That seems to be one of the most common questions I get regarding rehabilitation of the shoulder. It seems like clinicians want to know how everyone else is rehabilitation their patients following rotator cuff repair surgery. My guess is because most people feel that their physicians are too restrictive in their postoperative guidelines? Does that sound like you?
Unfortunately the most optimal rehabilitation progression following a cuff repair has not been documented. There are no research reports stating that one technique is better than another, that starting ROM immediately is better than not, or that avoiding isometrics for 12 weeks is safer for the repair than beginning immediately.
Notice above that I highlighted “optimal.” That was a specific choice of wording. Optimal can mean many things. For these patients it could mean “safest rehabilitation progression” or even “most effective rehabilitation progression.” But even those phrases are vague.
Let me ask you a question:
What is your definition of the optimal outcome following rotator cuff repair?
Is it that the patients returns to their premorbid work or athletic activity? That the patient restores ROM and strength as quickly and safely as possible? Or that the patient have an intact cuff repair when performing a MRI or ultrasound 2 years after surgery?
We may all have a different answer to that question, but let me share with your how I would answer. The most optimal outcome following rotator cuff repair for me is having your patient return to their normal activities as quickly and safely as possible. I would bet that if you asked this question to a surgeon, they would respond with the above comment regarding having the repair intact at time X after surgery. I would also bet that if you ask the patient this same question, they would respond with something along the lines of “I want to be able to lift my arm overhead while doing [insert activity here!] without pain.”
What would you say if I told you that 35% of rotator cuff repair surgeries fail? Again, I highlighted “fail” because I am talking about two research reports that examined the percentage of repairs that were still intact 5 years after surgery (Harryman: JBJS ‘91 & Fealy: Arthroscopy ‘02). Here are some interesting findings:
- 35% of all tears fail
- 20% of supraspinatus repairs fail
- 50% of repairs of two tendons fail
- 68% of repairs of three tendons fail
- 25% of repairs to people aged 34-55 fail
- 35% of repairs to people aged 56-70 fail
- 45% of repairs to people aged 71-85 fail
Pretty shocking, right?
This is the primary factor why I believe surgeons promote a decelerated rehabilitation approach – they do not want failure
Well how about this information, also from those studies:
- 96% of patients with intact cuff report being satisfied
- 87% without cuff intact are STILL satisfied
What does this mean to me? This tells me that integrity of the repair is not the most optimal factor associated with success following rotator cuff repair. I would argue that we should be more worried about satisfaction than integrity of the cuff
Now don’t get me wrong, I realize that if your cuff remains intact that you will likely have a better outcome. I am just saying that I don’t believe that we need to be unnecessarily cautious and decelerate our rehabilitation approaches.
There are safe and effective ways to achieve satisfaction and integrity of the repair
Want to know how I believe we can achieve this? Want to know how I rehabilitate my patients using what limited evidence we have? Want to know what I do each week following surgery, and more importantly – why?
Harryman DT 2nd et al (1991). Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff J Bone joint Surg, 73 (7), 982-989 DOI: 12098132