Comparative Responsiveness of Shoulder PROMs to Rotator Cuff Repair Surgery and Healing.

Abstract

Patient-reported outcome measures (PROMs) are routinely used to assess pain, function, and quality of life in shoulder care. Although rotator cuff repair (RCR) is a highly effective treatment for symptomatic tears, the relationship between structural healing and PROM responsiveness remains unclear. This study aimed to evaluate and compare the responsiveness of five common shoulder PROMs-the Penn Shoulder Score (PSS), modified American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), Shoulder Activity Level (SAL), and Patient-Reported Outcome Measure Information System Upper Extremity (PROMIS-UE)-as well as individual items from these measures and the Western Ontario Rotator Cuff Index (WORC), to RCR surgery and healing at 1-year postoperatively, with secondary analyses at 6 months and 2 years. A prospective cohort of 117 patients undergoing arthroscopic RCR for fully reparable 1-5 cm supraspinatus/infraspinatus tears was analyzed. PROMs were collected preoperatively and at 6 months, 1 year, and 2 years postoperatively. RCR healing was assessed using MRI-based Sugaya classification and CT-measured tendon retraction. Responsiveness was evaluated using standardized response means (SRMs), with subgroup analyses comparing healed and non-healed patients. Correlations between PROMs and structural healing were analyzed. All PROMs and their individual items (except SAL) demonstrated high responsiveness to RCR surgery (SRM >0.8) during the first 2 postoperative years, regardless of structural healing status, with the majority of gains occurring within the first 6 months. However, neither total PROMs nor select high-function items demonstrated correlations with structural healing (r <0.3), indicating PROMs improvements primarily reflected reduced pain and enhanced daily function rather than RCR integrity. At 1 year, 92% of patients reported an acceptable symptom state (PASS "yes"), including all patients meeting stringent criteria for failed RCR. SAL was unresponsive to RCR surgery in the overall cohort and demonstrated limited utility in assessing functional differences in this patient population. PSS, ASES, SANE and PROMIS-UE demonstrated progressively increasing ceiling effects postoperatively. Shoulder PROMs are highly responsive to RCR surgery but even their highest function items lack sensitivity to structural healing during the first two postoperative years. PROM improvements primarily reflect subjective gains in pain relief and daily function, highlighting the need for alternate outcome measures incorporating objective functional assessments to better define the impact of RCR healing in the early term. Future research should focus on developing PROMs with lesser ceiling effects postoperatively and evaluating the longer-term clinical consequences of failed structural RCR healing.