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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.

44 citationsUpdated Sep 2026
Illustration: PROM Thresholds & Interpretation

Overview

Patient-reported outcome measures (PROMs) are central to orthopaedic assessment, yet most total knee arthroplasty instruments have limited evidence supporting their psychometric properties [1]. The orthopaedic community has shifted toward including patient-based measures in outcome assessments to expand the understanding of intervention effects, with a notable increase in their use in randomized controlled trials between 1991 and 2001 [10]. This shift is supported by a demonstrated increase in core outcome sets developed for both research and routine practice, which consistently include high participation of patients [28]. However, barriers to adoption persist; reasons for limited use by orthopaedic surgeons include a lack of knowledge on how to use these tools and the perception that they are too time-consuming to add to regular clinical routine [8]. Additionally, there is evidence of limited familiarity with knee and hip patient-reported outcome measures among orthopaedic surgeons [26].

Interpreting these data requires distinct thresholds for individual and group contexts. 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 [2]. To accurately interpret patient-reported outcome data in clinical trials, an anchor question should be included so that the Minimum Clinically Important Difference (MCID) can be determined for the specific patient population included in the study [16]. For evaluating studies reporting health-related quality of life, it is important to understand the fundamentals of reliability, validity, and responsiveness of the outcome measure being used in addition to appraising the validity of the study [21]. Comparisons of internal consistency and test-retest reliability across measures reveal minimal differences between instruments, with reported values acceptable for group comparisons but insufficient for individual clinical use [12]. Data from long-term test-retest reliability studies help establish the effects of longer, clinically pragmatic testing intervals on test-retest reliability [5].

Standardized thresholds such as MCID, Patient Acceptable Symptomatic State (PASS), and Substantial Clinical Benefit (SCB) provide surgeons with values to determine scores that are clinically meaningful to patients, assisting with therapeutic decision making and expectation setting [7]. A comprehensive understanding of differences in MCID, SCB, and PASS thresholds is essential to assist surgeons in evaluating outcomes and counseling patients [27]. Caution should be exercised in conflating PASS thresholds across different studies [27]. While PROMIS measures are less burdensome than legacy patient-reported outcome measures for the hip and demonstrate no floor or ceiling effects [13], the availability of clinically significant outcome thresholds remains relatively limited for shoulder instability surgery outcomes [4]. If standards and procedures for patient-reported outcomes are used, their use will contribute to improved patient care and clinical research [20].

Anatomy & Pathophysiology

Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint [54]. This condition is often associated with mechanical block from periarticular osteophytes [54].

Classification

Patient Acceptable Symptomatic State (PASS): PASS thresholds aid clinicians in determining when patients can safely return to activities after anterior cruciate ligament reconstruction [3]. These thresholds provide surgeons with values to help determine Patient-Reported Outcomes Measurement Information System (PROMIS) scores that are clinically meaningful to patients [7].

Minimum Clinically Important Difference (MCID): MCID and PASS provide threshold values for interpreting PROMIS scores [7]. A clinically significant improvement between time points is established if an outcome score improvement significantly exceeds the previously established MCID for the specific outcome measure [17]. When multiple MCIDs are reported for an individual patient-reported outcome measure (PROM), the smallest MCID is used for analysis to remain consistent with the definition of MCID as the smallest difference in score which patients perceive as beneficial [17]. An anchor question should be included so that the MCID can be determined for the specific patient population included in a study to accurately interpret PRO data in clinical trials [16].

Substantial Clinical Benefit (SCB): A novel methodology presents recommended MCID and SCB values identified through a comprehensive methodology for common reverse total shoulder arthroplasty PROMs [9]. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and Maximal Outcome Improvement (MOI) thresholds for reverse total shoulder arthroplasty may allow for improved assessment of PROMs [18].

Minimal Detectable Change (MDC): The MDC needed to discern a true health change from measurement error-induced variability was calculated based on score distribution by implementing a correction factor to the standard error of measurement [35]. The specific formula for MDC is MDC = Z-score x SEM x √2, where SEM = SD x √(1-ICC) [35]. Z-scores of 1.28, 1.64, and 1.96 were applied to MDC 80, MDC 90, and MDC 95, respectively [35].

Other Considerations: The availability of clinically significant outcome thresholds such as MCID and PASS for shoulder instability surgery outcomes remains relatively limited [4]. The MCID can be calculated using a distribution-based method wherein threshold values are derived based on one-half of the standard deviation of the mean change in outcome score [19]. This method of clinically relevant threshold calculation has been deemed valid in prior studies and in the absence of routinely collected anchor questions [19].

The orthopaedic community has shifted toward the inclusion of patient-based measures in outcome assessments, with a notable increase in the use of these measures in randomized controlled trials between 1991 and 2001 [10]. There has been a demonstrated increase in core outcome sets developed for both research and routine practice, and consistently high inclusion of patient participants [28]. Content validity is defined as the degree to which the content of an instrument is an adequate reflection of the construct to be measured [25].

Reported values for internal consistency and test-retest reliability across generic health-related quality of life measures are acceptable for group comparisons but insufficient for individual clinical use [12]. 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 [23].

Scales for the measurement of severity of symptoms and functional status in carpal tunnel syndrome are reproducible, internally consistent, and responsive to clinical change [14]. These scales measure dimensions of outcomes not captured by traditional measurements of impairment of the median nerve [14]. The M-SANE, a single-question, joint-specific patient-reported outcome measure, performed similarly across multiple psychometric properties to more burdensome PROMs in assessing patient-reported outcomes after total hip arthroplasty [6]. 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 [13].

Reasons for the non-use of patient-reported outcome measures by orthopedic surgeons include a lack of knowledge on how to use them and the perception that it is too time-consuming to add to regular clinical routine [8]. The use of PROs will contribute to improved patient care and clinical research if the standards and procedures as outlined are used [20]. Integrating PROMs into clinical workflows and decision-making processes allows healthcare organizations to align their objectives with the core tenets of value-based care [24]. The Cleveland Clinic's Orthopaedic Minimal Data Set Episode of Care (OME) cohort serves as an exemplary model of a comprehensive PROMs data collection platform tailored specifically for total joint arthroplasty [24]. By integrating PROMs collection into the routine clinical workflow, the OME system achieves high baseline completion rates (>97%) without requiring major additional personnel or resources [24].

CMS's mandatory PROM-based performance measures face significant challenges regarding compliance, financial burden, and potential exacerbation of health disparities [22]. PROM scores often plateau by six months to one year, making extended data collection inefficient [22].

Clinical Presentation

The assessment of shoulder instability surgery outcomes is currently limited by the relative scarcity of clinically significant outcome thresholds, such as the Minimum Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) [4]. These thresholds provide surgeons with values to determine Patient-Reported Outcome Measurement Information System (PROMIS) scores that are clinically meaningful to patients, thereby assisting with therapeutic decision-making and expectation setting [7]. Standardizing the methodologic calculation and utilization of MCID, Substantial Clinical Benefit (SCB), PASS, and Maximal Medical Improvement (MOI) thresholds for reverse total shoulder arthroplasty may allow for improved assessment of patient-reported outcomes [18]. Recommended MCID and SCB values identified through comprehensive methodologies suggest how these thresholds should be calculated for common reverse total shoulder arthroplasty PROMs to standardize the assessment of clinically significant improvement [9]. A comprehensive understanding of differences in MCID, SCB, and PASS thresholds stratified by implant type, preoperative diagnosis, and sex is essential to assist surgeons in evaluating outcomes and counseling patients [27].

Preoperative sex-based differences in PROMIS scores are underappreciated in the shoulder arthroplasty literature, with females undergoing reverse total shoulder arthroplasty showing significantly lower baseline scores than males exceeding the minimal clinically important difference [49]. It is important to compare a patient's outcome scores with age-normalized scores to establish an accurate reference frame with which to interpret outcomes [23]. 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 [15]. Cutoff scores for treatment success after arthroscopic rotator cuff repair are time dependent [32]. Failure to achieve an early distribution-based MCID is strongly associated with poor patient-reported outcomes up to one year following total hip arthroplasty [29].

MCID can be calculated using a distribution-based method wherein threshold values are derived based on one-half of the standard deviation of the mean change in outcome score [19]. PASS thresholds can be used to define treatment success in future outcome studies following unicompartmental knee arthroplasty [11]. Evaluating studies reporting health-related quality of life requires understanding the fundamentals of reliability, validity, and responsiveness of the outcome measure being used [21]. According to the COSMIN group, no gold standard exists for health-related, patient reported outcomes, and using another comparative instrument as a "gold standard" to establish criterion validity is incorrect [40]. When both instruments have continuous scores, the preferred method for estimating criterion validity is presenting the correlation coefficient, which should preferably be above 0.70 [40]. When the outcome instrument has a continuous score but the gold standard has a dichotomous score, the area under the receiver operating characteristic (ROC) curve is the preferred method for estimating criterion validity, with a criterion of 0.70 suggested [40]. When both scores are dichotomous, specificity and sensitivity are the preferred methods to use for estimating criterion validity [40].

Content validity is defined as the degree to which the content of an instrument is an adequate reflection of the construct to be measured, meaning the body of items in the PROM can actually reflect how the patient is functioning and feeling in relation to a condition or treatment [25]. Comparisons of internal consistency and test-retest reliability across generic health-related quality of life measures reveal minimal differences between instruments, with reported values acceptable for group comparisons but insufficient for individual clinical use [12]. Scales for the measurement of severity of symptoms and functional status in carpal tunnel syndrome are reproducible, internally consistent, and responsive to clinical change, measuring dimensions of outcomes not captured by traditional measurements of median nerve impairment [14]. The reliability, convergent validity, and sensitivity to change of the Stockerau Activity Score for Psoriatic Arthritis (SASPA) were demonstrated [51]. A comparison of item-reduction approaches for the QuickDASH suggested that the retention of clinically sensible and important content produced a comparable, if not slightly better, instrument than did more statistically driven approaches [99].

The Short Form-36 Version 2.0 (SF36v2) is a self-report instrument that measures an individual’s own perception of their health status across eight domains, with scores ranging from 0–100 where higher scores represent better health status [39]. The minimal clinically important difference of SF36v2 Physical and Mental Component Scores ranges from 2 to 7 for different diseases, with 5 selected as a commonly used threshold [39]. The PTSD Checklist Civilian Version (PCL-C) is a self-report 17-item checklist with total scores ranging from 17–85, where a cut-off score of 44 is recommended for overall diagnostic efficiency for people injured in a motor vehicle crash [39]. Evidence suggests 5 points is the minimum threshold to report clinical change on the PTSD Checklist Civilian Version [39].

Telephone surveys demonstrate higher patient-reported outcome scores and greater improvement compared to in-person or online surveys [50]. Integrating PROMs into clinical workflows and decision-making processes allows healthcare organizations to align their objectives with the core tenets of value-based care, which prioritize optimizing patient outcomes while efficiently managing resources [24]. The Cleveland Clinic's Orthopaedic Minimal Data Set Episode of Care (OME) cohort achieves high baseline completion rates (>97%) without requiring major additional personnel or resources by integrating PROMs collection into the routine clinical workflow [24]. If standards and procedures for patient-reported outcomes are used, their use will contribute to improved patient care and clinical research [20]. There has been a demonstrated increase in core outcome sets developed for both research and routine practice, with consistently high inclusion of patient participants [28]. CMS's mandatory PROM-based performance measures face significant challenges regarding compliance, financial burden, and potential exacerbation of health disparities, while noting that PROM scores often plateau by six months to one year [22].

Investigations

Patient-Reported Outcome Measures (PROMs): Most PROMs used in total knee arthroplasty have limited evidence for their psychometric properties [1]. Four of five frequently used orthopedic PROMs (mHHS, HAGOS, IKDC-SKF, KOOS, KNEES-ACL) possess inadequate content validity according to a COSMIN evaluation [25]. Reported values for internal consistency and test-retest reliability of generic health-related quality of life measures are acceptable for group comparisons but insufficient for individual clinical use [12]. 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 [6]. The ASES standardized shoulder assessment form is offered as a baseline measure of shoulder function applicable to all patients regardless of diagnosis [46].

Thresholds and Interpretation: Patient Acceptable Symptom State (PASS) thresholds can aid clinicians when considering when patients can safely return to activities after anterior cruciate ligament reconstruction [3]. Recommended MCID and Substantial Clinical Benefit (SCB) values for reverse total shoulder arthroplasty have been identified through a comprehensive methodology to standardize assessment of clinically significant improvement [9]. MCID thresholds for the Simple Shoulder Test differ for different types of shoulder arthroplasty [30]. Maximal Outcome Improvement (MOI) thresholds for patient-reported outcome measures after primary ACL reconstruction can be recalculated for subgroups based on the time from injury to surgery [31]. Following primary total hip arthroplasty for hip osteoarthritis, percentage thresholds for achieving the MOI for the Forgotten Joint Score, Harris Hip Score, and VAS for pain were 54.2%, 65%, and 67.1%, respectively [116].

Statistical Methodology: 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 [16]. The minimal detectable change (MDC) needed to discern a true health change from measurement error-induced variability is calculated based on score distribution by implementing a correction factor to the standard error of measurement [35]. Data from baseline cognitive assessments using ImPACT help establish the effects of longer, clinically pragmatic testing intervals on test-retest reliability [5].

Other Considerations: Reasons for limited use of PROMs by orthopaedic surgeons include a lack of knowledge on how to use them and the perception that they are too time-consuming to add to regular clinical routine [8]. There is evidence of limited familiarity with knee and hip PROMs among orthopaedic surgeons in mainland China [26]. Patient expectations for function evolve over long-term follow-up, with lower expectations resulting in a higher percentage of patients meeting PASS and SCB thresholds [15]. If standards and procedures for health measurement are used, the use of PROs will contribute to improved patient care and clinical research [20]. Future orthopaedic research should employ the MCID with transparency and caution and continue to develop patient-centered metrics that have greater reproducibility and that bridge statistical results with real clinical meaning [56].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections.

Operative

Indications: Using PASS thresholds for patient-reported outcomes can aid clinicians when considering when patients can safely return to activities after anterior cruciate ligament reconstruction [3].

Implant Selection: The availability of clinically significant outcome thresholds such as MCID and PASS for shoulder instability surgery outcomes remains relatively limited [4]. For reverse total shoulder arthroplasty, recommended MCID and SCB values have been identified through a comprehensive methodology for common PROMs [9]. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for this procedure may allow for improved assessment of PROMs [18]. MCID thresholds are also available for assessing the effectiveness of each common type of shoulder arthroplasty [30].

Pain Management: Cutoff scores for treatment success after arthroscopic rotator cuff repair using Oxford, Constant, and UCLA shoulder scores are time dependent [32].

Other Considerations: The shift toward value-based health care has underscored the critical role of PROMs in evaluating the quality and effect of care delivered [24]. Determining the optimal timing for PROMs collection is crucial for ensuring the validity and cost-effectiveness of outcomes assessment in total joint arthroplasty [24]. To ensure strong response rates at the 1-year follow-up, the OME system employs a combination of passive methods, such as automated reminders, and active methods, including telephone calls and personalized letters [24].

In specific studies, the MCID was calculated using a distribution-based method wherein threshold values were derived based on one-half of the standard deviation of the mean change in outcome score [19]. The threshold value for each respective outcome metric was quantitatively established and applied to determine the proportion of patients achieving the MCID at various follow-up time points [19]. The study suggests how MCID and SCB thresholds should be calculated for common reverse total shoulder arthroplasty PROMs to standardize assessment of clinically significant improvement [9].

Complications

Other Considerations: Failure to achieve an early distribution-based minimum clinically important difference (MCID) is strongly associated with poor patient-reported outcomes up to one year following total hip arthroplasty [29]. This failure almost triples the odds of poor patient-reported outcomes within the first year following total hip arthroplasty [29]. 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 thresholds [15]. Reported values for internal consistency and test-retest reliability across measures are acceptable for group comparisons but insufficient for individual clinical use [12].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range or specific activities (such as desk work, driving, or light ADLs) for the light activity phase.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for when pain, strength, and final functional outcomes stabilise.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range of motion progression, or sling/brace removal timing.

Functional milestones: Using PASS thresholds for PROs can aid clinicians when considering when patients can safely return to activities after ACLR [3]. The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients [7]. These thresholds can assist with therapeutic decision making as well as expectation setting [7]. If multiple MCIDs are previously reported for an individual PROM, the smallest MCID is used for analysis to remain consistent with the definition of MCID as the smallest difference patients perceive as beneficial [17]. Using the smallest MCID for analysis errs on the side of more frequent visits owing to increased sensitivity of detecting change [17]. Failure to achieve an early distribution-based MCID is strongly associated with poor patient-reported outcomes up to one year [29]. The cutoff scores for treatment success are time dependent [32].

Other Considerations: For untreated patients, the mean score was unchanged after a median of seven months (10.3±6.0 to 10.8±6.5; P=0.35) [115].

Key Evidence

  • [L1] Most TKA PROMs have limited evidence for their psychometric properties. [1] (10.1016/j.arth.2016.12.052)
  • [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. [2] (10.1002/ksa.12805)
  • [L3] Using PASS thresholds for PROs can aid clinicians when considering when patients can safely return to activities after ACLR. [3] (10.1177/03635465241298917)
  • [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. [4] (10.1016/j.arthro.2024.07.039)
  • [L4] These data help establish the effects of longer, clinically pragmatic testing intervals on test-retest reliability. [5] (10.1177/0363546509343805)
  • [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. [6] (10.1016/j.arth.2020.01.015)
  • [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. [7] (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. [8] (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. [9] (10.1016/j.jse.2025.02.018)
  • [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] (10.1097/01.blo.0000079772.06654.c8)
  • [L3] PASS thresholds can be used to define treatment success in future outcome studies. [11] (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. [12] (10.1016/j.injury.2010.11.044)
  • [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. [13] (10.1177/0363546518825252)
  • [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. [14] (10.2106/00004623-199311000-00002)
  • [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. [15] (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. [16] (10.1177/1558944718812180)
  • [L4] [17] (10.1016/j.jse.2018.03.007)
  • [L2] Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs. [18] (10.1016/j.jse.2024.03.051)
  • [L3] [19] (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. [20] (10.1016/j.injury.2019.10.073)
  • [Paper] For the purpose of evaluating studies reporting health-related quality of life it is important to understand the fundamentals of reliability, validity, and responsiveness of the outcome measure being used in addition to appraising the validity of the study. [21] (10.1097/01.blo.0000079771.06654.13)
  • [L5] The paper concludes that CMS's mandatory PROM-based performance measures face significant challenges regarding compliance, financial burden, and potential exacerbation of health disparities, while noting that PROM scores often plateau by six months to one year, making extended data collection inefficient. [22] (10.1016/j.arth.2025.12.002)
  • [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. [23] (10.1177/03635465211056666)
  • [L5] [24] (10.5435/jaaos-d-25-00977)
  • [L3] [25] (10.1007/s00167-021-06761-y)
  • [L4] There is evidence of limited familiarity with knee and hip PROMs among orthopaedic surgeons. [26] (10.1186/s12891-021-04459-3)
  • [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. [27] (10.1016/j.jse.2024.01.040)
  • [L2] There has been a demonstrated increase in core outcome sets developed for both research and routine practice, and consistently high inclusion of patient participants. [28] (10.1371/journal.pone.0244878)
  • [L3] Failure to achieve an early distribution-based MCID is strongly associated with poor patient-reported outcomes up to one year. [29] (10.1016/j.arth.2026.04.043)
  • [L3] This study reports MCID thresholds that can be used when assessing the effectiveness for each of the common types of shoulder arthroplasty. [30] (10.1016/j.jse.2022.02.010)
  • [L4] [31] (10.2106/jbjs.23.01330)
  • [L2] The cutoff scores are time dependent. [32] (10.1016/j.arthro.2018.07.047)
  • [L3] [35] (10.1016/j.arth.2024.01.051)
  • [L2] [39] (10.1186/s12891-016-1152-2)
  • [Paper] [40] (10.1016/j.injury.2010.11.042)
  • [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. [46] (10.1016/s1058-2746(09)80019-0)
  • [L3] Preoperative sex-based differences in PROMIS scores are underappreciated in the shoulder arthroplasty literature, with females undergoing rTSA showing significantly lower baseline scores than males exceeding the minimal clinically important difference. [49] (10.1016/j.jseint.2023.07.012)
  • [L4] This study demonstrates higher patient-reported outcome scores and greater improvement by telephone surveys compared to in-person or online. [50] (10.1007/s00167-015-3802-6)
  • [L4] Its reliability, convergent validity, and sensitivity to change were demonstrated. [51] (10.1186/s12891-015-0512-7)
  • [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. [54] (10.2106/00004623-199806000-00015)
  • [L5] Future orthopaedic research should employ the MCID with transparency and caution and continue to develop patient-centered metrics that have greater reproducibility and that bridge statistical results with real clinical meaning. [56] (10.2106/jbjs.25.00868)
  • [L4] A comparison of item-reduction approaches suggested that the retention of clinically sensible and important content produced a comparable, if not slightly better, instrument than did more statistically driven approaches. [99] (10.2106/jbjs.d.02060)
  • [L3] Following primary THA for hip osteoarthritis, percentage thresholds for achieving the MOI for the FJS, HHS, and VAS for pain were 54.2, 65, and 67.1%, respectively. [116] (10.1016/j.arth.2024.10.119)

References

[1] 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

[2] 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

[3] 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

[4] 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

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

[6] 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

[7] 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

[8] 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

[9] 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

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

[11] 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

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

[13] 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

[14] 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

[15] 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

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

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

[18] 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

[19] 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

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

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

[22] Facing the Challenges of the Centers for Medicare and Medicaid Services: Total Hip and Knee Arthroplasty Patient-Reported Outcome-Based Performance Measures. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.12.002

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

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