in the ASES
scale that represents a clinically important difference
in functional status was not established. The limita-
tions involve the use of a large, prospectively main-
tained computer database, which showed the hetero-
geneity among patients and the lack of uniformity
among the surgical techniques that were used.
Shoulder Rating Questionnaire
In 1997 L’Insalata et al.13 published the SRQ,
which is a self-administered evaluation of symptoms
and function of the shoulder. The method for item
generation is unknown. There are 6 separately scored
domains: global assessment, pain, daily activities, rec-
reational and athletic activities, work, and satisfaction.
The satisfaction domain is composed of a single
question that is scored and presented separately. An
additional, nongraded domain allows the patient to
select 2 areas in which he or she believes improve-
ment is most important. Test-retest reliability was
completed in 40 patients at a mean of 3 days.
However, the diversity of the population chosen as
well as the short time to retesting may have erro-
neously inflated the degree of correlation. The SRQ
is applicable to a broad range of disorders related to
the shoulder but may not be specific enough for use
within the instability population.
Melbourne Instability Shoulder Score
The MISS is a self-administered tool that was de-
veloped in 2004.11 There are a total of 100 points, and
some questions are not part of the scoring system. The
test is valid and reliable and has been directly com-
pared with the SRQ of L’Insalata et al.13 There is
increased responsiveness compared with the SRQ,
giving the MISS greater range to show change. Poor
agreement exists between the MISS and the SRQ, and
it is more difficult to obtain a high score on the MISS
system. The authors believe that the MISS offers a
greater spread of questions relating to functional tasks
and instability than the WOSI, DASH, or ASES in-
struments. They believe that these other scoring sys-
tems may not truly reflect the full functional status of
patients and may underestimate the patients’ clinical
impairment. This, however, is only the authors’ opin-
ion and has not been proven. The DASH and ASES
instruments do not have as many specific questions
relating to instability as the MISS and would most
likely be unable to fully discover the clinical impair-
ment of patients in that population. The WOSI, on the
other hand, asks questions similar to those of the
MISS but in a somewhat broader manner. For in-
stance, the MISS, using a Likert scale, asks patients to
mark their ability to carry heavy objects by their side,
whereas the WOSI, using a VAS, asks patients to
grade how much difficulty they experience lifting
heavy objects below shoulder level. We suspect that
both of these scoring systems have a role in evaluating
patients with shoulder instability. The scoring system
that best estimates the patient’s full functional status
remains to be determined.
One of the sections asks for patients to give a
percentage rating score, the percentage that they
would give the affected shoulder compared with what
they consider a “normal” shoulder. Overall, the MISS
has a good correlation to the patient’s percentage
rating score, unlike the SRQ. The system is sensitive
 SHOULDER INSTABILITY
to clinical change in nonathletic and athletic popula-
tions. The MID is 5. The main disadvantage of the
MISS system is that it is not applicable to the general
shoulder population.
DASH Score
The DASH score was developed by the American
Academy of Orthopaedic Surgeons along with the
Institute for Work & Health (Toronto, Ontario, Can-
ada). This is a general shoulder score that can be used
for patients with any condition of any joint of the
upper extremity. The methodology for item generation
and reduction has been published,22 and a user’s man-
ual is available.23 There are several advantages of the
DASH instrument. It can be completed before a diag-
nosis is made, there is a detailed user’s manual, and
the system covers a broad scope of pathologies. On
the other hand, there are many disadvantages of the
scoring system; the item-generation phase did not
include interviews with patients, the format only uses
5-category Likert-type responses, there is redundancy
of some questions, and the test is less responsive than
condition-specific instruments, making it less effec-
tive in the field of research. We cannot recommend
using this scoring system for patients with instability.
Western Ontario Shoulder Instability Index
Kirkley et al.15 developed the WOSI in 1998, the
first in a series of disease-specific quality-of-life mea-
sure tools. The methodology is well described, using a
VAS and applying equal weighting to questions based
on uniformly high impact scores. There are a total of
21 items, with 4 domains. Physical symptoms account
for 10 items; sport/recreation/work function, 4; life-
style function, 4; and emotional function, 3. The
WOSI was originally designed to be used as the pri-
mary outcome measure in the evaluation of clinical
trial treatments for patients with shoulder instability.
To make an instrument that could potentially be used
to evaluate both nonoperative and operative treat-
ments, the patients included in the study received no
treatment or any combination of physical therapy and
operative treatment.
In the original article published in The American
Journal of Sports Medicine, Kirkley et al.15 compared
the WOSI with other scoring systems. They adminis-
tered the measurement tool to a randomly selected
group of 47 patients undergoing treatment for anterior
shoulder instability and found the WOSI to be more
responsive than the Rowe, DASH, CM, ASES,
903
UCLA, and SF-12 scoring systems. The WOSI corre-
lated highly with the DASH scale, as predicted be-
cause many of the items are similar. The DASH scale,
however, includes items relating to other joints of the
upper extremity and conditions other than shoulder
instability. There is a correlation with the UCLA sys-
tem, reflecting the emphasis that patients place on
pain, even with instability. The WOSI lacked a cor-
relation with the CM scoring system. Range of motion
has been shown to correlate poorly with shoulder
function, and the CM system emphasizes range of
motion.
Another study by Kirkley et al.,24 published in
Arthroscopy in 1999, evaluated first-time anterior
shoulder dislocators. The validated WOSI was used
to show statistically better results in the surgically
treated group compared with the non–surgically
treated group. The authors also noted improvement
in disease-specific quality of life by early surgical
stabilization. This study shows appropriate clinical
use of the WOSI to aid in the determination of
functional improvement.
Oxford Instability Score/Oxford Shoulder Score
The Oxford Shoulder Score was developed by Daw-
son et al.25 Two different questionnaires exist; one
was constructed in 1999 for instability patients, now
called the OIS, and the other was constructed for
shoulder operations other than instability, a few years
earlier, in 1996.26 Both contain a total of 12 items
scored from 1 to 5. There is no statement on how the
items were selected or eliminated. Construct validity
has been shown compared with other outcome tools.
The OIS is more sensitive than the CM system but not
as sensitive as the Rowe system. The reliability and
sensitivity of the CM score relative to the OIS were
significantly reduced over long-term follow-up. There
is a possibility that the OIS may be used as an appro-
priate testing tool for patients with instability. How-
ever, with only 12 questions and less sensitivity than
the Rowe system, we believe that other scoring sys-
tems would be better suited as testing instruments.
CM Score
The CM scoring system was developed in 1987 and
is the most widely used instrument in the European
literature.27 There are a total of 100 points, with 35
being assigned to pain and function and the remaining
65 for range of motion and strength. There is no
category for patient satisfaction and only 1 pain scale,
904 PLANCHER AND LIPNICK
making an inadequate assessment. The initial publica-
tion does not include any rationale for item selection,
relative weighting, or data on validity or responsive-
ness. However, the method for administering the tool
is well described, and reliability has been evaluated,
but only on a limited basis.
Both Conboy et al.28 and Dawson et al.25 evaluated
the CM scoring system in The Journal of Bone and
Joint Surgery, British Edition, in 1996 and 1999,
respectively. Conboy et al. believed that the CM scor-
ing system is easy to use and has a low systematic
error but is not sufficiently reliable for use in the
clinical follow-up of patients. In addition, it is impre-
cise in repeated measurements and not sensitive for
instability. Dawson et al. agreed that the CM system is
relatively insensitive to changes in clinical status in
patients with instability and therefore not an appropri-
ate tool to measure outcome in patients with shoulder
instability. They further concluded that the CM score
places undue weight on concerns such as pain and
power, which are frequently not relevant to patients
with instability.
Athletic Shoulder Outcome Rating Scale
Tibone and Bradley developed the ASORS, which
combines subjective and objective evaluations.29 The
subjective evaluation is allocated 90 points, which
includes pain, strength/endurance, stability, intensity,
and performance. The other 10 points are allocated for
objective testing. The ASORS may be more sensitive
for high-level athletes, but the expectations and goals
for shoulders in athletes are greater than those in the
general population. There are multiple disadvantages
to the scoring system; the scale is only applicable to
competitive athletes, it does not define the position for
testing range of motion, the responses have greater
than 1 variable (similar to the UCLA system), it has a
combined scoring system, and it requires proper psy-
chometric testing. This scoring system may be ade-
quate for competitive athletes, but further testing
needs to be performed. The scoring system has yet to
be found reliable, responsive, or valid.
UCLA Score
The UCLA scoring system was developed by Am-
stutz et al.30 in 1981. This system was intended to
study patients who underwent a total shoulder arthro-
plasty for degenerative joint disease. The original ver-
sion had a total of 30 points divided between pain,
function, and muscle power/motion. There was no
category for satisfaction. The newer version, intro-
duced by Ellman et al.31 in 1986, has 5 separate areas
scored for a total of 35 points. Pain is allocated 10
points; function, 10 points; active forward flexion, 5
points; strength in forward flexion, 5 points; and sat-
isfaction, 5 points. An excellent score is 34 to 35
points, a good score is 29 to 33 points, and a poor
score is less than 29 points. The following year, Ell-
man32 changed the scoring system so that an excellent
score is 34 to 35 points; a good score, 28 to 33 points;
a fair score, 21 to 27 points; and a poor score, 0 to 20
points.
The test is easy to administer, but there are no data
on methodology of development or testing, and the
position of forward flexion is not standardized. There
are double-barrel questions with multiple variables
and descriptors per item, and weighting is not sup-
ported. The older version of the UCLA scoring system
can only be used after intervention and combines 2 items
of subjective evaluation with 2 items of physical exam-
ination. The newer version should also be used only after
intervention and combines 3 items of subjective evalua-
tion with 2 items of physical examination. There are only
5 total questions on the newer version, with no specific
questions on instability. The scoring system is minimally
responsive for patients with instability and should not be
used for this population.
Burkhart et al.33 published an article in Arthroscopy
in 1994 in which they evaluated 14 patients who
underwent partial repair of a massive rotator cuff tear.
The mean score was 27.6 points, which is only be-
tween good and fair according to the criteria of Ell-
man32 from 1987 and poor according to the original
criteria of Ellman et al.31 Although 6 of 14 patients
had a fair or poor score, 13 of 14 patients answered
“satisfied and better” on the rating scale, leading to
doubt regarding the consistency of the subjective find-
ings of the patient with the scoring system.
In The American Journal of Sports Medicine in
1996, Romeo et al.34 evaluated 52 patients with 53
shoulder stabilization procedures. The majority (85%)
of the patients had an excellent result with the UCLA
scoring system, but only 38% of the patients had an
excellent result with the modified Rowe system. The
authors believed that the UCLA scoring system was
the most “forgiving” of the systems evaluated. For
example, a patient can have no pain and have full use
of the arm for activities of daily living yet lose 50% of
his or her external rotation and still obtain an excellent
result, with 28 of 30 points (scoring done before the
addition of the satisfaction category).
 SHOULDER INSTABILITY
Simple Shoulder Test
The SST, developed in 1992 by Lippitt et al.35 from
the University of Washington, has a total of 12 yes/no
questions. The scale indirectly assesses pain, range of
motion, and strength through the questionnaire. The
main goal of the score is to document functional
improvement resulting from a specified procedure by
a specific surgeon, in response to a given diagnosis.
There are no patient satisfaction items, and no formal
testing of reliability was done by the authors. The
dichotomous responses diminish sensitivity, and the
development methodology does not include any pa-
tient input. The main advantage to the system is that it
does not require a clinician to administer the test or
any elaborate equipment.
Godfrey et al.36 evaluated the reliability, validity,
and responsiveness of the SST in the Journal of Shoul-
der and Elbow Surgery in 2006. This article compared
psychometric properties by age and injury type. Over-
all, the SST was found to reliable, valid, and generally
responsive. However, the SST was only moderately
responsive in patients aged younger than 40 years
regardless of injury type. The SST was also only
moderately responsive in patients with instability in-
juries. The authors cautioned against using the system
in a clinical investigation. Kirkley et al.17 published an
article in Arthroscopy in 2003 that critically evaluated
scoring systems for the functional assessment of the
shoulder. They concluded that the SST is unlikely to
be sensitive to small but clinically important changes
in patient function because of the dichotomous re-
sponse option. In addition, the test was likely to have
poor discriminative function, with a decreased ability
to differentiate between patients with varying severi-
ties of the same condition.
Additional Studies
Additional studies have been performed to compare
and contrast the numerous scoring systems that have
been used. Soldatis et al.,37 in 1997, performed a
comparison study in healthy college athletes during
the midseason. They compiled scores from the ASES,
Rowe, UCLA, CM, and SST scoring systems. They
added a sport-specific function item, an item for pain
in high-demand situations, and items for the ability to
weight train and throw. This was named the Baylor/
Houston Athletic Shoulder Assessment Questionnaire.
They concluded that significant shoulder symptoms
exist in athletes during full participation in their re-
spective sports. Pain was the most frequent symptom,
occurring in 47% of all shoulders. The UCLA system
905
was found to be the most sensitive, but an ideal
scoring system has yet to be developed. The authors
realized that a “normal” or “symptom-free” shoulder
after injury or surgery may not be realistic.
Uhorchak et al.38 published their results on recur-
rent shoulder instability after open reconstruction in
athletes who participated in collision and contact
sports, in The American Journal of Sports Medicine in
2000. The study used both the ASES (before 1994)
and Rowe systems for comparison evaluations. The
ASES scores were much higher, because stability was
only allocated 5 of 100 points. Conversely, a patient
received a Rowe score of only 10 of 50 points if he or
she had recurrent subluxation. The authors concluded
that the ASES score may not be applicable to insta-
bility. In fact, the current ASES system does not even
have a section for instability. The Rowe score more
accurately reflects the occurrence of instability. How-
ever, recurrence of instability was not consistent with
functional status or patient satisfaction in the popula-
tion tested. The group with only rare (⬍3) subluxa-
tions had a low Rowe score but high satisfaction. Of
note, the population was US military academy cadets,
and all patients had to return to collision sports and
military training after surgery.
As discussed previously, Romeo et al.34 evaluated and
compared 5 commonly used scoring systems for shoul-
der evaluation: Rowe, modified Rowe, UCLA, and pre-
1994 ASES scoring systems. This was a retrospective
analysis of 53 consecutive patients undergoing shoulder
stabilization procedures. The UCLA scores showed ex-
cellent results in 85% of patients, whereas the modified
Rowe score showed excellent results in only 38%. The
UCLA scoring system correlated poorly with the other
systems. In addition, the inter-rater reliability among the
4 systems was poor. This shows that generalized results
of an investigation can be biased based on the selection
of a scoring system. Scoring systems are frequently used
to describe the results of various procedures. Romeo et
al.34 concluded that the lack of a widely accepted scoring
system limits comparison of management for shoulder
conditions.
DISCUSSION
Overall, there were a total of 11 scoring systems
that were thoroughly evaluated. Systems were evalu-
ated for proper development, reliability, validity, and
responsiveness for a homogeneous subset of patients
with known instability (Table 2). Only 3 of the 11
scoring systems, the MISS, the DASH, and the WOSI,
appear to have used an adequately described develop-
906 PLANCHER AND LIPNICK

TABLE 2. Development, Reliability, Validity, and Responsiveness for Shoulder Scoring Systems
Scoring System Proper Development Reliable for Instability Valid for Instability Responsive for Instability

ASES self-report20 No No (ICC ⱖ0.75*; IC, 0.61) Large Moderate/large (SRM, 0.54/0.93)
ASORS29 No Unknown Small Unknown
CM27 No Unknown Small Moderate (SRM, 0.59)
DASH22,23 Yes Unknown Small Moderate (SRM, 0.71)
MISS11 Yes Yes (ICC, 0.98) Moderate Large (SRM, 1.57)
OIS25,26 No Yes (IC, 0.91) Moderate Large (ES, 0.8)
Rowe18 No No Small Moderate (SRM, 0.76)
SRQ13 No Yes† (ICC ⱖ0.94, IC ⱖ0.71) Moderate Large (SRM, 1.4)
SST35 No Yes (ICC, 0.97) Moderate Moderate (SRM, 0.63; ES, 0.61)
UCLA30,31 No Unknown Small Small (SRM, 0.39)
WOSI15 Yes Yes (ICC, 0.95) Large Large (SRM, 0.93)

Abbreviation: ES, effect size; SRM, standardized response mean.

*Ten of eleven domains. Testing was performed in patients with instability, rotator cuff disease, and glenohumeral arthritis.
†The article13 states that the instability group was evaluated separately; however, exact numbers not provided.

ment process. Most of the other systems either did not
provide a description of item generation and/or reduc-
tion or provided a limited description.
Some of the scoring systems, as depicted in Table 1,
include both subjective and objective components. It
has been suggested that clinical examination variables
be collected and reported separately, because these
variables tend to have very poor reliability and corre-
late poorly with patients’ subjective evaluations of
their function, even when performed by experienced
clinicians.15 The Rowe, CM, ASORS, and UCLA
scoring systems all have objective components incor-
porated into them.
Reliability was determined by both the ICC and IC.
IC was acceptable at levels greater than 0.70, with
0.80 indicating good, 0.90 indicating excellent, and
1.0 indicating perfect. As discussed earlier in this
review, this cutoff is subject to debate, because some
authors classify levels greater than 0.60 as acceptable.
However, numerous systems evaluated had an IC
level greater than 0.90, and therefore we believed that
the higher limit should be used. Some studies were
found to be reliable for a broad category of patients
with multiple pathologies, not just instability. If there
was no specific population of patients with instability
noted, the scoring system was unable to be labeled as
reliable. The SRQ, MISS, WOSI, OIS, and SST sys-
tems were all found to be reliable for instability. The
ASES system was found to be unreliable, with an IC
of 0.61 in instability patients and an ICC of 0.75 or
greater in only 10 of 11 domains in all patients,
including those with pathologies other than instability.
There has been no reliability testing for the Rowe,
DASH, CM, ASORS, or UCLA systems.
Responsiveness was evaluated by both the SRM
and the effect size. The ASORS has not yet been
evaluated. The UCLA system was found to be mini-
mally responsive, with an SRM of 0.39. The Rowe,
DASH, CM, and SST systems were found to be mod-
erately responsive. The ASES system was found to be
largely responsive (SRM, 0.93) by Kocher et al.12
However, Kirkley et al.15 found the ASES system to
be only moderately responsive (SRM, 0.54), placing
below the Rowe, DASH, and CM systems. Systems
that were found to be largely responsive include the
SRQ, MISS, WOSI, and OIS.
The validity of the scoring systems was also eval-
uated taking into account construct, criterion, and
content validity. Many authors claim that certain scor-
ing systems are valid; however, there currently is no
formal gold standard that can be used for comparison
to determine criterion validity. Thus criterion validity
cannot solely be used for verification. There is also no
specific set of questions to truly predict that what is
being measured is actually what is supposed to be
measured. Therefore the determination of validity is
very difficult and somewhat subjective. For instance,
the model used for criterion validity for the SRQ was
the Arthritis Impact Measurement Scales 2, which has
been validated in patients with osteoarthritis. Al-
though the authors of the SRQ concluded that their
findings support validity for patients in each diagnos-
tic group, including instability, they are using an ar-
bitrary scoring system that has not been validated for
patients with instability. In addition, the MISS ques-
tionnaire used the SRQ as a comparison tool to aid in
the validation process, based on the claim that the
SRQ is one of the few self-administered shoulder
scores that has been shown to be a reliable and valid
measure for the assessment of glenohumeral instabil-
 SHOULDER INSTABILITY
ity. There is clearly some confusion when it comes to
the validation of a system when there is no clear gold
standard for comparison.
At present, validity cannot be confirmed in patients
with instability for the Rowe, DASH, CM, ASORS, or
UCLA scoring systems. The SRQ, MISS, OIS, and
SST systems all appear to have moderate validity. The
ASES and WOSI systems have both been shown to
have significant support to conclude high validity for
patients with instability.
Even though the ASES system has been shown to
be valid, we strongly caution against using it for
patients with instability, because it does not appear to
optimally determine outcome measurement and was
found to be less responsive in patients with instability
compared with other pathologies. Like the ASES, the
SRQ may not be specific enough in the evaluation of
patients with instability.
The SST was found to be only moderately respon-
sive in patients aged younger than 40 years as well as
patients presenting with instability. This scoring sys-
tem will most likely be unable to detect small but
clinically important changes and therefore is not an
ideal system to use in patients with instability.
Although the OIS has potential, the development
process is questionable and the Rowe system was
found to have a larger effect size after direct compar-
ison, implying that the OIS is even less responsive
than the Rowe in patients with instability. The MISS,
a relatively new scoring system, also appears to have
potential for use in the evaluation of patients with
shoulder instability. The development process is ade-
quate, and the system has been shown to be respon-
sive, reliable, and valid by use of the SRQ for com-
parison.
The WOSI has been shown to be reliable, valid, and
responsive in patients with instability. The WOSI was
originally tested in patients undergoing both nonop-
erative and operative treatment, making the scoring
system available for use in both subsets of patients.
However, there was no distinction in scoring in the
2 groups, leaving the reader to wonder whether the
WOSI could differentiate between the benefits of
surgery versus physical therapy. Kirkley et al.24 did
follow the original article using the WOSI in a
prospective, randomized clinical trial comparing
early arthroscopic stabilization versus rehabilitation
in first-time anterior shoulder dislocators. They con-
cluded that each of the 4 domains reached or ap-
proached statistical significance.
907
CONCLUSIONS
It is imperative to develop common guidelines and
criteria for treatment, which will facilitate identifica-
tion of effective outcomes for similar conditions.
Comparative prospective studies should be encour-
aged. There is a need for a standardized measuring
system that incorporates the following: (1) it must
satisfy the needs of those using it, (2) it must satisfy
development testing criteria, (3) it must be strongly
weighted toward functional outcome, (4) it must be
simple and effective, and (5) it should include self
(patient)–assessment.
Both the WOSI and the MISS meet these criteria.
The SRQ and the OIS both have potential but may or
may not be adequately responsive in the instability
population. Although a discussion on the optimal scor-
ing system for shoulder pathologies other than shoulder
instability is beyond the scope of this article, the ASES
scoring system may be considered, because it has been
proven to be valid, reliable, and responsive. We recom-
mend using both the WOSI and the MISS to evaluate
patients with instability to make clinical decisions. Fur-
ther testing evaluating these tools in a clinical setting will
determine whether these scoring systems can later be
used as the gold standard for patients with shoulder
instability.
Standardizing the scoring system used in clinical
studies performed for the treatment of shoulder insta-
bility will lead to more consistent results as well as
results that may be able to be compared between
studies. With the multitude of scoring systems used in
clinical trials, a direct comparison between studies is
difficult and what is tested may not even be an accu-
rate measure of shoulder instability outcome mea-
sures.
There are still a number of outstanding questions.
We have yet to determine whether problem-specific
measuring tools are more desirable than a single sys-
tem. This review is specific to shoulder instability
problems and would not necessarily be adequate for
the arthritic shoulder or other shoulder dysfunctions. It
is possible that the development of population-specific
tools for competitive athletes and other groups may be
advantageous; however, it may merely add further
confusion and difficulty for testing.
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