Musculoskeletal Science and Practice 61 (2022) 102593

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Musculoskeletal Science and Practice

journal homepage: www.elsevier.com/locate/msksp

Original article

Assessing shoulder disability in orthopaedic specialist care: Introducing the

Copenhagen Shoulder Abduction Rating (C-SAR)
Mikkel Bek Clausen a, b, *, Adam Witten b, Karl Bang Christensen c, Mette Kreutzfeldt Zebis a,
Morten Foverskov b, Ann Cools d, Per Hölmich b, Kristian Thorborg b
a
Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy, Faculty of Health, University College Copenhagen, Sigurdsgade 26,
Copenhagen N, Denmark
b
Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, Hvidovre,
Denmark
c
Section of Biostatistics, Department of Public Health, University of Copenhagen, Øster Farigmagsgade 5, Copenhagen, Denmark
d
Department of Rehabilitation Sciences and Physiotherapy, Ghent University, De Pintelaan 185, Ghent, Belgium

A B S T R A C T

Background: Differences in shoulder-disability among common shoulder-disorders in orthopaedic specialist care is unknown. Furthermore, rating of shoulder-
disability using patient-reported outcomes is time-consuming, and a faster approach is needed.
Objectives: First, compare shoulder-disability among common shoulder-disorders. Secondly, rate shoulder-disability according to the new and quick Copenhagen
Shoulder Abduction Rating (C-SAR) and investigate criterion validity of C-SAR.
Methods: Cross-sectional study including 325 consecutive patients with shoulder-disorders in orthopaedic specialist care. We assessed shoulder abduction range-of-
motion and pain during testing (NRS:0-10), and shoulder-disability using Shoulder Pain and Disability Index (SPADI) subscales. Patients were sub-grouped using C-
SAR, which is based on shoulder abduction range-of-motion and pain during testing: Severe (range-of-motion ≤90◦ ), Medium (range-of-motion >90◦ , NRS:>5), Mild
(range-of-motion >90◦ , NRS:≤5). Shoulder-disability was compared among diagnostic categories and C-SAR subgroups using ANCOVA-models.
Results: Most patients were diagnosed with either subacromial impingement (n = 211) or full-thickness/complete rotator-cuff tear (n = 18), but adhesive capsulitis (n
= 22) was the diagnostic category related to worst SPADI scores. Data for C-SAR subgrouping were available from 187/229 (82%) patients with rotator-cuff related
disorders (subacromial impingement or rotator-cuff tears). C-SAR subgrouping was not feasible for patient with adhesive capsulitis or glenohumeral injury. Dif­
ferences in shoulder-disability between Mild (n = 67) and Medium (n = 56) C-SAR subgroups were large for both SPADI-subscales (ES: 1.0, p < .0001). Only SPADI-
function differed significantly between Severe (n = 64) and Medium C-SAR subgroups (ES: 0.4, p = .017).
Conclusion: In orthopaedic specialist care, adhesive capsulitis relates to highest level of shoulder-disability, while C-SAR is a promising test to rate shoulder-disability
for most patients, namely those with rotator-cuff related disorders.

1. Introduction evaluation. Understanding the variability in severity between shoulder

diagnoses in secondary care could add to our understanding of the so­
Subacromial impingement syndrome, rotator cuff tears, adhesive cietal burden related to each of these and provide valuable insight to
capsulitis and glenohumeral labral tears account for the vast majority of allow researchers and policy makers to focus on improving rehabilita­
shoulder disorders (Juel and Natvig, 2014; Malavolta et al., 2017). tion for the most severe shoulder diagnoses. At this point it is unknown
These common shoulder disorders are related to shoulder pain and how shoulder disability differs among the most common shoulder di­
impaired shoulder function, with accompanying limitations in shoulder agnoses in secondary care.
activities. The level of disability is best assessed from the patients perspective
In general, patients with more pronounced symptoms are of special (Chin and Lee, 2008; Deshpande et al., 2011), which is why
interest, as higher levels of shoulder disability have been linked to patient-reported outcome measures (PROMs) are optimal for this (Chin
increased societal costs (Kuijpers et al., 2006). These severe cases are and Lee, 2008; Deshpande et al., 2011). While most shoulder-specific
more common in secondary care, as patients with persistent or pro­ PROMs include items related to limitations in participation and more
nounced symptomatology are often referred for orthopaedic specialist general activities (Roe et al., 2013), the Shoulder Pain And Disability

* Corresponding author. Faculty of Health, University College Copenhagen, Sigurdsgade 26, Copenhagen N, Denmark.
E-mail address: [email protected] (M.B. Clausen).

https://doi.org/10.1016/j.msksp.2022.102593
Received 3 January 2022; Received in revised form 24 May 2022; Accepted 29 May 2022
Available online 31 May 2022
2468-7812/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M.B. Clausen et al. Musculoskeletal Science and Practice 61 (2022) 102593

Index (SPADI) has a stringent focus on joint-specific disability (Roe were categorized into one of the following diagnostic categories: 1)
et al., 2013; Roach et al., 1991), making it ideal for comparing the level Subacromial impingement syndrome (SIS) with or without concomitant
of shoulder disability among common shoulder disorders. AC-joint pathology and partial thickness rotator-cuff tear, 2) labral
Assessment of shoulder disability might also be useful to guide care injury and/or glenohumeral dislocation sequelae (glenohumeral injury),
(McClure and Michener, 2015), since a shoulder diagnosis in itself does 3) complete or full-thickness rotator-cuff tear (complete/full-thickness
not provide such information. Currently, the information is obtained RC-tear), 4) adhesive capsulitis, or 5) other (Fig. 1, Study flow).
through PROMs, but the use of PROMs in everyday clinical practice is
often considered too time-consuming (Jette et al., 2009; Tygiel, 2013). 2.3. Outcomes
Therefore, there is a need for a quick method to rate the level of shoulder
disability. The newly developed Copenhagen Shoulder Abduction Rat­ 2.3.1. Descriptive variables
ing (C-SAR) test could be a solution to this. The C-SAR test is a simple Age (years) and gender was collected from all patients. Worst pain
and quick method, that combines abduction ROM and pain during the last week was assessed using the validated 11-point numeric rating scale
test to rate the level of shoulder disability into three levels: Mild, Me­ (NPRS, 0 = no pain, 10 = worst imaginable pain) (Jensen et al., 1999).
dium and Severe. This impairment rating could prove a useful alterna­ Patient-reported function was assessed using the Quick Disability of the
tive to PROMs, but this requires that C-SAR scores are valid Arm, Shoulder and Hand (Q-DASH) (Gummesson et al., 2006). Q-DASH
representation of patient-rated shoulder disability. is scored from 0 (best) to 100 (worst) and consists of eight physical
The current study has two purposes. First, to investigate and compare function items and three symptom items, each scored from 1 to 5. All
shoulder disability among patients diagnosed with the most common items are weighted equally for calculation of the total score. The
shoulder diagnoses in secondary care. Secondly, to rate shoulder Q-DASH questionnaire covers symptoms related to the arm, shoulder
disability in patients with shoulder disorders according to C-SAR and and hand, as well as aspects related to limitations in body functions,
investigate the criterion validity of C-SAR scores, by comparing shoulder activity and participation (Roe et al., 2013). The Danish versions of
disability among C-SAR subgroups. Q-DASH has been found to have excellent reliability (Sch ø nnemann and
Eggers, 2016), though it has not been investigated specifically for
2. Materials and methods shoulder disorders.

2.1. Design, settings and procedures 2.3.2. Shoulder disability

Disability covers impairments, activity limitations, and participation
This is a cross-sectional study including a consecutive cohort of pa­ restrictions as defined by the International Classification of Functioning,
tients referred to secondary care at Arthroscopic Center in Hvidovre Disability and Health (World Health Organisation, 2022). Data on
Hospital, a public outpatient clinic in the capital region of Denmark. All shoulder disability were collected using the Shoulder Pain and Disability
patients referred for initial examination of their shoulder disorder at the Index (SPADI) (Roach et al., 1991), as SPADI is one of the most
department during a 3-months period (March to Jun 2014) were eligible joint-specific shoulder PROMs, focusing on pain and shoulder impair­
for inclusion. ments and limitations in shoulder-specific activities (Roe et al., 2013).
On the day of examination, one of six trained assessors (two phys­ Shoulder disability was quantified as the total SPADI score, which range
iotherapists, three physiotherapy undergraduates and one medical stu­ from 0 (best) to 100 (worst) and is calculated as the average of the
dent) collected data on patient-reported shoulder function, five-item pain sub-scale and the eight-item function sub-scale. The
kinesiophobia and pain, and conducted a clinical assessment of shoulder Danish version of SPADI has been found to have good reliability
strength and ROM. For safety reasons, assessment of strength and ROM (Christiansen et al., 2013). Recently, however, Rasch analyses has
was omitted in cases where the patient reported a tendency to disloca­ revealed that the validity of the SPADI total score could be questioned
tion of the shoulder. After data collection, an orthopaedic shoulder (Christensen et al., 2018; Jerosch-Herold et al., 2017), and SPADI should
specialist, blinded to all test results, performed a clinical examination therefore be reported as two separate sub-scales; SPADI-pain (five items)
from which the diagnosis was made. Patients were diagnosed according and SPADI-function (six items). For the current study, we report both the
to the clinical judgement of the orthopaedic specialist, using any para­ original total score and the sub-scale scores, with SPADI-pain scores
clinical investigation (X-ray, MR, ultrasound) performed or requested on being adjusted for differential item function by age and omitting two
the day of the examination. All patients with a valid measure of active items from the SPADI-function sub-scale, as suggested by Christensen
abduction ROM were further sub-classified according to C-SAR score, et al. (2018). The SPADI total score is reported to facilitate comparisons
which is based on their abduction ROM and pain during the assessment. to existing evidence as many previous studies only report the total score.
For the purpose of the current study, we included the outcomes of
patient-reported shoulder function, worst pain last week, active 2.3.3. Copenhagen Shoulder Abduction Rating (C-SAR)
abduction ROM, and pain during test of active abduction ROM. Details Copenhagen Shoulder Abduction Rating (C-SAR) is a shoulder
about other outcomes have been described previously alongside data on disability rating (Fig. 2) based on the results from the assessment of
a sub-group of patients (Clausen et al., 2017; Witten et al., 2018). None active abduction ROM and pain during the test. The use of active
of the analyses or results from the current study has been published abduction ROM was deemed relevant because assessment of active
elsewhere. The study has been evaluated by the Capitol Region Com­ range of motion is advised in the examination of patients with shoulder
mittee on Health Research Ethics in Denmark, where it was evaluated as disorders (Codsi and Howe, 2015) and low levels of active abduction
not requiring formal ethical approval (H-3-2013-FSP29). Written ROM have been reported in some shoulder patients (Engebretsen et al.,
informed consent was obtained from all participants. 2010). Furthermore, pain during active abduction is a key component in
the test for painful arc syndrome (Kessel and Watson, 1977), which is
2.2. Participants often used in diagnostic examination (Hegedus et al., 2015), but the
level of pain is not taken into account when performing the painful arc
All patients with a shoulder disorder referred to the department were test. In this study, active abduction ROM was measured in degrees using
considered eligible for inclusion based on the following inclusion a digital inclinometer. The subject was instructed to raise the arm as
criteria: age 18 years or more, sufficient Danish language ability, high as possible, in the coronal plane towards the ceiling, with the elbow
informed written consent, and no competing disorder affecting the fully extended. ROM was measured with the inclinometer aligned par­
shoulder function or the ability to answer questionnaires. Based on the allel to the humerus, close to the insertion of the deltoid muscle. The
diagnosis provided by the orthopaedic specialist, all included patients inter-tester reliability of the test is excellent with ICC 0.95 (95%CI 0.89

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M.B. Clausen et al. Musculoskeletal Science and Practice 61 (2022) 102593

Fig. 1. Flow chart.

to 0.97), SEM = 1.6◦ and MDC90 = 4◦ (Kolber et al., 2011). After the test, 2.3.5. Sample size consideration
patients were asked to rate their maximum pain experienced during the As the specific sizes of diagnostic groups were not known a priori, no
assessment on the 11-point NPRS. C-SAR scores were defined as: Severe, formal sample size calculation was conducted prior to data collection. Of
≤ 90◦ abduction ROM; Medium, > 90◦ abduction ROM with pain during relevance when interpreting the contrasts estimates in this study, com­
abduction ROM assessment ≥6 (NPRS 0-10) and; Mild, > 90◦ abduction parisons of equally sized groups, requires 26 and 64 patients in each
ROM with pain during abduction ROM assessment ≤5 (NPRS 0-10). We group to have a statistical power of 80% to detect a large or medium ES,
tested the reliability of C-SAR score based on test-retest data from a respectively (Cohen’s d 0.8 and 0.5, respectively), with a significance
convenience sample of 20 patients with shoulder disorders, who were level of 0.05.
not included in this study, and found excellent inter-tester reliability
(Weighted Kappa = 0.84 95%CI 0.68 to 1.00). 3. Results

2.3.4. Data analyses The majority of the 325 included patients were diagnosed with SIS
Descriptive statistics with means and standard deviations (SD) or (65%), while glenohumeral injury (9%) adhesive capsulitis (7%),
median with interquartile range [IQR] were applied for continuous complete/full-thickness RC-tear (6%) or other diagnoses (14%) were
variables, and numbers (percentages) for categorical variables. SPADI, less common (Fig. 1). The group diagnosed with glenohumeral injuries
SPADI-function and SPADI-pain scores were compared among diag­ consisted of 17 patients with labral injury, 2 patients with glenohumeral
nostic categories using ANCOVA models (with no covariates included), dislocation sequelae, and 11 patients with both (Fig. 3). The mean age of
making sure that model assumptions were met (i.e. no outliers, the full cohort was 51 years (SD 16) and 48% were females.
approximate normal distribution of residuals for each category of the
independent variable, and homogeneity of variance). Groups were
compared using the CONTRAST subcommand in SPSS. Patients were 3.1. Comparing shoulder disability among common shoulder disorders
divided according to C-SAR score, separately for each diagnostic cate­
gory and the distribution of ratings within each diagnosis presented as Compared to patients with SIS, the patients diagnosed with adhesive
numbers (percentages). To investigate the criterion validity (Mokkink capsulitis scored worse in SPADI (mean diff. 11 points (95%CI: 1 to 21),
et al., 2010) of C-SAR scores, we used SPADI, SPADI-function and ES 0.5, p = .025) and SPADI-function (mean diff. 15 points (95%CI: 4 to
SPADI-pain scores as gold standard and compared these among C-SAR 26), ES 0.6, p = .009), but SPADI-pain did not differ significantly (mean
subgroups, using ANCOVA models (as described above). For all com­ diff. 10 points (95%CI: 0 to 20), ES 0.4, p = .059). Patients diagnosed
parisons made using ANCOVA models, effect-sizes (ES) were estimated with complete/full-thickness RC-tear did not differ from those diag­
as the mean difference divided by the common SD. All analyses were nosed with SIS or adhesive capsulitis in any of the analyses (p = .141 to
conducted as available-case analyses and a significance level of 5% was p = .991) (Table 1 and Fig. 4). Patients diagnosed with glenohumeral
applied. All analyses were conducted using IBM SPSS v24. injury scored better in SPADI, SPADI-pain and SPADI-function
compared to all other diagnostic groups (ES 0.8 to 1.4, p < .01)

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M.B. Clausen et al. Musculoskeletal Science and Practice 61 (2022) 102593

Fig. 3. Distribution of diagnosis for 325 consecutive patients with shoulder

disorder. Other diagnosis includes: Fracture sequelae (n = 7), Glenohumeral
arthrosis (n = 7), Acromioclavicular dislocation sequelae (n = 6), Biceps tear (n
= 5), Acromioclavicular arthrosis (n = 4), Sternoclavicular dislocation (n = 1)
and non-categorized (n = 14). From the 11 patients with both Labral injury and
GH-dislocation sequelae four also had a Hill Sachs lesion.

3.3. Validity of C-SAR score in patients with SIS or complete/full-

thickness RC-tear

The subgroup with Mild C-SAR score had lower level of shoulder
disability than those with Medium C-SAR score, as measured with SPADI
(mean diff. 21 points 95%CI: 15 to 27, ES 1.0, p < .0001), SPADI-pain
(mean diff. 20 points 95%CI: 14 to 27, ES 1.0, p < .0001) and SPADI-
function (mean diff. 21 points 95%CI: 14 to 28, ES 1.0, p < .0001)
(Table 2 and Fig. 6). Patients with Medium C-SAR score had lower levels
of shoulder disability than those with Severe C-SAR score, when
measured with SPADI-function (mean diff. 9 points 95%CI: 2 to 16, ES
Fig. 2. Copenhagen Shoulder Abduction Rating (C-SAR), Schematic overview. 0.4, p = .017), but not SPADI (mean diff. 6 points 95%CI: − 1 to 12, ES
0.3, p = .085) and SPADI-pain (mean diff. 2 points 95%CI: − 5 to 9, ES
(Table 1, Fig. 4). 0.1, p = .536) (Table 2 and Fig. 6).

3.2. Disability rating and sub-classification of patients using C-SAR 4. Discussion

Disability rating was possible for 212 (75%) of the 281 patients in the Firstly, our findings indicate that glenohumeral dislocation sequelae
four diagnostic categories (see Fig. 1 for details). Distributions among C- and/or labral injury (glenohumeral injury) are associated with less se­
SAR subgroups were fairly even or slightly skewed for patients with SIS vere shoulder disability compared to SIS, complete/full-thickness RC-
and complete/full-thickness RC-tear (Fig. 5). Patients with adhesive tear and adhesive capsulitis, while adhesive capsulitis was associated
capsulitis were all in the Severe C-SAR subgroup, while 7 out of 9 pa­ with more severe shoulder disability compared to SIS. A main finding of
tients with glenohumeral injury were in the Mild C-SAR subgroup. the current study is also that shoulder-disability can be assessed in pa­
Within the diagnostic categories of adhesive capsulitis and gleno­ tients with SIS or complete/full-thickness RC-tears using the newly
humeral injury it was not deemed feasible to do further comparisons developed Copenhagen Shoulder Abduction Rating (C-SAR). The C-SAR
because of the small number of patients and the lack of distribution is a valid assessment of shoulder-disability, requiring only 10 s to
between C-SAR subgroups. Furthermore, considering the similarities of perform.
complete/full-thickness RC-tears and SIS, these groups were merged for In the current study, we compared shoulder disability, in terms of
further comparisons among C-SAR subgroups. From the 187 patients SPADI, SPADI-pain and SPADI-function scores, across the most common
with SIS or complete/full-thickness RC-tear, C-SAR score was Severe for shoulder diagnoses. To the best of our knowledge, such comparisons
34% (n = 64), Medium for 30% (n = 56), and Low for 36% (n = 67). have not previously been described. Most pronounced differences in
shoulder disability were found when comparing patients with gleno­
humeral injury to the other three diagnostic groups (SIS, complete
rotator-cuff tears, and adhesive capsulitis). These differences were me­
dium to large (ES 0.8 to 1.4) with SPADI mean differences ranging from

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M.B. Clausen et al. Musculoskeletal Science and Practice 61 (2022) 102593

Table 1
Descriptive variables and shoulder-specific disability, separately for each of the four diagnostic groups.
Subacromial impingement Glenohumeral injury Complete rotator-cuff tear Adhesive capsulitis

Descriptive n= n= n= n=
Age in years, mean ±SD 53 ± 14 211 32 ± 12 30 67 ± 12 18 55 ± 11 22
Gender, %female 53% 211 17% 30 44% 18 64% 22
Worst pain (0-10), median [IQR] 8 [6; 9] 199 6.5 [2; 8] 22 8 [7; 10] 15 9 [8; 10] 20
Q-DASH (0-100), mean ±SD 45 ± 19 209 32 ± 22 28 49 ± 22 18 50 ± 17 21
Shoulder disability
SPADI (0-100), mean ±SD 55 ± 22 210 36 ± 23 29 59 ± 24 17 66 ± 19 21
SPADI-P (0-100), mean ±SD 60 ± 22 210 40 ± 26 29 60 ± 28 18 69 ± 22 21
SPADI-F (0-100), mean ±SD 43 ± 25 210 24 ± 24 29 52 ± 23 17 58 ± 23 21

considered less severe when compared to SIS, complete/full-thickness

RC-tear and adhesive capsulitis, considering that the level of shoulder
disability has previously been linked to increased societal costs (Kuijpers
et al., 2006) while pain, by itself, also affects health related quality of life
(Skevington, 1998). In the other end of the shoulder disability spectrum,
adhesive capsulitis was related to higher levels of shoulder disability
when compared to SIS, with differences in SPADI approximating the
MCID (mean diff. 11, p = .025). For the SPADI sub-scales, the difference
was only significant for function (p = .009) and not for pain (p = .059).

Table 2
Shoulder disability, pain and abduction ROM for each C-SAR group of patients
with SIS or complete/full-thickness RC-tear.
Severe Medium Mild
C-SAR C-SAR C-SAR

(N = 64) (N = 56) (N = 67)

SPADI (0-100), mean ±SD 66 ± 19 61 ± 16 40 ± 18

SPADI-pain (0-100), mean ±SD 69 ± 20 66 ± 16 46 ± 20
Fig. 4. Level of shoulder disability (SPADI-pain and SPADI-function) for each
SPADI-function (0-100), mean ±SD 57 ± 23 48 ± 19 27 ± 19
of the four diagnostic groups, including 95% confidence intervals. *p < .05, Q-DASH (0-100), mean ±SD 54 ± 19 43 ± 16 34 ± 17
**p < .01, ***p < .001, ****p < .0001. Worst pain last week (0-10), 8 [7; 10] 8 [7; 9] 7 [5; 8]
median [IQR]
19 to 31 points, thereby surpassing the minimal clinical important dif­ Abduction ROM (degrees), median 62◦ [43; 122◦ [104; 153◦ [122;
[IQR] 75] 141] 166]
ference (MCID) of SPADI total score (MCID: 8-13 26,27). These findings Pain in Abduction ROM (0-10), 8 [5; 9] 7.5 [6; 8] 3 [1; 5]
are not surprising, considering that the cardinal symptoms related to median [IQR]
glenohumeral injuries, such as laxity and sense of instability (Kirkley
et al., 1998), are not included in SPADI. However, based on the results of
the current study, it seems that glenohumeral injuries could be

Fig. 6. Level of shoulder disability (SPADI-pain and SPADI-function) for each

Fig. 5. Distribution of C-SAR levels within each of the four diag­ of the C-SAR levels in patients with SIS or complete/full-thickness RC-tear
nostic categories. including 95% confidence intervals.

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M.B. Clausen et al. Musculoskeletal Science and Practice 61 (2022) 102593

This could indicate that functional limitations differ more between pa­ Secondly, in the consecutive cohort included in this study, diagnosis of
tients with SIS and adhesive capsulitis, respectively, than do pain. complete/full-thickness RC-tear, adhesive capsulitis and glenohumeral
To the best of our knowledge, this is the first study to introduce a injury were not common (6-9% with each diagnosis) resulting in
quick method for shoulder disability rating of shoulder disorders in group-sizes of less than 26, which was the cut-point used for sample-size
specialist orthopaedic care, the Copenhagen Shoulder Abduction Rating justification. This increases the risk of type II errors for statistical com­
(C-SAR). When subgrouping patients with SIS or complete/full- parisons among these groups. Thirdly, the cut-off criteria for C-SAR
thickness RC-tear according to the C-SAR, the subgroups differed scores were not based on a data-driven approach, but rather on the
significantly in shoulder disability scores. Accordingly, having a Mild C- face-validity and time-efficiency of the method. While more advanced
SAR score was related to significantly and clinically relevant better criteria might be more sensitive in determining shoulder disability, this
scores in SPADI when compared to both a Medium and Severe C-SAR also comes with the risk that identified cut-offs are too specific to the
score, with medium to large ES and mean differences surpassing the 8 to sample, at the cost of generalizability. Further, our approach was
13 points MCID for SPADI (Paul et al., 2004; Angst et al., 2008). Dif­ assumed to best fit the aim of the study, namely to provide a quick
ferences between patients with Medium and Severe C-SAR scores were method to easily obtain information on shoulder disability. Importantly,
less pronounced; Severe C-SAR scores were related to significantly worse this study is the first to describe and test the C-SAR, and though our
SPADI-function scores when compared to Medium C-SAR scores (mean results show promising validity of the test, this needs further
diff. 9 points, ES 0.4, p = .017), but SPADI (6 points, ES 0.3, p = .085) investigation.
and SPADI-pain (2 points, ES 0.1, p = .536) did not differ. This indicates
that functional limitations are the main difference between patients with 5. Conclusion
Severe and Medium C-SAR scores, which is further supported by the
much lower abduction ROM in the patients with Severe C-SAR score We found that adhesive capsulitis is associated with the highest
(median ROM 62◦ [43; 75]) compared to patients with Medium C-SAR levels of shoulder disability, followed by SIS and complete/full-
score (median ROM 122◦ [104; 141]), while pain intensities were thickness RC-tears. We also found that the Copenhagen Shoulder
similar in the two groups (median Worst pain last week: 8 [7; 10] and 8 Abduction Rating (C-SAR) can be introduced in specialist orthopaedic
[7; 9], Table 2). Collectively, these findings demonstrate that relevant care as a quick method to obtain valid information on the level of
differences in shoulder disability exists even though pain ratings are shoulder disability in patients with SIS or complete/full-thickness RC-
similar. In contrast, the severity of shoulder disorders is sometimes tear. Future studies should investigate the relevance of stratified care
judged based on pain alone (Dunn et al., 2014), which is why relevant based on the C-SAR scores, as the same surgical and/or conservative
differences in disability might be overlooked. treatment modalities might not be relevant across subgroups with
Our results demonstrate that the level of disability differs to a high different levels of shoulder disability.
degree within the population of patients with SIS. However, the avail­
able guidelines (Danish Health Authority, 2016; Diercks et al., 2014; The Funding
Royal College of Surgeons of England, 2014; Vandvik et al., 2019) and
level-one evidence (Abdulla et al., 2015; Dong et al., 2015; Hanratty The study was funded by the Danish Ministry of Higher Education
et al., 2012; Hopewell et al., 2021; Beard et al., 2018; Paavola et al., and Science and Fysioterapipraksisfonden.
2018; Clausen et al., 2021) does not distinguish between patients based
on the level of disability, which is why the treatment of SIS is guided by Conflict of interest
the same evidence, irrespective of the level of shoulder disability. In
contrast, acknowledgement of the large variations in levels of shoulder All authors declare no financial or nonfinancial conflicts of interests.
disability within the SIS population will allow for the development of
relevant stratified care. To give an example; an intervention that de­ Author’s contribution
creases disability in patients with low disability (e.g. Mild C-SAR score:
pain during abduction ≤5) might not have the same effect in patients MBC contributed to conception and design of the study, analysis and
who are unable to abduct their arm above 90◦ (i.e. Severe C-SAR score), interpretation of data, and acquisition of data. AW contributed to
and vice versa. Hence, C-SAR might be a useful tool to guide stratified acquisition and analysis of data. KBC contributed to analysis and
care, but further studies are needed to assess its prescriptive validity and interpretation of data. MKZ contributed to conception and design of the
responsiveness to change. As an interesting observation, a subgroup of study, and interpretation of data. MF contributed to acquisition and
patients with SIS or complete/full-thickness RC tear had SPADI scores analysis of data. AC contributed to conception and design of the study.
similar to patients with adhesive capsulitis that indicated high levels of KT contributed to conception and design of the study and interpretation
disability (66 vs 66 points, p = .95) and this subgroup included 64 pa­ of data. PH contributed to conception and design of the study and
tients with Severe C-SAR. Thus, the number of patients with SIS or interpretation of data. All authors have contributed to the manuscript,
complete/full-thickness RC tear with Severe C-SAR was at least three have approved the final version and agree to be accountable for all as­
times greater than the number of patients with adhesive capsulitis with pects of the work in ensuring that questions related to the accuracy or
Severe C-SAR (n = 16), which is why it seems that a large proportion of integrity of any part of the work are appropriately investigated and
the patients with the highest level of shoulder disability are to be found resolved.
in the group of patients with SIS or complete/full-thickness RC-tear. This
indicate that an increased focus on improving care for this distinct
Acknowledgements
sub-group could have a substantial impact on the overall socio-economic
consequences of shoulder disorders.
The authors would like to thank all orthopaedic specialists and
There are certain limitations to the current study. Firstly, diagnoses
nurses at Sports Orthopaedic Research Center (SORC-C), Orthopaedic
were based on the overall clinical judgement with the aid of paraclinical
Department, Hvidovre Hospital, and Peter Andreas Rothe, Jens Lan­
investigations, rather than relying on specific pre-defined criteria,
germann and Kika Holm for assisting with the data collection.
possibly reducing the replicability of the results. However, considering
the limited accuracy of diagnostic tests for the shoulder (Hegedus et al.,
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