Do you see better outcomes with longer immobilization after a rotator cuff repair?

Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises

Lee BG, Cho NS, Rhee YG. Arthroscopy. 2012 Jan;28(1):34-42. Epub 2011 Oct 20. http://www.ncbi.nlm.nih.gov/pubmed/22014477

Rotator cuff tears are common injuries to the shoulder and typically require surgical repair. The success of the repair has had mixed results due to several controllable and uncontrollable factors. One factor that is controllable is the rehabilitation following surgery. It is currently not known if more early aggressive motion or a more limited early motion rehabilitation protocol is more effective for proper rotator cuff healing. Therefore, the objective of this study was to compare the clinical and structural outcome between 2 different rehabilitation protocols after arthroscopic single-row repair for full-thickness rotator cuff tears. Sixty-four patients with full-thickness rotator cuff repairs were randomly assigned to either the aggressive early passive rehabilitation group (immediate passive motion with no limitation; twice per day for 6 weeks) or the limited early passive rehabilitation group (minimum passive stretching to prevent joint stiffness; twice per day for 3 weeks). For the remaining 3 weeks both groups performed the same rehabilitation. Six weeks following surgery both groups received the same rehabilitation program, which progressed through shoulder strengthening and a return-to-activity protocol. Patients were examined for pain (visual analog score, VAS), shoulder range of motion (forward flexion, external rotation at side and 90°, internal rotation at 90°, and abduction), shoulder strength (same as range of motion), functional outcome questionnaire (University of California, Los Angeles score, UCLA), and structural tendon assessment (magnetic resonance imaging) pre-operatively and at 3, 6, and 12 months post-operatively. They found that pain significantly decreased and shoulder strength increased in both groups following surgery at all time points; however, there was no significant difference in pain between the groups. The aggressive group had larger amounts of shoulder range of motion at 3 and 6 months post-operatively; however, at one year follow-up there were no significant differences between the groups. For the UCLA score the aggressive group had significantly improved scores at 3 months post-operatively; however, at 6 and 12 months there were no group differences. When assessing the structural integrity of the tendon at 12 months post-operatively the aggressive group had a re-tear rate of 23.3% while the limited group had a re-tear rate of 8.8% (these findings were not statistically different).

This is an interesting study that examines the structural and functional outcome measures of two different rehabilitation strategies following rotator cuff repair. Previous work from Soslowski’s lab has found that extended immobilization following supraspinatus repair improves tendon to bone healing in a rat model. Research examining the Achilles tendon has found that early mobilization improves healing following a surgical repair. This is unlike the current results found in the rotator cuff. These results may be characteristic to the rotator cuff tendons due to their loading environment and function. In addition, the rotator cuff tendon retracts following a tear and requires large loads to reapproximate the tendon to the humeral attachment site. Many of these factors likely contribute to the high re-tear rates and also the need for longer bouts of immobilization following repair. The most significant results in the current study are that the limited motion group had a lower re-tear rate (which was not significant) and that the range of motion was not significantly different at 12 months post-operatively. One reason for initiating passive motion early is to prevent the shoulder from becoming stiff. However, these results suggest that range of motion is not different at 12 months and therefore longer amounts of immobilization do not cause secondary stiffness that will decrease the patient’s functional outcome. How many of your rotator cuff repair patients are being immobilized for longer periods of time? Do you see better outcomes with longer immobilization?

Written by: Stephen Thomas
Reviewed by: Jeffrey Driban

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Lee BG, Cho NS, & Rhee YG (2012). Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy, 28 (1), 34-42 PMID: 22014477