Rehabilitation After Rotator Cuff Repair

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<p>IJSPT1</p> <p>CLINICAL COMMENTARY</p> <p>REHABILITATION AFTER ARTHROSCOPIC ROTATOR CUFF REPAIR: CURRENT CONCEPTS REVIEW AND EVIDENCEBASED GUIDELINESOlivier A. van der Meijden, MD1 Paul Westgard, PT2 Zachary Chandler, PT3 Trevor R. Gaskill, MD4 Dirk Kokmeyer, PT3,5 Peter J. Millett, MD1,4</p> <p>ABSTRACTPurpose: To provide an overview of the characteristics and timing of rotator cuff healing and provide an update on treatments used in rehabilitation of rotator cuff repairs. The authors protocol of choice, used within a large sports medicine rehabilitation center, is presented and the rationale behind its implementation is discussed. Background: If initial nonsurgical treatment of a rotator cuff tear fails, surgical repair is often the next line of treatment. It is evident that a successful outcome after surgical rotator cuff repair is as much dependent on surgical technique as it is on rehabilitation. To this end, rehabilitation protocols have proven challenging to both the orthopaedic surgeon and the involved physical therapist. Instead of being based on scientific rationale, traditionally most rehabilitation protocols are solely based on clinical experience and expert opinion. Methods: A review of currently available literature on rehabilitation after arthroscopic rotator cuff tear repair on PUBMED / MEDLINE and EMBASE databases was performed to illustrate the available evidence behind various postoperative treatment modalities. Results: There is little high-level scientific evidence available to support or contest current postoperative rotator cuff rehabilitation protocols. Most existing protocols are based on clinical experience with modest incorporation of scientific data. Conclusion: Little scientific evidence is available to guide the timing of postsurgical rotator cuff rehabilitation. To this end, expert opinion and clinical experience remains a large facet of rehabilitation protocols. This review describes a rotator cuff rehabilitation protocol that incorporates currently available scientific literature guiding rehabilitation. Key Words: Arthroscopic rotator cuff repair, rehabilitation, scientific rationale</p> <p>Visiting Research Scholar, Steadman Philippon Research Institute, Vail, CO, USA 2 Howard Head Sports Medicine Center, Vail, CO, USA 3 Howard Head Sports Medicine Center, Denver, CO, USA 4 The Steadman Clinic, Vail, CO, USA 5 Rocky Mountain University of Health Professions, South Provo, UT, USA This study was performed at the Steadman Philippon Research Institute and Howard Head Sports Medicine Center in Vail, CO, USA, and in the Howard Head Sports Medicine Center in Denver, CO, USA. Statement of nancial disclosure This work was not supported directly by an outside funding or grant. However, Peter J. Millett, MD, MSc, is a consultant and receives payments from Arthrex and has stock options in Game Ready. The visiting research scholarship position of Olivier A.J. Van der Meijden, MD, was supported by Arthrex. In addition, this research was supported by The Steadman Philippon Research Institute which is a 501(c)3 non-prot</p> <p>institution supported nancially by private donations and corporate support from the following entities: Smith &amp; Nephew Endoscopy, Arthrex, Arthrocare, Siemens Medical Solutions, OrthoRehab, Ossur Americas and Conmed Linvatec.</p> <p>CORRESPONDING AUTHOR Peter J. Millett, MD, MSc The Steadman Clinic, Steadman Philippon Research Institute 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA Email: Telephone number: +1 970-479-9797 Fax number: +1 970-479-9753</p> <p>The International Journal of Sports Physical Therapy | Volume 7, Number 2 | April 2012 | Page 197</p> <p>INTRODUCTION Rotator cuff (RC) disease is a frequent cause of shoulder pain and can result in weakness, alterations in glenohumeral kinematics, and shoulder instability in some circumstances.1 Symptomatic rotator cuff tears are thought to affect between 4% and 32% of the population and appear to be more prevalent with increasing age.2 Although patient age, activity level and tear size influence surgical decision-making, non-surgical management is frequently the preferred method of initial treatment after a rotator cuff tear. When non-surgical management of a symptomatic rotator cuff tear is not successful, operative repair is frequently necessary. Both open and arthroscopic repair of full or high-grade partial thickness rotator cuff tears have historically provided satisfactory pain relief and improvement in functional outcome scores.3-9 While successful arthroscopic rotator cuff repair requires meticulous surgical technique, it is also apparent that an individualized rehabilitation protocol supervised by skilled therapists is equally important. Rehabilitation protocols have traditionally varied considerably among providers with respect to timing of progression and appropriate therapeutic exercise.10 To this end, rehabilitation protocols are frequently based on clinical experience and expert opinion rather than scientific rationale. The purpose of this clinical commentary, therefore, is to provide an update on current treatment strategies used in rotator cuff repair rehabilitation. The scientific rationale behind current treatment strategies is discussed where available. ANATOMY AND BIOMECHANICS The RC consists of the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles. It functions to initiate glenohumeral joint abduction, provide internal and external rotation, and contributes to dynamic glenohumeral stability.2 It has been established that the rotator cuff is arranged histologically into five interlocking layers with distinct articular and bursal sides.11 The humeral insertion of the rotator cuff represents a confluence of the articular capsule, glenohumeral and coracohumeral ligaments, and the rotator cuff muscles.12-14 The coupled force vectors of the subscapularis and teres minor muscles contribute to depression of the humeral head in the glenoid cavity. This provides</p> <p>dynamic stability to the glenohumeral joint and prevents impingement of the humeral head with the acromion during deltoid activation. They also function to prevent superior translation of the humeral head after rotator cuff tear.15 Contrary to the rotator cuff tendons ability to tolerate up to 100 N/mm of tensile strength, the tendons endurance of compressive and shear forces is much less.16 The scapula also plays an important role in glenohumeral function by providing a stable base for muscle activation and load transfer within the kinetic chain. Alteration in normal scapular position or kinematics has been termed scapular dyskinesis and can affect rotator cuff function.17 Scapular dyskinesia has also been described following rotator cuff tears and is thought to represent a compensatory mechanism for glenohumeral motion deficits.18 Irritation and inflammation of the subacromial bursa, which is rich in nerve fibers, can also lead to pain inhibition of the rotator cuff.19 TENDON HEALING POTENTIAL Though some partial-thickness and some small full thickness tears of the rotator cuff may heal spontaneously without surgical intervention, the natural history of rotator cuff injury appears to indicate that most small tears will enlarge if not surgically repaired.20 It remains unclear, however, over what time period this is likely to occur, but enlargement is typically associated with increased pain and dysfunction. Healing of ruptured rotator cuff tendons, therefore, only occurs when the tendon is surgically repaired back to its footprint on the proximal humerus. Histological studies suggest that three phases of rotator cuff healing occur after surgical repair. These include an inflammatory phase, a proliferative or repair phase, and a remodeling phase.21 A firm understanding of the timing of these phases is important to safely individualize rehabilitation protocols after rotator cuff repair. Following surgical tendon-to-bone fixation, inflammatory cells followed by platelets and fibroblasts migrate into the repair site over the first week and begin to proliferate over the next 23 weeks. The cellular proliferation and matrix deposition of this phase is thought to be regulated by several growth factors and initially yields primarily type III collagen.22 Approximately three to four weeks following repair,</p> <p>The International Journal of Sports Physical Therapy | Volume 7, Number 2 | April 2012 | Page 198</p> <p>the remodeling phase begins and scar tissue organizes through extracellular matrix turnover. The initial type III collagen deposition is slowly replaced by type I collagen, continuing until mature scar tissue is formed.22 Remodeling repair tissue does not reach maximal tensile strength for a minimum of 1216 weeks post repair.22-23 The normal tendon to bone transition including unmineralized and mineralized fibrocartilage is not recreated during the remodeling phase.22,24-25 Rather, repairing the rotator cuff to its anatomic location facilitates the formation of scar tissue in a manner that secures the torn tendon to the greater tuberosity in a more anatomic location. This, in turn, allows the rotator cuff to function at an anatomic length and tension, which is important if normal function is to be restored. SCIENTIFIC RATIONALE BEHIND POSTOPERATIVE TREATMENT MODALITIES Allowing healing of the repaired rotator cuff tendon while minimizing stiffness and muscle atrophy are the primary goals of postsurgical rehabilitation. Unfortunately, there is a paucity of high-level evidence in the literature to support or develop various postoperative rehabilitation protocols.26 Millett et al27 previously reported a widely used protective rehabilitation protocol based on available scientific evidence. Koo and Burkhart28 similarly presented both protective and accelerated rehabilitation protocols utilized based on individual patient risk for developing postoperative stiffness. The protective protocol, in which muscle strengthening exercises are delayed, is applied after arthroscopic repair of rotator cuff tears greater than 5 cm or involving more than 2 tendons, poor tissue quality, or repairs with greater tension.28 Each of these protocols implement various treatment modalities at different times to maximize healing and minimize stiffness based on repair characteristics such as tissue quality and repair robustness. The following sections report on the available evidence behind these various postoperative treatment modalities. A review of currently available literature on rehabilitation after rotator cuff tear repair on PUBMED / MEDLINE and EMBASE databases was performed. Immobilization Postoperative stiffness is reportedly the most common complication occurring after surgical repair of the rotator cuff, regardless of an arthroscopic or open</p> <p>technique, and is likely to occur with prolonged immobilization.28-32 Animal models, however, indicate that postoperative immobilization can minimize the tension on rotator cuff repairs and may lead to improved collagen orientation and visco-elastic properties as compared to immediate postoperative exercise treatment.33-34 The optimal duration of immobilization following rotator cuff repair, therefore, continues to be controversial. Though some advocate early (passive) mobilization to reduce the rate of postoperative stiffness,29,35-36 a recent study suggests that longer immobilization periods, often recommended to protect surgical repairs, may not increase the incidence of post-operative stiffness.37 In addition, recent animal studies suggest that immobilization after rotator cuff repair of at least two weeks duration results in significantly less postoperative stiffness and increased active motion.38-39 The theory behind this assertion is that passive motion increases scar formation in the subacromial space resulting in decreased range of motion and increased stiffness.39 The arm position during immobilization is also of importance during the early healing phase of the tendon repair. The use of an abduction immobilizer is currently widely used because of evidence suggesting that vascularization is improved and tension on the repaired tendon(s) is minimized in this position.40 Therefore, immobilization of the shoulder for 46 weeks in a slightly abducted position may minimize tension and maximize vascularization of the repair. The patient may come out of the immobilizer for supervised passive motion exercises in phase I of the rehabilitation, approximately week 14 postoperatively, and active assisted range of motion when commencing to phase II, usually week 4 6 postoperatively. Continuous Passive Motion (CPM) Continuous passive motion has been shown to minimize postoperative pain while maintaining range of motion following articular cartilage treatments and joint arthroplasty of the knee.41-42 The potential benefit after shoulder surgery, however, is less clear. Researchers performing several prospective controlled trials reported no significant difference in clinical outcome of a group of patients treated with CPM during the first 34 weeks following rotator cuff repair compared to a control group treated without</p> <p>The International Journal of Sports Physical Therapy | Volume 7, Number 2 | April 2012 | Page 199</p> <p>CPM.35-36 Additionally, Dockery et al found no difference in activity of rotator cuff muscles between mechanical CPM and manually-assisted CPM in an electromyographic study. Higher muscle activity was noted during patient self-assisted range of motion exercises as compared to mechanical CPM.43 To this end, CPM may be used to help maintain motion gains after glenohumeral manipulation while minimizing muscle activity; however its long term benefit is unclear and is otherwise not routinely prescribed. Cryotherapy Cryotherapy is used post-surgically to decrease pain, swelling, muscle spasm, and minimize the inflammatory response. Speer et al44 examined the use of cryotherapy in a prospective, randomized, controlled clinical trial that showed decreased pain and narcotic medication requirement during the first 24 postoperative hours. In addition, these patients had fewer pain complaints with therapy 10 days postoperatively and were better able to tolerate their rehabilitation. Others confirm these findings and report increased comfort and improved ability to sleep.45-46 Some evidence suggests that the use of pneumatic compression in conjunction with cryotherapy may enhance the effectiveness of both modalities.47 It is important to note, however, that high-quality, well-controlled studies examining the use of cryotherapy in conjunction with pneumatic compression do not exist. Based on this evidence the authors recommend the use of a home cryotherapy device for 1014 days after surgery. Joint mobilization Joint mobilization techniques can be used to address joint stiffness and passive range of motion (PROM) deficits. Muraki et al demonstrated that glenohumeral distraction as well as ant...</p>