#early mobility

Rehabilitation protocol following arthroscopic rotator cuff repair is a highly debated issue, specifically the timing of post-operative mobility. Surgeons and rehab protocols vary greatly in regard to initiating range of motion after rotator cuff repair, with some starting passive motion within one week after surgery, while others keep the shoulder immobilized for four to six weeks before initiating motion. Advocates of early mobility following rotator cuff repair propose that it leads to increased shoulder range of motion by preventing postoperative stiffness. In contrast, advocates of delayed mobility argue that early mobility does not allow proper tendon healing time and increases risk of retear. In recent years, there has been a surge in meta-analyses comparing the rehabilitation protocols, aiming to discover which protocol leads to superior patient outcomes. 

A meta-analysis by Li et. al. [1] found that early passive motion (EPM) protocols led to significant increases in shoulder flexion and external rotation range of motion at short-term follow up when compared to delayed passive motion (DPM) protocols. At long-term follow up, flexion remained significantly higher in the EPM group, but external rotation measurements were equivalent between groups. There were no significant differences in tendon healing between groups at long-term follow up, but the researchers found that larger sized tears were more susceptible to retear with early mobility. A systematic review by Saltzman et. al. [2] also found a significantly higher retear rate in patients with large-sized tears who followed the early passive motion protocol compared to those that used the delayed motion protocol. Therefore, it is important to consider initial tear size and other factors, such as patient demographics and surgical technique, when determining the best rehab protocol for each patient. An overview of systematic reviews by Mazuquin et. al. [3] concluded that passive motion can begin on post-op day one for patients with small-medium size tears, but passive motion should be delayed four to six weeks for patients with more complex, larger sized tears.

Another important consideration is cost-effectiveness of treatment. It may not be beneficial for some patients to pay for and attend several more weeks of physical therapy in order to gain an additional five to ten degrees of shoulder range of motion. Therefore, it is crucial to discuss and reach a consensus between not only the physical therapist and surgeon, but also the patient. The patient’s goals for treatment should be taken into consideration as well. Overhead athletes and manual laborers may benefit from an early motion protocol to recover range of motion more rapidly, whereas older patients with risk factors for retear may prefer to delay motion to promote tendon-bone healing.

References

Li, S., Sun, H., Luo, X., Wang, K., Wu, G., & Zhou, J. et al. (2018). The clinical effect of rehabilitation following arthroscopic rotator cuff repair. Medicine, 97(2), e9625. https://doi-org.proxy.kumc.edu/10.1097/md.0000000000009625

Saltzman, B., Zuke, W., Go, B., Mascarenhas, R., Verma, N., & Cole, B. et al. (2017). Does early motion lead to a higher failure rate or better outcomes after arthroscopic rotator cuff repair? A systematic review of overlapping meta-analyses. Journal of Shoulder and Elbow Surgery, 26(9), 1681-1691. https://doi-org.proxy.kumc.edu/10.1016/j.jse.2017.04.004