Outcomes of Accelerated Physical Therapy in Patients with Transtendinous Rotator Cuff Repair (234)

Objectives: Surgical treatment options for the repair of symptomatic partial thickness and minimally retracted full-thickness rotator cuff tears include transtendinous or tear-completion transosseous-equivalent approaches. While transtendinous repairs are associated with superior biomechanical outcomes and lower rates of cuff re-tear, they have been linked to greater stiffness and a slower rate of recovery in comparison to tear-completion transosseous-equivalent repairs, especially in the first three months postoperatively. The purpose of this retrospective matched cohort study was to examine whether expediting a patient’s physical therapy (PT) regimen immediately following transtendinous rotator cuff repair can avert complications of postoperative stiffness and improve range of motion. Methods: After institutional review board approval, the medical records of all patients who underwent arthroscopic rotator cuff repair by the senior author between March of 2015 and May of 2019 were reviewed for inclusion in the study. Inclusion criterion was transtendinous repair. Patients that underwent an accelerated PT regimen were compared to a historical control cohort. The accelerated rehabilitation cohort was allowed passive range of motion (PROM) at 2-4 weeks, active-assisted range of motion (AAROM) at 2-4 weeks, active range of motion (AROM) at 4-6 weeks and strengthening exercises at 6-8 weeks. The historical control cohort received transtendinous rotator cuff repair between February 2005 and February 2015, and subsequently underwent a standard postoperative protocol with no shoulder motion until 6 weeks, PROM at 6-12 weeks, and AROM and strengthening exercises at 3-6 months. These cohorts were propensity matched for age, sex, BMI, and smoking status (with exact matches for sex and smoking status). Medical charts were reviewed for arthroscopic findings, including the tendons repaired (supraspinatus, infraspinatus, subscapularis, or a combination), arthroscopic classification of the tear thickness (partial, high-grade partial, focal full, or full), and presence of a concurrent labral tear. Patient data were analyzed with a mixed effects model to evaluate differences in active ROM at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Forward flexion, abduction, and external rotation were recorded in degrees. Internal rotation was converted from vertebral levels to the Constant Shoulder Score’s numerical ten-point scale for analysis. Finally, re-tear complications were recorded at final follow-up of 6 months and then analyzed with Fisher’s exact test. Results: Sixty-one accelerated PT patients and 61 standard PT controls were included in the study. Mean age (57.02 ±2.70 years [95% confidence interval] vs. 57.45 ± 2.78 years, p=0.83), BMI (28.13 ± 1.13 kg/m2 vs. 28.28 ± 0.99 kg/m2, p=0.84), sex (61.66% female vs. 61.66% female p=1.00), and smoking status (p=1.00) were similar between groups. There were no significant differences between groups in the tendons repaired, the arthroscopic tear thickness, nor the presence of labral tears. (Table 1). The accelerated PT cohort showed significantly increased AROM at 6 weeks and 3 months postoperatively. At 6 weeks, ROM in forward flexion (136.97° vs. 110.52°; p<0.001), abduction (126.08° vs. 100.73°; p=0.003), and external rotation (51.65° vs. 37.90°; p=0.009) were all significantly higher in the accelerated PT cohort. A similar increase was seen at 3 months, with superior forward flexion (147.47° vs. 132.84°; p=0.009), abduction (140.44° vs. 121.91°; p=0.02), and external rotation (57.70° vs. 40.76°; p=0.001) in patients who received accelerated PT. With the exception of forward flexion, which was improved in the accelerated cohort (151.32° vs. 139.11°; p=0.04), there were no other differences in active ROM at 6 months. Internal rotation metrics approached statistical significance at 2 and 6 weeks postoperatively (p=0.07 and p=0.06, respectively). There were no re-tears (0.00%) in the accelerated PT cohort and 1 re-tear (1.64%) in the standard PT cohort (p=1.00). (Table 2). Conclusions: Accelerated PT following transtendinous rotator cuff repair is associated with substantial improvement in AROM at 6 weeks and 3 months when compared to standard PT protocols. Further, the early motion does not seem to result in a higher rotator cuff re-tear rate. Thus, early motion and liberation from obligate sling wear may reduce stiffness and be better tolerated following transtendinous rotator cuff repair surgery.

Download Full-text

Conservative Rehabilitation Provides Superior Clinical Results Compared to Early Aggressive Rehabilitation for Rotator Cuff Repair: A Retrospective Comparative Study

Medicina ◽

10.3390/medicina55080402 ◽

2019 ◽

Vol 55 (8) ◽

pp. 402 ◽

Cited By ~ 2

Author(s):

Umile Giuseppe Longo ◽

Giacomo Rizzello ◽

Stefano Petrillo ◽

Mattia Loppini ◽

Nicola Maffulli ◽

...

Keyword(s):

Rotator Cuff ◽

Rotator Cuff Repair ◽

External Rotation ◽

Clinical Results ◽

Postoperative Rehabilitation ◽

Forward Flexion ◽

Surgery Group ◽

Significant Difference ◽

Group A ◽

Cuff Repair

Background and objectives: To compare the long term clinical outcomes, range of motion (ROM) and strength of two different postoperative rehabilitation protocols after arthroscopic rotator cuff repair (RCR) for full-thickness rotator cuff (RC) tears. Materials and Methods: Patients undergoing RCR were divided into two groups. In 51 patients (56 shoulders), rehabilitation was performed without passive external rotation, anterior elevation ROM, and active pendulum exercises in the first 2 weeks after surgery (Group A). In 49 patients (50 shoulders) aggressive rehabilitation was implemented, with early free passive external rotation, anterior elevation ROM, and active pendulum exercises were allowed from the day after surgery (Group A). Results: No statistically significant differences were found in clinical scores, muscle strength, passive forward flexion, passive and active internal/external rotation between the two groups. However, the mean active forward flexion was 167.3° ± 26° (range 90–180°) in group A and 156.5° ± 30.5° (range 90–180°) in group B (p = 0.04). Conclusions: A statistically significant difference between the 2 groups was found in active forward flexion ROM, which was better in patients of group A.

Download Full-text

Postoperative stiff shoulder after open rotator cuff repair: a 3- to 20-year follow-up study

Scandinavian Journal of Surgery ◽

10.1177/1457496913514383 ◽

2014 ◽

Vol 103 (4) ◽

pp. 263-270 ◽

Cited By ~ 16

Author(s):

H. Vastamäki ◽

M. Vastamäki

Keyword(s):

Rotator Cuff ◽

Range Of Motion ◽

Rotator Cuff Repair ◽

External Rotation ◽

Long Term Results ◽

Shoulder Stiffness ◽

Stiff Shoulder ◽

Cuff Repair ◽

Postoperative Shoulder

Background and Aims: Stiffness after a rotator cuff tear is common. So is stiffness after an arthroscopic rotator cuff repair. In the literature, however, postoperative restriction of passive range of motion after open rotator cuff repair in shoulders with free passive range of motion at surgery has seldom been recognized. We hypothesize that this postoperative stiffness is more frequent than recognized and slows the primary postoperative healing after a rotator cuff reconstruction. We wondered how common is postoperative restriction of both active and passive range of motion after open rotator cuff repair in shoulders with free passive preoperative range of motion, how it recovers, and whether this condition influences short- and long-term results of surgery. We also explored factors predicting postoperative shoulder stiffness. Material and Methods: We retrospectively identified 103 postoperative stiff shoulders among 416 consecutive open rotator cuff repairs, evaluating incidence and duration of stiffness, short-term clinical results and long-term range of motion, pain relief, shoulder strength, and functional results 3–20 (mean 8.7) years after surgery in 56 patients. Results: The incidence of postoperative shoulder stiffness was 20%. It delayed primary postoperative healing by 3–6 months and resolved during a mean 6.3 months postoperatively. External rotation resolved first, corresponding to that of the controls at 3 months; flexion and abduction took less than 1 year after surgery. The mean summarized range of motion (flexion + abduction + external rotation) increased as high as 93% of the controls’ range of motion by 6 months and 100% by 1 year. Flexion, abduction, and internal rotation improved to the level of the contralateral shoulders as did pain, strength, and function. Age at surgery and condition of the biceps tendon were related to postoperative stiffness. Conclusions: Postoperative stiff shoulder after open rotator cuff repair is a common complication resolving in 6–12 months with good long-term results.

Download Full-text

Short-term Comparison of Supervised Rehabilitation and Home-based Rehabilitation for Earlier Recovery of Shoulder Motion, Pain, and Function after Rotator Cuff Repair

Clinics in Shoulder and Elbow ◽

10.5397/cise.2018.21.1.15 ◽

2018 ◽

Vol 21 (1) ◽

pp. 15-21

Author(s):

Si Jung Song ◽

Tae Ho Jeong ◽

Jung Wha Moon ◽

Han Vit Park ◽

Si Yung Lee ◽

...

Keyword(s):

Rotator Cuff ◽

Internal Rotation ◽

Rotator Cuff Repair ◽

External Rotation ◽

Exercise Group ◽

Short Term ◽

Forward Flexion ◽

Supervised Exercise ◽

Arthroscopic Rotator Cuff ◽

Cuff Repair

BACKGROUND: This study was undertaken to compare the outcome of supervised and home exercises with respect to range of motion (ROM), pain, and Single Assessment Numeric Evaluation (SANE). We further correlated the ROM recovery and pain reduction as well.METHODS: The study included 49 patients who underwent arthroscopic rotator cuff repair. Rehabilitation was initiated after 4 weeks of immobilization. A total of 29 patients performed supervised exercise 3 times a week. Standardized education and brochures for review were provided to the remaining 20 patients who insisted on home rehabilitation. Statistical analysis was performed for comparing pain Numerical Rating Scale (NRS), SANE, and ROM. In addition, we also evaluated the correlation between pain and ROM.RESULTS: Comparison of the two groups revealed no significant differences in forward flexion, internal rotation, abduction, and pain NRS. However, SANE at the 9th week (63.8 vs. 55.0, p=0.038) and improvement of external rotation from the 5th to the 9th week (17.6 vs. 9.3, p=0.018) were significantly higher in the supervised exercise group as compared to the home exercise group. Correlation of pain NRS with forward flexion, external rotation, internal rotation and abduction were statistically not significant (correlation coefficient=0.032 [p=0.828], ?0.255 [p=0.077], 0.068 [p=0.642], and ?0.188 [p=0.196], respectively).CONCLUSIONS: The supervised rehabilitation after arthroscopic rotator cuff repair showed better improvement in external rotation and higher SANE score after 4 weeks of rehabilitation exercise. However, no statistically significant correlation was observed between the recovery of ROM and short-term pain relief.

Download Full-text

Delayed Rehabilitation Protocol after Rotator Cuff Repair

Osteology ◽

10.3390/osteology1010003 ◽

2020 ◽

Vol 1 (1) ◽

pp. 29-38

Author(s):

Alessandra Berton ◽

Sergio De Salvatore ◽

Vincenzo Candela ◽

Gabriele Cortina ◽

Daniela Lo Presti ◽

...

Keyword(s):

Rotator Cuff ◽

Muscle Strength ◽

Internal Rotation ◽

Outcome Measures ◽

Rotator Cuff Repair ◽

External Rotation ◽

Shoulder Function ◽

Rehabilitation Protocol ◽

Patient Reported ◽

Cuff Repair

Rotator cuff tears are a frequent cause of shoulder pain that often require arthroscopic repair. After surgery an intense and well-studied rehabilitation protocol is needed to obtain the complete recovery of shoulder function. Fifty patients, who sustained arthroscopic rotator cuff repair for symptomatic, atraumatic and full-thickness supraspinatus tendon tear, were involved. According to our rehabilitation protocol, during the first four postoperative weeks, the arm was supported with an abduction sling pillow, and pendulum exercises, table slide and active elbow extension and flexion were conceded. Outcome measures (Oxford shoulder score (OSS), simple shoulder test (SST), patient-reported satisfaction), shoulder function (range of motion (ROM) and muscle strength), and MRI examination were evaluated. The mean OSS score and SST score increased from 16 to 30.2 and from 5.3 to 11.4, respectively. Patient-reported satisfaction was 96%. At 12 months, patients improved ROM and muscle strength. Postoperative passive anterior elevation was 176; external rotation averaged 47; internal rotation was 90. Postoperative muscle strength during anterior elevation was 8.3 ± 2.2 kg, internal rotation 6.8 ± 3 kg, external rotation 5.5 ± 2.3 kg. Five out of seven patients with recurrent tears evaluated their results as satisfactory. They reported improvements in terms of OSS and SST mean scores despite recurrent tears; therefore, they did not undergo revision surgery. The delayed postoperative physical therapy protocol was associated with improvements in the outcome measures and shoulder function compared to the preoperatory state and rotator cuff healing demonstrated by MRI.

Download Full-text

Outcome and Structural Integrity of Rotator Cuff after Arthroscopic Treatment of Large and Massive Tears with Double Row Technique: A 2-Year Followup

Advances in Orthopedics ◽

10.1155/2013/914148 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 13

Author(s):

Ignacio Carbonel ◽

Angel A. Martínez ◽

Elisa Aldea ◽

Jorge Ripalda ◽

Antonio Herrera

Keyword(s):

Rotator Cuff ◽

Range Of Motion ◽

Functional Outcome ◽

Rotator Cuff Repair ◽

Structural Integrity ◽

Rotator Cuff Tears ◽

Full Thickness ◽

Double Row ◽

Massive Rotator Cuff Tears ◽

Cuff Repair

Purpose. The purpose of this study was to evaluate the functional outcome and the tendon healing after arthroscopic double row rotator cuff repair of large and massive rotator cuff tears.Methods. 82 patients with a full-thickness large and massive rotator cuff tear underwent arthroscopic repair with double row technique. Results were evaluated by use of the UCLA, ASES, and Constant questionnaires, the Shoulder Strength Index (SSI), and range of motion. Follow-up time was 2 years. Magnetic resonance imaging (MRI) studies were performed on each shoulder preoperatively and 2 years after repair.Results. 100% of the patients were followed up. UCLA, ASES, and Constant questionnaires showed significant improvement compared with preoperatively (P<0.001). Range of motion and SSI in flexion, abduction, and internal and external rotation also showed significant improvement (P<0.001). MRI studies showed 24 cases of tear after repair (29%). Only 8 cases were a full-thickness tear.Conclusions. At two years of followup, in large and massive rotator cuff tears, an arthroscopic double row rotator cuff repair technique produces an excellent functional outcome and structural integrity.

Download Full-text

Repair Integrity and Retear Pattern After Arthroscopic Medial Knot-Tying After Suture-Bridge Lateral Row Rotator Cuff Repair

The American Journal of Sports Medicine ◽

10.1177/0363546520934786 ◽

2020 ◽

Vol 48 (10) ◽

pp. 2510-2517

Author(s):

Yasutaka Takeuchi ◽

Hiroyuki Sugaya ◽

Norimasa Takahashi ◽

Keisuke Matsuki ◽

Morihito Tokai ◽

...

Keyword(s):

Stress Concentration ◽

Rotator Cuff ◽

Rotator Cuff Repair ◽

External Rotation ◽

Knot Tying ◽

Failure Group ◽

Suture Bridge ◽

Cuff Repair

Background: Type 2 failure is a big issue after suture-bridge rotator cuff repair, which may be because of stress concentration at the medial row stitches. We have been performing medial knot-tying after suture-bridge lateral row repair to avoid the stress concentration. This study aimed to evaluate clinical and radiological outcomes after arthroscopic rotator cuff repair using this technique. Hypothesis: This technique would yield better radiological outcomes with a reduced type 2 failure rate compared with reported outcomes after conventional suture-bridge repair. Study Design: Case series; Level of evidence, 4. Methods: The inclusion criteria of this study were (1) full-thickness tears, (2) primary surgery, and (3) minimum 2-year follow-up with pre- and postoperative magnetic resonance imaging (MRI). We investigated active ranges of motion (forward elevation and external rotation), as well as the Japanese Orthopaedic Association (JOA) and University of California, Los Angeles (UCLA), scores preoperatively and at the final follow-up. Results: This study included 384 shoulders in 373 patients (205 men and 168 women) with a mean age of 65 years (range, 24-89 years) at the time of surgery. The mean follow-up was 29 months (range, 24-60 months). There were 91 small, 137 medium, 121 large, and 35 massive tears. Postoperative MRI scans demonstrated successful repair in 324 shoulders (84.4%, group S) and retear in 60 shoulders (15.6%). Among 60 retears, 40 shoulders (67%) had type 1 failure (group F1) and 20 shoulders (33%) had type 2 failure (group F2). Forward elevation and external rotation significantly improved after surgery ( P < .001 for both). Postoperative JOA and UCLA scores in group F2 were significantly lower than those in the other groups. Conclusion: The medial knot-tying after suture-bridge lateral row repair demonstrated excellent functional and radiological outcomes after surgery, with a retear rate of 15.6%. The type 2 failure showed significantly inferior functional outcomes; however, the rate of type 2 failure was less relative to previous studies using conventional suture-bridge techniques. Our technique could be a good alternative to conventional suture-bridging rotator cuff repair because it may reduce the rate of postoperative type 2 failure.

Download Full-text