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Tinetti Gait / Balance Scale
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Shoulder Strength Scale
(All Information is Strictly Confidential)
Overall Pain Level
None (15)
Mild (10)
Moderate (5)
Severe (0)
ADLs -- does your shoulder allow you to perform 100% of your occupation or daily activities?
4 pts: No limitations at work
2 pts: Moderate limitations
0 pts: You can’t do your job.
ADL's -- can you participate in your usual sports or hobbies without restriction?
4 pts: Full golf swing, gym, or hobbies
2 pts: You can play, but with pain/limits
0 pts: You've had to stop the activity
ADL's -- does your shoulder let you sleep through the night?
2 pts: Sleep is totally fine
1 pt: Woken up occasionally by pain
0 pts: Woken up every night
Which of the following can you reach comfortably with your affected arm?
I can reach my waistline. (2 pts)
I can reach the bottom of my breastbone (xiphoid process). (4 pts)
I can reach my neck. (6 pts)
I can reach the top of my head. (8 pts)
I can reach high above my head. (10 pts)
Forward Elevation (Flexion) — How high can you lift your arm straight in front of you without pain?
0 to 30 degrees (Just off the hip) (0 pts)
31 to 60 degrees (1/3 of the way up) (2 pts)
61 to 90 degrees (Parallel to the floor) (4 pts)
91 to 120 degrees (Slightly above shoulder height) (6 pts)
121 to 150 degrees (Reaching for the ceiling) (8 pts)
151 to 180 degrees (Straight up by the ear) (10 pts)
Lateral Elevation (Abduction) — How high can you lift your arm out to the side without pain?
0 to 30 degrees (Just off the hip) (0 pts)
31 to 60 degrees (1/3 of the way up) (2 pts)
61 to 90 degrees (Parallel to the floor) (4 pts)
91 to 120 degrees (Slightly above shoulder height) (6 pts)
121 to 150 degrees (Reaching for the ceiling) (8 pts)
151 to 180 degrees (Straight up by the ear) (10 pts)
How far can you reach behind your back (Internal Rotation)?
Back of my hand to my outer thigh. (0 pts)
Back of my hand to my buttock. (2 pts)
Back of my hand to the top of my glutes/tailbone. (4 pts)
Back of my hand to my waistline. (6 pts)
Back of my hand to the middle of my back (bra strap level). (8 pts)
Back of my hand to the top of my shoulder blades. (10 pts)
Which of these describes your BEST reach behind your head?
Level 1: Hand behind head, elbow forward (2 pts)
Level 2: Hand behind head, elbow BACK (4 pts)
Level 3: Hand ON TOP of head, elbow forward (6 pts)
Level 4: Hand ON TOP of head, elbow BACK (8 pts)
Level 5: Full arm reach straight up from the top of the head (10 pts)
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