Shoulder PROMs in Athletes: Which Outcome Measures Actually Hold Up

Ask ten physiotherapists which shoulder outcome questionnaire they use and you will get ten different answers, and several of them will be using more than one at once without a clear reason why. The shoulder PROM space is crowded with condition-specific tools, generic upper-limb scales and hybrid instruments, most of them developed in populations that look nothing like the overhead athlete sitting in front of you. Before you pick one, it is worth knowing what the measurement properties evidence actually says, because a lot of what gets used in clinic has never been properly tested in athletic populations.

The problem with condition-specific shoulder questionnaires

Self-reported questionnaires dominate shoulder outcome tracking because they are quick and cheap to administer. But a systematic review of the psychometric properties of self-reported tools for rotator cuff disorders found substantial variability in how well these instruments have actually been validated, with responsiveness and minimal clinically important difference data missing or poorly reported for many of the questionnaires in routine use (St-Pierre et al., 2016). That matters clinically: if you cannot say with confidence what change on a scale represents a meaningful improvement, you cannot use it to justify a discharge decision or a change in programme.

The problem compounds in athletic populations. Condition-specific scales are built around activities of daily living and general upper-limb function, not the demands of throwing, serving or overhead lifting. A shoulder score that asks about combing your hair or reaching a high shelf tells you very little about whether a bowler can tolerate a full training load. Reviews of outcome measurement in other conditions with similarly heterogeneous trial evidence, such as adhesive capsulitis, show the same pattern: a wide spread of outcome tools used across studies, with limited consistency in what is actually being measured or how (Fares et al., 2023). When the evidence base itself cannot agree on a primary outcome, picking a questionnaire because it is familiar rather than because it is validated for your population is a weak starting point.

What the reliability evidence actually shows

Reliability is a separate question from validity, and shoulder assessment has a patchy record on both. A systematic review and meta-analysis of physical examination tests for shoulder pathology found that many of the special tests physiotherapists rely on for diagnosis have inconsistent inter-rater reliability, with agreement varying widely between studies and settings (Lange et al., 2017). If the clinical tests feeding into your assessment are not reliably reproduced between clinicians, any outcome measure built on top of that assessment inherits the same uncertainty.

This is not an argument against structured shoulder testing. It is an argument for choosing measures with demonstrated reliability and for standardising how they are collected. Remote and technology-assisted assessment methods have shown promise here: a meta-analysis of remote shoulder motion capture methods found accuracy comparable to in-person goniometry for several measurement approaches (Chen et al., 2026), and a broader review of telehealth-delivered physiotherapy assessment found acceptable reliability across a range of outcome domains when protocols were standardised (Zischke et al., 2021). The common thread is standardisation, not the specific tool. A consistent protocol, applied the same way every time, produces more trustworthy data than a well-regarded questionnaire applied inconsistently.

Performance-based tests: a different measurement problem

Self-report and performance-based testing measure different things, and athletes need both. A systematic review and meta-analysis of performance-based functional tests in shoulder pathology found that while several tests demonstrated acceptable reliability, evidence for validity and responsiveness was far less consistent, and many tests had only been studied in small, non-athletic samples (Nazari et al., 2020). That is a meaningful gap for a sports physiotherapist trying to clear an athlete for return to overhead activity using a test that was validated in a population of desk workers with shoulder pain.

The strongest evidence for performance-based testing in this space comes from return-to-sport batteries built specifically around athletic demands. A reliability study of a shoulder and arm return-to-sport test battery reported good to excellent reliability across its component tests, which matters because a battery you cannot reproduce session to session is not a battery you can use to track progress or clear an athlete with any confidence (Olds et al., 2019). This is the standard other shoulder tests should be held to: not just face validity for an athletic population, but demonstrated test-retest reliability in one.

Qualitative movement assessment sits at the weaker end of this evidence base. A systematic review of methods for assessing scapular dyskinesis in asymptomatic subjects found poor to moderate reliability across visual observation methods, with substantial disagreement between raters even among trained clinicians (Paraskevopoulos et al., 2020). Visual movement assessment has intuitive appeal, but if two experienced physiotherapists watching the same movement cannot agree on what they saw, it has no place as a measure you build treatment decisions or discharge criteria around. Where reliability is unproven, treat the finding as a talking point, not a data point.

Why patient-specific measurement fits athletes better

The alternative to hunting for the perfect condition-specific questionnaire is to stop assuming one instrument fits every athlete's presentation. A patient-specific approach, where the athlete identifies their own limiting activities and rates them directly, sidesteps the mismatch between generic item banks and sport-specific demand. It also solves the responsiveness problem that condition-specific scales struggle with: you are tracking change in the activities that actually matter to that individual, not an average across items that may be irrelevant to them.

This is why Benchmark uses the Patient-Specific Functional Scale rather than a fixed shoulder questionnaire. It captures what the athlete cannot yet do, rated on a 0–10 scale, and tracks it longitudinally alongside a minimal clinically important difference and expected rate of change so you know whether progress is on track. Pair that with the three-dimensional pain score, the mean of pain frequency, intensity and duration, and you have a self-report picture that is specific to the individual but still standardised enough to compare against normative expectations and track over a rehab programme.

Building a measurement protocol that holds up

None of this means abandoning objective physical testing. It means pairing patient-specific self-report with performance measures that have actual reliability data behind them, and being honest about which of your current tests do not. In practice that looks like:

• Use patient-specific over condition-specific for self-report. Track the athlete's own limiting activities rather than forcing their presentation into a fixed item set.
• Standardise the protocol, not just the tool. Positioning, instructions and timing affect reliability as much as the instrument itself, whether you are measuring range of movement, endurance or strength.
• Compare strength against normative data, not last visit alone. Handheld dynamometer results benchmarked against peer-reviewed normatives, or gym-based lifts compared against Strengthlevel data, give you a percentage of expected score matched to age, sex and weight, rather than a number with no reference point.
• Treat unproven qualitative assessment as descriptive, not diagnostic. Movement observation can inform your clinical reasoning conversation but should not carry the same weight as a measure with demonstrated reliability.
• Track everything longitudinally. A single time point, however well measured, cannot tell you whether an athlete is progressing at the expected rate.

The Philadelphia Panel guidelines on shoulder rehabilitation interventions, now over two decades old, made the same underlying point that still holds: treatment decisions should rest on evidence-graded interventions and consistent outcome tracking, not habit (Philadelphia, 2001). What has changed since then is how much easier standardised measurement has become to deliver in a normal appointment slot.

Where this leaves your assessment

The honest answer to which shoulder PROM holds up is that most of the widely used ones have thinner evidence than their popularity suggests, and almost none were built with athletic demand in mind. Rather than searching for a single validated scale that solves this, combine a patient-specific self-report measure with performance tests that have documented reliability, and be deliberate about which findings feed into clinical decisions versus which ones are just useful conversation.

If you want to see how patient-specific PROM tracking and normative strength comparison work together in a standard appointment slot, Benchmark PS is built to run both without added clinic time or extra equipment. Book a walkthrough to see it against your current shoulder caseload.

References

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2. Fares MY, Koa J, Abboud JA. Assessment of therapeutic clinical trials for adhesive capsulitis of the shoulder. JSES international. 2023;7(3):412-419. PubMed
3. Lange T, Matthijs O, Jain NB et al. Reliability of specific physical examination tests for the diagnosis of shoulder pathologies: a systematic review and meta-analysis. British journal of sports medicine. 2017;51(6):511-518. PubMed
4. Chen P, Prosser M, Phillips B et al. Accuracy and reliability of remote shoulder motion capturing methods: a systematic review and meta-analysis. Journal of shoulder and elbow surgery. 2026;35(6):1570-1586. PubMed
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9. Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain. Physical therapy. 2001;81(10):1719-30. PubMed