Measures of Adult Shoulder Function

Constant-Murley score categorization to assess outcomes after reverse shoulder arthroplasty following complex proximal humeral fracture

BACKGROUND

The Constant-Murley (CM) score is considered the gold standard of shoulder scoring systems. However, it does not include scoring categorization, and in some acute traumatic processes, a paired comparative analysis is not feasible. The purpose of this study was to determine cutoff values for the CM score that indicate a specific category on the outcome score following reverse total shoulder arthroplasty (rTSA) for fracture.

METHODS

Consecutive patients with complex proximal humeral fracture who underwent rTSA from 2010 to 2022, were included in the study. Two years of postoperative follow-up was required. Postoperative clinical evaluations were conducted using the CM and University of California, Los Angeles (UCLA) scores. The correlation between CM and UCLA scores was analyzed. Then, the receiver-operating characteristic (ROC) curve was utilized to determine the cutoff points in CM scores that most effectively distinguished between categories. The UCLA categories were used as the external criterion.

RESULTS

132 patients completed the evaluations at the 2-year follow-up. Among them, 112 (84.8 %) were females and 20 (15.2 %) were males, with a mean age of 73.5 years. The UCLA score showed a strong correlation with the CM score (r = 0.936; 95% CI 0.911-0.954; p = 0.000). For the CM score, the cutoff for an excellent outcome was 67.5 (AUC 0.963, 95% CI 0.925-1.000), 56.5 (AUC 0.920, 95% CI 0.872-0.969) for good, 41.5 (AUC 0.701, 95% CI 0.617-0.784) for fair, and <41.5 (AUC 0.965, 95% CI 0.939-0.990) for poor.

DISCUSSION

According to the cut-off values in the CM score used to categorize the outcomes after rTSA in proximal humeral fractures, an excellent outcome was considered a score equal to or greater than 68, good between 57 and 67 points, fair between 41 and 56 points, and a poor outcome with a score equal to or less than 40 points.

LEVEL OF EVIDENCE

III.

Comparison of the clinical outcomes and radiological parameters between the greater tuberosity strengthened proximal humeral plate and the proximal humeral internal locking system plate in the minimally invasive plate osteosynthesis treatment of proximal humeral fractures involving the greater tuberosity: a retrospective cohort study

BACKGROUND

With the gradual promotion of minimally invasive plate osteosynthesis (MIPO) in the treatment of proximal humeral fractures, some patients using the proximal humeral internal locking system (PHILOS) plate experience significant displacement of the fixed greater tuberosity. However, this is rarely seen in patients using a new plate named the greater tuberosity strengthened proximal humeral plate (GTSPHP). Notably, a comparison of these two plates is lacking. Therefore, we aimed to retrospectively compare the clinical outcomes and radiological parameters of MIPO using the GTSPHP and PHILOS plates.

METHODS

The data of 40 patients with proximal humeral fractures involving the greater tuberosity who underwent MIPO performed by the same physician between 1 April 2019 and 31 December 2022 were retrospectively analysed. Sixteen and 24 patients were included in the GTSPHP and PHILOS plate groups, respectively and followed up for at least 1 year postoperatively. General clinical characteristics, perioperative data, postoperative follow-up clinical outcomes, complications, and reduction loss of the greater tuberosity were compared between the two groups.

RESULTS

No significant differences were found in age, sex, affected side, injury mechanism, fracture type, injury to surgery time, operative time, postoperative hospital stay, the shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) score, and Constant score between the two groups. However, the GTSPHP group was superior to the PHILOS plate group regarding surgical incision length, intraoperative blood loss, and the 11-point numerical rating scale score on the first, second and third postoperative days. In the PHILOS plate group, three patients had fracture malunion; both groups showed no signs of incision infection, fracture non-union, screw cut-out, or subacromial impingement syndrome. Both groups showed no significant differences in complication rates. The risk of reduction loss of greater tuberosity was lower in the GTSPHP group than in the PHILOS plate group.

CONCLUSIONS

Our study showed that in MIPO treatment of proximal humeral fractures involving the greater tuberosity, the GTSPHP outperformed the PHILOS plate in terms of intraoperative blood loss, surgical incision length, short-term postoperative pain, and fixation capability of the greater tuberosity. However, further research is needed to confirm these findings.

CLINICAL TRIAL NUMBER

Not applicable.

Releasing Forces in Adhesive Capsulitis Are Imporant Indicators of Shoulder Stiffness and Postoperative Function

BACKGROUND

Manipulation under anesthesia is a widely used treatment for frozen shoulder, but the factors that influence patient outcomes after manipulation remain unclear. The degree of shoulder stiffness, a critical feature of frozen shoulder, likely reflects the severity of the condition but currently lacks standardized, objective assessment methods.

QUESTIONS/PURPOSES

(1) What are the releasing forces in patients with frozen shoulder, and do the forces vary across different stages of frozen shoulder? (2) Are there differences in postoperative outcomes of manipulation under anesthesia among patients with frozen shoulder at different stages of the condition? (3) Is a higher releasing force associated with poorer outcomes of manipulation, and what threshold of releasing force is optimal for better outcomes? (4) What clinical factors influence the magnitude of releasing forces?

METHODS

This prospective cohort study included patients with primary unilateral frozen shoulder who underwent manipulation under anesthesia after at least 3 months of unsuccessful nonsurgical treatment, which was defined as progressive worsening ROM, failure to make progress, or residual functional impairment after 3 months of treatment. Between December 1, 2022, and December 31, 2023, we treated 280 patients with unilateral frozen shoulder, all of whom were considered potentially eligible for this study. The inclusion criteria were: a reduction of passive external rotation in the affected shoulder to less than 50% compared with the contralateral side, at least 3 months of unsuccessful nonsurgical treatment, absence of shoulder trauma, radiographs and MRI showing no other pathologic lesions in the shoulder, and no prior medical history in the contralateral shoulder. The exclusion criteria were patients who had previously undergone shoulder surgery, those who had bilateral frozen shoulder, patients with anesthesia intolerance, and those with incomplete preoperative assessments. One hundred fifty-six patients were enrolled in follow-up assessments at 1, 3, and 6 months after manipulation. The mean ± SD age for enrolled patients was 54 ± 8 years, 35% (55 of 156) of all participants were male, and the mean BMI was 23 ± 3 kg/m2. Two percent (3 of 156) withdrew consent, and 4% (7 of 156) were lost to follow-up, leaving 94% (146 of 156) for analysis. The contralateral unaffected shoulder was used as a self-control. During the manipulation process, the force-time curves for the affected and unaffected shoulders were sequentially recorded using a handheld dynamometer, following the order of forward flexion, external rotation, and internal rotation. Two key force values, an initial tear value and a peak value, were extracted from the curve for the affected shoulder, while only the peak value was recorded for the unaffected shoulder. Passive ROM, the Oxford shoulder score (OSS), and the VAS were evaluated at the baseline and at 1, 3, and 6 months postoperatively. Patients were categorized into four stages according to the patient-reported duration of pain: Stage 1 (0 to 3 months), Stage 2 (3 to 9 months), Stage 3 (9 to 15 months), and Stage 4 (> 15 months). To address our first and second questions, we used ANOVA for multistage comparisons of continuous variables, followed by a post hoc Tukey test for pairwise comparisons. For the third question, we performed univariate regression to analyze the correlation between factors like age, sex, symptom duration, frozen shoulder stage, preoperative ROM, upper arm circumference, fat-free mass, diabetes, thyroid disease, hyperlipidemia, tear value, peak value, and 6-month postoperative ROM, VAS, and the OSS. Factors with p < 0.05 were included in a multivariate regression. A tear value threshold of poor ROM outcomes was evaluated with a receiver operating characteristic (ROC) curve and the Youden index. For the fourth question, we used similar regression models to examine potential factors associated with the releasing force, focusing on both tear and peak values. Pairwise comparisons in this subgroup analysis were performed using the Student t-test. All p values less than 0.05 were considered significant.

RESULTS

Tear values of each stage were as follows: 25 ± 13 N in Stage 2, 28 ± 15 N in Stage 3, and 38 ± 18 N in Stage 4. The tear value for patients in Stage 4 was higher compared with both Stage 2 and Stage 3 (Stage 4 versus Stage 2, mean difference 13 [95% CI 6 to 20]; p < 0.001; Stage 4 versus Stage 3, mean difference 10 [95% CI 2 to 19]; p = 0.01). Patients in Stage 4 exhibited an increased peak value relative to the other two stages (Stage 4 versus Stage 2, mean difference 11 [95% CI 2 to 20]; p = 0.02; Stage 4 versus Stage 3, mean difference 8 [95% CI 0 to 16]; p = 0.04). The peak value in the affected shoulder was higher than that in the unaffected (mean difference 40 [95% CI 36 to 44] in forward flexion; p < 0.001). At the 6-month endpoint after manipulation, patients in Stage 2 and 3 showed greater ROM in forward flexion than those in Stage 4 (Stage 2 versus Stage 4, mean difference 12 [95% CI 9 to 14]; p < 0.001; Stage 3 versus Stage 4, mean difference 14 [95% CI 11 to 17]; p < 0.001) and a lower OSS than those in Stage 4 (Stage 2 versus Stage 4, mean difference -8 [95% CI -9 to -7]; p < 0.001; Stage 3 versus Stage 4, mean difference -7 [95% CI -8 to -6]; p < 0.001). Two factors were associated with the OSS at the 6-month endpoint: increased tear value (β = 0.47; p = 0.004) and diabetes (β = 0.28; p = 0.02). The optimal thresholds for predicting a forward flexion at least 164° at 6 months was a tear value of 53 N (area under curve [AUC] 0.79 [95% CI 0.68 to 0.91]). Patients with a tear value of below 53 N demonstrated better postoperative ROM (mean difference 10 [95% CI 3 to 16]; p = 0.004) and OSS (mean difference -4 [95% CI -8 to 0]; p = 0.04). The tear value was associated with male sex (β = 0.36; p = 0.03) and ROM in flexion (β = 0.20; p = 0.049), whereas peak value was associated with male sex (β = 0.45; p = 0.001) and diabetes (β = 0.16; p = 0.048).

CONCLUSION

These findings suggest that performing manipulation before reaching Stage 4 may result in more favorable outcomes for patients, and evaluating shoulder stiffness by measuring releasing force proved to be feasible.

LEVEL OF EVIDENCE

Level II, prognostic study.

Ultrasound-guided vs. non-guided trigger finger release: a systematic review and meta-analysis

PURPOSE

Trigger finger (TF) is a common hand condition that can be treated with surgery. We conducted a systematic review and meta-analysis to assess whether ultrasound-guided (US-guided) percutaneous surgery is superior to other conventional surgical methods.

METHODS

We conducted a comprehensive search in Medline, Embase, and the Cochrane Library to identify relevant studies. We included randomized clinical trials (RCTs) and observational studies comparing US-guided TF release with blind percutaneous or open approaches. We combined Risk Ratios (RR) and Mean Differences (MD) with 95% Confidence Intervals (CI) across studies. Data processing and analysis were conducted using R software, version 4.3.1.

RESULTS

Our analysis included eight RCTs and two observational studies with 555 patients. US-guided surgery significantly reduced postoperative DASH scores (MD -3.75 points; 95% CI = -7.48, -0.02; p < 0.01), shortened time to resume activities (MD -11.52 days; 95% CI = -16.13, -6.91; p < 0.01), hastened discontinuation of oral analgesics (MD -4.44 days; 95% CI = -8.01, -0.87; p < 0.01), and improved patient satisfaction scores (RR 1.13; 95% CI = 1.04, 1.23; p = 0.75). There were no significant differences in VAS scores, time to movement recovery, or surgical success rate.

CONCLUSION

Ultrasound-guided percutaneous release is a safe, effective, and superior alternative for treating TF compared to other methods, leading to improved DASH scores, quicker recovery, faster cessation of oral analgesics, and enhanced patient satisfaction.

Measurement Properties of the Oxford Shoulder Score and Minimal Clinically Important Changes After Primary Total Shoulder Replacement Surgery

OBJECTIVE

We evaluated the measurement properties of the Oxford Shoulder Score (OSS) and estimated the minimal clinically important change (MCIC) in patients undergoing primary total shoulder replacement in Australia.

METHODS

Deidentified data from the Australian Orthopaedic Association National Joint Replacement Registry were used for this analysis. Pre- and 6-month postoperative OSS scores were used, with the 5-level EuroQoL quality of life instrument and shoulder pain scores used as comparators. Floor and ceiling effects, internal consistency reliability, construct validity, and responsiveness to change were evaluated using standard psychometric methods. Mean change and predictive modeling approaches (with and without adjustment for the proportion of improved patients) were used to calculate MCIC thresholds, with patient-perceived improvement after surgery as the anchor.

RESULTS

Preoperative OSS data were available for 1,117 patients (59% female; 90% aged ≥60 years) undergoing primary total shoulder replacement. No floor or ceiling effects were observed pre- or postoperatively. The OSS showed high internal consistency reliability (Cronbach alpha >0.89), good construct validity, and high responsiveness to change (effect size 1.88). The MCIC derived from the mean change method was 6.50 points (95% confidence interval [95% CI] 4.41-8.61). The predictive modeling approach produced an MCIC estimate of 8.42 points (95% CI 5.68-12.23) after adjustment.

CONCLUSION

The OSS has good measurement properties to capture pain and function outcomes after shoulder replacement procedures and is highly responsive to change. Based on robust methods, an increase in OSS scores of at least eight points can be considered as meaningful improvement after surgery from the patient's perspective.

Clinical and cost-effectiveness of individualised (early) patient-directed rehabilitation versus standard rehabilitation after surgical repair of the rotator cuff of the shoulder: protocol for a multicentre, randomised controlled trial with integrated Quintet Recruitment Intervention (RaCeR 2)

INTRODUCTION

Despite the high number of operations and surgical advancement, rehabilitation after rotator cuff repair has not progressed for over 20 years. The traditional cautious approach might be contributing to suboptimal outcomes. Our aim is to assess whether individualised (early) patient-directed rehabilitation results in less shoulder pain and disability at 12 weeks after surgical repair of full-thickness tears of the rotator cuff compared with current standard (delayed) rehabilitation.

METHODS AND ANALYSIS

The rehabilitation after rotator cuff repair (RaCeR 2) study is a pragmatic multicentre, open-label, randomised controlled trial with internal pilot phase. It has a parallel group design with 1:1 allocation ratio, full health economic evaluation and quintet recruitment intervention. Adults awaiting arthroscopic surgical repair of a full-thickness tear are eligible to participate. On completion of surgery, 638 participants will be randomised. The intervention (individualised early patient-directed rehabilitation) includes advice to the patient to remove their sling as soon as they feel able, gradually begin using their arm as they feel able and a specific exercise programme. Sling removal and movement is progressed by the patient over time according to agreed goals and within their own pain and tolerance. The comparator (standard rehabilitation) includes advice to the patient to wear the sling for at least 4 weeks and only to remove while eating, washing, dressing or performing specific exercises. Progression is according to specific timeframes rather than as the patient feels able. The primary outcome measure is the Shoulder Pain and Disability Index total score at 12-week postrandomisation. The trial timeline is 56 months in total, from September 2022.

TRIAL REGISTRATION NUMBER

ISRCTN11499185.

Effect of extracorporeal shock wave combined with Kinesio taping on upper limb function during individuals with biceps brachii tendinopathy：protocol for a double-blind, randomised controlled trial

INTRODUCTION

Long head of biceps brachii tendinopathy (LHBT) is characterised by persistent pain and disability of shoulder joint, impairing patients' quality of life. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment, which promotes tissue regeneration and repair. However, ESWT has a side effect that often causes short-term pain and swelling in the treatment area. It is known that the effects of Kinesio taping (KT) on relieving swelling and pain. Due to insufficient clinical evidence from current limited studies, this randomised controlled study aims to explore the effects of ESWT combined with KT on upper limb function during individuals with LHBT.

METHODS AND ANALYSIS

A 2×2 factorial design, double-blind, randomised controlled trial will be conducted. A total of 144 participants will be randomly allocated into one of four groups (KT+ESWT, KT+sham ESWT, sham KT+ESWT or sham KT+sham ESWT) to participate in a 4-week treatment programme. Measurements will be taken at pretreatment (baseline), immediately after treatment and 6 weeks after treatment. The primary endpoint will be the Constant-Murley score (CMS), the secondary endpoints will include the pain Numerical Rating Scale, range of motion, pressure pain threshold and soft tissue hardness of biceps, speed test and global rating of change. Repeated measures analysis of variance will be used to compare differences among the effects of different interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. In addition to international conference reports, findings will be disseminated through international publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100051324.

Long-term conservative treatment outcomes for midshaft clavicle fractures: a 10-to-30-year follow-up

BACKGROUND

Few reports exist on the long-term outcomes of midshaft clavicle fracture conservative treatments. Therefore, this study investigated the long-term outcome of this treatment in patients with midshaft clavicle fractures.

METHODS

Patients were treated conservatively for midshaft clavicle fractures with a figure-of-eight bandage between 10 and 30 years ago. Subsequently, a telephone survey was used to follow-up these patients, and 38 were successfully evaluated. The mean term after trauma was 17.0 years. Afterward, the American Shoulder and Elbow Surgeons Shoulder (ASES) score and Shoulder pain and disability index (SPADI) on the affected and unaffected sides were calculated based on the filled questionnaires. We defined patients whose ASES and SPADI on the affected side were worse than the unaffected side as the symptomatic group. Furthermore, plain radiographs measured proportional changes in clavicular length and displacement.

RESULTS

The ASES scores of the affected side were significantly lower than those of the unaffected side, and the SPADI of the affected side was significantly higher than that of the unaffected side. Furthermore, the symptomatic group's proportional changes in clavicular length and displacement were significantly larger than the asymptomatic group.

CONCLUSION

The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. Moreover, several patients became symptomatic for fractures with a larger proportional change in clavicular length or displacement.

Treatment of proximal humeral fractures accompanied by medial calcar fractures using fibular autografts: A retrospective, comparative cohort study

BACKGROUND

Severe proximal humerus comminuted fractures are often accompanied by medial calcar comminuted fractures and loss of medial support, which are important factors that lead to internal fixation failure. The appropriate treatment for proximal humerus comminuted fractures has not been established. Therefore, this study assessed the outcomes of using a fibular autograft with locking plates to treat severe proximal humerus comminuted fractures.

AIM

To investigate the outcomes of using a fibular autograft with locking plates to treat severe proximal humerus comminuted fractures.

METHODS

This retrospective, comparative cohort study included two groups of patients. Group 1 comprised 22 patients and group 2 comprised 25 patients with complete follow-up data. Group 1 was treated with a fibular autograft with open reduction and locking plates to enable internal fixation. Group 2 was treated with open reduction and locking plates to enable internal fixation. The intraoperative blood loss volume from the shoulder wound, operative time, shoulder wound pain, bone fracture healing time, Constant-Murley score of the shoulder joint, preoperative Holden walking function score, Mallet score of the shoulder joint, and humeral neck-shaft angle during surgery of the two groups were compared, and the differences were analysed using an independent sample t-test.

RESULTS

Group 1 had a shorter mean operative time than group 2 (2.25 ± 0.30 h vs 2.76 ± 0.44 h; P = 0.000). Group 1 had a lower shoulder wound pain score on the first day after surgery than group 2 (7.91 ± 1.15 points vs 8.56 ± 1.00 points; P = 0.044). Group 1 had a shorter fracture healing time than group 2 (2.68 ± 0.48 mo vs 3.64 ± 0.64 mo; P = 0.000). Group 1 had higher Constant-Murley scores of the shoulder joint at 3, 6, and 12 mo after surgery than group 2 (76.64 ± 4.02 points vs 72.72 ± 3.02 points, 86.36 ± 3.53 points vs 82.96 ± 3.40 points, and 87.95 ± 2.77 points vs 84.68 ± 2.63 points, respectively; P = 0.000, 0.002, and 0.000, respectively). Group 1 had higher Mallet scores of the shoulder joint at 3, 6, and 12 mo after surgery than group 2 (10.32 ± 0.57 points vs 9.96 ± 0.54 points, 13.36 ± 1.00 points vs 12.60 ± 0.87 points, and 13.91 ± 0.75 points vs 13.36 ± 0.70 points, respectively; P = 0.032, 0.007, and 0.013, respectively).

CONCLUSION

Using locking plates with a fibular autograft can recreate medial support, facilitate fracture healing, and improve shoulder function; therefore, this may be an effective treatment option for severe proximal humerus comminuted fractures.

Cross-cultural adaptation and measurement properties of the Malay Shoulder Pain and Disability Index

Objective

The purpose of this study is to cross-culturally adapt the Shoulder Pain and Disability Index from English to Malay, and to evaluate the measurement properties of the Malay version among Malay speakers with shoulder pain.

Methods

Cross-cultural adaptation of the Malay version of Shoulder Pain and Disability Index (M-SPADI) was conducted according to international guidelines. 260 participants (Shoulder pain = 130, No shoulder pain = 130) completed the M-SPADI, the Numerical Rating Scale (NRS), and measurement of shoulder active range of motion (AROM). 54 participants repeated M-SPADI within a mean of 9.2 days.

Results

Cross-cultural adaptation of M-SPADI had no major issues. The M-SPADI had good face validity; item and scale content validity indexes (I-CVI, S-CVI) were >0.79 except for Disability Item 3 (I-CVI = 0.75), and exploratory factor analysis showed that M-SPADI had a bidimensional structure. There was a strong positive correlation between M-SPADI and NRS (rPain = 0.845, rDisability = 0.722, rTotal = 0.795, p <0.001) and a negative correlation between M-SPADI and shoulder AROM with the following correlation ranges (rPain = -0.316 to -0.637, rDisability = -0.419 to -0.708, rTotal = -0404 to -0.697, p<0.001). M-SPADI’s total score was higher in participants with shoulder pain (Mdn: 33.8, IQR = 37.3) compared to no shoulder pain (Mdn:0, IQR = 0.8) and the difference was statistically significant (U = 238.5, z = -13.89, p<0.001). M-SPADI had no floor or ceiling effects (floor/ceiling <15%), high internal consistency (Cronbach’s αPain = 0.914, Cronbach’s αDisability = 0.945) and good to excellent test-retest reliability (ICCPain = 0.922, ICCDisability = 0.859, ICCTotal = 0.895).

Conclusion

M-SPADI has a bi-dimensional structure with no floor or ceiling effects, established face, content and construct validity, internal consistency, and test-retest reliability. M-SPADI is a reliable and valid tool for assessing Malay-speaking individuals with shoulder pain in clinical and research settings.

A comparison between measurement properties of four shoulder-related outcome measures in Nepalese patients with shoulder pain

Purpose

The Patient-Specific Functional Scale (PSFS), Disability of the Arm, Shoulder and Hand (DASH), Quick-DASH, and Shoulder Pain and Disability Index (SPADI) are frequently used instruments in shoulder functional assessment. They are available in Nepali and all but the PSFS has been validated for shoulder assessment. Therefore, the aim of this study was to validate the Nepali PSFS in shoulder pain patients and to compare validity, reliability, and responsiveness of all four instruments to provide a recommendation for their use.

Method

Patients attending physiotherapy completed the Nepali PSFS at baseline and follow-up (1–3 weeks). It was tested for reliability using internal consistency (Cronbach’s α), intraclass correlation coefficient (ICC), construct validity by hypothesis testing and responsiveness by anchor-based method using Area Under the Curve (AUC). The instruments were compared based on reported measurement properties and patients’ preference.

Results

156 patients enrolled at baseline and 121 at follow-up. The PSFS showed sufficient reliability (α = 0.70, ICC = 0.82), construct validity (all three hypotheses met) and responsiveness (AUC = 0.83). Measurement property comparison demonstrated adequate reliability and validity, while PSFS was the most responsive instrument. Patients favoured the verbal rating scale of the DASH/Quick-DASH. The DASH had a lower completion rate for ‘culturally sensitive’ and ‘uncommon’ activities.

Conclusion

The Nepali PSFS is a reliable, valid, and responsive instrument in shoulder functional assessment. The combined use of the Quick-DASH or SPADI with the PSFS is recommended for a comprehensive assessment of Nepali shoulder pain patients in clinical and research settings. They are shorter, more appropriate to the Nepali context and provide balanced self-evaluation.

Effectiveness of early versus delayed rehabilitation following rotator cuff repair: Systematic review and meta-analyses

Objective

To investigate the effectiveness of early rehabilitation compared with delayed/standard rehabilitation after rotator cuff repair for pain, function, range of movement, strength, and repair integrity.

Design

Systematic review and meta-analyses.

Methods

We searched databases and included randomised controlled trials (RCTs) comparing early with delayed/standard rehabilitation for patients undergoing rotator cuff repair surgery. We assessed risk of bias of the RCTs using the Cochrane RoB 2 tool.

Results

Twenty RCTs, with 1841 patients, were included. The majority of the RCTs were of high or unclear risk of overall bias. We found substantial variations in the rehabilitation programmes, time in the sling and timing of exercise progression. We found no statistically significant differences for pain and function at any follow-up except for the outcome measure Single Assessment Numeric Evaluation at six months (MD: 6.54; 95%CI: 2.24–10.84) in favour of early rehabilitation. We found statistically significant differences in favour of early rehabilitation for shoulder flexion at six weeks (MD: 7.36; 95%CI: 2.66–12.06), three (MD: 8.45; 95%CI: 3.43–13.47) and six months (MD: 3.57; 95%CI: 0.81–6.32) and one year (MD: 1.42; 95%CI: 0.21–2.64) and similar differences for other planes of movement. In terms of repair integrity, early mobilisation does not seem to increase the risk of re-tears (OR:1.05; 95%CI: 0.64–1.75).

Discussion

Current approaches to early mobilisation, based largely on early introduction of passive movement, did not demonstrate significant differences in most clinical outcomes, although we found statistically significant differences in favour of early rehabilitation for range of movement. Importantly, there were no differences in repair integrity between early and delayed/standard rehabilitation. Most rehabilitation programmes did not consider early active movement as soon as the patient feels able. With ongoing variation in rehabilitation protocols there remains a need for large high quality RCT to inform the optimal approach to rehabilitation after rotator cuff repair surgery.