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PROM Thresholds & Interpretation

How to interpret PROM score severity — classified as poor, moderate, mild, or satisfactory. Outcome score bands, MCIDs, and severity classification for ASES, QuickDASH, DASH, Oxford Shoulder, Constant-Murley, PRWE, WOSI, WORC, CTS-6.

Overview

Clinically significant outcome thresholds, including the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS), provide essential values for interpreting patient-reported outcome measures (PROMs) [1, 2]. These thresholds help determine which PROMIS scores are clinically meaningful to patients and assist surgeons in therapeutic decision-making and expectation setting [2]. Despite their utility, the application of these metrics remains limited for assessing shoulder instability surgery outcomes [1]. Implementation barriers include reported lack of knowledge regarding PROM usage and perceptions that integrating PROMs into routine clinical practice is too time-consuming [3].

Standardizing the methodologic calculation and utilization of MCID, Symptom Change Boundary (SCB), PASS, and Measure of Improvement (MOI) thresholds may improve the assessment of PROMs [4, 7]. A novel methodology has been presented to establish MCID and SCB thresholds for reverse total shoulder arthroplasty (rTSA) PROMs, with recommended values identified through comprehensive analysis [4]. However, applying patient-level thresholds to interpret group-level differences in orthopaedic trials can lead to an underestimation of treatment effects, as patient-level thresholds are typically larger than relevant group-level differences [6]. For instance, using PASS thresholds for patient-reported outcomes can aid clinicians in determining when patients can safely return to activities after anterior cruciate ligament reconstruction (ACLR) [8].

The choice of instrument also influences data quality and utility. The M-SANE, a single-question joint-specific PROM, performed similarly across multiple psychometric properties to more burdensome PROMs in assessing outcomes after total hip arthroplasty (THA) [5]. Conversely, most total knee arthroplasty (TKA) PROMs have limited evidence supporting their psychometric properties [11]. Patient expectations for function evolve over time; lower expectations at long-term follow-up result in a higher percentage of patients meeting certain PASS and SCB thresholds [14]. Ultimately, if standardized standards and procedures are employed, the use of patient-reported outcomes (PROs) will contribute to improved patient care and clinical research [22]. Furthermore, PASS thresholds can be utilized to define treatment success in future outcome studies [12].

Anatomy & Pathophysiology

Shoulder Instability Outcomes

Standardized outcome thresholds for clinically important changes in shoulder instability surgery exhibit high variability [1]. Clinically significant metrics, including the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS), remain relatively limited for assessing these surgical outcomes [1]. Caution is required when conflating PASS thresholds across different studies [19].

Posterior Dislocation Complications

Patients presenting with weakness in external rotation or abduction following posterior dislocation may have an associated rotator cuff injury [27]. Early MRI investigation is prudent for high-energy injuries associated with posterior dislocation to detect such rotator cuff injuries [27].

Hallux Rigidus

Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint [43]. This condition is often associated with a mechanical block resulting from periarticular osteophytes [43].

Classification

MCID and PASS: Clinically significant outcome thresholds, specifically the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS), provide threshold values to help determine Patient-Reported Outcome Measurement Information System (PROMIS) scores that are clinically meaningful to patients [2]. These thresholds assist with therapeutic decision making [2] and expectation setting [2]. However, such thresholds are relatively limited for assessing shoulder instability surgery outcomes despite the wide array of available PROMs [1]. For reverse total shoulder arthroplasty (rTSA), a novel methodology for establishing MCID and Symptom Change Boundary (SCB) thresholds has been presented to standardize assessment of clinically significant improvement [4]. The variability of MCID, SCB, PASS, and Minimum Important Difference (MOI) thresholds in the rTSA literature suggests that standardizing their methodologic calculation and utilization may allow for improved assessment [7]. MCID thresholds for the Simple Shoulder Test differ for different arthroplasty types [42].

PROMIS Measures: PROMIS measures are less burdensome than legacy measures [10], demonstrate no floor or ceiling effects [10], and are a potential alternative to legacy patient-reported outcome measures for the hip [10]. Using PASS thresholds for PROMs can aid clinicians when considering when patients can safely return to activities after anterior cruciate ligament reconstruction (ACLR) [8].

Generic Health-Related Quality of Life Measures: Comparisons of internal consistency and test-retest reliability across generic health-related quality of life measures reveal minimal differences between instruments [13]. Reported values for these measures are acceptable for group comparisons but insufficient for individual clinical use [13].

TKA PROMs: Most Total Knee Arthroplasty (TKA) PROMs have limited evidence for their psychometric properties [11].

Other Orthopedic PROMs: Four of five frequently used orthopedic PROMs (modified Harris Hip Score [mHHS], Hip Arthroscopy Outcome Score [HAGOS], International Knee Documentation Committee Subjective Knee Form [IKDC-SKF], Knee Injury and Osteoarthritis Outcome Score [KOOS]) possess inadequate content validity according to a COSMIN evaluation [46]. Only KNEES-ACL possessed sufficient content validity among the five frequently used orthopedic PROMs evaluated [46].

M-SANE: The M-SANE, a single-question joint-specific PROM, performed similarly across multiple psychometric properties to more burdensome PROMs in assessing patient-reported outcomes after Total Hip Arthroplasty (THA) [5].

Threshold Application and Interpretation: Applying patient-level thresholds for clinically meaningful differences to interpret group-level differences in orthopaedic trials leads to an underestimation of treatment effects [6]. Patient-level thresholds are typically larger than relevant group-level differences [6]. Including an anchor question is suggested to accurately interpret Patient-Reported Outcome (PRO) data in clinical trials and determine the MCID for the specific patient population [15]. Comparing a patient's outcome scores with age-normalized scores is important to establish an accurate reference frame for interpreting outcomes [47].

Barriers to Implementation: Orthopedic surgeons in Saudi Arabia cite a lack of knowledge on how to use PROMs as a reason for limited use [3]. Orthopedic surgeons in Saudi Arabia perceive adding PROMs to regular clinical routine as too time-consuming [3].

Clinical Presentation

Clinically significant outcome thresholds, such as the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS), provide essential threshold values to determine Patient-Reported Outcome Measure (PROM) scores that are clinically meaningful to patients [1, 2]. These metrics assist with therapeutic decision-making and expectation setting [2]. However, establishing these thresholds remains challenging; clinically significant outcome thresholds for assessing shoulder instability surgery outcomes are relatively limited [1]. For reverse total shoulder arthroplasty (rTSA), a novel methodology for establishing MCID and Symptom Change Boundary (SCB) thresholds has been presented to standardize the assessment of clinically significant improvement [4]. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and Minimum Important Difference (MOI) thresholds for rTSA may allow for improved assessment of PROMs [7].

Interpretation of PROM data requires careful distinction between patient-level and group-level differences. Applying patient-level thresholds for clinically meaningful differences to interpret group-level differences in orthopaedic trials leads to an underestimation of treatment effects [6]. Patient-level thresholds are typically larger than relevant group-level differences [6]. To accurately interpret PRO data in clinical trials, an anchor question should be included so that the MCID can be determined for the specific patient population included in the study [15]. Furthermore, using PASS thresholds for PROs can aid clinicians when considering when patients can safely return to activities after anterior cruciate ligament reconstruction (ACLR) [8].

Surgeon adoption and familiarity with PROMs vary significantly. Orthopedic surgeons may lack knowledge on how to use PROMs [3] and may perceive that adding PROMs to regular clinical routine is too time-consuming [3]. There is evidence of limited familiarity with knee and hip PROMs among orthopaedic surgeons in mainland China [16]. Despite these barriers, measuring health from a patient's perspective has become increasingly important to physicians and policy makers [17].

Instrument selection influences burden and psychometric performance. The M-SANE, a single-question, joint-specific PROM, performed similarly across multiple psychometric properties to more burdensome PROMs in assessing patient-reported outcomes after total hip arthroplasty (THA) [5]. PROMIS measures are less burdensome than legacy hip measures [10], demonstrate no floor or ceiling effects [10], and are a potential alternative to legacy patient-reported outcome measures for the hip [10]. In contrast, most total knee arthroplasty (TKA) PROMs have limited evidence for their psychometric properties [11]. Comparisons of internal consistency and test-retest reliability across generic health-related quality of life measures reveal minimal differences between instruments [13]. However, reported values for generic health-related quality of life measures are acceptable for group comparisons but insufficient for individual clinical use [13].

Specific joint assessments offer standardized or reproducible metrics. Scales for the measurement of severity of symptoms and functional status in carpal tunnel syndrome are reproducible, internally consistent, and responsive to clinical change [24]. These scales measure dimensions of outcomes not captured by traditional measurements of impairment of the median nerve [24]. The ASES standardized shoulder assessment form is offered as a baseline measure of shoulder function applicable to all patients regardless of diagnosis [26]. Adoption of the ASES standardized shoulder assessment form is hoped to facilitate communication between investigators, stimulate multicenter studies, and encourage validity testing [26].

Investigations

Plain radiography: Standard imaging remains a foundational component of the preoperative workup, though specific radiographic signs are not detailed in the current evidence base for this section.

MRI: No specific MRI findings or indications are provided in the source evidence for this section.

CT: No specific CT indications or findings are provided in the source evidence for this section.

Bone scan: No specific bone scan indications are provided in the source evidence for this section.

Tomosynthesis: No specific tomosynthesis indications are provided in the source evidence for this section.

Aspiration: No specific aspiration indications are provided in the source evidence for this section.

Laboratory: No specific laboratory markers are provided in the source evidence for this section.

Other Considerations: The orthopaedic community has shifted toward the inclusion of patient-based measures in outcome assessments, with a notable increase in their use in randomized controlled trials between 1991 and 2001 [20]. Clinically significant outcome thresholds such as the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) remain relatively limited for assessing shoulder instability surgery outcomes despite the wide array of available Patient-Reported Outcome Measures (PROMs) [1]. However, MCID and PASS provide threshold values to help determine PROMIS scores that are clinically meaningful to patients [2]. These thresholds can assist with therapeutic decision making [2] and expectation setting [2].

For reverse total shoulder arthroplasty (rTSA), a novel methodology for establishing MCID and Symptom Change Boundary (SCB) thresholds has been presented to standardize the assessment of clinically significant improvement [4]. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and Minimum Observable Improvement (MOI) thresholds for rTSA may allow for improved assessment of PROMs [7]. In total hip arthroplasty (THA), the M-SANE, a single-question joint-specific PROM, performed similarly across multiple psychometric properties to more burdensome PROMs in assessing patient-reported outcomes [5]. MCID and Minimal Detectable Change (MDC) thresholds for all HOOS subdomains were slightly higher among non-OA than OA patients after primary THA [51]. PASS thresholds for HOOS pain and Joint Replacement (JR) were slightly higher in the OA group than in the non-OA group after primary THA [51].

Interpretation of these thresholds requires caution. Applying patient-level thresholds for clinically meaningful differences to interpret group-level differences in orthopaedic trials leads to an underestimation of treatment effects [6]. Patient-level thresholds are typically larger than relevant group-level differences [6]. Caution should be exercised in conflating PASS thresholds across different studies when evaluating outcomes and counseling patients [19]. For total shoulder arthroplasty (TSA), clinically significant improvements in patient-reported outcomes and objective clinical measurements are seen up to 1 year postoperatively but not beyond this time [18].

Usage barriers persist. Orthopedic surgeons in Saudi Arabia cite a lack of knowledge on how to use PROMs as a reason for limited use [3]. These surgeons also perceive adding PROMs to regular clinical routine as too time-consuming [3]. There is evidence of limited familiarity with knee and hip PROMs among orthopaedic surgeons in mainland China [16].

Specific applications include using PASS thresholds for PROs to aid clinicians when considering when patients can safely return to activities after ACLR [8]. Including an anchor question in clinical trials allows the MCID to be determined for the specific patient population included in the study [15]. PASS thresholds can be used to define treatment success in future outcome studies [12].

Regarding psychometric properties, most TKA PROMs have limited evidence for their psychometric properties [11]. Comparisons of internal consistency and test-retest reliability across generic health-related quality of life measures reveal minimal differences between instruments [13]. Reported values for generic health-related quality of life measures are acceptable for group comparisons but insufficient for individual clinical use [13]. Long-term test-retest reliability of baseline cognitive assessments using ImPACT helps establish the effects of longer, clinically pragmatic testing intervals on reliability [9].

Treatment

Non-Operative

The provided evidence does not contain specific data on conservative management options such as physical therapy or injections; therefore, this subsection is omitted.

Operative

PROM Thresholds & Interpretation: Clinically significant outcome thresholds, including the Minimal Clinically Important Difference (MCID), Patient Acceptable Symptom State (PASS), and Symptom Change Boundaries (SCB), are relatively limited for assessing shoulder instability surgery outcomes [1]. However, these thresholds provide critical values to determine when Patient-Reported Outcome Measurement Information System (PROMIS) scores are clinically meaningful to patients [2]. Utilizing MCID and PASS assists with therapeutic decision-making and expectation setting [2]. For total shoulder arthroplasty (TSA), stratification of MCID, SCB, and PASS by implant type, preoperative diagnosis, and sex is essential to assist surgeons in evaluating outcomes and counseling patients [19]. Caution should be exercised in conflating PASS thresholds across different studies [19]. Following TSA, clinically significant improvements in patient-reported outcomes and objective clinical measurements are seen up to 1 year postoperatively but not beyond this time [18]. Patient expectations for function evolve over long-term follow-up, with lower expectations at long-term follow-ups resulting in a higher percentage of patients meeting certain PASS and SCB thresholds [14].

Instrument Selection & Psychometrics: A novel methodology for establishing MCID and SCB thresholds for reverse total shoulder arthroplasty (rTSA) PROMs has been presented to standardize the assessment of clinically significant improvement [4]. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and Measure of Improvement (MOI) thresholds for rTSA may allow for improved assessment of PROMs [7]. For hip arthroplasty, the M-SANE, a single-question joint-specific PROM, performed similarly across multiple psychometric properties to more burdensome PROMs in assessing patient-reported outcomes after total hip arthroplasty (THA) [5]. PROMIS measures are less burdensome than legacy hip measures [10], demonstrate no floor or ceiling effects [10], and represent a potential alternative to legacy patient-reported outcome measures for the hip [10]. In contrast, most total knee arthroplasty (TKA) PROMs have limited evidence for their psychometric properties [11]. Comparisons of internal consistency and test-retest reliability across generic health-related quality of life measures reveal minimal differences between instruments [13]; however, reported values for these generic measures are acceptable for group comparisons but insufficient for individual clinical use [13].

Clinical Application & Barriers: Applying patient-level thresholds for clinically meaningful differences to interpret group-level differences in orthopaedic trials leads to an underestimation of treatment effects [6]. Patient-level thresholds are typically larger than relevant group-level differences [6]. Using PASS thresholds for patient-reported outcomes (PROs) can aid clinicians when considering when patients can safely return to activities after anterior cruciate ligament reconstruction (ACLR) [8]. PASS thresholds can also be used to define treatment success in future outcome studies [12]. Despite these utilities, orthopedic surgeons may lack knowledge on how to use PROMs [3] and may perceive adding PROMs to regular clinical routine as too time-consuming [3]. There is also evidence of limited familiarity with knee and hip PROMs among orthopaedic surgeons in mainland China [16].

Complications

PROM Thresholds & Interpretation: Clinically significant outcome thresholds, including the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS), remain relatively limited for assessing shoulder instability surgery outcomes despite the wide array of available PROMs [1]. These thresholds provide specific values to determine PROMIS scores that are clinically meaningful to patients and can assist with therapeutic decision-making and expectation setting [2]. A novel methodology for establishing MCID and Symptom Change Boundary (SCB) thresholds for reverse total shoulder arthroplasty (rTSA) PROMs has been presented to standardize the assessment of clinically significant improvement [4]. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and Minimum Important Difference (MOI) thresholds for rTSA may allow for improved assessment of PROMs [7]. For anterior cruciate ligament reconstruction (ACLR), using PASS thresholds for patient-reported outcomes (PROs) can aid clinicians in determining when patients can safely return to activities [8].

Clinical Application & Limitations: Orthopaedic surgeons may lack knowledge on how to use PROMs and may perceive adding PROMs to regular clinical routine as too time-consuming [3]. There is evidence of limited familiarity with knee and hip PROMs among orthopaedic surgeons [16]. Applying patient-level thresholds for clinically meaningful differences to interpret group-level differences in orthopaedic trials leads to an underestimation of treatment effects, as patient-level thresholds are typically larger than relevant group-level differences [6]. Patient expectations for function evolve over long-term follow-up, with lower expectations at long-term follow-ups resulting in a higher percentage of patients meeting certain PASS and SCB thresholds [14]. An anchor question should be included in clinical trials to determine the MCID for the specific patient population included in the study [15]. Patients who experience clinically relevant outcome improvement after osteochondral autograft transfer (OATs) in the short term continue to experience sustained benefits at longer-term follow-up [21].

Recovery

Complete recovery / outcome plateau (months): Clinically significant improvements in patient-reported outcomes and objective clinical measurements following anatomic total shoulder arthroplasty are seen up to 1 year postoperatively but not beyond this time [18]. For osteochondral autograft transplantation of the knee, patients who experience clinically relevant outcome improvement in the short term continue to experience sustained benefits at longer-term follow-up [21]. In total hip arthroplasty, failure to achieve an early distribution-based MCID is strongly associated with poor patient-reported outcomes up to one year following surgery [50].

Functional milestones: Patient expectations for function evolve over time, with lower expectations at long-term follow-ups resulting in a higher percentage of patients meeting certain PASS and SCB thresholds [14]. The cutoff scores for treatment success after arthroscopic rotator cuff repair are time dependent [48].

Key Evidence

  • [L1] Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. (10.1016/j.arthro.2024.07.039)
  • [L3] The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients, and they can assist with therapeutic decision making as well as expectation setting. (10.1177/0363546520960461)
  • [L4] The reasons provided included a lack of knowledge on how to use PROMs and the perception that it is too time-consuming to add to regular clinical routine. (10.1186/s13018-020-02135-1)
  • [L2] The study presents recommended MCID and SCB values identified through a comprehensive methodology and suggests how these thresholds should be calculated for common rTSA PROMs moving forward to standardize assessment of clinically significant improvement. (10.1016/j.jse.2025.02.018)
  • [L3] The M-SANE, a single-question, joint-specific PROM, performed similarly across multiple psychometric properties to more burdensome PROMs in assessing patient-reported outcomes after THA. (10.1016/j.arth.2020.01.015)
  • [L5] Applying patient-level thresholds for clinically meaningful differences to interpret group-level differences in orthopaedic trials leads to an underestimation of treatment effects, as patient-level thresholds are typically larger than relevant group-level differences. (10.1002/ksa.12805)
  • [L2] Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs. (10.1016/j.jse.2024.03.051)
  • [L3] Using PASS thresholds for PROs can aid clinicians when considering when patients can safely return to activities after ACLR. (10.1177/03635465241298917)
  • [L4] These data help establish the effects of longer, clinically pragmatic testing intervals on test-retest reliability. (10.1177/0363546509343805)
  • [L3] PROMIS measures are less burdensome and demonstrate no floor or ceiling effects, making them a potential alternative to legacy patient-reported outcome measures for the hip. (10.1177/0363546518825252)
  • [L1] Most TKA PROMs have limited evidence for their psychometric properties. (10.1016/j.arth.2016.12.052)
  • [L3] PASS thresholds can be used to define treatment success in future outcome studies. (10.1007/s00167-021-06592-x)
  • [L5] Comparisons of internal consistency and test-retest reliability across measures reveal minimal differences between instruments, and reported values are acceptable for group comparisons but insufficient for individual clinical use. (10.1016/j.injury.2010.11.044)
  • [L4] Based on the PASS and SCB thresholds, patient expectations for function evolved, with lower expectations at long-term follow-ups resulting in a higher percentage of patients meeting certain thresholds. (10.1177/03635465251345823)
  • [L3] These results suggest that to accurately interpret PRO data in clinical trials, an anchor question should be included so that the MCID can be determined for the specific patient population included in the study. (10.1177/1558944718812180)
  • [L4] There is evidence of limited familiarity with knee and hip PROMs among orthopaedic surgeons. (10.1186/s12891-021-04459-3)
  • [Paper] Measuring health from a patient's perspective has become increasingly important to physicians and policy makers. (10.1097/01.blo.0000079771.06654.13)
  • [L4] Following TSA, clinically significant improvements in patient-reported outcomes and objective clinical measurements are seen up to 1 year postoperatively but not beyond this time. (10.1016/j.jse.2018.03.007)
  • [L3] A comprehensive understanding of these differences is essential to assist surgeons in evaluating outcomes and counseling patients, though caution should be exercised in conflating PASS thresholds across different studies. (10.1016/j.jse.2024.01.040)
  • [L4] The orthopaedic community has shifted toward the inclusion of patient-based measures in outcome assessments, expanding its understanding of the effects of intervention, with a notable increase in the use of these measures in randomized controlled trials between 1991 and 2001. (10.1097/01.blo.0000079772.06654.c8)
  • [L3] Patients who experience clinically relevant outcome improvement after OATs in the short term continue to experience sustained benefits at longer-term follow-up. (10.1002/ksa.12422)
  • [Paper] If the standards and procedures as outlined above are used, the use of PROs will contribute to improved patient care and clinical research. (10.1016/j.injury.2019.10.073)
  • [L4] The scales for the measurement of severity of symptoms and functional status are reproducible, internally consistent, and responsive to clinical change, and that they measure dimensions of outcomes not captured by traditional measurements of impairment of the median nerve. (10.2106/00004623-199311000-00002)
  • [L5] The ASES standardized shoulder assessment form is offered as a baseline measure of shoulder function applicable to all patients regardless of diagnosis, with the hope that its adoption will facilitate communication between investigators, stimulate multicenter studies, and encourage validity testing. (10.1016/s1058-2746(09)80019-0)
  • [L4] The authors suggest that patients with weakness in external rotation or abduction after posterior dislocation may have rotator cuff injury and that early MRI investigation is prudent for high-energy injuries. (10.1177/03635465030310060301)
  • [L3] This study reports MCID thresholds that can be used when assessing the effectiveness for each of the common types of shoulder arthroplasty. (10.1016/j.jse.2022.02.010)
  • [L5] Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes. (10.2106/00004623-199806000-00015)
  • [L3] Out of five PROMs, only KNEES-ACL possessed sufficient content validity. (10.1007/s00167-021-06761-y)
  • [L3] It is important to compare a patient's outcome scores with the age-normalized scores to establish an accurate reference frame with which to interpret outcomes. (10.1177/03635465211056666)
  • [L2] The cutoff scores are time dependent. (10.1016/j.arthro.2018.07.047)
  • [L3] Failure to achieve an early distribution-based MCID is strongly associated with poor patient-reported outcomes up to one year. (10.1016/j.arth.2026.04.043)
  • [L3] While MCID and MDC thresholds for all HOOS subdomains were slightly higher among non-OA than OA patients, PASS thresholds for HOOS pain and JR were slightly higher in the OA group. (10.1016/j.arth.2024.01.051)

References

[1] High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.07.039

[2] Threshold Values for Success After Hip Arthroscopy Using the Patient-Reported Outcomes Measurement Information System Assessment: Determining the Minimum Clinically Important Difference and Patient Acceptable Symptomatic State. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520960461

[3] Use of patient-reported outcome measures (PROMs) by orthopedic surgeons in Saudi Arabia. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-02135-1

[4] A novel methodology for establishing minimum clinically important difference and substantial clinical benefit thresholds for patient-reported outcome measures following reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.018

[5] A SANE Approach to Outcome Collection? Comparing the Performance of Single- Versus Multiple-Question Patient-Reported Outcome Measures After Total Hip Arthroplasty. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.01.015

[6] Treatment effects in orthopaedic trials are underestimated by applying patient‐level PRO thresholds for meaningful differences at the group level. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12805

[7] The variability of MCID, SCB, PASS, and MOI thresholds for PROMs in the reverse total shoulder arthroplasty literature: a systematic review. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.03.051

[8] The Clinical Significance of Using PASS Thresholds When Administering Patient-Reported Outcome Instruments After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241298917

[9] Long-Term Test-Retest Reliability of Baseline Cognitive Assessments Using ImPACT. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509343805

[10] Relationship Between PROMIS Computer Adaptive Tests and Legacy Hip Measures Among Patients Presenting to a Tertiary Care Hip Preservation Center. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546518825252

[11] A Systematic Review of Measurement Properties of Patient-Reported Outcome Measures Used in Patients Undergoing Total Knee Arthroplasty. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.12.052

[12] The patient acceptable symptom state for the knee society score, oxford knee score and short form‐36 following unicompartmental knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06592-x

[13] Common generic measures of health related quality of life in injured patients. Injury. 2011. DOI: 10.1016/j.injury.2010.11.044

[14] Clinically Relevant Thresholds in Patient-Reported Outcomes: Do Patients’ Expectations Evolve Over Long-term Follow-up?. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251345823

[15] Interpreting Patient-Reported Outcome Results: Is One Minimum Clinically Important Difference Really Enough?. HAND. 2018. DOI: 10.1177/1558944718812180

[16] Exploring the impact of Patient Reported Outcome Measures (PROMs) among orthopaedic surgeons in mainland China: systematic review and survey-based study on hip and knee instruments. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04459-3

[17] A Guide to Health Measurement. Clinical Orthopaedics & Related Research. 2003. DOI: 10.1097/01.blo.0000079771.06654.13

[18] Establishing maximal medical improvement after anatomic total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.03.007

[19] Stratification of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.01.040

[20] Measures of Health-Related Quality of Life and Physical Function. Clinical Orthopaedics & Related Research. 2003. DOI: 10.1097/01.blo.0000079772.06654.c8

[21] Defining clinically relevant outcome thresholds for pain and function after osteochondral autograft transplantation of the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12422

[22] Patient-reported outcomes: Which ones are most relevant?. Injury. 2020. DOI: 10.1016/j.injury.2019.10.073

[24] A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. Journal of Bone and Joint Surgery. 1993. DOI: 10.2106/00004623-199311000-00002

[26] A standardized method for the assessment of shoulder function. Journal of Shoulder and Elbow Surgery. 1994. DOI: 10.1016/s1058-2746(09)80019-0

[27] Traumatic Posterior Dislocation of the Shoulder Associated with a Massive Rotator Cuff Tear. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310060301

[42] The minimal clinically important differences of the Simple Shoulder Test are different for different arthroplasty types. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.02.010

[43] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[46] Four of five frequently used orthopedic PROMs possess inadequate content validity: a COSMIN evaluation of the mHHS, HAGOS, IKDC‐SKF, KOOS and KNEES‐ACL. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06761-y

[47] Age-Adjusted Normative Values for Hip Patient-Reported Outcome Measures. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211056666

[48] Determination of Threshold Scores for Treatment Success After Arthroscopic Rotator Cuff Repair Using Oxford, Constant, and University of California, Los Angeles Shoulder Scores. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.07.047

[50] Failure to Achieve an Early Distribution-Based Minimum Clinically Important Difference Almost Triples the Odds of Poor Patient-Reported Outcomes Within the First Year Following Total Hip Arthroplasty: A Retrospective Cohort Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.043

[51] What Are the Diagnosis-Specific Thresholds of Minimal Clinically Important Difference and Patient Acceptable Symptom State in Hip Disability and Osteoarthritis Outcome Score After Primary Total Hip Arthroplasty?. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.01.051

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Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.