Tuesday, July 17, 2012

Rehabilitation following rotator cuff surgery

Rehabilitation Following Rotator Cuff Surgery Requires Change is the title of a release in Medical News Today.

The study, actually is a study of tendon-bone repair in the rat knee from which there has been an extrapolation to the treatment of the human rotator cuff.

The authors point out the dilemma surgeons face after rotator cuff repair surgery: immobilize to optimize healing or move to reduce the risk of stiffness. In the lab they cut and repaired the patellar tendon and then compared a low load motion program, a moderate load motion program and an immobilization program for up to four weeks after the repair. 

The tendon repairs that had been immobilized had stronger appearing bone at the repair site, stronger healing on load to failure tests and better looking histology in terms of tendon structure.  They suggest that immobilization may minimize inflammation which may favor the formation of scar tissue rather than healing at the repair site. 

There surely have been many studies showing that surgeons' attempts to re-establish rotator cuff integrity often fail. See our posts from October 2, 2011, April 1, 2012,  April 19, 2012, and June 4, 2012 as well as the classic article by Harryman.

In spite of all the recent work that has been done regarding special techniques in open and arthroscopic repair, the failure rate remains high, perhaps, as the authors of this article suggest, surgeons are trying to rehabilitate the shoulder too fast. Perhaps even more importantly, many torn rotator cuffs simply have insufficient quality and quantity to enable a durable repair. Some simple clinical observations seem to be predictive of repairability as we provided in the August 29, 2011 post.

For this reason, we emphasize to patients that repair is worth the prolonged rehabilitation period (even longer if we follow the recommendations of these authors) only if good quality tissue can be securely reattached to the anatomical insertion site without undue tension. Otherwise the patient may prosper more with a smooth and move procedure. Our approach is shown here.

An example of restoring comfort and function without attempting to re-establish cuff integrity is shown in the July 15, 2012 post.


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