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http://ajs.sagepub.com/Medicine
The American Journal of Sports
http://ajs.sagepub.com/content/40/4/815Theonline version of this article can be found at:
DOI: 10.1177/0363546511434287
2012 40: 815 originally published online January 27, 2012Am J Sports MedYang-Soo Kim, Seok Won Chung, Joon Yub Kim, Ji-Hoon Ok, In Park and Joo Han Oh
Is Early Passive Motion Exercise Necessary After Arthroscopic Rotator Cuff Repair?
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Is Early Passive Motion Exercise NecessaryAfter Arthroscopic Rotator Cuff Repair?
Yang-Soo Kim,* MD, PhD, Seok Won Chung,y MD, Joon Yub Kim,y MD,Ji-Hoon Ok,* MD, In Park,* MD, and Joo Han Oh,yz MD, PhDInvestigation performed at the Department of Orthopaedic Surgery, Seoul National UniversityCollege of Medicine, Seoul National University Bundang Hospital, Korea
Background:Early passive motion exercise has been the standard rehabilitation protocol after rotator cuff repair for preventing
postoperative stiffness. However, recent approaches show that longer immobilization may enhance tendon healing and quality.
Purpose: To elucidate whether early passive motion exercise affects functional outcome and tendon healing after arthroscopic
rotator cuff repair.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: One hundred five consecutive patients who underwent arthroscopic repair for small to medium-sized full-thicknessrotator cuff tears were included. Patients with large to massive tears and concomitant stiffness or labral lesions were excluded.
Patients were instructed to wear an abduction brace for 4 to 5 weeks after surgery and to start active-assisted shoulder exercise
after brace weaning. Fifty-six patients were randomly allocated into group 1: early passive motion exercises were conducted 3 to
4 times per day during the abduction brace-wearing period. Forty-nine patients were allocated into group 2: no passive motion
was allowed during the same period. Range of motion (ROM) and visual analog scale (VAS) for pain were measured preoperatively
and 3, 6, and 12 months postoperatively. Functional evaluations, including Constant score, Simple Shoulder Test (SST), and
American Shoulder and Elbow Surgeons (ASES) score, were also evaluated at 6 and 12 months postoperatively. Ultrasonography,
magnetic resonance imaging, or computed tomography arthrography was utilized to evaluate postoperative cuff healing.
Results:There were no statistical differences between the 2 groups in ROM or VAS for pain at each time point. Functional eval-
uations were not statistically different between the 2 groups either. The final functional scores assessed at 12 months for groups 1
and 2 were as follows: Constant score, 69.81 6 3.43 versus 69.83 6 6.24 (P = .854); SST, 9.00 6 2.12 versus 9.00 6 2.59 (P=
.631); and ASES score, 73.29 6 18.48 versus 82.90 6 12.35 (P= .216). Detachment of the repaired cuff was identified in 12% of
group 1 and 18% of group 2 (P = .429).Conclusion:Early passive motion exercise after arthroscopic cuff repair did not guarantee early gain of ROM or pain relief but also did
not negatively affect cuff healing. We suggest that early passive motion exercise is not mandatory after arthroscopic repair of small to
medium-sized full-thickness rotator cuff tears, and postoperative rehabilitation can be modified to ensure patient compliance.
Keywords: arthroscopic rotator cuff repair; early passive motion exercise; functional outcome; rotator cuff healing
Rotator cuff repair is one of the most successful treatment
modalities in orthopaedics, and most patients enjoy func-
tional recovery after the procedure. However, the nonhealing
rate after rotator cuff repair still remains at 20% to 90% in
spite of the great advances in the surgical technique.1,3,6
Two key factors for successful tendon healing and satisfac-
tory functional outcome are skillful surgical technique and
a well-programmed rehabilitation protocol. That is, even
with an excellent surgical technique, we cannot expect a sat-
isfactory outcome if postoperative care is poor. In general,
early joint motion after surgery is recommended to prevent
stiffness and muscle atrophy. The advantages of this early
passive motion after surgery have been well reported for
the knee and ankle joints.7,13,15 In the shoulder joint, early
passive motion is also the standard rehabilitation protocol
after rotator cuff repair to avoid postoperative stiffness, espe-
cially in the era of open or mini-open surgery, and Raab
et al20 suggested in their prospective randomized study
that early continuous passive motion after rotator cuff repair
has a beneficial effect on range of motion (ROM) and pain
relief. Recently, however, some authors suggested that early
motion after rotator cuff repair could have a negative effect
on cuff healing, and their reports showed that anatomic
zAddress correspondence to Joo Han Oh, MD, PhD, Department of
Orthopaedic Surgery, Seoul National University College of Medicine, Seoul
National University Bundang Hospital, 166 Goomi-ro, Bundang-gu, Seong-
nam-si, Gyeonggi-do 463-707, Korea (e-mail: [email protected]).
*Department of Orthopaedic Surgery, Seoul St. Marys Hospital, Col-
lege of Medicine, The Catholic University of Korea, Seoul, Korea.yDepartment of Orthopaedic Surgery, Seoul National University Col-
lege of Medicine, Seoul National University Bundang Hospital, Korea.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: This researcher-led study was sup-
ported by funds received from Smith & Nephew Corporation (B-0807-
059-032). However, the authors received no payment, other benefits, or
a commitment or agreement to provide such benefits from a commercial
entity. The funding sources played no role in the study design, data anal-
ysis, or results interpretation.
The American Journal of Sports Medicine, Vol. 40, No. 4
DOI: 10.1177/0363546511434287 2012 The Author(s)
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outcomes were rather disappointing with high nonhealed
rates, even with use of the new technique to maximize cuff
healing.1 In animal models of rotator cuff repair, immobilized
supraspinatus tendons had markedly higher collagen orien-
tation and more nearly normal extracellular matrix genes
than did the tendons from participants exercised.4,21 In addi-
tion, Parsons et al18 recently reported that immobilization for
6 weeks after arthroscopic rotator cuff repair did not result in
increased long-term stiffness and might improve the rate oftendon healing. These studies recommended shoulder immo-
bilization for a period after surgery and a delay of active
motion to enable sound healing.
As far as our knowledge, the benefits of early passive
motion after rotator cuff repair still remain unproved, and
very few reports are published in the literature regarding
postoperative rehabilitation after rotator cuff surgery. Fur-
thermore, there is no well-designed clinical trial that inves-
tigates the efficacy of early passive motion exercise on the
postoperative stiffness, functional outcome, and failure
rate of cuff healing. Therefore, we designed this prospective,
randomized comparative trial to verify whether early pas-
sive motion exercise affects functional and anatomic out-comes after arthroscopic repair in patients with small to
medium-sized rotator cuff tears. We hypothesized that early
passive motion after arthroscopic cuff repair does not dem-
onstrate a significant difference in terms of ROM, function,
or cuff healing compared with immobilization.
MATERIALS AND METHODS
Inclusion and Exclusion Criteria
We prospectively enrolled 117 consecutive patients from
August 2007 to July 2009 who met the following inclusion
criteria from 2 hospitals: (1) had a small to medium-sized
(less than 3 cm) full-thickness rotator cuff tear confirmed by
preoperative magnetic resonance arthrography (MRA) and
arthroscopy, (2) underwent arthroscopic rotator cuff repair,
and (3) had a degenerative tear with no evident trauma his-
tory. We excluded patients with preoperative shoulder stiff-
ness, concomitant glenohumeral injuries (eg, superior labral
anterior-posterior [SLAP] lesion, Bankart lesion), any previ-
ous shoulder surgery, and large or massive cuff tears (largerthan 3 cm in size or 2 tendon tears). The definition of the pre-
operative stiffness was the limitation of both active and pas-
sive motion in at least 2 directions (abduction and forward
flexion \100, external rotation \20, or internal rotation
\L3) in this study. Among these 117 patients, 12 were lost
to follow-up; therefore, 105 were finally enrolled in this study
(Figure 1). We obtained the approval of the Institutional
Review Board for the study protocol, and all patients gave
written informed consent from both institutions. In addition,
this study was registered at the National Clinical Research
Coordination Center of Korea (registry number:
KCT0000123).
Clinical Characteristics
There were 44 men and 61 women. A thorough physical
examination, including ROM and visual analog scale (VAS)
for pain, was completed the day before surgery. Patients
were randomly assigned into 2 groups according to an auto-
matic generated randomization list. There were 56 patients
in the early passive motion group (group 1: EM) and 49 in
the delayed motion group (group 2: DM). Group 1 consisted
of 26 men and 30 women with a mean age of 60.06 6 9.04
years and included 37 right and 19 left shoulders. Group 2
consisted of 18 men and 31 women with a mean age of
Assessed for eligibility (n = 192)
Excluded (n = 75)
Inclusion criteria not met (n = 64)
Refused to participate (n = 11)
Analyzed (n = 56)
Lost to follow-up (n = 4)
Allocated to early passive motion group(n = 60)
Received allocated rahabilitation(n = 60)
Lost to follow-up (n = 8)
Allocated to delayed motion group(n = 57)
Received allocated rahabilitation(n = 57)
Analyzed (n = 49)
Allocation
Analysis
Follow-up
Enrollment
Randomized(n= 117)
Figure 1. CONSORT flow sheet.
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60.00 6 10.42 years (P . .05) and included 32 right and 17
left shoulders. The clinical characteristics of the enrolled
patients are described in Table 1.
Surgical Procedures
All surgical procedures were conducted by one senior sur-
geon in each hospital, and both surgeons performed all-
arthroscopic rotator cuff repairs. After glenohumeral
inspection, subacromial decompression was conducted toremove inflamed bursal tissue, and acromioplasty was per-
formed on all patients using a motorized bur (Vortex
Router and Linvatec Turbo Shaver System, Linvatec,
Largo, Florida) to create a flat acromion. Then, the greater
tuberosity of the humerus was prepared with a motorized
bur or ring curette to make a bleeding surface. Bioabsorb-
able anchors (Bio-Corkscrew, Arthrex, Naples, Florida; or
Spiralok, DePuy Mitek, Raynham, Massachusetts) were
used, and the anchors were inserted through an accessory
portal with a small stab incision. According to tear size and
pattern, either single- or double-row or suture bridge fixa-
tion was performed. In cases of small tears that were mea-
sured during arthroscopy, many of them were repaired by
the single-row technique. In cases of medium tears
(1-3 cm), many of them were repaired by the double-row
or suture bridge technique. The size of any full-thickness
rotator cuff tears was measured with a probe (with 5-mm
markings, Arthrex) during the arthroscopic surgery by
the senior surgeon at each site. The measurement method
was the same in both surgeons. After debridement of the
torn end, the anteroposterior dimension was measured at
the lateral edge of the torn cuff, and medial retraction
was measured as the distance from the apex of the tear
to the cuff insertion of the humeral head. The larger value
of the 2 measurements (anteroposterior dimension and
medial retraction) was used as the tear size; the tears
were divided into 2 groups based on size: small (\1 cm)
and medium (1-3 cm). Suture passing into the tendon
was done using a flexible suture passer (Expressew, DePuy
Mitek) or a suture passer (Spectrum, Linvatec), and all
knots were tied securely using a self-locking sliding knot.
Rehabilitation
Different standardized rehabilitation protocols were applied
to each group. For group 1, controlled early passive motion
exercise consisting of forward flexion, abduction, and external
rotation was conducted from 1 day after the operation during
the brace-wearing period. For group 2, no passive ROM was
allowed until brace removal (4 weeks for a small tear
[\1 cm] and 5 weeks for a medium-sized tear [1-3 cm]).
Immobilization was maintained with the abduction brace at
30. Shrugging of shoulders, active elbow flexion/extension,
active forearm supination/pronation, and active hand and
wrist motion were encouraged immediately after surgery for
both groups. Active-assisted shoulder exercise was encour-
aged after the weaning of the brace. Muscle strengthening
was usually initiated at 9 to 12 weeks postoperatively, and
all sports activities were permitted from 6 months after the
operation. All rehabilitation was referred to and supervisedby the Department of Rehabilitation at the authors
institutions.
Outcome Evaluation
Range of motion of the shoulder and VAS for pain were
checked at regular follow-up visits (4 or 5 weeks and 3, 6,
and 12 months postoperatively and then yearly). The VAS
for pain was scaled from 0 to 10, with a rating of 10 meaning
the highest level of pain. For measurement of ROM, forward
flexion and external rotation with the arm at the side were
evaluated with a goniometer in the supine position. Internal
TABLE 1
Demographic Data of Patients
Early Passive Motion Group Delayed Motion Group
No. of patients 56 (40a 1 16b) 49 (33a 116b)
Age, mean (range), y 60.06 (30-75) 60.00 (27-82)
Sex, male/female, n 26/30 18/31
Dominant arm, right/left, n 37/19 32/17
Comorbidities, n
Diabetes 8 7
Hypertension 16 15
Thyroid disease 1 1
Smoking, n 13 11
Tear size in anteroposterior dimension,c mean 6 standard deviation, mm 18.9 612.6 16.3 6 6.5
Medial retraction,c mean 6 standard deviation, mm 18.3 613.2 17.8 6 12.9
Repair technique, n
Single row 9 8
Double row 1 1
Suture bridge 46 40
aNumber of patients who had surgery at hospital 1.b
Number of patients who had surgery at hospital 2.cMeasured at surgery.
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rotation at the back was checked with patients in a seatedposition to minimize other compensatory motions. Passive
abduction was measured in degrees between the arm and
the thorax in the scapular plane, and external rotation at
the side was measured in degrees between the thorax and
the forearm with the arm held in an adducted position
with 90 of flexion at the elbow. Internal rotation at the
back was measured by the tip of the thumb reaching the
vertebral level. For the analysis, the vertebral level was
numbered serially as follows: 12 for the twelfth thoracic ver-
tebra, 13 for the first lumbar vertebra, 17 for the fifth lum-
bar vertebra, and 18 for any level below the sacral region.
Functional outcomes were assessed by the use of the
Constant score, the Simple Shoulder Test (SST) score, and
the American Shoulder and Elbow Surgeons (ASES) score.
These were checked at preoperative admission and at regu-
lar follow-up visits (6 and 12 months postoperatively and
then yearly). The anatomic outcome was evaluated with
ultrasonography at 3 or 6 months after rotator cuff repair,
and computed tomography (CT) arthrography or magnetic
resonance imaging (MRI) was conducted at a minimum of
1 year after the operation. However, the ultrasonographic
evaluation was performed at only one site and has limita-
tions such as difficult interpretation, low interobserver
agreement, and lower accuracy compared with CT arthrog-
raphy or MRI; for these reasons, we used only the data of
CT arthrography and MRI assessed at a minimum 1 year
after rotator cuff repair. As a recent study reported, thediagnostic value of CT arthrography in the detection of
full-thickness tears appears comparable with MRA.16 The
interpretation of MRI and CT arthrography was performed
by experienced musculoskeletal radiologists who were
unaware of this study. Intact cuff was defined as mainte-
nance of the cuff insertion into the footprint; failure of heal-
ing was defined as discontinuity at the footprint.17
Statistical Methods
Sample sizes are calculated to detect a significant difference
(mean difference, 8 points; standard deviation, 12 points) in
ASES scores. The ASES score has been validated and widely
used for the evaluation of outcome after arthroscopic rotator
cuff repair.12,17 This was based on the mean and standard
deviation of ASES scores observed in a pilot study of
20 patients. A sample size of 49 patients in each group
was required for a power of 90% at a type I error level of
.05. Expected follow-up loss was about 20% (Figure 1).
All statistical analyses were performed using the SPSS
software package (version 12.0, SPSS Inc, Chicago, Illi-
nois), and a P value less than .05 was taken as the level
of statistical significance. An independent t test was used
to evaluate differences between the 2 groups for pain
VAS, ROM, and functional scores. A x2 test was used for
comparison of the anatomic outcome of the 2 groups.
TABLE 2
Forward Flexion (in Degrees)
Time
Early Passive Motion Group
(95% Confidence Interval)
Delayed Motion Group
(95% Confidence Interval) P Value
Preoperative 144.70 (135.79-153.61) 144.84 (135.94-153.74) .982
Postoperative 3 mo 144.86 (140.08-149.64) 140.00 (133.26-146.74) .319
Postoperative 6 mo 150.57 (141.66-159.48) 147.14 (141.04-153.24) .392
Postoperative 12 mo 159.75 (151.46-168.04) 153.67 (146.93-160.41) .206
TABLE 3
External Rotation With the Arm at the Side (in Degrees)
Time
Early Passive Motion Group
(95% Confidence Interval)
Delayed Motion Group
(95% Confidence Interval) P Value
Preoperative 67.27 (59.94-74.60) 69.84 (62.49-77.19) .633
Postoperative 3 mo 71.22 (63.46-78.98) 66.33 (59.20-73.46) .349
Postoperative 6 mo 77.21 (71.82-82.60) 72.86 (64.32-81.40) .393
Postoperative 12 mo 78.50 (71.58-85.42) 81.33 (70.83-91.83) .623
TABLE 4
Internal Rotation at the Back
Time
Early Passive Motion Group
(95% Confidence Interval)
Delayed Motion Group
(95% Confidence Interval) P Value
Preoperative T 9.7 (T 8.6-T 10.8) T 9.2 (T 8.1-T 10.3) .552
Postoperative 3 mo T 7.6 (T 6.4-T 8.8) T 8.4 (T 7.3-T 9.5) .256
Postoperative 6 mo T 9.0 (T 8.2-T 9.8) T 10.1 (T 9.0-T 11.2) .104
Postoperative 12 mo T 10.0 (T 9.2-T 10.9) T 9.9 (T 8.4-T 11.4) .854
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RESULTS
All 105 patients completed the minimum 1-year follow-upevaluation. There were no significant demographic differ-
ences between the 2 groups (all P . .05) (Table 1). At
6 months postoperatively, there were no significant differ-
ences between the 2 groups for all 3 directions of ROM. The
average for forward flexion (Table 2) was 150.6in group 1
and 147.1 in group 2 (P = .392) and for external rotation
with the arm at the side (Table 3) was 77.2 in group 1
and 72.9 in group 2 (P = .393). Internal rotation at
the back (Table 4) was T 9.0 in group 1 and T 10.1 in
group 2 (P= .104). At the final follow-up visit at 12 months
after surgery, there were also no significant differences
between the 2 groups for all 3 directions of ROM.
The pain VAS was 3.0 in group 1 and 3.2 in group 2 atpostoperative 6 months (P = .745) and 2.8 and 1.8 at the
final follow-up (P = .34), respectively. The functional out-
come scores, including Constant (Table 5), SST (Table 6),
and ASES (Table 7) scores, were significantly improved
after arthroscopic rotator cuff repair in both groups, but
no significant differences were found between the 2 groups
at postoperative 6 months or at the final follow-up at
12 months after surgery. Imaging at a minimum of
1 year after surgery to evaluate healing of the repaired
cuff revealed that the rotator cuff tendon was healed in
49 of 56 patients (88%) in group 1 and in 40 of 49 patients
(82%) in group 2 (P = .429).
DISCUSSION
It has been generally accepted to initiate passive shouldermotion early after rotator cuff repair to avoid stiffness,
especially during the era of open surgery.11,14 Many
authors reported faster recovery of ROM and more favor-
able functional outcome with early passive motion exer-
cise.2,5,8 On the other hand, recently, several authors
reported that immobilization for a certain period after sur-
gical repair did not lead to postoperative shoulder stiff-
ness18; furthermore, that delayed shoulder motion could
promote tendon healing to bone.4,21 For these reasons, we
designed this prospective, randomized comparative trial
to verify whether early passive shoulder exercise affects
ROM, functional outcome, and cuff healing after arthro-
scopic repair of small to medium-sized rotator cuff tears.As a result, we demonstrated that early passive motion
had no advantage for either early gain of ROM or clinical
outcome. That is, delayed rehabilitation after arthroscopic
rotator cuff repair did not result in postoperative stiffness
and poor clinical outcome compared with early motion.
In the literature, there are limited reports that compare
early passive motion and delayed rehabilitation after
arthroscopic rotator cuff repair. However, there are several
reports regarding the individual rehabilitation protocols.
Early passive motion after arthroscopic rotator cuff sur-
gery has been advocated because it could reduce the possi-
bility of adhesion formation. Raab et al20 suggested in their
TABLE 5
Constant Score
Time
Early Passive Motion Group
(95% Confidence Interval)
Delayed Motion Group
(95% Confidence Interval) P Value
Preoperative 53.73 (49.77-57.69) 49.93 (45.87-53.99) .186
Postoperative 3 mo 63.23 (60.24-66.22) 63.33 (59.70-66.96) .966
Postoperative 6 mo 66.11 (63.26-68.96) 64.52 (60.87-68.17) .991
Postoperative 12 mo 69.81 (67.81-71.81) 69.83 (65.97-73.69) .854
TABLE 6
Simple Shoulder Test Score
Time
Early Passive Motion Group
(95% Confidence Interval)
Delayed Motion Group
(95% Confidence Interval) P Value
Preoperative 4.06 (3.06-5.06) 3.52 (2.58-4.46) .424
Postoperative 3 mo 6.34 (5.35-7.33) 6.05 (4.92-7.18) .738
Postoperative 6 mo 7.81 (6.96-8.66) 6.70 (5.68-7.72) .120
Postoperative 12 mo 9.00 (7.54-10.46) 9.00 (7.65-10.35) .631
TABLE 7
American Shoulder and Elbow Surgeons Score
Time
Early Passive Motion Group
(95% Confidence Interval)
Delayed Motion Group
(95% Confidence Interval) P Value
Preoperative 48.38 (42.99-53.77) 46.27 (41.15-51.39) .566
Postoperative 3 mo 65.19 (59.95-70.43) 64.68 (58.60-70.76) .896
Postoperative 6 mo 67.08 (61.71-72.45) 69.89 (64.12-75.66) .561
Postoperative 12 mo 73.29 (58.25-88.33) 82.90 (74.99-90.81) .216
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prospective randomized study that early continuous pas-
sive motion after rotator cuff repair has a beneficial effect
on ROM and level of pain in female patients and those
older than 60 years of age. Li et al9 suggested that contin-
uous passive motion in rabbits promoted basic fibroblast
growth factor expression, leading to enhanced type III col-
lagen synthesis at the tendon-bone interface in the early
stages of tendon-bone repair after acute rupture of the
supraspinatus tendon, thereby contributing to tendon-
bone recovery after rotator cuff injury. On the contrary,
several recent studies reported that delayed motion had
benefits for clinical and biological outcomes. Peltz et al19
reported that immediate postoperative passive motion
was found to be detrimental to passive shoulder mechanics
by increasing scar and extracellular tissue formation in the
subacromial space, resulting in decreased ROM and
increased joint stiffness in their rat model study. In addi-
tion, Parsons et al18 suggested in their retrospective study
that sling immobilization for 6 weeks after arthroscopic
rotator cuff repair did not result in increased long-term
stiffness and might improve the rate of healing.The structural integrity of the repaired rotator cuff ten-
don is the critical issue that influences both clinical and
functional outcome. Even with rapid advancement of the
arthroscopic rotator cuff repair technique, the rate of cuff
healing failure is reported to be 20% and 90%.1,3,6,10 There
have been concerns that early motion after rotator cuff
repair might negatively affect the healing of tendon to
bone. Gimbel et al4 reported that immobilization of the
shoulder improved tendon-to-bone healing in the rat model
because it allowed for an increase in the organization of
collagen fibers, which led to an increase in mechanical
properties. In the current study, however, there was no
statistical difference in the healing rate between the 2groups at the 1-year follow-up. This implies that rotator
cuff tendon healing is not negatively affected by early pas-
sive motion given use of the modern arthroscopic tech-
nique. That is, the healing of repaired tendon to bone
might not only be affected by rehabilitation; other factors
such as operation technique and tendon and bone quality
are also important.
There are several limitations of the current study. This
study was performed at 2 different sites. That is, the oper-
ations were done by 2 different surgeons, and measure-
ment of ROM, tear size, and functional scores was also
conducted by 2 different researchers. Even though the
same surgical procedure and rehabilitation protocol
were employed, some variation and error could exist in
the analysis of the results. Second, the follow-up period
of at least 1 year after surgery was relatively short.
This is a serious limitation in our study. The clinical
and anatomic outcomes including healing rate of the rota-
tor cuff might change over a longer follow-up period, and
long-term observation is necessary. Third, we did not per-
form a stratified randomization. As 2 surgeons performed
all the surgical procedures at 2 hospitals, the randomiza-
tion needed to be stratified to prevent the possible intro-
duction of performance bias and co-intervention bias.
Finally, we included patients with small and medium-
sized rotator cuff tears, not large or massive cuff tears,
as delayed motion is usually recommended for these big
tears in most clinics.
In conclusion, we failed to show a difference in outcome
between the 2 treatment protocols. Early passive motion
exercise after arthroscopic repair of small to medium-
sized rotator cuff tears does not seem to guarantee the
early gain of shoulder ROM, pain relief, or functional
recovery and does not seem to negatively affect cuff heal-
ing in this prospective, randomized comparative study.
We believe that early passive motion exercise may not
be mandatory after arthroscopic repair of small to
medium-sized full-thickness rotator cuff tears, and post-
operative rehabilitation can be modified to ensure patient
compliance.
ACKNOWLEDGMENT
The authors thank Hye Ran Kim and Shang Mi Shim for
data collection.
REFERENCES
1. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM,
Krishnan SG. Arthroscopic repair of full-thickness tears of the supra-
spinatus: does the tendon really heal? J Bone Joint Surg Am.
2005;87(6):1229-1240.
2. Cofield RH. Rotator cuff disease of the shoulder. J Bone Joint Surg
Am. 1985;67(6):974-979.
3. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The
outcome and repair integrity of completely arthroscopically repaired
large and massive rotator cuff tears. J Bone Joint Surg Am.
2004;86(2):219-224.
4. Gimbel JA, Van Kleunen JP, Williams GR, Thomopoulos S, Soslow-
sky LJ. Long durations of immobilization in the rat result in enhancedmechanical properties of the healing supraspinatus tendon insertion
site.J Biomech Eng. 2007;129(3):400-404.
5. Gristina A, Craig E, Neviaser R, Norris T. Symposium: management
of rotator cuff problems. Contemp Orthop. 1990;20:621-646.
6. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML,
Matsen FA 3rd. Repairs of the rotator cuff: correlation of functional
results with integrity of the cuff. J Bone Joint Surg Am.
1991;73(7):982-989.
7. Indelicato PA. Non-operative treatment of complete tears of the
medial collateral ligament of the knee. J Bone Joint Surg Am.
1983;65(3):323-329.
8. Lastayo PC, Wright T, Jaffe R, Hartzel J. Continuous passive motion
after repair of the rotator cuff: a prospective outcome study. J Bone
Joint Surg Am. 1998;80(7):1002-1011.
9. Li S, Min SX, Zhang H, Fu GJ, Wang PC, Jin AM. [Effect of continuous
passive motion on basic fibroblast growth factor expression during
tendon-bone repair after surgical repair of acute rupture of the supra-
spinatus tendon in rabbits]. Nan Fang Yi Ke Da Xue Xue Bao.
2010;30(5):1020-1023.
10. Liem D, Lichtenberg S, Magosch P, Habermeyer P. Magnetic reso-
nance imaging of arthroscopic supraspinatus tendon repair. J Bone
Joint Surg Am. 2007;89(8):1770-1776.
11. Mansat P, Cofield RH, Kersten TE, Rowland CM. Complications of
rotator cuff repair. Orthop Clin North Am. 1997;28(2):205-213.
12. Michener LA, McClure PW, Sennett BJ. American Shoulder and
Elbow Surgeons Standardized Shoulder Assessment Form, patient
self-report section: reliability, validity, and responsiveness. J Shoul-
der Elbow Surg. 2002;11(6):587-594.
13. Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after
operative treatment of a rupture of the Achilles tendon: a prospective,
820 Kim et al The American Journal of Sports Medicine
at KANSAS STATE UNIV LIBRARIES on July 15, 2014ajs.sagepub.comDownloaded from
http://ajs.sagepub.com/http://ajs.sagepub.com/http://ajs.sagepub.com/http://ajs.sagepub.com/7/26/2019 2012 Early Passive Motion Exercise Necessary After Arthroscopic
8/8
randomized clinical and radiographic study. J Bone Joint Surg Am.
1999;81(7):983-990.
14. Norberg FB, Field LD, Savoie FH 3rd. Repair of the rotator cuff:
mini-open and arthroscopic repairs. C lin Sp or ts Med .
2000;19(1):77-99.
15. Noyes FR, Mangine RE, Barber S. Early knee motion after open and
arthroscopic anterior cruciate ligament reconstruction. Am J Sports
Med. 1987;15(2):149-160.
16. Oh JH, Kim JY, Choi JA, Kim WS. Effectiveness of multidetector
computed tomography arthrography for the diagnosis of shoulder
pathology: comparison with magnetic resonance imaging with
arthroscopic correlation. J Shoulder Elbow Surg. 2010;19(1):14-20.
17. Oh JH, Kim SH, Ji HM, Jo KH, Bin SW, Gong HS. Prognostic factors
affecting anatomic outcome of rotator cuff repair and correlation with
functional outcome. Arthroscopy. 2009;25(1):30-39.
18. Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow
EL. Does slower rehabilitation after arthroscopic rotator cuff repair
lead to long-term stiffness? J Shoulder Elbow Surg.
2010;19(7):1034-1039.
19. Peltz CD, Dourte LM, Kuntz AF, et al. The effect of postoperative pas-
sive motion on rotator cuff healing in a rat model. J Bone Joint Surg
Am. 2009;91(10):2421-2429.
20. Raab MG, Rzeszutko D, OConnor W, Greatting MD. Early results of
continuous passive motion after rotator cuff repair: a prospective,
randomized, blinded, controlled study. Am J Orthop (Belle Mead
NJ). 1996;25(3):214-220.
21. Thomopoulos S, Williams GR, Soslowsky LJ. Tendon to bone heal-
ing: differences in biomechanical, structural, and compositional
properties due to a range of activity levels. J Biomech Eng.
2003;125(1):106-113.
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