Reverse Total Shoulder Arthroplasty Inconsistently Improves Self-Reported Overhead Shoulder Strength

DOI: 10.70885/hmsj.2026.07.004

Abstract

Background: Composite patient-reported outcome measures (PROMs) following reverse total shoulder arthroplasty (rTSA) are widely used to assess postoperative outcomes, yet individual items targeting overhead strength recovery are rarely analyzed in isolation.Hypothesis: We hypothesized that while composite American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores would improve reliably following rTSA, patients would continue to report poor improvement in overhead strength-specific questionnaire items when treated for rotator cuff-deficient shoulder conditions.Methods: This is a retrospective review of patients who underwent primary rTSA for either massive rotator cuff tear without arthritis or rotator cuff tear arthropathy between 2017-2023. ASES and SST patient reported outcome measures (PROMs) were collected preoperatively and at one-year postoperative follow-up. Patients answering “unable” or “very difficult” for ASES question 14 (ASES14) were deemed to have poor self-reported strength. Similarly, a negative answer for SST question 7 (SST7) was used as a proxy for poor self-reported strength. Univariate analysis was used to evaluate statistical significance comparing preoperative and postoperative PROMs. Multivariate logistic regression models were used to identify predictors of improvement in self-reported overhead strength for both ASES and SST PROMs.Results: (ASES) Preoperatively, 96% (66/69) of patients self-reported poor strength by ASES14. Of those, only 52% (34/66) improved in self-reported ability to lift >10lbs overhead at one-year postoperative follow-up. (SST) Preoperatively, 96% (46/48) self-reported poor strength. Of those, only 35% (16/46) improved in self-reported ability to lift >8lbs to the level of the top of the head with the elbow straight at one-year postoperative follow-up. Multivariable logistic regression of age, sex and presence or absence of subscapularis repair demonstrated male sex as the only significant variable influencing self-reported strength improvement by ASES14.Conclusion: This study demonstrates unreliable clinical improvement in patient-reported overhead strength at 1-year post-rTSA despite significant improvement in overall ASES (p<0.0001) and SST (p<0.0001) scores. Male sex was associated with self-report improvement in overhead strength as queried by ASES question 14, while age and subscapularis repair were not. Neither sex, age, nor subscapularis repair were associated with self-report strength improvement by SST question 7. These results can help guide specific aspects of preoperative counselling as patients consider rTSA for cuff deficient shoulder pathologies.What this study adds to existing knowledge: This study quantifies a clinically recognized limitation of reverse total shoulder arthroplasty for rotator cuff–deficient conditions: improvement in composite PROM scores does not consistently translate into recovery of patient-reported overhead strength.How this study might affect research, practice, or policy: This study can help guide patient preoperative counseling about the likelihood of strength improvement after reverse total shoulder arthroplasty for rotator cuff deficient indications.Study Design: Retrospective ReviewLevel of Evidence: IVKeywords: Reverse total shoulder arthroplasty (rTSA); Rotator cuff deficient shoulder; Overhead shoulder strength: Self-reported overhead strength; ASES and SST questionnaireshttps://doi.org/10.70885/hmsj.2026.07.004

References

  1. Gabig AM, Burkhart SS, Denard PJ, Proffitt JM, Hartzler RU. Similar Value Demonstrated in the Short-Term Outcomes of Superior Capsular Reconstruction and Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears. Arthrosc Sports Med Rehabil. 2023;5(1):e249-e55.
  2. Hao KA, Wright TW, Schoch BS, Wright JO, Dean EW, Struk AM, et al. Association Between Preoperative Shoulder Strength and Clinical Outcomes After Primary Reverse Total Shoulder Arthroplasty. J Am Acad Orthop Surg. 2022;30(9):e730-e40.
  3. Edwards PK, Ebert JR, Morrow MM, Goodwin BM, Ackland T, Wang A. Accelerometry evaluation of shoulder movement and its association with patient-reported and clinical outcomes following reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2020;29(11):2308-18.
  4. Nolan BM, Ankerson E, Wiater JM. Reverse total shoulder arthroplasty improves function in cuff tear arthropathy. Clin Orthop Relat Res. 2011;469(9):2476-82.
  5. Hao KA, Wright TW, Schoch BS, Wright JO, Dean EW, Struk AM, et al. Rate of improvement in shoulder strength after anatomic and reverse total shoulder arthroplasty. JSES Int. 2022;6(2):247-52.
  6. Puskas B, Harreld K, Clark R, Downes K, Virani NA, Frankle M. Isometric strength, range of motion, and impairment before and after total and reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(7):869-76.
  7. Ogrodzka-Ciechanowicz K, Kurzeja P, Sorysz T. Assessment of Isokinetics and Range of Motion of the Shoulder in Patients after Reverse Shoulder Arthroplasty in the Late Follow-Up Period. J Clin Med. 2023;12(23).
  8. Seth B. Wilson AJS, Jordan A. Haber, Erryk Katayama, Louis Barry, John Barnett, George Durisek, Mitchell Borin, Amogh I. Iyer, Akshar V. Patel, Gregory L. Cvetanovich, Julie Y. Bishop, Ryan C. Rauck,. Clinical evaluation of patients over the age of 75 receiving either anatomic or reverse total shoulder arthroplasty: a single-institution retrospective analysis. Seminars in Arthroplasty: JSES,. 2024.
  9. Pluta NA, Littleford K, Kotzur T, et al. Minimal improvements in objective shoulder strength following shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2026;35(2):634-642.
  10. Alta TD, Veeger HE, Janssen TW, Willems WJ. Are shoulders with a reverse shoulder prosthesis strong enough? A pilot study. Clin Orthop Relat Res. 2012;470(8):2185-2192.
  11. Cronin KJ, Magnuson JA, Murphy ML, Unger RZ, Jacobs CA, Blake MH. Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring? J Shoulder Elbow Surg. 2021;30(5):1174-80.
  12. Schoch BS, King JJ, Fan W, et al. Characteristics of anatomic and reverse total shoulder arthroplasty patients who achieve ceiling scores with 3 common patient-reported outcome measures. J Shoulder Elbow Surg. 2022;31(8):1647-1657.
  13. Jo YH, Lee KH, Jeong SY, Kim SJ, Lee BG. Shoulder outcome scoring systems have substantial ceiling effects 2 years after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2021;29(7):2070-2076.
  14. Pandy MG, Yang K, Guan S, Schmidt II CM, Frankle MA. Effect of reverse shoulder arthroplasty design on deltoid and rotator cuff function in abduction. J Shoulder Elbow Surg. 2026;35(6):1605-1617.
  15. Tashjian RZ, Hung M, Keener JD, Bowen RC, McAllister J, Chen W, et al. Determining the minimal clinically important difference for the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog scale (VAS) measuring pain after shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26(1):144-8.
  16. Yendluri A, Alexanian A, Lee AC, Megafu MN, Levine WN, Parsons BO, Kelly JD 4th, Parisien RL. The variability of MCID, SCB, PASS, and MOI thresholds for PROMs in the reverse total shoulder arthroplasty literature: a systematic review. J Shoulder Elbow Surg. 2024;33(10):2320-2332.
  17. Schoch BS, Vigan M, Roche CP, Parsons M, Wright TW, King JJ, Werthel JD. Deltoid fatigue: a longitudinal assessment of reverse shoulder arthroplasty over time. J Shoulder Elbow Surg. 2021;30(6):1375-1383.
  18. Friedman RJ, Cheung EV, Flurin PH, Wright T, Simovitch RW, Bolch C, Roche CP, Zuckerman JD. Are Age and Patient Gender Associated With Different Rates and Magnitudes of Clinical Improvement After Reverse Shoulder Arthroplasty? Clin Orthop Relat Res. 2018;476(6):1264-1273.
  19. Roy JS, Macdermid JC, Goel D, Faber KJ, Athwal GS, Drosdowech DS. What is a Successful Outcome Following Reverse Total Shoulder Arthroplasty? Open Orthop J. 2010;4:157-63.
  20. Lawrence TM, Ahmadi S, Sanchez-Sotelo J, Sperling JW, Cofield RH. Patient reported activities after reverse shoulder arthroplasty: part II. J Shoulder Elbow Surg. 2012;21(11):1464-9.
  21. Cuff D, Pupello D, Virani N, Levy J, Frankle M. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am. 2008;90(6):1244-51.
  22. 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(3):260-7.
  23. Roy JS, Macdermid JC, Faber KJ, Drosdowech DS, Athwal GS. The simple shoulder test is responsive in assessing change following shoulder arthroplasty. J Orthop Sports Phys Ther. 2010;40(7):413-21.
  24. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587-94.
  25. Furtado R, Bobos P, Ziebart C, Vincent J, MacDermid J. Patient-reported outcome measures used for shoulder disorders: An overview of systematic reviews. J Hand Ther. 2022;35(2):174-85.
  26. Schmidt S, Ferrer M, González M, González N, Valderas JM, Alonso J, et al. Evaluation of shoulder-specific patient-reported outcome measures: a systematic and standardized comparison of available evidence. J Shoulder Elbow Surg. 2014;23(3):434-44.
  27. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3(6):347-52.
  28. Matsen FA, 3rd, Ziegler DW, DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint disease. J Shoulder Elbow Surg. 1995;4(5):345-51.

Full text PDF