If I have had an arthroscopic rotator cuff repair, will I start physical therapy right away?

This is an increasingly common question, particularly for those who  are allowed a limited number of visits by there insurance company or for those who are understandably burdened by higher copays at the time of each visit.Understand that despite the minimally invasive nature of an arthroscopic repair, the biology of healing still requires around 6 weeks for healing at the new tendon-bone interface. In that light, most post cuff repair PT protocols have included an initial 6 week period of passive range of motion only (active motion would result in failure since healing has not yet occured, but if the therapist moves the joint, then the repair is not jeopardized). At 6 weeks the sling is discontinued, and active motion begins; strengthening starts at 3 months. Although may activities like golf and tennis may be ok to start at 4 months, recovery usually is about 75% of the way at 6 months, and full between 9 and 12 months after surgery.

That having been said, there has been a growing interest in whether healing rates at 1 year may be "better" (higher) if no motion started until 6 weeks---to prioritize structural cuff healing, and to minimize the risk that stresses at the tendon-bone interface, even with passive motion, might result in incomplete healing. Afterall, the best strength outcomes occur if the tendon heals--even though numerous studies suggest that patient satisfaction is pretty good even if incomplete tendon-bone healing occurs.

Two recent studies have examined whether stiffness results when this "conservative protocol" is followed.  In a large study published in Arthroscopy (2009, Aug:25(8)p880-890) , Dr Burkhart reported only  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 so-called "stiff group"(the patients who were stiff at 6 weeks) compared to 36% in the "non stiff group". At the one year follow-up, there were no differences in range of motion, however. In other words, NO MOTION for 6 weeks may improve healing without long term stiffness as a complication.

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.
 

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