Physical Therapy after Rotator cuff Repair

[mtomaino]

Physical therapy after arthroscopic repair of a torn rotator cuff continues to be an area of interest and research. Fundamental principles continue to prevail including the need to have tendon healing prior to exposing the tendon-bone interface to loads that might jeopardize the integrity of the repair. Preoperatively, it is very helpful to be instructed in a "Scapulothoracic program" as proper scapular mechanics effectively improves subacromial space and supraspinatus force.

In that light, a typical regimen after an arthroscopic repair of a small or medium tear might look like this:

0-6 weeks: full time use of sling; passive range of motion only.
6-12 weeks: sling is discontinued; passive motion continues; active motion begins.
At 3 months: isometric exercises begin, with progression to pre's(progressive resistnce exercises).


However, concern about retear rates has led some to utilize a more conservative approach that holds off on any motion until after 6 weeks. The rationale is that it is better to have a healed tendon, and deal with a little stiffness, than to have great "early" motion, but a failed repair. In general, observations that motion typically returns by 1 year postop have led to a more conservative approach for large and massive tears.

In a large study published in Arthroscopy (2009, Aug:25(8)p880-890, Dr Burkhart reported a 4.9% incidence of stiffness after 489 consecutive rotator cuff repairs. He has advocated a more conservative postoperative PT approach except in patients at higher risk for stiffness.

He identified risk factors for the development of postoperative stiffness: calcific tendonitis, adhesive capsulitis, PASTA lesion (partial tear), single tendon repair, concomitant labral repair, age less than 50 years, and claims that involved worker's compensation.

His Conservative and Accelerated Protocols were recently published (Clin Sports Med 29; 2010: 203-211).

The "Conservative" regimen is:
1.weeks 0-6: arom hand, wrist, elbow; passive ER with arm at side; NO PROM or AAROM.
2.weeks 7-16: D/C sling; tabletop slides/pulley; NO AAROM
3.at 4 months: AAROM with elevation; IR stretching; resistance (arm at side); Scapular program
4.at 6 months: Gym/Sports

The "Accelerated" regimen is:

1.weeks 0-6: arom hand, wrist, elbow; passive ER with arm at side; table top slides (NO AAROM)
2.weeks 7-12: d/c sling; AAROM with elevation (pulleys)
3.at 3 months: IR stretching; Resistance (arm at side); scapula program
4.At 6 months; Gym/sports
Further supporting a more conservative approach are the results of a recent study by Parsons et al (2010) which showed a 56% re-tear rate at 12 months on MRI, BUT---70% of the repairs were in tact in the "stiff group" compared to 36% in the "non stiff group".

When I plan your postoperative therapy, I will take into consideration these studies as well as other variables such as tear size and chronicity, fixation method, quality of the tissue, risk factors for stiffness, your health status and functional goals.

[mtomaino]

"Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness"
was published in the October issue of the Journal of Shoulder and Elbow Surgery by Brad Parsons, Evan Flatow and colleagues from the Mt Sinai shoulder group in NYC.

These authors hypothesized that conservative rehabilitation (similar to what was included in my post above) does not result in long-term stiffness AND improves rates of rotator cuff tendon healing.

43 patients were retrospectively evaluated following arthroscopic repairs of full thickness rotator cuff tears and an initial period of 6 weeks in a sling without any shoulder motion.At 6-8 weeks of follow-up, patients were deemed either "stiff" (if they had less than 100 degrees of forward elevation and 30 degrees of external rotation, passively) or "nonstiff" (all others).

At 6-8 weeks formal PT started, which included only passive range of motion, and at 3 months active motion and strengthening began. At 1 year MRI was obtaied to assess the integrity of the tendon repair (had the tendon healed?)

Results were very interesting. 23% of patients were deemed "stiff" at 6 weeks, but at 1 year follow-up, there was no difference in range of motion between the "stiff" and "nonstiff" patients. Further, outcome scores were similar.

MRI suggested a lower re-tear rate in "stiff" patients (70% tendon in tact in stiff group versus 36% in the nonstiff group.)

In short, this study shows that sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in long-tern stiffness, and may improve the rate of tendon healing.

How does this impact on my practice? Well, if I am pleased with the quality of your tendon and the security of the repair, I will typically start passive range of motion the 1st 6 weeks. Afterall, the "stiff" group was no different at 1 year----and for many patients, they do not want to work to overcome any loss of motion. But, it's reassuring to know that if we need to be extra safe---adhering to a no motion program for the 1st 6 weeks may not only help prevent re-tears, but it does not appear to result in long-term stiffness. I will routinely employ this conservative approach when I repair large and massive tears.