The relationship between musculoskeletal health literacy and upper extremity patient-reported outcome measures (PROMs) in the setting of atraumatic shoulder pain

Konrad Gruson, Shady Mahmoud, Nina Zhu, Yungtai Lo, Hiroko T. Gruson, Brittany Schwartz

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Introduction: Patient-reported outcome measures (PROMs) are commonly utilized to assess patient-derived orthopaedic health status and function. The prevalence of limited musculoskeletal health literacy (MHL) has been demonstrated to be high within the orthopaedic literature. The purpose of this study was to evaluate the association between MHL and upper extremity-specific PROMs and to determine which patient- and symptom-related factors affect baseline PROMs in patients with atraumatic shoulder pain. Hypothesis: Patients with limited MHL would demonstrate lower median scores on baseline PROMs compared with those with adequate MHL. Materials and methods: New patients with atraumatic shoulder pain presenting to an academic practice were administered the Literacy in Musculoskeletal Problems (LiMP), in addition to the American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and Single Assessment Numeric Evaluation (SANE) questionnaires. A detailed physical exam and history was performed by a fellowship-trained shoulder surgeon. Demographic patient data, in addition to prior imaging and orthopaedic treatment, was tabulated. The association between demographics, pain-related variables, and MHL with the ASES, SANE, and QuickDASH scores were examined using Spearman correlation coefficients for continuous variables and Wilcoxon rank-sum tests for categorical variables. Non-parametric analysis of covariance (ANCOVA) was used to examine the independent association of predictor variables with PROMs. Results: A total of 439 patients met the inclusion criteria and were enrolled. The mean age was 58.8 ± 12.6 years (range: 24–93) with 162 (37%) being men. Overall, 172 patients (39.2%) attained a college degree or higher and 183 (41.7%) were currently employed. MHL was significantly associated with ASES (p = 0.03), but not with the QuickDASH (p = 0.75) or SANE score (p = 0.16). Similarly, age, having been in the medical profession or having previously visited an orthopaedist were not associated with PROMs, while employment status correlated to the SANE score (p = 0.002). Visual Analogue Scale (VAS) pain level demonstrated varying strengths of association with each of the scores [ASES (r = −0.729, p < 0.001), QuickDASH (r = 0.557, p < 0.001), and SANE (r = −0.430, p < 0.001)]. MHL demonstrated no association with initial patient-derived treatment selection. Discussion: The SANE and QuickDASH may be administered to patients presenting for atraumatic shoulder pain in the outpatient setting regardless of MHL. Further research should be focused on the utility of the ASES instrument amongst patients with lower educational levels and/or limited MHL. Level of evidence: II; diagnostic.

Original languageEnglish (US)
Article number103165
JournalOrthopaedics and Traumatology: Surgery and Research
Issue number5
StatePublished - Sep 2022


  • Atraumatic shoulder pain
  • Health disparities
  • Musculoskeletal health literacy
  • Patient-centered care
  • Patient-reported outcome measures
  • QuickDASH
  • Single Assessment Numeric Evaluation

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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