These authors point out that stiffness and retear are 2 common complications of rotator cuff repair. They studied 69 patients with stiff and 63 with non stiff shoulders at least two years after arthroscopic rotator cuff repair. Assessment of stiffness was based on external rotation measurements at 6 weeks postoperatively.
There was no significant association of age, sex, side, tear size, tear type, number of anchors, or years since surgery with shoulder stiffness.
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The Relationship Between Shoulder Stiffness and Rotator Cuff Healing A Study of 1,533 Consecutive Arthroscopic Rotator Cuff Repairs
These authors reviewed 1,533 consecutive shoulders having an arthroscopic rotator cuff repair.
After rotator cuff repair, there was an overall significant loss of patient-ranked and examiner-assessed passive shoulder motion at 6 weeks compared with preoperative measurements (p < 0.0001), a partial recovery at 12 weeks, and a full recovery at 24 weeks.
These authors reviewed 25 patients who had rotator cuff repairs along with management of concomitant shoulder stiffness (manipulation without or with capsular release). These shoulders were different than a group of shoulders having cuff repair only:
The stiff patients tended to have smaller and partial thickness tears, to have diabetes and to have shorter symptom duration.
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For patients with postoperative stiffness at 6 weeks, the retear rate at 6 months was 3%,whereas the rate for nonstiff patients was 19%. This association persisted up to 9 years after surgery.
Postoperative stiffness resolved by 5 years after surgery for all motions except external rotation.
Postoperative stiffness resolved by 5 years after surgery for all motions except external rotation.
Patients with stiff shoulder had greater overall satisfaction at the final follow-up.
Comment: These results suggest that postoperative stiffness is associated with healing while postoperative flexibility is associated with reduced likelihood of healing. In this light, it would be of interest to learn whether preoperative stiffness is associated with an increased likelihood of healing
Comment: These results suggest that postoperative stiffness is associated with healing while postoperative flexibility is associated with reduced likelihood of healing. In this light, it would be of interest to learn whether preoperative stiffness is associated with an increased likelihood of healing
Here are some related thoughts
The Relationship Between Shoulder Stiffness and Rotator Cuff Healing A Study of 1,533 Consecutive Arthroscopic Rotator Cuff Repairs
These authors reviewed 1,533 consecutive shoulders having an arthroscopic rotator cuff repair.
Patients assessed their shoulder stiffness using a Likert scale preoperatively and at 1, 6, 12, and 24 weeks (6 months) postoperatively, and examiners evaluated passive range of motion preoperatively and at 6, 12, and 24 weeks postoperatively. Repair integrity was determined by ultrasound evaluation at 6 months.
Intraoperatively, 62% of the shoulders were noted to have a full-thickness tear and 38% had a partial-thickness tear, with amean tear-size area of 3.5 ± 1.4 cm2 (range, 0 to 64 cm2; Fig. 1). Of note is that most of these patients had partial or small full thickness tears.
An undersurface repair technique was used in 58% of the repairs, while 19%were bursal and 23% required both approaches.
After rotator cuff repair, there was an overall significant loss of patient-ranked and examiner-assessed passive shoulder motion at 6 weeks compared with preoperative measurements (p < 0.0001), a partial recovery at 12 weeks, and a full recovery at 24 weeks.
Shoulders that were stiff before surgery were more likely to be stiff at 6, 12, and, to a lesser extent, 24 weeks after surgery (r = 0.10 to 0.31; p < 0.0001).
A stiffer shoulder at 6 and 12 weeks (but not 24 weeks) postoperatively correlated with better rotator cuff integrity at 6 months postoperatively (r = 0.11 to 0.18; p < 0.001).
The retear rate of patients with ≤20° of external rotation at 6 weeks postoperatively was 7%, while the retear rate of patients with >20° of external rotation at 6 weeks was 15% (p < 0.001).
From these data one might deduce that patients with a stronger fibroblastic response to surgery are more likely to have stiffer and healed repairs in contrast with those with a weak fibroblastic response who tend on average to be less stiff and heal less well. An alternate deduction is that a cuff repair is, in effect, a capsulorrhaphy (i.e. a shoulder tightening operation) and that a re-tear releases the surgically created limitation to passive range of motion.
We were not provided data on the comfort and function of these shoulders before and after surgery, so are unable to determine the relationship of stiffness and healing to the clinical condition of the shoulder before or after surgery.
The effect of concomitant glenohumeral joint capsule release during rotator cuff repair-a comparative study.These authors reviewed 25 patients who had rotator cuff repairs along with management of concomitant shoulder stiffness (manipulation without or with capsular release). These shoulders were different than a group of shoulders having cuff repair only:
The stiff patients tended to have smaller and partial thickness tears, to have diabetes and to have shorter symptom duration.
The patients with cuff repair and concurrent management had results comparable to those of the patients without stiffness.
Stiffness can be a major part of the symptomatology of cuff pathology as shown in this article:
These authors used MRI to investigate the prevalence of rotator cuff lesions in a a series of 379 patients with stiff shoulders (excluding those with traumatic etiology, diabetes, or radiographic abnormalities).
Group 1 included 89 shoulders with severe and global loss of passive motion (≤100° of forward flexion, ≤10° of external rotation with the arm at the side, and internal rotation not more cephalad than the L5 level). 91% of these patients had an intact rotator cuff and 9% had a partial-thickness rotator cuff tear
Group 2 included 290 shoulders with severe but not global loss. 44% of these patients had intact cuffs, 17% had partial thickness tears and 39% had full thickness tears.
Group 3 included 179 shoulders with mild to moderate limitation. 35% of these had intact cuffs, 16% had partial thickness tears, and 50% had full thickness tears.
The results are easier to see in this chart we prepared from their data
The results are easier to see in this chart we prepared from their data
The take home message is that shoulders with cuff tears can have mild, moderate or severe stiffness. This stiffness may be as much a contribution to the patient's loss of comport and function as the tear itself. If a cuff repair is attempted on a stiff shoulder, there is a real risk that the stiffness will be exacerbated as a result of the surgical tightening and the post operative protection of the repair, unless it is addressed at the time of surgery.
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