2012 Early Passive Motion Exercise Necessary After Arthroscopic

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The American Journal of Sports

http://ajs.sagepub.com/content/40/4/815Theonline version of this article can be found at:

DOI: 10.1177/0363546511434287

2012 40: 815 originally published online January 27, 2012Am J Sports MedYang-Soo Kim, Seok Won Chung, Joon Yub Kim, Ji-Hoon Ok, In Park and Joo Han Oh

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

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Is Early Passive Motion Exercise NecessaryAfter Arthroscopic Rotator Cuff Repair?

Yang-Soo Kim,* MD, PhD, Seok Won Chung,y MD, Joon Yub Kim,y MD,Ji-Hoon Ok,* MD, In Park,* MD, and Joo Han Oh,yz MD, PhDInvestigation performed at the Department of Orthopaedic Surgery, Seoul National UniversityCollege of Medicine, Seoul National University Bundang Hospital, Korea

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-thicknessrotator 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 eval-

uations 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 6 3.43 versus 69.83 6 6.24 (P = .854); SST, 9.00 6 2.12 versus 9.00 6 2.59 (P=

.631); and ASES score, 73.29 6 18.48 versus 82.90 6 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.

Keywords: arthroscopic rotator cuff repair; early passive motion exercise; functional outcome; rotator cuff healing

Rotator cuff repair is one of the most successful treatment

modalities in orthopaedics, and most patients enjoy func-

tional recovery after the procedure. However, the nonhealing

rate after rotator cuff repair still remains at 20% to 90% in

spite of the great advances in the surgical technique.1,3,6

Two key factors for successful tendon healing and satisfac-

tory functional outcome are skillful surgical technique and

a well-programmed rehabilitation protocol. That is, even

with an excellent surgical technique, we cannot expect a sat-

isfactory outcome if postoperative care is poor. In general,

early joint motion after surgery is recommended to prevent

stiffness and muscle atrophy. The advantages of this early

passive motion after surgery have been well reported for

the knee and ankle joints.7,13,15 In the shoulder joint, early

passive motion is also the standard rehabilitation protocol

after rotator cuff repair to avoid postoperative stiffness, espe-

cially in the era of open or mini-open surgery, and Raab

et al20 suggested in their prospective randomized study

that early continuous passive motion after rotator cuff repair

has a beneficial effect on range of motion (ROM) and pain

relief. Recently, however, some authors suggested that early

motion after rotator cuff repair could have a negative effect

on cuff healing, and their reports showed that anatomic

zAddress correspondence to Joo Han Oh, MD, PhD, Department of

Orthopaedic Surgery, Seoul National University College of Medicine, Seoul

National University Bundang Hospital, 166 Goomi-ro, Bundang-gu, Seong-

nam-si, Gyeonggi-do 463-707, Korea (e-mail: [email protected]).

*Department of Orthopaedic Surgery, Seoul St. Marys Hospital, Col-

lege of Medicine, The Catholic University of Korea, Seoul, Korea.yDepartment of Orthopaedic Surgery, Seoul National University Col-

lege of Medicine, Seoul National University Bundang Hospital, Korea.

One or more of the authors has declared the following potential con-

flict of interest or source of funding: This researcher-led study was sup-

ported by funds received from Smith & Nephew Corporation (B-0807-

059-032). However, the authors received no payment, other benefits, or

a commitment or agreement to provide such benefits from a commercial

entity. The funding sources played no role in the study design, data anal-

ysis, or results interpretation.

The American Journal of Sports Medicine, Vol. 40, No. 4

DOI: 10.1177/0363546511434287 2012 The Author(s)

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outcomes were rather disappointing with high nonhealed

rates, even with use of the new technique to maximize cuff

healing.1 In animal models of rotator cuff repair, immobilized

supraspinatus tendons had markedly higher collagen orien-

tation and more nearly normal extracellular matrix genes

than did the tendons from participants exercised.4,21 In addi-

tion, Parsons et al18 recently reported that immobilization for

6 weeks after arthroscopic rotator cuff repair did not result in

increased long-term stiffness and might improve the rate oftendon healing. These studies recommended shoulder immo-

bilization for a period after surgery and a delay of active

motion to enable sound healing.

As far as our knowledge, the benefits of early passive

motion after rotator cuff repair still remain unproved, and

very few reports are published in the literature regarding

postoperative rehabilitation after rotator cuff surgery. Fur-

thermore, there is no well-designed clinical trial that inves-

tigates the efficacy of early passive motion exercise on the

postoperative stiffness, functional outcome, and failure

rate of cuff healing. Therefore, we designed this prospective,

randomized comparative trial to verify whether early pas-

sive motion exercise affects functional and anatomic out-comes after arthroscopic repair in patients with small to

medium-sized rotator cuff tears. We hypothesized that early

passive motion after arthroscopic cuff repair does not dem-

onstrate a significant difference in terms of ROM, function,

or cuff healing compared with immobilization.

MATERIALS AND METHODS

Inclusion and Exclusion Criteria

We prospectively enrolled 117 consecutive patients from

August 2007 to July 2009 who met the following inclusion

criteria from 2 hospitals: (1) had a small to medium-sized

(less than 3 cm) full-thickness rotator cuff tear confirmed by

preoperative magnetic resonance arthrography (MRA) and

arthroscopy, (2) underwent arthroscopic rotator cuff repair,

and (3) had a degenerative tear with no evident trauma his-

tory. We excluded patients with preoperative shoulder stiff-

ness, concomitant glenohumeral injuries (eg, superior labral

anterior-posterior [SLAP] lesion, Bankart lesion), any previ-

ous shoulder surgery, and large or massive cuff tears (largerthan 3 cm in size or 2 tendon tears). The definition of the pre-

operative stiffness was the limitation of both active and pas-

sive motion in at least 2 directions (abduction and forward

flexion \100, external rotation \20, or internal rotation

\L3) in this study. Among these 117 patients, 12 were lost

to follow-up; therefore, 105 were finally enrolled in this study

(Figure 1). We obtained the approval of the Institutional

Review Board for the study protocol, and all patients gave

written informed consent from both institutions. In addition,

this study was registered at the National Clinical Research

Coordination Center of Korea (registry number:

KCT0000123).

Clinical Characteristics

There were 44 men and 61 women. A thorough physical

examination, including ROM and visual analog scale (VAS)

for pain, was completed the day before surgery. Patients

were randomly assigned into 2 groups according to an auto-

matic generated randomization list. There were 56 patients

in the early passive motion group (group 1: EM) and 49 in

the delayed motion group (group 2: DM). Group 1 consisted

of 26 men and 30 women with a mean age of 60.06 6 9.04

years and included 37 right and 19 left shoulders. Group 2

consisted of 18 men and 31 women with a mean age of

Assessed for eligibility (n = 192)

Excluded (n = 75)

Inclusion criteria not met (n = 64)

Refused to participate (n = 11)

Analyzed (n = 56)

Lost to follow-up (n = 4)

Allocated to early passive motion group(n = 60)

Received allocated rahabilitation(n = 60)

Lost to follow-up (n = 8)

Allocated to delayed motion group(n = 57)

Received allocated rahabilitation(n = 57)

Analyzed (n = 49)

Allocation

Analysis

Follow-up

Enrollment

Randomized(n= 117)

Figure 1. CONSORT flow sheet.

816 Kim et al The American Journal of Sports Medicine

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60.00 6 10.42 years (P . .05) and included 32 right and 17

left shoulders. The clinical characteristics of the enrolled

patients are described in Table 1.

Surgical Procedures

All surgical procedures were conducted by one senior sur-

geon in each hospital, and both surgeons performed all-

arthroscopic rotator cuff repairs. After glenohumeral

inspection, subacromial decompression was conducted toremove inflamed bursal tissue, and acromioplasty was per-

formed on all patients using a motorized bur (Vortex

Router and Linvatec Turbo Shaver System, Linvatec,

Largo, Florida) to create a flat acromion. Then, the greater

tuberosity of the humerus was prepared with a motorized

bur or ring curette to make a bleeding surface. Bioabsorb-

able anchors (Bio-Corkscrew, Arthrex, Naples, Florida; or

Spiralok, DePuy Mitek, Raynham, Massachusetts) were

used, and the anchors were inserted through an accessory

portal with a small stab incision. According to tear size and

pattern, either single- or double-row or suture bridge fixa-

tion was performed. In cases of small tears that were mea-

sured during arthroscopy, many of them were repaired by

the single-row technique. In cases of medium tears

(1-3 cm), many of them were repaired by the double-row

or suture bridge technique. The size of any full-thickness

rotator cuff tears was measured with a probe (with 5-mm

markings, Arthrex) during the arthroscopic surgery by

the senior surgeon at each site. The measurement method

was the same in both surgeons. After debridement of the

torn end, the anteroposterior dimension was measured at

the lateral edge of the torn cuff, and medial retraction

was measured as the distance from the apex of the tear

to the cuff insertion of the humeral head. The larger value

of the 2 measurements (anteroposterior dimension and

medial retraction) was used as the tear size; the tears

were divided into 2 groups based on size: small (\1 cm)

and medium (1-3 cm). Suture passing into the tendon

was done using a flexible suture passer (Expressew, DePuy

Mitek) or a suture passer (Spectrum, Linvatec), and all

knots were tied securely using a self-locking sliding knot.

Rehabilitation

Different standardized rehabilitation protocols were applied

to each group. For group 1, controlled early passive motion

exercise consisting of forward flexion, abduction, and external

rotation was conducted from 1 day after the operation during

the brace-wearing period. For group 2, no passive ROM was

allowed until brace removal (4 weeks for a small tear

[\1 cm] and 5 weeks for a medium-sized tear [1-3 cm]).

Immobilization was maintained with the abduction brace at

30. Shrugging of shoulders, active elbow flexion/extension,

active forearm supination/pronation, and active hand and

wrist motion were encouraged immediately after surgery for

both groups. Active-assisted shoulder exercise was encour-

aged after the weaning of the brace. Muscle strengthening

was usually initiated at 9 to 12 weeks postoperatively, and

all sports activities were permitted from 6 months after the

operation. All rehabilitation was referred to and supervisedby the Department of Rehabilitation at the authors

institutions.

Outcome Evaluation

Range of motion of the shoulder and VAS for pain were

checked at regular follow-up visits (4 or 5 weeks and 3, 6,

and 12 months postoperatively and then yearly). The VAS

for pain was scaled from 0 to 10, with a rating of 10 meaning

the highest level of pain. For measurement of ROM, forward

flexion and external rotation with the arm at the side were

evaluated with a goniometer in the supine position. Internal

TABLE 1

Demographic Data of Patients

Early Passive Motion Group Delayed Motion Group

No. of patients 56 (40a 1 16b) 49 (33a 116b)

Age, mean (range), y 60.06 (30-75) 60.00 (27-82)

Sex, male/female, n 26/30 18/31

Dominant arm, right/left, n 37/19 32/17

Comorbidities, n

Diabetes 8 7

Hypertension 16 15

Thyroid disease 1 1

Smoking, n 13 11

Tear size in anteroposterior dimension,c mean 6 standard deviation, mm 18.9 612.6 16.3 6 6.5

Medial retraction,c mean 6 standard deviation, mm 18.3 613.2 17.8 6 12.9

Repair technique, n

Single row 9 8

Double row 1 1

Suture bridge 46 40

aNumber of patients who had surgery at hospital 1.b

Number of patients who had surgery at hospital 2.cMeasured at surgery.

Vol. 40, No. 4, 2012 Early Passive Motion After Cuff Repair 817



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rotation at the back was checked with patients in a seatedposition to minimize other compensatory motions. Passive

abduction was measured in degrees between the arm and

the thorax in the scapular plane, and external rotation at

the side was measured in degrees between the thorax and

the forearm with the arm held in an adducted position

with 90 of flexion at the elbow. Internal rotation at the

back was measured by the tip of the thumb reaching the

vertebral level. For the analysis, the vertebral level was

numbered serially as follows: 12 for the twelfth thoracic ver-

tebra, 13 for the first lumbar vertebra, 17 for the fifth lum-

bar vertebra, and 18 for any level below the sacral region.

Functional outcomes were assessed by the use of the

Constant score, the Simple Shoulder Test (SST) score, and

the American Shoulder and Elbow Surgeons (ASES) score.

These were checked at preoperative admission and at regu-

lar follow-up visits (6 and 12 months postoperatively and

then yearly). The anatomic outcome was evaluated with

ultrasonography at 3 or 6 months after rotator cuff repair,

and computed tomography (CT) arthrography or magnetic

resonance imaging (MRI) was conducted at a minimum of

1 year after the operation. However, the ultrasonographic

evaluation was performed at only one site and has limita-

tions such as difficult interpretation, low interobserver

agreement, and lower accuracy compared with CT arthrog-

raphy or MRI; for these reasons, we used only the data of

CT arthrography and MRI assessed at a minimum 1 year

after rotator cuff repair. As a recent study reported, thediagnostic value of CT arthrography in the detection of

full-thickness tears appears comparable with MRA.16 The

interpretation of MRI and CT arthrography was performed

by experienced musculoskeletal radiologists who were

unaware of this study. Intact cuff was defined as mainte-

nance of the cuff insertion into the footprint; failure of heal-

ing was defined as discontinuity at the footprint.17

Statistical Methods

Sample sizes are calculated to detect a significant difference

(mean difference, 8 points; standard deviation, 12 points) in

ASES scores. The ASES score has been validated and widely

used for the evaluation of outcome after arthroscopic rotator

cuff repair.12,17 This was based on the mean and standard

deviation of ASES scores observed in a pilot study of

20 patients. A sample size of 49 patients in each group

was required for a power of 90% at a type I error level of

.05. Expected follow-up loss was about 20% (Figure 1).

All statistical analyses were performed using the SPSS

software package (version 12.0, SPSS Inc, Chicago, Illi-

nois), and a P value less than .05 was taken as the level

of statistical significance. An independent t test was used

to evaluate differences between the 2 groups for pain

VAS, ROM, and functional scores. A x2 test was used for

comparison of the anatomic outcome of the 2 groups.

TABLE 2

Forward Flexion (in Degrees)

Time

Early Passive Motion Group

(95% Confidence Interval)

Delayed Motion Group

(95% Confidence Interval) P Value

Preoperative 144.70 (135.79-153.61) 144.84 (135.94-153.74) .982

Postoperative 3 mo 144.86 (140.08-149.64) 140.00 (133.26-146.74) .319



TABLE 3

External Rotation With the Arm at the Side (in Degrees)

Time





Preoperative 67.27 (59.94-74.60) 69.84 (62.49-77.19) .633




TABLE 4

Internal Rotation at the Back

Time





Preoperative T 9.7 (T 8.6-T 10.8) T 9.2 (T 8.1-T 10.3) .552

Postoperative 3 mo T 7.6 (T 6.4-T 8.8) T 8.4 (T 7.3-T 9.5) .256






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RESULTS

All 105 patients completed the minimum 1-year follow-upevaluation. There were no significant demographic differ-

ences between the 2 groups (all P . .05) (Table 1). At

6 months postoperatively, there were no significant differ-

ences between the 2 groups for all 3 directions of ROM. The

average for forward flexion (Table 2) was 150.6in group 1

and 147.1 in group 2 (P = .392) and for external rotation

with the arm at the side (Table 3) was 77.2 in group 1

and 72.9 in group 2 (P = .393). Internal rotation at

the back (Table 4) was T 9.0 in group 1 and T 10.1 in

group 2 (P= .104). At the final follow-up visit at 12 months

after surgery, there were also no significant differences

between the 2 groups for all 3 directions of ROM.

The pain VAS was 3.0 in group 1 and 3.2 in group 2 atpostoperative 6 months (P = .745) and 2.8 and 1.8 at the

final follow-up (P = .34), respectively. The functional out-

come scores, including Constant (Table 5), SST (Table 6),

and ASES (Table 7) scores, were significantly improved

after arthroscopic rotator cuff repair in both groups, but

no significant differences were found between the 2 groups

at postoperative 6 months or at the final follow-up at

12 months after surgery. Imaging at a minimum of

1 year after surgery to evaluate healing of the repaired

cuff revealed that the rotator cuff tendon was healed in

49 of 56 patients (88%) in group 1 and in 40 of 49 patients

(82%) in group 2 (P = .429).

DISCUSSION

It has been generally accepted to initiate passive shouldermotion early after rotator cuff repair to avoid stiffness,

especially during the era of open surgery.11,14 Many

authors reported faster recovery of ROM and more favor-

able functional outcome with early passive motion exer-

cise.2,5,8 On the other hand, recently, several authors

reported that immobilization for a certain period after sur-

gical repair did not lead to postoperative shoulder stiff-

ness18; furthermore, that delayed shoulder motion could

promote tendon healing to bone.4,21 For these reasons, we

designed this prospective, randomized comparative trial

to verify whether early passive shoulder exercise affects

ROM, functional outcome, and cuff healing after arthro-

scopic repair of small to medium-sized rotator cuff tears.As a result, we demonstrated that early passive motion

had no advantage for either early gain of ROM or clinical

outcome. That is, delayed rehabilitation after arthroscopic

rotator cuff repair did not result in postoperative stiffness

and poor clinical outcome compared with early motion.

In the literature, there are limited reports that compare

early passive motion and delayed rehabilitation after

arthroscopic rotator cuff repair. However, there are several

reports regarding the individual rehabilitation protocols.

Early passive motion after arthroscopic rotator cuff sur-

gery has been advocated because it could reduce the possi-

bility of adhesion formation. Raab et al20 suggested in their

TABLE 5

Constant Score

Time





Preoperative 53.73 (49.77-57.69) 49.93 (45.87-53.99) .186




TABLE 6

Simple Shoulder Test Score

Time





Preoperative 4.06 (3.06-5.06) 3.52 (2.58-4.46) .424




TABLE 7

American Shoulder and Elbow Surgeons Score

Time





Preoperative 48.38 (42.99-53.77) 46.27 (41.15-51.39) .566







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prospective randomized study that early continuous pas-

sive motion after rotator cuff repair has a beneficial effect

on ROM and level of pain in female patients and those

older than 60 years of age. Li et al9 suggested that contin-

uous passive motion in rabbits promoted basic fibroblast

growth factor expression, leading to enhanced type III col-

lagen synthesis at the tendon-bone interface in the early

stages of tendon-bone repair after acute rupture of the

supraspinatus tendon, thereby contributing to tendon-

bone recovery after rotator cuff injury. On the contrary,

several recent studies reported that delayed motion had

benefits for clinical and biological outcomes. Peltz et al19

reported that immediate postoperative passive motion

was found to be detrimental to passive shoulder mechanics

by increasing scar and extracellular tissue formation in the

subacromial space, resulting in decreased ROM and

increased joint stiffness in their rat model study. In addi-

tion, Parsons et al18 suggested in their retrospective study

that sling immobilization for 6 weeks after arthroscopic

rotator cuff repair did not result in increased long-term

stiffness and might improve the rate of healing.The structural integrity of the repaired rotator cuff ten-

don is the critical issue that influences both clinical and

functional outcome. Even with rapid advancement of the

arthroscopic rotator cuff repair technique, the rate of cuff

healing failure is reported to be 20% and 90%.1,3,6,10 There

have been concerns that early motion after rotator cuff

repair might negatively affect the healing of tendon to

bone. Gimbel et al4 reported that immobilization of the

shoulder improved tendon-to-bone healing in the rat model

because it allowed for an increase in the organization of

collagen fibers, which led to an increase in mechanical

properties. In the current study, however, there was no

statistical difference in the healing rate between the 2groups at the 1-year follow-up. This implies that rotator

cuff tendon healing is not negatively affected by early pas-

sive motion given use of the modern arthroscopic tech-

nique. That is, the healing of repaired tendon to bone

might not only be affected by rehabilitation; other factors

such as operation technique and tendon and bone quality

are also important.

There are several limitations of the current study. This

study was performed at 2 different sites. That is, the oper-

ations were done by 2 different surgeons, and measure-

ment of ROM, tear size, and functional scores was also

conducted by 2 different researchers. Even though the

same surgical procedure and rehabilitation protocol

were employed, some variation and error could exist in

the analysis of the results. Second, the follow-up period

of at least 1 year after surgery was relatively short.

This is a serious limitation in our study. The clinical

and anatomic outcomes including healing rate of the rota-

tor cuff might change over a longer follow-up period, and

long-term observation is necessary. Third, we did not per-

form a stratified randomization. As 2 surgeons performed

all the surgical procedures at 2 hospitals, the randomiza-

tion needed to be stratified to prevent the possible intro-

duction of performance bias and co-intervention bias.

Finally, we included patients with small and medium-

sized rotator cuff tears, not large or massive cuff tears,

as delayed motion is usually recommended for these big

tears in most clinics.

In conclusion, we failed to show a difference in outcome

between the 2 treatment protocols. Early passive motion

exercise after arthroscopic repair of small to medium-

sized rotator cuff tears does not seem to guarantee the

early gain of shoulder ROM, pain relief, or functional

recovery and does not seem to negatively affect cuff heal-

ing in this prospective, randomized comparative study.

We believe that early passive motion exercise may not

be mandatory after arthroscopic repair of small to

medium-sized full-thickness rotator cuff tears, and post-

operative rehabilitation can be modified to ensure patient

compliance.

ACKNOWLEDGMENT

The authors thank Hye Ran Kim and Shang Mi Shim for

data collection.

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