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