Postoperative Mobilization After Superior Rotator Cuff Repair: Sling versus No-sling. A Randomized Controlled Trial: Sling versus no-sling after RCR

Abstract

Objectives: Patients are commonly advised to wear a sling for 4-6 weeks after rotator cuff repair (RCR) despite negative effects of early immobilization and benefits of motion rehabilitation. The study aimed to compare clinical and radiographic outcomes up to 6 months following RCR with sling immobilization and without sling immobilization. Methods: We randomized 80 patients scheduled for arthroscopic repair of small or medium superior rotator cuff tears into 2 equal groups: 'sling' and 'no-sling' groups. Passive mobilization was performed in both groups during the first 4 postoperative weeks followed by a progressive active mobilization. Patients were evaluated clinically at 10 days, 1.5, 3 and 6 months, and using ultrasound at 6 months. Uni-and multi-variable analyses were performed to determine if postoperative scores are associated with gender, age at surgery, immobilization, arm dominance, biceps procedure, resection of the distal clavicle, as well as preoperative scores. Results: The two groups had similar preoperative patient characteristics, function, or adjuvant procedures. At 10 days, there was no difference in pain among the two groups (5.2±2.3 vs 5.2±1.9, p=0.996). In comparison to the sling group, the no-sling group showed greater external rotation (23.5±15.6 vs 15.3±14.6, p=0.017) and active elevation (110.9±31.9 vs 97.0±25.0, p=0.038) at 1.5 months, as well as better active elevation (139.0±24.7 vs 125.8±24.4, p=0.015) and internal rotation (>T12 in 50% vs 27.5%, p=0.011) at 3 months. Ultrasound revealed no differences at 6 months in tendon thickness anteriorly (p=0.472) or posteriorly (p=639), bursitis (p=1.000), echogenicity (p=0.422), or repair integrity (p=0.902). Multi-variable analyses confirmed that ASES score increased with patient age (beta, 0.60; p=0.009), SANE decreased with sling immobilization (beta,-6.3; p=0.014), and that pain increased with sling immobilization (beta, 0.77; p=0.022). Conclusion: No immobilization after RCR is associated with better early mobility and functional scores in comparison to sling immobilization. Postoperative immobilization with slings may therefore not be required for patients treated for small or medium tears.

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.…”

Effectiveness of early versus delayed rehabilitation following rotator cuff repair: systematic review and meta-analyses

“…The method of immobilisation after rotator cuff repair was variable. The majority of the RCTs (3, 19, 20, 23-30)(11/20, 55%) reported the use of a standard sling, six RCTs (18, 21, 22, 31-33) used a sling with an abduction component and one RCT (34) used a standard sling for the early group and a sling with an abduction component for the delayed group. The time in the sling was also variable; eight RCTs (40%) (18, 21, 23-26, 29, 32) used a six-week period for both groups.…”

“…Three RCTs prescribed a sling for the early group to be used for comfort only and discarded as the patient felt appropriate (3, 19, 20). One RCT did not prescribe a sling for those in the early group (30).…”

“…Overall, the number of complications were low. Nine RCTs (3, 19, 20, 22, 23, 26, 27, 30, 34) reported post-operative complications. The most common complication, reported in five RCTs (19, 20, 22, 23, 34), was related to limited shoulder range of movement.…”

A Review of Online Rehabilitation Protocols Designated for Rotator Cuff Repairs

“…Overall, among the protocols designated for small (10 protocols) or medium (17 protocols) RTC tears, use of a postoperative sling or immobilizer was recommended for the first 4 weeks postoperatively or longer in 22 of 27 protocols (81.5%). However, in a study looking at immobilization after RTC repair, Tirefort et al 16 found that sling use may not be indicated after repair of small or medium RTC tears, owing to their finding that undergoing no immobilization was associated with better early mobility and functional scores than undergoing sling immobilization. They also determined that undergoing no immobilization was significantly associated with reduced pain and improved function at 6 months compared with patients undergoing 4 weeks of sling use or immobilization.…”