Question:
In patients having arthroscopic rotator cuff repair, does a delayed physical therapy protocol that limits early passive range of shoulder motion differ from an early postoperative physical therapy protocol?
Design:
Randomized (unclear allocation concealment), unblinded controlled trial with 1-year follow-up.
Setting:
The Suncoast Orthopaedic Surgery and Sports Medicine Center in Venice, Florida.
Patients:
68 patients (mean age, 63 years; 56% men) who had an isolated full-thickness crescent-shaped supraspinatus tear repaired arthroscopically with use of a transosseous equivalent suture-bridge technique and arthroscopic subacromial decompression in conjunction with the rotator cuff repair. Exclusion criteria were any labral or biceps procedure done at the same time as the rotator cuff repair; rotator cuff tears that were partial-thickness L-shaped pattern or reverse L-shaped pattern and that required margin convergence-type sutures or extended into the subscapularis or infraspinatus; evidence of glenohumeral arthritis; accompanying adhesive capsulitis; revision rotator cuff repairs; and Workers’ Compensation cases. All patients completed follow-up.
Intervention:
Patients were allocated to a delayed (n = 35) or an early (n = 33) physical therapy protocol. All patients wore a shoulder immobilizer for the first 6 weeks after surgery. The immobilizer could be removed for physical therapy sessions and personal hygiene. Active range of motion of the elbow, wrist, and hand was allowed. Patients in both groups progressed to active assisted shoulder range of motion at 7 weeks, full active range of motion at 10 weeks, and strengthening exercises at 12 weeks. The delayed therapy group did gentle circular pendulum exercises for 5 minutes, 3 times per day, for the first 6 weeks. Patients then began formal outpatient physical therapy 3 days per week, with motion limited to 120° of passive forward elevation and 30° of passive external rotation. The early therapy group began the physical therapy sessions on day 2. Exercises using passive forward elevation limited to 120° and passive external rotation limited to 30° were done 3 times per week, and pendulum exercises were done 3 times per day. At 3 weeks, patients progressed to passive forward elevation exercises to tolerance and passive external rotation exercises to 45°.
Main outcome measures:
Outcomes were assessed with use of the American Shoulder and Elbow Surgeons (ASES) score (100 possible points; higher scores indicate better outcome), the Simple Shoulder Test (SST), shoulder motion assessed with use of a digital camera, and rotator cuff healing assessed with use of high-resolution ultrasound imaging.
Main results:
The ASES scores in the delayed therapy group improved from 41.0 at baseline to 92.8 at one year, and the early therapy group improved from 43.9 to 91.1, with no significant difference between groups. The SST scores improved from 5.1 to 11.1 in the delayed therapy group and from 5.5 to 11.1 in the early therapy group, with no significant difference between groups. Shoulder motion measures were similar in the 2 groups (Table). The groups also had similar rates of rotator cuff healing (Table). A post hoc power analysis indicated that the study needed 138 patients in each group to detect a 10% difference in healing that would approach significance.
Conclusion:
In patients having arthroscopic rotator cuff repair, a delayed physical therapy protocol that limited passive shoulder motion produced similar outcomes to those of a protocol with early range-of-motion exercises.
Source of funding: The Foundation for Orthopaedic Research and Education.
For correspondence: Dr. D.J. Cuff, Suncoast Orthopaedic Surgery and Sports Medicine, 836 Sunset Lake Blvd, Venice, FL 34292. E-mail address: dcuff001@hotmail.com
Disclosure: The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
The study by Cuff and colleagues demonstrated no difference in clinical outcome (with use of validated outcome tools) between patients who had early or delayed passive range-of-motion exercises during the first 6 weeks after arthroscopic rotator cuff repair. The results are relevant to this well-defined patient population who underwent a specific surgical technique. However, the results cannot be extended to patients with larger rotator cuff tears, tears having extension into the rotator interval or infraspinatus tendon (L-shaped tears), or in patients with the same type of tear treated by a different surgical technique. Larger tears are associated with a greater risk of retearing, failing to heal, and causing postoperative stiffness, and tears of the same type but repaired with a different surgical technique may also yield different results with the same study design.
The clinical dilemma is in balancing the risks of postoperative stiffness and failure of the tendon to heal. Although no differences were found at one year, the study showed a significant lower level of forward elevation in the delayed motion group at the time of the 6-month follow-up.
In conclusion, this study supports a slower progression of rehabilitation for this type of tear and with this type of repair, without a significant increase in the risk of the patient experiencing postoperative stiffness. There may be a decreased risk for a retear, but a larger study would be required to prove this.