REVIEW ARTICLE
Outcomes Evaluation of the Athletic Elbow Michael T. Freehill, MD,* Sandeep Mannava, MD, PhD,* and Marc R. Safran, MDw
Abstract: The high-level athletic population poses difficulty when evaluating outcomes in orthopedic surgery, given generally good overall health and high function at baseline. Subtle differences in performance following injury or orthopedic surgery are hard to detect in high-performance athletes using standard outcome metrics; however, attaining these subtle improvements after injury or surgery are key to an athletes’ livelihood. Outcome measures serve as the cornerstone for critical evaluation of clinical outcomes following orthopedic surgery or injury. In the age of “evidence-based medicine” and “pay-for-performance” accountability for surgical intervention, understanding clinically relevant outcome measures is essential for careful review of the published literature, as well as one’s own critical review of surgical performance. The purpose of this manuscript is to evaluate clinical outcome measures in the context of the athletic elbow. An emphasis will be placed on evaluation of the 5 most clinically relevant outcome measures for sports-related elbow outcomes: (1) American Shoulder and Elbow Committee; (2) Mayo Elbow Performance Index; (3) AndrewsTimmerman [and its precursor the (4) Andrews-Carson]; and (5) Kerlan-Jobe Orthopaedic Clinic overhead athlete score. A final outcome measure that will be analyzed is “return to play” statistics, which has been published in various studies of athletes’ recovery from elbow surgery, as well as, the outcomes metric known as the “Conway-Jobe scale.” Although there is no perfect outcomes score for the athletic elbow, the Kerlan-Jobe Orthopaedic Clinic score is the only outcomes tool developed and validated for outcomes for elbow injuries in the overhead athlete, as compared with the Andrew-Timmerman and Conway-Jobe metrics, which were not validated outcome measures for the elbow in this patient population. Despite the Disabilities of Arm, Shoulder, Hand (DASH) (and DASH—Sport module) being validated in the general population, this upper extremity scale is not specific for elbow function. Key Words: athletic elbow, outcome measures, return to play, athletic outcomes, elbow outcomes
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THE ATHLETIC ELBOW Overhead athletic competition produces extreme biomechanical demands upon the upper extremity; particularly, the elbow joint, not experienced during activities of daily living (ADL). As such, athletes may experience elbow pain From the *Department of Orthopaedic Surgery, Medical Center Boulevard, Division of Sports Medicine and Shoulder Surgery, Wake Forest University School of Medicine, Winston-Salem, NC; and wDepartment of Orthopaedic Surgery, Division of Sports Medicine, Stanford University School of Medicine, Redwood City, CA. Disclosure: M.R.S. has fellowship support from Ossur, Smith and Nephew, ConMed Linvatec; Consultant, ConMed Linvatec, Biomimedica. M.T.F. has fellowship support from Depuy Mitek, DJO and is a consultant for Smith and Nephew. S.M. declares no conflict of interest. Reprints: Michael T. Freehill, MD, Department of Orthopaedic Surgery, Medical Center Boulevard, Division of Sports Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157. Copyright r 2014 by Lippincott Williams & Wilkins
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and/or injury, which may result in inability to perform at a high athletic level during competition; however, this same shortcoming may not be evident during everyday activities. Assessing the athletic elbow is further complicated by an injured athletes’ ability to often continue to compete and perform at an elite level despite injury, in many instances. When studying the athletic elbow during injury and recovery, many outcome metrics can be used to assess surgical repair, rehabilitation, and nonoperative management. Measures of strength, range of motion, and radiographic healing may not fully capture an athlete’s ability to compete during specific sporting maneuvers. The simple metric of return to play1–6 may represent an important goal when treating athletic elbow injuries, but simply returning to competition may not capture a truly successful return to sport at both a psychological and functionally meaningful level which either meets or exceed preinjury levels. During sporting competition, both the physical functionality and psychological health play crucial roles in the effectiveness of athletic participation; thus, athlete-oriented patient questionnaires may provide the best assessment measure for return to effective participation after elbow injury or orthopedic surgical intervention. Furthermore, sport-specific measurement tools may provide the most useful outcomes.
THE STUDY OF ATHLETIC ELBOW OUTCOMES Outcome measures are the cornerstone for evaluation and study of clinical outcomes following injury and/or surgery. More broadly, validated outcome measures allow for evaluation of injury impact or clinical efficacy of a particular intervention, such as surgery, in terms of that intervention’s impact on a patient’s general health, satisfaction, function, and pain. To be useful, clinical outcome measures should allow for “reliability, validity, and responsiveness.”7–9 In the age of “evidence-based medicine” and “pay-for-performance” accountability for the surgeon, understanding clinically relevant outcome measures is essential for careful review of the published literature, as well as one’s own critical review of surgical performance. The purpose of this manuscript is to evaluate clinical outcome measures in the context of the athletic elbow. In particular, this manuscript critically reviews and discusses several clinically relevant measures used in sports medicine and orthopedic research to quantify outcomes of elbow injury and surgery. The high-level athletic population can be somewhat problematic to study in orthopedic surgery, given their generally good overall health and high function at baseline. The difficulty in assessing the outcomes of various surgical interventions in high-level athletes is correlating results with general outcomes measurement tools originally designed to detect differences in less functional or even lower performing individuals. Thus a high-performing athlete, even though injured, may stay close to the “ceiling” of a detection instrument’s range, as subtle differences in performance,
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which are key to a high-level athlete’s livelihood, are difficult to detect and quantify meaningfully.4 In the development of outcomes measurement tools for athletes, it is important that the instrument used to study operative outcomes be calculated and developed based upon outcomes from a cohort of patient’s for which the tool was developed; in this case other high-level athletes. Simply stated, it is not meaningful or appropriate to use a metric developed to quantitate a major league pitcher’s outcome following surgical ulnar collateral ligament reconstruction and apply this same metric to a sedentary rheumatoid patient undergoing total elbow arthroplasty. This manuscript will review general measures of overall health, namely the Short Form-36 (SF-36) and Short Form-12 (SF-12)7,10,11; one of the most common orthopedic pain scales; the Visual Analog Pain scale (VAS)7,12–14; and the general orthopedic generic upper extremity score; the Disabilities of Arm, Shoulder, Hand (DASH) including the sports/performing arts module.15,16 In addition, this manuscript will review the 5 most clinically relevant outcome measures for sports elbow-related outcomes: (1) American Shoulder and Elbow Committee9,17; (2) Mayo Elbow Performance Index18; (3) AndrewsTimmerman [and its precursor the (4) Andrews-Carson]19,20; and (5) Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete score.1–4,6 A final outcome measure analyzed will be the “return to play” statistics, which has been published routinely in studies of athletes recovery from elbow surgery,5,21–25 as well as the outcomes metric known as the “Conway-Jobe scale.”2,5 A summary of these outcome metrics can be found in Tables 1 and 2.
GENERIC HEALTH MEASURE (SF-36 AND SF-12): THE FLOOR AND CEILING LIMITATION WHEN STUDYING ATHLETES In clinical research, in particular upper extremity surgery, the SF-36 and the SF-12 questionnaire are often used to quantify the generic overall health of a patient.7,10,11 The domains covered by the SF-36 include mental health, emotional
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role, social function, general health, bodily pain, physical function, physical role, and vitality.7,10,11,26 The SF-36 dedicated 2/36 (5.5%) to specific evaluation of pain; whereas the SF-12 dedicates 1/12 (8.3%) to the evaluation of pain.7,10,11,26 The SF-12 is a validated, shortened version of the SF-36, which has been demonstrated to correlate with the longer SF-36 questionnaire.10,11 These particular scales have been developed to measure the general health of a patient, as such, use of these generic measures helps to compare an outcome of surgery with other interventions, such as nonoperative conservative management. For example, to compare the effect of 2 different interventions from 2 separate studies on the general overall health of a patient, then the validated and widely used SF-36 or SF-12 metric would help to establish the impact of those interventions on overall general health of the patient. Unfortunately, most orthopedic sports medicine elbow procedures have limited influence on general health measures. The fundamental problem with the SF-36 and SF-12 metric on evaluating outcomes of surgery on athletes may be linked to the responsiveness of these metrics at the extremes of the scale, known as the floor and ceiling effects. The “floor effect” refers to the inability for a scale to differentiate an outcome below a certain level of performance, thus classifying all below this certain threshold as similar. Conversely, the “ceiling effect” refers to the inability of the metric to identify incremental or subtle differences in performance at the top of the scale. Unfortunately, in most cases, meaningful outcomes for athletes exist at the upper extreme, “ceiling,” of overall health for the general population. Therefore, outcome metrics such as the SF-36 and SF-12 designed to study the average patient population are inappropriate tools for quantifying improvement after surgical intervention in high-level athletes.4,7
VAS: QUANTIFYING THE PERCEPTION OF PAIN Pain is difficult to quantify as a phenomena in both the practice of medicine and research. Pain is a subjective physical feeling, which is a highly individualized perception,
TABLE 1. Overview of Outcome Measures
Elbow Joint Specific
Athletic Outcome Specific
Short Form-36 (SF-36)7,10,11 Short Form-12 (SF-12)7,10,11 Visual Analog Scale (VAS)7,12–14 Disabilities of the Arm, Shoulder, and Hand (DASH)15,16
No No No No
No No No Yes*
American Shoulder and Elbow (ASES)9,17
Yes
No
Yes
No
Andrews-Carson or Andrews-Timmerman Elbow Rating Scale19,20
Yes
No
Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder Elbow Score1–4,6 Conway-Jobe Outcome Measure2,5
Yes
Yes
No
Yes
Outcome Measures
Mayo Elbow Performance
Index18
Comments Comprehensive generic overall health metric Abridged generic overall health metric Easily obtained subjective pain perception metric Entire upper extremity assessment metric of disability related to upper extremity physical performance, symptoms, and social/ function roles; can be administered with optional module* Elbow-specific metric consisting of both subjective patient questionnaire and objective physical examination findings A metric that assesses the ability to perform certain activities of daily living dependent upon elbow function with both subjective and objective components Elbow-specific metric consisting of both subjective and objective metrics, although not originally designed for assessment of athletes—half of original cohort of patient’s assessed with metric were baseball players Specifically designed for subjective assessment of shoulder elbow function in the high-demand overhead athlete Metric assessing an athlete’s ability to “return to play”
*Optional DASH-S module includes specific questions related to sports/recreation/music or work activities.15,16
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TABLE 2. Components of the Elbow-specific Outcome Measures
Outcome Measures American Shoulder and Elbow (ASES)9,17 Mayo Elbow Performance Index18 Andrews-Carson or AndrewsTimmerman Elbow Rating Scale19,20 Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder Elbow Score1–4,6
Athletic Outcome Specific No No No Yes
Subjective
thus self-reporting measures are used. One of the most commonly used metrics of pain quantification is the VAS, which consist of a straight line in which the patient is asked to point on the spectrum of that line where there pain lies.7,12–14 The scale of the line typically moves from “0,” which represents no pain on the left most portion of the line, to “10,” which represents the “worst pain imaginable.” After the study subject marks along the straight line, the researcher is able to quantify the pain by measuring the distance between “0” and the marking, with the resulting number representing the VAS pain metric. A clear limitation of this scale is the fundamental assumption that pain is linear and that a pain scale rating of an “8” represents double the pain experience of a pain scale rating of a “4.” Further, pain experiences vary based upon the patient’s perception of their nociceptive experience—most patient’s would agree upon the bottom anchor of the scale that represents no pain at all; however, the top-most anchor of the scale representing “worst imaginable pain” could be highly variable. Often, during research analysis of pain, intrasubject reliability is far better than intersubject reliability, as subjects do not respond to pain similarly based on multidimensional factors, which can include a patient’s emotional state and psychiatric status.7,13 As such, multidimensional pain scales have been developed but are not widely used, as these scales are more cumbersome upon the study subject.7 In the treatment of an athletic elbow injury, pain relief is a fundamental goal of orthopedic sports medicine; therefore, the VAS represents a reasonably simple metric for which to quantify pain relief before and after intervention, as well as during recovery and rehabilitation. Given the high intrasubject reliability, the pain scale can help to track the progress of a patient throughout the course of athletic elbow surgery. However, when treating athletes, timing of assessment is the key in determining the success of a surgical intervention. The pain experienced before, during, and after athletic competition can be quite different than pain perceived by the athlete in the office and this must be accounted for while studying an athlete’s pain. In addition, many athletes play with varying degrees of discomfort during the course of a playing season without a specific lesion. Given the highly subjective nature of pain and the multidimensional factors that influence an athlete’s pain perception, caution should be exercised while collecting and interpreting pain data during assessment of an athlete.
DASH: A COMMON UPPER EXTREMITY RESEARCH METRIC DASH is a 30-item validated patient questionnaire which is scored in a standard manner and then tallied, with r
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Objective
57% pain, perceived function, satisfaction 70% pain, activities of daily living 50% pain, swelling, locking/catching, activities 100% perceived physical function during sports, competitive level during sports
42% motion, stability, strength 30% stability, motion 50% motion, fixed flexion contraction 0%
a range of between “0” which represents no disability to “100” which represents most disability.16 This particular metric is responsive, reliable, and valid when assessing changes to patient-rated upper extremity function for the general population.15,16 As compared with other upper extremity metrics, such as the American Shoulder Elbow Society score (to be discussed later in this manuscript), function has a greater emphasis in the scoring of DASH.26 As the DASH metric is specifically designed to assess and detect the influence of upper extremity disability and recovery on overall patient status, the floor and ceiling affect described previously, as a limitation of the SF-36 and SF-12, is less of a factor for the DASH metric.27 However, when specifically applied to athletes, who tend to perform at the extremes of standard metrics, the standard DASH metric may not be sufficient to meaningfully assess outcomes of athletic elbow injury or surgery. In its standard format, DASH is a 30-item questionnaire that assesses patient’s physical performance, symptoms, and social/functional roles. In addition, the DASH could be concomitantly administered with optional sections including the sports/recreational/music or work activities and is sometimes referred to as DASH sports module (DASH-S).28 When the DASH is administered with the optional sports/recreational/music section, the applicability of this metric to assessing the athletic elbow is further strengthened. DASH-S has an advantage when assessing the athletic elbow because it is specifically designed to not only assess the entire upper extremity, but specifically the athlete’s upper extremity.1 Furthermore, DASH is relatively easy to administer in that it is not too time consuming and it is not specific to 1 particular sporting activity.1 A disadvantage of the DASH metric in the assessment of the athletic elbow is that the instrument is not specifically designed for the elbow.1 The standard 30-item DASH questionnaire dedicates 23/30 (76.7%) of the questions to the evaluation of a patient’s ability to perform specific tasks such as yard work, turning a key, preparing a meal, and other similar activities. Specific evaluation of pain accounts for 2/30 (6.7%) of the total questions with 1/30 (3.3%) additional question being related to the patient’s ability to sleep due to pain; so in total about 10% of the 30-item DASH outcome metric is dedicated to the assessment of pain. The remaining 5 questions 5/30 (16.6%) comprise evaluation of upper extremity symptoms such as tingling, weakness, stiffness, and evaluation of the patient’s self-confidence in using the affected extremity.1 The additional 4-item sports module assesses (1) the ability of the athlete to use usual technique when playing the sport; (2) assess pain in the upper www.sportsmedarthro.com |
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extremity while participating in athletic competition; (3) assess the ability to perform to the level the athlete desires; (4) and the ability of the athlete to dedicate the appropriate amount of time to the sport.28
AMERICAN SHOULDER AND ELBOW SOCIETY (ASES) OUTCOME MEASURE The ASES outcome measure for assessment of elbow function was developed by the ASES research committee. The ASES evaluation consists of 2 major components, a patient self-evaluation section, which consists of 20 specific questions, as well as a physician assessment, which consists of 15 specific measures recorded by the examiner. The patient self-assessment portion consists of a self-evaluation of pain and of function, with 7/20 (35%) of the questions assessing pain; 12/20 (60%) of the questions assessing patient perceived function; and finally 1/20 (5%) of the questions assessing satisfaction.9,17 The self-evaluation pain section quantifies a patient’s pain at its worst, at rest, when lifting heavy objects, when doing repetitive activities, and at nighttime. The patient rates their pain in a series of VAS measurements with “0” representing no pain and “10” representing the worst pain ever.9,17 The patients’ self-evaluation of function section consists of 12 various self-reported ADL. The patient is asked to rate on a scale of “0” which represents “unable to do” to “3” which represents “not difficult.” The scaling system for this portion of the outcome measure is scored in integers only. Self-evaluation of ADL consists of their ability to button up a shirt, manage toileting, comb their hair, tie shoes, eat with utensils, carry heavy objects, rise from a chair pushing with an arm, perform household chores, and turning keys. The most applicable measures to the athletic elbow consist of the patient’s self-perception of their ability to throw a ball, do usual work, and do usual sport. These 3 sections represent one fourth of the total patient self-evaluation of function section of the ASES elbow outcomes measure. Similar to general health assessment outcome measures, such as the SF36, a limitation of the ASES elbow outcome measure as applied to athletes is that most athletic injuries would not affect the patient’s ability to perform ADL. In fact, on occasion, any perceptible difference in the athlete’s ability to perform may only be demonstrated at the highest level of sport or competition. For example, an athlete may only notice dysfunction while attempting to pitch during baseball competition, but their elbow may otherwise function well within normal limits with ADLs. Although these ADL outcome measures may be crucial in assessing the final outcomes from a total elbow arthroplasty or open reduction and internal fixation of an elbow fracture, these particular ADL milestones will be easily performed by athletes who will perform beyond the “ceiling” of the ASES elbow outcomes measure scale despite being injured and potentially performing significantly below their baseline.9,17 The final portion of the ASES elbow scale is the physician’s assessment of motion (6/15 or 40% of the physical examination portion), stability (3/15 or 20% of the physical examination portion), and strength (6/15 or 40% of the physical examination portion). Again, these assessments are somewhat arbitrary in that a physician’s ability to objectively assess a specific degree of elbow flexion is subject of intrarater and interrater variability, making the reliability of these measurements somewhat questionable. Further, in assessing stability of an elbow, there is certainly a lack of
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objective measure. Particularly, there is some nuance and uncertainty when attempting to differentiate the difference between a “1” which represents mild laxity with a good endpoint to a “2” which represents moderate laxity with no endpoint, especially when the amount of laxity is so small— often a 2 mm side-to-side difference is consistent with an ulnar collateral ligament injury, resulting in valgus instability. For the strength-testing portion of the physician assessment, often athletes will perform at the highest end of the rating scale despite injury, making the ASES outcomes assessment somewhat inadequate when attempting to assess objectively an athlete’s elbow function.9,17 Specifically, the strength measures are in the classic 0 to 5 British Medical Research Council range, and not using a dynamometer.29 Thus, subtle strength differences often go undetected. A multitude of factors contribute to an athlete’s ability to continue to have a relatively high ASES elbow outcome metric measurement despite being injured. The fundamental issue at the heart of this particular shortcoming of the ASES scale at assessing the elbow in this population is that the athlete often performs at an extremely high level, necessitating a specific outcome measure which can differentiate between minute differences during athletic competition where the elbow is placed under unusually high stresses not experienced during ADL. In other words, there is a ceiling effect that exists with the ASES score, when applied to athletes. As a result, the ASES outcome measure, although well designed for overall assessment of elbow function, has not been specifically designed with the particular goal of assessment of the athletic elbow. As such, the ASES metric, although joint specific and particularly well designed for elbow assessment in the context of an individual’s overall general well-being, may not always capture meaningful differences in athletic elbow injuries and treatment outcomes. Some strengths of the ASES outcome measure is that this particular metric does attempt to combine a patient centered questionnaire of pain and function with objective physician-related findings.9,17 The only additional section of the ASES elbow outcomes metric attempting to quantify a patient’s ability to perform at a rate sufficient for their desired outcome is the “satisfaction” portion of the outcome measurement, in which a patient rates from a scale of “0” (representing not at all satisfied) to “10” (representing very satisfied). This particular ASES outcomes measurement section, may capture an athletes’ ability to satisfactorily perform at the athletic level they desire. However, this section of the ASES rating scale does not particularly address an athletes’ ability to return to play or return to a high level of competitive play, nor does it necessarily attribute a reason as to why an athlete is or is not satisfied with their elbow. So despite the multimodal subjective assessment combined with objective assessment of elbow function measured in the ASES elbow outcomes metric, there are some shortcomings when ultimately attempting to use this ASES measurement tool as applied to the athletic elbow.9,17
MAYO ELBOW PERFORMANCE INDEX The Mayo Elbow Performance Index was developed for the evaluation of elbow outcomes.18 The scale consists of both objective and subjective evaluation of a patient’s elbow. The elbow is evaluated for pain intensity; motion in flexion and extension arc; stability; and finally function, with points being awarded for a patients’ ability to comb r
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their hair, eat, perform hygiene, don a shirt, and don pants. A cumulative score of 90 to 100 is considered excellent, a score of 75 to 89 is considered good; a score of 60 to 74 is considered fair, and a score 12 months. The outcome is considered “fair” if the patient is able to play regularly at a recreational level. The patient has a “poor” outcome if the athlete is no longer able to play.2,5 One of the advantages of the Conway-Jobe scale is that it attempts to simply quantify a clinically relevant outcome measure for athletes, namely their ability to return to competition at an equal or higher level for a sustained period of time. The scale in particular is able to assess the functional status of an athlete in a clinically relevant manner.2,5 However, some claim that this particular outcome metric is specific for the elbow and is not validated for sports other than baseball; and even for baseball some investigators claim the Conway-Jobe scale metric may not be valid.1 r
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In terms of patient relevant metrics, for the athletic elbow, return to play at an equal or higher level is a relevant outcome measure for the patient. In particular the ConwayJobe scale is able to detect and quantify if the athlete is able to perform during athletic competition after orthopedic intervention. This metric is specifically designed for athletes and does not attempt to quantify range of motion, strength, or other functional metrics, nor does it attempt to quantify patient’s satisfaction. The simple metric of return to play and the time and level of that particular return to play is of particular interest to the orthopedic sports medicine practitioner treating athletes with elbow injuries. This scale does not particularly attempt to quantify if the patient switched positions, if the patient patent was particular effective after returning to play, or if the patient was particularly satisfied by their orthopedic sports medicine outcome. However, implied in the outcome metric is that the patient who was able to return for a full year of competition was able to perform at a sufficient level to compete and maintain a roster spot for that period of time.
DISCUSSION AND CONCLUSIONS Assessing the clinical outcome of the athletic elbow remains problematic to study, in that the athlete will often perform at a high enough level, that ADL or gross assessment of dysfunction will not be evident. Often, an athlete will only display signs consistent with their injury during the stress of competition, at which point minute differences in function may result in significant athletic impairment. Most outcome tools were developed to evaluate patient function after elbow arthroplasty or fracture fixation, and thus not for athletic function. As a result, general outcome metrics often display a “ceiling effect” when applied to the athletic elbow, as these metrics were not designed to evaluate the athletic elbow and cannot meaningfully differentiate athletic elbow dysfunction and returned function. Specific outcome measures such as the DASH-S,1,15,16 KJOC,1–4,6 Andrews-Timmerman,20 Andrews-Carson,19 and Conway-Jobe scale2,5 may be more appropriate metrics for the evaluation of the athletic elbow. On the basis of this review, the KJOC seems to represent the most appropriate scale to use for the overhead athlete with an elbow problem because it was validated for this cohort of athletic patients, as compared with the Andrew-Timmerman and Conway-Jobe metrics, which were not validated outcome measures. Despite the DASH (and DASH-S) being validated in the general population this upper extremity scale is not specific for elbow function. When evaluating the athletic elbow literature or one’s own outcomes following orthopedic sports medicine intervention for elbow dysfunction, appropriate assessment of outcomes is dependent upon the understanding of elbow outcome measures as well as appropriate selection of a clinically relevant elbow outcome metric. Objective clinical measurements are more difficult to obtain and have interobserver variability; however, performance measures may provide real value in assessing function after injury or surgery. For example, the pitcher may subjectively rate their velocity as decreased, but pitches recorded on a radar gun show regained velocity or alternatively; they feel good but never regain preinjury velocity or control. Although other outcome metrics may exist for evaluation of the athletic elbow, this review focuses on the metrics commonly used and reported upon in the athletic elbow literature. Continued efforts in evidence-based medicine and critical r
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evaluation of orthopedic sports medicine outcomes after intervention using the outcome metrics discussed in this manuscript will build upon the validation for these metrics. REFERENCES 1. Alberta FG, ElAttrache NS, Bissell S, et al. The development and validation of a functional assessment tool for the upper extremity in the overhead athlete. Am J Sports Med. 2010; 38:903–911. 2. Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am. 1992;74:67–83. 3. Domb BG, Davis JT, Alberta FG, et al. Clinical follow-up of professional baseball players undergoing ulnar collateral ligament reconstruction using the new Kerlan-Jobe Orthopaedic Clinic overhead athlete shoulder and elbow score (KJOC Score). Am J Sports Med. 2010;38:1558–1563. 4. Franz JO, McCulloch PC, Kneip CJ, et al. The utility of the KJOC score in professional baseball in the United States. Am J Sports Med. 2013;41:2167–2173. 5. Jones KJ, Dines JS, Rebolledo BJ, et al. Operative management of ulnar collateral ligament insufficiency in adolescent athletes. Am J Sports Med. 2014;42:117–121. 6. Kraeutler MJ, Ciccotti MG, Dodson CC, et al. Kerlan-Jobe Orthopaedic Clinic overhead athlete scores in asymptomatic professional baseball pitchers. J Shoulder Elbow Surg. 2013; 22:329–332. 7. Badalamente M, Coffelt L, Elfar J, et al. Measurement scales in clinical research of the upper extremity, part 1: general principles, measures of general health, pain, and patient satisfaction. J Hand Surg. 2013;38:401–406; quiz 406. 8. Feinstein A. Clinimetrics. New Haven: Yale University Press; 1987. 9. 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;11:587–594. 10. Stewart AL, Hays RD, Ware JE Jr. The MOS short-form general health survey. Reliability and validity in a patient population. Med Care. 1988;26:724–735. 11. Ware J Jr, Kosinski M, Keller SD. A 12-item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–233. 12. Clark P, Lavielle P, Martinez H. Learning from pain scales: patient perspective. J Rheumatol. 2003;30:1584–1588. 13. de C Williams AC, Davies HT, Chadury Y. Simple pain rating scales hide complex idiosyncratic meanings. Pain. 2000;85: 457–463. 14. Litcher-Kelly L, Martino SA, Broderick JE, et al. A systematic review of measures used to assess chronic musculoskeletal pain in clinical and randomized controlled clinical trials. J Pain. 2007;8:906–913. 15. Beaton DE, Katz JN, Fossel AH, et al. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128–146. 16. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29: 602–608. 17. King GJ, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999;8:351–354. 18. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. Volume 2. Philadelphia: W.B. Saunders; 1993:86–97. 19. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy. 1985;1:97–107.
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20. Timmerman LA, Andrews JR. Arthroscopic treatment of posttraumatic elbow pain and stiffness. Am J Sports Med. 1994;22:230–235. 21. Cain EL Jr, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38:2426–2434. 22. Jones KJ, Conte S, Patterson N, et al. Functional outcomes following revision ulnar collateral ligament reconstruction in Major League Baseball pitchers. J Shoulder Elbow Surg. 2013;22:642–646. 23. Koh JL, Schafer MF, Keuter G, et al. Ulnar collateral ligament reconstruction in elite throwing athletes. Arthroscopy. 2006;22: 1187–1191. 24. Purcell DB, Matava MJ, Wright RW. Ulnar collateral ligament reconstruction: a systematic review. Clin Orthop Relat Res. 2007;455:72–77. 25. Watson JN, McQueen P, Hutchinson MR. A systematic review of ulnar collateral ligament reconstruction techniques. Am J Sports Med. 2013. [Epub ahead of print]. PubMed PMID: 24220014. 26. MacDermid JC. Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation. J Hand Ther. 2001;14:105–114.
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27. Badalamente M, Coffelt L, Elfar J, et al. Measurement scales in clinical research of the upper extremity, part 2: outcome measures in studies of the hand/wrist and shoulder/elbow. J Hand Ther. 2013;38:407–412. 28. Wright RW, Baumgarten KM. Shoulder outcomes measures. J Am Acad Orthop Surg. 2010;18:436–444. 29. Hislop HJ, Montgomery J. Daniels and Worthingham’s Muscle Testing: Techniques of Manual Examination. 7th ed. Philadelphia: WB Saunders Co.; 2002:1–10. 30. Turchin DC, Beaton DE, Richards RR. Validity of observerbased aggregate scoring systems as descriptors of elbow pain, function, and disability. J Bone Joint Surg Am. 1998;80: 154–162. 31. Kirkley A, Alvarez C, Griffin S. The development and evaluation of a disease-specific quality-of-life questionnaire for disorders of the rotator cuff: The Western Ontario Rotator Cuff Index. Clin J Sport Med. 2003;13:84–92. 32. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg. 2007;16: 717–721. 33. Mihata T, Safran MR, McGarry MH, et al. Elbow valgus laxity may result in an overestimation of apparent shoulder external rotation during physical examination. Am J Sports Med. 2008;36:978–982.
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Outcomes Evaluation of the Athletic Elbow Michael T. Freehill, MD,* Sandeep Mannava, MD, PhD,* and Marc R. Safran, MDw
Abstract: The high-level athletic population poses difficulty when evaluating outcomes in orthopedic surgery, given generally good overall health and high function at baseline. Subtle differences in performance following injury or orthopedic surgery are hard to detect in high-performance athletes using standard outcome metrics; however, attaining these subtle improvements after injury or surgery are key to an athletes’ livelihood. Outcome measures serve as the cornerstone for critical evaluation of clinical outcomes following orthopedic surgery or injury. In the age of “evidence-based medicine” and “pay-for-performance” accountability for surgical intervention, understanding clinically relevant outcome measures is essential for careful review of the published literature, as well as one’s own critical review of surgical performance. The purpose of this manuscript is to evaluate clinical outcome measures in the context of the athletic elbow. An emphasis will be placed on evaluation of the 5 most clinically relevant outcome measures for sports-related elbow outcomes: (1) American Shoulder and Elbow Committee; (2) Mayo Elbow Performance Index; (3) AndrewsTimmerman [and its precursor the (4) Andrews-Carson]; and (5) Kerlan-Jobe Orthopaedic Clinic overhead athlete score. A final outcome measure that will be analyzed is “return to play” statistics, which has been published in various studies of athletes’ recovery from elbow surgery, as well as, the outcomes metric known as the “Conway-Jobe scale.” Although there is no perfect outcomes score for the athletic elbow, the Kerlan-Jobe Orthopaedic Clinic score is the only outcomes tool developed and validated for outcomes for elbow injuries in the overhead athlete, as compared with the Andrew-Timmerman and Conway-Jobe metrics, which were not validated outcome measures for the elbow in this patient population. Despite the Disabilities of Arm, Shoulder, Hand (DASH) (and DASH—Sport module) being validated in the general population, this upper extremity scale is not specific for elbow function. Key Words: athletic elbow, outcome measures, return to play, athletic outcomes, elbow outcomes
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THE ATHLETIC ELBOW Overhead athletic competition produces extreme biomechanical demands upon the upper extremity; particularly, the elbow joint, not experienced during activities of daily living (ADL). As such, athletes may experience elbow pain From the *Department of Orthopaedic Surgery, Medical Center Boulevard, Division of Sports Medicine and Shoulder Surgery, Wake Forest University School of Medicine, Winston-Salem, NC; and wDepartment of Orthopaedic Surgery, Division of Sports Medicine, Stanford University School of Medicine, Redwood City, CA. Disclosure: M.R.S. has fellowship support from Ossur, Smith and Nephew, ConMed Linvatec; Consultant, ConMed Linvatec, Biomimedica. M.T.F. has fellowship support from Depuy Mitek, DJO and is a consultant for Smith and Nephew. S.M. declares no conflict of interest. Reprints: Michael T. Freehill, MD, Department of Orthopaedic Surgery, Medical Center Boulevard, Division of Sports Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157. Copyright r 2014 by Lippincott Williams & Wilkins
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and/or injury, which may result in inability to perform at a high athletic level during competition; however, this same shortcoming may not be evident during everyday activities. Assessing the athletic elbow is further complicated by an injured athletes’ ability to often continue to compete and perform at an elite level despite injury, in many instances. When studying the athletic elbow during injury and recovery, many outcome metrics can be used to assess surgical repair, rehabilitation, and nonoperative management. Measures of strength, range of motion, and radiographic healing may not fully capture an athlete’s ability to compete during specific sporting maneuvers. The simple metric of return to play1–6 may represent an important goal when treating athletic elbow injuries, but simply returning to competition may not capture a truly successful return to sport at both a psychological and functionally meaningful level which either meets or exceed preinjury levels. During sporting competition, both the physical functionality and psychological health play crucial roles in the effectiveness of athletic participation; thus, athlete-oriented patient questionnaires may provide the best assessment measure for return to effective participation after elbow injury or orthopedic surgical intervention. Furthermore, sport-specific measurement tools may provide the most useful outcomes.
THE STUDY OF ATHLETIC ELBOW OUTCOMES Outcome measures are the cornerstone for evaluation and study of clinical outcomes following injury and/or surgery. More broadly, validated outcome measures allow for evaluation of injury impact or clinical efficacy of a particular intervention, such as surgery, in terms of that intervention’s impact on a patient’s general health, satisfaction, function, and pain. To be useful, clinical outcome measures should allow for “reliability, validity, and responsiveness.”7–9 In the age of “evidence-based medicine” and “pay-for-performance” accountability for the surgeon, understanding clinically relevant outcome measures is essential for careful review of the published literature, as well as one’s own critical review of surgical performance. The purpose of this manuscript is to evaluate clinical outcome measures in the context of the athletic elbow. In particular, this manuscript critically reviews and discusses several clinically relevant measures used in sports medicine and orthopedic research to quantify outcomes of elbow injury and surgery. The high-level athletic population can be somewhat problematic to study in orthopedic surgery, given their generally good overall health and high function at baseline. The difficulty in assessing the outcomes of various surgical interventions in high-level athletes is correlating results with general outcomes measurement tools originally designed to detect differences in less functional or even lower performing individuals. Thus a high-performing athlete, even though injured, may stay close to the “ceiling” of a detection instrument’s range, as subtle differences in performance,
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which are key to a high-level athlete’s livelihood, are difficult to detect and quantify meaningfully.4 In the development of outcomes measurement tools for athletes, it is important that the instrument used to study operative outcomes be calculated and developed based upon outcomes from a cohort of patient’s for which the tool was developed; in this case other high-level athletes. Simply stated, it is not meaningful or appropriate to use a metric developed to quantitate a major league pitcher’s outcome following surgical ulnar collateral ligament reconstruction and apply this same metric to a sedentary rheumatoid patient undergoing total elbow arthroplasty. This manuscript will review general measures of overall health, namely the Short Form-36 (SF-36) and Short Form-12 (SF-12)7,10,11; one of the most common orthopedic pain scales; the Visual Analog Pain scale (VAS)7,12–14; and the general orthopedic generic upper extremity score; the Disabilities of Arm, Shoulder, Hand (DASH) including the sports/performing arts module.15,16 In addition, this manuscript will review the 5 most clinically relevant outcome measures for sports elbow-related outcomes: (1) American Shoulder and Elbow Committee9,17; (2) Mayo Elbow Performance Index18; (3) AndrewsTimmerman [and its precursor the (4) Andrews-Carson]19,20; and (5) Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete score.1–4,6 A final outcome measure analyzed will be the “return to play” statistics, which has been published routinely in studies of athletes recovery from elbow surgery,5,21–25 as well as the outcomes metric known as the “Conway-Jobe scale.”2,5 A summary of these outcome metrics can be found in Tables 1 and 2.
GENERIC HEALTH MEASURE (SF-36 AND SF-12): THE FLOOR AND CEILING LIMITATION WHEN STUDYING ATHLETES In clinical research, in particular upper extremity surgery, the SF-36 and the SF-12 questionnaire are often used to quantify the generic overall health of a patient.7,10,11 The domains covered by the SF-36 include mental health, emotional
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role, social function, general health, bodily pain, physical function, physical role, and vitality.7,10,11,26 The SF-36 dedicated 2/36 (5.5%) to specific evaluation of pain; whereas the SF-12 dedicates 1/12 (8.3%) to the evaluation of pain.7,10,11,26 The SF-12 is a validated, shortened version of the SF-36, which has been demonstrated to correlate with the longer SF-36 questionnaire.10,11 These particular scales have been developed to measure the general health of a patient, as such, use of these generic measures helps to compare an outcome of surgery with other interventions, such as nonoperative conservative management. For example, to compare the effect of 2 different interventions from 2 separate studies on the general overall health of a patient, then the validated and widely used SF-36 or SF-12 metric would help to establish the impact of those interventions on overall general health of the patient. Unfortunately, most orthopedic sports medicine elbow procedures have limited influence on general health measures. The fundamental problem with the SF-36 and SF-12 metric on evaluating outcomes of surgery on athletes may be linked to the responsiveness of these metrics at the extremes of the scale, known as the floor and ceiling effects. The “floor effect” refers to the inability for a scale to differentiate an outcome below a certain level of performance, thus classifying all below this certain threshold as similar. Conversely, the “ceiling effect” refers to the inability of the metric to identify incremental or subtle differences in performance at the top of the scale. Unfortunately, in most cases, meaningful outcomes for athletes exist at the upper extreme, “ceiling,” of overall health for the general population. Therefore, outcome metrics such as the SF-36 and SF-12 designed to study the average patient population are inappropriate tools for quantifying improvement after surgical intervention in high-level athletes.4,7
VAS: QUANTIFYING THE PERCEPTION OF PAIN Pain is difficult to quantify as a phenomena in both the practice of medicine and research. Pain is a subjective physical feeling, which is a highly individualized perception,
TABLE 1. Overview of Outcome Measures
Elbow Joint Specific
Athletic Outcome Specific
Short Form-36 (SF-36)7,10,11 Short Form-12 (SF-12)7,10,11 Visual Analog Scale (VAS)7,12–14 Disabilities of the Arm, Shoulder, and Hand (DASH)15,16
No No No No
No No No Yes*
American Shoulder and Elbow (ASES)9,17
Yes
No
Yes
No
Andrews-Carson or Andrews-Timmerman Elbow Rating Scale19,20
Yes
No
Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder Elbow Score1–4,6 Conway-Jobe Outcome Measure2,5
Yes
Yes
No
Yes
Outcome Measures
Mayo Elbow Performance
Index18
Comments Comprehensive generic overall health metric Abridged generic overall health metric Easily obtained subjective pain perception metric Entire upper extremity assessment metric of disability related to upper extremity physical performance, symptoms, and social/ function roles; can be administered with optional module* Elbow-specific metric consisting of both subjective patient questionnaire and objective physical examination findings A metric that assesses the ability to perform certain activities of daily living dependent upon elbow function with both subjective and objective components Elbow-specific metric consisting of both subjective and objective metrics, although not originally designed for assessment of athletes—half of original cohort of patient’s assessed with metric were baseball players Specifically designed for subjective assessment of shoulder elbow function in the high-demand overhead athlete Metric assessing an athlete’s ability to “return to play”
*Optional DASH-S module includes specific questions related to sports/recreation/music or work activities.15,16
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TABLE 2. Components of the Elbow-specific Outcome Measures
Outcome Measures American Shoulder and Elbow (ASES)9,17 Mayo Elbow Performance Index18 Andrews-Carson or AndrewsTimmerman Elbow Rating Scale19,20 Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder Elbow Score1–4,6
Athletic Outcome Specific No No No Yes
Subjective
thus self-reporting measures are used. One of the most commonly used metrics of pain quantification is the VAS, which consist of a straight line in which the patient is asked to point on the spectrum of that line where there pain lies.7,12–14 The scale of the line typically moves from “0,” which represents no pain on the left most portion of the line, to “10,” which represents the “worst pain imaginable.” After the study subject marks along the straight line, the researcher is able to quantify the pain by measuring the distance between “0” and the marking, with the resulting number representing the VAS pain metric. A clear limitation of this scale is the fundamental assumption that pain is linear and that a pain scale rating of an “8” represents double the pain experience of a pain scale rating of a “4.” Further, pain experiences vary based upon the patient’s perception of their nociceptive experience—most patient’s would agree upon the bottom anchor of the scale that represents no pain at all; however, the top-most anchor of the scale representing “worst imaginable pain” could be highly variable. Often, during research analysis of pain, intrasubject reliability is far better than intersubject reliability, as subjects do not respond to pain similarly based on multidimensional factors, which can include a patient’s emotional state and psychiatric status.7,13 As such, multidimensional pain scales have been developed but are not widely used, as these scales are more cumbersome upon the study subject.7 In the treatment of an athletic elbow injury, pain relief is a fundamental goal of orthopedic sports medicine; therefore, the VAS represents a reasonably simple metric for which to quantify pain relief before and after intervention, as well as during recovery and rehabilitation. Given the high intrasubject reliability, the pain scale can help to track the progress of a patient throughout the course of athletic elbow surgery. However, when treating athletes, timing of assessment is the key in determining the success of a surgical intervention. The pain experienced before, during, and after athletic competition can be quite different than pain perceived by the athlete in the office and this must be accounted for while studying an athlete’s pain. In addition, many athletes play with varying degrees of discomfort during the course of a playing season without a specific lesion. Given the highly subjective nature of pain and the multidimensional factors that influence an athlete’s pain perception, caution should be exercised while collecting and interpreting pain data during assessment of an athlete.
DASH: A COMMON UPPER EXTREMITY RESEARCH METRIC DASH is a 30-item validated patient questionnaire which is scored in a standard manner and then tallied, with r
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57% pain, perceived function, satisfaction 70% pain, activities of daily living 50% pain, swelling, locking/catching, activities 100% perceived physical function during sports, competitive level during sports
42% motion, stability, strength 30% stability, motion 50% motion, fixed flexion contraction 0%
a range of between “0” which represents no disability to “100” which represents most disability.16 This particular metric is responsive, reliable, and valid when assessing changes to patient-rated upper extremity function for the general population.15,16 As compared with other upper extremity metrics, such as the American Shoulder Elbow Society score (to be discussed later in this manuscript), function has a greater emphasis in the scoring of DASH.26 As the DASH metric is specifically designed to assess and detect the influence of upper extremity disability and recovery on overall patient status, the floor and ceiling affect described previously, as a limitation of the SF-36 and SF-12, is less of a factor for the DASH metric.27 However, when specifically applied to athletes, who tend to perform at the extremes of standard metrics, the standard DASH metric may not be sufficient to meaningfully assess outcomes of athletic elbow injury or surgery. In its standard format, DASH is a 30-item questionnaire that assesses patient’s physical performance, symptoms, and social/functional roles. In addition, the DASH could be concomitantly administered with optional sections including the sports/recreational/music or work activities and is sometimes referred to as DASH sports module (DASH-S).28 When the DASH is administered with the optional sports/recreational/music section, the applicability of this metric to assessing the athletic elbow is further strengthened. DASH-S has an advantage when assessing the athletic elbow because it is specifically designed to not only assess the entire upper extremity, but specifically the athlete’s upper extremity.1 Furthermore, DASH is relatively easy to administer in that it is not too time consuming and it is not specific to 1 particular sporting activity.1 A disadvantage of the DASH metric in the assessment of the athletic elbow is that the instrument is not specifically designed for the elbow.1 The standard 30-item DASH questionnaire dedicates 23/30 (76.7%) of the questions to the evaluation of a patient’s ability to perform specific tasks such as yard work, turning a key, preparing a meal, and other similar activities. Specific evaluation of pain accounts for 2/30 (6.7%) of the total questions with 1/30 (3.3%) additional question being related to the patient’s ability to sleep due to pain; so in total about 10% of the 30-item DASH outcome metric is dedicated to the assessment of pain. The remaining 5 questions 5/30 (16.6%) comprise evaluation of upper extremity symptoms such as tingling, weakness, stiffness, and evaluation of the patient’s self-confidence in using the affected extremity.1 The additional 4-item sports module assesses (1) the ability of the athlete to use usual technique when playing the sport; (2) assess pain in the upper www.sportsmedarthro.com |
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extremity while participating in athletic competition; (3) assess the ability to perform to the level the athlete desires; (4) and the ability of the athlete to dedicate the appropriate amount of time to the sport.28
AMERICAN SHOULDER AND ELBOW SOCIETY (ASES) OUTCOME MEASURE The ASES outcome measure for assessment of elbow function was developed by the ASES research committee. The ASES evaluation consists of 2 major components, a patient self-evaluation section, which consists of 20 specific questions, as well as a physician assessment, which consists of 15 specific measures recorded by the examiner. The patient self-assessment portion consists of a self-evaluation of pain and of function, with 7/20 (35%) of the questions assessing pain; 12/20 (60%) of the questions assessing patient perceived function; and finally 1/20 (5%) of the questions assessing satisfaction.9,17 The self-evaluation pain section quantifies a patient’s pain at its worst, at rest, when lifting heavy objects, when doing repetitive activities, and at nighttime. The patient rates their pain in a series of VAS measurements with “0” representing no pain and “10” representing the worst pain ever.9,17 The patients’ self-evaluation of function section consists of 12 various self-reported ADL. The patient is asked to rate on a scale of “0” which represents “unable to do” to “3” which represents “not difficult.” The scaling system for this portion of the outcome measure is scored in integers only. Self-evaluation of ADL consists of their ability to button up a shirt, manage toileting, comb their hair, tie shoes, eat with utensils, carry heavy objects, rise from a chair pushing with an arm, perform household chores, and turning keys. The most applicable measures to the athletic elbow consist of the patient’s self-perception of their ability to throw a ball, do usual work, and do usual sport. These 3 sections represent one fourth of the total patient self-evaluation of function section of the ASES elbow outcomes measure. Similar to general health assessment outcome measures, such as the SF36, a limitation of the ASES elbow outcome measure as applied to athletes is that most athletic injuries would not affect the patient’s ability to perform ADL. In fact, on occasion, any perceptible difference in the athlete’s ability to perform may only be demonstrated at the highest level of sport or competition. For example, an athlete may only notice dysfunction while attempting to pitch during baseball competition, but their elbow may otherwise function well within normal limits with ADLs. Although these ADL outcome measures may be crucial in assessing the final outcomes from a total elbow arthroplasty or open reduction and internal fixation of an elbow fracture, these particular ADL milestones will be easily performed by athletes who will perform beyond the “ceiling” of the ASES elbow outcomes measure scale despite being injured and potentially performing significantly below their baseline.9,17 The final portion of the ASES elbow scale is the physician’s assessment of motion (6/15 or 40% of the physical examination portion), stability (3/15 or 20% of the physical examination portion), and strength (6/15 or 40% of the physical examination portion). Again, these assessments are somewhat arbitrary in that a physician’s ability to objectively assess a specific degree of elbow flexion is subject of intrarater and interrater variability, making the reliability of these measurements somewhat questionable. Further, in assessing stability of an elbow, there is certainly a lack of
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objective measure. Particularly, there is some nuance and uncertainty when attempting to differentiate the difference between a “1” which represents mild laxity with a good endpoint to a “2” which represents moderate laxity with no endpoint, especially when the amount of laxity is so small— often a 2 mm side-to-side difference is consistent with an ulnar collateral ligament injury, resulting in valgus instability. For the strength-testing portion of the physician assessment, often athletes will perform at the highest end of the rating scale despite injury, making the ASES outcomes assessment somewhat inadequate when attempting to assess objectively an athlete’s elbow function.9,17 Specifically, the strength measures are in the classic 0 to 5 British Medical Research Council range, and not using a dynamometer.29 Thus, subtle strength differences often go undetected. A multitude of factors contribute to an athlete’s ability to continue to have a relatively high ASES elbow outcome metric measurement despite being injured. The fundamental issue at the heart of this particular shortcoming of the ASES scale at assessing the elbow in this population is that the athlete often performs at an extremely high level, necessitating a specific outcome measure which can differentiate between minute differences during athletic competition where the elbow is placed under unusually high stresses not experienced during ADL. In other words, there is a ceiling effect that exists with the ASES score, when applied to athletes. As a result, the ASES outcome measure, although well designed for overall assessment of elbow function, has not been specifically designed with the particular goal of assessment of the athletic elbow. As such, the ASES metric, although joint specific and particularly well designed for elbow assessment in the context of an individual’s overall general well-being, may not always capture meaningful differences in athletic elbow injuries and treatment outcomes. Some strengths of the ASES outcome measure is that this particular metric does attempt to combine a patient centered questionnaire of pain and function with objective physician-related findings.9,17 The only additional section of the ASES elbow outcomes metric attempting to quantify a patient’s ability to perform at a rate sufficient for their desired outcome is the “satisfaction” portion of the outcome measurement, in which a patient rates from a scale of “0” (representing not at all satisfied) to “10” (representing very satisfied). This particular ASES outcomes measurement section, may capture an athletes’ ability to satisfactorily perform at the athletic level they desire. However, this section of the ASES rating scale does not particularly address an athletes’ ability to return to play or return to a high level of competitive play, nor does it necessarily attribute a reason as to why an athlete is or is not satisfied with their elbow. So despite the multimodal subjective assessment combined with objective assessment of elbow function measured in the ASES elbow outcomes metric, there are some shortcomings when ultimately attempting to use this ASES measurement tool as applied to the athletic elbow.9,17
MAYO ELBOW PERFORMANCE INDEX The Mayo Elbow Performance Index was developed for the evaluation of elbow outcomes.18 The scale consists of both objective and subjective evaluation of a patient’s elbow. The elbow is evaluated for pain intensity; motion in flexion and extension arc; stability; and finally function, with points being awarded for a patients’ ability to comb r
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their hair, eat, perform hygiene, don a shirt, and don pants. A cumulative score of 90 to 100 is considered excellent, a score of 75 to 89 is considered good; a score of 60 to 74 is considered fair, and a score 12 months. The outcome is considered “fair” if the patient is able to play regularly at a recreational level. The patient has a “poor” outcome if the athlete is no longer able to play.2,5 One of the advantages of the Conway-Jobe scale is that it attempts to simply quantify a clinically relevant outcome measure for athletes, namely their ability to return to competition at an equal or higher level for a sustained period of time. The scale in particular is able to assess the functional status of an athlete in a clinically relevant manner.2,5 However, some claim that this particular outcome metric is specific for the elbow and is not validated for sports other than baseball; and even for baseball some investigators claim the Conway-Jobe scale metric may not be valid.1 r
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In terms of patient relevant metrics, for the athletic elbow, return to play at an equal or higher level is a relevant outcome measure for the patient. In particular the ConwayJobe scale is able to detect and quantify if the athlete is able to perform during athletic competition after orthopedic intervention. This metric is specifically designed for athletes and does not attempt to quantify range of motion, strength, or other functional metrics, nor does it attempt to quantify patient’s satisfaction. The simple metric of return to play and the time and level of that particular return to play is of particular interest to the orthopedic sports medicine practitioner treating athletes with elbow injuries. This scale does not particularly attempt to quantify if the patient switched positions, if the patient patent was particular effective after returning to play, or if the patient was particularly satisfied by their orthopedic sports medicine outcome. However, implied in the outcome metric is that the patient who was able to return for a full year of competition was able to perform at a sufficient level to compete and maintain a roster spot for that period of time.
DISCUSSION AND CONCLUSIONS Assessing the clinical outcome of the athletic elbow remains problematic to study, in that the athlete will often perform at a high enough level, that ADL or gross assessment of dysfunction will not be evident. Often, an athlete will only display signs consistent with their injury during the stress of competition, at which point minute differences in function may result in significant athletic impairment. Most outcome tools were developed to evaluate patient function after elbow arthroplasty or fracture fixation, and thus not for athletic function. As a result, general outcome metrics often display a “ceiling effect” when applied to the athletic elbow, as these metrics were not designed to evaluate the athletic elbow and cannot meaningfully differentiate athletic elbow dysfunction and returned function. Specific outcome measures such as the DASH-S,1,15,16 KJOC,1–4,6 Andrews-Timmerman,20 Andrews-Carson,19 and Conway-Jobe scale2,5 may be more appropriate metrics for the evaluation of the athletic elbow. On the basis of this review, the KJOC seems to represent the most appropriate scale to use for the overhead athlete with an elbow problem because it was validated for this cohort of athletic patients, as compared with the Andrew-Timmerman and Conway-Jobe metrics, which were not validated outcome measures. Despite the DASH (and DASH-S) being validated in the general population this upper extremity scale is not specific for elbow function. When evaluating the athletic elbow literature or one’s own outcomes following orthopedic sports medicine intervention for elbow dysfunction, appropriate assessment of outcomes is dependent upon the understanding of elbow outcome measures as well as appropriate selection of a clinically relevant elbow outcome metric. Objective clinical measurements are more difficult to obtain and have interobserver variability; however, performance measures may provide real value in assessing function after injury or surgery. For example, the pitcher may subjectively rate their velocity as decreased, but pitches recorded on a radar gun show regained velocity or alternatively; they feel good but never regain preinjury velocity or control. Although other outcome metrics may exist for evaluation of the athletic elbow, this review focuses on the metrics commonly used and reported upon in the athletic elbow literature. Continued efforts in evidence-based medicine and critical r
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evaluation of orthopedic sports medicine outcomes after intervention using the outcome metrics discussed in this manuscript will build upon the validation for these metrics. REFERENCES 1. Alberta FG, ElAttrache NS, Bissell S, et al. The development and validation of a functional assessment tool for the upper extremity in the overhead athlete. Am J Sports Med. 2010; 38:903–911. 2. Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am. 1992;74:67–83. 3. Domb BG, Davis JT, Alberta FG, et al. Clinical follow-up of professional baseball players undergoing ulnar collateral ligament reconstruction using the new Kerlan-Jobe Orthopaedic Clinic overhead athlete shoulder and elbow score (KJOC Score). Am J Sports Med. 2010;38:1558–1563. 4. Franz JO, McCulloch PC, Kneip CJ, et al. The utility of the KJOC score in professional baseball in the United States. Am J Sports Med. 2013;41:2167–2173. 5. Jones KJ, Dines JS, Rebolledo BJ, et al. Operative management of ulnar collateral ligament insufficiency in adolescent athletes. Am J Sports Med. 2014;42:117–121. 6. Kraeutler MJ, Ciccotti MG, Dodson CC, et al. Kerlan-Jobe Orthopaedic Clinic overhead athlete scores in asymptomatic professional baseball pitchers. J Shoulder Elbow Surg. 2013; 22:329–332. 7. Badalamente M, Coffelt L, Elfar J, et al. Measurement scales in clinical research of the upper extremity, part 1: general principles, measures of general health, pain, and patient satisfaction. J Hand Surg. 2013;38:401–406; quiz 406. 8. Feinstein A. Clinimetrics. New Haven: Yale University Press; 1987. 9. 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;11:587–594. 10. Stewart AL, Hays RD, Ware JE Jr. The MOS short-form general health survey. Reliability and validity in a patient population. Med Care. 1988;26:724–735. 11. Ware J Jr, Kosinski M, Keller SD. A 12-item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–233. 12. Clark P, Lavielle P, Martinez H. Learning from pain scales: patient perspective. J Rheumatol. 2003;30:1584–1588. 13. de C Williams AC, Davies HT, Chadury Y. Simple pain rating scales hide complex idiosyncratic meanings. Pain. 2000;85: 457–463. 14. Litcher-Kelly L, Martino SA, Broderick JE, et al. A systematic review of measures used to assess chronic musculoskeletal pain in clinical and randomized controlled clinical trials. J Pain. 2007;8:906–913. 15. Beaton DE, Katz JN, Fossel AH, et al. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128–146. 16. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29: 602–608. 17. King GJ, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999;8:351–354. 18. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. Volume 2. Philadelphia: W.B. Saunders; 1993:86–97. 19. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy. 1985;1:97–107.
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20. Timmerman LA, Andrews JR. Arthroscopic treatment of posttraumatic elbow pain and stiffness. Am J Sports Med. 1994;22:230–235. 21. Cain EL Jr, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38:2426–2434. 22. Jones KJ, Conte S, Patterson N, et al. Functional outcomes following revision ulnar collateral ligament reconstruction in Major League Baseball pitchers. J Shoulder Elbow Surg. 2013;22:642–646. 23. Koh JL, Schafer MF, Keuter G, et al. Ulnar collateral ligament reconstruction in elite throwing athletes. Arthroscopy. 2006;22: 1187–1191. 24. Purcell DB, Matava MJ, Wright RW. Ulnar collateral ligament reconstruction: a systematic review. Clin Orthop Relat Res. 2007;455:72–77. 25. Watson JN, McQueen P, Hutchinson MR. A systematic review of ulnar collateral ligament reconstruction techniques. Am J Sports Med. 2013. [Epub ahead of print]. PubMed PMID: 24220014. 26. MacDermid JC. Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation. J Hand Ther. 2001;14:105–114.
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27. Badalamente M, Coffelt L, Elfar J, et al. Measurement scales in clinical research of the upper extremity, part 2: outcome measures in studies of the hand/wrist and shoulder/elbow. J Hand Ther. 2013;38:407–412. 28. Wright RW, Baumgarten KM. Shoulder outcomes measures. J Am Acad Orthop Surg. 2010;18:436–444. 29. Hislop HJ, Montgomery J. Daniels and Worthingham’s Muscle Testing: Techniques of Manual Examination. 7th ed. Philadelphia: WB Saunders Co.; 2002:1–10. 30. Turchin DC, Beaton DE, Richards RR. Validity of observerbased aggregate scoring systems as descriptors of elbow pain, function, and disability. J Bone Joint Surg Am. 1998;80: 154–162. 31. Kirkley A, Alvarez C, Griffin S. The development and evaluation of a disease-specific quality-of-life questionnaire for disorders of the rotator cuff: The Western Ontario Rotator Cuff Index. Clin J Sport Med. 2003;13:84–92. 32. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg. 2007;16: 717–721. 33. Mihata T, Safran MR, McGarry MH, et al. Elbow valgus laxity may result in an overestimation of apparent shoulder external rotation during physical examination. Am J Sports Med. 2008;36:978–982.
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