Last updated: Thursday, May 26, 2011
About the simple shoulder test
The shoulder is essential for many activities of daily living. The ability of the shoulder to carry out these functions characterizes perhaps the most important aspect of its health. Conversely, the severity of shoulder conditions may be documented in terms of the compromise of these functions.
Because of the critical importance of systematic documentation of shoulder function, we have developed the Simple Shoulder Test (SST): a series of 12 "yes" or "no" questions the patient answers about the function of the involved shoulder. The answers to these questions provides a standardized way of recording the function of a shoulder before and after treatment. Our practice is to obtain the Simple Shoulder Test on all patients presenting to the University of Washington Shoulder and Elbow Service so we will have a benchmark for comparison of their subsequent course.
More about the SST
The questions of the SST are:
- Is your shoulder comfortable with your arm at rest by your side?
- Does your shoulder allow you to sleep comfortably?
- Can you reach the small of your back to tuck in your shirt with your hand?
- Can you place your hand behind your head with the elbow straight out to the side?
- Can you place a coin on a shelf at the level of your shoulder without bending your elbow?
- Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow?
- Can you lift eight pounds (a full gallon container) to the level of the top of your head without bending your elbow?
- Can you carry 20 pounds at your side with the affected extremity?
- Do you think you can toss a softball underhand 10 yards with the affected extremity?
- Do you think you can throw a softball overhand 20 yards with the affected extremity?
- Can you wash the back of your opposite shoulder with the affected extremity?
- Would your shoulder allow you to work full-time at your usual job?
Each of the conditions potentially afflicting the shoulder may vary substantially in severity. The diagnoses of instability, cuff disease, arthritis, or frozen shoulder do not of themselves indicate the need for treatment. The need for treatment arises from the effect of the condition on the patient's function.
These data are easily presented in charts which show the percent of patients who cannot perform each of the 12 functions. Consult figures 1 and 2 to review SST data for patients presenting to the University of Washington Shoulder and Elbow Service with degenerative glenohumeral joint disease. The SST also facilitates comparisons, for example of the shoulder function of patients presenting with degenerative and rheumatoid glenohumeral joint disease (see figures 3 and 4).
The success of a treatment method is determined largely by its ability to restore function. The SST provides a practical method for evaluating results. We prefer to present the results in terms of the percent of patients gaining (and losing) each function after the treatment was instituted. Consult figures 5 and 6 for data about patients with degenerative glenohumeral joint disease treated with total shoulder arthroplasty. The standardized nature of the SST facilitates comparison of the effectiveness of different treatment methods, different diagnoses and different surgeons. For a comparison with the DJD results, see figures 7 and 8 with data about patients with rheumatoid glenohumeral joint disease treated with total shoulder arthroplasty.
Origins of the simple shoulder test
The Simple Shoulder Test questions were derived from the common complaints of patients presenting to the University of Washington Shoulder Service for evaluation.
Patient's own evaluation
It is important that the patient answer these questions without assistance: it is the patient's own evaluation of his or her shoulder function that is wanted. Because the patient is the consistent evaluator of the shoulder, concern about inter observer variability is eliminated. The SST reflects the status of the shoulder in functional terms, rather than in degrees of motion, appearance of radiographs or isokinetic torque measurements. If the situation requires, we can add questions to the original twelve, keeping the minimal data set intact. For example in studying high performance athletes, we add to the basic SST such questions as: "Does your shoulder allow you to pitch (or serve) with your usual speed and control?" "Does your shoulder allow you to swim your normal workout?" "Does your shoulder allow you to compete at the varsity level in your sport?"
Prior to the clinical introduction of the Simple Shoulder Test we verified that almost all normal patients aged 60 to 70 years were able to perform the twelve basic functions. Subsequently, we have used the Simple Shoulder Test on thousands of clinical occasions.
Attributes of the simple shoulder test
Reproducibility, practicality, and more
The SST has demonstrated a high degree of reproducibility. In normal subjects, the reproducibility is essentially 100%, with almost all subjects answering "yes" to all twelve questions. As a more stringent test, we tested seventy patients with abnormal SST's and then retested them 5 to 30 days later (average 14 days). Sixty-three percent of the patients had identical responses on retesting. Ninety percent of the patients answered no more than one question differently on retest. Over 96 percent made no more than two different responses on retest. This lack of absolute reproducibility is not a deficiency of the SST; instead it reflects an actual day-to-day variation in some patients' view of their shoulder function.
The Simple Shoulder Test provides a practical method for determining the pretreatment shoulder function as well as the shoulder function at various intervals after the treatment. Sequential SST's indicate the length of time required to achieve maximum functional benefit after treatment. The difference between the shoulder function before treatment and after the recovery period is the effectiveness of the treatment.
The simplicity of the SST facilitates the communication of results to patients. Prospective surgical candidates are able to compare their own pretreatment status with the typical pretreatment status of others having the same diagnosis. This information enables them to answer questions such as, "How bad is my arthritis in comparison with other individuals who have had a total shoulder replacement?" Similarly, by reviewing the functional results of a given treatment for their diagnosis, patients can answer the questions, "What are the chances that I will be able to do these activities after the treatment?" and "How long will it take before I see improvement?"
The SST facilitates comparisons because
- the questions are standardized,
- the SST is a patient self-assessment (eliminating concerns about inter-observer variations),
- the SST is simple and free (so it can be repeated often and used by anyone).