What does rehabilitation after rotator cuff repair look like for the average patient in the UK? A study by UK researchers in Sheffield conducted an electronic survey to find out. Authors Littlewood and Bateman sent links to an electronic survey by email, Twitter and Facebook to physiotherapists and surgeons involved in the treatment of rotator cuff repairs. 100 valid responses were received from professionals matching the criteria for inclusion. Any duplicate responses or similar results between professionals located at the same clinic were eliminated to reduce bias.
Patients are generally immobilized in a sling or abduction brace for 4-6 weeks, with passive movement exercises before active movement exercises. Resisted exercise from 7-12 weeks and light work duties and a return to manual work and non-contact sports after 13 weeks. The protocol used by a majority of respondents is similar to a published recommendation from 2002, showing little change in practice in the last decade. While there has been little research on postoperative recommendations, the research published in the last decade tends to support early mobilization instead of prolonged immobilization.
Early mobilization is especially recommended in studies for patients who have undergone arthroscopic procedures. This raises the question: why has practice not changed in the last 10 years? It is certainly possible that the survey reflects a cautiousness on the part of providers, not wanting to re-damage new repairs or encourage the growth of scar tissue. Previously these concerns were well founded due to a lack of research into possible negative effects of early mobilizations. Additionally, advancements in surgical techniques, particularly in sutures, have made for more sturdy repairs. Current knotless anchors have an estimated strength of 650 N in areas only known to generate a force of 26.1N (Hire et al). Currently, research tends to show little risk of re-tear or negative patient reported outcomes, but most studies have a small number of participants or other methodological problems.
One of the larger and more recent early mobilization studies on sling weaning progression is by Hire et al. Hire et al studied early mobilization combined with weaning sling use. Weaning of sling use was done according to the type(s) of arthroscopic surgery performed, reductions in pain and analgesic use, return to normal sleeping habits, tolerance during time out of the sling and compliance with progression protocol. In this study of US active duty soldiers, patients with less invasive surgeries like subacromial decompression or coracoplasty could cease sling use in as little as 2 or 3 weeks. The results were promising. Most patients (63%) were able to perform and pass the Army Physical Fitness Test without special modification (profile) within 6 months of surgery. The test includes a 2-minute push up test. Despite some patients needing a profile for the APFT, all 82 study patients were well enough to be deployable at six months. A few shortfalls of this study are that the study was retrospective, did not use a control group, was highly skewed in terms of gender (73 males and 9 females), and had a very young group of participants (average age 34.2 years).
Another study by Lee et al compared early mobilization (manual therapy 2 times per day and unlimited self-directed passive exercise) to immobilization (“limited” continuous passive motion exercise and “limited” self-directed passive exercise) in full thickness rotator cuff repairs. The study of 64 shoulders found no statistically significant difference between groups in terms of range of motion, healing or pain at 1 year. The early mobilization group had more failed repairs (7 of 30 vs 3 of 34) identified by MRI, but the number was determined to not be statistically significant. However; the early mobilization group had significantly greater range of motion at 3 months post-operation, and patients were able to return to their regular daily activities faster. The study did not comment on stiffness.
What is needed? New, large prospective studies of early mobilization in the general population with proper controls and randomization. The small number of studies on early mobilization have made it hard to determine if prolonged immobilization is better than early mobilization in terms of patient outcomes. Additionally, methodological problems with studies that have been published to date make it hard to draw conclusions from the available evidence.
References
Littlewood C, Bateman M. Rehabilitation following rotator cuff repair: a survey of current UK practice. Shoulder Elbow. 2015 Jul;7(3):193-204. doi: 10.1177/1758573215571679. Epub 2015 Feb 4. Review. PubMed PMID: 27582979; PubMed Central PMCID: PMC4935154. [Free full text at PubMed Central]
Hire JM, Pniewski JE, Dickston ML, Jacobs JM, Mueller TL, Abell BE, Bojescul JA. A criterion based sling weaning progression (SWEAP) and outcomes following shoulder arthroscopic surgery in an active duty military population. Int J Sports Phys Ther. 2014 Apr;9(2):179-86. PubMed PMID: 24790779; PubMed Central PMCID: PMC4004123. [Free full text at PubMed Central]
Lee BG, Cho NS, Rhee YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy. 2012 Jan;28(1):34-42. doi: 10.1016/j.arthro.2011.07.012. Epub 2011 Oct 20. PubMed PMID: 22014477. Abstract.[Paid full text at The Journal of Arthroscopic and Related Surgery]
