When should you wear a sling for a rotator cuff injury. How does a sling work for shoulder immobilization. What are the different types of slings used for rotator cuff repairs. Is wearing a sling necessary for non-surgical rotator cuff injuries. How long should you wear a sling after rotator cuff surgery.

Understanding Rotator Cuff Injuries and Their Impact

Rotator cuff injuries are a common source of shoulder pain and discomfort. These injuries affect the group of muscles and tendons that surround the shoulder joint, providing stability and allowing for a wide range of motion. Understanding the nature of these injuries is crucial for proper treatment and recovery.

What Exactly is a Rotator Cuff Injury?

A rotator cuff injury involves damage to the muscles and tendons that make up the rotator cuff. These injuries can range from mild strains to complete tears. The severity of the injury is typically classified into three grades:

• Grade 1: A minor strain with no significant tearing
• Grade 2: A partial thickness tear
• Grade 3: A full-thickness rotator cuff tear

Interestingly, having a grade 3 tear does not automatically mean surgery is necessary. Many individuals live with full-thickness rotator cuff tears without experiencing significant symptoms or even being aware of the injury.

The Role of Slings in Rotator Cuff Treatment

Slings play a crucial role in the treatment and recovery process for rotator cuff injuries, particularly following surgical repair. However, their use is not always necessary or recommended for non-surgical cases.

What is a Shoulder Sling and How Does it Function?

A shoulder sling is a supportive device designed to immobilize the shoulder and reduce traction forces experienced at the shoulder joint. Its primary function is to provide rest and protection to the injured or surgically repaired rotator cuff.

There are two main types of slings used for rotator cuff repairs:

1. Shoulder sling with an abduction pillow (e.g., DonJoy sling)
2. Standard slings without an abduction pillow

The abduction pillow keeps the arm slightly away from the body, which can be beneficial for certain types of repairs.

When to Wear a Sling for Rotator Cuff Injuries

The decision to wear a sling for a rotator cuff injury depends on various factors, including the severity of the injury and whether surgical intervention has been performed.

Post-Surgical Sling Usage

If you have undergone rotator cuff surgery, wearing a sling is typically recommended for approximately six weeks. This period allows the surgical site to heal and strengthen before introducing any traction forces. Most surgeons advise wearing the sling continuously during this time, including while sleeping.

The primary reason for this extended sling use is to improve outcomes and decrease the risk of re-tears, which are relatively common after rotator cuff repairs.

Non-Surgical Sling Usage

For non-surgical rotator cuff injuries, sling use is generally not recommended unless there is severe and intractable pain that only subsides when the arm is supported. However, prolonged immobilization without surgical intervention can lead to increased pain, avoidance behaviors, and decreased muscle mass, potentially complicating the rehabilitation process.

The Debate: To Sling or Not to Sling

The use of slings in rotator cuff treatment has been a topic of debate among medical professionals. While there are clear benefits to sling use following surgery, the approach for non-surgical cases is less straightforward.

Arguments for Sling Use

Proponents of sling use argue that it provides necessary rest and protection for the injured shoulder, potentially accelerating the healing process. In post-surgical cases, sling use has been associated with better outcomes and reduced re-tear rates.

Arguments Against Sling Use

Critics of prolonged sling use, especially in non-surgical cases, point out potential drawbacks such as:

• Increased risk of shoulder stiffness
• Muscle atrophy due to disuse
• Potential development of frozen shoulder
• Psychological dependence on the sling

Guidelines for Sling Use in Rotator Cuff Injuries

Based on current evidence and expert opinions, here are some guidelines for sling use in rotator cuff injuries:

Post-Surgical Cases

For patients who have undergone rotator cuff repair surgery:

• Wear the sling as directed by your surgeon, typically for six weeks
• Use the sling continuously, including during sleep
• Follow your surgeon’s instructions regarding any permitted exercises or movements
• Attend all follow-up appointments and physical therapy sessions as scheduled

Non-Surgical Cases

For patients with non-surgical rotator cuff injuries:

• Avoid prolonged sling use unless specifically recommended by your healthcare provider
• If sling use is necessary for pain relief, keep it to a minimum
• Focus on alternative pain management techniques such as ice, heat, and appropriate exercises
• Work with a physical therapist to maintain shoulder mobility and strength

Potential Risks of Prolonged Sling Use

While slings can be beneficial in certain situations, prolonged use, especially in non-surgical cases, can lead to various complications.

Shoulder Stiffness and Frozen Shoulder

Extended immobilization of the shoulder can result in stiffness and, in some cases, lead to the development of a frozen shoulder (adhesive capsulitis). This condition is characterized by severe pain and significant limitation in shoulder movement.

Muscle Atrophy

When the shoulder muscles are not used for an extended period, they can begin to atrophy or waste away. This loss of muscle mass can make the rehabilitation process more challenging and prolong overall recovery time.

Psychological Dependence

Some patients may develop a psychological dependence on the sling, feeling insecure or unstable without it. This can lead to prolonged avoidance of normal shoulder movements and activities, potentially hindering recovery.

Alternatives to Sling Use for Non-Surgical Rotator Cuff Injuries

For patients with non-surgical rotator cuff injuries, there are several alternatives to sling use that can help manage pain and promote healing:

Pain Management Techniques

• Ice therapy: Apply ice to the affected area for 15-20 minutes at a time, several times a day
• Heat therapy: Use heat to improve blood flow and reduce muscle tension
• Over-the-counter pain medications: Consult with your healthcare provider about appropriate pain relief options

Therapeutic Exercises

Working with a physical therapist to develop a tailored exercise program can help maintain shoulder mobility and strength. Exercises may include:

• Gentle range of motion exercises
• Pendulum exercises
• Isometric strengthening exercises
• Scapular stabilization exercises

Activity Modification

Adjusting daily activities to avoid aggravating the injured shoulder can help manage pain and promote healing without the need for constant sling use.

When is Rotator Cuff Surgery Necessary?

The decision to undergo rotator cuff surgery is not always straightforward and depends on various factors. Generally, surgery may be considered in the following situations:

• Inability to lift the arm due to significant weakness
• Severe pain persisting for more than 6 months despite conservative treatment
• Failure to improve with extensive, high-quality physical therapy
• Large or complete tears in younger, active individuals

It’s important to note that not all rotator cuff tears require surgical intervention. Many individuals with partial or even full-thickness tears can achieve satisfactory outcomes with conservative management.

Seeking a Second Opinion

If surgery is recommended, it’s advisable to seek a second opinion, especially if you can lift your arm without significant weakness. Ensure that the recommendation aligns with current evidence-based practices for rotator cuff tear management.

Rehabilitation After Rotator Cuff Injury or Surgery

Proper rehabilitation is crucial for optimal recovery from rotator cuff injuries, whether treated surgically or conservatively. The rehabilitation process typically involves several phases:

Phase 1: Protection and Pain Management

This initial phase focuses on protecting the injured or repaired tissue and managing pain. For surgical cases, this is when sling use is most critical.

Phase 2: Range of Motion Restoration

As healing progresses, gentle exercises are introduced to improve shoulder mobility and prevent stiffness.

Phase 3: Strengthening

Once adequate range of motion is achieved, strengthening exercises for the rotator cuff and surrounding muscles are incorporated.

Phase 4: Functional Training

The final phase focuses on returning to normal activities and, if applicable, sport-specific training.

Throughout the rehabilitation process, it’s essential to work closely with your healthcare provider and physical therapist to ensure proper progression and avoid re-injury.

Long-Term Outlook and Prevention of Rotator Cuff Injuries

Understanding the long-term prognosis and implementing preventive measures is crucial for individuals who have experienced rotator cuff injuries.

Prognosis After Treatment

The long-term outlook for rotator cuff injuries varies depending on the severity of the injury, the treatment approach, and individual factors such as age and overall health. Many patients experience significant improvement in pain and function with appropriate treatment, whether conservative or surgical.

However, it’s important to note that even after successful treatment, there may be some residual limitations in strength or range of motion. Additionally, the risk of re-injury or developing arthritis in the affected shoulder may be slightly increased.

Preventing Future Rotator Cuff Injuries

To reduce the risk of future rotator cuff injuries, consider the following preventive measures:

• Maintain good posture to reduce stress on the shoulder muscles
• Practice proper form during activities that involve overhead movements
• Incorporate regular shoulder strengthening exercises into your fitness routine
• Avoid repetitive overhead activities when possible, or take frequent breaks
• Warm up adequately before engaging in physical activities
• Listen to your body and avoid pushing through shoulder pain

Ongoing Maintenance

Even after full recovery, it’s beneficial to continue with a maintenance program that includes stretching and strengthening exercises for the shoulder. This can help maintain flexibility, strength, and overall shoulder health.

Regular check-ups with your healthcare provider or physical therapist can help identify and address any emerging issues before they become significant problems.

The Role of Technology in Rotator Cuff Treatment and Rehabilitation

Advancements in technology are continually shaping the landscape of rotator cuff treatment and rehabilitation. These innovations offer new possibilities for diagnosis, treatment, and recovery monitoring.

Diagnostic Advancements

Improved imaging techniques, such as high-resolution MRI and ultrasound, allow for more accurate diagnosis of rotator cuff injuries. This precision can help guide treatment decisions and improve outcomes.

Surgical Innovations

Minimally invasive surgical techniques, including arthroscopic procedures, have revolutionized rotator cuff repair. These approaches often result in less post-operative pain and faster recovery times compared to traditional open surgery.

Rehabilitation Technology

Various technological tools are now available to enhance the rehabilitation process:

• Wearable sensors to track movement and provide feedback on exercise form
• Virtual reality systems for engaging and interactive rehabilitation exercises
• Smartphone apps that guide patients through their home exercise programs
• Telemedicine platforms for remote consultations and monitoring

These technologies can improve patient engagement, ensure proper exercise execution, and allow for more frequent communication between patients and healthcare providers.

The Importance of Patient Education in Rotator Cuff Management

Effective management of rotator cuff injuries relies heavily on patient understanding and active participation in the treatment process. Comprehensive patient education is crucial for achieving optimal outcomes.

Understanding the Injury

Patients should be provided with clear, accessible information about:

• The anatomy of the rotator cuff and its function
• The nature and severity of their specific injury
• The rationale behind the chosen treatment approach

Treatment Expectations

Setting realistic expectations is essential for patient satisfaction and compliance. This includes discussing:

• The expected timeline for recovery
• Potential challenges or setbacks that may occur
• The importance of adherence to the treatment plan

Self-Management Strategies

Empowering patients with self-management techniques can enhance recovery and prevent future injuries. This may include instruction on:

• Proper posture and body mechanics
• Home exercise programs
• Pain management strategies
• Activity modification techniques

By providing comprehensive education, healthcare providers can foster a collaborative approach to rotator cuff management, leading to improved outcomes and patient satisfaction.

Should You Wear a Sling For A Rotator Cuff Injury?

A sling does not need to be worn for a rotatory cuff injury. However, if you have undergone rotator cuff surgery, you will likely wear a sling for six weeks to allow the surgical site to heal and strengthen before introducing any traction forces.  

When should you wear a sling for a rotator cuff injury?

If you have recently had rotator cuff surgery, the majority of surgeons will recommend that you should wear the sling for six weeks, including when you’re sleeping. 

Some people have the concern that the shoulder will get too stiff if you immobilize it in a sling while at rest for six weeks, however, this fear is largely unfounded as the shoulder will be stiff, regardless. 

The primary reason that most surgeons want to wait six weeks before getting out of the sling is that it’s shown to have better outcomes, namely a decreased re-tear rate. 

It is worth noting that RTC retears are pretty common so I encourage you to read this article about whether you should even get the surgery or not.

Other reasons you should wear the sling if you haven’t had the surgery would be severe and intractable pain that only feels better when it’s in the sling. 

I’m generally not a huge fan of immobilizing a body part for an extended period of time if there has not been a surgical procedure, done, as it often creates more pain, avoidance, and worst of all, decreased muscle mass. This makes the rehab process more difficult. 

When should you not wear a sling for a rotator cuff injury?

(Unboxing) Shoulder Sling before Ro…

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(Unboxing) Shoulder Sling before Rotator Cuff Repair Surgery (Part 1)

As I shared briefly, above, I do not recommend you wear a sling any other time other than if you are post-op in weeks zero to six. 

If you are wearing a sling outside of that because it helps with pain, I would recommend considering not doing that, but also keeping it at a minimum if you must. 

It would be better to use ice, heat, and different exercises to see if you can improve symptoms.  

This will help keep your shoulder more mobile and reduce the risk of the shoulder locking up and turning into a frozen shoulder. 

Will the tear get worse if you don’t wear a sling?

There is no evidence that I have seen that says you are at a higher risk if you don’t wear a sling and you have a partial rotator cuff tear. 

That’s not to say that it’s not possible, however, if this issue was happening to me, I wouldn’t be worried about it. 

What is a rotator cuff injury?

A rotator cuff injury, often mistakenly called a rotary cup, is defined as pain, weakness, and decreased sensation of stability or any combination of those, at the shoulder. 

A rotator cuff can be strained or completely torn and these tears are graded in three stages. 

Grade one is a minor strain with no significant tearing. 

Grade two would be considered a partial thickness tear.

Grade three is defined as a full-thickness rotator cuff tear. 

Interestingly enough, having a grade three tear does not mean you will need surgery. In many cases, people live with full-thickness RTC tears and don’t even know they have them. This has been confirmed in several studies where they took MRIs of asymptomatic people who were then found to have rotator cuff tears. (source)

When do you need surgery?

I’ve explained this at length in another article, however, I’ll be brief, here. 

You likely need surgery if you can’t lift your arm, or have severe pain that has persisted longer than 6 months even after going through extensive, high-quality physical therapy. 

I’ve had too many clients come in over the years who can lift their arms straight over their head without any weakness whatsoever and who are told they need surgery. 

That is utter nonsense and whoever is recommending surgery to them needs their license to be revoked, or, at the very least, that person needs to be updated on the best available evidence around rotator cuff tears and when surgery is indicated, which I’ve also covered in other blog posts.  

What is a sling and how does it work?

Well, I think a sling is pretty self-explanatory once you see a picture…

Its main function is to immobilize the shoulder and reduce the traction forces that are experienced at the shoulder joint. 

Since the rotator cuff muscles are active “at rest” to stabilize your shoulder, without a sling, they are always working when you are in an upright position. 

There are two basic types of slings that are used for a RTC repair.

Shoulder sling with an abduction pillow (amazon link to Don Joy – this is the most popular sling), and then just some run-of-the-mill, old-school slings without the abduction pillow. 

Abduction just means that the arm is away from the body. It is the action of moving the arm away from the body and increasing the angle as measured by looking at the armpit. 

The abduction pillow places the shoulder in about 30 degrees of abduction which further reduces the traction forces that are placed upon the shoulder if you were in a regular sling without the abduction pillow.  

My clients have said these are much more comfortable than the regular slings. 

The only downside about the Don Joy slings and other slings with abduction pillows is that they are a bit bulkier and so you might have to be a bit more creative when walking through doorways and such. But, this only lasts for six weeks or so. 

Conclusion

Slings are widely used post-op for rotator cuff repair however they do not need to be used if you are not undergoing a surgical procedure. 

It’s best to find a rehab program that works for you, first, try that out, and then if that doesn’t work then proceed with a surgical procedure. This is always on a case-by-case basis. 

If you have any more questions and would like to speak to me directly please submit a consultation request by clicking the button below. 

Thank you!

Dr. Nate Kadlecek, PT

Nate Kadlecek, PT, DPT is a Columbia University-trained physical therapist committed to providing high-quality health information, largely focused on lower back pain and the gross overuse of diagnostic imaging, medication, surgery, low-quality treatment methods, and the over-diagnosis of pain conditions.
He competes in powerlifting and has recently taken up longer distance running, played football and baseball in college, successfully completed one mountaineering trip (barely), Shoe Dog by Phil Knight (a memoir about Nike) is his all-time favorite book and captures his own ethos, and few things get him as excited as presenting to groups of people eager to learn about the science of pain and talking about future tech and its integration with health.

Shoulder Slings and Immobilizers – Shoulder & Elbow

Shoulder Slings and Immobilizers

Posted on March 31, 2020March 31, 2020 by Shoulder&Elbow

Support and protection of the shoulder are important after injuries and surgery. Slings and immobilizers hold and safeguard the shoulder during healing. Those of you who have had shoulder surgery know that wearing a sling or immobilizer for several weeks is one of the least favorite parts of the recovery process. Getting the immobilizer on and off can be cumbersome, confusing, and may require some help. Wearing the sling feels unnatural, hot, and uncomfortable. However, use of a sling or shoulder immobilizer is a necessary evil for a good recovery! Mayo Clinic has published a number of videos to review use of slings and immobilizers. Links to these videos are provided below.

Are all slings and immobilizers the same?

Yes and no. Most slings and immobilizers have in common the use of a strap around the neck to help support the weight of the arm. Many immobilizers also include a strap around the waist to further protect the arm from rotating around the trunk. In our surgical practice, we use one of three shoulder immobilizers: the classic shoulder sling, an immobilizer with a small pillow (shoulder abduction sling), and a less common immobilizer with a larger pillow (external rotation brace).

Abduction sling

The abduction sling combines a classic sling connected through Velcro strips to a small pillow that fits the side of the trunk. The forearm rests over the pillow, keeping the shoulder slightly separated off the body. This position, called “abduction”, relaxes some of the structures of the shoulder, protecting them while they heal. The abduction sling also keeps the shoulder in some outward or external rotation, beneficial for some conditions. In addition, the fitting contour of the pillow limits how much the shoulder can rotate around the body. Abduction slings are commonly used for fracture management as well as after rotator cuff repair or shoulder replacement.  Click on the following links to understand how to put on a shoulder abduction sling while seating or standing.

Abduction sling

Classic sling

The classic sling combines a strap around the neck with a strap around the trunk, supporting the shoulder and keeping the forearm resting on the body. The shoulder rests in an inwards or internal rotation position, which may be particularly beneficial after soft-tissue anterior instability surgery and other procedures. Click on the following links to understand how to put on a shoulder sling while seating or standing.

Classic shoulder sling

External rotation brace

Certain procedures benefit from keeping the shoulder outwards in an externally rotated position. This can be achieved with the use of a shoulder immobilizer similar to the abduction sling, but with a larger pillow. This immobilizer, called external rotation brace, is recommended after surgery for posterior shoulder instability, transfer of the lower trapezius, and other procedures. Click on the following link to understand how to put on an external rotation brace.

External rotation brace

How about a shower?

After surgery, you should talk to your shoulder specialist regarding when to take a shower. Some surgeons prefer skin incisions to be completely sealed (about two weeks) before allowing a shower, whereas others find it reasonable to shower within a day or two after surgery. The immobilizers shown above are not ideal to take into the shower: they are bulky and hard to dry when they get wet. We recommend an alternative, very simple, shoulder sling for showers. Click on the following link to understand how to put on a shower sling. Alternatively, it may be safe to take a shower without a sling, just letting the arm by your side. In general, it is not recommended to rub over skin incisions when applying soap and water or when drying. It is best to gently let water run over incisions and to tap incisions dry.

Shower sling

Getting dressed

Getting dressed during the first few days to weeks after shoulder surgery can be a challenge too. The trickiest part is getting a shirt or a pullover on. The combination of discomfort after surgery and the need to protect the shoulder during healing can make getting dressed particularly complicated. Click on the following link to review how to get a shirt or pullover on.

Do I really need my immobilizer all day and night?

When recovering from an injury or surgery, it is typically best to use your sling or immobilizer the majority of the day and night. However, the immobilizer does come off to get dressed,  take a shower, and perform physical therapy exercises. In addition, whenever sitting in a nice chair or couch, it is perfectly reasonable to remove the immobilizer completely and let the forearm rest on your lap. On the contrary, when being active, especially outside, or when going to sleep, the shoulder immobilizer provides protection and should be used. The shoulder immobilizer also functions a sign to others: if you attend a family reunion or a gathering of friends with your immobilizer on, people will be more careful around you!

Most common mistakes when using a shoulder sling or immobilizer

Poor fitting is the most common reason for individuals to be uncomfortable when using their sling or shoulder immobilizer. Slings and immobilizers are manufactured in multiple sizes, and if you were provided with one too large or too small for you, it will just not fit and feel uncomfortable. Even if the size is correct, sometimes the strap around the neck is too long, so that the immobilizer does not really support the arm. The patient then feels the need to hold the weight of the arm through active muscle contraction, which leads to pain around the shoulder and shoulder blade. Finally, abduction slings tend not to fit well in overweight individuals: abdominal fat combined with the thickness of the abduction pillow will result in raising the arm excessively.

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Rehabilitation program after rotator cuff surgery

Rehabilitation program after rotator cuff surgery includes several stages. The goal of the early post-operative phase is to protect the repaired tissues along with providing the necessary range of motion and strengthening the surrounding muscles.

Shoulder Strengthening Exercises Promote Recovery After Rotator Cuff Surgery

Stretching and strengthening the tissues around an inflamed rotator cuff improves metabolism and, as a result, speeds up recovery and positively affects functional performance. Inflamed cuff tissues are characterized by an increased volume of fluid between cells and an increase in the number of blood vessels. As a result of the inflammatory reaction in the body, new collagen fibers are formed, the task of which is to restore injured tissues. If the shoulder is in a state of immobility for a long time, new collagen fibers are formed in a chaotic manner, forming a scar or contracture. The task of gentle stretching, constant movement of the joint in different planes, strengthening and anti-inflammatory components is to stimulate cells to form collagen along lines of stress, forming normal strong ligaments. The combination of a good warm-up, gentle stretching, painless firming, post-exercise cold, and anti-inflammatory therapy can greatly speed up the recovery process.
The rotator cuff stretch is great for anti-inflammatory and warming up before strenuous exercise.

Specific stretches are preferred for different activities. For example, before skiing, take a ski pole at opposite ends with both hands, stretch your arms straight and lift the pole from waist level to head level to the limit, slowly repeat the movements.
With a stick above your head, lean as far as possible to the left, then to the right. This movement can be repeated with the arms extended forward. Other types of stretching are also possible, provided there is no acute pain.

This protocol is a general guideline that can be adjusted to suit each individual case.
• Early passive development of the shoulder joint is essential to prevent capsular adhesions. It is optimal to use the mechanotherapy apparatus for the development of the shoulder joint, which allows you to bend, unbend and rotate the arm in the correct physiological mode. Learn more about mechanotherapy
• Early passive movements should be done in such a way as to avoid further adduction of the midline and external rotation
• Do not lift the operated arm above 70 degrees in any plane for the first 4 weeks after surgery
• Do not lift more than 2.5 kg with the operated arm for the first 6 months
• Avoid excessive extension and internal/external rotation during the first 6 weeks
• Cool your shoulder 3-5 times for 15 minutes a day to control swelling and inflammation.
• Wear a sling for the first 4 weeks. Wearing a sling during sleep is optional, depending on comfort
• Use a quality vertical support brace at all times – especially while wearing a sling
• Doctor’s follow-up: 1 day, removal of sutures – 14th day, further visits to the doctor after 1 month, after 3 months and one year after surgery

Rehabilitation program after rotator cuff surgery: weeks 0-2

• Day 1: clinic, dressing change and home program determination
• Exercise 3 times a day:
1) pendulum
2) ball squeeze
3) biceps and triceps training with a rubber band (Theraband)
4) passive flexion and extension in the plane of the scapula (from bottom to top) 0-60 degrees 3-4 hours on the Artromot-S3 mechanotherapy device for the shoulder or using manual techniques.
5) Isometric abduction, adduction, flexion, and extension of the arm
6) Scapular contraction every hour
7) Neck stretch for comfort
• Day 14: Removal of sutures

Learn about recommended exercises for shoulder recovery after injuries and surgeries on the shoulder joint

Find out how to rent a mechanical therapy machine for shoulder development

Rehabilitation program after rotator cuff surgery: 2-4 weeks

-clavicular joint (optional)
• Soft tissue care of the affected shoulder and neck muscles for a comfortable feel
• Continue passive flexion and extension in the plane of the scapula 0-60 degrees for a minimum of 4 hours using the Artromot-S3 shoulder mechanotherapy device or manual technique

Rehabilitation program after rotator cuff surgery: weeks 4-8

Week 4: visit to the doctor
In the fourth week, you can gradually increase the angle of flexion and increase the load
• Start external and internal rotations and active exercises on the lung resistance (approximately 75% of total range of motion as symptoms permit) avoiding elevation and sudden increases in degrees
• Aim for flexion and abduction up to 90 degrees

Rehabilitation program after rotator cuff surgery: weeks 8-12

• Achieve full range of motion in all planes: especially in flexion, abduction, external and internal rotation
• Mobilize the soft tissues of both the shoulder and scapula joints to increase range of motion
• Exercises: elastic band exercises, shoulder blade training (rowing, stretching, lower trapezium work, etc. ) and PNF therapy
• DO NOT raise your arm above your head

Rehabilitation program after rotator cuff surgery: Week 12 onwards

• Move to a more active rehabilitation program, adjust the load according to your condition
• Start progressive exercise with tolerance resistance resistance weights
• Continue to work on range of motion in all planes
• Increase the intensity of load and functional training to gradually return to sports activities
• Return to sports is possible after functional testing and determined by a physiotherapist

Source: http://www.stoneclinic.com/rotator-cuff-repair-rehab-protocol

This article is for informational purposes only. Be sure to consult your doctor to find out if this rehabilitation program is right for you after rotator cuff surgery

The effectiveness of passive long-term movements after rotator cuff arthroscopy for a month

Introduction

Postoperative physiotherapy is necessary for arthroscopy (suturing) of ruptures of the rotator cuff of the shoulder. The rehabilitation program aims to restore the full symmetry of active and passive movements, balance muscle strength in the frontal and axial planes and return painless motion, freedom, and functionality.

Factors that can affect the success of the rehabilitation process include: the size and location of the injury, the presence of any concomitant pathologies, as well as the surgical technique used.

Doctors are especially concerned about maximizing the effectiveness of physical therapy, since simply reducing the time allotted for rehabilitation procedures can have negative consequences and increase the recovery period for the normal physiological functioning of the ligaments.

Postoperative diagnostics in restoring the integrity of the tendons of the shoulder joint is widely discussed. It has been hypothesized that if the restoration of the motor ability of the shoulder is started too early, there may be a loss of range of motion due to the formation of fibrous adhesions in the area of ​​the rupture. In this regard, it is recommended to carry out active and passive postoperative mobilization (restoration of motor ability) under the guidance of specialists. Also, if necessary, water therapy and neuromuscular electrical stimulation can be included in the complex of restorative procedures.

The purpose of this study is to evaluate the effectiveness of continuous passive mobilization (PPM) using the device for passive development of the shoulder joint ARTROMOT S3.

PPM is carried out by an external mechanized device that allows passive restoration of the motor ability of the tendons along the selected motor axis.

The biological basis for PPM was proposed by Salter in the early 1980s.

He demonstrated that through PPM, the rabbit’s knee can recover faster, cartilage tissue regenerates faster compared to prolonged resting of the ligaments.

Coutts and colleagues were the first to use PPM in the clinic immediately after total knee arthroplasty: Salter’s earlier study served as the basis for Coutts and his associates. Scientists have suggested that PPM increases the rate of recovery of connective tissues, ensuring the correct arrangement of fibers without mutual crossing and, therefore, the restoration of motor functions in the proper volume.

For the past 20 years, PPM has been widely used as an adjunct to physiotherapy after total knee replacement, but the search for the most effective method is still ongoing.
Although many doctors recommend PPM, others believe that this technique does not bring anything significantly new to the rehabilitation process.

A serious assessment of the effectiveness of these devices in restoring the functioning of the upper limb is now very relevant.

The hypothesis of the present study is that PPM in combination with a standard rehabilitation program after rotator cuff arthroscopy can accelerate the recovery of motor functions, compared with the standard rehabilitation program alone.

Means and methods

From January 2004 to March 2007, 100 patients (47 males and 53 females), mean age 60 years (range 38 to 80 years), who underwent arthroscopy of a rotator cuff tear were enrolled in this prospective, randomized study.

Approval was obtained from the local ethics committee, and all patients gave written informed consent to participate in the study.

The criteria for selecting subjects were as follows: the presence of a rupture of the upper ligaments of the shoulder joint of the second / third degree according to the Snyder scale; No history of operations on this area of ​​the body, absence of concomitant diseases and a sufficient level of education.

All operations were performed by the same surgeon, at the Department of Shoulder Restoration, Humanitas Institute in Rosano, Milan, Italy, using a bilateral titanium suture fixator, sometimes in combination with a latero-lateral reinforcing suture. All patients were operated on in the supine position, under local local anesthesia.

After the operation, the shoulder was immobilized for 4 weeks using an Ultra Sling II bracelet. Immediately after the operation, the patients were randomly divided into two groups, matched by age and gender, A and B. Patients from group A (46 people) independently performed a set of mobilizing exercises under the supervision of a physiotherapist, consisting of three sessions of 10 approaches each: pendulum movements and progressive passive arm abduction, forward bending and external rotation; Whereas patients from group B (54 people), accompanied by specialists, performed an additional PPM complex on the Artromot S3 device (Ormed, Germany) for 2 hours a day, in 4 sets of 30 minutes each.

Then, from the fifth to the twenty-eighth week, a similar rehabilitation therapy was applied in both groups, namely, from the 5th to the 12th week, passive mobilization continued under the supervision of a physiotherapist. The following exercises were performed: passive progressive forward flexion, external rotation and limb abduction, plus elementary proprioceptive exercises (exercises to sense the position of the body in space).

From the 13th to the 28th week, classes continued according to the passive program in order to restore the full range of motion. Also, active exercises were carried out to restore the range of motion, performed under the supervision of a specialist, depending on the degree of pain tolerance; In addition, exercises began to be carried out for progressive isometric strengthening of the external and internal rotational muscles, as well as for the stabilization of the muscles of the shoulder girdle.

An independent expert assessed pain in patients on a VAS scale (from 0 to 10) and range of motion during abduction (ABD), upper limb forward flexion (FF), and external rotation during abduction (ER2, after 2.5, 6 and 12 months.

Paired Student’s t-test (T-test) and Wilcoxon test were used to analyze and compare the data. The reliability of the data is 95%. Statistical error at the level of P < 0.05.

Results

No complications were found in the subjects during and after the operation.

All subjects completed participation in the one-year prospective study on time.

At the first stage of a prospective study conducted 2. 5 months after surgery, subjects from group B had statistically significant higher scores on the VAS scale (7.5 ± 0.1) (P < 0.01), FF (133 ± 21.1) (P < 0.01) , ABD (66.7 ± 14.5) (error < 0.05), ER2 (63.5 ± 15.4) (P < 0.05) than in subjects from the group, A on the VAS scale (9.1 ± 0.2), FF (120.7 ± 20.6), ABD (60.1 ± 14), ER2 (56 ± 14).

After 6 months, a prospective study showed the following results: in patients from group B, the FF scores were still significantly different (158.1 ± 9.4) (P < 0.01), ABD (86.9 ± 5.3) (P < 0.01), ER2 (83 ± 7.7 ) (P < 0.05), while patients from group A had the following indicators: FF (151.7 ± 12.5), ABD (82.3 ± 7.6), ER2 (79.1 ± 7.4). No statistically significant differences in VAS scores between group B (0.5 ± 0.1) and group A (0.6 ± 0.1) (P > 0.05) were found.

At the third stage of the prospective study (after 12 months), no statistically significant differences in the parameters in both groups were found. In group B, the VAS scores are as follows: (0. 2 ± 0.1) (P > 0.05), FF (165.2 ± 8) (P > 0.05), ABD (90 ± 2.5) (P > 0.05), ER2 (86 ± 4) (P > 0.05), while in group A, the values ​​on the VAS scale are as follows: (0.2 ± 0.2), FF (158 ± 10.1), ABD (88 ± 1.8), ER2 (85 ± 4.2).

Figures 1, 2 and 3 show a summary of the results of restoration of range of motion in both groups of patients.

Rice. 1 – Results on the degree of arm abduction in group A (ABD) and in group B (ABD + PPM) at 2.5 months, 6 and 12 months.

Rice. 2 – Results on the degree of forward bending of the arm in group A (FFL) and in group B (FFL + PPM) at 2.5, 6 and 12 months.

Rice. 3 – results on the degree of excessive rotation during arm abduction in group A (ER2) and in group B (ER2 + PPM) at 2.5, 6 and 12 months.

Talk

The results of the study indicate that the use of PPM can accelerate the recovery of motor functions of the shoulder joint in the short term, however, in the long term, no statistically significant differences between the two rehabilitation programs were found in the course of a prospective study.

Some authors believe that immobilization after arthroscopy of the rotator cuff prevents the formation of excess fibrous tissue in the subacromial space, preventing hardening of the ligaments.

Moreover, it was found that mechanical stress “turns on” mitogen-activated protein kinase, triggering an avalanche of inflammatory cytokines, such as TNF-alpha and IL-6, which leads to the formation of fibroblasts and the formation of adhesive capsulitis.

Other authors, on the contrary, are convinced that passive mobilization is preferable to immobilization. Ferretti and colleagues demonstrated that prolonged passive mobilization in rabbit tendon arthrosis significantly prevents the inflammatory process caused by the formation of IL-10 and the suppression of the destruction of the capsid protein gene.

This leads to a significant qualitative and quantitative reorganization of connective tissues, as well as increased vascularization in the tendons and metabolic activity of tenocytes.

In a meta-analysis, Milne and colleagues concluded that the use of PPM in combination with segmental rehabilitation after knee replacement surgery in the short term gives better results compared to the standard rehabilitation program alone. However, no agreement was reached either on the period of application of the PPM, or on the duration of each session.

Some clinical reviews recommend the use of PPM in the early stages of postoperative rehabilitation.

In any case, only a few studies have evaluated the results of using devices like the Artromot system in rehabilitation for shoulder injuries.

In 1996, Raab and colleagues found better outcomes in 14 patients undergoing subacromial decompression after PPM combined with a standard postoperative rehabilitation program compared to 12 patients in the control group. After 3 months from the start of the prolonged study, the range of motion in patients from the experimental group was significantly greater, and in women over the age of 60, the level of pain was reduced.

In 1998, Lastio and colleagues applied PPM to 17 patients undergoing joint surgery for the first four weeks after surgery, 55 minutes a day; After 32 weeks, no statistically significant differences in VAS, muscle strength and range of motion compared with the control group were found.

In 2005, Michael and colleagues randomly assigned 55 patients undergoing shoulder surgery into two groups. Patients from one group performed the usual rehabilitation complex, and the other group used PPM in addition to the standard program. Scientists have found that patients from the second group (using PPM) 12 days earlier were able to abduct the upper limb by 90 degrees. In addition, these patients experienced less pain.

Compared to the previous three studies, the experience is based on the evaluation of a larger sample of patients and a longer prospective study. Data from 54 patients using PPM show that at 2.5 and 6 months from the start of the prospective study, daily 2-hour long-term passive mobilization significantly reduces pain and speeds up recovery of joint range of motion, compared with passive manual mobilization alone performed by an experienced physiotherapist. However, the final results of a prospective study (one year from the start) are the same in both cases.

Our study has some limitations. First of all, conducting an ideal experiment requires comparing the same surgical procedures performed simultaneously or sequentially on the same patient in order to eliminate the influence of the effect of individuality.

Secondly, there are various rehabilitation programs for restoring the functions of the rotator cuff. The program could be different from those taken by participants in other studies.

However, the study also has strengths: a large sample of subjects, all operations were performed by the same surgeon, physical therapy was carried out under the supervision of the same doctor and was performed by a qualified physiotherapist specializing in restoring the functions of the rotator cuff, working closely with doctor.

Moreover, no patient terminated participation in the prospective study ahead of schedule.

The main reasons why PPM has not received support in medical circles may be the high cost of the device, as well as the fact that in the long term, functional results do not seem to differ from those that occur with traditional rehabilitation methods.

Since the data indicate that the clinical use of PPM leads to a faster recovery of ligament range of motion and reduces pain, it is recommended to use PPM in combination with a classic rehabilitation program for patients who need accelerated recovery of upper limb functions for a faster return to work or sports. activities.

PPM allows you to quickly restore range of motion and muscle strength after surgery to restore the integrity of the rotator cuff.

In the medical literature, there are still recommendations for the use of PPM in the first 4 weeks after surgery: this is the best period, since it is at this time that the relationship between tendons and bone in the shoulder girdle area is restored and adjusted.