Is Early Passive Motion Exercise Necessary After Arthroscopic Rotator Cuff Repair?
Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Am J Sports Med. 2012 Jan 27. [Epub ahead of print]
Rotator cuff tears occur frequently and commonly require surgical repair to decrease pain and restore function. The success of rotator cuff repairs widely varies and both clinicians and researchers have been examining causes for failed healing. Post-op rehabilitation has been considered one of the limiting factors for successful rotator cuff healing specifically the amount of immobilization. Early motion has been the standard treatment option following surgical repair to reduce joint stiffness but several animal studies have found improved tendon healing following longer amounts of immobilization. Therefore, the objective of this randomized clinical trial was to determine if immobilization following rotator cuff repair improves functional outcomes and tendon healing in humans compared to early passive motion. Kim et al. divided 105 small (< 1cm) to medium (1 to 3cm) sized rotator cuff repair patients into two groups (early passive motion and 4 to 5 weeks of immobilization). Range of motion (ROM; forward flexion, internal and external rotation) and pain (visual analog scale) were measured at pre-op, 3-, 6-, and 12-months post-op. Three functional self-assessments were measured at 6 and 12 months. Diagnostic ultrasound was used to evaluate tendon healing at 3 and 6 months. Additionally, computed tomography arthrography or magnetic resonance imaging was performed at 12-months post-op. Following the first 4 to 5 weeks both groups received standardized rehabilitation. The authors found that there were no group differences for ROM, pain, or functional assessment at any of the time points studied. They also found that the re-tear rate was similar between groups: 12% in the early passive motion group and 18% in the immobilization group.
This study was the first randomized clinical trial to examine the effectiveness of immobilization on rotator cuff healing. Previous animal studies identified longer bouts of immobilization to improve supraspinatus tendon healing with no additional side effects of joint stiffness. It was thought that longer immobilization would create an optimal environment to allow collagen and extracellular matrix to be laid down to improve tendon strength before motion was initiated. Shoulder immobilization does not completely eliminate tension on the healing tendon although it does drastically reduce it. Recent animal model studies have shown that complete removal of tension results in poor rotator cuff healing. Therefore, the small amount of tension during immobilization was suggested to be beneficial. However, this clinical trial did not support the animal findings. There was no significant difference between the groups which suggest both treatments options are relatively successful. Previous rational for early motion was adopted from knee and ankle joints due to complications with joint stiffness. However, the shoulder is the most mobile joint in the body and the results of this study suggest that it can quickly improve after remobilization is started. There were no reductions in shoulder ROM between the 2 groups at any of the time points. This study suggests that immobilization is comparable to early motion for improving rotator cuff healing in humans. What is the standard post-op protocol for your patients with rotator cuff repairs? Have you had improved success with longer immobilization following rotator cuff repair?
Written by: Stephen Thomas
Reviewed by: Jeffrey Driban
American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: Optimizing the Management of Rotator Cuff Problems
Kim YS, Chung SW, Kim JY, Ok JH, Park I, & Oh JH (2012). Is Early Passive Motion Exercise Necessary After Arthroscopic Rotator Cuff Repair? The American Journal of Sports Medicine PMID: 22287641
Interesting article, thanks for the write-up, Steve. I noticed that the authors focused on small- to medium-sized tears. Clinically, larger tears are more likely to experience a failed repair than smaller tendon tears (e.g. https://www.ncbi.nlm.nih.gov/pubmed/17337727). Recently, it was presented at the Orthopaedic Research Society annual meeting that immobilization following a two-tendon injury and repair in a rat model had an unexpected effect on the healing infra and supra tendons: immobilization improved healing infra tendon mechanical properties but worsened healing supra tendon mechanical properties when compared to cage activity (Ilkhani-Pour et al., 2012). These differences between tendons may be due to differences in the loading environments the two tendons see. Additionally, joint mechanics are altered in a two-tendon tear compared to a single-tendon tear. I would be interested in understanding the effects of immobilization on different sized tears. While I know that early mobilization is not normally prescribed for massive repairs, have any clinicians noticed trends in how tear size and rehab protocols affect healing following rotator cuff repair? Has anyone noticed differences in healing between tendons (supra and infra) following a massive repair?
Sarah thanks for the comment. You bring up some great points. The basic science side of this research is clearly has progressed more than the clinical side. This information can help us design controlled experiments in humans to see if the results translate. Anecdotically massive cuff tears are prescribed longer bouts of immobilization to help protect the healing rotator cuff. Although several other factors including age, activity level, co-morbities (smoking, diabetes, etc), and length of time the tendon was torn are factored into the decision making. Based on your research and others I believe for massive tears longer immobilization will have better outcomes due to the improved infraspinatus healing. If the infraspinatus is healed effectively, even in the absence of a healed supraspinatus, then the anterior/posterior force couple is balanced and may help to restore proper function. Clearly more research is needed. Are there clinicians out there that has observed this to be true?