Modification of the Constant–Murley shoulder score—introduction of the individual relative Constant score: Individual shoulder assessment

doi:10.1016/j.injury.2004.12.023

Injury

Volume 36, Issue 10, October 2005, Pages 1159-1165

https://doi.org/10.1016/j.injury.2004.12.023 Get rights and content

Summary

The Constant–Murley shoulder assessment score has proven to be a valuable diagnostic instrument. Thus, in the literature it has been mentioned that the clinical accuracy of this score varies especially when comparing patients in larger, inhomogeneous patient groups. The “relative Constant score” (CS_rel) tries to minimize these problems by using reference parameters out of healthy age and gender related control groups. The authors of this study tried to show that it is even more accurate to use the functional performance of the uninjured collateral shoulder of the same individual as reference, introducing the “individual relative Constant score” (CS_indiv). The CS_indiv and the CS_rel were compared for 125 consecutive patients with shoulder disorders, and a group of 125 healthy volunteers as a control group.

In a non-parametric comparison of the reciever operating characteristics the CS_indiv shows the higher ability to discriminate between patients and healthy volunteers (p = 0.004). This indicates that the individual relative Constant score gives a more accurate view about the functional result for shoulder disorders. It is expected to be more reliable for larger and incoherent patient populations, because specific interindividual differences, regarding the patient's age, gender and constitution are eliminated as well as other individual physiological parameters.

Introduction

Since its introduction in 1987, the Constant score has evolved to one of the most frequently used scoring systems in the follow-up of shoulder injuries.7, 9 This diagnostic tool is based on objective parameters (65%) as well as on subjective parameters (35%).¹⁶ There is a total of 100 points for the assessment of the injured shoulder. Ten points each are calculated for internal rotation, external rotation, lateral elevation, forward elevation and positioning of the arm. In addition, 10 points are given for the ability to perform activities of daily living. Pain, as a subjective parameter, is included with 15 points and strength with a maximum of 25 points.

Several authors discussed the significance of the Constant score and concluded that the use of an absolute value can lead to incoherent results, particularly in inhomogeneous groups of patients (e.g., concerning age and gender distribution).⁶ Therefore, the so-called relative Constant score was introduced.7, 8 It is based on average values using a healthy population sorted by gender and age in decades (see Table 1). The relative Constant score is expressed as a percentage of the respective reference values. Regarding the clinical accuracy of this score, there is still a broad range of values seen in the standardised groups of patients.

The authors of this study hypothesised that the sole adjustment to gender and age is still insufficient. A countless number of individual factors, such as strength, biological fitness and many other physiological variables are not included in the relative Constant score. Subsequently the goal of our study was to develop the so-called “individual relative Constant score” (CS_indiv), which is based on the performance of the contra-lateral, unaffected shoulder of the individual patient as a reference. The data obtained by using this score was statistically evaluated and compared with the application of the “relative Constant score” (CS_rel).

Section snippets

Patients and methods

The study included a consecutive group of 125 patients (87 male and 38 female). All patients were seen at the Shoulder Service of the Department of Traumatology, Vienna General Hospital. The average age was 43 years (ranging from 18 to 91 years). Inclusion criteria were patients with an injured shoulder, under current treatment, a negative history of the opposite shoulder, and a minimum age of 18 years. All patients agreed to be included into the study.

The control group consisted of 125

Results

All 250 patients and control persons were divided into subgroups according to life decades as suggested by Constant, forming 125 matched pairs. The study population was built out of 87 male and 38 female individuals. More than 50% (66/125) were younger than 40 years. The shoulder pathologies were mainly instabilities of the glenohumeral or acromioclavicular joint (56/125), rotator cuff lesions (37/125), intrarticular fractures (15/125) and various degenerative conditions of the shoulder

Discussion

Scoring systems have not only evolved as a major diagnostic tool but are also frequently used for the post-operative prognosis of patients. In addition, they serve as accepted tools for scientific means, such as comparison of various surgical techniques or different groups of patients.7, 12, 13, 22, 24

The use of the most scoring systems is limited to very specific questions. If the indication for these scores is extended to other pathologies concerning the same joint, statistical mistakes are

Conclusion

Our results show that the use of the Constant score leads to more accurate results if the findings of the index extremity are compared with the performance of the collateral uninjured side, rather than being compared to reference parameters of age and gender matched groups of individuals, as recommended before. To use the same individual as its own reference allows a custom made prognosis in daily practice in the treatment of each patient, because the goal of treatment is the individual

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The footprint medialization allows a tension free repair in severely retracted rotator cuff tears (RCT), thereby de-creasing the rate of retear. The purpose of the study was to evaluate the clinical and radiological results in a cohort of chronic RCT treated with medialized repair. Secondary purpose was to analyze the impact of medialization length on shoulder function and tendon healing.
It was hypothesized that the medialization length would have an impact on clinical and radiological outcome.
A consecutive series of thirty patients that underwent arthroscopic repair of a massive posterosuperior RCT at a single institution were retrospectively studied at mean follow-up 18.4 months (SD 15.3; range 9–58). The medialization of the medial footprint was measured intraoperatively. Preoperative and postoperative examination included active range of motion, abduction strength, pain assessment, and functional scores. The postoperative rotator cuff integrity was evaluated according to the Sugaya's classification. Types IV–V were categorized as absence of healing.
At final follow-up the clinical outcomes were significantly improved in all patients (p ≤ 0.001) with the exception of external rotation that displayed no significant improvement (p = 0.05). In group 1 (n = 8) medialization length was ≤ 10 mm (mean 8, SD 1.9) and in group 2 (n = 14) > 10 mm (mean 12.6, SD 1.7). There were no significant differences regarding preoperative and postoperative clinical outcomes (p > 0.05) between two groups. Group 2 demonstrated moderate correlation between length of medialization and Sugaya stage of tendon healing (r = 0.53, p = 0.049). Absence of healing was noted in 4/22 patients, 1/8 in group 1 and 3/14 in group 2.
Medialized repair is an effective technique for treating chronic, massive and retracted posterosuperior RCT. A medialization of the footprint less than or equal to 10 mm is recommended, as it was associated with good clinical and radiological results. The rate of tendon healing decreases when medialization exceeds 10 mm.
III.
Medialized rotator cuff repair for retracted, massive, postero superior tears: Clinical and radiological outcomes
2023, Revue de Chirurgie Orthopedique et Traumatologique
La médialisation de la réinsertion d’une rupture des tendons de la coiffe des rotateurs rétractée à la glène permet une réparation sans tension, diminuant ainsi le taux de re-rupture. Le but de l’étude était d’évaluer les résultats cliniques et radiologiques d’une cohorte de ruptures de la coiffe des rotateurs traitées par une technique de médialisation de la réparation. Le but secondaire était d’analyser l’impact de la longueur de cette médialisation sur la fonction de l’épaule et la cicatrisation du tendon.
L’hypothèse était que la longueur de la médialisation de la réinsertion aurait un impact sur les résultats cliniques et radiologiques.
Il s’agit d’une étude rétrospective de 30 patients, présentant une rupture da la coiffe des rotateurs chronique, postéro-supérieure massive ayant bénéficié d’une réparation arthroscopique selon une technique de médialisation. La médialisation de la réinsertion du tendon a été mesurée en peropératoire. Les examens préopératoires et postopératoires comprenaient l’amplitude active des mouvements, la force d’abduction, l’évaluation de la douleur et les scores fonctionnels. L’intégrité postopératoire de la coiffe des rotateurs a été évaluée selon la classification de Sugaya. Les types IV-V ont été classés comme un défaut complet de cicatrisation tendineuse.
Avec un recul moyen de 18,4 mois (SD 15,3 ; gamme 9–58) les résultats cliniques ont été significativement améliorés chez tous les patients (p ≤ 0,001), à l’exception de la rotation externe qui n’a montré aucune amélioration significative (p = 0,05). Dans le groupe 1 (n = 8), la longueur de médialisation était inférieure ou égale à 10 mm (moyenne 8, écart-type 1,9) et dans le groupe 2 (n = 14) supérieur ou égale à 10 mm (moyenne 12,6, écart-type 1,7). Il n’y avait pas de différence significative concernant les résultats cliniques préopératoires et postopératoires (p > 0,05) entre les deux groupes. Le groupe 2 a démontré une corrélation modérée entre la longueur de la médialisation et le stade de Sugaya de la cicatrisation du tendon (r = 0,53, p = 0,049). Une absence de cicatrisation a été notée chez 4 patients sur 22 soit 1/8 dans le groupe 1 et 3/14 dans le groupe 2.
La réinsertion des tendons de la coiffe des rotateurs selon la technique de médialisation est efficace pour traiter les ruptures postéro-supérieures chroniques, massives et rétractées à la glène. Une médialisation égale ou inférieure à 10 mm est recommandée, car elle a été associée à de bons résultats cliniques et radiologiques. Le taux de cicatrisation du tendon diminue lorsque la médialisation dépasse 10 mm.
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The normative Western Ontario Rotator Cuff Index values for age and sex
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Citation Excerpt :
It was conceived to assess overall shoulder function and is independent of the diagnosis.2 The clinical accuracy of the Constant score varies, especially when comparing patients in larger, inhomogeneous patient groups.7 In the Constant score, only 35 of 100 points are allocated for subjective assessment.
The Western Ontario Rotator Cuff Index (WORC) is a widely used disease-specific outcome tool developed for patients with rotator cuff injuries. The determination of age- and sex-adjusted normative WORC values enables us to determine whether a procedure is more beneficial in specific patient groups because the results can be compared with a matched standard. The purpose of this study was to determine normative WORC values and assess whether the WORC needs an adjusted score for age and sex.
We included participants using an online data-capturing program. We collected the following variables: age, sex, presence of shoulder pathology, Subjective Shoulder Value, and WORC score. We defined the mean normative WORC score per age category and analyzed sex differences in WORC scores per age category and in all domains of the WORC score.
A total of 470 participants filled out the questionnaire. We excluded 44 participants because of pre-existing shoulder complaints or incomplete questionnaires. The mean total WORC score was 94% (standard deviation, 9%), and the mean total WORC score in every age and sex category was >90%. Of all participants, 85% scored between 91% and 100%; 63 participants (15%) scored 100%. The mean overall Subjective Shoulder Value was 98% (standard deviation, 6%). We found no statistically significant differences between sexes in the overall score, in the domain scores, and within the age categories.
We defined normative values for the WORC questionnaire in a random prospective cohort and found no difference in scores between sexes. The mean normative scores all were within the variance of the maximum, and the WORC score did not deteriorate with age. It seems that the results of this subjective questionnaire change with the participant's perspective. An adjusted WORC score for age and sex is not necessary. This information can serve as a basis for comparison with patients with shoulder disease.
Interchangeability of Diverse Analog Scales Used Within the Constant–Murley Score
2021, Arthroscopy, Sports Medicine, and Rehabilitation
To assess the interchangeability of various existing answering scales within the subjective part of the Constant–Murley Score (CMS) and to determine the effect of the different answering scales on the inter- and intraobserver reliability.
In this prospective, single-center, cross-sectional trial, patients with shoulder problems were included from June to September 2018. Subjects recruited were 18 years or older, presented various shoulder complaints, e.g., diagnosis of osteoarthritis, subacromial pain syndrome, rotator cuff or biceps tendon problems, or frozen shoulder. An extended version of the CMS was prepared including the same questions multiple times but with varying answer scales. Six versions were made with random order of the questions. The answering scales were a verbal and paper based visual analog scale (VAS), smiley face scale, Numeric Rating Scale (NRS), and categories. Internal consistency of the various CMS, Spearman correlation coefficients, intraobserver, and interobserver agreement was assessed (ICC).
In total, 93 patients were included. The total CMS using the paper-based VAS, smiley face score, and NRS were 46.9 ± 19.4, 45.2 ± 18.5, and 45.0 ± 18.7. Correlations of the total scores of the different versions varied from 0.98 to 0.99. CMS-category versus CMS-smiley face score and CMS-category versus CMS-NRS pain were significantly different (P = .02 and P = .01). Good internal consistency (0.76-0.79) and acceptable inter- and intraobserver reliability were found (ICC: 0.89-0.97, 0.98-0.99; P < .001).
The different answering scales for the subjective subscales within the CMS for pain, work, and recreational activity were not interchangeable on item level and significantly influenced the total CMS score. Differences were below the smallest detectable change and interpreted as not clinically relevant. Particularly on item level, data from different studies cannot be pooled and compared when different answering scales are being used. The inter- and intraobserver reliability were excellent.
Level I, prospective cross-sectional study.
Video examination via the smartphone: A reliable tool for shoulder function assessment using the constant score
2019, Journal of Orthopaedic Science
The use of video examinations (VE) may improve patient care by offering them a low-cost and easy access to physicians, save traveling expenses and shorten waiting time. The aim of this study was to validate the use of Smartphones for distant assessment of shoulder function by comparing the Constant scores (CS) of patients obtained by both VE and conventional face-to-face (FTF) examination.
Fifty-one subjects (age 19–80 years; women:men 18:33) who presented to a shoulder clinic with a variety of complaints were prospectively recruited and underwent FTF and VE in alternating order. CS obtained by the two methods were compared. Four patients were unable to complete the VE due to technical problems or non-compliance.
Forty-seven (92%) subjects successfully completed both examinations. The mean difference in CS was −0.53 points (95%CI: −2.6:1.6), with limits of agreement of −7.7:6 points. Agreement of correlation coefficient, accuracy and precision were 0.91 (95%CI: 0.86:0.96), 0.99 (95%CI: 0.92:1.00) and 0.91 (95%CI: 0.86:0.96), respectively.
VE can obtain a reliable estimate of shoulder function. The mean video CS was only −0.53 points from the mean frontal CS. Individual variations of CS did not exceed a 7-point distance from the “gold standard” estimate.
Shoulder strength value differences between genders and age groups
2018, Journal of Shoulder and Elbow Surgery
The strength of a normal shoulder differs according to gender and decreases with age. Therefore, the Constant score, which is a shoulder function measurement tool that allocates 25% of the final score to strength, differs from the absolute values but likely reflects a normal shoulder. To compare group results, a normalized Constant score is needed, and the first step to achieving normalization involves statistically establishing the gender differences and age-related decline. In this investigation, we sought to verify the gender difference and age-related decline in strength.
We obtained a randomized representative sample of the general population in a small to medium-sized Spanish city. We then invited this population to participate in our study, and we measured their shoulder strength. We performed a statistical analysis with a power of 80% and a P value < .05.
We observed a statistically significant difference between the genders and a statistically significant decline with age.
To the best of our knowledge, this is the first investigation to study a representative sample of the general population from which conclusions can be drawn regarding Constant score normalization.

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Modification of the Constant–Murley shoulder score—introduction of the individual relative Constant score: Individual shoulder assessment

Summary

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Age and sex related Constant–Murley score

J Shoulder Elbow Surg

Shoulder joint movement and its relationship to disability in the elderly

J Rheumatol

An evaluation of the Constant–Murley shoulder assessment

J Bone Joint Surg Br

Assessment of shoulder function

Orthopade