The debate over postoperative rehabilitation after rotator cuff repair continues to evolve.
In this episode of the podcast, we review a recent article that looked at outcomes between two groups, one that was stiff and one that wasn’t.
Here are our thoughts on the paper.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 363: Does Stiffness Lead to Better Outcomes After Rotator Cuff Repair?
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Show Notes
Transcript
Mike Reinold:
Welcome back everybody to the latest episode of The Ask Mike Reinold Show. We are here at Champion PT and Performance up in Boston, answering your questions. I have Dave Tilley, Lisa Lowe, Anthony Videtto, Dan Pope, Lenny Macrina, Kevin Coughlin, part of our crew of performance physical therapists here at Champion to answer your questions. That being said, we’re going to try something different. We’re going to try something different the next couple of episodes, and we want to hear your feedback on this. But maybe we’ll do a whole podcast dedicated to this if we end up changing in the future here.
But man, we’ve been doing this for 10 years. That’s a lot of questions. We’re getting a lot of repetition, right? There’s only so many questions you can answer in a decade. Now, some of them we keep getting updated answers. Some of that’s good, but the other thing we do at Champion is we’re always talking… We’re always going over new research. We’re always chit-chatting about things that we’re researching on our own. So we thought we’d share, and we’ve always said, “Do we turn this podcast into more like a journal article thing? Do we try to use it as still a question and answer, where we use an article to answer a question?” That sort of thing. We’re not a hundred percent sure, but we’re going to give it a shot. So the next two episodes, this one and the one coming out in a couple of weeks, what we’re going to do is, we’re going to talk about journal articles that come out and just kind of see how this goes.
So this first one, we’re going to talk rotator cuff, and essentially, I’ll give a little bit of an intro to kind of figure out a little bit where we get started. Then we’re going to hear everybody’s thoughts, and then kind of go from there. And you, as the listener, you’ve been used to this format for 10 years, so I guess you’re kind of used to it. One of the things that we still think is important is these are quick. So, this isn’t about going deep into an article. It’s our clinical interpretation of articles and how we’re going to change our practices because of it. And that’s kind of what we’re going to do with this the next couple episodes.
So anyway, the article we’re talking about today is from Arthroscopy in 2024, A very recent article, and it’s on the early postoperative stiffness after arthroscopic rotator cuff repair and how it correlates with improved tendon healing. And I’ll start it off by talking about this article. Essentially, what they did, over the course of the study, they had 155 patients with an arthroscopic cuff repair. And what they did was, they tried to divide them into two groups based on stiffness: were they stiff or not stiff? And essentially, they determined at the 3-month mark, at 12 months, if you had, and I’m going to read this because this is pretty good… I want to get the actual numbers there. You were stiff if you had “forward flexion less than 120 degrees, external rotation less than 30 degrees, and internal rotation below L3,” which is quite low.
But anyway, so at three months, you were stiff if you had that. And they tried to compare the outcomes of that. And what they showed, kind of in a nutshell, was that if you were stiff at three months, you tend to be stiff for the majority of the study, but you had a lower rate of retears of the rotator cuff. So, an interesting finding here. So, who wants to start? I want to hear people’s thoughts. What do you think of the article? What were some of your take-homes? What were some of your questions or critiques of it? And let’s kind of tackle this one by one, so who wants to start?
Dave Tilley:
Yeah, sure. Or Dan, go ahead.
Dan Pope:
I don’t know, I’ll take a crack at it, I guess. I thought it was interesting. Just for a little context, I think part of the thought is that… You hear this from surgeons, like if it stiffens down, that’s potentially a good thing. If I have someone that’s three months out and they’re that stiff, that does scare me. I’m like, “Wow, this person is very stiff.” I’m probably referring back to the doctor, considering that they have a frozen shoulder. One of the things I was kind of curious about is, did they start range of motion right away? And it looks like they did. They started flexion range of motion, I think like post-op day two or something along those lines. And the other thing I thought was interesting is that they basically had two different groups for different types of tear sizes. So they had small-medium, they had like larger, and they just delayed things a little bit for the larger-massive.
The other thing that I thought was very interesting is that there wasn’t a difference with stiffness, and then also retear rates for small-medium versus larger, which I really thought there was going to be a difference based on what I’ve seen in the past. I think at the end of the day, and I don’t want to take up too much time with this, but it doesn’t seem to change a lot for me clinically. I would probably give folks a little bit more mobility if they’re starting to get stiff. I don’t know if they had that conversation with patients. I didn’t see that in the article. If someone’s starting to get stiff or like, all right, let’s increase the mobility or increase the sessions, because I think that’s something naturally you do at physical therapy.
But one of the takeaways is kind of like, if you are stiff, maybe that’s not bad from a healing perspective, although those are pretty severely restricted folks. But I’ll also say, I think the average age was in the mid-60s or 62 or something along those lines. So it’s not like they’re getting back to tennis or something along those lines, although some may be. But yeah, interesting study.
Mike Reinold:
The retear rates were essentially 5.9% in the stiff group and 17.2% in the non-stiff group. So the non-stiff group had essentially three times more retears. I think those numbers are pretty low. If you actually look at the numbers, that’s kind of scary when you think of it like, “Oh, three times more.” But I think in general, pretty low. I mean, most of these were small and medium. There’s one massive in each group. There were some large, but mostly small to medium here. I think in general, those are pretty low, but that’s a big difference here in that retear rate, which I thought was kind of interesting in there, but still fairly low. But Dave, what do you think?
Dave Tilley:
Yeah, I was just going to go off Dan, kind of like my thoughts were very much on the piggyback of that. I think that it’s tricky because in this population and their demographic, it’s like what do they need to be comfortable and happy with their shoulder? Typically, people who are a little older and maybe are doing a little less active type sporting or fitness type stuff, they don’t need a ton of range of motion and they care about, “It doesn’t hurt, I can do my daily life and I can more or less be okay and not worry about something going elsewhere.”
If you scale that down into someone who’s 40 or 45 and they want to be active, they want to go to the gym, that amount of stiffness might not go over well in their daily life. Because that long-term healing is good, but if they can’t do any basic fitness type work, or they can’t do stuff around the house, or they’re really not happy with how their shoulder is moving… Sure, their overall status of retear and pain is better, but they don’t feel successful in their own view, because of how tight their shoulder is.
And the one I can think about is, I work with a professional pianist who had a frozen shoulder and has had some rotator cuff pathology in the past. For a frozen shoulder, I was like, “You are doing great. This thing is really loosening up quite well. I’m actually surprised at how well…” Apparently you need a lot of cross-body adduction to play high-level piano, and that was the most important thing for her. So she got back 90% of her motion and she’s doing really well, no pain, but she’s like, “No, I want all my motion back, because I want to be active and I want to do stuff.” She’s 50. She’s in her fifties, and she wants to be, I don’t know, she wants to do a lot more stuff. So in her eyes, she’s actually really good. I know it’s adhesive capsulitis, but it kind of comes in tandem with what they had a risk factor for stiffness. That’s not good enough for her. And so she doesn’t have pain, it feels good, but she wants more out of her overall mobility.
So I think it depends on what demographic you’re looking at and what their goals are. A 30 to 40 to 50-year-old with an acute cuff tear, it’s a very different situation than a 65-year-old progressive, slow degenerative tear. I think you’ve got to view it in the context of the patient’s goals.
Mike Reinold:
You know what, I would add too here, just thinking this through while Dave was talking a little bit here too, is like, none of these people… They didn’t say this in the article, so they didn’t go over this, but none of these people necessarily were like rotator cuff failures. They had an MRI at 12 months that showed failure of the cuff. So you want to keep that in mind, too. We know that there’s a percentage that fail, and there’s a very large percentage of people that do fail, that don’t care, that are functionally still much, much improved in terms of pain, range of motion, strength even. There’s a big part of that. So remember, this is just determined failure based on MRI. So, gosh, if I was that tight at three months, that’s life changing, Three months of having that much range of motion is functionally very, very unhappy for these people. And then you’re still tight at six months, at 12 months.
But I don’t know, who’s next? Kev, you want to jump in? I know you and I were talking about this the other day. What are you thinking?
Kevin Coughlin:
Yeah, I’ll just say that what we were talking about the other day was that, perhaps the reason that these folks had less retear rates at that 12-month mark was just that throughout the whole process, if you look at kind of their functional scoring with the Constant Murley Score, the UCLA Score, and then the pain score, so preoperatively… And then at that post-op, 3, 6, 12 months, they were having more pain and less function the whole time. So it does make sense. They’re not using their shoulder as much because it doesn’t feel good, and then they’re having less retears, so I think that’s one thing.
And then I think the other thing, like you had just said, I remember kind of talking about this with Dan in the past, is it’s kind of amazing when they do those follow-ups, and you do see kind of higher rates of retears. But people, they don’t know they’re functioning really well, they’re not going back and getting an MRI. In this study, because of pain, it’s just part of the follow-up. So I guess I would prefer to be functioning at a higher level with less pain and maybe have a slight retear. Like you said, not a total failure, but I wonder if there was no follow-up MRI, how much of these patients would have even noticed. Because again, looking at the function scores and the pain scores, the group that was non-stiff throughout did have higher retears, they were functioning better, and they had less pain. So I think that is pretty interesting.
Mike Reinold:
Yeah. I wondered. You said preference, I wonder, if you were to tell somebody on day one, “Look, do you want to be tight or not? And then if you’re tight, you have a 6% chance of retearing. If you’re not, you have a 17% chance. What do you want to do?” I wonder where people would say, and that probably goes on how old you are and your activity level and stuff, but I don’t know, I think a lot of people would really question that. It was interesting.
I thought that was interesting too, Kevin. And I think a lot of people are going to read this study and they’re going to say that stiffness is protective, or they’re going to say that if you get too much motion, it leads to cuff tears. Which, those are huge leap of faith statements. The first thing that I thought of here, and this is my first take, not as a skeptical kind of person, which I guess I am… But I actually thought that people with poor preoperative status, with more pain and less function, tend to get stiffer over time. That was my take, and that sort of thing. And you got to wonder if during the first three to six months, the people that had less pain and more range of motion just did more things around the house, did more things in life, and maybe that’s what led to it. And it’s not a stiffness thing, it’s just that maybe they did more, but hard to kind of say. But what else? Anybody else have any other thoughts?
Lisa Lowe:
So I just have one thing. I feel like when I was reading this, I was picturing all three of those range of motion deficits happening at the same time, and the way the study actually qualified stuff was if they only had one of them. So at least it’s not, can’t reach behind their back at all, can’t go into more than 30 external rotate. Like not everybody was all of the things, they just had to have one to be the stiff group. Which I feel like then is one of those where, within the discussion of the personality of somebody who maybe has more stiffness and more pain, especially if they’re overhead flexion is limited and it’s painful… I would imagine that the person’s not really pushing to, like we’ve kind of already said, someone’s not going to necessarily push to do those activities.
It was also… I feel like they measured an ER or ER was at their side. It wasn’t like up at a 90-degree position like I know you guys all, and we all prefer to measure ER. So I feel like from the capsular stiffness sides and all those pieces, the way this research was presented in the range of motions that they’re reporting, at least from the way that we would measure stuff, is a little bit different. So I feel like… just pieces to kind of keep in mind when interpreting it, and I feel like I wouldn’t want someone to feel like they have to be excessively aggressive with their shoulder just for the fear of creating a stiff…
I feel like a newer clinician could take this kind of the wrong direction pretty quickly, of either being like, “Okay, we’re going to make sure you’re really not stiff and we’re going to push through all these things,” and then creating a lot of inflammation and all those problems. Or being too passive and being like, “Well, stiff is a more successful outcome in the long run.” When it’s, well, really, it’s not. Like you said, Mike, the numbers aren’t really that different. The percentage of success rate at the year out is not massively different. I feel like that’s just, I don’t know. Studies like this, to me, can scare people to kind of shy away from the right interpretation of what their patient is feeling and what they’re doing for them.
Mike Reinold:
Right. Yeah, right.
Lenny Macrina:
This is what’s out there right now with doctors and many PTs and friends of mine that I’ve spoken with, is, get them stiff. Like would they prefer a stiff? The doctors are making their protocols more conservative: “No PT for four or six weeks. We want them to stiffen down. We don’t trust what PT is doing, blah, blah, blah.” So this is what’s out there because of papers like this and the others. They quote a few other papers in here. And so that’s what we’re up against, is the patient doesn’t want to get stiff, the patient doesn’t want to be in a ton of pain, but the doctors want that because they want structural integrity. And I think what everybody has said today is true.
A one-year MRI does not tell us anything about the function of a person. I’d like to see two, three, five-year MRIs. There are papers out there where tendon integrity improves up to five years. I’ve seen papers like that. And so if you keep MRI-ing these people, you may see an improvement in their tendon integrity on an MRI, so I don’t know. I’m not a proponent of getting people stiff and trying to get people stiff, I just try to get their motion comfortably. And I just use common biological timeframes to allow the tendon to heal and don’t do aggressive active range of motion, but I’m doing passive motion early because we know that’s good, and that’s what’s allowed here. And our PT that takes one hour, three times a week at the most… Three hours of PT is not compromising a rotator cuff repair. It’s the other 23 hours a day of what the person is doing, is probably going to be the issue, so, yeah.
Mike Reinold:
That and that aggressive passive range of motion…
Lenny Macrina:
Right, exactly. Yeah.
Mike Reinold:
That’s actually a good point to kind of think of it that way. When you think of it that way, that’s kind of crazy, but…
Lenny Macrina:
Right.
Mike Reinold:
Man, I’d say my take homes from this, just kind of bringing it kind of full closure here, is like, man, if you’re getting stiff, I actually take the results of the study, saying if you’re stiff at three months, you’re going to be stiff for the rest of your program and you’re going to be stiff going on at six months and 12 months. And who knows, maybe that leads to some of the worst functional outcomes and the pain scales that we have too. So if you’re getting stiff, I’m probably going to speed it up. If you are not getting stiff, I’m going to not push it. I think that’s the other answer here, is you check their range of motion and you don’t push it. But gosh, me bringing them into external rotation once to just say like, “Hey, you’re not getting that stiff.” Like great, let’s focus on some other things, that’s not awful here.
Lenny Macrina:
Yeah.
Mike Reinold:
Again, I think studies like this are misinterpreted on social media quite a bit. If we continue to do these journal article things, I think this is almost going to be what it’s going to be about. It’s almost like social media myth-busting. That’s a tough phrase. Where you’re just going like, “There’s five things you could take from this article that are probably wrong and misconstrued if you don’t kind of look at it completely in context.” So yeah, interesting.
I don’t think this answers the question of, “Does stiffness correlate to a retear?” And I think a lot of people are going to say this. You could argue functional status might too. But for me, I am definitely going to use this on a case-by-case. Kevin and I were talking about one of his patients now that we’re working with, that he’s extra stiff at two weeks, we’re not going to let him get tight. I’d be really worried about him getting tight, right Kev?
Kevin Coughlin:
Yeah.
Mike Reinold:
Yeah. Yeah, that’s going to be a tough one. And they’re going to be really hard to function, so…
Anyway, really good article. I’ll put a link to this on the website so you can read it yourselves, and you can kind of take a peek at it. But we thought it was a good one because it’s something that we probably all see every day. So anyway, let us know what you think. Send us some messages, comment on this on social media, and let us know if you like this format, if you like this thing, if you want us to go back to answering questions. Love to hear your feedback. And as always, subscribe so you get notifications to these things. Rate and review, and we’ll see you on the next episode. Thanks so much.
