Rotator cuff repair surgery is one of the most common procedures in physical therapy, yet the recommended postoperative guidelines vary significantly.
Different doctors worldwide disagree on what’s best. Some want to be conservative and delay range of motion and physical therapy to maximize the chance that the repair does not fail.
But is that best? Are there negatives?
In this episode, we discuss some of the science behind delaying range of motion after rotator cuff repair surgery.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 344: Should You Delay Range of Motion after a Rotator Cuff Repair?
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Show Notes
• EMG activity while wearing a shoulder immobilizer
• Dan Pope’s Rotator Cuff Master Class video
• The Shoulder Sleeper Pillow
Transcript
Devin Limerick:
Yeah, I will. Danielle from California says, “The surgeons I work with recommend patients wait 12 weeks until they start physical therapy after rotator cuff repair.” She said they don’t want the patient to do too much range of motion and injure the repair. Do you think you need to delay the start of motion after rotator cuff repair or not?
Lenny Macrina:
Where is this again? What state is it? And I’m already fired up. Where was this again?
Devin:
California.
Lenny Macrina:
Don’t have shoulder surgery in California. I’m just kidding, people. We love California. Seems a little conservative. That’s my answer.
Mike Reinold:
That’s California, right? To the T… But anyway, anyway, anyway. All right. So Lenny couldn’t even get through the question without… You almost choked on your water there. I don’t know. I would like to start with Lenny because obviously, this is probably going to be his whole episode probably. But we move from an environment with a group of surgeons. A lot of people think we just worked with one doctor down in Birmingham when we were with Dr. Andrews, but there’s a large group of surgeons down there and I think we were all on the same page that we didn’t necessarily like to wait this long. So as physical therapists, we’re always bothered when they say, “Hey, no rehab for the first three months.” That’s enormous, right? But Len, what do you think? How does this make you feel? Let’s talk about your feelings.
Lenny Macrina:
I wish I was wearing some kind of heart rate monitor as Devin was reading that question so you could see the spike. No, that seems… 12 weeks, that’s something I’ve never heard of. It’s usually four to six weeks and my mind can handle that. It’s not what I like because like you said, we used to see people a day out of surgery, literally post-op day one. We were doing range of motion on them. That was 20 years ago. So that was when we were doing single row repairs and maybe it was a little bit more open and mini open type repairs where there’s a bigger view of the shoulder, and in theory, a better repair. But I don’t even think so. Now the double row repairs that are arthroscopic do just as well if not better.
So you got to consider what’s being repaired, how much tissue. Is it a one centimeter or a five centimeter repair? Is it just an isolated super versus super infer and sometimes even teres? Is the person older? Do they smoke? Is it a workers’ comp case? Comorbidities? So many different things to consider. The tissue type, the tissue quality that the surgeon saw when he or she was in there. So many different things. To just put a blanket statement of 12 weeks is preposterous. Smaller repairs tend to get, I would say, stiffer, and need a little bit more love earlier on and they do well. It’s the bigger repairs that we may want to be a little bit more conservative on, and I would say maybe wait a couple weeks, four weeks maybe at the most. But you just have to adjust your rehab accordingly and not push through the motion.
Because when people come in at 12 weeks out of surgery, you now have probably a higher rate of chronic regional pain syndrome. They haven’t moved their joint. Mentally, they’re just shot from not being able to use that joint for 12 weeks. Weakness, stiffness. You have so many things you’re now fighting, but the surgeons want a repair that is strong and firm and not going to re-tear. But I think the same thing statistically happens in the research if you have early motion versus delayed motion. Usually, the delayed motion is six weeks. So I don’t know why the 12-week thing is coming on. It’s probably insurance-based. Either the insurance won’t approve it or you are limited in visits and now you can do more. You can do motion and strengthening at 12 weeks and the doctors are trying to capture that window, that envelope of what you can do, and use those visits. I’m guessing because none of the research that I’ve seen said wait 12 weeks. So that’s my soapbox.
I say get them in earlier. Within two weeks, I think they do fine, especially smaller repairs. Big repairs go slower and it’s just a matter of when you take them through active range of motion. It seems like active range of motion or strengthening stuff is the key that can lead to higher re-tear rates. If you do it too early, then you are going to put them at risk of a re-tear. So if you are patient and work on their motion and do isometrics and basic stuff, they will be fine, especially if they don’t have significant comorbidities. If they do, you adjust accordingly.
Mike Reinold:
Do you promise?
Lenny Macrina:
All right, I’m Done.
Mike Reinold:
Do you promise because you just said they’ll be fine. So now every PT listening to this is going to go against physician orders and do it… And you promise, Len?
Lenny Macrina:
Well statistically, they do fine if you look at the research, but you can’t go against the orders of the physician because you’ll be violating your oath of honor or whatever.
Mike Reinold:
I think I talk to more people online or just around the country. I actually have heard of the 12 weeks before. That doesn’t surprise me as much as you, but I will say I think you’re right, Len. I think we have settled in the four to six range more than we had in the past, but there are certainly doctors that said 12 weeks in the past and I guess it didn’t… It annoyed me as much as it annoyed you for lots of reasons, but I would say it didn’t surprise me as much. But again, it’s very regional. The physicians in your area may feel differently, and even different doctors in different practices will do that. Dan Pope, I know you’ve done some deep dives on some of this stuff here. What are your thoughts on the science of this?
Dan Pope:
Yeah, it’s a good point. I think a lot of times what doctors are doing, and it just rubs us the wrong way, is that they’re trying to protect their patients. And there’s a lot of re-tears obviously, and one of the issues is that the re-tears are occurring mostly between zero and three months, and then some between three and six months. But what can a surgeon do to protect the patient as much as possible when they’re not able to follow the rehab at all? They can just say, “Don’t move this for the first three months.” And hopefully, reduce those re-injury rates. But the other thing is people are re-tearing, if you look at these same studies, while they still have their sling on and they’re not doing physical therapy. So it’s not completely fair.
I do think that what’s happening is that the surgeon is trying to keep the patient as safe as possible. Obviously, this is crazy. When I heard the 12 weeks, I was like, “Wow, that’s really a long time.” And I did do a lit review and what’s funny is I forgot a lot of it, so I had to go back and listen to it. If you guys want, maybe we can send the episode out at some point in the show notes or something. I don’t know.
You could reach out to me if you guys really want a deep dive on this because I broke it down a lot at one point, but largely for passive range of motion, just like Lenny said, and these studies are all over the place and they’re also mixed. What you’ll find is that if you start passive range of motion early for the large and massive tears, you do have a slightly increased re-tear risk and that’s mixed. So it’s not every study that’s showing this. So some of the studies show if you start passive range of motion early, and some of these studies, it’s tough because there are a lot of meta-analyses out there. They’re lumping together lots of different start times. So some people are starting post-op day one, some are starting post-op day two, or excuse me, post-op week two. Some are starting post-op week four, and they’ll lump that into one group and call that the early and then delayed is like six, eight, 12. So take it all with a grain of salt there.
But I think the big takeaway, like Lenny said, is that you’re starting really early for the large tears and massive tears. You slightly elevate that re-tear risk. But for the small and medium, what you’ll also find in the research, if you start them sooner, their outcomes are better. This is usually in the short term, so like six months and before, but for pain, outcome measures and range of motion all improve. So again, we have quite a bit of research on this, but it’s not definitive. And I think the big takeaway is are you dealing with a small or medium, or are you dealing with a massive or large? And I do think that’s a little crazy for a physician to say 12 weeks, but I get what they’re trying to accomplish, I think.
Mike Reinold:
Right. We know what their intentions are, why they’re doing it. It makes sense. Yeah, you look at these studies and I think it actually supports that it’s okay to start some early range of motion. If you actually look at the studies in detail, the people that failed fail early and they often fail before PT even starts, whether it be early or late. So showing that PT is not the reason. And you know what? I took a huge step back when I started really thinking that way about that. And I wondered here, now if these tears are happening early, they’re probably happening early, meaning they probably were never going to work anyway and we haven’t even started PT yet for a lot of those. Then what about their activities of daily living?
And then Daniel, I’ll put it in the show notes here with Dan’s episode there, I think he talks about it here, but I’ve done some presentations on this too. The things you do around the house are very, very, stressful is the wrong word, but the things you do around the house and with activities of daily living, stress the repair. So I think it’s almost worse to say don’t go to physical therapy because we can’t guide them. We can’t tell them what to do, not to do. We can’t slow them down if they’re going too fast. We can’t almost just be their guide through this process. So that’s what I thought of through this process. But who else? Mike, do you have any thoughts?
Mike Scaduto:
Yeah, I was just going to add to what we were saying. From a patient perspective, I think the first 12 weeks is when they have a ton of questions. They’re really unsure as to what they can do, even how long they should be wearing a sling. Sometimes the post-op reports are a little contradictory that we get from doctors, so they have a ton of questions. I think as physical therapists, we’re able to answer a lot of those questions for them, make their recovery process a little bit smoother. Maybe that leads to improved outcomes in the long term because they had some guidance early on, maybe even more than what we’re doing hands-on with them in the clinic. Just giving them that guidance for the first 12 weeks seems to be super important.
Mike Reinold:
Yeah, think about how many times have you had somebody come in early and they’re struggling. There’s a lot of pain, they can’t sleep, and you’re like, “Has your physician prescribed you a shoulder sleeper pillow?” and something like that. Those are the things that you can jump in, but there’s this pillow that you can wear at night and you sleep in and their satisfaction goes through the roof.
Dan Pope:
Here’s your rotator cuff.
Mike Reinold:
The testimonials on the website are amazing, but it’s just little things like that where you can jump in and say like, “Oh, you’re struggling with sleep,” for example, “I have some thoughts on that.” And we’ll put a link to the shoulder sleeper pillow in the show notes this week too. But lots of show notes this week. We’re not real show notes people.
Dan Pope:
Sorry, I know.
Mike Reinold:
We’re going to do it this week. So everybody’s sending me notes. But anyway, so moral of the story, I think wrapping up this episode here. If your physician does that, it is what it is. Hopefully over time, that physician will maybe start seeing that maybe their people are behind, maybe they’re getting stiff, maybe they’re getting sore, and then maybe as they get a little bit more comfortable, maybe this is a new physician that just wants to be successful and doesn’t know that the holistic approach might be the best way.
So my thought is just we can do the best to educate, but I think going in guns blazing to a physician and trying to show meta-analyses that say that they can do range of motions… Probably not a good start to the relationship. But over time, I think maybe if they learn about you as a physical therapist and they trust you specifically, maybe they will send you patients earlier because they know you, like you, and trust you versus them just being blanket 12 weeks because they don’t know you and they’d almost rather their patients do nothing than bad therapy. So maybe you just need to prove to them that you’re a reputable source, that’s somebody that they can trust, and I think hopefully that might really help. And then you could always move, Danielle. That’s the other thing too. But anyway, sorry.
Lenny Macrina:
Look up the Smith paper in 2004, Shoulder and Elbow Surgery, and it’ll be eye-opening on EMG Study. Just saying. Smith et al, Smith and Padgett 2004 Shoulder and Elbow Surgery.
Dave Tilley:
Put it in the show notes.
Lenny Macrina:
I’ll tweet it, I’ll tweet it, I’ll tweet it. Put it in the show notes. I’ll put it in my Twitter notes.
Mike Reinold:
I think we can put it in the show notes. I almost feel like this is a great TV episode. I feel like we’re wrapping up and then Lenny hits you with the cliffhanger.
Lenny Macrina:
Ba-bang.
Mike Reinold:
You’re like, “Look it up. It’ll blow your mind.” We don’t know why it’ll blow our mind, but we just blew our minds.
Lenny Macrina:
We try near the end the episode, so I was trying to end it.
Mike Reinold:
Great episode. All right, so everybody send me links. Slack me links, I’ll put them in the show notes. You have 10 minutes to Slack me links. But yeah, appreciate that one, Danielle. Great question. If you have questions, remember: head to mikereinold.com and ask away. We’re here to answer your questions and please, please, please subscribe, rate and review us on Apple Podcasts and Spotify. And we will see you on the next episode. Thank you so much.
