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At least a 6-month delay
Massive rotator cuff tears are typically defined as rupture of at least two of the four rotator cuff tendons and/or retraction away from the attachment site of 5 cm or greater. Thus, these are generally accepted as more challenging repairs with a longer recovery. Tendon healing to bone biologically takes 3 months. Strengthening typically will not start until after this time, and therefore maximal recovery of strength can take up to 1 year. We must proceed with caution when rehabbing massive repairs as these repairs are at the highest risk for either re-rupture or not healing. Meta-analyses show the overall re-tear rate of all rotator cuff repairs is around 26%; however, when massive repairs are isolated, some studies report up to a 91% non-healing rate. Although many factors are important in predicting which rotator cuff tears will not heal, the size of the tear is paramount. Several studies have shown that despite many repairs not healing, clinical outcomes are still good. However, it has been shown shoulder strength is better if the repair heals and, therefore, every attempt should be made to ensure healing. Several well-done studies have shown rotator cuff repairs are most vulnerable to re-tear or non-healing in the first 6 months after repair. Therefore, when considering all these factors, it would be wise to delay return to demanding activity until at least the 6-month mark. However, it is even wiser to begin to ease into full activity at the 6-month mark with a goal of full return between 6 months and 1 year postoperatively.
Julie Bishop, MD, is director of the Division of Shoulder Surgery at The Ohio State University Wexner Medical Center in Columbus, Ohio.
Disclosure: Bishop reports no relevant financial disclosures.
Mature healing timeline unknown
The timeline for return to full physical activity after rotator cuff repair is a particularly relevant topic given the active nature of some patients and the desire to return to full recreational and occupational demands. These desires, coupled with the unpredictable healing of massive rotator cuff tears, make counseling patients following rotator repair challenging on many levels.
The precise timeline for mature healing of the rotator cuff in humans in largely unknown. Studies in large animals suggest a reasonable healing response occurs at 12 to 16 weeks although the tendon remains disorganized at these time points. Clinical research suggests gentle rotator cuff strengthening is safe at 3 months for routine repairs. However, many surgeons advocate for delayed strengthening at 4 months for large to massive tears, allowing for a more mature healing response. Although the success of traditional rehabilitation for standard repairs has been well studied, the potential benefits of delayed rehabilitation for higher risk tears is largely unknown. It is generally felt that 6 to 8 weeks of dedicated rotator cuff strengthening is necessary before resumption of heavier lifting and normal gym-related activities.
It has been shown the majority of re-tears following cuff repair happen in the first 6 months following surgery and recurrent tears that occur more the 1 year after successful healing are unusual. There is a known risk of recurrent tears in massive tears that generally ranges from 25% to 40% depending on patient age and repair construct. When considering the relatively high risk of re-tears in these tears combined with the “normal” healing timeline, it is advisable to delay return to demanding activities for at least 6 months following surgery, possibly longer. The rate of progression and ultimate limitations for these patients must be individualized based upon progress in rehabilitation and return of cuff strength.
Jay D. Keener, MD, is an associate professor, chief of Shoulder and Elbow Service and fellowship director in the department of orthopedic surgery at Washington University, in St. Louis.
Disclosure: Keener reports he received a grant from the NIH.