ASES scores not predictive of level of return to play

Many elite overhead athletes can’t compete at their previous level of play after a superior labral anterior posterior (SLAP) tear, said Kevin C. Owsley, MD.

“Despite achieving good American Shoulder and Elbow Surgeons (ASES) scores, only 57 percent of elite overhead athletes in our study returned to their pre-injury level of competition at a mean of 3 years after isolated type II SLAP repair,” Dr. Owsley told members of the American Orthopaedic Society for Sports Medicine.

Concomitant partial-thickness rotator cuff tears, he asserted, likely played a large role in keeping the athletes from performing at their peak.

Evaluating athletes
Researchers reviewed their clinic’s database between June 2003 and April 2007 and recruited 39 patients who were elite collegiate or professional overhead athletes. These patients had a minimum of 1 year of clinical follow-up after undergoing an isolated arthroscopic suture anchor repair of a type II SLAP lesion.

Researchers were able to contact 23 of the 39 patients (Table 1) at a mean follow-up of 38 months (range, 12–70 months). Twenty patients underwent clinical assessment and physical examination, while three patients were only available for telephone follow-up.

All the athletes answered questionnaires designed to evaluate their ability to perform everyday activities (ASES score) and to assess their level of play and functional performance (Kerlan-Jobe Orthopaedic Clinic [KJOC] Shoulder and Elbow score). (See sidebar below for more information about the ASES and KJOC scoring systems.)

“We assessed range of motion by using hand-held goniometers and by measuring forward elevation in the scapular plane and internal and external rotation at 90 degrees abduction,” said Dr. Owsley.

Researchers compared the ASES and KJOC scores to those obtained from a cohort of healthy, athletic, sport-matched individuals and investigated the relationship between ASES and KJOC scores.

Rotator cuff tears hold some patients back
Of the 23 patients, 13 had returned to their preinjury level of competition at final follow-up. The mean time of full return to sport was 8.8 months (range, 4–16 months).

“We found that at a mean of 3 years after isolated SLAP repairs, 57 percent of elite overhead athletes had returned to their preinjury level of competition,” said Dr. Owsley. “An additional 26 percent of patients had returned to their sport, but were limited by pain. The remaining 17 percent were still unable to return to sport, which may be due, in part, to the higher demand elite overhead athletes place on their shoulders compared to the general population.”

Researchers identified partial-thickness rotator cuff tears (Fig. 1) as concomitant pathology in 8 of the 23 patients and found a significant correlation between the presence of such tears with the inability to return to preinjury level of competition (p=0.0059).

“Only 12.5 percent of patients with concomitant tears were able to return to prior levels of play, compared to 80 percent of those without tears,” said Dr. Owsley.

Although all but one of the 23 patients had good-to-excellent ASES scores, the KJOC scores painted a different picture. According to the KJOC scale, only 9 patients had excellent scores, while 3 had good results, 4 had fair results, and 7 had poor results. This difference, noted Dr. Owsley, is statistically translated into lower accuracy for the ASES score (70 percent) compared to the KJOC score (85 percent).

“The correlation between the KJOC and ASES scores was statistically significant (correlation=0.62, p=0.0022) and the relationship was intrinsically linear,” stated Dr. Owsley. “Specifically, for a one-unit decrease in KJOC score, the ASES score decreased on average by only 0.21 units and was therefore less sensitive to changes in performance.”

The ASES score, noted Dr. Owsley, cannot detect the presence of associated rotator cuff tears or their negative correlation with return to play.

“Our findings confirm that the ASES scoring system is less accurate in detecting subtle changes in the performance of high-level overhead athletes and predicting level of return to play than the KJOC scoring system,” concluded Dr. Owsley.

Brian R. Neri, MD, was the lead author of “Outcome of type II SLAP repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears.” Coauthors included Dr. Owsley, Karen J. Mohr, PT; Neal S. ElAttrache, MD, and Lewis A. Yocum, MD. Drs. Neri and Owsley report no conflicts of interest. Disclosure information for coauthors is in the online version of this article, at www.aaosnow.org

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

More about ASES and KJOC scores
The ASES scoring system assesses a patient’s ability to perform everyday activities such as reaching a high shelf. Patients rate their ability to perform tasks according to the following scale: 0=unable, 1=with great difficulty, 2=with little difficulty, 3=able.

The KJOC Shoulder and Elbow scoring system evaluates the performance of elite overhead athletes. Patients use the following scale: 1=playing pain-free; 2=playing with pain; 3=not playing due to pain. Patients also respond to 10 questions that require them to rate their functional performance on a scale of 1 to 10, with higher scores indicating better function.