What is the recommended management approach for post-operative rotator cuff repair?

Post-Operative Rotator Cuff Repair Management

The optimal management approach for post-operative rotator cuff repair should include an arthroscopic surgical approach, multimodal pain management, and a rehabilitation protocol with early passive mobilization for small to medium tears, while reserving opioids only for rescue analgesia. 1

Pain Management Protocol

Immediate Post-Operative Pain Control

1. Systemic Analgesia

   • Paracetamol (acetaminophen): Administer pre-operatively or intra-operatively and continue postoperatively 1
   • NSAIDs/COX-2 inhibitors: Begin pre-operatively or intra-operatively and continue postoperatively 1
   • Single dose of IV dexamethasone: Recommended to increase analgesic duration of nerve blocks, decrease analgesic use, and provide anti-emetic effects 1
   • Opioids: Reserve only for rescue analgesia 1

2. Regional Analgesia (in order of preference)

   • First choice: Interscalene brachial plexus block (continuous or single-shot) 1
   • Alternative: Suprascapular nerve block with or without axillary nerve block 1

Surgical Technique Considerations

• Arthroscopic approach is strongly recommended over open repair due to reduced postoperative pain 1
• Strong evidence does not support routine use of acromioplasty as a concomitant treatment for small to medium-sized tears 1
• Strong evidence does not support double-row over single-row mattress repair constructs for improving patient-reported outcomes 1

Rehabilitation Protocol

Mobilization Timing

• Strong evidence suggests similar outcomes between early mobilization and delayed mobilization (up to 8 weeks) for small to medium-sized tears 1
• Current evidence shows no significant differences in healing rates between early passive motion and delayed motion protocols 2
• Early motion (whether passive or active) leads to greater flexion than strict immobilization 2

Recommended Rehabilitation Timeline

1. Weeks 0-4:

   • Immobilization with abduction pillow sling with arm in neutral or slight internal rotation 3
   • For small to medium tears: Begin passive range of motion exercises 1, 4
   • For large tears: Consider delayed mobilization to reduce risk of re-tear 5

2. Weeks 4-6:

   • Progress to unrestricted passive shoulder range of motion 3
   • Continue protection from active motion

3. Weeks 6-12:

   • Begin strengthening exercises 3
   • Gradual progression of active motion

4. Months 3-6:

   • Progressive strengthening
   • Sport-specific or work-specific rehabilitation

5. Months 5-6:

   • Unrestricted return to activities 3

Special Considerations

Patient-Specific Factors Affecting Outcomes

• Age: Strong evidence indicates older age is associated with higher failure rates and poorer patient-reported outcomes 1
• Diabetes: Moderate evidence suggests patients with diabetes have higher retear rates and poorer quality of life scores 1
• Other Comorbidities: Moderate evidence supports association of poorer patient-reported outcomes in patients with comorbidities 1

Biological Augmentation

• Strong evidence does not support routine use of platelet-derived products for improving patient-reported outcomes 1
• Limited evidence supports use of dermal allografts to augment repair of large and massive tears 1
• Limited evidence suggests marrow stimulation may decrease retear rates in patients with larger tear sizes 1

Common Pitfalls and How to Avoid Them

1. Overuse of opioids: Implement multimodal analgesia with regional techniques and non-opioid medications to minimize opioid requirements 1

2. Inappropriate mobilization timing: Consider tear size, patient age, and tissue quality when determining mobilization protocol - not all patients should follow the same timeline 5

3. Neglecting pain control during rehabilitation: Ensure adequate pain management during therapy sessions to allow proper participation 1, 6

4. Multiple corticosteroid injections: Limit to 3-4 injections per year in the same location as multiple injections may weaken tendon tissue 6

5. Failure to recognize rehabilitation protocol variations: Be aware that there is tremendous variability in postoperative rehabilitation protocols, with a trend toward later mobilization among surgeons 3

By following these evidence-based recommendations, clinicians can optimize outcomes following rotator cuff repair while minimizing complications and maximizing functional recovery.