Sports Medicine Research: In the Lab & In the Field: Aggressive versus Limited Early Passive Exercises After Rotator Cuff Repair (Sports Med Res)


Friday, April 20, 2012

Aggressive versus Limited Early Passive Exercises After 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.

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

Related Posts:
Is Early Passive Motion Exercise Necessary After Arthroscopic Rotator Cuff Repair?
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


Jeffrey Driban said...

Steve: Nice post. Is it accurate to state that you are advocating limited early passive stretching after a rotator cuff repair instead of aggressive early motion? Both groups seem to have similar range of motion and function after a year but didn't the early aggressive motion group have better results during the first few months, which may translate to earlier return to activities (granted that needs to be tested)? It seems like your decision is being influenced by the retear rate but among such a small sample size it's hard to tell which group would really have the higher retear rate. In fact, the Kim article that was reviewed in January (first link under "Related Posts") had a larger sample size and found no differences between retears among those performing early range of motion or immobilization. If the retear data is actually equivalent between groups would you still slow the patient's recovery? Thanks!

Stephen Thomas said...

Jeff thanks for the comment. You are correct based on this study it is difficult to determine if the retear rate is actually different between groups. However, animal model research has shown better tendon to bone healing of the supraspinatus with longer immobilization. There are also a large number of factors that may increase your chance of retear that are completely out of our control (duration of tear, fatty degeneration, etc). So it is difficult to determine what is causing the retears. Some patients may retear regardless of the rehab protocol. The one finding I did find encouraging is that in terms of ROM and function at 1 year both groups were the same. We often are worried about leaving patients immobilized for longer durations due to having difficulties with stiffness and ROM. This study shows that stiffness and ROM can be returned to normal values. If I have a patient that is older and has other conditions that may increase the chances of a successful rotator cuff repair I would immobilize them for longer durations. There is no down side to it.

Anonymous said...

Can you advise the rates of adhesive capsulitis following rotator cuff repair? Can you direct me to research regarding treatment for Frozen Shoulder post 12 months?

Stephen Thomas, PhD, ATC said...

The numbers are typically variable but here is one study suggesting it is around 15% ( As for the treatment post 12 months I don't know of any specific research but the treatment is typically very similar. If the patient isnt making gains in rehab then they might elect for alternative treatments. These may include corticosteroid injections, surgical manipulation, or arthroscopic release.

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