Journal of Shoulder and Elbow Surgery

Comparing patient-reported outcome measures and physical examination for internal rotation in patients undergoing reverse shoulder arthroplasty: does surgery alter patients' perception of function?

Published:February 15, 2021DOI:


      The purpose of this study was to evaluate how patients treated with reverse shoulder arthroplasty (RSA) achieve internal rotation (IR) using video assessment and to compare this to patient-reported outcome measures (PROMs).


      We reviewed 215 preoperative and 657 postoperative videos (3-78 months) for 215 patients who underwent primary RSA, performing IR using the modified vertebral level method. Their functional motion pattern was then grouped into 3 types: type I, could not reach behind their back; type II, able to reach to at least waist level, with assistance; and type III, able to reach to a minimum of waist level in an uninterrupted fashion. Patients completed functional questions (put on a coat, wash back, tuck in a shirt, and manage toileting) and a diagram of perceived IR. Patients’ functional motion types were compared to PROM answers. Pre- and postoperative scores were also compared to assess the effect of surgery on patients’ perception of IR function.


      Patients undergoing RSA will achieve IR in 3 distinct motion patterns. Analysis of self-reported IR indicated statistically significant difference between the 3 functional types of IR (P < .001). Patient-perceived IR was not significantly different between the 3 studied IR functional types (P = .076) in the analysis of preoperative measures but was significantly different in the postoperative setting (P < .001).


      Patients attempt IR in 3 distinct functional motion patterns. The improvement of IR after RSA is measured better by patient questionnaires than by physical examination.

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        • Aleem A.W.
        • Chamberlain A.M.
        • Keener J.D.
        The functional internal rotation scale: a novel shoulder arthroplasty outcome measure.
        JSES Int. 2019; 4: 202-206
        • Awan R.
        • Smith J.
        • Boon A.J.
        Measuring shoulder internal rotation range of motion: a comparison of 3 techniques.
        Arch Phys Med Rehabil. 2002; 83: 1229-1234
        • Bigdon S.
        • Bollinger L.
        • Albers C.
        • Collin P.
        • Zumstein M.
        Subscapularis in reverse total shoulder arthroplasty.
        J Shoulder Elbow Arthroplasty. 2019; 3: 1-8
        • Chelli M.
        • Levy Y.
        • Lavoué V.
        • Clowez G.
        • Gonzalez J.F.
        • Boileau P.
        The "Auto-Constant": can we estimate the Constant-Murley score with a self-administered questionnaire? A pilot study.
        Orthop Traumatol Surg Res. 2019; 105: 251-256
        • Collin P.
        • Baverel L.
        • Ferrand M.
        • Gain S.
        Internal rotation after reverse shoulder arthroplasty.
        in: Favard L. Mansat P. Reverse shoulder arthroplasty. Elsevier Masson, Paris2020: 153-156
        • Friedman R.
        • Flurin P.H.
        • Wright T.W.
        • Zuckerman J.D.
        • Roche C.
        Comparison of reverse total shoulder arthroplasty outcomes with and without subscapularis repair.
        J Shoulder Elbow Surg. 2017; 26: 662-668
        • Godfrey J.
        • Hamman R.
        • Lowenstein S.
        • Briggs K.
        • Kocher M.
        Reliability, validity, and responsiveness of the Simple Shoulder Test: psychometric properties by age and injury type.
        J Shoulder Elbow Surg. 2007; 16: 260-267
        • Goodman J.
        • Lau B.C.
        • Krupp R.J.
        • Getz C.L.
        • Feeley B.T.
        • Ma C.B.
        • et al.
        Clinical measurements versus patient-reported outcomes: analysis of the American Shoulder and Elbow Surgeons physician assessment in patients undergoing reverse total shoulder arthroplasty.
        JSES Open Access. 2018; 2: 144-149
        • Hsu J.E.
        • Russ S.M.
        • Somerson J.S.
        • Tang A.
        • Warme W.J.
        • Matsen 3rd, F.A.
        Is the Simple Shoulder Test a valid outcome instrument for shoulder arthroplasty?.
        J Shoulder Elbow Surg. 2017; 26: 1693-1700
        • Kim M.S.
        • Jeong H.Y.
        • Kim J.D.
        • Ro K.H.
        • Rhee S.M.
        • Rhee Y.G.
        Difficulty in performing activities of daily living associated with internal rotation after reverse total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2020; 29: 86-94
        • McClure P.
        • Michener L.
        Measures of adult shoulder function: The American Shoulder and Elbow Surgeons Standardized Shoulder Form Patient Self-Report Section (ASES), Disabilities of the Arm, Shoulder, and Hand (DASH), Shoulder Disability Questionnaire, Shoulder Pain and Disability Index (SPADI), and Simple Shoulder Test.
        Arthritis Rheum. 2003; 49: S50-S58
        • McHugh M.L.
        Interrater reliability: the kappa statistic.
        Biochem Med (Zagreb). 2012; 22: 276-282
        • Rojas J.
        • Bitzer A.
        • Joseph J.
        • Srikumaran U.
        • McFarland E.G.
        Toileting ability of patients after primary reverse total shoulder arthroplasty.
        JSES Int. 2019; 4: 174-181
        • Rojas J.
        • Joseph J.
        • Srikumaran U.
        • McFarland E.G.
        How internal rotation is measured in reverse total shoulder arthroplasty: a systematic review of the literature.
        JSES Int. 2019; 4: 182-188
        • Roy J.S.
        • Macdermid J.C.
        • Faber K.J.
        • Drosdowech D.S.
        • Athwal G.S.
        The Simple Shoulder Test is responsive in assessing change following shoulder arthroplasty.
        J Orthop Sports Phys Ther. 2010; 40: 413-421
        • Sraj S.A.
        Internal rotation behind-the-back angle: a reliable angular measurement for shoulder internal rotation behind the back.
        Sports Health. 2015; 7: 299-302
        • Torrens C.
        • Guirro P.
        • Santana F.
        The minimal clinically important difference for function and strength in patients undergoing reverse shoulder arthroplasty.
        J Shoulder Elbow Surg. 2016; 25: 262-268
        • Wirth B.
        • Kolling C.
        • Schwyzer H.-K.
        • Flury M.
        • Audige L.
        Risk of insufficient internal rotation after bilateral reverse shoulder arthroplasty: clinical and patient-reported outcome in 57 patients.
        J Shoulder Elbow Surg. 2016; 25: 1146e54