Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis

Quinn A. Stillson, BS; John Q. Sun, BS; Michael Maninang, PT; Nicholas H. Maassen, MD; Jason A. Strelzow, MD; Lewis L. Shi, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(3):e444-e452.

Abstract and Introduction

Abstract

Introduction: One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR.

Methods: Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate.

Results: The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P= <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086,

Abstract and Introduction
Methods
Results
Discussion
Conclusion
References

Table 1. Demographics and Comorbidities of Study Cohort (Patients Receiving PT Within 13 Week After RCR
Demographics/Comorbidities	Patients (n = 64,842)
Diabetes	49.6% (32,178)
Tobacco use	43.7% (28,334)
Obesity	30.1% (19,496)
Rheumatoid arthritis	7.6% (4,944)
Coronary artery disease	40.7% (26,429)
Hypertension	85.5% (55,422)
Female sex	52.1% (33,772)
Younger than 64 yr	18.8% (12,158)
65–69 yr	34.9% (22,612)
70–74 yr	25.2% (16,334)
75–79 yr	14.5% (9,390)
80–84 yr	5.5% (3,532)
Older than 85 yr	1.3% (816)

PT = physical therapy; RCR = rotator cuff repair
Percentage of patients with history of diabetes, tobacco use, obesity, osteoarthritis, rheumatoid arthritis, coronary artery disease, hypertension, and female gender. Percentage of patients in varying age ranges at the time of their initial RCR was also reported.

Table 2. 1-Year Revision and Revision Surgery Rates Associated With Timing of First PT Session After Arthroscopic RCR (CPT-29827; n = 42,971)
Timing of First PT Session	No. of Arthroscopic RCR Patientsn = 42,971	Revision Rate	P Value	Revision Surgery Rate	P Value
≤ 1 wk	3,730 (8.7%)	4.6%	<0.001	5.8%	<0.001
2–5 wk	21,264 (49.5%)	2.7%	0.119	3.6%	0.119
6–9 wk	13,557 (31.5%)	2.5%	0.027	3.4%	0.026
10–13 wk	4,420 (10.3%)	2.8%	0.462	3.7%	0.473

PT = physical therapy, RCR = rotator cuff repair
First PT session defined as the time until a CPT-97001, 97110, or 97140 is coded for after a patients' first RCR. Revision is defined as a subsequent, ipsilateral RCR (CPT-23410, 23412, 23420, 24341, 29827). Reoperation is defined as any subsequent, ipsilateral shoulder surgery (See Appendix, http://links.lww.com/JAAOS/A745 for CPT codes defining shoulder surgeries)

Table 3. 1-Year Revision and Revision Surgery Rates Associated With Timing of First PT Session After Open RCR (n = 21,871; CPT-23410, 23412, 23420, and 24341)
Timing of First PT Session	No. of Open RCR Patientsn = 21,871	Revision Rate	P Value	Revision Surgery Rate	P Value
≤1 wk	1,590 (7.3%)	8.1%	<0.001	9.3%	<0.001
2–5 wk	10,774 (49.3%)	3.1%	0.052	4.0%	0.094
6–9 wk	7,286 (33.3%)	3.0%	0.029	3.8%	0.026
10–13 wk	2,221 (10.2%)	2.7%	0.050	3.4%	0.030

Table 4. Univariate Analysis of Timing of First PT Session, Open versus Arthroscopic RCR, Demographic, and Comorbidity Groups, for Number of Patients With Reoperations 1 Year After Initial RCR
Variables	Revision Surgery Rate	P Value
First PT session <1 wk after RCR (5,320)	6.9%	<0.001
First PT session 1–13 wk after RCR (59,522)	3.6%
Open RCR (21,871)	4.2%	<0.001
Arthroscopic RCR (42,971)	3.7%
Diabetes (32,178)	4.5%	<0.001
No diabetes (32,664)	3.4%
Tobacco use (28,334)	4.6%	<0.001
No tobacco use (36,508)	3.4%
Obesity (19,496)	4.9%	<0.001
No obesity (45,346)	3.5%
Rheumatoid arthritis (4,944)	5.0%	<0.001
No rheumatoid arthritis (59,898)	3.8%
Coronary artery disease (26,429)	4.4%	<0.001
No coronary artery disease (38,413)	3.6%
Hypertension (55,422)	4.0%	0.005
No hypertension (9,420)	3.3%
Female sex (33,772)	4.1%	0.001
Male sex (31,070)	3.6%
Younger than 64 yr (12,158)	5.9%	<0.001
Older than 64 yr (52,864)	3.4%

PT = physical therapy, RCR = rotator cuff repair
Reoperation is defined as any subsequent, ipsilateral shoulder surgery (See Appendix, http://links.lww.com/JAAOS/A745 for CPT codes defining shoulder surgeries). Bolded values signify statistical significance.

Table 5. Multivariate Analysis of 1-Year Revision Surgery Rate Including Variables That Demonstrated a Notable ( P < 0.05) Effect on 1-Year RCR Revision Surgery Rate in the Univariate Analysis First PT Session Within 1 Week After Initial RCR, Open RCR, Diabetes, Tobacco Use, Obesity, Rheumatoid Arthritis, Coronary Artery Disease, Hypertension, Female Sex, and Age younger Than 64 Years.
Variables	OR (95% CI)	P Value
First PT session <1 wk after RCR	2.086 (1.857–2.337)	<0.001
Open RCR	1.497 (1.381–1.624)	<0.001
Diabetes	1.195 (1.097–1.303)	<0.001
Tobacco use	1.250 (1.149–1.359)	<0.001
Obesity	1.181 (1.081–1.291)	<0.001
Rheumatoid arthritis	1.144 (0.994–1.311)	0.057
Coronary artery disease	1.160 (1.064–1.264)	<0.001
Hypertension	1.015 (0.894–1.155)	0.824
Female sex	1.169 (1.075–1.271)	<0.001
Younger than 64 years	1.615 (1.470–1.773)	<0.001

PT = physical therapy, RCR = rotator cuff repair. Bolded values signify statistical significance.

Table 6. Six Month Capsulitis Rates Associated With Timing of First PT Session in Both Arthroscopic and Open RCR (n = 64,842)
Timing of First PT Session	6-Month Capsulitis Rate for Arthroscopic RCR (n = 42,971)	P Value (Comparison Among Different PT Groups after Arthroscopic RCR)	6-Month Capsulitis Rate for Open RCR (n = 21,871)	P Value (Comparison Among Different PT Groups after Open RCR)	P Value (Comparison of all Open vs all RCR)
≤ 1 wk	21.61% (806/5,746)	0.116	22.64% (360/1,590)	0.256	—
2–5 wk	20.42% (4,342/21,264)	0.169	20.99% (2,261/10,774)	0.024	—
6–9 wk	20.99% (2,845/13,557)	0.247	22.74% (1,657/7,286)	0.056	—
10–13 wk	20.59% (910/4,420)	0.424	22.78% (506/2,221)	0.180	—
Total (PT within 13 wk)	20.72% (8,903/42,971)	—	21.87% (4,784/21,871)	—	0.014

PT = physical therapy, RCR = rotator cuff repair
First PT session defined as the time until a CPT-97001, 97110, or 97140 is coded for after a patients' first RCR. Capsulitis is defined as a ICD-9-D-7260 or ICD-9-D-71951 diagnosis within 90 days after RCR.

Table 7. One-Year Capsulitis Rates Associated With Timing of First PT Session in Both Arthroscopic and Open RCR (n = 64,842)
Timing of First PT Session	6-Month Capsulitis Rate for Arthroscopic RCR (n = 42,971)	P Value (Comparison Among Different PT Groups after Arthroscopic RCR)	6-Month Capsulitis Rate for Open RCR (n = 21,871)	P Value (Comparison Among Different PT Groups After Open RCR)	P Value (Comparison of All Open vs All RCR)
≤ 1 wk	22.84% (852/5,746)	0.096	23.90% (380/1,590)	0.214	—
2–5 wk	21.55% (4,583/21,264)	0.183	21.97% (2,367/10,774)	0.017	—
6–9 wk	22.05% (2,989/13,557)	0.305	23.79% (1,733/7,286)	0.068	—
10–13 wk	21.76% (962/4,420)	0.456	24.27% (539/2,221)	0.097	—
Total (PT within 13 wk)	21.84% (9,386/42,971)	—	22.95% (5,019/21,871)	—	0.022

PT = physical therapy, RCR = rotator cuff repair
First PT session defined as the time until a CPT-97001, 97110, or 97140 is coded for after a patients' first RCR. Capsulitis is defined as an ICD-9-D-7260 or ICD-9-D-71951 diagnosis within 1 year after RCR.