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Comparison of the SANE Method and Two Shoulder Rating Scales

Comparison of the SANE Method and Two Shoulder Rating Scales - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related

Comparison of the Single Assessment
Numeric Evaluation Method and Two
Shoulder Rating Scales
Outcomes Measures After Shoulder Surgery*
Glenn N. Williams, CPT, SP, USA, Timothy J. Gangel, MAJ, SP, USA,
Robert A. Arciero, COL, MC, USA, John M. Uhorchak, LTC, MC, USA, and
Dean C. Taylor,† LTC, MC, USA
From the Physical Therapy and Orthopaedic Surgery Services, Keller Army Community
Hospital, West Point, New York
The purpose of this study was to determine the corre-
lation between the Single Assessment Numeric Eval-
uation method and the Rowe and American Shoulder
and Elbow Surgeons scores. Between April 1993 and
December 1996, 209 follow-up examinations were per-
formed on 163 United States Military Academy cadets
after shoulder surgery. These 209 examinations were
divided into five follow-up categories: 3 months, 6
months, 1 year, 2 years, and greater than 2 years. The
Rowe and American Shoulder and Elbow Surgeons
scores from each subject’s follow-up questionnaire
were correlated with his or her Single Assessment
Numeric Evaluation rating, which is determined by the
subject’s written response to the following question:
“How would you rate your shoulder today as a percent-
age of normal (0% to 100% scale with 100% being
normal)?” Correlation coefficients between the Single
Assessment Numeric Evaluation and the two scores
were 0.51 to 0.79 for the Rowe score and 0.46 to 0.69
for the American Shoulder Elbow Surgeons score. The
results of this study indicate that the Single Assess-
ment Numeric Evaluation correlates well with these
two scores after shoulder surgery. This study suggests
that this new evaluation method provides clinicians
with a mechanism to gather outcomes data with little
demand on their time and resources.
In recent years, increased emphasis has been placed on
clinical outcomes data. In today’s health care environ-
ment, evidence-based treatment is becoming mandated.
Clinical outcomes data are important in determining our
surgical and rehabilitation results and helping us to refine
our approach to treating pathologic conditions, with the
goal of finding more effective and cost-efficient methods of
treatment. Clinical rating scales and patient question-
naires are commonly used to gather these data.
Several clinical rating scales and patient questionnaires
have been proposed to gather outcomes data after shoul-
der injury or shoulder surgery.
Some of these rating scales have been proposed for a
variety of shoulder conditions,
others are designed to evaluate specific pathologic
Rowe et al.
were among the first clinicians to present
a clinical rating scale for the shoulder. In their classic
article on the long-term results after Bankart repair, they
proposed a 100-point scale that evaluates the patient’s
stability, motion, and function. This rating scale is now
known as the Rowe score. The Rowe score has been criti-
cized because it is biased toward stability (50 points);
however, this score was specifically designed to differen-
tiate successful results from unsuccessful results after
Bankart repair.
Jobe and Bradley
have described a modification of the
* Presented at the 39th annual meeting of the Society of Military Orthopae-
dic Surgeons, Lake Placid, New York, October 1997; at the 65th annual
meeting of the American Academy of Orthopaedic Surgeons, New Orleans,
Louisiana, March 1998; and at the AACR Specialty Day Meeting, New Or-
leans, Louisiana, March 1998.
† Address correspondence and reprint requests to LTC Dean C. Taylor,
MD, Orthopaedic Surgery Service, Keller Army Community Hospital, West
Point, NY 10996.
The views expressed in this paper are those of the authors and do not
reflect the official policy or position of the Department of the Army, the De-
partment of Defense, or the United States Government.
No author or related institution has received any financial benefit from
research in this study.
© 1999 American Orthopaedic Society for Sports Medicine

Rowe score specifically designed to assess anterior insta-
bility in the athlete. Because this score is focused on
athletes, this modification emphasizes function. This mod-
ified Rowe score is not generalizable to conditions other
than shoulder stabilization procedures or to patients who
are not athletes. Tibone and Bradley
have also devel-
oped a rating system specifically for the athlete’s shoulder
(The Athletic Shoulder Outcome Rating Scale); this scale
is designed to objectively evaluate a broad range of shoul-
der abnormalities.
The Society of the American Shoulder and Elbow Sur-
geons (ASES) rating scale is a functional rating scale
designed for broad applicability.
This rating scale
evaluates the patient’s pain level, strength, stability, and
function in activities of daily living, work, and sports.
Unlike the Rowe score, this rating scale is more heavily
weighted toward function in the activities of daily living
than toward stability.
Authors have recognized that there is no unanimously
accepted rating system for the shoulder.
In addition,
validity and reliability studies are lacking for most of the
shoulder rating systems. The current trend is toward a
more holistic evaluation of the patient involving multiple
aspects of health.
The consensus is that the assessment of clinical out-
comes is necessary and that shoulder rating systems are a
good means by which to gather these data. In this study
we introduce the Single Assessment Numeric Evaluation
(SANE) method as an easier method of obtaining out-
comes data. The purpose of this study was to correlate the
SANE method with the Rowe and ASES rating scores.
At the United States Military Academy at West Point,
postoperative results for shoulder operations after dislo-
cation, chronic recurrent subluxations, and significant ac-
romioclavicular joint separations are gathered prospec-
tively at repeated follow-up examinations. These
prospectively gathered data include subjective patient
questionnaires, traditional objective clinical meas-
urements (such as range of motion and manual muscle
tests), tests of shoulder stability (for example, load and
shift, sulcus, relocation), the Rowe score, the ASES score,
isokinetic testing, and the SANE rating. The SANE rating
is determined by the cadet’s written response to the fol-
lowing question: “How would you rate your shoulder today
as a percentage of normal (0% to 100% scale with 100%
being normal)?” Patients are instructed to provide SANE
ratings in whole numbers. Routine follow-up examina-
tions after shoulder surgery are performed at 3 months, 6
months, 1 year, and yearly thereafter until the cadet grad-
uates or departs the Military Academy. A final follow-up
examination is usually performed before the cadet’s
Between April 1993 and December 1996, 209 complete
follow-up examinations were performed on 163 cadets who
underwent shoulder surgery. There were 146 male and 17
female cadets with a mean age of 20 6 0.58 years (range,
18 to 24). Although most subjects were treated for shoul-
der instability, several different surgical procedures were
used to treat these subjects. Table 1 lists the surgical
procedures the subjects in our study were treated with
and quantifies the number of subjects who received each
surgical procedure. Because this study examines data
gathered prospectively between April 1993 and December
1996, the number of times each cadet was evaluated var-
ies. Subjects with incomplete patient questionnaires or
missing examination data had all data from the incom-
plete follow-up examination excluded from the study.
Subjects were provided with a questionnaire on arrival
at their follow-up examination. This questionnaire in-
cluded questions related to the patient’s personal profile
(age, class, medical history), the Rowe score, the ASES
score (pre-1994 version), and the SANE rating. We have
made some minor modifications to the wording of the
Rowe score (see Fig. 1) and the ASES score (see Fig. 2) to
enable the subjective portions of these scores to be more
easily read and understood in the format of a patient
questionnaire. The content of these scores remains un-
changed. Questionnaires were completed in the waiting
room (in the absence of the patient’s physician). Clinic
support personnel were available to answer patient ques-
tions related to the subject matter of the questionnaire or
the procedures for completing it.
Each subject underwent a physical examination after he
or she completed the patient questionnaire. A physical
therapist performed goniometric measurements of shoul-
der range of motion, manual muscle testing, and isokinetic
strength testing. An orthopaedic surgeon questioned the
patient regarding his or her current status, performed a
traditional shoulder evaluation, including tests for joint
stability, and discussed the results of all testing with the
patient. The tests for stability were performed in a tradi-
tional fashion. Translation of the head of the humerus on
the glenoid was assessed and graded with a load and shift
type test as described by Warren.
The relocation test
was performed as described by Jobe and Bradley.
Subjects were blinded to the scoring of their Rowe and
ASES scores and to the fact that the authors were evalu-
ating the correlation between these scores and the SANE
rating. Subjects were informed that all data from their
patient questionnaires were used to 1) assist their medical
providers with further treatment planning (if necessary),
2) provide their medical team with detailed information
regarding their operative and postoperative results, and
3) research our treatment methods for shoulder injuries.
The 209 examinations were divided into the following
five routine follow-up times: 3 months, 6 months, 1 year, 2
Description of Surgical Procedures Used in this Sample
Surgical procedure No. in sample
Open Bankart repair 115
Open anterior-inferior capsular shift 11
Arthroscopic Bankart repair 29
Posterior capsular shift 5
Revision open Bankart or capsular shift 1
Distal clavicle resection/AC joint repair 2
Vol. 27, No. 2, 1999 Single Assessment Numeric Evaluation After Shoulder Surgery 215

years, and greater than 2 years. The Rowe and ASES
scores from each of the 209 cadet follow-up questionnaires
were correlated with the SANE rating from the same
questionnaire. The correlations between the SANE
method and the Rowe and ASES scores for all records
combined were also calculated. The Pearson product cor-
relation statistic (r) was used for all correlations.
The following descriptive data for each of the five groups
are found in Table 2: forward elevation deficit at the time
of evaluation; external rotation deficit at the side and in
90° of abduction (supine); and the side-to-side differences
in anterior translation, posterior translation, and inferior
Figure 1. The Rowe Score (West Point modification).
216 Williams et al. American Journal of Sports Medicine

Figure 2. The ASES score (modified pre-1994 version).
Vol. 27, No. 2, 1999 Single Assessment Numeric Evaluation After Shoulder Surgery 217

translation. The sample size, Rowe score, ASES score,
SANE rating, and time to follow-up are described in Table
3. The Rowe score, ASES score, and the SANE rating are
plotted across the five follow-up categories in Fig. 3 to
provide a better understanding of the similarity between
the raw scores obtained on these outcomes measures.
All data were normally distributed and demonstrated
homogeneity of variance. Each correlation was significant
at the P , 0.001 level. The correlation coefficients and
descriptive terms for the strength of the correlations be-
tween the three outcomes measures are found in Table 4.
The strengths of the correlations are described using es-
tablished guidelines.
The means for the Rowe score, ASES score, and SANE
rating for all records combined were 88.3 6 13.0, 94.7 6
6.3, and 89.2 6 11.4, respectively. The correlation coeffi-
cient between the Rowe score and SANE rating for all
records was 0.77, which indicates there is a good correla-
tion between the two measures. The overall correlation
between the ASES score and the SANE rating was 0.69,
also indicative of a good correlation. The correlations be-
tween the Rowe score and the ASES score were 0.63, 0.68,
0.67, 0.33, and 0.37, for the 3-month, 6-month, 1-year,
2-year, and greater than 2-year follow-up categories, re-
spectively. The overall correlation between these two
shoulder rating scores was 0.58.
Assessment of clinical outcomes is becoming increasingly
important in today’s health care environment. Outcomes
data serve many purposes: 1) to provide clinicians with
knowledge of a specific patient’s perception of his or her
results, 2) to provide patients with a simple method of
Range of Motion and Stability Measurements for Subjects at Each of the Five Follow-up Times
(All Data Are Presented as Mean 6 SD)
Range of motion deficit from opposite side (degrees) Side-to-side difference in translation (grade)
at the
ER at 90°
Anterior Posterior Inferior
3 months 9.2 6 10.2 18 6 13.7 20.7 6 16.9 20.23 6 0.7 0.0 6 0.4 0.0 6 0.4
6 months 2.0 6 5.2 6.9 6 7.2 11.1 6 11.8 0.3 6 0.7 0.2 6 0.5 0.2 6 0.5
1 year 1.2 6 3.1 6.4 6 8.6 8.7 6 9.3 0.0 6 0.6 0.0 6 0.4 0.0 6 0.3
2 years 2.3 6 5.6 5.2 6 9.4 5.3 6 6.4 0.3 6 0.8 0.2 6 0.5 0.3 6 1.0
.2 years 0.8 6 2.5 5.3 6 7.4 4.3 6 6.6 0.0 6 0.7 20.1 6 0.4 0.0 6 0.2
External rotation.
Outcome Measure Descriptive Data for the Five Follow-up Times (All Data Are Presented as Mean 6 SD)
Follow-up N Rowe score ASES score SANE rating
Mean time to
follow-up (months)
3 months 26 72.5 6 17.3 88.2 6 7.8 74.3 6 13.1 3.2 6 0.6
6 months 43 86.8 6 13.8 93.7 6 5.6 87.7 6 10.5 6.4 6 0.88
1 year 84 88.4 6 13.1 95.1 6 6.6 90.7 6 11.3 13.6 6 2.4
2 years 21 90.6 6 10.6 95.8 6 3.0 92.9 6 5.5 23.8 6 3.1
.2 years 35 94.5 6 5.6 98.1 6 2.2 95.2 6 4.2 36.0 6 6
Correlation Coefficients (r) and Strengths of the Correlations of the Rowe and ASES Scores with the SANE Method
Rowe score
Strength of
ASES score
Strength of
3 months 0.72 Good 0.66 Good
6 months 0.79 Good 0.69 Good
1 year 0.62 Moderate 0.56 Moderate
2 years 0.54 Moderate 0.64 Moderate
.2 years 0.51 Moderate 0.46 Fair
Figure 3. Plot of the Rowe Score, ASES score, and SANE
method over time.
218 Williams et al. American Journal of Sports Medicine

understanding how their outcomes compare with the
norm, 3) to facilitate collection of data and analysis of
long-term results, 4) to produce evidence on the effective-
ness of treatment methods, and 5) to compare different
treatment methods to determine which treatment meth-
ods are most effective and cost-beneficial.
There is no unanimously accepted rating system for the
In addition, the validity and reliability of
most shoulder rating systems in the literature is lacking.
Collecting outcomes data with shoulder rating systems
requires time, resources, and patient follow-up schedules
that are prohibitive to many clinicians. If effective, a sin-
gle question assessing a patient’s impression of his or her
condition is a more rational approach to assessing an
outcome, as our acronym implies.
This study evaluated the correlation between the pa-
tient’s response to a single question related to his or her
functional outcome (SANE rating) and two established
shoulder rating scores (Rowe and ASES scores). The
SANE method correlated well with the Rowe and ASES
scores (r 5 0.77 and 0.69, respectively). This finding sug-
gests that meaningful outcomes data may be gathered
with minimal cost to the clinician in terms of time and
The strength of the correlations across the follow-up
categories was variable (Table 4). One possible explana-
tion for the decreasing correlations observed with greater
follow-up is the nature of the correlation coefficient. The
strength of the correlation coefficient is a function of how
closely the data set resembles a straight line. When the
range of scores is limited, this statistic will not adequately
reflect the extent of the relationship between data because
it is difficult to demonstrate covariance in these circum-
stances (that is, the relationship is “crowded”).
In this
study, the range of raw scores became narrower and vari-
ability decreased with longer follow-up, but the correla-
tion coefficients also decreased. It is likely that the oper-
ation of the correlation coefficient in these circumstances
resulted in somewhat lower strength correlations than
would have been observed with a larger range of scores.
In the early stages after surgery patients are primarily
concerned with pain and function in the basic activities of
daily living. As a patient recovers from surgery his or her
focus changes from basic shoulder function to perfor-
mance, and the expectations for “normal” function in ath-
letics become stronger. The patient’s focus on sport per-
formance instead of basic shoulder function and his or her
increased expectations for “normal function” in the later
categories may provide an additional explanation for the
lower correlations observed in these categories. For exam-
ple, in the 1st year after the patient returns to sports, he
or she may have a clinically “normal” shoulder and excel-
lent basic shoulder function but may not be performing at
his or her prior level in sports or may not have attained
the expected level of performance. Such a patient may
have a near perfect Rowe or ASES score but provide a
lower SANE rating because he or she is not fully satisfied
with the outcome. This discrepancy would affect the cor-
relation between the two measures.
The mean SANE rating fell between the means of the
Rowe score and ASES score for all categories but was more
similar to the Rowe score than the ASES score (Table 3).
The Rowe score was specifically designed for patients who
had undergone a shoulder stabilization procedure,
whereas the ASES evaluation system was designed to be
more globally applicable.
Because all but two subjects in
this sample had shoulder stabilization procedures (Table
1), it is likely that the Rowe score was more specific to our
subjects and that this score’s focus on stability and motion
may have been more sensitive to the deficits perceived by
our subjects.
It is interesting to note that the correlations between
the SANE rating and each of the two rating scales were
stronger than the correlation between the Rowe score and
the ASES score (r 5 0.77 and 0.69 versus r 5 0.58). The
ASES score was consistently higher than the other two
measures. This finding, coupled with the lower correla-
tions with the SANE rating, suggests that this score may
not have been very specific to our subjects, although it
certainly contains valuable information. The ASES score
was originally proposed as an evaluation system, but it
has since become a popular rating system.
The inclusion
of a grading system within this evaluation tool implies
that a rating score was envisioned when the tool was
designed. There is some variation in how the ASES score
is tabulated in the literature.
The most common
method of grading the pre-1994 score used in this study is
to provide 5 points for pain, 60 points for function, 20
points for strength, and 15 points for stability (Fig. 2). The
ASES published another standardized method for the as-
sessment of shoulder function in 1994.
The assessment
was developed over a 3-year period in which all prior
scores and recommendations were reviewed. The result-
ant assessment tool is similar to the pre-1994 score used
in this study, but it uses visual analog scales to measure
pain and stability and contains fewer questions on activ-
ities of daily living. A shoulder score index is computed
with a simple formula including the patient’s pain scores
and the cumulative score for activities of daily living.
Stability does not contribute to the score. The pre-1994
score used in this study should not be confused with the
shoulder score index adopted by the ASES.
Romeo and coworkers
compared several shoulder rat-
ing systems and found that there was poor correlation
between the rating systems evaluated. These authors
noted that the generalized results of an investigation can
be biased because of the rating scale chosen as the pri-
mary measure of outcomes in the study. Romeo and co-
workers concluded that a widely accepted shoulder scoring
system is needed. The current trend is toward a more
holistic evaluation of the patient involving multiple as-
pects of health. These outcomes measures are usually
based on the patient’s perception of their shoulder func-
tion rather than clinical measures. Several disease-spe-
cific measures for the shoulder have been proposed in the
Beaton and Richards
compared sev-
eral of these disease-specific shoulder rating systems with
the SF-36, a generic health-status measure. These au-
thors found that the shoulder-specific questionnaires per-
formed differently than the SF-36, and they recommended
Vol. 27, No. 2, 1999 Single Assessment Numeric Evaluation After Shoulder Surgery 219

the use of both a generic health-status measure and a
disease-specific measure. Like other rating schemes, the
disease-specific measures and the SF-36 require instruc-
tion, time, and resources that may be prohibitive to
The SANE method is a patient-based outcomes meas-
ure. Keller
has noted that outcomes research should be
ures evaluate the patient’s own perceptions of his or her
outcome and are generally self administered. Process-
based measures are the objective findings we acquire dur-
ing our clinical evaluations (for example, tests of stability,
radiographs, isokinetic data). Although objective clinical
findings are important and do effectively measure
whether clinicians have achieved their clinical objectives,
these findings may not mirror the patient’s perception of
his or her outcome. For this reason, there is an ongoing
debate in the orthopaedic community about whether out-
comes measures should be primarily patient based or pro-
cess based.
A patient with a history of a chronic, recurrent subluxa-
ting shoulder who has been treated with a capsulorraphy
or a Bankart repair may have a mild loss of range of
motion (usually external rotation) after surgery. This loss
of motion or a single subluxation event after surgery can
significantly reduce the score this patient obtains on a
rating scale; yet, this patient may be very pleased with his
or her overall result and have better function than he or
she had previously because the instability has been
treated. Because of the incongruity frequently observed
between patient-based and process-based evaluations (as
demonstrated in the previous scenario), we have chosen to
use both a measure of the patient’s perception of their
outcome (the SANEmethod), a detailed clinical evaluation
(process based), and one or more process-based scores (for
example, Rowe, ASES), to provide us with a more compre-
hensive picture of our patient’s outcomes. We are not
recommending that the SANE method replace the use of
other established outcomes measures, but we do advocate
this method as a convenient adjunct to process-based
scores and a simple, but meaningful, alternative when
time and resources are limited.
It is inevitable that some patients will not be able to
come to the clinic for follow-up evaluations. When this
occurs, it would be useful to have a simple but meaningful
method of evaluating general functional outcome that
could be performed over the telephone or electronically.
The results of this study suggest that the SANE method
may be a means by which we can accomplish this task.
The obvious weakness of the SANE method is its inabil-
ity to answer why patients rate their shoulders the way
they do at a certain point in time. However, this informa-
tion is generally easy to acquire by simply asking the
patient, by performing a thorough clinical evaluation, or
by using other assessment tools in conjunction with this
method. In optimal circumstances where time and re-
sources are plentiful, sophisticated outcomes measures
and detailed clinical tools can be used to help determine a
patient’s outcome; however, in many clinical settings the
limitations on personnel, resources, and time make de-
tailed measures impractical. The SANE method provides
clinicians in these settings with a starting point.
The SANE method appears to be a good measure of
patient status after shoulder operations. Our institution
has also studied the correlation of the SANE method with
knee and ankle rating systems (J. M. Molloy et al., unpub-
lished data, 1997; G. N. Williams et al., unpublished data,
1997). These studies have demonstrated results similar to
those in this study. Of interest, the SANE method corre-
lated better with a quality of life assessment scale than
with a clinical rating scale both in subjects who had sus-
tained ankle sprains and in uninjured subjects. This is
most likely because of the SANE method’s qualitative
nature (J. M. Molloy et al., unpublished data, 1997). It
appears that the SANE method may have broad
The excellent overall physical and mental health of the
United States Military Academy cadets and their young
age should be noted when attempting to generalize our
findings to other patient populations. The authors’ expe-
rience from treating a significant number of noncadet,
college-aged patients leads us to believe that our findings
are applicable to other young, athletic, college-aged popu-
lations. Although we believe that this evaluation method
will also demonstrate applicability in other age groups,
research that confirms this belief is needed before this
method can be advocated as applicable in patient popula-
tions whose ages differ significantly from the age of our
sample. Future research should examine the applicability
of the SANE method to different patient populations and
patients with other types of shoulder disorders, and eval-
uate its correlation with other outcomes measures.
In conclusion, this study introduces the SANE method
as a new method of gathering outcomes data. The SANE
method correlated well with measured Rowe and ASES
scores. This patient-based, single-question assessment di-
rectly establishes the patient’s perception of his or her
results. The combination of this simple measure with ob-
jective data from clinical evaluations or process-based
scores may provide clinicians with a good understanding
of a patient’s results. The results of this study suggest that
clinicians can use the SANE method to gather meaningful
outcomes data with little demand on their time and
The authors recognize J. Parry Gerber, MPT, SCS, for his
assistance in data collection and data analysis. We also
acknowledge Joachim J. Tenuta, MD, Charles R. Scoville,
MPT, Bryan L. Boyea, MPT, OCS, Barbara A. Springer,
MSPT, OCS, and Joseph M. Molloy, MPT, for their assis-
tance in the data collection for this study.
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