Rehabilitation after Rotator Cuff Repair

Does the Timing of the Initiation of Physical Therapy Post-Rotator Cuff Repair Impact Shoulder Function?

Background

Rehabilitation typically restores shoulder function after a common rotator cuff repair; however, it is unclear when to initiate physical therapy (PT) post-surgery. To understand effective start times, this study analyzed PT start times and their effect on shoulder function. The most effective shoulder outcomes were hypothesized to occur when PT started 0-4 weeks post-surgery.

Methods

Data from 1002 patients who underwent rotator cuff repair were analyzed retrospectively from 52 outpatient clinics in the years of 2016-2021. The primary data of timings between surgery and the start of PT (0-2 weeks [0-14 days], 2-4 weeks [15-28 days], 4-6 weeks [29-42 days], and 6-14 weeks [43-100 days]), change in functional shoulder scores, number of PT visits utilized, and functional scores changed per visit were analyzed. Regression analyses of the impact of age, sex, payor source, and tear size were completed.

Results

The change in functional scores and functional scores changed per visit are not affected by the initiation timing of PT post- rotator cuff surgery, when controlling for baseline functional scores. This result is revealed despite initial functional scores being significantly different. Functional scores change per visit may have been affected by payor source (R 2 = 0.004, p ≤ 0.010). PT start times may have been impacted by age (R 2 = 0.010, p = 0.007), payor source (R 2 = 0.016, p = 0.001), and tear size (R 2 = 0.007, p = 0.026). Payor source may have influenced the number of PT visits (R 2 = 0.060, p < 0.001).

Conclusions

After rotator cuff surgery, patients should choose to complete rehabilitation to optimize shoulder function. However, the initiation timing of PT may not affect functional shoulder outcomes.

Is it necessary to use a sling or abduction pillow sling after superior rotator cuff repair? A preliminary report

Objectives

The study aimed to evaluate the effects of the use of a shoulder sling, shoulder sling with a pillow, or not using a sling on the shoulder functional score and pain levels following arthroscopic rotator cuff tear repair.

Patients and methods

This randomized prospective study was performed with 90 patients (49 males, 41 females; mean age: 56.2±12.2 year; range, 33 to 77 years) with a small-to-mid, full-thickness rotator cuff tear between July 2020 and October 2022. All patients underwent arthroscopic double-row repair. The nonsling group wore no sling, the sling group wore a sling, and the abduction pillow sling group wore a sling with an abduction pillow. The same rehabilitation program was performed. The Visual Analog Scale (VAS) score, Constant-Murley scores, and degrees of flexion and abduction were recorded preoperatively, on the 15th and 45th days, and at three months, six months, and one year.

Results

On the 15th postoperative day, the VAS score was found to be significantly lower in the nonsling group. On the 45th day, the Constant-Murley score was found to be significantly higher in the abduction pillow sling group. There was no significant difference between the groups regarding the Constant-Murley scores at three weeks, six months, and one year. The shoulder forward flexion angle was significantly lower in the nonsling group on the 45th day. There was no significant difference between the three groups in respect of the shoulder forward flexion at three months, six months, and one year.

Conclusion

No difference was determined between the groups at the six-month and one-year functional results. Not using a sling bandage can be recommended by reducing pain in the early postoperative period.

Changes in shoulder function and muscle strength following rehabilitation exercise program in male patients with forward shoulder posture undergoing rotator cuff repair

BACKGROUND

Abnormal posture is known to affect the efficacy of exercise therapy for musculoskeletal diseases. However, no studies to date have examined the effect of exercise programs should take into account the posture of the upper body in patients with rotator cuff disease. This study aimed to assess how rotator cuff and corrective exercises impact shoulder function and muscle strength post-arthroscopic rotator cuff repair surgery, providing tailored rehabilitation programs for patients with forward posture.

METHODS

Ninety male patients who underwent arthroscopic rotator cuff repair participated in this study. The patients were randomly divided into three groups corrective exercise group (CEG, n = 29), rotator cuff exercise group (REG, n = 27), and control group (CG, n = 28). Each group was instructed to apply different exercise programs to correct posture and enhance rotator cuff strength. All patients were checked by the American Shoulder and Elbow Surgeons (ASES) score, Constant score and muscle strength, and range of motion preoperatively and postoperatively at 6 months and 1 year.

RESULTS

ASES shoulder function scores showed significant difference between the three groups (p = 0.002, F = 7.03), indicating that the corrective exercise program was more beneficial than rotator cuff exercises (p = 0.009, F = 3.78). A significant intergroup difference in mean Constant score was also noted (p = 0.025, F = 3.86), while a statistically significant interaction between time and group was observed (p = 0.032, F = 2.96).

CONCLUSIONS

These results suggested that a corrective exercise program can improve shoulder muscle strength and function after rotator cuff repair in male patients with a forward shoulder posture.

Nanofiber Graft Therapy to Prevent Shoulder Stiffness and Adhesions after Rotator Cuff Tendon Repair: A Comprehensive Review

Stiffness and adhesions following rotator cuff tears (RCTs) are common complications that negatively affect surgical outcomes and impede healing, thereby increasing the risk of morbidity and failure of surgical interventions. Tissue engineering, particularly through the use of nanofiber scaffolds, has emerged as a promising regenerative medicine strategy to address these complications. This review critically assesses the efficacy and limitations of nanofiber-based methods in promoting rotator cuff (RC) regeneration and managing postrepair stiffness and adhesions. It also discusses the need for a multidisciplinary approach to advance this field and highlights important considerations for future clinical trials.

Home-Based or Supervised Physical Therapy Shows Similar Functional Outcomes and Healing After Massive Rotator Cuff Repair

PURPOSE

To compare postoperative clinical outcomes at the 3-month, 6-month, 12-month, and latest follow-up in patients undergoing supervised physical therapy (PT) or a home-based exercise program after arthroscopic repair (ARCR) of massive rotator cuff tears (MRCTs).

METHODS

A retrospective review was conducted on a prospectively maintained database of patients who underwent either supervised PT or home-based therapy after ARCR of MRCTs between January 2015 and December 2018 at a single center with a minimum 24-month follow-up. At their 2-week postoperative routine follow-up, patients were allowed to choose between home-based and supervised PT. Patient-reported outcomes (PROs) and range of motion (ROM) were collected and compared between cohorts preoperatively and at the 3-month, 6-month, 12-month, and latest follow-up. The percentage of patients reaching or exceeding the minimal clinically important difference (MCID) and patient accepted symptomatic state (PASS) for visual analog scale for pain, American Shoulder and Elbow Surgeon (ASES) score, and Subjective Shoulder Value was recorded for both cohorts at each time point. Complications, healing, satisfaction, and return to work were reported. Healing was evaluated via ultrasound at the latest follow-up.

RESULTS

Ninety-nine patients met the study criteria: 61 in the supervised PT cohort and 38 in the home-based cohort. The supervised PT and home-based cohorts returned to the clinic for their most recent follow-up at 53 ± 20 and 55 ± 16 months (P = .496) after surgery, respectively. There was no difference when comparing tendon involvement (supraspinatus, P = .574; infraspinatus, P = .288; subscapularis, P = .592), tear retraction (P = .603), or high-grade fatty infiltration (supraspinatus, P = .684; infraspinatus, P = .397; subscapularis, P = .473) based on preoperative magnetic resonance imaging assessment and surgery-related factors, including anterior (P = .473) or posterior (P = .386) slides, fixation constructs (P = .829), or complete repair (P = .912). Both cohorts showed similar PROs and ROM at baseline. Postoperative PROs and ROM were similar among groups at the 3-month, 6-month, 12-month, and latest follow-up. However, ASES (71.4 vs 61.2; P = .013) and forward flexion (135° vs 118°; P = .023) were significantly higher at 3-month follow-up in the home-based cohort. Both groups comparably achieved MCID and PASS for PROs at the 3-month, 6-month, and 12-month follow-up. At the latest follow-up, the supervised PT and home-based cohort achieved MCID and PASS for visual analog scale (75% vs 81%, P = .573; 70% vs 72%, P = .911), ASES (76% vs 74%, P = .777; 72% vs 72%, P = .873), and Subjective Shoulder Value (82% vs 84%, P = .734; 72% vs 66%, P = .489), respectively. Satisfaction, healing, complication, and return-to-work rates were similar.

CONCLUSIONS

Patients undergoing rehabilitation using a home-based protocol showed largely similar functional scores and healing to those with supervised PT after ARCR of MRCTs at the latest follow-up. Although patients with home-based therapy achieved higher forward flexion and ASES at the 3-month follow-up, these became comparable starting at the 6-month postoperative mark. MCID and PASS were achieved similarly for PROs at each time point.

LEVEL OF EVIDENCE

Level III, retrospective case series comparison.

Functional recovery prediction during rehabilitation after rotator cuff tears by decision support system

BACKGROUND

Today's rehabilitation decision-making still relies on conventional methods and different specific targeted rehabilitation protocols. Our study focuses on the decision support system for early rehabilitation after rotator cuff (RC) tears repair, where a multicriteria decision-making framework (MCDM) is applied for the prediction of successful functional recovery and selection of a rehabilitation protocol.

OBJECTIVE

To identify factors that affect recovery outcomes and to develop a decision support system methodology for predicting functional recovery outcomes at early rehabilitation after RC repair.

METHODS

Twelve rehabilitation experts were involved in the design, calibration, and evaluation of a rehabilitation protocol based on the proposed decision support system constructed using the MCDM framework. For the development of a decision support system, 20 patients after RC surgery undergoing outpatient rehabilitation were enrolled in a prospective cohort clinical trial.

RESULTS

The MCDM framework (SWARA method) sensitively assesses different criteria and determines the corresponding criteria weights that were similar to criteria weights assessed subjectively by rehabilitation experts. The assignment of patients into the classes, according to the heuristic evaluation method based on expert opinion and the standard qualitative evaluation methods showed the validity of MCDM methods remain the best new alternative in predicting recovery during rehabilitation.

CONCLUSIONS

The results of this paper show that sustainable rehabilitation is an area that is quite suitable for the use of MCDM. The most of rehabilitation protocols are based on traditional methods and approaches, but the sensitive results showed the validity of MCDM methods and remains the best new alternative in prediction recovery protocols during rehabilitation.

Enhancing Post-Surgical Rehabilitation Outcomes in Patients with Chronic Ankle Instability: Impact of Subtalar Joint Axis Balance Exercises Following Arthroscopic Modified Broström Operation

Background and Objectives: This study aimed to evaluate the effects of subtalar joint axis-based balance exercises on the anterior talofibular ligament (ATFL) thickness, ankle strength, and ankle stability after an arthroscopic modified Broström operation (AMBO) for chronic ankle instability (CAI). Materials and Methods: The study included 47 patients diagnosed with CAI who underwent AMBO and were randomly divided into three groups: control (n = 11), general balance exercise (n = 17), and subtalar joint axis balance exercise (n = 19), regardless of the affected area. Participants in the exercise rehabilitation group performed exercises for 60 min twice a week for six weeks, starting six weeks after AMBO. ATFL thickness, ankle strength, and ankle dynamic stability were measured using musculoskeletal ultrasonography, Biodex, and Y-balance test, respectively, before and after treatment. Results: Compared with the remaining groups, the subtalar joint axis balance exercise group had reduced ATFL thickness (p = 0.000), improved ankle strength for eversion (p = 0.000) and inversion (p = 0.000), and enhanced ankle stability (p = 0.000). Conclusions: The study results suggest that subtalar joint axis-based balance exercises may contribute to the early recovery of the ankle joint after AMBO.

The effect of video-assisted training on upper extremity problems and functions after rotator cuff repair: a randomized controlled trial

Background/aim

The shoulder is the most mobile joint in the body, and is frequently exposed to injuries. The applied surgical treatments, protection of the shoulder after surgery, care in the use of the shoulder in activities of daily living (ADLs) and gradual exercise programs are all vital to the recovery process. The present study investigates the effect of video-assisted training (VAT) on upper extremity complications and functions after rotator cuff repair (RCR).

Materials and method

Included in this prospective, parallel two-armed, randomized controlled study were an experimental group (n: 24) that received VAT detailing early postoperative care for RCR and instructions on performing ADLs, and that had access to a 90-day gradual exercise program, and a control group (n: 24) that received routine care. The primary outcomes were upper extremity problems and functions, as assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) and modified Constant-Murley scores (MCM), while secondary outcomes were complications that had developed within the past three months. The outcomes were measured at baseline, after six weeks and at three months.

Results

After 3 months, a statistically significant difference was noted in the DASH-Work (p = 0.001) and MCM ADLs scores (p = 0.003) of the two groups, and significant changes in which the scale scores of both groups when compared to the initial measurement. Only one patient in the VAT group developed complications after RCR at one month; there were no significant differences in the complications of the two groups (p = 0.235).

Conclusion

VAT can increase function in RCR patients. Healthcare professionals, especially nurses, can use the VAT method to improve shoulder function in patients after RCR.

Disruptions in Standard Care in Patients After Arthroscopic Rotator Cuff Repair During the COVID-19 Pandemic

Background

The coronavirus disease-2019 (COVID-19) pandemic led to disruptions in care for orthopaedic patients who underwent surgery just before the outbreak, rendering some unable to participate in standard postoperative care. Many of these patients underwent clinical follow-up and physical therapy via telehealth.

Purpose

To evaluate the methods of postoperative care in patients who underwent arthroscopic rotator cuff repair (RCR) and had follow-ups during the height of the pandemic versus those who received prior standard of care. We aimed to compare the 1-year outcomes between these cohorts.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective chart review was used to identify patients who underwent primary RCR in February and March 2020 (COVID cohort) and the same period in 2019 (control cohort) at a single institution. Excluded were patients who underwent revision RCR, used workers' compensation, or were incarcerated or deceased. The included patients reported the postoperative care received, their satisfaction with care, physical therapy appointment type (in person, home based, telehealth, or self-guided), satisfaction with physical therapy, and minimum 1-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn Shoulder Score (PSS) outcomes.

Results

Overall, 428 patients were included for final analysis--199 in the COVID cohort and 229 controls. Follow-up data were collected for 160 patients in the COVID group (80.4%) and 169 control patients (73.8%). In the COVID group, 110 patients (68.8%) had ≥1 clinical visit conducted via telehealth, compared with zero in the control group. There were no differences between the COVID and control groups in the ASES (84.2 ± 16.5 vs 86.5 ± 17; P = .27 ), SANE (83.9 ± 15.4 vs 84.8 ± 17.5; P = .66), PSS (84.8 ± 15.3 vs 87.1 ± 15.1; P = .22), or patient satisfaction with the care received (81.7 ± 22.6 vs 86.3 ± 23.5; P = .09). Satisfaction with physical therapy was significantly higher in the control group (88.3 ± 18.9 vs 81.9 ± 22.5; P = .01).

Conclusion

Despite disruptions in care, RCR patients had comparable 1-year outcomes during the pandemic versus before the pandemic. Telehealth clinical follow-up appointments did not adversely affect patient-reported outcome measures and may be appropriate for RCR patients beyond the pandemic.

Increased HbA1c Levels in Diabetics During the Postoperative 3-6 Months After Rotator Cuff Repair Correlated With Increased Retear Rates

PURPOSE

To evaluate whether glycemic control affects the integrity of the repaired rotator cuff during the postoperative healing period after arthroscopic double-row suture bridge rotator cuff repair (RCR) METHODS: We retrospectively reviewed patients with diabetes mellitus (DM) who underwent arthroscopic double-row suture bridge RCR at our institution between March 2016 and November 2019. We included the patients who evaluated for serum glycosylated hemoglobin (HbA1c) levels within 1 month before and 3-6 months after surgery. Magnetic resonance imaging was conducted 6 months after surgery to evaluate the integrity of the repaired cuff tendon. Patients were categorized into two groups based on comparison between preoperative and postoperative HbA1c values: Group I (increased postoperative HbA1c) and Group D (same or decreased postoperative HbA1c). The correlation between preoperative/postoperative HbA1c, HbA1c increase/same or decrease (during the healing period), and post-RCR integrity was evaluated, including various demographic and radiologic factors.

RESULTS

A total of 103 patients were analyzed, group I was 47, and group D was 56, respectively. The retear rate of 51.1% (24/47) in Group I was significantly higher than 14.3% (8/56) in Group D (P < .001). HbA1c levels measured 3-6 months after surgery (mean: 6.9; 95% CI: 6.6-7.3 vs mean: 6.5; 95% CI: 6.3-6.7, P = .034), and the proportion of group I and group D were significantly different (75%/25% vs 32.4%/67.6%, P < .001) between the retear and healing groups. Multivariable logistic regression analysis identified increased HbA1c as an independent risk factor for retear (odds ratio: 5.402; 95% CI: 2.072-14.086; P < .001).

CONCLUSIONS

The glycemic control within 3-6 months after surgery when the healing process of the tendon was in progress had a significant effect on retear rate. In particular, the retear rate was higher when the HbA1c level increased at postoperative 3-6 months compared to before surgery.

LEVEL OF EVIDENCE

Retrospective case-control comparative study, Level III.

Translational therapy from preclinical animal models for muscle degeneration after rotator cuff injury

Chronic rotator cuff tears are debilitating diseases which significantly affect patients’ quality of life and pose substantial financial burden to the society. The intraoperative reparability of injured tendon and postoperative probability of tendon retear are highly associated with the quality of torn muscles, specifically, the severity of muscle atrophy and fatty infiltration. Animal models that reproduce the characteristic muscle pathology after rotator cuff injury have been developed and used to provide insight into the underlying biology and pathophysiology. In this review, we briefly summarize the current information obtained from preclinical animal studies regarding the degenerative change of cuff muscle subsequent to tendon release and/or suprascapular nerve denervation. Importantly, we focus on the potential translational therapeutic targets or agents for the prevention or reversal of muscle atrophy and fatty infiltration. While further studies are warranted to assess the safety and efficacy of novel therapies derived from these preclinical animal research, we believe that their clinical translation for the treatment of rotator cuff disorders is on the horizon.

The Translational potential of this article

Novel therapeutic strategies described in this review from preclinical animal studies hold a great translational potential for preventing or reversing rotator cuff muscle pathology, while further assessments on their safety and efficacy are warranted.

Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis

INTRODUCTION

One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR.

METHODS

Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate.

RESULTS

The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P = <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086, P < 0.001). No association was found between timing of beginning PT and capsulitis rates.

CONCLUSION

In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR.

LEVEL OF EVIDENCE

Level III.

Rehabilitation protocols following rotator cuff repair: a meta-analysis of current evidence

BACKGROUND

Rotator cuff tears are a common shoulder pathology with an increasing incidence. The optimum post-operative rehab protocol remains unclear and can consist of either conservative rehabilitation or more aggressive early range-of-motion. Multiple studies have assessed these treatment protocols. This meta-analysis aims to compare post-operative clinical outcomes following either conservative or aggressive rehabilitation post rotator cuff repair.

METHODS

A systematic electronic literature search was undertaken using a number of databases. Eligible studies included randomized control trials published between January 2013 and April 2019 in English with patients having had received rotator cuff repair. Post-operative clinical outcomes considered included shoulder range-of-motion, overall function status (Costant-Murley score) and rates of rotator-cuff re-tear. Studies were evaluated for methodological quality in accordance with the Physiotherapy Evidence Database (PEDro) scale. Summarized pooled statistics were calculated using Review Manager (v5.3) software.

RESULTS

A total of six randomized controlled trials were included. Standardized mean difference (SMD) in shoulder flexion, abduction and external rotation was not statistically significant at either 6 or 12 months post rotator cuff repair. Functional assessment suggests a slight benefit in Constant-Murley Score (SMD = 1.77; 95% CI -3.93, 7.47) in aggressive treatment groups with no significant risk increase for cuff re-tear (RR = 1.22; 95% CI 0.60, 2.47).

CONCLUSION

This meta-analysis suggests there is no clear benefit of either rehabilitation protocol when considering range-of-motion, with a possible benefit in functional outcome at the cost of increased re-tear risk post aggressive rehabilitation. Both protocols have been shown to offer safe reproducible short- and long-term outcomes.

Comparing in vivo three-dimensional shoulder elevation kinematics between standing and supine postures

Background

It is often assumed that body posture, standing vs. supine, changes shoulder muscle activation and range of motion, but these altered shoulder mechanics have not been objectively assessed. We expected the supine posture might facilitate scapular rotation and change subacromial pressure. The purpose of this study is to evaluate the influence of body posture on shoulder kinematics during arm elevation.

Methods

Ten males and eight females with a mean age of 33 years participated in this study. Shoulder kinematics were assessed during scapular plane elevation in the standing and supine postures by using single-plane fluoroscopic images. Kinematics were measured using 3-dimensional to 2-dimensional model-image registration techniques: matching the 3-dimensional bone model derived from computed tomography onto each fluoroscopic image. Glenohumeral superior/inferior translation, acromiohumeral distance, and scapular rotations were compared between the postures. The effect of sex also was evaluated.

Results

With the arm at the side position, the humeral head in the supine posture was located 0.5 mm superior compared to the standing posture (P < .001). During humeral elevation, the humeral head significantly shifted more inferiorly in the supine posture than in standing; the biggest mean difference was 0.6 mm, P = .003. But acromiohumeral distance during elevation was not significantly affected by the body posture (P = .05). Scapular upward rotation and posterior tilt were significantly different between the postures (P < .001). Sex had statistically significant, but quantitatively small, effects on shoulder kinematics.

Conclusions

Body postures affect shoulder kinematics during humeral elevation. This knowledge will be useful to optimize rehabilitation exercises and for diagnostic insight.

Treadmill running initiation times and bone-tendon interface repair in a murine rotator cuff repair model

Postoperative exercise has been demonstrated to be beneficial for bone-tendon interface (BTI) healing, yet the debate regarding the optimal time to initiate exercise after tendon enthesis repair is ongoing. This study aimed to evaluate the initiation times for exercise after enthesis repair. A total of 192 C57BL/6 mice underwent acute supraspinatus tendon injury repair. The animals were then randomly assigned to four groups: free cage activity after repair (control group); treadmill running started on postoperative day 2 (2-day delayed group); treadmill running started on postoperative day 7 (7-day delayed group), and treadmill running started on postoperative day 14 (14-day delayed group). Mice were euthanized at 4 and 8 weeks postoperatively, and histological, biomechanical, and bone morphometric tests were performed. Higher failure loads and bone volume fractions were found for the 7-day delayed group and the 14-day delayed group at 4 weeks postoperatively. The 7-day delayed group had better biomechanical properties and higher bone volume fractions than the 2-day delayed group at 4 weeks postoperatively. Histologically, the 7-day delayed group exhibited lower modified tendon-to-bone maturity scores than the control group and the 2-day delayed group at 4 and 8 weeks postoperatively. Quantitative reverse-transcription polymerase chain reaction results showed that the 7-day delayed group had higher expressions of chondrogenic- and osteogenic-related genes. Statement of clinical significance: Postoperative treadmill running initiated on postoperative day 7 had a more prominent effect on BTI healing than other treatment regimens in this study and could accelerate BTI healing and rotator cuff repair.

Conservative versus accelerated rehabilitation after rotator cuff repair: a systematic review and meta-analysis

Background

The purpose of this systematic review and meta-analysis is to compare the conservative and accelerated rehabilitation protocols in patients who underwent arthroscopic rotator cuff repair in terms of clinical outcomes and range of motions at 3, 6, 12, and 24-month follow-up.

Methods

According to PRISMA guidelines, a systematic review of the literature was performed. For each included article, the following data has been extracted: authors, year, study design, level of evidence, demographic characteristics, follow-up, clinical outcomes, range of motions, and retear events. A meta-analysis was performed to compare accelerated versus conservative rehabilitation protocols after arthroscopic rotator cuff repair. The retear rate, postoperative Constant-Murley score and range of motions at 3, 6, 12, and 24 months of follow-up were the outcomes measured.

Results

The search strategy yielded 16 level I-II clinical studies. A total of 1424 patients, with 732 patients and 692 in the accelerated and conservative group, were included. The average age (mean ± standard deviation) was 56.1 ± 8.7 and 56.6 ± 9 in the accelerated and conservative group. The mean follow-up was 12.5 months, ranging from 2 to 24 months. The meta-analysis showed no statistically significant differences in terms of retear rate between the groups (P = 0.29). The superiority of the accelerated group was demonstrated in terms of external rotation (P < 0.05) at 3-month follow-up; in terms of forward elevation, external rotation, abduction (P < 0.05), but not in terms of Constant-Murley score at 6-month follow-up; in terms of forward elevation (P < 0.05) at 12-month follow-up. No significant differences between the two group were highlighted at 24-month follow-up.

Conclusions

No statistically significant differences in the retear rate among the accelerated and conservative group have been demonstrated. On the other hand, statistically and clinically significant differences were found in terms of external rotation at 3 and 6 months of follow-up in favour of the accelerated group. However, no differences between the two groups were detected at 24 months follow-up.

Analysis of Functional Recovery and Subjective Well-Being after Arthroscopic Rotator Cuff Repair

Background: Rotator cuff tears are common causes of functional shoulder instability and often lead to arthroscopic rotator cuff repair. A well-programmed rehabilitation leads to successful tendon healing, positive functional recovery and subjective well-being (SWB). Objective: To evaluate the changes in shoulder functioning and SWB pre-, post-outpatient rehabilitation and after one-month follow-up. Materials and Methods: A total of 44 patients were assessed three times: at the beginning (six weeks’ post-surgery), at the end of outpatient rehabilitation (2–3 weeks) and one month after rehabilitation. The outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion (ROM), manual muscle testing (MMT), hand dynamometry (HD) and pain level by a Visual Analogue Scale (VAS). SWB was assessed by Rosenberg self-esteem scale (RSES), Positive and Negative Affect Schedule (PANAS) and the Lithuanian Psychological Well-Being Scale (LPWBS). Results are presented as a difference between periods. Results: Affected shoulder motor function (MMT, HD and ROM) significantly improved in three periods (p < 0.05); however, major recovery was observed in the follow-up period. VAS scores meaningfully decreased over all stages and negatively correlated with motor function recovery (p < 0.05). DASH rates exhibited significant retrieval in all phases, especially in follow-up. SWB results demonstrated the larger effects of self-evaluation in follow-up, improved daily functions and psychological wellness, then negative emotions significantly decreased (p < 0.05). Conclusions: The experienced pain and psychosocial factors significantly influence functional recovery of the shoulder during rehabilitation. The improvement in motor function, ability and pain relief during rehabilitation increases level of SWB, psychological wellness and positive emotional affect in long-term context.

Effect of Exercise Intensity on the Healing of the Bone-Tendon Interface: A Mouse Rotator Cuff Injury Model Study

BACKGROUND

Injuries at the bone-tendon interface (BTI) are common findings in clinical practice. Rehabilitation procedures after BTI surgery are important but are controversial.

PURPOSE

To investigate the effects of different exercise intensities on BTI healing by means of an established mouse rotator cuff injury model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 150 specific pathogen free male C57BL/6 mice, with supraspinatus insertion injury, were randomly assigned to 1 of 5 groups according to postoperative rehabilitation of different exercise intensities: (1) control group, (2) low-intensity exercise group, (3) moderate-intensity exercise group, (4) high-intensity exercise group, and (5) increasing-intensity exercise group (IG). The specimens were harvested 4 or 8 weeks postoperatively for microarchitectural, histological, molecular biological, and mechanical evaluations.

RESULTS

Histological test results showed that the degrees of tissue fusion and polysaccharide protein distribution at the healing interface at 4 and 8 weeks after surgery were significantly better in the IG than in the other 4 groups. Synchrotron radiation micro-computed tomography showed that the quantity of subchondral bone at the enthesis (bone volume/total volume fraction, trabecular thickness, trabecular number) was higher and trabecular separation was lower in the IG than in the other 4 groups. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) analysis revealed that the healing interface in the IG expressed more transcription factors, such as sox 9, runx 2, and scleraxis, than the interfaces in the other groups. Although no significant difference was seen in the cross-sectional area between the groups at postoperative weeks 4 and 8 (P > .05), the tensile load, ultimate strength, and stiffness of the specimens in the IG were significantly better than those in the other 4 groups (P < .05).

CONCLUSION

The rehabilitation program with increasing-intensity exercise was beneficial for BTI healing.

CLINICAL RELEVANCE

The results of this study provide evidence supporting the use of a simple and progressive exercise rehabilitation program after rotator cuff surgery.

Long-term prognoses of patients with and without re-rupture after arthroscopic rotator cuff repair

[Purpose] We followed-up patients who underwent arthroscopic rotator cuff repair (ARCR) for 2 years to assess the prognosis of rotator cuff tears and compared the outcomes of the patients with and without re-rupture. We also examined the usefulness of Shoulder36, a self-assessment tool, for assessing the long-term prognosis in patients undergoing ARCR. [Participants and Methods] We included 28 patients who received occupational therapy pre- and post-ARCR between April 2012 and August 2015 and categorized them based on the occurrence of re-rupture. We followed-up on their prognoses for 2 years using physical examination and Shoulder36 assessment. [Results] Re-rupture occurred in five patients within 3 months of treatment. During the 2 year follow-up, the control group showed a significant improvement in pain and bi-directional active range of motion during physical assessment and in five out of six domains during Shoulder36 assessment. In contrast, the re-rupture group showed significant differences for only three domains of the Shoulder36 assessment twelve months after surgery. [Conclusion] We confirmed the long-term functional improvement and maintenance in the re-rupture group, suggesting that continued rehabilitation, compensatory movements, and detailed guidance on daily life activities are required for patients after ARCR. Furthermore, Shoulder36 can be useful for assessing the prognosis of patients with and without re-rupture.

Post-surgery rehabilitation following rotator cuff repair. A survey of current (2020) Italian clinical practice

AIMS

To analyse the clinical practice of Italian physiotherapists within the framework of postoperative rehabilitation of rotator cuff (RC) surgery patients, and to compare it with similar studies carried out in other countries.

METHODS

A web-based, voluntary, cross-sectional survey with 27 closed multiple-choice questions was developed and submitted to Italian-based physiotherapists in order to assess their clinical practice.

RESULTS

Data from 1160 questionnaires were then analysed. Thirty-five percent of respondents (n = 413/1160) reported that they commence passive range of motion from the first postoperative week, while 49.2% (n = 571/1160) start during the second or third week. The majority of respondents (n = 603/1160, 52.0%) introduce active mobilisation between the fourth and the sixth week after surgery and 41.1% (n = 477/1160) introduce overhead movements between the fourth and the sixth week after surgery.

DISCUSSION AND CONCLUSIONS

When managing the postoperative rehabilitation of RC surgery patients, Italian physiotherapists' practice is congruent with the guidelines published by American Society of Shoulder and Elbow Therapists (ASSET) and also with other UK surveys. However, while Italian physiotherapists manage immobilisation periods, active and passive mobilisation and the return to sport activities, according to evidence-based best practice guidelines, there is less consistency with respect to physical exercise, patient follow-up and referral.IMPLICATIONS FOR REHABILITATIONItalian physiotherapists' practice with patients following rotator cuff (RC) repair complies with evidence-based practice guidelines regarding immobilisation periods, passive and active mobilisation, and return to sport activities.There is less consistency between reported/declared practice and available evidence concerning physical exercise, patient follow-up, and referral.Physiotherapist with Orthopaedic Manipulative Physical Therapy (OMPT) training is more aligned with the current literature compared to physiotherapists without specific training, in terms of managing rehabilitation programmes, period of immobilisation and therapeutic exercise.More careful adherence to the international guidelines is recommended, in order to manage patients following RC repair in accordance with the evidence and to achieve the best possible outcomes.

Long-term prognoses of patients with and without re-rupture after arthroscopic rotator cuff repair

[Purpose] We followed-up patients who underwent arthroscopic rotator cuff repair (ARCR) for 2 years to assess the prognosis of rotator cuff tears and compared the outcomes of the patients with and without re-rupture. We also examined the usefulness of Shoulder36, a self-assessment tool, for assessing the long-term prognosis in patients undergoing ARCR. [Participants and Methods] We included 28 patients who received occupational therapy pre- and post-ARCR between April 2012 and August 2015 and categorized them based on the occurrence of re-rupture. We followed-up on their prognoses for 2 years using physical examination and Shoulder36 assessment. [Results] Re-rupture occurred in five patients within 3 months of treatment. During the 2 year follow-up, the control group showed a significant improvement in pain and bi-directional active range of motion during physical assessment and in five out of six domains during Shoulder36 assessment. In contrast, the re-rupture group showed significant differences for only three domains of the Shoulder36 assessment twelve months after surgery. [Conclusion] We confirmed the long-term functional improvement and maintenance in the re-rupture group, suggesting that continued rehabilitation, compensatory movements, and detailed guidance on daily life activities are required for patients after ARCR. Furthermore, Shoulder36 can be useful for assessing the prognosis of patients with and without re-rupture.

The 3D-Printed PLGA Scaffolds Loaded with Bone Marrow-Derived Mesenchymal Stem Cells Augment the Healing of Rotator Cuff Repair in the Rabbits

The healing of tendon-bone in the rotator cuff is featured by the formation of the scar tissues in the interface after repair. This study aimed to determine if the 3D-printed poly lactic-co-glycolic acid (PLGA) scaffolds loaded with bone marrow-derived mesenchymal stem cells (BMSCs) could augment the rotator cuff repair in the rabbits. PLGA scaffolds were generated by the 3D-printed technology; Cell Counting Kit-8 assay evaluated the proliferation of BMSCs; the mRNA and protein expression levels were assessed by quantitative real-time polymerase chain reaction and western blot, respectively; immunohistology evaluated the rotator cuff repair; biomechanical characteristics of the repaired tissues were also assessed. 3D-printed PLGA scaffolds showed good biocompatibility without affecting the proliferative ability of BMSCs. BMSCs-PLGA scaffolds implantation enhanced the cell infiltration into the tendon-bone injunction at 4 weeks after implantation and improved the histology score in the tendon tissues after implantation. The mRNA expression levels of collagen I, III, tenascin, and biglycan were significantly higher in the scaffolds + BMSCs group at 4 weeks post-implantation than that in the scaffolds group. At 8 and 12 weeks after implantation, the biglycan mRNA expression level in the BMSCs-PLGA scaffolds group was significantly lower than that in the scaffolds group. BMSCs-PLGA scaffolds implantation enhanced collagen formation and increased collagen dimeter in the tendon-bone interface. The biomechanical analysis showed that BMSCs-PLGA scaffolds implantation improved the biomechanical properties of the regenerated tendon. The combination of 3D-printed PLGA scaffolds with BMSCs can augment the tendon-bone healing in the rabbit rotator cuff repair model.

A Review of Online Rehabilitation Protocols Designated for Rotator Cuff Repairs

Purpose

To compare publicly available rehabilitation protocols designated for rotator cuff (RTC) repairs published online by academic residency programs and private practice institutions.

Methods

A systematic electronic search using the Fellowship and Residency Electronic Interactive Database Access System (FREIDA) was performed for RTC repair rehabilitation protocols. Private practice programs with published rehabilitation protocols that were discovered during the Google search were also included for review, but no comprehensive search for private practice protocols was performed. The main exclusion criteria consisted of non–English-language protocols and protocols without any of the time-based components in question. Included protocols were assessed independently based on the specified RTC tear size (small [≤1 cm], medium [1-4 cm], large or massive [≥5 cm], or no mention of size). Protocols were compared based on the inclusion, exclusion, and timing of certain rehabilitation components.

Results

A total of 96 rehabilitation protocols were included for review, from 39 academic institutions and 28 private practice programs. Specific instructions for concomitant biceps tenodesis were included in 26 protocols (27.1%). Of the 96 protocols, 88 (91.7%) did not place restrictions on early postoperative passive range of motion (PROM) of the shoulder. Isolated PROM with restrictions on active range of motion was most commonly recommended for the first 4 or 6 weeks postoperatively (80.2%). Use of a sling or immobilizer was most frequently recommended for the first 4 or 6 weeks postoperatively (78.1%). Wide variation was noted in recommendations for returning to resistance strengthening, with the highest incidence being 27 protocols recommending returning at 12 weeks (28.1%); this further varied based on the size of the tear. A total of 21 protocols (21.9%) recommended the use of cryotherapy postoperatively.

Conclusions

Although certain rehabilitation components were common, such as duration of PROM and sling or immobilizer use, a large degree of variation remains among published rehabilitation protocols after RTC repair, and this variability is still seen even when subdividing by the size or severity of the RTC tear.

Clinical Relevance

Rehabilitation after RTC repair is crucial to patient outcomes. This study summarizes the variability among online rehabilitation protocols for RTC repair in the United States and emphasizes the importance of appropriate rehabilitation after RTC surgery.

Cost-Effectiveness of Supervised versus Unsupervised Rehabilitation for Rotator-Cuff Repair: Systematic Review and Meta-Analysis

Background: The objective of the present study was to compare the efficacy between supervised and unsupervised rehabilitation after rotator-cuff (RC) repair in terms of clinical outcomes, visual-analog-scale (VAS) score, range of motion (ROM), and risk of retear. Material: a comprehensive search of Pubmed, CINAHL, Cochrane, EMBASE, Ovid, and Google Scholar databases through a combination of the following keywords with logical Boolean operators: “informed”, “uninformed”, “unsupervised”, “supervised”, “rehabilitation”, “physical therapy”, “physical therapies”, “postoperative period”, “physical-therapy techniques”, “physical-therapy technique”, “exercise”, “exercise therapy”, “rotator cuff”, “rotator-cuff tear”, and “rotator-cuff repair”. For each article included in the study, the following data were extracted: authors, year, study design, sample size and demographic features, RC tear characteristics, clinical outcomes, ROM, VAS score, retear rate, and time of follow-up. Meta-analysis was performed in terms of VAS score. Results: Four randomized control trials with 132 patients were included. One study demonstrated significant improvement in VAS, active ROM, and the activity of the muscle’s motor units at stop and during maximal effort in supervised patients. Another one showed lower retear rates in the supervised group. The remaining two randomized controlled trials did not reveal any significant differences between supervised and unsupervised rehabilitation in terms of clinical outcomes. Moreover, higher costs were described for supervised rehabilitation. The VAS was not significantly different in the two groups (9.9 compared with 8.25, p = 0.23). Conclusions: although several publications address the problem of RC lacerations, there is a paucity of evidence in the literature regarding the effectiveness of supervised and unsupervised rehabilitation protocols. This systematic review and meta-analysis showed no significant differences between the two types of rehabilitation in terms of VAS scores, while outlining the pros and cons of each protocol.

Does quality of life influence retear rate following arthroscopic rotator cuff repair?

BACKGROUND

The primary objective was to assess whether a patient's early postoperative quality of life (QOL) correlates with the retear rate following single-tendon double-row rotator cuff repair.

METHODS

We performed a secondary analysis of a randomized clinical trial of 58 patients who underwent single-tendon arthroscopic rotator cuff repair of full-thickness tears performed by a single surgeon. Patients were randomized to an early- or delayed-motion protocol. At 6 months, all patients underwent magnetic resonance imaging to assess whether the rotator cuffs were intact or retorn. QOL was assessed preoperatively and at 3 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postoperatively using the Western Ontario Rotator Cuff (WORC) index.

RESULTS

After 6 months of rehabilitation, 41 patients (71%) had intact rotator cuff repairs whereas 17 (29%) had full-thickness tears. Patients with torn rotator cuffs at 6 months postoperatively had significantly lower WORC scores at 6 weeks postoperatively (P = .041). Patients with greater improvements in QOL perioperatively (preoperative WORC score minus 6-week postoperative WORC score > 264.5) were more likely to have full-thickness tears by 6 months postoperatively. Compliant patients assigned to the delayed-motion protocol had a failure rate of 11% (2 of 19) compared with 38% (15 of 39) in the noncompliant and early-motion protocol patients (P < .01). Overall, patients who were noncompliant with the shoulder immobilizer were 8.2 times more likely to have a failed repair on magnetic resonance imaging (P = .01).

CONCLUSIONS

Patients with better QOL shortly after arthroscopic rotator cuff repair were more likely to have retears by 6 months.

Preoperative Pain Control in Arthroscopic Rotator Cuff Repair: Does It Matter?

Background

The purpose of this study was to clarify the importance of preoperative pain control using corticosteroid injections in patients with persistent rest pain (RP) before arthroscopic rotator cuff repair (ARCR).

Methods

A total of 360 patients (374 shoulders) who underwent primary ARCR and were followed up for at least 2 years were enrolled. After one-to-one propensity score matching, 266 patients (145 men and 128 women, 273 shoulders) were included in the study. Their mean age was 65.2 ± 7.7 years (range, 42 to 88 years) at the time of surgery. The patients were divided into three groups: those who required several intra-articular or subacromial bursa corticosteroid injections preoperatively for refractory RP (group A+), those in whom RP was resolved preoperatively (group A−), and those who had no RP and did not require any injections (group B). The incidence of postoperative RP and preoperative and final follow-up American Shoulder and Elbow Surgeons (ASES) scores were compared among the three groups.

Results

The incidence of postoperative RP was significantly higher in group A+ (35/91 cases, 38.5%) than in group A− (10/91, 11.0%) and group B (7/91, 7.7%, p < 0.001 for both). The preoperative ASES score was significantly lower in group A+ (33.2 ± 14.2) than in group A− (53.9 ± 11.9) and group B (62.3 ± 11.2, p < 0.001 for both), and it was significantly lower in group A− than in group B (p = 0.000). The final follow-up ASES score was significantly lower in group A+ (92.1 ± 8.4) than in group A− (97.6 ± 5.4) and group B (99.0 ± 2.5, p < 0.001 for both). There was no significant difference in the final follow-up ASES score between group A− and group B (p = 0.242).

Conclusions

Patients in whom preoperative RP could be resolved before surgery achieved postoperative outcomes comparable to those in patients who had no RP before surgery, whereas the outcomes in patients with refractory preoperative RP were inferior. The results suggest that preoperative pain control is important in patients undergoing ARCR.

The Effects of a Standard Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair on Pain, Function, and Health Perception

Purpose  There is still conflicting evidence to support postoperative rehabilitation protocols using immobilization following rotator cuff repair over early motion. The objective of the study was to evaluate the evolution of pain, shoulder function, and patients' perception of their health status up to 1 year after cuff rotator repair and a standard postoperative rehabilitation protocol consisting of 4 weeks of immobilization followed by a 2-week assisted controlled rehabilitation.

Methods  Descriptive, longitudinal, uncontrolled case-series study was performed on 49 patients who underwent arthroscopic rotator cuff repair following traumatic or degenerative lesions. VAS scale for pain, Constant–Murley score for function, and SF-12 score for quality of life were used as outcome measures and were administered before the rehabilitation treatment, at the end of the 2-week rehabilitation, 3 months, and 1 year after surgery.

Results  VAS pain score decreased significantly along the follow-up reaching almost a nil value after 1 year (0.2). Function as measured by Constant–Murley score had a significant improvement during follow-up, reaching a mean value of 84.6. The short form (SF)-12 score increased over time reaching 46.3 for the physical and 43.8 for the psychological dimension, respectively, at 1 year.

Conclusion  The present study confirmed an excellent outcome at 1 year after rotator cuff repair using a traditional 4-week immobilization followed by a 2-week rehabilitation protocol without evidence of tendon un-healing or re-tearing.

Level of Evidence  This is a level IV, therapeutic case series.

Early promising outcome following arthroscopic implantation of the subacromial balloon spacer for treating massive rotator cuff tear

BACKGROUND

Massive rotator cuff tear (RCT) can result in disability and severe pain. When conservative treatment fails, surgical treatment should be considered, as various surgical options can provide relatively satisfactory results. However, choosing an optimal treatment remains controversial. A relatively new treatment for irreparable RCT is the arthroscopic implantation of a biodegradable balloon spacer into the subacromial space. Here, we examined whether placement of this balloon spacer reduces pain and improves functional outcome in patients with an irreparable RCT. Patients were followed for 1 year following implantation.

METHODS

In this prospective single-arm study, a biodegradable balloon spacer was implanted into the subacromial space of patients with a massive RCT. Pain was evaluated using a numeric rating scale (NRS), and functional outcome was evaluated using the Oxford shoulder score (OSS) and the Constant-Murley shoulder score (CMS). Five follow-up visits were performed during the first postoperative year.

RESULTS

Forty-six shoulders in 44 patients with massive RCT were treated by surgical implantation of the subacromial balloon spacer. The mean reduction in NRS score was 3.5 points (95% CI 2.5-4.4), and 74% of patients achieved the minimal clinically important difference of 2 points by the 1-year follow-up visit. Functional outcome improved significantly based on OSS and CMS scores, and 80% of patients reported that they were satisfied with their outcome. No surgical or postoperative medical complications due to implantation of the balloon spacer were reported.

CONCLUSIONS

Our results suggest that arthroscopic implantation of a biodegradable balloon spacer in the subacromial space significantly reduces pain and improves activities of daily living in patients with massive RCT during 1 year of follow-up. The specific contribution of the balloon with respect to improved clinical outcome needs further study, ideally in a randomized controlled trial.