On this episode of the #AskMikeReinold show we talk about how fast we progress range of motion after rotator cuff repair surgery. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 221: Range of Motion After Rotator Cuff Repair Surgery
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Show Notes
- Rotator Cuff Repair Rehabilitation: How Fast Should We Go?
- Should We Delay Range of Motion After a Rotator Cuff Repair Surgery?
- Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair
Transcript
Mike Reinold:
Dominic from Arizona asked this question. Are you ready? I’m trying to get suspenseful with this. “How quickly do you progress range of motion with a small to medium rotator cuff tear?” Okay? Then he says, “I’ve been seeing more and more conservative post-op protocols compared to what I’ve seen in the past and I’m starting to question how quickly to go in restoring range of motion and when to start using things like passive range and active assists and things like pulleys and L-bars.”
Mike Reinold:
So couple of questions here, but really, I guess the question is, how fast do we go with that rotator cuff tears? But maybe we start off with, do we have a period of immobilization and that sort of thing? But I’ll talk about the evolution maybe, and then I don’t know who wants to jump in, maybe Len with some of his experience over his years too, but the evolution of rotator cuff repairs in just my career, I went from open to mini-open to arthroscopic, and we’ve seen this huge progression in technology. I guess we’ll call that technology. It’s surgical skill, technology, technique, whatever you want it to be, but you can see this progression over time.
Mike Reinold:
And there was so much less invasiveness with these procedures as we’ve continued to progress. A rotator cuff repair just 20 years ago, like in the late 90s, it was either open or mini-open, and an open one was big. That was a big deal. You had a lot of muscles you were cutting through, a lot of scarring postoperative, a lot of pain, those sorts of things. And we’ve progressed all the way now to arthroscopic, which really has so much less pain. I hate to say minimal because I don’t think that’s fair to the people that just had that surgery. But compared to an open and even a mini-open, it’s much less pain. So I’m wondering if what happened evolution-wise is any time this happens in physical therapy, we tend to think, “Well, they’re doing much better. Maybe we can speed up the range of motion progression,” and maybe we just regretted that a little bit.
Mike Reinold:
So that’s a little bit of the evolution of the cuff repairs and maybe how it progressed. I don’t know. Len, you want to maybe kick it off, and then you guys think about anything else in your experience?
Lenny Macrina:
Yeah. That’s good. I agree with Mike. It’s been crazy even in my career and my career’s a little shorter than Mike’s and it’s definitely been an evolution of the repairs being a ton better just in technique. The pain with even a mini-open, the incision was tiny going through a deltoid split, and now with the scope, the pain is significantly less but not crazy less. But I think because it’s significantly less, people want to do more quickly. And so I think even after an ACL, we try to push people. I was getting people back after an ACL four months after their surgery and then we realized, “Uh-oh. It’s not probably the best thing to do,” because retear rates were high.
Lenny Macrina:
I think the same thing is happening right now with the rotator cuff where we tried to push the envelope a little, and maybe retear rates are not where we want them to be, but that doesn’t mean their function is not going to be good. So we’re in a seesaw battle right now with doctors and therapists because the research is saying they’re functionally stable and functionally good, but their retear rates can be 50%, 60%, 80% after a rotator cuff repair two years out, and so the doctors are looking to say, “Well, maybe if we went slower with rehab,” because some of the research is saying if the patient gets tight and they begin to scar down, which as a PT, you know that that’s a pain in the butt if they start to scar down and get stiff.
Lenny Macrina:
That’s what the doctors want. They want them to scar down and get stiff because that potentially is saying that the cuff is healing really well, which means retear rates could go down long term. And so the doctors want scarring, healing. We want motion and function and we’re at a battle right now. So what I’ve done is-
Mike Reinold:
What’s the patient want though, Len?
Lenny Macrina:
Right. The patient wants their pain to go away, the patient wants their life back and function back, and that’s where we kind of-
Mike Reinold:
Right. Pain and function.
Lenny Macrina:
Right.
Mike Reinold:
So the surgeons want low retear rates.
Lenny Macrina:
They want low retear rates.
Mike Reinold:
The therapists want range of motion and strength back.
Lenny Macrina:
Right. Right.
Mike Reinold:
We’re so easy to figure out. And the patient just wants less pain and more functional activity.
Lenny Macrina:
Yeah, exactly. But the problem is, when you scar down and get tight, there’s more pain in therapy, and you’re still not getting your function back because now you’re trying to raise your arm up and you’re shrugging.
Mike Reinold:
Right.
Lenny Macrina:
So it’s a seesaw battle back and forth and it’s tough because I’m on the camp of, I say, “Let’s get them moving early.” I think the hands of a good therapist is not over aggressive with them, we can get them moving early, we’re not pushing through a ton of pain. It helps with their pain levels, it helps with their ability to control themselves at home with pain and just some of their function, and we can educate them early on on stuff they can and can’t do and stuff they should feel and shouldn’t feel.
Lenny Macrina:
And so otherwise, they go six and sometimes 12 weeks without any PT, and now they’re in no man’s land. They don’t know what’s good pain, what’s bad pain, what they should be doing, what they should not be doing, and they’re only getting orders from maybe the PA or the doc in their post-op visits and they’re confused. They come in confused. So I say get them into PT early, get them some easy motion going early, and I know I’ve seen very good things happen after that. For a small to medium size tear. If we’re talking a big tear, different world, you know what I mean?
Mike Reinold:
Yeah. I was just going to say-
Lenny Macrina:
It comes down to tissue quality and all that stuff. But in that small to medium size tear, 50 year old, I say get them going early. If they’re 75 and they’ve got a big tear and it’s been going on for a while, you’ve got to go really slow with those people. Let them scar down, let them get stiff.
Mike Reinold:
Right. I think that’s a good thing you said that, actually, because I was going to ask that question. I was going to say, does it matter who the patient is? Does it matter if they’re older? Does it matter if they have poor tissue quality? Does it matter if they have a huge rotator cuff tear? Saying rotator cuff tear means nothing, right?
Lenny Macrina:
Right. Yeah.
Mike Reinold:
Just like, “What do you do after a rotator cuff tear?” Well, it depends on about, I don’t know, I can think of 20 factors that would significantly change what I do and there’s probably more, but I’m just thinking briefly. So what else? What about anybody else in the crowd? You guys have any other thoughts on this? I’ve got a few things. Actually, this is the benefit of Zoom, I’ve got some slides up that I can cite some articles, which we never do. But what do you guys think?
Dan Pope:
Well, I was going to say, and I think hopefully the listeners kind of got this from what you said, but if you have a huge tear, those retear rates are enormous. But if you have a much smaller tear, the retear rates are much lower. So age is going to play a role, as you said, so if you have an older individual, obviously, that you might want to be a little bit more careful, but I think the size of the tear is going to be the biggest determinant of the failure rate. So if we want to try to figure out how fast we push range of motion, you probably want to go a little bit slower with that person that has a huge tear.
Mike Reinold:
Yeah. So I think it’s size, tissue quality, and age, which you could argue all feed together. They’re probably all related, but that definitely changes it. So think about it, so just in this conversation, we’ve talked about how the techniques for rotator cuff have progressed a bunch, but then I think the first evolution of this is that we found that retear rates didn’t improve and I think that scared everybody. So what do the doctors say? The doctors say, “Well, let’s slow down some of the range of motion.”
Mike Reinold:
Some of the research studies actually show that the retears happen in the first six to 12 weeks. So again, therefore the doctors say like, “Well, let’s do nothing for six to 12 weeks,” but I think it’s actually funny. If you actually dig into the research a little bit and you actually really read the methodology of some of these things, I actually think doing that isn’t very helpful, if that makes sense. I kind of go through this in some of my talks, but it was kind of funny in some of the studies that go over the retear rates. So I have Miller in AJSM in 2011, they did no passive range for the first four weeks and they still had 22% fail in that period.
Lenny Macrina:
Yeah.
Mike Reinold:
So that wasn’t very helpful. [inaudible 00:08:47] JBJS 2013 they had immediate range of motion and only 10% fail, so what does that tell you? Theoretically, if we’re using the … What is it? A equals B equals C kind of concept, then you would say that that passive range of motion early would be helpful. But I think as we get older and we learn a little bit more, Kim AJSM 14 kind of said, “Immediate passive range of motion for small to medium tear had no failures. No passive range of motion for six weeks with a large tear still had 33% failures.”
Mike Reinold:
So I think what we’re learning here is it’s probably not physical therapy. Excuse me. It’s probably not the range of motion that we’re performing. I don’t know. Excuse me. There’s probably five, six systematic reviews right now that kind of look at this and it doesn’t really show a difference in there, but doctors are still conservative. And I think the main thing is we should be conservative with the large tears. And I think we all should be conservative. Anybody else have anything? I’ve got one other thing I want to hit, but anybody else have anything? I don’t want to just keep talking.
Dave Tilley:
Yeah. I just have one thing I’ve learned from Lenny and Mike especially as I’ve kind of gone through this is, we look at the retear rates and we look at on an ultrasound or something like that, they’re tearing, but the person’s okay. Their arm doesn’t hurt, they’re moving their arm pretty well six, seven, eight months down. So you’ve got to just throwing a wrench in the gears, just because they have a retear on a clinical exam or in some sort of imaging, if they’re doing fine, then who’s to say that was an unsuccessful therapy? If they can move their arm well and they’re back to their daily life, then it’s like, “Okay.”
Dave Tilley:
And I remember Lenny citing some stuff where people do great, but the retear rates were high under imaging. It’s like, “Okay, what do we define as successful then?” So that’s just my two cents.
Lenny Macrina:
Right. Will that tear increase though over time? In two, three, four, five years, will that tear get worse? I think about 50% of those people it may happen to, it seems like the research is saying. 40% to 60% if you have a tear in your shoulder and treated non-operatively, for those people, it turns into a bigger tear. So I think the same concept would probably happen in somebody who has a repair, shows retear. It’s a coin toss. Is that tear going to get worse over time? And the doctors say, “We don’t want that coin toss. We want the odds in our favor.” I get it. I completely get it.
Mike Reinold:
Yeah. That sounds like fear mongering, Lenny.
Dave Tilley:
Yeah.
Mike Reinold:
I dare you to put that on Instagram that people with tears will extend to worse tears over time which is, I don’t know, the journal of common sense.
Lenny Macrina:
Right. And Pope just put that on Instagram.
Dan Pope:
Like three days ago.
Mike Reinold:
Right?
Lenny Macrina:
Pope just put that on Instagram. So full credit and it made me think deeper about it too.
Mike Reinold:
I love the Instagram things that say, “Well, having a tear doesn’t mean they have symptoms or anything like that.” But man, I don’t want a tear. Do you want a tear? I don’t want a tear. And so let’s not keep snatching. That seems like a terrible idea.
Lenny Macrina:
Yeah.
Dan Pope:
Yeah.
Mike Reinold:
Dan?
Lenny Macrina:
I think … Oh, go ahead, Dan. Go ahead, go ahead.
Dan Pope:
I was just going to say, this is pretty fresh in my mind because I did a pretty big lit review on the rotator cuff recently, and Dave’s right with most of the research. The outcomes, a lot of the outcomes are insignificant differences between the ones that had failures and the ones that did. I think the main thing that popped up is there’s a difference in strength, generally, from what I’ve found. So they are a little bit different, and then the last piece, like you said, the retear rates and whether or not that matters. And again, that probably comes down to the person’s age and a lot of other factors. So it’s a tough call.
Lenny Macrina:
Listen, we can cherry-pick the research. The doctors can find stuff for them, we can find stuff for us. The way I usually, if people ask me this question, my one hour of rehab two to three times a week, there’s no way I am retearing that rotator cuff with my three hours worth of total PT maybe in a week compared to what? How many hours in a week? 24 times seven? That’s a lot of hours. How is my three hours of rehab and education and all that going to really retear when the research is back and forth? We know it’s back and forth. It says PT is helpful and good, and then some say no. So there’s so many different factors that just blame PT. That’s the way I usually sum it up to people.
Mike Reinold:
All right, fantastic leadway to my last point here. So looking at EMG of the supraspinatus during functional activities with two ends of the spectrum. Passive range of motion is 5% EMG of the supraspinatus. Which I don’t know, I wonder if you can argue that’s noise. I don’t even know. Or just there’s something, you’re just using it a little bit. On the other end of this, let’s say full can. Full can exercise with a weight. That’s 73% EMG activity, so there’s our end range. Passive range of motion’s right down there. 5%. It’s passive. It’s passive. That’s the name of it. So it’s 5%.
Mike Reinold:
Pendulum’s right there. Do you know what’s more than passive range of motion for EMG of the rotator cuff? Brushing your teeth, taking a bath, eating. All those things. So I think that’s a good thing with Len there. I don’t think it’s our passive range of motion. Now, don’t get me wrong, there are some stupid active range of motion activities you can do like a standing L-bar or the walk up the wall. Why does every surgeon want you to walk up the wall? Just that makes no sense. But they say that’s a good exercise for range of motion when [inaudible 00:13:49] passive range from the basic active range.
Mike Reinold:
But how about this? I’ll end it with this one because this will get you thinking right here. There is more EMG activity of the rotator cuff when you open a heavy door with your other arm.
Lenny Macrina:
Yeah.
Mike Reinold:
Your other arm. So you’re healthy, you’re in the big bracing. You open a door with your left. There’s reciprocal EMG activity to help stabilize probably your thorax, your scapulothoracic joint. There’s more EMG activity in opening a heavy door than there is doing passive range of motion. So I don’t think our passive range of motion is what is bothering people.
Dave Tilley:
[crosstalk 00:14:27].
Mike Reinold:
Yeah. So as a summary, I think we should say this because we should give good information here, we’re pro-passive range of motion. We think there are maybe some active assisted range of motion things you can do, but the older, the larger the tear, and the worse the tissue quality, the more conservative we are too. And believe it or not, I don’t even know if that helps. They may tear anyway. Because when those factors come in, they may tear anyway.
Mike Reinold:
So look, that doesn’t mean you have to be rogue, that doesn’t mean you have to go argue with the surgeon that’s sending you people, that’s going to never get you another patient from them again. But you should know some of this information, that we can do some gentle passive range of motion, you can do some pendulums in the early phases of rotator cuff repair. And they’re probably going to have better functional outcomes, less pain, and then be ultimately happier down the road. So if you can get a physician that understands that, that’s a great person to work with. Make sense? Awesome.
Mike Reinold:
So good episode. I felt like we did that one and we gave a lot of good advice on that one, so hopefully you guys enjoyed that at home and learned a little bit about rotator cuffs and some of our current practices. It’s questions like that, I think, the evolution of things where even just in our short careers, we’ve seen things change over time that I think are super helpful. So if you have another question like that, head to MikeReinold.com, click on the podcast link, and there’s a big form you can fill out to ask us anything you want to talk about. We try to answer as many as we can, so keep them coming and we will see you on the next episode. Thanks.
