Delayed Passive Range of Motion in Post-Op Physical Therapy

Andrew Lourenco

Delayed Passive Range of Motion in a Post-Op Physical Therapy Protocol after Arthroscopic Rotator Cuff Repair

Introduction

Physical therapy is a vital part of the recovery process for those who've undergone an arthroscopic rotator cuff repair. Through physical therapy, a patient can gain improved range of motion and strength that was previously limited prior to an arthroscopic rotator cuff repair. There have been some discussion and disagreements within the surgical profession as to the timing of starting physical therapy after having the surgical procedure.

Some traditional surgeons support passive range of motion (PROM) treatment soon after surgery in order to lessen the chance of developing stiffness and adhesions.  However, opponents to this approach of treating patients soon after the procedure claim early PROM can cause strain in the healing area of rotator cuff tendons; specifically the supraspinatus tendon (Cuff et al). They argue that postponing PROM would allow for less strain in the area involved as the tendon starts to heal.

This issue is important because this conflict of opinion within the orthopedic surgical community creates a divide when arguing which post-surgical rotator cuff protocol should be implemented. Traditionally, early implementation of PROM through physical therapy was the gold standard in regards to a treatment protocol (Keenan et al). However, over time, more orthopedic physicians began to grow concerned that there was not enough time for tendon healing to occur. Many believed early PROM could result in tendon micro-trauma which would result in negative patient outcomes (Keenan et al). Interestingly, there is little to no information in the literature regarding the timeline of tendon healing after a surgical rotator cuff repair. However, there are studies of larger animal models that show full tendon healing does not occur until 3-4 months post-surgery (.  Orthopedic surgeons who implement an early PROM protocol have patients start as early as a few days after surgery. In contrast, other surgeons wait until up to 6 weeks before their rotator cuff repair patients even begin PROM.

The purpose of this case study is to compare the clinical outcome of one man's delayed PROM protocol after undergoing an arthroscopic rotator cuff repair with a 6 week immobilization period to those who have had completed an early PROM protocol with success and positive outcomes. There is some research demonstrating the positive outcomes of both protocols but there's limited research directly comparing the different approaches. My hypothesis was that there would be a similar clinical outcome between this patient in the delayed PROM protocol and those who underwent an early PROM treatment course.

Case Description

George is a right handed dominant 64 year old male who was status post right arthroscopic rotator cuff repair which had occurred 6 weeks prior. George stated he was helping his neighbor remove some debris that were remnants of Hurricane Matthew in early November  when he heard his right shoulder pop after lifting a garbage bag full of tree limbs and shrubbery overhead. He waited until the next day to be seen by a doctor at the local Mediquick who ordered an x-ray and an MRI of his right shoulder revealing a complete tear of the supraspinatus tendon. George said he was given an immobilizer for his right shoulder and was instructed by his orthopedic doctor to remain in the sling at all times for the first four weeks. George reported inability to complete basic activities of daily living (ADL's) including cleaning, bathing, dressing, grooming and that he's heavily reliant on both his wife and left upper extremity to aid him in completing those activities. Prescribed pain medication and NSAID's helped alleviate his pain. His goal through physical therapy was to return to being independent with ADL's and to be able to play golf and tennis again. George's cardiovascular system, pulmonary system, integument, neuromuscular and cognition were all either all within normal limits/unremarkable after conducting his systems review. George's orthopedic doctor has a protocol for him outlining no PROM until week 6 post-surgery.