Postoperative Mobilization After Superior Rotator Cuff Repair: Sling Versus No Sling

Abstract

Background: Patients are commonly advised to wear a sling for 4 to 6 weeks after rotator cuff repair despite negative effects of early immobilization and benefits of motion rehabilitation. The aim of this study was to compare clinical and radiographic outcomes up to 6 months following rotator cuff repair with and without postoperative sling immobilization. Methods: We randomized 80 patients scheduled for arthroscopic repair of a small or medium superior rotator cuff tear into sling and no-sling groups (40 patients each). Passive mobilization was performed in both groups during the first 4 postoperative weeks, and this was followed by progressive active mobilization. Patients were evaluated clinically at 10 days and 1.5, 3, and 6 months and using ultrasound at 6 months. Univariable and multivariable analyses were performed to determine if postoperative scores were associated with sex, age at surgery, immobilization, arm dominance, a biceps procedure, resection of the distal part of the clavicle, or preoperative scores. Results: The sling and no-sling groups had similar preoperative patient characteristics, function, and adjuvant procedures. At 10 days, there was no difference in pain between the 2 groups (mean pain score [and standard deviation], 5.2 ± 2.3 versus 5.2 ± 1.9, p = 0.996). In comparison with the sling group, the no-sling group showed greater mean external rotation (23.5° ± 15.6° versus 15.3° ± 14.6°, p = 0.017) and active elevation (110.9° ± 31.9° versus 97.0° ± 25.0°, p = 0.038) at 1.5 months as well as better mean active elevation (139.0° ± 24.7° versus 125.8° ± 24.4°, p = 0.015) and internal rotation (T12 or above in 50% versus 28%, p = 0.011) at 3 months. Ultrasound evaluation revealed no significant differences at 6 months in tendon thickness anteriorly (p = 0.472) or posteriorly (p = 0.639), bursitis (p = 1.000), echogenicity (p = 0.422), or repair integrity (p = 0.902). Multivariable analyses confirmed that the mean American Shoulder and Elbow Surgeons (ASES) score increased with patient age (beta, 0.60; p = 0.009), the Single Assessment Numeric Evaluation (SANE) decreased with sling immobilization (beta, −6.33; p = 0.014), and pain increased with sling immobilization (beta, 0.77; p = 0.022). Conclusions: No immobilization after rotator cuff repair is associated with better early mobility and functional scores in comparison with sling immobilization. Postoperative immobilization with a sling may therefore not be required for patients treated for a small or medium tendon tear. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Rehabilitation following rotator cuff repair: A multi-centre pilot & feasibility randomised controlled trial (RaCeR)

“…Other recent randomised controlled trials have been reported. 11 , 20 , 21 Mazzocca et al 20 ( n = 73) compared early movement (starting two to three days after surgery) versus delayed movement (starting 28 days after surgery), similar to standard rehabilitation reported here. There was no statistically significant difference in Western Ontario Rotator Cuff scores at six months, but the early movement group reported lower scores (better clinical status) throughout the post-operative period.…”

“…After one year there was no difference in re-tear rates (30% vs 33%) and after two years there was no difference in clinical outcomes. Tirefort et al 21 ( n = 80) compared no sling versus the use of a sling for the first four post-operative weeks following arthroscopic rotator cuff repair (small to medium tears included). There was a statistically significant improvement in range of movement at six and 12 weeks for the no sling group.…”

Rehabilitation following rotator cuff repair: A nested qualitative study exploring the perceptions and experiences of participants in a randomised controlled trial

“…Clinical tension and anxiety about compromising the surgical repair with early patient-directed rehabilitation was apparent. Recent international randomised controlled trials have reported similar re-tear rates in early versus delayed mobilisation groups, 12 , 13 but were not powered to detect a difference in re-tear rates between groups. To enable a valid comparison in a future randomised controlled trial this tension needs to be recognised and pro-actively discussed with the aim of working with clinicians in equipoise.…”

An accurate method of measuring shoulder sling compliance: a validation study

“…It is important to address the debate of the importance of sling wear postoperatively for rotator cuff tears. Tirefort et al [ 17 ] recently showed no difference in outcomes when comparing sling immobilization versus no restrictions postoperatively for small-to-medium sized tears. Compliance with sling immobilization was self-reported, however, and may not reflect actual sling wear.…”