A review of the Constant score: Modifications and guidelines for its use Christopher R. Constant, MA, LLM, MCh, FRCS, Christian Gerber, MD, Roger J. H. Emery, MS, FRCS(Ed), Jens Ole Søjbjerg, MD, Frank Gohlke, MD, and Pascal Boileau, MD, Saint-Genis-Laval, France, and London, England INTRODUCTION The requirement to assess surgical results and the means of quantifying them have always provoked intense debate. 3 Since Codman’s introduction of ‘‘the end result idea,’’ the main aim in assessment has not changed, but our requirements are now more sophisticated and include observation of natural history, follow-up, and disability quantification. The Constant score was devised by Christopher Constant with the assistance of the late Alan Murley during the years 1981-1986. The score was first pre- sented in a university thesis in 1986 6 and the method- ology published in 1987. 5 This functional assessment score was conceived as a system of assessing the over- all value, or functional state, of a normal, a diseased, or a treated shoulder. If universally accepted, it would further progress in clinical research in shoulder sur- gery and enhance the value of multicenter trials. In this score, 35 points are allocated for subjective assessments of pain and activities of daily living and 65 points are available for objective measures of range of movement and shoulder strength. A young healthy patient can therefore have a maximum score of 100 points. METHODOLOGY Pain Pain is allotted 15 points; the assessment is made on the most severe pain felt by the patient during ordinary activities over a 24-hour period. Thus, many patients will be recording the most severe pain at night. Previously, pain was graded as none, mild, moderate, or severe. This has been replaced by a visual analog scale. It has been proposed that a sliding cursor system with an ungraduated line marked at either end with ‘‘no pain’’ and ‘‘intolerable pain,’’ respectively, be used (Figure 1). Equivalent terms have been agreed on for the French language. The numeric score can be seen on the reverse side of the scale. It is important to stress that episodic severe pain (eg, as in disloca- tion) is not relevant to a functional assessment score. Activities of daily living The activities of daily living can score a total of 20 points. Undisturbed sleep is allotted 2 points; occa- sional disturbance, 1 point; and disturbance every night, 0 points. Eight points are allotted to work and recreational activities. This is scored from 1 to 4 on a fractional basis as a response to the following ques- tions: ‘‘How much of your normal work does your shoulder allow?’’ and ‘‘How much of your normal rec- reational activity does your shoulder allow?’’ This would similarly be assessed on a visual analog scale with a sliding cursor (Figure 1). The terms ‘‘all’’ and ‘‘none’’ define the range. Activities of daily living also include the ability to functionally use the arm up to a certain level, and this part of the assessment is allotted up to a further 10 points. This is recorded by asking patients to which level they can use their hand comfortably, from below the waist (0 points) to above the head (10 points) (Table I). Movement The 40 points allotted to movement are divided equally into forward elevation, lateral elevation, func- tional external rotation, and functional internal rota- tion. All movements must be painless and active. These functional movements are composite and dis- tinct from the standard assessment of range of motion (ie, as commonly used for diagnostic purposes). The range of functional active movement is assessed. Thus, if the subject can lift his or her arm to 140  with pain but gets to 110  without pain, the value cho- sen in the score is 110  . Pain-free forward elevation and lateral elevation should be measured with a goniometer, with the pa- tient seated to avoid spinal tilting. The reference points are the axis of the arm and the spinous processes of the From the Research and Development Committee, Socie ´te ´ Europe ´- enne pour la Chiurgie de l’E ´ paule et du Coude Reprint requests: Roger J. H. Emery, MS, FRCS(Ed), St Mary’s Hospi- tal, Imperial College London, Surgical Oncology and Technology, Praed Street, 10th Floor, QEQM Building, London, England W1 1NY (E-mail: roger.emery@dial.pipex.com). Copyright ª 2008 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2008/$34.00 doi:10.1016/j.jse.2007.06.022 355