Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. Previous studies have indicated that the CS values associated with a full-thickness rotator cuff tear (RCT) are lower than for normal shoulders. This study was designed to investigate which parameters of the CS were most influenced by the presence of a RCT. As ultrasonograpy has now been shown to have a high accuracy for diagnosing full-thickness RCTs it was used to establish the diagnosis.

Methods: 28 patients attending the Shoulder Clinic were invited to take part in this study for which Local Ethics Committee approval had been obtained. The majority of patients had a painful shoulder on at least one side. All patients had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a commercial myometer – M(max); 3) mean force from 2 to 4 seconds using a commcercial Myometer – M(mean). The CS was measured with no knowledge of the patient’s history or diagnosis and blinded to the state of the rotator cuff. The patients were then assessed using ultrasonograpy of the shoulder (Diasus with an 8–16MHz head) to establish the presence of a full-thickness RCT.

Results: The CS Values for the left and right shoulders have been analysed separately.

The results have also been analysed for each part of the Constant Score – Pain, Activities of Daily Living, Range of Movement and Strength and these will be presented.

Discussion: It was anticipated that subjects with a RCT would be found to be weaker and have a reduced CS in an affected shoulder. This was found to be the case for the left shoulder but not for the right. The reasons for this will be discussed. The abnormally low CS for the normal right shoulders (Group 1) will also be explored.

Conclusion: The CS may be a valuable method of identifying those patients with a RCT. This study indicates that a more careful evaluation of “Strength” measurements still needs to be undertaken.

Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. It has been observed that the CS values decrease with age and attempts have been made in Canada (Constant, 1986), Germany (Tempelhof, 1999), Switzerland (Gerber, 1992) and US (Romeo, 2002) to produce national norms against which the subject’s Constant Score might be compared. Unfortunately the methods used for measuring the “Strength” category of the CS have varied and thus the results are not uniformly comparable. This study has used three methods of evaluating “Strength” for the CS in a randomised group of subjects aged over 50 in order to establish the UK norms.

Methods: 200 patients stratified for age over 50 were invited to take part in this study for which Local Ethics Committee approval had been obtained. Of these 200, 46 patients (21 males) attended and all attenders had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a commercial myometer – M(max); 3) mean force from 2 to 4 seconds using a commercial Myometer – M(mean). The CS values have been plotted for age and sex.

Results: The results for the 25 females and 21 males using M(mean) are shown below. The middle line represents the linear regression with the 95% Confidence Intervals above and below.

Discussion: The results confirm that there is a deterioration in the CS with age in both men and women. The outliers in three of the four graphs will be discussed and the analysis represented after removal of outliers for which there is a justification for exclusion. The differences between the left and right shoulders will be discussed.

Significant differences were identified between the 3 methods of “Strength” measurement, highlighing the need for a uniform method of carrying out the CS.

Conclusion: The UK pattern of deteriorating CS with age mirrors that seen in other countries but the values are different. These differences are significant and make it necessary to reconsider the use of the corrected CS. It is probably wiser to use the uncorrected CS but refer to normal values as a guide for the expected CS at different ages.

Introduction: Our previous work has shown that angiogenesis occurs within the cartilaginous callus during long bone fracture healing1. Our aim in this study was to investigate the mechanisms involved in endochondral ossification within callus tissue during the secondary stages of fracture healing.

Methods: In this study, immunohistochemical techniques were used to localise the following proteins within the fracture callus at different times following injury. The angiogenic factors vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) were localised; bFGF is also involved in matrix remodelling and cell proliferation. In addition, urokinase plasminogen activator and its receptor (uPA and uPAr respectively), a proteolytic enzyme involved in matrix remodelling, was immunolocalised. The model used for the study was a standardised midtibial osteotomy performed on New Zealand white rabbits.

Results: Results showed that from early time points, VEGF and bFGF were detected in pericellular locations around the chondrocytes. However, VEGF was only detected around the chondrocytes in close proximity to infiltrating vessels whereas homogenous localisation of bFGF was seen throughout the cartilage. Urokinase was localised throughout the cartilage callus as well as within vascular cavities and its receptor was detected on the chondrocyte cell surface from early time points.

Discussion: The immunolocalisation of VEGF around large hypertrophic chondrocytes in close proximity to infiltrating vessels suggests that this growth factor plays a role in chondrocyte hypertrophy and death, similar to its role in the growth plate. In contrast, bFGF was strongly detected throughout cartilage from early time points, suggesting that it may also be involved with cartilage proliferation during callus formation and subsequent matrix remodelling. The localisation of urokinase around chondrocytes and within vascular cavities suggests that this enzyme plays an important role in matrix remodelling and the vascularisation of the cartilage. In conclusion, our work suggests that the following sequence of events takes place within the cartilaginous callus. Firstly, bFGF is involved in the rapid proliferation of chondrocytes in the early stages of cartilage formation following fracture. Chondrocytes then express high levels of urokinase and its receptor which is actively involved in the degradation of cartilage matrix and formation of vascular spaces which leads to angiogenesis, VEGF expression, chondrocyte hypertrophy and eventual death.

Introduction and Aims: To establish whether basic fibroblast growth factor (bFGF) plays a role in the changes in chondrocyte metabolism exhibited in human osteoarthritis (OA).

Method: BFGF and its receptor was localised by immunohistochemistry within human OA. The results from OA tissue graded ‘early’ and ‘advanced’ were compared. This was correlated with the identification of proliferating chondrocytes (using by localising PCNA) and dead/dying chondrocytes (using the TUNEL technique).

Results: Results showed that bFGF and its receptor were strongly localised around chondrocytes in proliferating clusters in ‘early’ OA, whereas no bFGF was detected in ‘advanced’ OA. In addition, a loss of bFGF activity in ‘advanced’ OA correlated with the identification of large numbers of dead/dying chondrocytes.

Conclusion: Results suggest that high levels of bFGF activity in OA play an important role in chondrocyte proliferation and the formation of chondrocyte clusters. In addition, the loss of this activity appears to be directly related to an increase in cell death in ‘advanced’ OA, suggesting that bFGF acts as a ‘survival’ factor in this tissue. The more we understand about the metabolic changes in chondrocytes during OA, the closer we come to delaying or preventing this debilitating joint disease.

Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. It has been observed that CS values decrease with age and attempts have been made in Canada (Constant, 1986), Germany (Tempelhof, 1999), Switzerland (Gerber, 1992) and US (Romeo, 2002) to produce national norms. Unfortunately the methods used for measuring the “Strength” category of the CS have varied. This study aimed to establish UK norms.

Methods: 200 patients stratified for age over 50 were invited to take part in this study for which Local Ethics Committee approval had been obtained. Of these 200, 46 patients (21 males) attended and all attendees had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a Nottingham myometer – M(max); 3) mean force from 2 to 4 seconds using a Nottingham myometer – M(mean). Results: The results for the 25 females and 21 males using M(mean) show a general trend of decreasing Constant Score with increasing age for the left and right shoulders of both the male and female subjects. There were some outliers, particularly in the female results, which were reflected in widened 95% confidence intervals. Paired student t-tests found statistically significant differences between M(mean) and FSB (max) results (left, p< 0.01; right, p=0.013) and M(mean) and M(max) (left, p< 0.01; right, p< 0.01).

Discussion: The results confirm deterioration in the CS with age in both men and women. Constant Score values from our study differ from previous studies, with up to 15 points difference between our results and those from Romeo 2002.

Significant differences were identified between the 3 methods of “Strength” measurement, highlighting the need for a uniform method of carrying out the CS. Conclusion: The UK pattern of deteriorating CS with age mirrors that seen in other countries but the values are different. These differences are significant and make it necessary to reconsider the use of the corrected CS. It is probably wiser to use the uncorrected CS but refer to normal values as a guide for the expected CS at different ages.

Introduction: This study was designed to investigate which parameters of the Constant Score are most influenced by the presence of a Rotator Cuff Tear (RCT).

Methods: 28 patients attending the Shoulder Clinic took part in this study for which Ethics approval had been obtained. Strength measurements were assessed in three ways: 1) maximum force using a fixed spring balance (FSB) 2) maximum force using the Nottingham Mecmesin Myometer 3) mean force during 2nd to 4th seconds using Nottingham Myometer. The CS assessor was blind to the volunteer’s history and state of their rotator cuff. Ultrasonography was used to establish the presence of a full-thickness RCT.

Results: The CS values for the left and right shoulders were analysed separately. No statistically significant difference (p> 0.05) was found between shoulders with a RCT and without a RCT in the pain, ADL and ROM parameters. Left shoulders with a RCT scored significantly different strength scores to those without (p< 0.05) but this significance was not seen in the right shoulders (p> 0.05). Shoulder strength measurements were highest with the FSB and lowest when measured using the mean force.

Discussion: The results obtained so far suggest that a shoulder with a full-thickness tear of the RC may obtain a significantly lower strength score than a normal shoulder. It does not suggest that any of the other three parameters of the CS can indicate the presence of a tear.

Conclusion: A reduction of shoulder strength alone might be a good indicator of a full-thickness RCT. However, this study indicates the importance of standardising the method of shoulder strength assessment for the Constant Score.