'Better functional outcomes were noted in patients who had re-torn their cuffs' - how's that again?

The influence of intraoperative factors and postoperative rehabilitation compliance on the integrity of the rotator cuff after arthroscopic repair.

These authors sought to determine when cuff re-tear commonly occurs in the postoperative period and to investigate the clinical factors that might predispose to an early cuff re-tear. They reviewed 127 cases having arthroscopic repair for supraspinatus ± infraspinatus tears with serial ultrasound examinations at 6 weeks, 12 weeks, and 26 weeks postoperatively.

The mean age of patients was 60 years. The overall re-tear rate was 29.1%, most occurring in the first 12 weeks postoperatively (25.2%) but continuing into the second 12 weeks (3.9%).

The patient's postoperative compliance, primary tear size, tendon quality, repair tension, cuff retraction, and footprint coverage were significant prognostic factor for re-tearing. The patients were questioned by a nurse to determine their compliance with the postoperative rehabilitation protocol.

There was a significant association between the rate of cuff re-tears and patients’ compliance at each time period after surgery:

Poor compliance of patients was highest (17.3%) during the second 6 weeks postoperatively.

There was a trend of increasing percentage of cuff re-tear with increasing tear size, retraction, and repair tension. An increasing percentage of cuff re-tear was also noted with decreasing tendon quality and footprint coverage. However, in the  multinomial logistic regression analysis, only the postoperative compliance was significantly associated with the rate of retear.

In contrast to the patients with good compliance, the relative risk ratio of retear in poorly compliant patients was 152 times higher at 6 weeks, 7 times higher at 12 weeks, and 39 times higher at 26 weeks.

At 12 weeks the Oxford score demonstrated a statistically significant increase in the patients with re-tears than in those with intact cuffs. There were no other differences in functional outcome between the shoulders with intact or failed repairs.

The authors concluded that "Better functional outcomes were noted in patients who had re-torn their cuffs at the 12-week period (Oxford mean scores, P . 04)."  and "an early significant improvement of the clinical outcome should be a warning sign to a surgeon that the patient's compliance may be suboptimal, resulting in an increased risk of the cuff's re-tearing."

Comment: Their 29% retear rate is consistent with that in our recent review of the literature.
The fact that repairs are continuing to fail at 26 weeks after surgery brings into question the assumption made in an article on the economics of cuff repair that folks return to work 6 weeks after cuff repair.

While the focus of this article is on the relationship between compliance and cuff integrity, it seems that the real message is that there the clinical outcome as reflected by the Oxford Score is no better for intact than for retorn rotator cuff repairs. This makes us reflect on the clinical value of repair and of compliance with the postoperative rehabilitation program.

The improved clinical scores at 12 weeks in retorn repairs may be due to stress relaxation.

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Does it matter if the patient is compliant with restrictions after cuff repair?

Patient adherence with postoperative restrictions after rotator cuff repair

Many surgeons believe that the position and activity of shoulders needs to be restricted after cuff repair, perhaps for months after surgery. Abduction braces are used in the hope that the repair is protected from tension that may result in a retear. However, the amount of abduction necessary to unload the repair is substantial.

This study aimed to measure self-reported patient adherence to postoperative restrictions after rotator cuff repair, to evaluate correlations between adherence and functional outcome in 50 consecutive patients undergoing repair for rotator cuff tears. Patients were instructed to wear an abduction brace for 6 weeks after surgery.

Patient-reported adherence to the recommendation average 88% (range, 59.2-100). There were no significant correlations between adherence and improvement in American Shoulder and Elbow Surgeons, University of California–Los Angeles, or Simple Shoulder Test scores after rotator cuff repair. Of the patient demographics analyzed, only smoking status had a positive effect on adherence All other demographics, including hand dominance, mechanism of injury, repair complexity, comorbidities, living status, employment status, and age, had no significant effect on self-measured adherence to postoperative restrictions.

Unfortunately, the authors did not present data on the effect of adherence on the integrity of the repair at followup. 

This article needs to be compared to that discussed in a previous post that came to a somewhat different conclusion.

Comment: One of the major 'costs' of cuff repair surgery is the amount of time the shoulder is 'out of use' after surgery. If it is shown that abduction bracing after repair has no effect on either cuff integrity or shoulder function after repair, one must question whether it is reasonable to subject the patient to this major inconvenience. There are other questions evident from the picture below.

How does one get the brace on and off to bathe or dress without loading the cuff? To what degree does the patient actively abduct the shoulder to move the brace around?

Our thought is that if abduction is required to help close a gap in the cuff, the chances of failure are increased and it is unlikely that abduction will matter. The evidence of the benefit of abduction bracing appears inconclusive.

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Click here to see the new Rotator Cuff Book

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Rotator cuff repair - workers' compensation

Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims.

This study prospectively evaluated compliance and outcomes after rotator cuff repair in 42 consecutive patients with Workers' Compensation claims and 50 consecutive patients without a Workers' Compensation claim who underwent arthroscopic rotator cuff repair (transosseous equivalent suture bridge or margin convergence). There were important differences between the WC and non WC groups with respect to female gender (19% vs 38%), smoking (60% vs 24%) and age (51 vs 63 years). Tear size was similar for the two groups: 32% small, 39% medium, 25% large, and 4% massive.

Post operative rehab prescribed included sling + pendulum X 6 weeks. Compliance was documented in terms of sling wear and attendance at post operative PT appointments. Noncompliance with protocol was documented in 52% in the Work Comp group compared with 4% in the non-Work Comp group (P < .001). The Work Comp group had less improvement in preoperative to postoperative outcome scores for the Simple Shoulder Test (SST) score (3.9 to 6.0) compared with the non-Work Comp group 4.3 to 10.7.  The compliant Work Comp patients had more favorable results in final SST, 7.9  than noncompliant Work Comp patients SST.

Postoperative ultrasounds showed 84% of the non Work Comp group had intact cuffs in comparison to 75% of the compliant Work Comp and 59% of the non compliant Work Comp group.

The authors did not perform a multivariate analysis to explore the relationship between age, smoking, tear size, tendon retraction, repair method, compliance, Work Comp status, and gender with retears or the relationship between age, smoking, tear size, tendon retraction, repair method, compliance, Work Comp status, gender, and post operative cuff integrity with the functional outcome. Such analyses would be helpful in determining the most important predictors of the results of cuff repair surgery.

Some other studies of 'what matters' in cuff repair are highlighted here.

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Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims. JSES

Rotator cuff failure - check out this link
Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims. JSES

This important study drives home the lesson that important determinants of the outcome of treatment are related to the patient and not to the shoulder (again Osler: it is more important to know what patient the disease has than to know what disease the patient has).  In this study the authors found that individuals having Workman's Compensation Claims are less likely to be compliant with the postoperative protocol for shoulder immobilization and physical therapy than patients without such claims. Furthermore, at a minimum of 12 months after surgery the Simple Shoulder Test scores after treatment were higher for the non-WC group (10.7) than for the WC group (6.0). Among the WC group, compliant patients had higher SSTs (7.9) than non compliant patients (4.3). 

Ultrasound examination of the cuff one year after surgery showed that 28 of 42 patients (66%) in the Work Comp group had an intact and healed repair compared with 42 of 50 patients (84%) in the non-Work Comp group. 75% of compliant WC patients had intact cuffs in comparison to 59% of the non-compliant WC patients.


We previously asked the question, "Do shoulder patients insured by workers' compensation present with worse self-assessed function and health status?" We found that patients covered by worker's compensation had lower SST scores and lower SF 36 scores than similar non WC patients. Other studies have shown that patients with workers' compensation claims have worse outcomes after rotator cuff repair.

The study reported here suggests that, in this population, a primary determinant of the structural and functional results after cuff repair was patient compliance - a feature found more commonly in non-WC patients.

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