Rehabilitation of the rotator cuff: an evaluation-based approach

Provider opinions on effectiveness of physical therapy as treatment for glenohumeral arthritis

BACKGROUND

Physical therapy (PT) is a described first-line treatment option for glenohumeral arthritis, but its efficacy for treating this spectrum of disease is not well understood. The purpose of this study is to evaluate the opinions of expert providers-orthopedic surgeons and physical therapists-regarding the utility of PT in treating glenohumeral arthritis in different stages of radiographic severity. Our goal is to identify areas of interprofessional majority agreement as well as areas without agreement that warrant further investigation.

METHODS

A 35-question survey was created and distributed via email to members of the American Shoulder and Elbow Surgeons and the American Society of Shoulder and Elbow Therapists, collecting information on demographics, professional experience, and the perceived benefit of PT for patients with different stages of glenohumeral arthritis based on radiographic severity. Survey responses were analyzed for inter-professional differences in distribution of answer choices as well as for majority agreement statements. Items with >50% agreement from a professional group were considered statements of majority agreement.

RESULTS

One hundred and ninety surgeons and 39 physical therapists completed the survey. Surgeons and therapists demonstrated different distribution of answer choices in 25 of the 29 nondemographic related questions (86%). Surgeons and therapists reached the same majority statement in 8 items (28%) and reached disagreeing majority statements in 4 items (14%). They agreed on the benefits of PT for mild arthritis, the benefits of corticosteroid injections, the frequency of strengthening exercises, and that PT failure should not be required for surgical approval in patients with severe arthritis. They disagreed on the whether PT exacerbates symptoms in patients with moderate arthritis, and whether preoperative PT influences postoperative outcomes.

CONCLUSION

Both surgeons and therapists agreed that PT may be less beneficial for patients with more advanced radiographic arthritis and that PT failure should not be required for insurance approval for surgical intervention in patients with severe glenohumeral arthritis. Further research is needed to determine the efficacy of PT for patients with moderate arthritis as well as the utility of preoperative PT for improving postoperative outcomes.

The effect of rehabilitation time on functional recovery after arthroscopic rotator cuff repair: a systematic review and meta-analysis

Objective

We compared the effects of early and delayed rehabilitation on the function of patients after rotator cuff repair by meta-analysis to find effective interventions to promote the recovery of shoulder function.

Methods

This meta-analysis was registered in PROSPERO (CRD42023466122). We manually searched the randomized controlled trials (RCTs) in the Cochrane Library, Pubmed, Cochrane Library, EMBASE, the China National Knowledge Infrastructure (CNKI), the China VIP Database (VIP), and the Wanfang Database to evaluate the effect of early and delayed rehabilitation after arthroscopic shoulder cuff surgery on the recovery of shoulder joint function. Review Manager 5.3 software was used to analyze the extracted data. Then, the PEDro scale was employed to appraise the methodological quality of the included research.

Results

This research comprised nine RCTs and 830 patients with rotator cuff injuries. According to the findings of the meta-analysis, there was no discernible difference between the early rehabilitation group and the delayed rehabilitation group at six and twelve months after the surgery in terms of the VAS score, SST score, follow-up rotator cuff healing rate, and the rotator cuff retear rate at the final follow-up. There was no difference in the ASES score between the early and delayed rehabilitation groups six months after the operation. However, although the ASES score in the early rehabilitation group differed significantly from that in the delayed rehabilitation group twelve months after the operation, according to the analysis of the minimal clinically important difference (MCID), the results have no clinical significance.

Conclusions

The improvement in shoulder function following arthroscopic rotator cuff surgery does not differ clinically between early and delayed rehabilitation. When implementing rehabilitation following rotator cuff repair, it is essential to consider the paradoxes surrounding shoulder range of motion and tendon anatomic healing. A program that allows for flexible progression based on the patient's ability to meet predetermined clinical goals or criteria may be a better option.

Health Care Utilization for Common Shoulder Disorders: Analysis of the 2010-2019 National Patient Sample Data from the Health Insurance Review and Assessment Service in Korea

Background and Objective: The aim of this study was to analyze trends in surgical and non-surgical service utilization for common shoulder disorders in Korea from 2010 to 2019. Methods and Materials: This retrospective, cross-sectional, descriptive study utilized National Patient Sample data from the Health Insurance and Review Assessment Service (HIRA) of Korea. These data constitute a 2% sample out of the entire Korean population and include data for a variety of parameters instrumental for health care research. Patients with at least one medical service use for rotator cuff syndrome or tear, impingement syndrome, or adhesive capsulitis between January 2010 and December 2019 were included. Trends in healthcare utilization by disorder type, patient demographics, seasonal service use, and treatment details were examined. Results: There was an upward trend in the total number of patients and costs for shoulder disorders, from 35,798 patients and USD 5,485,196 in 2010 to 42,558 and USD 11,522,543 in 2019, respectively. The number of patients aged ≥60 and hospital visits increased. March had the highest number of claims. Physical therapy was the most common non-surgical procedure, while nerve block claims more than doubled. Opioid prescription rates also tripled. Surgical treatments were dominated by shoulder rotator cuff repair and acromioplasty. Conclusions: There was a significant increase in healthcare utilization for shoulder disorders, marked by rising costs and patient numbers. The use of nerve blocks and opioids notably increased. These data are valuable for clinicians, researchers, and policymakers.

A randomized controlled trial of postoperative rehabilitation using digital healthcare system after rotator cuff repair

A digital healthcare system based on augmented reality (AR) has promising uses for postoperative rehabilitation. We compare effectiveness of AR-based and conventional rehabilitation in patients after rotator cuff repair (RCR). This study randomly allocates 115 participants who underwent RCR to digital healthcare rehabilitation group (DR group) and conventional rehabilitation group (CR group). The DR group performs AR-based home exercises using UINCARE Home+, whereas the CR group performs brochure-based home exercises. The primary outcome is a change in the Simple Shoulder Test (SST) score between baseline and 12 weeks postoperatively. The secondary outcomes are the Disabilities of the Arm, Shoulder and Hand (DASH) score; Shoulder Pain And Disability Index (SPADI) score; EuroQoL 5-Dimension 5-Level (EQ5D5L) questionnaire score; pain; range of motion (ROM); muscle strength; and handgrip strength. The outcomes are measured at baseline, and at 6, 12, and 24 weeks postoperatively. The change in SST score between baseline and 12 weeks postoperatively is significantly greater in the DR group than in the CR group (p = 0.025). The SPADI, DASH, and EQ5D5L scores demonstrate group×time interactions (p = 0.001, = 0.04, and = 0.016, respectively). However, no significant differences over time are observed between the groups in terms of pain, ROM, muscle strength, and handgrip strength. The outcomes show significant improvement in both groups (all p < 0.001). No adverse events are reported during the interventions. AR-based rehabilitation shows better improvement in terms of shoulder function after RCR compared to conventional rehabilitation. Therefore, as an alternative to the conventional rehabilitation, the digital healthcare system is effective for postoperative rehabilitation.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Cervical Versus Shoulder Surgery

STUDY DESIGN

Retrospective analysis of outcomes in cervical spine and shoulder arthroscopy patients.

OBJECTIVE

The objective of this study is to assess differential improvements in health-related quality of life for cervical spine surgery compared with shoulder surgery.

SUMMARY OF BACKGROUND DATA

An understanding of outcome differences between different types of orthopedic surgeries is helpful in counseling patients about expected postoperative recovery. This study compares outcomes in patients undergoing cervical spine surgery with arthroscopic shoulder surgery using computer-adaptive Patient-reported Outcome Information System scores.

MATERIALS AND METHODS

Patients undergoing cervical spine surgery (1-level or 2-level anterior cervical discectomy and fusion, cervical disc replacement) or arthroscopic shoulder surgery (rotator cuff repair±biceps tenodesis) were grouped. Patient-reported Outcome Information System scores of physical function, pain interference, and pain intensity at baseline and at 3, 6, and 12 months were compared using paired t tests.

RESULTS

Cervical spine (n=127) and shoulder (n=91) groups were similar in sex (25.8% vs. 41.8% female, P =0.731) but differed in age (51.6±11.6 vs. 58.60±11.2, P <0.05), operative time (148.3±68.6 vs. 75.9±26.9 min, P <0.05), American Society of Anesthesiologists (ASAs) (2.3±0.6 vs. 2.0±0.5, P =0.001), smoking status (15.7% vs. 4.4%, P =0.008), and length of stay (1.1±1.0 vs. 0.3±0.1, P =0.000). Spine patients had worse physical function (36.9 ±12.6 vs. 49.4±8.6, P <0.05) and greater pain interference (67.0±13.6 vs. 61.7±4.8, P =0.001) at baseline. Significant improvements were seen in all domains by 3 months for both groups, except for physical function after shoulder surgery. Spine patients had greater physical function improvements at all timepoints (3.33 vs. -0.43, P =0.003; 4.81 vs. 0.08, P =0.001; 6.5 vs. -5.24, P =<0.05). Conversely, shoulder surgery patients showed better 6-month improvement in pain intensity over spine patients (-8.86 vs. -4.46, P =0.001), but this difference resolved by 12 months.

CONCLUSIONS

Cervical spine patients had greater relative early improvement in physical function compared with shoulder patients, whereas pain interference and intensity did not significantly differ between the 2 groups after surgery. This will help in counseling patients about relative difference in recovery and improvement between the 2 surgery types.

LEVEL OF EVIDENCE

III.

Effects of Different Orthoses on Neuromuscular Activity of Superficial and Deep Shoulder Muscles during Activities of Daily Living and Physiotherapeutic Exercises in Healthy Participants

BACKGROUND

This study aimed to investigate the effects of different shoulder orthoses on the neuromuscular activity of superficial and deep shoulder muscles during activities of daily living (ADL) and physiotherapeutic exercises.

METHODS

Ten participants with healthy shoulders (31 ± 3 years, 23.1 ± 3.8 kg/m²) were randomized to receive a "shoulder sling", an "abduction pillow" and a "variably adjustable orthosis" on the dominant side. With each orthosis, they completed seven ADL with and four physiotherapeutic exercises without wearing the orthoses. An electromyographic system was used to record the neuromuscular activity of three superficial (trapezius, deltoid, pectoralis major) and two deep shoulder muscles (infraspinatus, supraspinatus) using surface and intramuscular fine-wire electrodes.

RESULTS

The neuromuscular activity differs between the orthoses during ADL (p ≤ 0.045), whereby the "variably adjustable orthosis" mostly showed the highest activation levels associated with the worst subjective wearing comfort rated on a visual analog scale. In addition, differences exist between the physiotherapeutic exercises (p ≤ 0.006) demonstrating the highest activations of the infra- and supraspinatus muscles for assistive elevation and wipe across a table, middle for pendulum and lowest for continuous passive motion exercises.

CONCLUSIONS

The neuromuscular activity of superficial and deep shoulder muscles differs between the orthoses during ADL and also between the physiotherapeutic exercises.

Functional biomaterials for tendon/ligament repair and regeneration

With an increase in life expectancy and the popularity of high-intensity exercise, the frequency of tendon and ligament injuries has also increased. Owing to the specificity of its tissue, the rapid restoration of injured tendons and ligaments is challenging for treatment. This review summarizes the latest progress in cells, biomaterials, active molecules and construction technology in treating tendon/ligament injuries. The characteristics of supports made of different materials and the development and application of different manufacturing methods are discussed. The development of natural polymers, synthetic polymers and composite materials has boosted the use of scaffolds. In addition, the development of electrospinning and hydrogel technology has diversified the production and treatment of materials. First, this article briefly introduces the structure, function and biological characteristics of tendons/ligaments. Then, it summarizes the advantages and disadvantages of different materials, such as natural polymer scaffolds, synthetic polymer scaffolds, composite scaffolds and extracellular matrix (ECM)-derived biological scaffolds, in the application of tendon/ligament regeneration. We then discuss the latest applications of electrospun fiber scaffolds and hydrogels in regeneration engineering. Finally, we discuss the current problems and future directions in the development of biomaterials for restoring damaged tendons and ligaments.

Long-term Results of Arthroscopic Repair of Full-Thickness Traumatic Rotator Cuff Tears in Active Duty Military Patients Under the Age of 40 Years

BACKGROUND

Arthroscopic rotator cuff repair is an effective procedure through which to decrease pain and increase strength, with favorable long-term outcomes demonstrated in older patient populations with full-thickness rotator cuff tears. The long-term outcomes after this procedure in younger, higher-demand patients, however, is not as clearly defined.

PURPOSE

To report on the long-term outcomes after arthroscopic rotator cuff repair of traumatic full-thickness rotator cuff tears in active duty military patients under the age of 40 years at the time of surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Preoperative, midterm, and final evaluations were collected, including scores on the visual analog scale for pain, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons shoulder form. A total of 42 patients were screened for inclusion: 3 underwent additional surgical procedures on the operative shoulder and 2 were lost to follow-up, leaving 37 patients with mean follow-up of 104.51 months available for analysis. A subgroup analysis was performed comparing outcomes between patients with Southern California Orthopaedic Institute grade 1 or 2 tears and those with grade 3 or 4 tears.

RESULTS

At final follow-up, pain per the visual analog scale decreased to 1.16 from 8.03 (P < .0001); the Single Assessment Numeric Evaluation score increased to 87.32 from 48.24 (P < .0001); and the American Shoulder and Elbow Surgeons score increased to 88.68 from 41.00 (P < .0001). There was no statistically significant difference in outcome scores or range of motion between midterm and final follow-up. Improvement in outcome scores and range of motion at final follow-up did not vary between patients with small and large tears. Of 42 patients, 37 (88.1%) were able to return to full unrestricted active duty and sporting activity, while 5 (11.9%) were medically separated from the military.

CONCLUSION

Active duty military patients under the age of 40 years with traumatic full-thickness rotator cuff tears had statistically and clinically significant increases in outcome scores and decreases in pain after arthroscopic rotator cuff repair at long-term follow-up.

The Efficacy of Pain Neuroscience Education on Active Rehabilitation Following Arthroscopic Rotator Cuff Repair: A CONSORT-Compliant Prospective Randomized Single-Blind Controlled Trial

Pain neuroscience education (PNE), a modern educational therapy, has been reported to be effective in pain control by reducing fear of movement. This study investigated the effects of additional PNE on a physical therapy rehabilitation protocol (PTRP) following arthroscopic rotator cuff repair (ARCR). In this single-blind, randomized controlled trial, 34 patients who had undergone ARCR were randomly allocated (1:1) into two groups: PNE (PTRP plus PNE) and PTRP. PTRP was performed five times a week, for four weeks, 115 min per session (physical agents, manual therapy, and exercises), and PNE was performed twice at the beginning (face-to-face PNE) and end (non-face-to-face) of the PTRP. The outcome measures were measured four times for pain intensity, pain cognition, and shoulder function; two times for a range of motion; and once for satisfaction. No significant difference in pain intensity was observed between the groups. However, in pain cognition, the Tampa Scale for Kinesiophobia avoidance showed a significant interaction between time and group, and PNE showed a higher effect size than PTRP in the post-test and follow-up in several variables. In conclusion, the significant improvement in avoidance in postoperative rehabilitation suggests that there is a partially positive benefit in terms of pain, range of motion, and shoulder function in ARCR patients.

Digitally Assisted Versus Conventional Home-Based Rehabilitation After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

OBJECTIVE

The aim of this study was to evaluate the clinical impact of a 12-wk home-based digitally assisted rehabilitation program after arthroscopic rotator cuff repair against conventional home-based rehabilitation.

DESIGN

The digital therapy group performed independent technology-assisted sessions complemented with 13 face-to-face sessions, and the conventional therapy group had conventional face-to-face physical therapy (30 sessions). Primary outcome was functional change between baseline and 12 wks, measured through the Constant-Murley score. Secondary outcomes were the change in the QuickDASH Scale and shoulder range of motion.

RESULTS

Fifty participants enrolled; 41 completed the 12-wk program (23 digital therapy group vs. 18 conventional therapy group), and 32 (15 vs. 17) were available for the 12-mo follow-up assessment. No differences were found between groups regarding study endpoints at the end of the 12-wk program. However, follow-up results revealed the superiority of the digital therapy group for QuickDASH (P = 0.043), as well as an interaction between time and group in the Constant-Murley score (P = 0.047) in favor of the digital therapy group.

CONCLUSIONS

The results demonstrate that digital therapeutics can be used to achieve similar, if not superior, short- and long-term outcomes as conventional approaches after arthroscopic rotator cuff repair, while being far less human resource intensive than conventional care.Level of evidence: II.

The Greek version of shoulder rating questionnaire (SRQ): Translation, cultural adaptation, a reliability and validity study in patients with rotator cuff related shoulder pain

BACKGROUND

The Shoulder Rating Questionnaire (SRQ) was created in the English language to assess shoulder disorders in six areas: global function, pain, daily activities, recreational and athletic activities, and work.

PURPOSE

The study aimed to translate and culturally adapt Shoulder Rating Questionnaire (SRQ) into Greek.

METHODS

The SRQ English version was translated and adapted into the Greek language using forward translation, expert panel synthesis, and backward translation procedures. A pilot testing has been made in the target population, and the final version was created. A cross-sectional study was conducted in clinical settings with the SRQ and the Shoulder Pain and Disability Index. A total of 168 Greek adult patients with rotator cuff-related shoulder pain were recruited from physical therapy clinics. Τhe reliability of the SRQ Greek version was assessed using intraclass correlation coefficients. Internal consistency was assessed using the Cronbach alpha coefficient. Concurrent validity was measured by correlating the Shoulder Rating Questionnaire with the Shoulder Pain and Disability Index using Pearson's correlation coefficient.

RESULTS

The results showed that the SRQ Greek version has excellent internal consistency (Cronbach's α = 0.99), test-retest reliability (ICC = 0.976), and concurrent validity (r > 0.9). No ground or ceiling effects were found. The standard error of measurement and the minimum detectable change of the total score were 5.55 and 15.38.

CONCLUSIONS

The Greek Language Version of the SRQ is a reliable and valid instrument that can be used to evaluate adult patients with shoulder rotator cuff-related disorders in the acute or chronic phases and in clinical trials.

Treatment of Partial-Thickness Rotator Cuff Tears With a Resorbable Bioinductive Bovine Collagen Implant: 1-Year Results From a Prospective Multicenter Registry

Background:

Surgical treatment of partial-thickness rotator cuff tears remains challenging and controversial, with several traditional options including debridement with acromioplasty, transtendon or in situ repair, and take-down and repair. A resorbable bioinductive bovine collagen implant has shown promise as an alternative treatment option for partial-thickness tears.

Purpose:

Data from a registry were analyzed to further establish that the implant contributes to improved patient-reported outcome (PRO) scores across a large number of patients treated for partial-thickness rotator cuff tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 19 centers in the United States enrolled patients >21 years old with partial-thickness tears of the rotator cuff in a comprehensive prospective multicenter registry. PRO scores were recorded preoperatively and postoperatively at 2 and 6 weeks, 3 and 6 months, and 1 year: American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey (physical and mental component scores), and Western Ontario Rotator Cuff scores. Revisions were reported throughout the study.

Results:

The registry included 272 patients with partial-thickness tears (49 grade 1 tears, 101 grade 2 tears, and 122 grade 3 tears), 241 who underwent isolated bioinductive repair (IBR; collagen implant placed after bursectomy without a traditional rotator cuff repair), and 31 who had take-down and repair with bioinductive augmentation. Patients experienced statistically significant and sustained improvement from baseline for all PRO scores beginning at 3 months. Among patients with grade ≥2 tears, those with take-down and repair had significantly inferior scores at 2 and 6 weeks for most PRO scores as compared with those who underwent IBR, but the difference was no longer significant at 1 year for all but the physical component score of the Veterans RAND 12-Item Health Survey. There were 11 revisions, which occurred at a mean ± SD of 188.7 ± 88.0 days after the index surgery. There were no infections.

Conclusion:

This registry analysis further establishes across a large data set that this resorbable bioinductive bovine collagen implant improves PROs in all grades of partial-thickness tears, whether used as IBR or in conjunction with take-down and repair. IBR may offer improved early clinical outcomes (≤6 weeks) and comparable outcomes at 1 year when compared with a more invasive “take-down and repair” approach.

Isolated bioinductive repair of partial-thickness rotator cuff tears using a resorbable bovine collagen implant: two-year radiologic and clinical outcomes from a prospective multicenter study

BACKGROUND

Current surgical treatment options for partial-thickness tears (eg, takedown and repair, in situ repair) are limited by the degenerative nature of the underlying tendon and may require extensive intervention that can alter the anatomic footprint. The complexity of available techniques to address these issues led to the development of a resorbable collagen implant, which can be used to create a bioinductive repair of partial-thickness tears.

METHODS

We prospectively enrolled 33 patients with chronic, degenerative, intermediate-grade (n = 12), or high-grade (n = 21) partial-thickness tears (11 articular, 10 bursal, 4 intrasubstance, and 8 hybrid) of the supraspinatus tendon in a multicenter study. After arthroscopic subacromial decompression without a traditional rotator cuff repair, a bioinductive implant was secured over the bursal surface of the tendon. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores (CMS) preoperatively and at 3 months, 1 year, and 2 years postoperatively. Magnetic resonance imaging was performed to assess postoperative tendon healing and thickness at the original tear site.

RESULTS

At 2-year follow-up, mean ASES and CMS scores improved both clinically and statistically at 1 and 2 years, compared with baseline, for intermediate- and high-grade tears. There was magnetic resonance imaging evidence of new tissue fill-in within the original baseline tear in 100% of the intermediate-grade tears and 95% of the high-grade tears. In 90.9% of the intermediate-grade tears and 84.2% of the high-grade tears, this new tissue fill-in represented at least an additional 50% of the volume of the initial lesion. From baseline to 2-year follow-up, the mean tendon thickness increased by 1.2 mm (standard deviation, 1.3; P = .012) and 1.8 mm (standard deviation, 2.2; P = .003) in the intermediate- and high-grade tears, respectively. The analysis of tear grade and location revealed no statistically significant difference in the change in mean tendon thickness at any time point. One patient with a high-grade articular lesion demonstrated progression to a full-thickness tear; however, the patient was noncompliant and the injury occurred while shoveling snow 1 month after surgery. Neither tear location nor treatment of bicep pathology affected the ASES or CMS scores at any follow-up point. No serious adverse events related to the implant were reported.

CONCLUSION

Final results from this 2-year prospective study indicate that the use of this resorbable bovine collagen implant for isolated bioinductive repair of intermediate- and high-grade partial-thickness rotator cuff tears of the supraspinatus is safe and effective, regardless of tear grade and location.

Subscapularis-sparing approaches in shoulder arthroplasty: A systematic review

Background

Novel approaches for anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) that spare the subscapularis (SSC) have recently been described. Outcomes for the SSC-sparing approach were evaluated through this systematic review.

Methods

Medline, Embase, PubMed, and CENTRAL were searched.

Results

From 2051 citations, 8 studies were included (aTSA group, n = 241; rTSA group, n = 68). SSC-sparing aTSA and rTSA were associated with significant postoperative improvements in shoulder function and range of motion at 12- to 24-month follow-up.

Conclusion

The SSC-sparing approach may provide a safe alternative for up to two years post-surgery. Evidence for long-term use remains inconclusive.

Superior Capsular Reconstruction: A Systematic Review of Surgical Techniques and Clinical Outcomes

PURPOSE

To evaluate surgical techniques and clinical outcomes of arthroscopic superior capsular reconstruction (SCR) for the treatment of massive irreparable rotator cuff tears.

METHODS

A systematic review was registered with PROSPERO and performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Scopus, and Cochrane databases were searched. Studies investigating SCR with reported surgical techniques were included. Animal studies, cadaveric studies, review studies, and letters to the editor were excluded. The technical aspects of the surgical techniques for SCR were analyzed in each article, which included graft type, glenoid fixation method, greater tuberosity fixation method, graft passage technique, suture management, margin convergence, concomitant procedures, and postoperative rehabilitation protocol. Clinical outcomes, when available, were also analyzed.

RESULTS

We screened 365 articles, of which 29 described surgical techniques for SCR. According to the Modified Coleman Methodology Score, 24 articles were rated as poor (score < 55), 4 were rated as fair (score between 55 and 69), and 1 was rated as good (score between 70 and 84), with an average score of 25.8 ± 20.9. The most commonly performed technique for SCR used the following: an acellular dermal allograft, 2 biocomposite suture anchors for glenoid fixation, transosseous-equivalent double-row suture anchor fixation for greater tuberosity fixation with 2 biocomposite medial-row anchors and 2 biocomposite lateral-row anchors, the double-pulley technique combined with an arthroscopic grasper and/or pull suture to pass the graft into the shoulder, the performance of both anterior and posterior margin convergence, and a native rotator cuff repair when possible. Only 8 studies reported clinical outcomes, and they showed that SCR provides significant improvement in patient-reported outcomes, significant improvement in shoulder range of motion, variable graft failure rates, low complication rates, and variable reoperation rates. There were no studies comparing outcomes among the various surgical techniques.

CONCLUSIONS

Many surgical techniques exist for arthroscopic SCR. However, no superior technique was shown because there were no studies comparing clinical outcomes among these various techniques.

LEVEL OF EVIDENCE

Level V, systematic review of Level III, IV, and V studies.

Effect of cryotherapy on pain and analgesic consumption after wrist or thumb surgery

Cryotherapy has demonstrated its efficacy in post-traumatic soft tissue pain, through its anti-inflammatory action. Its postoperative use has also been the topic of many studies and has now proved its efficacy in indications such as ligament or knee arthroplasty surgery. The aim of this study was to analyze the effect of cryotherapy on pain and analgesic consumption after wrist or base of the thumb surgery. We prospectively included 60 patients from March 2017 to May 2018. All these patients had undergone wrist or base of the thumb surgery involving a bone procedure. Thirty patients were managed with cryotherapy (the Handfreez® splint), 30 patients were included in the control group with conventional immobilization. The data collected included a visual analogue scale (VAS), and analgesic and non-steroidal anti-inflammatory drug (NSAID) consumption, both during the hospital stay and then at home for one week. The results from the two groups were compared. During the hospital stay, morphine consumption was significantly lower in the cryotherapy group (p = 0.04). At home, NSAID consumption was significantly lower in the cryotherapy group (p = 0.009). The VAS score was not significantly different between the two groups. In our study, we demonstrated the benefits of cryotherapy on consumption of analgesics and NSAIDs after bone surgery of the wrist or the base of the thumb.

Comparing expert opinion within the care team regarding postoperative rehabilitation protocol following rotator cuff repair

INTRODUCTION

There is no established consensus regarding the optimal rehabilitation protocol following rotator cuff repair, including duration of immobilization, timing to initiate range of motion and resistance exercises, and the importance of supervised, formal therapy. The purpose of this study was to determine agreement in opinion regarding rotator cuff rehabilitation between orthopedic surgeons and physical therapists (PTs).

METHODS

A 50-question survey was created on a secure data capture system and distributed via e-mail to members of professional organization affiliations. Surgeon participants were recruited from the American Shoulder and Elbow Surgeons, and PTs were recruited from the American Society of Shoulder and Elbow Therapists and the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Survey responses were analyzed for interprofessional differences in majority opinion and distribution of answer choices.

RESULTS

A total of 167 surgeons and 667 PTs responded to the survey. Of the 39 questions evaluated, surgeons and PTs reached intraprofessional majority agreement in 26 (67%) and 28 (72%) statements, respectively, with agreements matching in 17 instances and differing in 4. The 2 groups had different answer preferences in 32 questions (82%). PTs were more likely to support shorter immobilization intervals (P < .001), earlier strengthening (P < .001), and more frequent home exercises (P = .002), whereas surgeons endorsed more conservative weight-bearing restrictions (P < .001), time-based phase transitions (P < .001), and web-based technological platforms for rehabilitation (P < .001).

CONCLUSION

Our findings show that although significant discrepancy of opinion exists within professions, greater differences in preferences exist between surgeons and PTs regarding rotator cuff repair rehabilitation.

Sub-regional activation of supraspinatus and infraspinatus muscles during activities of daily living is task dependent

The supraspinatus and infraspinatus muscles each have multiple sub-regions that may activate differentially in activities of daily living. Awareness of these differential demands critically informs rehabilitation of rotator cuff muscle following injury, particularly if centered on recovering and strengthening the rotator cuff to perform daily tasks. This study quantified muscle activation of supraspinatus and infraspinatus sub-regions during the performance of six activities of daily living. Twenty-three participants (mean: 22.6 ± 2.6 years) completed the following tasks: opening a jar, reaching at shoulder height, overhead reaching, pouring water from a pitcher, eating with a spoon, and combing hair. Indwelling electromyography was collected from the anterior and posterior supraspinatus and superior, middle, and inferior infraspinatus. Tasks requiring high arm elevations (e.g. reaching at shoulder and overhead height) activated anterior supraspinatus between 21 and 28% MVC. The posterior supraspinatus consistently activated between 10 and 30% MVC across all tasks. All sub-regions of infraspinatus activated highly (between 18 and 25% MVC) in tasks requiring high arm elevations in flexion. These findings may be leveraged to define effective measures to increase rotator cuff function in daily tasks.

Arthroscopic Transosseous Repair of Rotator Cuff Tear and Greater Tuberosity Cysts

Purpose

To evaluate the short-term outcomes of rotator cuff repair in the presence of a greater tuberosity cyst (GTC) using a transosseous repair technique.

Methods

This study included patients who underwent arthroscopic rotator cuff tear repair with a transosseous technique and were evaluated clinically and by postoperative magnetic resonance imaging (MRI) after 1 year. The inclusion criteria were based on the results of preoperative MRI and were as follows: patients identified as having a repairable full-thickness rotator cuff tear associated with the presence of cystic changes at the tendon insertion site of the greater tuberosity, defined as a GTC involving the footprint area of the torn tendon (supraspinatus and/or infraspinatus tendons).

Results

We evaluated 25 patients. The mean preoperative and postoperative American Shoulder and Elbow Surgeons scores were 39.48 (P = .530) and 84.64 (P = .035), respectively; Constant shoulder scores, 38.96 (P < .005) and 80.28 (P = .425), respectively; and University of California–Los Angeles shoulder rating scale scores, 10.6 (P = .045) and 29.04 (P = .315), respectively. The GTC mapping system was easily adopted in all the MRI examinations independently from the quality of the images. The GTCs were mostly located in the superficial anterolateral section of the humeral head and in both the posterolateral sections (superficial and deep).

Conclusions

Arthroscopic transosseous rotator cuff repair led to significant mid-term improvement and satisfactory subjective outcomes with low complication and failure rates in this study. The GTC mapping system could be useful to evaluate GTCs and to aid surgeons in the choice of the best surgical technique.

Level of Evidence

Level IV, therapeutic case series.

Evaluating the Uptake and Acceptability of Standardized Postoperative Rehabilitation Guidelines Using an Online Knowledge Translation Approach

BACKGROUND

Providing physical therapists with evidence-based and consensus-derived guidelines to manage postoperative shoulder patients is essential; these guidelines should be readily available and provide clinically applicable information. Knowledge translation (KT) initiatives that encourage interaction between clinicians and researchers, that have multifaceted components and use a variety of strategies, can significantly change practice.

OBJECTIVE

The objective of this study was to determine the uptake and acceptability of standardized postoperative shoulder guidelines with an accompanying online KT resource through evaluation of website analytics and a quantitative survey.

DESIGN

A multi-pronged approach was used to assess uptake and acceptability of the guidelines and online KT resource.

METHODS

Website analytics of usage and geographical location of users was measured as were physical therapist survey responses.

RESULTS

Website analytics revealed that 5406 individuals used the online resource between October 2012 and September 2013 with the average visit lasting 8 minutes; only 47% of users were within the guideline developers' surgical referral region. Physical therapists who used the new shoulder guidelines were very satisfied or satisfied (96%) with the guidelines, reporting they promoted patient-specific clinical decision-making extremely or very well (68%). They viewed the online KT resource positively, with 79% rating it as "very useful" or "quite useful." Physical therapists from regions beyond those expected to use the new shoulder guidelines were also aware of the website and also rated it as very useful.

LIMITATIONS

The survey sample was relatively small and did not directly assess patient outcomes.

CONCLUSIONS

An online KT web resource developed in conjunction with standardized postoperative shoulder guidelines was perceived as useful based on website analytics and survey responses. Active KT strategies such as this can improve uptake and dissemination of best practice in physical therapy.

Surgery for rotator cuff tears

BACKGROUND

This review is one in a series of Cochrane Reviews of interventions for shoulder disorders.

OBJECTIVES

To synthesise the available evidence regarding the benefits and harms of rotator cuff repair with or without subacromial decompression in the treatment of rotator cuff tears of the shoulder.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry unrestricted by date or language until 8 January 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including adults with full-thickness rotator cuff tears and assessing the effect of rotator cuff repair compared to placebo, no treatment, or any other treatment were included. As there were no trials comparing surgery with placebo, the primary comparison was rotator cuff repair with or without subacromial decompression versus non-operative treatment (exercises with or without glucocorticoid injection). Other comparisons were rotator cuff repair and acromioplasty versus rotator cuff repair alone, and rotator cuff repair and subacromial decompression versus subacromial decompression alone. Major outcomes were mean pain, shoulder function, quality of life, participant-rated global assessment of treatment success, adverse events and serious adverse events. The primary endpoint for this review was one year.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

We included nine trials with 1007 participants. Three trials compared rotator cuff repair with subacromial decompression followed by exercises with exercise alone. These trials included 339 participants with full-thickness rotator cuff tears diagnosed with magnetic resonance imaging (MRI) or ultrasound examination. One of the three trials also provided up to three glucocorticoid injections in the exercise group. All surgery groups received tendon repair with subacromial decompression and the postoperative exercises were similar to the exercises provided for the non-operative groups. Five trials (526 participants) compared repair with acromioplasty versus repair alone; and one trial (142 participants) compared repair with subacromial decompression versus subacromial decompression alone. The mean age of trial participants ranged between 56 and 68 years, and females comprised 29% to 56% of the participants. Symptom duration varied from a mean of 10 months up to 28 months. Two trials excluded tears with traumatic onset of symptoms. One trial defined a minimum duration of symptoms of six months and required a trial of conservative therapy before inclusion. The trials included mainly repairable full-thickness supraspinatus tears, six trials specifically excluded tears involving the subscapularis tendon. All trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding, but also for other reasons such as unclearly reported methods of random sequence generation or allocation concealment (six trials), incomplete outcome data (three trials), selective reporting (six trials), and other biases (six trials). Our main comparison was subacromial decompression versus non-operative treatment and results are reported for the 12 month follow up. At one year, moderate-certainty evidence (downgraded for bias) from 3 trials with 258 participants indicates that surgery probably provides little or no improvement in pain; mean pain (range 0 to 10, higher scores indicate more pain) was 1.6 points with non-operative treatment and 0.87 points better (0.43 better to 1.30 better) with surgery.. Mean function (zero to 100, higher score indicating better outcome) was 72 points with non-operative treatment and 6 points better (2.43 better to 9.54 better) with surgery (3 trials; 269 participants), low-certainty evidence (downgraded for bias and imprecision). Participant-rated global success rate was 873/1000 after non-operative treatment and 943/1000 after surgery corresponding to (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.96 to 1.22; low-certainty evidence (downgraded for bias and imprecision). Health-related quality of life was 57.5 points (SF-36 mental component score, 0 to 100, higher score indicating better quality of life) with non-operative treatment and 1.3 points worse (4.5 worse to 1.9 better) with surgery (1 trial; 103 participants), low-certainty evidence (downgraded for bias and imprecision). We were unable to estimate the risk of adverse events and serious adverse events as only one event was reported across the trials (very low-certainty evidence; downgraded once due to bias and twice due to very serious imprecision).

AUTHORS' CONCLUSIONS

At the moment, we are uncertain whether rotator cuff repair surgery provides clinically meaningful benefits to people with symptomatic tears; it may provide little or no clinically important benefits with respect to pain, function, overall quality of life or participant-rated global assessment of treatment success when compared with non-operative treatment. Surgery may not improve shoulder pain or function compared with exercises, with or without glucocorticoid injections. The trials included have methodology concerns and none included a placebo control. They included participants with mostly small degenerative tears involving the supraspinatus tendon and the conclusions of this review may not be applicable to traumatic tears, large tears involving the subscapularis tendon or young people. Furthermore, the trials did not assess if surgery could prevent arthritic changes in long-term follow-up. Further well-designed trials in this area that include a placebo-surgery control group and long follow-up are needed to further increase certainty about the effects of surgery for rotator cuff tears.

Early and Delayed Postoperative Rehabilitation after Arthroscopic Rotator Cuff Repair: A Comparative Study of Clinical Outcomes

BACKGROUND

The duration of immobilization after arthroscopic rotator cuff repair and the optimal time to commence rehabilitation are still the subject of ongoing debates. This study was undertaken to evaluate the functional outcome and rotator cuff healing status after arthroscopic rotator cuff repair by comparing early and delayed rehabilitation.

METHODS

Totally, 76 patients with small, medium, and large sized rotator cuff tears underwent arthroscopic repair using the suture-bridge technique. In early rehabilitation group, 38 patients commenced passive range of motion at postoperative day 2 whereas 38 patients assigned to the delayed rehabilitation group commenced passive range of motion at postoperative week 3. At the end of the study period, clinical and functional evaluations (Constant score, the University of California, Los Angeles [UCLA] shoulder score) were carried out, subsequent to measuring the range of motion, visual analogue scale for pain, and isokinetic dynamometer test. Rotator cuff healing was confirmed by magnetic resonance imaging at least 6 months after surgery.

RESULTS

No significant difference was obtained in range of motion and visual analogue scale between both groups. Functional outcomes showed similar improvements in the Constant score (early: 67.0-88.0; delayed: 66.9-91.0; p<0.001) and the UCLA shoulder score (early: 20.3-32.3; delayed: 20.4-32.4; p<0.001). Furthermore, rotator cuff healing showed no significant differences between the groups (range, 6-15 months; average, 10.4 months).

CONCLUSIONS

Delayed passive rehabilitation does not bring about superior outcomes. Therefore, early rehabilitation would be useful to help patients resume their daily lives.

Does arthroscopic preemptive extensive rotator interval release reduce postoperative stiffness after arthroscopic rotator cuff repair?: a prospective randomized clinical trial

BACKGROUND

To investigate whether preemptive extensive rotator interval (RI) release during arthroscopic rotator cuff repair (ARCR) would reduce postoperative stiffness.

METHODS

From July 2015 to September 2016, a total of 80 patients who were scheduled for ARCR were enrolled and randomly allocated into 2 groups: the preemptive extensive RI release group (group 1, n=40) and the RI nonrelease group (group 2, n=40). The American Shoulder and Elbow Surgeons scale, Constant score, Korean Shoulder Scale (KSS), visual analog scale (VAS) pain score, and range of motion (ROM) were evaluated before surgery; 3, 6, and 12 months after surgery; and at last follow-up. Magnetic resonance imaging was performed at postoperative 12 months.

RESULTS

The mean follow-up period was 26.5 months. The functional and pain scores in both groups were significantly improved at the last follow-up (P < .05). Group 1 showed a significantly higher sum of ROM with a difference of 27° and 1.6 vertebral level of internal rotation compared to group 2 at postoperative 3 months (P < .05). Constant score and KSS were significantly higher in group 1 than in group 2 at this time point (P < .05). Functional scores and ROM were not significantly different between 2 groups at postoperative 6 or 12 months or at the last follow-up (P > .05). The retear rate and pathologic change of the long head of the biceps tendon during follow-up were not significantly different between the 2 groups (P > .05).

CONCLUSION

Arthroscopic preemptive extensive RI release can reduce early postoperative shoulder stiffness after ARCR but does not significantly change the overall clinical outcome after surgery.

Superior Capsular Reconstruction for Massive Rotator Cuff Tear Leads to Significant Improvement in Range of Motion and Clinical Outcomes: A Systematic Review

PURPOSE

To determine if arthroscopic superior capsular reconstruction for massive irreparable rotator cuff tears results in statistically significant and clinically significant improvement in patient-reported outcomes and shoulder range of motion with low graft failure, complication, and reoperation rates.

METHODS

A systematic review was registered with PROSPERO and performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane databases were searched. Studies investigating superior capsular reconstruction in adults were included. Animal, cadaveric, and review studies, letters to the editor, and technique papers were excluded. Study methodological quality was analyzed using the Modified Coleman Methodology Score. Shoulder motion and patient-reported outcome scores were analyzed. Statistical significance was defined by P < .05, and clinical significance was defined by the minimal clinically important difference.

RESULTS

Six articles (286 subjects, 292 shoulders, 67.7% males, mean age 63.4 ± 4.1 years, mean follow-up 25.7 ± 14.5 months) were analyzed. The methodological quality was fair (59.7 ± 13.8). Five studies reported significant improvement in the American Shoulder and Elbow Surgeons (ASES) score (mean range: 30-55, P < .001 for all). Visual analog scale (VAS) scores significantly improved in 3 studies (mean range: 2.5-5.9, P < .001 for 2 and P = .005 for 1). Shoulder forward flexion (mean range: 28°-56°, P < .001 for 2 and P = .04 for 1) significantly increased in 3 studies. One hundred percent of subjects from 2 studies had clinically significant improvement in ASES and VAS scores and shoulder forward flexion. Thirty-six subjects (14.2% of 254) had graft failure on magnetic resonance imaging (MRI). Eleven subjects (3.8%) had complications, and 34 (11.7%) underwent reoperation.

CONCLUSIONS

Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff tears results in statistically significant and clinically significant improvement in patient-reported outcomes and shoulder range of motion with low graft failure, complication, and reoperation rates at short-term follow-up in fair-quality studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Subacromial decompression surgery for rotator cuff disease

BACKGROUND

Surgery for rotator cuff disease is usually used after non-operative interventions have failed, although our Cochrane Review, first published in 2007, found that there was uncertain clinical benefit following subacromial decompression surgery.

OBJECTIVES

To synthesise the available evidence of the benefits and harms of subacromial decompression surgery compared with placebo, no intervention or non-surgical interventions in people with rotator cuff disease (excluding full thickness rotator cuff tears).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry from 2006 until 22 October 2018, unrestricted by language.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials (RCTs) of adults with rotator cuff disease (excluding full-thickness tears), that compared subacromial decompression surgery with placebo, no treatment, or any other non-surgical interventions. As it is least prone to bias, subacromial decompression compared with placebo was the primary comparison. Other comparisons were subacromial decompression versus exercises or non-operative treatment. Major outcomes were mean pain scores, shoulder function, quality of life, participant global assessment of success, adverse events and serious adverse events. The primary endpoint for this review was one year. For serious adverse events, we also included data from prospective cohort studies designed to record harms that evaluated subacromial decompression surgery or shoulder arthroscopy.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

We included eight trials, with a total of 1062 randomised participants with rotator cuff disease, all with subacromial impingement. Two trials (506 participants) compared arthroscopic subacromial decompression with arthroscopy only (placebo surgery), with all groups receiving postoperative exercises. These trials included a third treatment group: no treatment (active monitoring) in one and exercises in the other. Six trials (556 participants) compared arthroscopic subacromial decompression followed by exercises with exercises alone. Two of these trials included a third arm: sham laser in one and open subacromial decompression in the other.Trial size varied from 42 to 313 participants. Participant mean age ranged between 42 and 65 years. Only two trials reported mean symptom duration (18 to 22 months in one trial and 30 to 31 months in the other), two did not report duration and four reported it categorically.Both placebo-controlled trials were at low risk of bias for the comparison of surgery versus placebo surgery. The other trials were at high risk of bias for several criteria, most notably at risk of performance or detection bias due to lack of participant and personnel blinding. We have restricted the reporting of results of benefits in the Abstract to the placebo-controlled trials.Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence, downgraded due to imprecision).At one year, mean pain (on a scale zero to 10, higher scores indicate more pain), was 2.9 points after placebo surgery and 0.26 better (0.84 better to 0.33 worse), after subacromial decompression (284 participants), an absolute difference of 3% (8% better to 3% worse), and relative difference of 4% (12% better to 5% worse). At one year, mean function (on a scale 0 to 100, higher score indicating better outcome), was 69 points after placebo surgery and 2.8 better (1.4 worse to 6.9 better), after surgery (274 participants), an absolute difference of 3% (7% better to 1% worse), and relative difference of 9% (22% better to 4% worse). Global success rate was 97/148 (or 655 per 1000), after placebo and 101/142 (or 708 per 1000) after surgery corresponding to RR 1.08 (95% CI 0.93 to 1.27). Health-related quality of life was 0.73 units (European Quality of Life EQ-5D, -0.59 to 1, higher score indicating better quality of life), after placebo and 0.03 units worse (0.011 units worse to 0.06 units better), after subacromial decompression (285 participants), an absolute difference of 1.3% (5% worse to 2.5% better), and relative difference of 4% (15% worse to 7% better).Adverse events including frozen shoulder or transient minor complications of surgery were reported in approximately 3% of participants across treatment groups in two randomised controlled trials, but due to low event rates we are uncertain if the risks differ between groups: 5/165 (37 per 1000) reported adverse events with subacromial decompression and 9/241 (34 per 1000) with placebo or non-operative treatment, RR 0.91 (95% CI 0.31 to 2.65) (moderate-certainty evidence, downgraded due to imprecision). The trials did not report serious adverse events.Based upon moderate-certainty evidence from two observational trials from the same prospective surgery registry, which also included other shoulder arthroscopic procedures (downgraded for indirectness), the incidence proportion of serious adverse events within 30 days following surgery was 0.5% (0.4% to 0.7%; data collected 2006 to 2011), or 0.6% (0.5 % to 0.7%; data collected 2011 to 2013). Serious adverse events such as deep infection, pulmonary embolism, nerve injury, and death have been observed in participants following shoulder surgery.

AUTHORS' CONCLUSIONS

The data in this review do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life. Including results from open-label trials (with high risk of bias) did not change the estimates considerably. Due to imprecision, we downgraded the certainty of the evidence to moderate for global assessment of treatment success; there was probably no clinically important benefit in this outcome either compared with placebo, exercises or non-operative treatment.Adverse event rates were low, 3% or less across treatment groups in the trials, which is consistent with adverse event rates reported in the two observational studies. Although precise estimates are unknown, the risk of serious adverse events is likely less than 1%.

[Rotator Cuff Rupture: When Is Conservative and When Is Surgical Therapy Indicated?]

Rotator Cuff Rupture: When Is Conservative and When Is Surgical Therapy Indicated? Abstract. Patients with rotator cuff tears can be treated conservatively or surgically. The treatment decision depends on the one hand on patient-specific factors like shoulder impairment, age, activity level, functional demand, and on the other hand on morphological or radiological circumstances like tear size, muscle degeneration and fatty infiltration of the rotator cuff muscles. In this review, the treatment approach of our institution is described.

Rotator cuff failure after surgery: an all-arthroscopic transosseous approach

BACKGROUND

Tear recurrence is considered the main complication of a rotator cuff repair. The best arthroscopic technique has not yet been established. The aim of the present study was to evaluate, from a clinical and a radiological standpoint, the all-arthroscopic transosseous rotator cuff repair with cortical lateral augmentation, performed in the setting of a revision surgery.

MATERIALS AND METHODS

Eleven consecutive cases were prospectively followed up for a minimum of 12 month after a rotator cuff repair with a novel all-arthroscopic transosseous rotator cuff repair. VAS and UCLA score and patients' satisfaction with the outcomes were analyzed, along with MRI evolution of the repair. All patients underwent a standardized surgery and postoperative rehabilitation program.

RESULTS

All patients showed a significant improvement in pain reduction and functional score. Satisfaction was achieved in 10 out of 11 cases, and only 1 case showed a minor discontinuous tendon signal on the 12-month MRI assessment. No complications were noted.

CONCLUSIONS

Our results favor the use of the all-arthroscopic transosseous rotator cuff revision surgery with the 2MC configuration (double MC means the initials of the authors-MM and CC, who have originally described it). It appears to be safe and effective, providing good clinical, functional, and radiological results, with a very high patient satisfaction.

No Functional Difference Between Three and Six Weeks of Immobilization After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Non-Inferiority Trial

PURPOSE

The aim of this study was to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff (RC) repair in a prospective randomized controlled non-inferiority trial.

METHODS

One hundred twenty patients were included after RC surgery for a small- to medium-sized tear of supraspinatus and upper infraspinatus tendons. Group A was immobilized in a simple sling for 3 weeks, and group B had a brace with a small abduction pillow with the arm in neutral position for 6 weeks. All patients started active range of motion when they removed the sling/brace. One hundred eighteen (98%) patients were assessed at 1-year follow-up. They underwent magnetic resonance imaging (MRI) of the shoulder, filled out the Western Ontario Rotator Cuff (WORC) index, and were evaluated with a Constant Murley (CM) score.

RESULTS

Statistical non-inferiority was demonstrated for the 2 groups on the basis of the WORC index, the primary endpoint at 1 year. The objective for the non-inferiority test was to determine whether the expected mean WORC index for group A was at most 13% worse than standard treatment (Group B). The WORC index at 1 year was similar in both groups, with mean percent scores of 83% in group A and 87% in group B (mean difference = -4; 95% one-sided CI -9, -4). Age-adjusted CM scores were also similar, with means of 86 in group A and 90 in group B (mean difference = -4; 95% CI -13, 5; P = .37). MRI after 1 year showed 50 (89%) patients in each group with healed RC repair. Four patients in group A had complications: 1 acute postoperative infection, 2 cases of postoperative capsulitis treated with corticosteroid injections, and 1 repeat operation because of a loose anchor and subacromial pain. No patients in group B had complications.

CONCLUSION

RC repair resulted in improved postoperative shoulder function, regardless of whether the shoulder was immobilized for 3 or 6 weeks. Three weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace with regard to the WORC index at 12 months' follow-up. MRI indicated similar degrees of healing between the groups. Based on these findings, it is safe to immobilize patients in a simple sling for 3 to 6 weeks after repair of small to medium RC tears.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial with statistically significant differences.

Nonoperative treatment of five common shoulder injuries: A critical analysis

Economic pressure highlights the critical need for appropriate diagnosis and treatment of various shoulder pathologies since under-diagnosis and under-treatment can result in increased costs to society in the form of disability and lost production. On the other hand, aggressive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore, it is crucial to distinguish the indications between operative and nonoperative management, especially in common shoulder pathologies such as rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular joint, and proximal humeral fractures. As a result, a detailed analysis of individual risk factors for potential failures should be performed and treatment should be based on individualized care with consideration given to each patient’s particular injury pattern, functional demands, and long-term goals.

Radiologic and clinical evaluation of a bioabsorbable collagen implant to treat partial-thickness tears: a prospective multicenter study

BACKGROUND

Treatment of partial-thickness cuff tears remains controversial. Although conservative therapy may treat symptoms, these defects do not spontaneously heal and conversion to a full-thickness lesion with subsequent repair may alter the tendon footprint. The ability to induce new tissue formation and limit tear progression in intermediate- and high-grade partial-thickness tears without surgical repair may represent a significant advancement in the treatment paradigm for these lesions.

METHODS

We prospectively enrolled 33 patients with chronic, degenerative, intermediate-grade (n = 12) or high-grade (n = 21) partial-thickness tears (11 articular, 10 bursal, 4 intrasubstance, and 8 hybrid) of the supraspinatus tendon in a multicenter study. Following arthroscopic subacromial decompression without repair, a bioinductive implant was attached over the bursal surface of the tendon. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons and Constant-Murley scores preoperatively and at 3 and 12 months postoperatively. Magnetic resonance imaging was performed to assess postoperative tendon healing and thickness at the original tear site.

RESULTS

At 1-year follow-up, clinical scores improved significantly (P <.0001) and the mean tendon thickness increased by 2.0 mm (P <.0001). Magnetic resonance imaging evidence of complete healing was found in 8 patients and a considerable reduction in defect size was shown in 23, whereas 1 lesion remained stable. In 1 noncompliant patient with a high-grade articular lesion, progression to a full-thickness tear occurred while shoveling snow 1 month after surgery. No serious adverse events related to the implant were reported.

CONCLUSIONS

Arthroscopic implantation of a bioinductive collagen scaffold is a safe and effective treatment for intermediate- to high-grade partial-thickness rotator cuff tears of the supraspinatus tendon.

Recovery after shoulder arthroscopy: Inpatient versus outpatient management

INTRODUCTION

Shoulder arthroscopy is particularly suited to outpatient surgery, thanks to advances in anesthetic and analgesic techniques. The main goal of this study was to compare postoperative recovery after shoulder arthroscopy between outpatient and inpatient management.

HYPOTHESIS

There is no difference in functional recovery between inpatient and outpatient management.

MATERIALS AND METHOD

A single-center, single-operator prospective study was conducted. Both groups received patient-controlled analgesia via an interscalene catheter. The inclusion criterion was shoulder arthroscopy for rotator cuff tendinopathy. The choice between inpatient and outpatient management was left to the patient. The study endpoint was postoperative recovery assessed on QOR-15 at days 1, 2, 3, 4 and 7 and on Quick-DASH at 6 weeks.

RESULTS

Forty-nine patients were included, divided into 2 groups. The outpatient (OP) and inpatient (IP) groups were comparable. Reconstructive surgery accounted for 54% of cases in OP versus 62% in IP. There was no significant difference in recovery in the first postoperative days (QOR-15) or at 6 weeks (Quick-DASH) (p>0.05). Pain on visual analog scale (VAS) was significantly greater in OP after discharge home.

DISCUSSION

No significant difference in postoperative recovery was observed between groups. Nevertheless, pain management and patient information for outpatients need improving.

LEVEL OF EVIDENCE

II, comparative study.

Subscapularis-On Approach in Reverse Shoulder Arthroplasty

Using a subscapularis- and deltoid-preserving anterior approach is an option for patients undergoing reverse shoulder arthroplasty. Outcomes are better at short term than compared with the standard deltopectoral approach. Maintaining the integrity of the subscapularis tendon and preserving the deltoid muscle minimizes the need for postoperative immobilization and rehabilitation, allowing the patient to achieve active shoulder range of motion more rapidly, without increasing the incidence of shoulder dislocation. Overall length of hospital stay and duration of postoperative physical therapy are minimized, leading to significant economic gain. Future studies with longer follow-up are required to document the potential long-term benefits of this surgical technique.

Level of Evidence of the study: Review, Level IV

Subscapularis- and deltoid-sparing vs traditional deltopectoral approach in reverse shoulder arthroplasty: a prospective case-control study

Background

With the growth of reverse shoulder arthroplasty (RSA), it is becoming increasingly necessary to establish the most cost-effective methods for the procedure. The surgical approach is one factor that may influence the cost and outcome of RSA. The purpose of this study was to compare the clinical results of a subscapularis- and deltoid-sparing (SSCS) approach to a traditional deltopectoral (TDP) approach for RSA. The hypothesis was that the SSCS approach would be associated with decreased length of stay (LOS), equal complication rate, and better short-term outcomes compared to the TDP approach.

Methods

A prospective evaluation was performed on patients undergoing RSA over a 2-year period. A deltopectoral incision was used followed by either an SSCS approach or a traditional tenotomy of the subscapularis (TDP). LOS, adverse events, physical therapy utilization, and patient satisfaction were collected in the 12 months following RSA.

Results

LOS was shorter with the SSCS approach compared to the TDP approach (from 8.2 ± 6.4 days to 15.2 ± 11.9 days; P = 0.04). At 3 months postoperative, the single assessment numeric evaluation score (80 ± 11% vs 70 ± 6%; P = 0.04) and active elevation (130 ± 22° vs 109 ± 24°; P = 0.01) were higher in the SSCS group. The SSCS approach resulted in a net cost savings of $5900 per patient. Postoperative physical therapy, pain levels, and patient satisfaction were comparable in both groups. No immediate intraoperative complications were noted.

Conclusion

Using a SSCS approach is an option for patients requiring RSA. Overall LOS is minimized compared to a TDP approach with subscapularis tenotomy. The SSCS approach may provide substantial healthcare cost savings, without increasing complication rate or decreasing patient satisfaction.

Rehabilitation after Rotator Cuff Repair

BACKGROUND

Rotator cuff tears are a very common condition that is often incapacitating. Whether non-surgical or surgical, successful management of rotator cuff disease is dependent on appropriate rehabilitation. If conservative management is insufficient, surgical repair is often indicated. Postsurgical outcomes for patients having had rotator cuff repair can be quite good. A successful outcome is much dependent on surgical technique as it is on rehabilitation. Numerous rehabilitation protocols for the management of rotator cuff disease are based primarily on clinical experience and expert opinion. This article describes the different rehabilitation protocols that aim to protect the repair in the immediate postoperative period, minimize postoperative stiffness and muscle atrophy.

METHODS

A review of currently available literature on rehabilitation after arthroscopic rotator cuff tear repair was performed to illustrate the available evidence behind various postoperative treatment modalities.

RESULTS

There were no statistically significant differences between a conservative and an accelerated rehabilitation protocol . Early passive range of motion (ROM) following arthroscopic cuff repair is thought to decrease postoperative stiffness and improve functionality. However, early aggressive rehabilitation may compromise repair integrity.

CONCLUSION

The currently available literature did not identify any significant differences in functional outcomes and relative risks of re-tears between delayed and early motion in patients undergoing arthroscopic rotator cuff repairs. A gentle rehabilitation protocol with limits in range of motion and exercise times after arthroscopic rotator cuff repair would be better for tendon healing without taking any substantial risks. A close communication between the surgeon, the patient and the physical therapy team is important and should continue throughout the whole recovery process.

Early active rehabilitation after arthroscopic rotator cuff repair: a prospective randomized pilot study

OBJECTIVE

To compare two different rehabilitation strategies, primary passive motion versus early isometric loading of the rotator cuff.

DESIGN

Prospective randomized controlled observer-blinded pilot study.

SETTING

Institute of Physical Medicine and Rehabilitation.

SUBJECTS

Thirty patients after rotator cuff surgery.

INTERVENTION

All participants were randomly assigned to one of the two outpatient treatment groups: primary passive motion versus early isometric loading of the rotator cuff. Both groups were treated for 12 weeks and performed additionally a home exercise program.

MAIN MEASURES

The primary outcome measure for functional assessment was the Constant Murley score. The secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion, pain level and strength. Patients were assessed before, 6, 12 and 24 weeks after surgery.

RESULTS

Repeatedly measured metric variables were compared by the Quade rank analysis of covariance and revealed substantially better Constant Murley scores in the early activated group at all 3 assessments (6 weeks: 41 [31;45] versus 30 [23;37]; 12 weeks: 68 [56;77] versus 59 [53;62]; 24 weeks: 79 [76;81] versus 66 [62;74]; data as median [25%;75%]). Postoperative changes of Constant score were in favour of the active group with the biggest difference at week 12 (28 [38;12] versus 9 [27;-4]). Maximal pain levels showed clear more reduction 6 and 24 weeks after surgery in the early activated group.

CONCLUSIONS

This pilot study with early isometric loading of the rotator cuff shows better function and less maximal pain. Further research is warranted to confirm our results.

The validity and reliability of ultrasound on identifying supraspinatus tears during passive external rotation from 0° to 30°: a pilot project

BACKGROUND

Controversy exists regarding how much external rotation should be allowed following rotator cuff repair. Clinicians may use ultrasound imaging (USI) to visualize the supraspinatus (SSp) tendon during passive external rotation. However, the validity and reliability of USI used to assess supraspinatus tendon gap formation during external rotation needs to be established prior to using this technique in patient cohorts.

METHODS

Ten subjects with magnetic resonance imaging (MRI) confirmation of full-thickness SSp tears were matched to 10 control subjects. Images of the SSp were obtained at 0°, 10°, 20° and 30° of external rotation by a blinded tester on two occasions to establish both validity and reliability of the measure.

RESULTS

Validity was established as 70% agreement between the USI and MRI confirmed SSp tear group; reliability was established at greater than 0.90 at all positions of external rotation measured.

CONCLUSIONS

USI may be used to detect SSp tears with 70% validity, and the technique is reliable in all positions of external rotation.

Rotator cuff rehabilitation: current theories and practice

A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the population, increasing with age, and can lead to significant disability and social and health costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the result of trauma or occur as a result of chronic degeneration. They can be acutely painful, limited to certain activities or completely asymptomatic and incidental findings. A wide variety of treatment options exists ranging from conservative local and systemic pain modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in proper treatment. Length of treatment, types of therapy and timing may vary if therapy is definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing must always be considered when implementing ROM and strengthening after surgery. With current rehabilitation methods, patients with all spectrums of RCT pathology can improve their function, pain and quality of life. This manuscript reviews current theories and practice involving rehabilitation for RCT injuries.

Prognosis Driven Rehabilitation After Rotator Cuff Repair Surgery

Background:

Rehabilitation after rotator cuff repair surgery has been the focus of several clinical trials in the past decade. Many illuminate new evidence with regard to the prognosis of structural and functional success after surgery.

Methods:

A selective literature search was performed and personal physiotherapeutic and surgical experiences are reported.

Results:

Post-operative rehabilitation parameters, namely the decision to delay or allow early range of motion after surgery, play a large role in the overall success after surgery. Using a prognosis driven rehabilitation program offers clinicians a means of prescribing optimal rehabilitation parameters while ensuring structural and functional success. This commentary aims to synthesize the evidence in a spectrum of prognostic factors to guide post-operative rehabilitation.

Conclusion:

The optimal rehabilitation program after rotator cuff repair surgery is debatable; therefore, we suggest using a spectrum of prognostic factors to determine a rehabilitation program suited to ensure structural and functional success, quickly and safely.

Non-Operative Management of Rotator Cuff Tears

Background:

The role of nonoperative management for rotator cuff tears remains a matter of debate. Clinical results reported in the literature mainly consist of level IV studies, oftentimes combining a mixed bag of tear sizes and configurations, and are contradictory to some extent.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

Most studies show an overall success rate of around 75% for nonoperative treatment. However, the majority of studies also present a progression of tear size and fatty muscle infiltration over time, with however debatable clinical relevance for the patient. Suggested factors associated with progression of a rotator cuff tear are an age of 60 years or older, full-thickness tears, and fatty infiltration of the rotator cuff muscles at the time of initial diagnosis.

Conclusion:

Non-operative management is indicated for patients with lower functional demands and moderate symptoms, and/or of course for those refusing to have surgery. Close routinely monitoring regarding development of tear size should be performed, especially in patients that remain symptomatic during nonoperative treatment. To ensure judicious patient counseling, it has to be taken into account that 1) tears that are initially graded as reparable may become irreparable over time, and 2) results after secondary surgical therapy after failed nonoperative treatment are usually reported to be inferior to those who underwent primary tendon repair.

Irreparable Rotator Cuff Tears: Restoring Joint Kinematics by Tendon Transfers

Background:

Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L’Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis.

Conclusion:

Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.

Electromyographic activities of the subscapularis, supraspinatus and infraspinatus muscles during passive shoulder and active elbow exercises

PURPOSE

Postoperative exercises may increase load on repaired tendons. Differences in the activity of the rotator cuff muscles were assessed during several different types of passive shoulder and active elbow exercises.

METHODS

In 15 healthy subjects, passive forward flexion of the shoulder was performed using a table, pulley and rope, and a cane, and external rotation was performed using a cane and a wall. The active elbow flexion-extension exercise was also performed while holding the upper arm with the contralateral hand. Activation amplitudes of the supraspinatus, infraspinatus and subscapularis muscles were evaluated using electromyography with fine wires.

RESULTS

During passive forward flexion, the supraspinatus and infraspinatus muscles exhibited lower activity when using a table compared with a cane (both P < 0.01) and a pulley and rope (both P < 0.05). Flexion of <90° decreased supraspinatus activation compared with 170° (P = 0.047). During external rotation of the shoulder while using the cane and wall, there was no difference in the activity of any muscles. Electromyographic activity during the active elbow exercise was lower in the supraspinatus while holding the upper arm (P = 0.018).

CONCLUSION

The table sliding exercise may reduce stress on the rotator cuff during passive forward flexion more than the other exercises do. Decreasing the range of motion to less than 90° in forward flexion activated the supraspinatus less. Moreover, movement of the elbow can be performed holding the upper arm to activate the rotator cuff to a lesser extent.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Are Pulley Exercises Initiated 6 Weeks After Rotator Cuff Repair a Safe and Effective Rehabilitative Treatment? A Randomized Controlled Trial

BACKGROUND

There are few level 1 or 2 evidence studies that examine rehabilitation after rotator cuff repair. Pulleys have been used in postoperative shoulder rehabilitation with the intention of improving range of motion and developing strength. There is a concern that the use of pulleys in rehabilitation of rotator cuff repairs may contribute to excessive scapular motion (scapular substitution) and potentially inferior outcomes.

HYPOTHESIS

Rotator cuff repair patients treated with pulley exercises would have increased scapular substitution and inferior patient-determined outcome scores, range of motion, and strength compared with patients treated with an alternative rehabilitation program without pulleys.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 27 patients who underwent rotator cuff repair were randomized to a rehabilitation group that used pulleys initiated 6 weeks postoperatively, and 26 patients followed a rehabilitation protocol without pulleys. Inclusion criteria were patients undergoing arthroscopic rotator cuff repair. Exclusion criteria were large to massive rotator cuff tears, revision rotator cuff repair, glenohumeral osteoarthritis, adhesive capsulitis, and a symptomatic contralateral shoulder. Outcomes of intervention were patient-determined outcome scores (Western Ontario Rotator Cuff Index [WORC], American Shoulder and Elbow Surgeons [ASES] Shoulder Score, Single Assessment Numeric Evaluation [SANE], Shoulder Activity Level, and Simple Shoulder Test [SST]), range of motion, scapular substitution, and strength. Outcomes were determined at 6, 12, 18, 26, and 52 weeks. A power analysis determined that 22 patients were needed per group to have a power of 0.80, α = 0.05, and effect size of f = 0.5.

RESULTS

Both groups had statistically significant improvements in WORC, ASES Shoulder Score, SST, and SANE scores over time after rotator cuff repair (P < .0001). There were no differences between the interventions for WORC (P = .18), ASES Shoulder Score (P = .73), SANE (P = .5), Shoulder Activity Level (P = .39), or SST (P = .36). Both interventions demonstrated improvements in shoulder flexion (P = .002), abduction (P = .0001), external rotation (P = .02), strength (P ≤ .0002), and scapular substitution (P ≤ .07) over time after rotator cuff repair. However, there was no difference in range of motion (P ≥ .26), strength (P ≥ .20), or scapular substitution (P ≥ .17) between interventions.

CONCLUSION

A rotator cuff repair rehabilitation program that uses pulleys does not result in inferior outcomes, as determined by patient-determined outcome scores, measurements of scapular substitution, range of motion, and scaption strength.

REGISTRATION

ClinicalTrials.gov NCT01819909.

Chronic rupture of the long head of the biceps tendon: comparison of 2-year results following primary versus revision open subpectoral biceps tenodesis

INTRODUCTION

The purpose of this study was to evaluate the clinical results of surgical repair for proximal long head of the biceps (LHB) tendon ruptures comparing chronic primary and postsurgical revision LHB tendon ruptures.

MATERIALS AND METHODS

Patients who underwent subpectoral LHB tenodesis for chronic ruptures with a minimum of 2 years from surgery were identified. ASES and SF-12 PCS scores and surgical and demographic data were collected prospectively. At final follow-up, patients were interviewed regarding symptoms related to their biceps. Symptoms were converted into a Subjective Proximal Biceps Score (SPBS).

RESULTS

Twenty-seven patients (22 males, 5 females) with a mean age of 61 years (range 40-76 years) underwent LHB tenodeses. Twenty patients (74.1 %) were primary repairs for chronic ruptures and seven patients (25.9 %) were revision repairs after failed prior LHB tenodesis. Twenty-five patients (92.6 %; n = 18 primary; n = 7 revision) were available for follow-up a mean of 3.8 years (range 2-6.1). The overall median postoperative SPBS showed significant improvement over the preoperative baseline (p < 0.001). Individual components of the SPBS showed substantial improvements. The SPBS significantly correlated with the postoperative ASES score (r = -0.478; p = 0.038). There were no differences in postoperative SPBSs between the primary and revision tenodesis groups. The mean postoperative ASES score was 90.3 and SF-12 PCS was 52.6.

CONCLUSIONS

Open subpectoral LHB tenodesis was a safe and effective method for the treatment of chronic LHB tendon ruptures and for the revision of failed post-surgical LHB ruptures. Patients had less pain, cramping, and deformity after LHB tenodesis. The SPBS, ASES, and SF-12 PCS scores significantly improved among this group of patients.

LEVEL OF EVIDENCE

Level III; Retrospective comparative study.

Rotator cuff tears: Review of epidemiology, clinical assessment and operative treatment

Rotator cuff tears (RTCs) are the most common cause of shoulder disability. There has been a proportional increase in the prevalence of RCT in accordance with the rising trend of an ageing population. In this article we review the current literature encompassing RCT epidemiology, risk factors and aetiopathogenesis. We also summarize the current diagnostic modalities, treatment options, rehabilitation and outcomes.

Arthroscopic Knotless, Double-Row, Extended Linked Repair for Massive Rotator Cuff Tears

The management of massive rotator cuff tears remains a challenge for physicians, with failure rates being higher when compared with smaller tears. Many surgical treatment options exist including debridement with biceps tenodesis, complete repair, partial repair, repair with augmentation devices, superior capsule reconstruction, tendon transfer, and reverse total shoulder arthroplasty. The purpose of this article is to describe our preferred surgical technique for a complete arthroscopic repair using an extended linked, knotless, double-row construct.

Early Incorporation of an Evidence-Based Aquatic-Assisted Approach to Arthroscopic Rotator Cuff Repair Rehabilitation: Prospective Case Study

BACKGROUND AND PURPOSE

Both traditional and progressive rotator cuff repair rehabilitation protocols often delay active motion of the shoulder for 6 weeks or more. The early inclusion of a comprehensive aquatic-assisted exercise program presents a unique approach to postoperative management. The purpose of this case study is to describe a comprehensive evidence-based, aquatic-assisted rehabilitation program following arthroscopic rotator cuff repair.

CASE DESCRIPTION

A 73-year-old woman with a nonretracted, medium-size, full-thickness tear (2.5 cm) of the supraspinatus tendon underwent arthroscopic rotator cuff repair and was referred for postoperative physical therapy. The rehabilitation program was initiated at 2 weeks postoperatively and consisted of concurrent land- and aquatic-based interventions over 6 weeks for a total of 18 physical therapy visits.

OUTCOMES

Improvements were made in all 5 patient-reported outcome measures that were recorded weekly over the course of care. Improvements reached or exceeded minimal detectable change levels for the Shoulder Pain and Disability Index and the Penn Shoulder Score. Her numeric pain rating scale score at rest decreased from 4/10 at the initial evaluation to 2/10 at 8 weeks postoperatively and with activity decreased from 9/10 to 6/10. Shoulder strength and range of motion values also exhibited improvement over the course of care. No adverse events occurred during the case study.

DISCUSSION

This case study illustrates the safe inclusion of low-stress aquatic exercises as an early adjunct to traditional land-based rotator cuff repair rehabilitation programs in small- to medium-size repairs. Further studies are needed to determine the long-term effectiveness of adding aquatic therapy to traditional postoperative programs.

Mechanical risk of rotator cuff repair failure during passive movements: A simulation-based study

BACKGROUND

Despite improvements in rotator cuff surgery techniques, re-tear rate remains above 20% and increases with tear severity. Mechanical stresses to failure of repaired tendons have been reported. While optimal immobilization postures were proposed to minimize this stress, post-operative rehabilitation protocols have never been assessed with respect to these values. Purpose was to use musculoskeletal simulation to predict when the stress in repaired tendons exceeds safety limits during passive movements. Hence, guidelines could be provided towards safer post-operative exercises.

METHODS

Sixteen healthy participants volunteered in passive three-dimensional shoulder range-of-motion and passive rehabilitation exercises assessment. Stress in all rotator cuff tendons was predicted during each movement by means of a musculoskeletal model using simulations with different type and size of tears. Safety stress thresholds were defined based on repaired tendon loads to failure reported in the literature and used to discriminate safe from unsafe ranges-of-motion.

FINDINGS

Increased tear size and multiple tendons tear decreased safe range-of-motion. Mostly, glenohumeral elevations below 38°, above 65°, or performed with the arm held in internal rotation cause excessive stresses in most types and sizes of injury during abduction, scaption or flexion. Larger safe amplitudes of elevation are found in scapular plane for supraspinatus alone, supraspinatus plus infraspinatus, and supraspinatus plus subscapularis tears.

INTERPRETATION

This study reinforces that passive early rehabilitation exercises could contribute to re-tear due to excessive stresses. Recommendations arising from this study, for instance to keep the arm externally rotated during elevation in case of supraspinatus or supraspinatus plus infraspinatus tear, could help prevent re-tear.

The accuracy of diagnostic ultrasound imaging for musculoskeletal soft tissue pathology of the extremities: a comprehensive review of the literature

Musculoskeletal diagnostic ultrasound imaging (MSK-DUSI) has been growing outside the traditional radiology speciality. Increased use of this technology has been reported in several healthcare settings, however an apparent gap in the knowledge of the accuracy of this diagnostic technology indicated a review was warranted. We undertook a structured review of the literature to assess the accuracy of MSK-DUSI for the diagnosis of musculoskeletal soft tissue pathology of the extremities. An electronic search of the National Library of Medicine’s PubMed database (1972 to mid-2014) was conducted. All relevant systematic reviews of diagnostic studies, all diagnostic studies published after the date of the latest systematic reviews and relevant diagnostic studies outside the scope the systematic reviews that directly compared the accuracy of MSK-DUSI (the index test) to an appropriate reference standard for the target condition were included. A fundamental appraisal of the methodological quality of studies was completed. The individual sensitivity, specificity and likelihood ratio data were extracted and entered into diagnostic accuracy tables. A total of 207 individual studies were included. The results show that MSK-DUSI has acceptable diagnostic accuracy for a wide spectrum of musculoskeletal conditions of the extremities. However, there is a lack of high quality prospective experimental studies in this area and as such clinicians should interpret the results with some caution due to the potential for overestimation of diagnostic accuracy.