ARTICLE IN PRESS

J Shoulder Elbow Surg (2016) ■■, ■■–■■

www.elsevier.com/locate/ymse

ORIGINAL ARTICLE

Isokinetic shoulder strength correlates with level

of sports participation and functional activity
after reverse total shoulder arthroplasty
Allan Wang, FRACS, PhDa,b,c,*, Timothy Doyle, MDd, Gregory Cunningham, MBBSc,
Michael Brutty, BSce, Peter Campbell, FRACSb, Chrianna Bharat, BScc,
Timothy Ackland, PhDe

a
Department of Orthopaedic Surgery, The University of Western Australia, Nedlands, WA, Australia
b
St John of God Hospital, Murdoch, WA, Australia
c
Sir Charles Gairdner Hospital, Nedlands, WA, Australia
d
Craigavon Hospital, Craigavon, UK
e
School of Sport Science, Exercise and Health, The University of Western Australia, Crawley, WA, Australia

Background: Reverse total shoulder arthroplasty (RTSA) is increasingly being performed. Many pa-
tients may wish to return to high levels of sporting activity. This study aimed to evaluate the correlation
of isokinetic shoulder strength with level of participation in sport and recreation after RTSA.
Methods: We surveyed 51 patients at a mean of 29.5 months (range, 12-60 months) after surgery. Mean
age was 74.1 years. Patient-reported sporting activity was classified as low, medium, or high demand. All
patients completed the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire and the Oxford
Shoulder Score and underwent Biodex dynamometer testing of the RTSA evaluating isokinetic shoulder
strength in flexion and extension, abduction and adduction, and internal and external rotation.
Results: Reported sporting activity was high demand in 35% and moderate demand in 43%. There was
a large variation in shoulder isokinetic strength parameters especially for internal and external rotation.
With the exception of abduction, a significant correlation was noted between strength and the level of sports
participation that patients reported (P < .03). A significant correlation was also noted between strength and
patient-reported outcome measures for internal rotation and arm flexion and abduction (P < .05).
Conclusion: Most patients reported returning to moderate- or high-level sporting activity in the short term
after RTSA. Isokinetic shoulder strength, especially in internal rotation and arm flexion, positively cor-
relates with both patient-reported level of participation in sports and recreation and daily function.
Level of evidence: Level IV; Case Series; Treatment Study
© 2016 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Isokinetic strength; correlates; level of sports participation; reverse shoulder arthroplasty

Reverse total shoulder arthroplasty (RTSA) is now per-

This research was approved by the University of Western Australia Human
Research Ethics Committee (No. 2013-094).
*Reprint requests: Allan Wang, FRACS, PhD, St John of God Medical
Centre, Suite 10/100 Murdoch Drive, Murdoch, WA 6150, Australia.
E-mail address: allanwang@aapt.net.au (A. Wang).
formed more frequently than anatomic total shoulder
arthroplasty (TSA). 15,18 Indications for RTSA have ex-
panded from treatment of rotator cuff arthropathy to now
include post-traumatic arthritis, revision arthroplasty for failed

1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2016.01.025
 ARTICLE IN PRESS
2 A. Wang et al.
anatomic TSA, and treatment of massive rotator cuff tears
with pseudoparalysis.2,13,14
With expanding indications and midterm successful out-
comes, RTSA is now being performed in a wider patient
demographic.13,17 This may lead to increasing expectation of
patients for participation in more active and strenuous rec-
reational and sporting activities after surgery.
Patients undergoing anatomic TSA have successfully re-
turned to recreation and sports, such as swimming and golf.7,11,16
Zarkadas et al,20 in a mail survey of patients who had un-
dergone shoulder arthroplasty, classified 72 reported physical
activities as low demand (eg, cooking), medium demand (eg,
gardening), or high demand (weight training). Lawrence et al9
performed a subsequent mail survey of 78 subjects with RTSA.
At mean follow-up of 3.6 years, these authors reported that
84% were undertaking medium- to high-demand activity, in-
cluding snow shoveling, free weight training, and hunting.
Currently, there is a lack of information about factors that
correlate with participation in high-demand activity after RTSA
and factors that may also correlate with excellent patient-
reported outcomes after RTSA. In total knee and total hip
arthroplasty, the correlation of muscle strength with patient-
reported outcomes and sporting activity has been well
documented.12,19 In a pilot study of 33 patients with RTSA,
Alta1 measured isokinetic shoulder strength in abduction and
adduction and internal and external rotation and correlated
peak torque with patient-reported outcomes scores. These
scores included Disabilities of the Arm, Shoulder, and Hand
(DASH), Constant-Murley, and Simple Shoulder Test; however,
they did not focus specifically on participation in sport and
recreation. Only 65% of patients could complete the testing
protocol, and the time from surgery to evaluation varied from
4 months to 63 months. However, a moderate correlation was
demonstrated between isokinetic strength and patient-
reported function scores, suggesting that strength after RTSA
is an important factor influencing the level of function a patient
is performing after surgery.
The aims of this study were to measure isokinetic strength
after RTSA and to evaluate the correlation of various strength
parameters on participation in sports and recreation and patient-
reported outcome scores. Our hypothesis was that greater
isokinetic shoulder strength will correlate with superior patient-
reported outcomes and participation of patients in more
vigorous sports and recreation.
Methods
A retrospective study was performed of all patients having
undergone RTSA by 1 of 2 experienced shoulder surgeons
(A.W. and P.C.) during the period 2008 to 2013. During this
period, 83 RTSAs were performed. Study inclusion criteria
were age between 65 and 80 years at the time of surgery and
a minimum of 12 months from the time of surgery to the time
of evaluation. Formal physical therapy and supervised reha-
bilitation had ceased by the time of study recruitment in all
patients. Exclusion criteria were defined as those patients un-
dergoing revision arthroplasty or arthroplasty for neoplasm
and those patients with a neuromuscular disorder.
Surgical protocol
All patients underwent RTSA under general anesthetic in a
semi–beach chair position with routine antibiotic prophylax-
is. A deltopectoral approach was used in all cases. If present,
a tenotomy of the long head of the biceps was performed.
The subscapularis tendon was tagged and mobilized. A limited
tenotomy of the superior edge of the pectoralis major tendon
was performed for mobilization of the proximal humerus and
to improve exposure of the glenoid. RTSA was performed
using the uncemented SMR Modular Shoulder System (Lima
Corporate, Udine, Italy) in all cases. A 36-, 40-, or 44-mm
glenosphere was implanted as judged necessary to achieve
satisfactory soft tissue tension and stability. All glenospheres
were eccentric in design. The humeral component was im-
planted routinely in neutral version.
In closure, the subscapularis tendon was repaired as pos-
sible with No. 5 Ti-Cron (Ethicon, Somerville, NJ, USA)
horizontal mattress sutures. All patients wore a shoulder im-
mobilizer sling (DonJoy UltraSling; DJO Global, Vista, CA,
USA) for 6 weeks. Passive range of motion exercises com-
menced during this time, progressing to active assisted range
of motion exercises at 6 weeks and resistive exercises at 12
weeks after surgery. Both participating surgeons provided iden-
tical advice to patients about postoperative activity levels. This
included avoiding activity that caused pain in the RTSA and
being cautious with activity that involved a risk of falling or
activities involving heavy impact through the RTSA.
Clinical evaluation
Patients identified for inclusion in the study were initially con-
tacted by telephone and invited to enter the study. Patients
completed functional outcome questionnaires including
the Oxford Shoulder Score and the shortened DASH
(QuickDASH) as well as a survey focusing on participation
in sports and recreational activities. This survey recorded the
current recreational and sports activity after RTSA and also
included the recollected principal reason for undergoing RTSA,
the patient’s expectation of returning to sport after RTSA, and
a record of medical comorbidities that may affect physical
function.
The survey allowed stratification of patient-reported sports
and recreational activity into 1 of the 3 shoulder arthro-
plasty activity levels described by Zarkadas et al.20 High-
demand activities involved repetitive stress, loads >20 pounds,
and regular overhead movements. Moderate-demand activi-
ties involved occasional repetitive stress, lifting loads up to
20 pounds, and occasional overhead activities. Low-demand
activities are defined as not imposing repetitive stress on the
 ARTICLE IN PRESS
Isokinetic strength correlates with sports RTSA 3

shoulder, not involving heavy lifting, and most shoulder move- data collected. Fisher exact test was used to analyze cate-
ments being below shoulder height. gorical responses; linear regression was used to analyze
All subjects underwent evaluation of isokinetic shoulder responses with continuous variables after adjustment for age
strength of the arm that was operated on by use of a Biodex and sex. Statistical significance was accepted at P < .05.
System 3 Pro dynamometer (Biodex Medical Systems, New
York, NY, USA). Three protocols of shoulder movement were Results
tested: internal and external rotation, abduction and adduc-
tion, and forward flexion and extension. For each protocol,
Patient characteristics
patients were tested within a locked range of motion that was
predetermined by their limit of comfort. The isokinetic testing
Of 69 patients identified and fulfilling the study inclusion and
was performed with the dynamometer velocity set to 60°/s.
exclusion criteria, 51 patients consented to participate in the
Each protocol consisted of 1 practice motion to ensure comfort
study. The average age at the time of surgery was 74.1 years.
and technique. After 2 minutes of rest, 3 consecutive repeti-
The mean follow-up time from surgery was 29.5 months. Of
tions of the movement at maximum power were performed
the 51 subjects, 27 (52%) were female; 49 (96%) of the sub-
and measurements were recorded.
jects evaluated were right hand dominant. Surgery was
The first test performed was internal and external rota-
performed on the right shoulder in 27 (53%) of the cases.
tion. The chair was set at neutral rotation to the dynamometer,
The indications for RTSA were rotator cuff arthropathy
which was rotated to 20° and tilted 50°. After this, flexion
or massive cuff tear with pseudoparalysis in 47 cases and post-
and extension were measured with the chair set neutral to the
traumatic arthritis in 4 cases. Patients reported that the principal
dynamometer. Finally, abduction and adduction were tested
indication for undergoing RTSA was pain in 32 cases, loss
with the chair rotated 90° to the dynamometer, which was
of activities of daily living function in 17 cases, and inabil-
in neutral orientation and 10° tilt (Fig. 1).
ity to work in 2 cases. Inability to play sports was not listed
The isokinetic testing yielded measurements of peak torque
as a principal reason for undergoing surgery by any patient.
in newton meters, average torque in newton meters, and total
Notably, 14 patients stated they had no expectation to return
work done (TWD) in joules for the predetermined and achiev-
to sport after RTSA.
able comfortable range of motion. The TWD strength
In general, patients reported high levels of satisfaction with
parameter is measured as the total area under the torque curve.
their RTSA at follow-up review, with 37 patients (72%) re-
Participants unable to complete a protocol because of lack
porting good or excellent satisfaction levels (Table I). The
of strength or discomfort were included with a score of zero
patient-reported outcome measures (PROMs) showed a low
recorded.
mean QuickDASH disability score (22.7 of a maximum dis-
The institution’s biostatistician, using the R environment
ability score of 100) and a high mean Oxford Shoulder Score
for statistical computing, performed statistical analysis of the
(39.6 of a maximum of 48).
Table II summarizes the patient-reported sport and recre-
ation Zarkadas shoulder arthroplasty activity level after
RTSA.20 Of the 51 patients, 18 patients (35%) were classified

Table I Patient-reported outcomes

Satisfaction level No. (%)
Poor 2 (4)
Satisfactory 12 (24)
Good 19 (37)
Excellent 18 (35)
Patient-rated outcome Mean (SD)
measures
Oxford Shoulder Score 39.6 (6.92)
QuickDASH disability score 22.7 (15.58)

Table II Shoulder arthroplasty activity level20

Level No. (%)
Low demand 11 (22)
Moderate demand 22 (43)
Figure 1 Isokinetic abduction testing using the Biodex 3 High demand 18 (35)
dynamometer.
 ARTICLE IN PRESS
4 A. Wang et al.

Table III Total work done (J) for each plane of movement (mean ± SD) and correlations with shoulder arthroplasty activity level
Movement Activity level Correlation
Level 1 Level 2 Level 3 r P value
External rotation 3.9 ± 1.54 5.7 ± 1.06 9.6 ± 1.21 0.297 .018
Internal rotation 5.3 ± 2.19 5.6 ± 1.51 11.9 ± 1.72 0.322 .022
Arm flexion 23.2 ± 5.67 37.1 ± 3.91 53.2 ± 4.45 0.572 .001
Arm extension 29.2 ± 7.81 26.0 ± 5.39 49.0 ± 6.12 0.481 .027
Arm abduction 12.2 ± 4.21 21.2 ± 2.91 25.6 ± 3.30 0.384 .063
Arm adduction 15.7 ± 5.50 17.0 ± 3.80 31.7 ± 4.31 0.412 .034

as participating in high-demand activity, including swim- Table IV Correlation between total work done for each plane
ming, kayaking, golf, and gym. Moderate-demand activities of movement and the QuickDASH score and Oxford Shoulder Score
included carpentry, gardening, and aerobics. Light activities
Movement QuickDASH Oxford
included table tennis, lawn bowls, cycling, and walking. score Shoulder Score
R P value r P value
Biodex dynamometer measurements
External rotation 0.230 .047 0.226 .055
Isokinetic strength data were recorded by measuring torque Internal rotation 0.266 .045 0.324 .005
Arm flexion 0.481 .022 0.485 .019
(newton meters) for each position of the arm (degrees) in the
Arm extension 0.417 .16 0.460 .019
planes of motion: flexion-extension, abduction-adduction, and Arm abduction 0.364 .043 0.375 .027
internal rotation–external rotation. Torque-arm position graphs Arm adduction 0.358 .09 0.410 .009
were generated. From these curves, the Biodex software cal-
culates the mean TWD as the area under the torque curve,
through the tested and predetermined comfortable range of
motion. of implant failure have resulted in caution for surgeons per-
The association between isokinetic strength and shoul- forming RTSA in young and active patients.4,6,8 Golant et al,5
der arthroplasty activity level20 was evaluated. This study in a survey of 310 surgeons, reported that 74% of respon-
focused on TWD through the patient’s predetermined achiev- dents allowed patients to return to sport after shoulder
able range of motion as a more relevant functional strength arthroplasty. However, the recommendations for sporting ac-
parameter than peak torque, which is a measurement in 1 tivity were implant dependent. After humeral head resurfacing,
testing position only. TWD is recorded for each direction of 92% of surgeons allowed return to sport compared with only
movement and correlated with activity level (Table III). In 45% of surgeons allowing return to sport after RTSA.
every plane of motion, increased strength correlates with a Magnusson et al,10 in a survey of the type of sports that sur-
higher activity level. With the exception of abduction, a sig- geons recommended after RTSA, reported that overhead sports,
nificant positive correlation is noted between isokinetic strength such as basketball and tennis, and strength sports, such as gym
(as measured by TWD) in every direction of shoulder motion training and water skiing, were not recommended.
and activity level. These results indicate that patients with In this study, 78% of subjects had returned to moderate-
greater strength in global shoulder motion participate in more or high-grade recreational or sporting activity in the short term
vigorous recreation and sporting pursuits. after RTSA. This is a rate of participation similar to that re-
The association between isokinetic strength and PROMs ported in previously published patient surveys after RTSA as
was evaluated. Increased strength (as measured by TWD) has well as after anatomic TSA and hemiarthroplasty.9,11,16,20 In
a significant positive correlation with both superior addition, our study reports a high level of patient satisfac-
QuickDASH scores and Oxford Shoulder Scores, most notably tion and clinical function with RTSA, and our study results
in internal rotation, forward flexion, and abduction (Table IV). are consistent with those of the Norwegian Registry data re-
Strength in these arm movements has a significant positive porting that PROMs of RTSA are equivalent to those of
effect on a patient’s performance of activities of daily living. anatomic TSA.3
This study has also undertaken a detailed evaluation of
Discussion isokinetic strength parameters after RTSA. The aim of this
study was to determine if strength parameters correlated with
Early studies of RTSA have reported high complication rates, sports and recreation participation and PROMs after RTSA.
and surgery was initially recommended for low-demand and Sports performance is a dynamic activity requiring strength
older patients with the goals of restoring comfort and over- through a range of motion (eg, the rowing stroke or a golf
head motion.6,8 The semiconstrained implant design and risk swing). Static strength measurement in 1 position in 1 plane
of accelerated polyethylene wear, scapular notching, and risk of motion (eg, 90° of abduction) may be less relevant as a
 ARTICLE IN PRESS
Isokinetic strength correlates with sports RTSA
strength parameter to assess sports capability compared with
isokinetic assessment of strength through a range of motion.
In a pilot study of a heterogeneous group of patients having
undergone RTSA with 4 months to 63 months of follow-up,
Alta et al1 reported that isokinetic peak torque in abduction
and external rotation correlated moderately with PROMs. Our
study evaluated TWD through the subject’s achievable and
comfortable range of motion. A large variation was noted
within the patient group for these isokinetic strength param-
eters. Those subjects with greater strength as measured by
TWD in internal rotation, external rotation, and forward flexion
had highly significant positive correlations with higher shoul-
der arthroplasty activity levels.20 Increased isokinetic shoulder
strength correlates with greater participation in sports and rec-
reational activity after RTSA.
In addition, subjects with greater strength have superior
PROM scores. As measured by TWD, greater strength, notably
in internal rotation, forward flexion, and abduction, had sig-
nificantly superior QuickDASH scores and Oxford Shoulder
Scores.
However, this study does not establish a direct cause and
effect relationship between isokinetic strength and level of
sporting or functional activity. In this population of older pa-
tients, multiple factors including the patient’s motivation,
interest in sporting activity, and medical comorbidities are also
potential factors influencing level of activity after RTSA. In
addition, high-level sports participation conversely could be
the cause for the increased shoulder strength measured.
However, this study demonstrates that a significant positive
correlation exists between isokinetic shoulder strength and
the current level of sports and functional activity undertaken.
The importance of internal rotation strength after RTSA
has been highlighted by this study. Internal rotation strength,
as measured by TWD, has significant positive correlations
with sports activity level, QuickDASH score, and Oxford
Shoulder Score. On testing of this cohort of patients, the vari-
ation in internal rotation strength was large, with some patients
being unable to generate any measurable internal rotation
strength. Subscapularis is the major internal rotator of the gle-
nohumeral joint. This study has not specifically analyzed the
effect of performing subscapularis repair on improving the
measured outcomes after RTSA. Subscapularis preserva-
tion (or repair and rehabilitation) and the effect on
postoperative internal rotation strength and activity level are
potential areas for further investigation.
The limitations of this study include the retrospective nature
of this review. Of the 69 patients eligible to enter this study,
only 51 (74%) attended for review. However, every patient
completed the whole study protocol. Another limitation of
this retrospective study is the lack of preoperative data on the
level of recreation and sports participation and preoperative
data on isokinetic strength. However, the aim of this study
was not to compare activity levels or strength levels before
surgery with after surgery or to correlate various preopera-
tive factors with postoperative activity level. The objective
was to investigate the correlation of postoperative isokinetic
5
strength parameters with the current level of recreation and
sports participation.
A further limitation is that no radiologic studies were un-
dertaken to determine if implant-related complications, such
as osteolysis or scapular notching, were developing, as these
features would also affect sporting participation and isokinetic
strength testing. However, in evaluating factors affecting patient
activity levels in the short term (mean, 29.5 months) after
surgery, implant-related complications are less likely.
Conclusion
In the short term after RTSA, 78% of patients had re-
turned to moderate- or high-level recreational and sporting
activity. This study finds that patients demonstrating greater
isokinetic shoulder strength, especially in internal rota-
tion and forward flexion, participate in higher demand
recreational or sports activity and report fewer difficul-
ties with activities of daily living.
Acknowledgment
Dr Louise Sang assisted in the preparation of this
manuscript.
Disclaimer
LIMA Corporate (Udine, Italy) provided financial assis-
tance in the Biodex evaluation for this study.
The authors, their immediate families, and any re-
search foundation with which they are affiliated have not
received any financial payments or other benefits from any
commercial entity related to the subject of this article.
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