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, P < 0.001). No association was found between timing of beginning PT and capsulitis rates.

Conclusion: In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR.

Level of Evidence: Level III

Introduction

Rotator cuff tears are one of the most commonly treated orthopedic injuries, with more than 250,000 rotator cuff repairs (RCRs) occurring annually in the United States.^[1] RCRs, both open and arthroscopic, have a high rate of retear, with rates reported to be as high as 13% to 43%.^[2] These rates correlate with increasing age, with a recent meta-analysis demonstrating that retear rates double between the ages of 50 years (15%) and 70 years (30%).^[3] Many of these retears are not associated with significant symptoms and demonstrate only on imaging studies, especially in an older patient cohort in whom asymptomatic degenerative tears are common; however, retears after RCRs are occasionally significant enough to require revision surgery, and failure of repair continuity is associated with worse RCR outcomes.^[4,5] A 10-year follow-up study of RCRs completed in 2003 demonstrated this revision surgery rate to be 7%.^[6] One potential factor affecting this retear and repair failure rate, as identified by previous studies, is the timing of physical therapy (PT) and rehabilitation for patients after RCR.^[7–9] Historically, two approaches to PT were used after RCR: early passive range of motion (EPM) and delayed passive range of motion (DPM). Although the exact protocol varies based on the study, EPM typically refers to physical therapist–assisted passive range of motion within the first week but can occur as early as 1 day postoperatively.^[10] These early PT exercise programs consist of pendulum exercises and passive movements such as forward flexion, external and internal rotation, and glenohumeral abduction.^[11] By contrast, DPM consists of immobilizing the shoulder in a sling, with the exception of pendulum exercises and self-care, for up to 6 weeks postoperatively. After this immobilization period, physical therapist–assisted passive and active range of motion exercise programs can begin.^[7,10]

Considerable debate exists over using an EPM protocol versus a DPM protocol based on each of their effects on two main factors: (1) postoperative range of motion (ROM) and stiffness and (2) postoperative healing and retear or repair failure rates. Proponents of EPM note that the protocol is beneficial because of its supposed ability to increase ROM and decrease postoperative stiffness,^[11] one of the most common complications of RCR.^[12–14] These benefits were supported by a 2017 review of seven overlapping meta-analyses by Houck et al, which noted that most studies agreed that EPM increases postoperative ROM in comparison with DPM.^{[7,8,15–18]} This meta-analysis also demonstrated that EPM could possibly lead to an increased rate of rotator cuff retear, suggesting a delicate balance between stiffness and failure and when to start physical therapist–directed motion.^[7–9,15]

However, the relationship between EPM and DPM and retear rates remains difficult to fully characterize. A 2018 meta-analysis by Li et al concluded no significant difference in healing rates between EPM and DPM patients when analyzing six randomized controlled trials (RCTs).^[19–25] Similarly, in a 2017 study of seven overlapping meta-analysis, Saltzman et al noted no significant difference in retear rates between EPM and DPM protocols; however, through subgroup analysis, they suggested that patients with larger preoperative rotator cuff tears have significantly higher retear rates with EPM.^{[8,9,15–18,26–29]} Most recently, a 2019 RCT found no significant difference in repair integrity between EPM and DPM at 12 months post-operatively.^[30]

Concerning the purported benefit of increased ROM and decreased stiffness with EPM, the literature seems to have greater consensus. The studies by Saltzman et al and Li et al both agree that EPM results in significantly increased postoperative ROM.^[25,26] The RCT by Sheps et al demonstrated a significant increase in ROM in the EPM group at 6 weeks postoperatively; however, they also demonstrated no significant difference in ROM among the EPM and DPM groups at 24 months postoperatively.^[30]

Although the potential advantages of EPM versus DPM show good consensus, the possible disadvantages of the two methods are unclear, and a clearer picture may be possible with investigation using larger sample sizes. The problem of small sample sizes commonly limits analysis of differences in retear rates between the two treatment methods.^[10] Moreover, Li et al and Houck et al also call for additional studies to be completed, specifically for large tear sizes and for patients older than 65 years.^[25,26]

The goal of this study was to provide a large, population-based study detailing the associations of specific outcomes with patients who underwent either EPM or DPM after their RCR to provide additional insight into the significance of when PT begins post-RCR. Using this database, we planned to use revision rate, as a proxy for repair failure, and capsulitis diagnosis, as a proxy for postoperative stiffness, and then analyze for their association regarding the timing of the beginning of rehabilitation post-RCR. We hypothesized that an EPM method of rehabilitation will be associated with a higher revision rate and a lower capsulitis rate compared with a DPM method.

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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.