There are many reasons physical therapists (PTs) or orthopedic surgeons may progress patients with rotator cuff repairs at different paces. It is important to realize that rotator cuff tears range from small to massive in size. A small tear, less than one centimeter in length, will have more healthy rotator cuff tissue adjacent to provide support while the repaired tissue regrows into the upper arm bone. A massive tear will exceed five centimeters and will have multiple anchors supporting the repair as compared to healthy tissue, this requires a slower, more cautious approach. In addition to size, there are numerous other clinical reasons that a physical therapist in coordination with the orthopedic surgeon may incorporate into their judgement to set a rehabilitation pace. These may include:
- Smoking – Medical literature consistently supports the fact that heavy smoking impacts healing. In one study (American Journal of Sports Medicine – October 2018) there is a significantly higher non-healing rate of repaired rotator cuffs in smokers (29%) vs non-smokers (6%).
- Diabetes – A study published in the American Journal of Sports Medicine – April 2015, reported that 43% of diabetics with poor glycemic control with hemoglobin A1c elevated had a recurrent tear rate as opposed to 14% of non-diabetics.
- Soft bone – Surgical anchors are tapped or screwed into the bone with each anchor having sutures that pull and hold the rotator cuff to the upper arm bone to allow the rotator cuff to regrow into the bone. If the bone quality is soft there is a greater chance the anchor could come loose or back out. Therefore, a slower approach can give time for the bone to grow and stabilize the anchor more firmly.
- Poor tissue quality – Simple rotator cuff tears present as a healthy tendon that has disconnected from the bone, whereas other tears may present in a more shredded fashion. These poor tissue, shredded tears have a greater opportunity to have the stitches pull through the repaired rotator cuff, allowing the rotator cuff to left off the bone.
- Rotator cuff retracted – Retracted tears typically are present in tears that are several months or years old. In this case the muscle shrinks back to its other attachment. When the physician repairs retracted tears, they must pull the rotator cuff back to its original location, which may lead to the repair being under tension at rest or when the shoulder is moved.
- Non-compliance with rehab plan – As physical therapists, we generally are aware of which patients are following precautions and which are taking additional liberties and moving more or protecting their shoulders less. In the overactive patient, the risk of a negative outcome increases, therefore many physical therapists will slow the physical therapy plan to better balance the total stresses on the healing rotator cuff.
- General age and health – Simply put, the younger and healthier someone is, the faster their body will heal.
- Early onset of shoulder stiffness/frozen shoulder – No matter how skilled your surgeon and physical therapist are, there will be infrequent onsets of frozen shoulder. In these cases, the physical therapist may speed up the rehab motion plan to offset further motion restrictions from the frozen shoulder. The physical therapist will still err on the side of caution as a stiff shoulder with healed rotator cuff has more treatment options and less invasive options as opposed to the treatment of a re-torn rotator cuff from over aggressive therapy or patient taking additional activity liberties.
One size does not fit all, listen to your orthopedic surgeon and physical therapist to determine the best plan for you. Unless your friends and family members are surgeons and physical therapists, it is best to just thank them for their concern.
Written by OrthoKnox Physical Therapy Operations Manager, Michael Hoag, PT, DPT, MBA, OCS, MTC