Early Passive Motion Research Articles

What's New in Sports Medicine.

This update is based on the scientific and investigational activities in the specialty of sports medicine from September 2014 to August 2015. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine , and Arthroscopy: The Journal of Arthroscopic and Related Surgery. ### Rotator Cuff #### Degenerative Rotator Cuff Tear History The natural history of degenerative rotator cuff tear progression is still being elucidated. There are many studies that show the prevalence of asymptomatic rotator cuff tears, but few exist that evaluate the long-term prospective patient history. Keener et al. attempted to characterize the amount of rotator cuff tear enlargement and progression of symptoms with initial asymptomatic tears. They studied asymptomatic rotator cuff tears in patients who had a symptomatic contralateral rotator cuff tear. In their study, they showed that tears enlarged in almost one-half of the patients over a median of 3 years and those patients who experienced tear enlargement tended to have an onset of new pain. Progressive degenerative changes within the supraspinatus and infraspinatus muscles were associated with tear enlargement compared with the control group. These findings show that many of these tears may progress and may become symptomatic1. #### Therapy After Rotator Cuff Repair Although therapy after rotator cuff repair is universal, the optimal timing of rehabilitation initiation is still unknown. Studies have suggested that outcome scores are better with early passive motion (<6 weeks after the surgical procedure) than with delayed motion (≥6 weeks), but the association of rehabilitation schedule and retear rate is not fully understood. In a systematic review and meta-analysis, Kluczynski et al. found that, in randomized controlled studies, there was not a significant difference between the 2 rehabilitation schedules with respect to retear rates. With analysis of those studies that did not …

Impact of cyclic mechanical stimulation on the expression of extracellular matrix proteins in human primary rotator cuff fibroblasts

Mechanical stimulation plays an important role in the development and remodelling of tendons. The aim of the study was to evaluate the effects of mechanical stimulation on the expression of extracellular matrix proteins in human primary rotator cuff (RC) fibroblasts. RC fibroblasts were isolated from patients with degenerative RC tears and characterized using flow cytometry and immunohistochemistry. Cells were stimulated using the Flexcell FX5K™ Tension System. The stimulation regime was a uniaxial sinusoidal waveform with 10% elongation and a frequency of 0.5Hz, whereby each cycle consists of 10-s strain and 30-s relaxation. Data were normalized to mechanically unstimulated control groups for every experimental condition. RT-qPCR was performed to determine relative mRNA levels, and collagen production was measured by a colorimetric assay. The positive expression of CD91 and CD10, and negativity for CD45 and CD4 confirmed the fibroblast phenotype of RC primary cells. RT-qPCR revealed that 10% continuous cyclic strain for 7 and 14days induced a significant increase in the mRNA expression both on the matrix metalloproteinases MMP1, MMP3, MMP13, and MMP14 and on the extracellular matrix proteins decorin, tenascin-C, and scleraxis. Furthermore, mechanically stimulated groups produced significantly higher amounts of total collagen. These results may contribute to a better understanding of strain-induced tendon remodelling and will form the basis for the correct choice of applied force in rehabilitation after orthopaedic surgery. These findings underline the fact that early passive motion of the joint in order to induce remodelling of the tendon should be included within a rehabilitation protocol for rotator cuff repair.

Evidence based post-operative treatment of flexor tendons

Flexor Tendon injuries require surgical repair and intensive therapy post-operatively for optimal outcomes. “The repair technique is important but it is the way the tendon is managed afterwards that determines the outcome” ([1], page 112). Multiple protocols exist for the post-operative rehabilitation of tendon injuries. Currently four main options for post-operative treatment are utilized: immobilization, early passive mobilization, early active-passive mobilization and earlyactive mobilization. Early protected movement has been shown to decrease adhesion formation and stimulate tendon healing [2]. It is well established that protected early movement of the tendon results in a better outcome than immobilization [3-5]. There is less risk of tendon rupture with early passive motion protocols, but an increased risk for decreased range of motion in the final outcome, in comparison to early active motion protocols [6]. “The goal of tendon repair and rehabilitation is to achieve a normally gliding and functioning tendon.”([1], p 115). To achieve this goal the surgeon, the therapist and the patient must work closely together. The surgeon must create a repair that is strong enough to withstand the rehabilitation phase. The therapist must have a thorough understanding of: tendon anatomy, the mechanical limitations of the repair, the healing process and the biomechanical forces at work during the healing process. Additionally the therapist must understand the tendon’s response to the chosen treatment and continually adjust the treatment accordingly. The patient too must participate in the treatment; this requires that the patient receives sufficient instruction that allows him or her to understand the injury and participate in the subsequent rehabilitation process. In many clinics, flexor tendon rehabilitation is protocol driven; a standard post-operative protocol is implemented routinely for flexor tendon injury cases. This approach may work well when the patient meets the standard inclusion criteria. However when the patient does not meet the criteria for the prescribed protocol for post-operative treatment, treatment of acute flexor tendon injuries can be a challenge and if not adjusted for may result in less than optimal outcomes. “Functional outcomes do not depend on following a prescribed protocol, but on progressing each patient individually with the available evidence-based information and on observation of the individual’s healing process” [7]. There is ample evidence available to guide therapists and physicians in clinical decision making when patient characteristics do not fit the protocol. A review of evidence that supports and guides the therapist’s clinical decision making in rehabilitation of the flexor tendon will be presented. Options for clinical situations such as: delayed initiation of post-operative treatment, concomitant injuries and or conditions that require rest vs. movement, patients that cannot follow complex treatment programs and other clinical scenarios that require an adapted approach to obtain an optimal outcome, will be discussed.

Flexor tendon injuries in children: Rehabilitative options and confounding factors

Research pertaining to the rehabilitation of children with flexor tendon injuries is less prevalent than that in the adult population, and most authors agree that immobilization protocols comprise a safe and efficacious choice. This article presents suggested protocols and correlated literature regarding the outcomes of immobilization, early passive motion, and early active motion in the pediatric population. Confounding factors which influence rehabilitative choices, both personal and environmental, are also presented.

Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis

We conducted a meta-analysis of randomized trials to compare delayed vs early motion therapy on function after arthroscopic rotator cuff repair. We searched 4 electronic databases (Medline, Embase, Cochrane, and Physiotherapy Evidence Database [PEDro]). The methodologic quality of the included studies was assessed, and the relevant data were extracted. Data were pooled for functional outcomes, rotator cuff tear recurrence, and shoulder range of motion. Complications were reported descriptively. Three level I and 1 level II randomized trials were eligible and included. Pooled analysis revealed no statistically significant differences in American Shoulder and Elbow Surgeons scores between delayed vs early motion rehabilitation (mean difference [MD], 1.4; 95% confidence interval [CI], -1.8 to 4.7; P = .38, I(2) = 34%). The risk of retears after surgery did not differ statistically between treatment groups (risk ratio, 1.01; 95% CI, 0.63-1.64; P = .95). Early passive motion led to a statistically significant, although clinically unimportant, improvement in forward elevation between groups (MD, -1°; 95% CI, -2° to 0°; P = 0.04, I(2) = 0%). There was no difference in external rotation between treatment groups (MD, 1°; 95% CI, -2° to 4°; P = 0.63, I(2) = 0%). None of the included studies identified any cases of postoperative shoulder stiffness. The current meta-analysis did not identify any significant differences in functional outcomes and relative risks of recurrent tears between delayed and early motion in patients undergoing arthroscopic rotator cuff repairs. A statistically significant difference in forward elevation range of motion was identified; however, this difference is likely clinically unimportant.

Early Passive Motion Versus Immobilization After Arthroscopic Rotator Cuff Repair

To provide a synthesis of the highest-quality literature available comparing early passive motion (EPM) with strict sling immobilization during the first 4 to 6 weeks after surgery. The Medline, Cochrane, and Embase databases were searched for eligible studies. We reviewed 886 citations, and 5 randomized clinical trials (RCTs) (Level II) met the inclusion criteria for meta-analysis. Four RCTs contributed to the analysis of range of motion, and 5 contributed to the analysis of retear rates. A single Level IV study was available for qualitative review. Random-effects models were used for meta-analysis, computing mean differences for continuous variables and risk ratios for dichotomous variables. EPM resulted in improved shoulder forward flexion at 3 months (mean difference, 14.70°; 95% confidence interval [CI], 5.52° to 23.87°; P= .002), 6 months (mean difference, 4.31°; 95% CI, 0.17° to 8.45°; P= .04), and 12 months (mean difference, 4.18°; 95% CI, 0.36° to 8.00°; P= .03). External rotation at the side was only superior with EPM at 3 months (mean difference, 10.43°; 95% CI, 4.51° to 16.34°; P= .0006). Rotator cuff retear rates (16.3% for immobilization v 21.1% for EPM; risk ratio, 0.82; 95% CI, 0.57 to 1.20; P= .31) were not significantly different between EPM and immobilization at a minimum of 1 year of follow-up. A small number of RCTs with low to moderate risks of bias are currently available. Meta-analysis suggests that after primary arthroscopic rotator cuff repair of small to medium tears, EPM results in 15° of improved forward flexion at 3 months and approximately 5° at 6 and 12 months. External rotation is improved by 10° with EPM at 3 months only. The clinical importance of these differences has yet to be determined. Retear rates at a minimum of 1 year of follow-up are not clearly affected by type of rehabilitation. Level II, meta-analysis of Level II studies and qualitative review of Level IV study.

Effect of Postoperative Passive Motion on Rotator Cuff Reconstruction With Acellular Dermal Matrix Grafts in a Rat Model

Background: Although postoperative rehabilitation is critical for rotator cuff tendon-to-bone healing and shoulder function recovery, no standardized protocol has been established. Hypothesis: Postoperative immediate passive motion is detrimental to tendon-to-bone remodeling and tendon maturation after rotator cuff acellular dermal matrix (ADM) grafting, although postoperative delayed passive motion does no harm. Study Design: Controlled laboratory study. Methods: Male Sprague-Dawley rats underwent rotator cuff reconstruction with ADM grafts. Their shoulders were immobilized for 2 weeks thereafter. The rats were assigned to 3 different rehabilitation protocols: (1) immobilization without passive motion (nonpassive motion [N-PM], controls), (2) immobilization with immediate passive motion (I-PM), and (3) immobilization with delayed passive motion (D-PM). Specimens obtained 2, 6, and 12 weeks postoperatively were analyzed histologically, and semiquantitative histomorphological measurements of collagen organization, vascularity, and cellularity were obtained; the area of interest was divided into 2 zones, the midsubstance of the graft and the graft-bone interface. Another set of samples taken at 12 weeks was subjected to biomechanical analysis. Results: At 2 weeks, there was no significant difference among the groups in terms of semiquantitative histomorphological measurements of collagen organization, vascularity, and cellularity. At 6 weeks, collagen organization at the insertion site was significantly poorer in I-PM than in N-PM and D-PM rats (P = .0095). At 12 weeks, collagen organization at the insertion site and midsubstance of ADM grafts was also significantly poorer in I-PM rats (P = .0125 and P = .0018, respectively), and ultimate load-to-failure was lower in this group (P = .0043). Conclusion: While postoperative immediate passive motion was detrimental to remodeled tendon-to-bone healing and to the tendon maturation of ADM grafts placed in the rotator cuff tendon defects, delayed passive motion did no harm. Clinical Relevance: For patients with 6-week immobilization after rotator cuff reconstruction, we recommend that early passive motion be started no sooner than 3 weeks after surgery. Immediate early passive motion should be avoided.

Medial patellofemoral ligament

Traumatic and nontraumatic patellofemoral instability (PFI) in children and adolescents is a complex problem. It is determined by a large number of mechanical and pathomorphologic conditions, mainly seen in nontraumatic dislocations. Although conservative treatment with a short immobilization, followed by early passive motion and isometric quadriceps strengthening, can be considered in real traumatic dislocations without any cartilaginous injury, a surgical intervention should be considered in atraumatic cases. As 90% of PFI are nontraumatic and correlated with skeletal deformities, the redislocation rate is reported to be up to 80% after initial conservative treatment. To optimize the results, the causing disorder for PFI has to be considered imperatively. In addition to bony disorder, further risk factors have to be taken into consideration for determining the optimal time for surgery. As biomechanical and clinical studies have shown the importance of the medial patellofemoral complex, especially the medial patellofemoral ligament (MPFL), against patellar lateralization, the reconstruction or minimally invasive double-bundle reconstruction of the MPFL is the main surgical technique to treat PFI in children, as it can be used even in open epiphysial cartilage. Further surgical interventions correcting bone deformities, such as trochleoplasty or tibial tubercle osteotomies addressing lower limb deformities, should be performed after closure of the epiphysial cartilage. It is the goal of this overview to explain the pathoanatomy of PFI, the demanding clinical and radiological examinations and treatment options.

Functional Outcomes for Combined Acute Anterior and Posterior Cruciate Knee Injuries Treated Non-Operatively

Introduction: results after non-operative management for knees sustaining combined acute anterior and posterior cruciate ligament tears were presented. Subjects: 13 patients, 10 with medial, and 3 with lateral ligament injury. Methods: non-operative management consisted of employing a brace to prevent sagittal translation of the tibia. Quadriceps muscle and early passive knee motion exercises in the brace was encouraged immediately after arthroscopy. Weight-bearing was forbidden for 3 weeks. The brace was not removed for 3 months. Follow-up periods ranged from 2 to 6 years (mean, 3 years 2 months). Results: none, but one patient had a slight restriction of knee flexion. Quadriceps muscle strength revealed an average of 89.0% of normal side. The knee score indicated 2 patients rated good, 3 rated fair, and 8 rated poor. The score correlated with measurements of anterior and posterior translation on the stress radiograph significantly. Stress radiography revealed that anterior laxity was reduced better than posterior laxity significantly. Conclusion: non-operative brace therapy can be considered for this combined injury as the initial treatment. A late reconstruction would be performed when the result was not satisfactory. Preserved range of motion and muscle strength after brace therapy had a great advantage to the late reconstructive surgery.

The Tortoise Versus the Hare—It’s a Photo Finish

There are a number of known factors that can affect clinical outcomes and structural healing after rotator cuff repair. Some of these are fixed variables, such as patient age and comorbidities, tear size, and tissue quality, while others, such as patient-related factors like smoking, repair construct, and postoperative management, are modifiable and may allow for improvement in patient outcomes. The traditional school of thought regarding the initiation of postoperative rehabilitation following rotator cuff repair has favored early passive shoulder motion to prevent stiffness. Until recently, this approach has been largely uniform. However, over time, data suggesting poorer tendon healing in certain subsets of patients have accumulated, leading some surgeons to advocate a delayed rehabilitation protocol with an initial phase of strict immobilization. The theoretical “trade-off” of this approach would be to improve the likelihood of tendon healing at the potential expense of an increased risk of postoperative stiffness and a delayed recovery timeline. The current study by Keener and coauthors from Washington University analyzes this question and does so in a superb fashion. In this Level-I, prospective, randomized trial, the authors identified and enrolled 124 patients under the age of sixty-five years who underwent arthroscopic repair of a small or medium tear (<30 mm in anterior-to-posterior …

Early Passive Motion is Harmless to Shoulder Rotator Cuff Healing in Rabbit

Early Passive Motion is Harmless to Shoulder Rotator Cuff Healing in Rabbit

Flexor Tendon Repair Rehabilitation Protocols: A Systematic Review

To systematically review various flexor tendon rehabilitation protocols and to contrast those using early passive versus early active range of motion. We searched PubMed and Cochrane Library databases to identify articles involving flexor tendon injury, repair, and rehabilitation protocols. All zones of injury were included. Articles were classified based on the protocol used during early rehabilitation. We analyzed clinical outcomes, focusing on incidence of tendon rupture and postoperative functional range of motion. We also analyzed the chronological incidence of published tendon rupture with respect to the protocol used. We identified 170 articles, and 34 met our criteria, with evidence ranging from level I to level IV. Early passive motion, including both Duran and Kleinert type protocols, results included 57 ruptures (4%) and 149 fingers (9%) with decreased range of motion of 1598 tendon repairs. Early active motion results included 75 ruptures (5%) and 80 fingers (6%) with decreased range of motion of 1412 tendon repairs. Early passive range of motion protocols had a statistically significantly decreased risk for tendon rupture but an increased risk for postoperative decreased range of motion compared to early active motion protocols. When analyzing published articles chronologically, we found a statistically significant trend that overall (passive and active rehabilitation) rupture rates have decreased over time. Analyzing all flexor tendon zones and literature of all levels of evidence, our data show a higher risk of complication involving decreased postoperative digit range of motion in the passive protocols and a higher risk of rupture in early active motion protocols. However, modern improvements in surgical technique, materials, and rehabilitation may now allow for early active motion rehabilitation that can provide better postoperative motion while maintaining low rupture rates.

Delayed Early Passive Motion Is Harmless to Shoulder Rotator Cuff Healing in a Rabbit Model

Background: Postoperative passive motion is the most widely accepted rehabilitation protocol after rotator cuff repair; however, a rotator cuff retear remains a frequent surgical complication. Clinical outcomes indicate that early passive motion is harmless to rotator cuff healing, but no laboratory evidence supports this proposition. Hypotheses: (1) Immediate postoperative immobilization improves rotator cuff healing in rabbits. (2) Early passive motion after short-term immobilization does not harm rotator cuff healing in rabbits. Study Design: Controlled laboratory study. Methods: An injury to the supraspinatus tendon was created and repaired in 90 New Zealand White rabbits, after which they were randomly separated into 3 groups: (1) nonimmobilization (NI; n = 30), (2) continuous immobilization (IM; n = 30), and (3) immobilization with early passive motion (IP; n = 30). At 3, 6, and 12 weeks postoperatively, 5 rabbits from each group were sacrificed for histological evaluation, biomechanical testing, and magnetic resonance imaging. Results: The histological study demonstrated better postoperative healing in the IM and IP groups, with clusters of chondrocytes accumulated at the tendon-bone junction. Magnetic resonance imaging illustrated that the tendon-bone junction was intact in the IM and IP groups. The magnetic resonance quantification analysis showed that the signal-to-noise quotient (SNQ) of the NI group was not significantly higher than that of the immobilization groups at 3 weeks (P = .232) or 6 weeks (P = .117), but it was significantly different at 12 weeks (NI vs IM, P = .006; NI vs IP, P = .009). At 12 weeks, the failure load was significantly higher in the IM and IP groups than in the NI group (NI vs IM, P = .002; NI vs IP, P = .002), but no difference was found between the IM and IP groups (P = .599). Conclusion: Immediate postoperative immobilization led to better tendon-bone healing than immediate postoperative mobilization, and under immobilization, early passive motion was harmless to tendon-bone healing in this study. Clinical Relevance: The results have an implication in supporting the rehabilitation protocol of early passive motion after rotator cuff repair.

Should we think about wrist extensor after flexor tendon repair?

Objective:To evaluate the activity of wrist extensor muscle, correlating with wrist motion during gripping after flexor tendon repair.Design:Cross-sectional clinical measurement study.Setting:Laboratory for biomechanics and rehabilitation.Subjects:A total of 11 patients submitted to rehabilitation by early passive motion of the fingers with wrist flexion position were evaluated after 8 weeks of fingers flexor tendon repair and 11 healthy volunteers, all ranging from 20 to 37 years of age.Intervention:Volunteers performed an isometric standardized gripping task.Main measures:We used electrogoniometry to analyze wrist range of motion and surface electromyography, considering 100% maximum voluntary contraction to represent the amplitude of electromyographic activity of the extensor carpi radialis and flexor digitorum superficialis.Results:Patients with flexor tendon repair showed co-activation deficit between wrist extensor (extensor carpi radialis) and flexor finger muscles (flexor digitorum superficialis) during gripping in the intermediate phase of rehabilitation, despite some recovering mobility for wrist extension (p ≤ 0.05). A moderate correlation between range of motion and extensor carpi radialis was present only for injured group (r = 0.32). Total active motion score, which represents finger active excursion, was regular or poor in 65% of cases, all with nerve repair associated.Conclusion:Wrist extensors have an important synergist role at handgrip, although some imbalance can be present after flexor tendon repair. These preliminary findings suggest that emphasis could be directed to add synergistic wrist motion in rehabilitation protocols after flexor tendon repair. Future studies with early active rehabilitation are necessary.

Evidence-Based Hand and Upper Extremity Surgery

Stiffness is a concern after rotator cuff surgery, but early exercises risk disrupting tendon sutures. A prospective randomized trial of 105 consecutive patients undergoing arthroscopic suturing of small to mediumsize full-thickness rotator cuff defects was undertaken comparing early (postoperative day 1) passive motion exercises 3 to 4 times per day with delayed passive motion following brace removal (4 wk for tears 1 cm and 5 weeks for tears of 1–3 cm). Both groups began strengthening at 9 to 12 weeks, and unrestricted activities were allowed at 6 months. There were no significant differences in demographics between groups. At 12 months, there were improvements in both groups with no significant differences in pain, range of motion (ROM) and functional outcomes (Constant Score, Simple Shoulder Test [SST], and American Shoulder and Elbow Surgeons [ASES] scores). Ultrasound (3–6 mo) and computed tomography (CT) or magnetic resonance imaging (MRI) (12 mo) revealed healing in 49/56 patients in the early motion group and 40/49 in the delayed motion group.

Paper 171: Biomechanical Contact Properties of Rotator Cuff Repairs During Passive Arm Movement: Perilously Low Levels Occur with Single Versus Double-row Repairs

Significant rates of re-tear occur following rotator cuff repair (open or arthroscopic) especially when the repair is under some tension. This may in part be due to inadequate tendon-to-bone (TTB) contact pressure during the initial healing phase when mobilization has commenced. Awareness of the poor TTB contact properties with single row repairs (SRR) has resulted in significant studies in improving contact area and pressure with double row repairs including transosseous- equivalent repairs (TOE). Nevertheless there have been very few studies looking at these properties in a dynamic fashion, simulating what happens in the early postoperative period before any healing have occurred. A particular concern has been with repairs which utilize a tension-band effect to achieve TTB contact. With early abduction, it was postulated that lift-off could occur with complete loss of TTB contact which would significantly compromise the ability of the tendon to heal. Simulated rotator cuff tears were created in the supraspinatus tendon of six fresh cadaveric human shoulders. A SRR was then performed using the Opus Magnum arthroscopic instrumentation creating 2 horizontal mattress sutures in accordance with manufacturers specifications. An I-Scan 6900 electronic pressure-sensor (Tekscan, Boston, MA) was placed between the supraspinatus tendon and bone and the sutures were tensioned with the shoulder in 0 degrees abduction. The arm was then rested for 300secs (relaxation) before being passively moved twice through a set range-of-motion (0-90-0 degrees abduction, 0-45-0 external and 0-45-0 internal rotation) and finally returned to neutral. The contact force, pressure and area were recorded throughout each movement. The procedure was then repeated using a TOE technique with two parallel sutures (TOE-P) and TOE with a cross over suture pattern (TOE-C). Data were analyzed by ANOVA using SPSS. TOE parallel and cross-over repairs demonstrated no significant change in mean TTB contact pressure, force and area during abduction, external rotation and return to neutral when compared to the 300sec relaxation state. TOE-C demonstrated a higher contact force on internal rotation (+53%). The SRR demonstrated a significant drop in contact force on abduction (-63%), and return to neutral (-43%) and a trend on external rotation (-34%). SRR exhibited no change on internal rotation. Consistent TTB contact during the healing phase is thought to be vital. There have been very few biomechanical studies with which to base the postoperative rehabilitation. The electronic pressure sensor is a useful instrument for determining changes in TTB contact properties dynamically allowing the monitoring of changes when the arm is moved, simulating the postoperative rehabilitation. We showed a significant decrease in contact force and pressure with SRR during abduction and on return to neutral compared to the TOE repairs which remains unaltered. This is an important consideration when determining postoperative rehabilitation protocols. These findings justify the need to discourage abduction post SRR until some healing has occurred. On the other hand, with TOE technique, it appears safe to commence early passive motion.

Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: A prospective randomized study

Rehabilitation programs after rotator cuff repair should allow recovery of shoulder function without preventing tendon healing. The aim of this randomized prospective study was to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. We followed 100 patients, mean age 55 years old, who underwent arthroscopic repair of a non-retracted supraspinatus tear. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks. A clinical evaluation was performed in 92 patients, and CT arthrography in 82. Mean follow-up was 15 months. The mean preoperative Constant score improved significantly from 46.1 points to 73.9 at the final follow-up. The rate of intact cuffs was 58.5%. Functional results were statistically better after immediate passive motion with a mean passive external rotation of 58.7° at the final follow-up versus 49.1° after immobilization (P=0.011), a passive anterior elevation of 172.4° versus 163.3° (P=0.094) respectively, a Constant score of 77.6 points versus 69.7 (P=0.045) respectively, and a lower rate of adhesive capsulitis and complex regional pain syndrome. Results for healing seemed to be slightly better with immobilization, but this was not statistically significant: the cuff had a normal appearance in 35.9% of cases after immobilization compared to 25.6% after passive motion, an image of intratendinous addition was found in 25.6% versus 30.2%, punctiform leaks in 23.1% versus 20.9%, and recurrent tears in 15.4% versus 23.3% respectively. The rehabilitation program that results in better tendon healing by preventing postoperative stiffness has not yet been identified. Our results suggest that early passive motion should be authorized: the functional results were better with no significant difference in healing.

Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol

This study evaluated patient outcomes and rotator cuff healing after arthroscopic rotator cuff repair using a postoperative physical therapy protocol with early passive motion compared with a delayed protocol that limited early passive motion. The study enrolled 68 patients (average age, 63.2 years) who met inclusion criteria. All patients had a full-thickness crescent-shaped tear of the supraspinatus that was repaired using a transosseous equivalent suture-bridge technique along with subacromial decompression. In the early group, 33 patients were randomized to passive elevation and rotation that began at postoperative day 2. In the delayed group, 35 patients began the same protocol at 6 weeks. Patients were monitored clinically for a minimum of 12 months, and rotator cuff healing was assessed using ultrasound imaging. Both groups had similar improvements in preoperative to postoperative American Shoulder and Elbow Surgeons scores (early group: 43.9 to 91.9, P < .0001; delayed group: 41.0 to 92.8, P < .0001) and Simple Shoulder Test scores (early group: 5.5 to 11.1, P < .0001; delayed group: 5.1 to 11.1, P < .0001). There were no significant differences in patient satisfaction, rotator cuff healing, or range of motion between the early and delayed groups. Patients in the early group and delayed group both demonstrated very similar outcomes and range of motion at 1 year. There was a slightly higher rotator cuff healing rate in the delayed passive range of motion group compared with the early passive range of motion group (91% vs 85%).

Is Early Passive Motion Exercise Necessary After Arthroscopic Rotator Cuff Repair?

Background: Early passive motion exercise has been the standard rehabilitation protocol after rotator cuff repair for preventing postoperative stiffness. However, recent approaches show that longer immobilization may enhance tendon healing and quality. Purpose: To elucidate whether early passive motion exercise affects functional outcome and tendon healing after arthroscopic rotator cuff repair. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: One hundred five consecutive patients who underwent arthroscopic repair for small to medium-sized full-thickness rotator cuff tears were included. Patients with large to massive tears and concomitant stiffness or labral lesions were excluded. Patients were instructed to wear an abduction brace for 4 to 5 weeks after surgery and to start active-assisted shoulder exercise after brace weaning. Fifty-six patients were randomly allocated into group 1: early passive motion exercises were conducted 3 to 4 times per day during the abduction brace-wearing period. Forty-nine patients were allocated into group 2: no passive motion was allowed during the same period. Range of motion (ROM) and visual analog scale (VAS) for pain were measured preoperatively and 3, 6, and 12 months postoperatively. Functional evaluations, including Constant score, Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) score, were also evaluated at 6 and 12 months postoperatively. Ultrasonography, magnetic resonance imaging, or computed tomography arthrography was utilized to evaluate postoperative cuff healing. Results: There were no statistical differences between the 2 groups in ROM or VAS for pain at each time point. Functional evaluations were not statistically different between the 2 groups either. The final functional scores assessed at 12 months for groups 1 and 2 were as follows: Constant score, 69.81 ± 3.43 versus 69.83 ± 6.24 (P = .854); SST, 9.00 ± 2.12 versus 9.00 ± 2.59 (P = .631); and ASES score, 73.29 ± 18.48 versus 82.90 ± 12.35 (P = .216). Detachment of the repaired cuff was identified in 12% of group 1 and 18% of group 2 (P = .429). Conclusion: Early passive motion exercise after arthroscopic cuff repair did not guarantee early gain of ROM or pain relief but also did not negatively affect cuff healing. We suggest that early passive motion exercise is not mandatory after arthroscopic repair of small to medium-sized full-thickness rotator cuff tears, and postoperative rehabilitation can be modified to ensure patient compliance.

Comparing Three Postoperative Treatment Protocols for Extensor Tendon Repair in Zones V and VI of the Hand

This pilot study compared the effectiveness of 3 postoperative rehabilitation protocols for patients with Zones V and VI extensor tendon lacerations. Twenty-seven patients were recruited from 3 sites and randomly assigned to 1 of 3 established treatment protocols: immobilization, early passive motion (EPM), and early active motion (EAM). Outcome measures were collected at 3, 6, and 12 wk after treatment and included total active motion (TAM). At the end of Week 12, data on 24 injured digits of 18 patients were available for analysis. When data at Weeks 3, 6, and 12 were compared, patients in all groups showed steady improvement in TAM, but digits under the EAM treatment improved to a greater extent over time (F[2, 46] = 75.6, p < .001). Patients with Zones V and VI extensor tendon injuries treated with the EAM protocol recovered range of motion more rapidly.