SCORINGSYSTEMS FOR THE SHOULDER

BACKGROUND

The European Society for Shoulder and Elbow Surgery adopted the scoring system of C Constant and A Murley [1, 2, 3, 4, 5].
This scoring system consists of four variables that are used to assess the function of the shoulder. The right and left shoulders are assessed separately.
The subjective variables are pain and ADL (sleep, work, recreation / sport) which give a total of 35 points.
The objective variables are range of motion and strength which give a total of 65 points.
Altogether there are a total of 100 points:
SUBJECTIVE
Pain 15
ADL (sleep, work, recreation/sport) 20

OBJECTIVE
Range of motion 40
Strength 25


The Society of American Shoulder and Elbow Surgeons (ASES) only scores ; pain and function [6]. Other variables are presented individually. The Society believes that their evaluation form is purosely breif encompassing the lowest acceptable number of questions and examinations that should be administered at a quality follow-up of shoulder patients.




RANGE OF MOTION
Passive and active range of motion
Active and passive range of motion should always be measured!
A description is given below of the difference between range of motion measured according to European and American standards.

The European Society for Shoulder and Elbow Surgery (ESSES) measures range of motion according to the Constant score with the patient sitting on a chair or bed, with weight even distributed between the ischial tuberosities. No rotation of the upper body may take place during the examination.
In the case of active motion, the patient  lift his arm to a painfree level. Note that the number of degrees at which the pain starts determines the range of motion. If one measures the active range of motion with pain, this should be stated. The Constant score cannot then be applied beyond the initiation of pain.

The Society of American Shoulder and Elbow Surgeons (ASES) measures active motion in the same way, but in the case of passive motion, the patient lies on a bed.
Take note that the active range of motion is not as well defined according to painfree motion as the Constant score.
The most important thing is that range of motion is performed and measured in a standardized way.




Flexion / Elevation
The Constant score measures flexion and the Society of American Shoulder and Elbow Surgeons measures elevation.
During an examination of 341 patients in Uppsala who were measured preoperatively, we compared elevation and forward flexion in the healthy shoulder.
We found no statistically significant differences. In other words, elevation and forward flexion are comparable.
This is not true when measuring strength.


Number of patients Difference in degrees
290 0
40 5
5 15
4 20
2 25


Internal rotation posteriorly
The European Society for Shoulder and Elbow Surgery and The Society of American Shoulder and Elbow Surgeons  have the common feature that they both measure the anatomical landmarks reached by the end of the thumb.
These landmarks are the greater trochanter, the gluteal region and the sacroiliac joint. In the USA every vertebra is counted, while in Europe one measures up to L3 / the waist, up to Th12, and up to Th7 / interscapularly.



Other range of motion
External rotation is measured in The European Society according to a point system in the Constant score depending on where the elbow and hand are in relation to the head. The hand is not allowed to touch the head.
Forward flexion, abduction and internal rotation posteriorly are also measured.

In The American Society one measures elevation, external rotation with the arm in an abducted position of 0 and 90 degrees, internal rotation posteriorly and cross body adduction.
Cross body adduction, is measured in cm from the opposing acromion's front edge to the elbow crease. The same motion can be performed in degrees and is then called horizontal flexion. The cm is the unit of measurements which applies according to the recommendations of the American Society.

RANGE OF MOTION ESSES ASES
Flexion X
Elevation X
Abduction X
External rotation abd 0 X
External rotation abd 90 X
External rotation according to Constant X
Internal rotation posteriorly X X
Cross body adduction X


Point assessment of range of motion according to the
Constant score

In the Constant score system there is precise information about how the points are calculated. Bear in mind that 150 degrees of flexion give 8 points, while 151 degrees give 10 points. In the USA no points are calculated for this.

Forward flexion 10 points
0-30 0
31-60 2
61-90 4
91-120 6
121-150 8
151-180 10

Abduction 10 points
0-30 0
31-60 2
61-90 4
91-120 6
121-150 8
151-180 10

External rotation 10 points (hand is not allowed to touch the head)
Not reaching the head 0
Hand behind head with elbow forward 2
Hand behind head with elbow back 2
Hand on top of head with elbow forward 2
Hand on top of head with elbow back 2
Full elevation from on top of head 2

Internal rotation 10 points
End of the thumb to lateral thigh 0
End of the thumb to buttock 2
End of the thumb to lumbosacral junction 4
End of the thumb to L3 (waist) 6
End of the thumb to T 12 8
End of the thumb to T 7(interscapular) 10



STRENGTH
The objectivisation of strength has been, and continues to be, the
subject of much discussion.
The European Society for Shoulder and Elbow Surgery measures
strenght according to Constant score and it is given a maximum of
25 points.

The Society of American Shoulder and Elbow Surgeons measures
strength by having the examiner offer resistance to the patient's
arm. Strength is measured in 4 different directions, and it is
measured on a 5-grade scale.
Strength is measured in the following directions:

Elevation
Abduction
Internal rotation in 0 degrees of abduction.
External rotation in 0 degrees of abduction.

Strength is graded as follows:
No contractions 0
Flicker 1
Movement with gravity eliminated 2
Movement against gravity 3
Movement against some resistance 4
Normal power 5


QUALITY ASSURANCE
Before the treatment is started, subjective and objective variables should be measured.
Do not measure only for the sake of publicational.
Measure to check the quality of your own performance.



REFERENCES

1. Constant C R, Murley A H G. A clinical method of functional
assessment of the shoulder. Clinical Orthopaedics and Related Reserch
1987; 214: 160-164.
2. Constant C R. Assessment of the shoulder. In: Watson M. Surgical
disorders of the shoulder. Churchill Livingstone, New York. 1991; 39-45.
3. Constant C R. Constant Scoring Technique for Shoulder Function.
SECEC information. 1991. Nr 3
4. Gerber C. Integrated Scoring Systems for the Functional Assessment
of the Shoulder. In: Matsen F, Fu F, Hawkins (red). The Shoulder:
A Balance of Mobility and Stability. Rosemont, 1992; 531-50.
5. Circular to members of British Shoulder and Elbow Society. 1997.
6. Research Committee American Shoulder and Elbow Surgeons.
J Shoulder Elbow Surg 1994; 3: 347-52.