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PHYSICIAN UPDATE August 2021 TITLE: How Early Following Rotator Cuff Repair Should Active Motion Begin? by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario….What would you do? A 47 yr old male with a history of RC tendonitis symptoms injured his dominant arm throwing a football with friends while tailgating before a Bills game. MRI was (+) for full thickness Supraspinatus and partial thickness Infraspinatus tears. He was able to elevate actively to 1500 within two weeks and ordered a 6 wk trial with PT. Function and sx were not improving adequately so a RC-R was done. Sling immobilization for 6 wks chosen post-op. Which of the the following orders would be given for post-op PT care re ROM… PROM only for 6 weeks, AAROM x 2 weeks, then begin gravity neutral AROM for elevation and rot’s at 8 wks post op Immobilized x 2 weeks then begin 6 wks PROM, AAROM x 2+ wks, then begin gravity neutral AROM for elevation and rot’s at 10 wks post op PROM only x 3 wks, begin AAROM for 1-2 wks, then begin gravity neutral AROM for elevation and rot’s 4-5 wks post op Immobilized x 4 wks, begin PROM at 4 wks, add AAROM at 6 wks and then gravity neutral AROM for elevation and rot’s starting at 10 wks post op CURRENT EVIDENCE Silveira A, Luk J, Tan M, Kang SH, Sheps DM, Bouliane M, Beaupre L. Move It or Lose It? The Effect of Early Active Movement on Clinical Outcomes Following Rotator Cuff Repair: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2021 Jul;51(7):331-344. doi: 10.2519/jospt.2021.9634. Epub 2021 May 15. PMID: 33998264.. SUMMARY: Shoulder pain is one of the most common pathologies seen in orthopedics with a prevalence ranging from 70 and up to 260 per 1000 individuals in the general population. Physical therapy can be a great tool to reduce pain and improve functional ability, however after confirmation of a tear and failed conservative treatment, surgical intervention may be necessary. Post-op RC-R’s are commonly immobilized in the Rochester area for roughly 6 weeks with only passive shoulder ROM allowed per protocol as previous literature has demonstrated benefits of reducing stiffness while minimizing risk of damage to the repair and potential retearing. Silveira et al. conducted a systematic review using eight RCT’s to compare the effects of allowing early AROM after surgery before 6 weeks vs. delaying AROM regarding any significant benefits or risks on ROM, functional outcomes, strength, atrophy, or integrity of the repair. Silveira et al. showed that the integrity of the repair was maintained as per 12 month US or MRI imaging, not showing significant difference in retears between early AROM groups and PROM only for 6 weeks. Likewise, testing by 6+ months demonstrated both ROM and strength were also not significantly different among groups, despite 6 wk testing showing worse functional questionnaire responses early on with the early AROM group. These results pose the question: What are the benefits to immobilization with PROM only following RC-R vs early AROM before 6 weeks? A key perspective certainly is that while early AROM did not reveal any long term worsening of functional scores or objective findings, it also did not result in improved status either (ie. no clear benefit to offset the potential risks). Early AROM, while seemingly not practiced in the Rochester area as a standard, appears to be statistically safe but the potential benefits are still uncertain. Pairing the right individual with the treatment program may increase functional return at an earlier date; however, risks may also rise as loaded lifting rather than AROM reaching alone becomes more likely with earlier ADL use. RC-R post op planning considers case by case variables while working closely with a skilled therapist and surgeon to determine the best course of action. At minimum, this study lends some support to common patient requests for light reaching, movements, and possibly things like limited keyboarding or video games etc that may otherwise be prohibited during the immobilization + PROM only phase. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRoc.com or if you have a patient case you'd like to discuss.) Background: Immobilization s/p rotator cuff repair with restricted PROM is thought as a measure to protect the joint and reduce stiffness in the first 6 weeks after surgery, however it has not been concluded what benefits or harm can come from allowing early AROM before 6 weeks. Method: A systematic review with meta-analysis was conducted with studies included from 1990 to present reported as RCTs. Metrics were compared between a control group of patients with sling immobilization and PROM only until 6 weeks post-op against early AROM before 6 weeks or “self weaning from sling.” 8 studies were included with 756 participants. Outcomes of interest reported at different times post-op included ROM, strength, repair integrity, return to work ability, and self-reported quality of life. Results: Patients who commenced early AROM vs delayed had greater ROM for flexion and abduction at 6 weeks, and for ABD/ER at 90 deg. at the 6 week, 3 month and 6 month marks with a high certainty of evidence favoring this early active motion post surgery. However, this same group rated themselves worse on the Western Ontario Rotator Cuff Index (WORC) at 6 weeks. There were no differences in repair integrity between groups however the individual studies were underpowered for this measure. There were no group differences for ROM or strength measures at long term follow ups. Author’s Conclusion: Patients who started with early AROM had increased ROM at 6 weeks for elevation and up to 6 months for ER but had worse shoulder specific quality of life ratings by 6 wks compared to those of delayed AROM. Outcomes were similar by 6-12 months between groups in all ROM, strength, functional scales, and repair integrity measures. There was no benefit but also no compromise in the selected measures to early AROM following RC-R. THE PEAK PERFORMANCE PERSPECTIVE Rotator cuff repairs can be necessary treatment for those with full or partial tears and certainly for those who have failed conservative rehabilitation and are still experiencing pain and functional deficits. Orthopedists have varying protocols dependent on which tendon(s) was/were repaired in order to promote healing and avoid overstressing the repair as biological healing ensues. Despite subtle differences, a general theme in the Rochester area is to delay AROM until 6 weeks or longer for many surgeons post-op , moving sequentially to AAROM before actual AROM and continuing to utilize maximum ROM limits until 3+ months post op. Silveira et al. sought to determine if there were any benefits to initiating early AROM defined as before 6 weeks and/or “self weaning from sling” for individuals with a full-thickness tear. A successful rotator cuff repair relies on a strong team of surgeons and rehabilitation specialists to direct the patient in maximizing return to function in an appropriate time frame. There is no denying that protection of the repair is a high priority early after surgery and throughout different stages as ROM allowance and strength initiation is permitted per doctor and tendon specific protocols. A question that appears to remain is whether early AROM before 6 weeks is more of a risk vs the potential benefits of reducing stiffness and atrophy. Silveira et al’s systematic review may guide clinicians into best practice during shoulder rehabilitation. The results demonstrate that early AROM does improve shoulder ROM at 6 weeks for elevation and up to 6 months for ER, however those individuals rated themselves less functional according to the WORC at 6 weeks. Of course, the question remains - what is the value of substantially improved AROM at 6 wks for a RC-R that will likely not be allowed resisted work of any loads until oftentimes 8-12wks post op? The risk of improved AROM early on is limiting concurrent ADL in the presence of this improved AROM. Limitations to this review must always be considered and include that the 8 studies did not all report on the same desired/preferred outcome measures so interpretation of these results is graded on different levels of certainty of evidence and differences from how each study was conducted. Studies often lacked specific protocols for how AROM and sling use were instructed. Also, another limitation was assuming that the surgeons, therapists, and compliance of the patients were comparable across all studies - these variables are impossible to standardize. Nevertheless, it is important to note that by 6 and 12 months there were no statistical differences between delayed vs. early active ROM including cuff integrity, strength, ROM, and functional ratings. So why does this matter at all? If the current practice of delayed AROM until 6 weeks post-op leads to comparable 12 month results, then why bother to initiate early AROM? We cannot forget there are independent variables that cannot be controlled, such as clinical judgement, surgical technique and experience, exercise techniques and progressions, differing between the skilled surgeons and the physical therapists in charge of protecting the repair and guiding the patient on a successful path to functional return. Clinical judgement can be a huge factor especially when a patient is progressing “faster” or “slower” than preferred. If ROM is lagging compared to desired ranges, then the patient may risk increased stiffness and discomfort with loss of functional ability at certain stages of recovery. The opposite is also a common concern regarding trying to avoid straining the repair and compromising tissue integrity. The study reported that with moderate to high certainty, early AROM can be beneficial for increasing ROM at 6+ week mark without increasing risk for re-tear long term. This data does not reflect on ROM limits set forth in protocols nor whether repetitive early AROM was done as an exercise in regimented fashion, and if so, in gravity neutral or gravity resisted positions vs simply via limited ADL reaching etc. It was noted in the referenced studies that subjects in early AROM were cued to allow pain-free AROM. While a good concept and clinically sound, it remains a very subjective and difficult to control variable. Patient education on restrictions and appropriate functional use/ability and home exercises must be made clear to the individual and a potential risk in allowing early AROM without use of sling during ADLs and at rest, may have patients unwillingly reach for or grab object causing increased strain which may explain why the functional scores reported by the subjects were worse in the early AROM group. The risks of early AROM may not be as detrimental as perceived; however, a skilled therapist needs to direct safe return to function with continuous monitoring of progress. Simple AROM alone, out of the sling, does not afford substantial increases in ADL because most would involve holding or lifting or bracing with objects, adding weight (ie. resistance) that is not allowed yet...although some protocols do happen to specify approval for ADL < 5# despite not having yet approved any resistive training. High communications between the therapist and surgeon certainly are necessary. This serves to inform and collaborate with the surgeon when things are moving slower than ideal or when the patient is taking too many liberties and may risk injuring the tissue. Factors such as number of tendons, surgical technique, or number of sutures all may impact post op planning. Biomechanical considerations must be taken into account that are not often addressed or overlooked in traditional therapy for someone just following a protocol. For individuals who end up with a tendon repair due to years of tissue degeneration which may have once been “impingement syndrome,” underlying causes or what we refer to as “probable suspects” need to be addressed after surgery to ensure these factors will not slow or limit functional capacity. Thoracic mobility in both the transverse and sagittal plane will influence the strain on a cuff by restricting the scapula’s ability to move and clear the acromion with overhead reaching. Limited trunk rotation can also cause the individual to compensate through greater horizontal ADD and ABD reaching in elevated positions causing approximation of the cuff against bony anatomy. Specific manual therapy and exercise techniques, with a goal of restoring normal biomechanics, must be utilized following RC-R, despite oftentimes not being addressed specifically on RC-R “protocols” as part of thorough care planning and case management. Thoracic spine, cervical spine, scapular and hip regions especially must all be examined and attended to in order to both minimize undue stress on the healing repair but also to optimize function long term. In light of the lack of clear benefits associated with early AROM we would generally contend that delaying early AROM is still a “best practice” on the basis of avoiding potential risks with individual patients who would then be more likely to overuse the involved arm during ADL. While that likelihood existed for the study participants and did not ultimately result in clear (-) outcomes this study at least provides some reassurance regarding the safety of those who may be non-compliant from avoiding early AROM or in whom a surgeon and therapist determine can begin early light AROM for dressing, showering/bathing, keyboarding while still avoiding resistive/loaded ADL. The case presented below reports on a successful case of delayed AROM until after 6 weeks with good compliance and addressment of biomechanical nuances to maximize a successful return to function. THE PEAK PERFORMANCE EXPERIENCE Cliff said: “...after 20+ years of shoulder issues, I'm feeling completely better and looking forward to returning to hockey and other activities which have limited me for so many years.” History: The patient is a 54 year old male s/p L shoulder RC-R with pre-op diagnosis of a full thickness supraspinatus tear. Subjective: Max Sx 5/10 with any movements. Self-reported function at 0% as pt immobilized until initiating PT. QD questionnaire rated 75% limited. Objective: See table below. (Minimal PROM testing on Evaluation and 1st Re-evaluation secondary to protocol restrictions) MEASURE ( *=pain) Evaluation 1st Re-evaluation (7 weeks) PROM nER (deg.) -19* 34 PROM Flexion (deg.) 41* 125 PROM Ext (deg.) NT 22* AROM nER (deg.) NT 34 AROM flexion (deg.) NT 95 > stopped at first Sx MEASURE *=pain 1st Re-evaluation (7 weeks) ROM testing at 3.5 months PROM nER (deg.) 34 61/60(101%) PROM 90ER (deg) NT 80/80(100%) PROM 90IR (deg) NT 56/60(93%) PROM Flexion (deg.) 125 174/180(97%) AROM Flexion (deg) 95 > stopped at first Sx 174*/180(97%) AROM ABD (deg) NT 170*/175(97%) AROM Ext (deg.) NT 48/55(87%) AROM nER (deg.) NT 63/65(97%) AROM nIR (deg.) NT T9/T8(100+%) Isometric testing at 3.5 months DC Testing at 5.5 months Iso 90 deg. Flexion (kg) 5.8/12.9(45%) 11.5/15.9(72%) Iso 90 deg.ABD (kg) 6.0/13.9(43%) 11.0/13.2(83%) Iso nER (kg) 7.9/13.5(59%) 10.4/16.5(63%) Iso nIR (kg) 15.3/22.6(68%) 21.6/22.7(95%) Iso 90ER (kg) NT 11.6/16.9(69%) Iso 90IR (kg) NT 14.8/19.2(77%) FNXL OH Press 25# scaption to 83” sup wrist NT 16x/18x(89%) Deceleration tube nRow gray band with controlled pause at max tension (45 sec) NT 56x/54x (103%) Treatment: ADL education for early donn/doff sling and strict review of surgeon specific protocol restrictions Progressive self PROM with opp UE A...AAROM….AROM as able per protocol nER and flexion early...then nIR, ABD, and rotations at 90 deg ABD thoracic mobility addressed with rotation and extension self mobilizations to aid on scapulohumeral rhythm Manual mobilizations with focus on increasing pec minor mobility and posterior capsule pt presented with anterior scapular tilt predisposing them to reduced scapulohumeral rhythm secondary to pec minor tightness anterior GH translation noted through observation from likely posterior capsular tension Progressive RC strengthening with early isometrics before loading the shoulder with external loads short lever positions utilized early before long lever torque demands patient cued to remain symptom free; specifically with over head positions where the SS may become compromised through approximation serratus anterior loading focused though maintaining stability on the thorax without “winging” while undergoing NWB and WB loads at progressive angles from scaption > anterior force to increase demands on scapular stabilizers functional OH press and lifting a various angles of ABD/ER with emphasis on thoracic rotation/extension to reduce strain to cuff at various stages of healing to prep for 3D demands Speed and Impact - Sports retraining speed work completed though band and DB work focusing on the deceleration of tissue to prep for hockey and other patient specific goals impact training staged with bilateral landing prior to single arm strains when scapula demonstrated good control without increased winging Discharge Testing: Reported self fxn at testing visit to be 100%. Patient reported no sx or limitations in ADLs and was able to kayak. Did not attempt hockey yet while waiting for MD clearance due to under 6 months post op, however since discharge has returned to sport. 0/10 pain and 0% limited per Quick Dash functional questionnaire.