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Effects of slow and accelerated rehabilitation
protocols on range of motion after
arthroscopic rotator cuff repair
ORIGINAL ARTICLE
Acta Orthop Traumatol Turc 2014;48(6):642-648
doi: 10.3944/AOTT.2014.13.0125
İrem DÜZGÜN1, Gül BALTACI1, Elif TURGUT1, O. Ahmet ATAY2
1Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey;
2Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
Objective: e aim of the study was to investigate the effects of the early initiation of passive and active
range of motion exercises following arthroscopic rotator cuff repair.
Methods: e study included 40 patients who underwent arthroscopic rotator cuff repair. Patients
were quasi-randomly assigned into accelerated (ACCEL) protocol (n=19) and slow (SLOW) protocol
(n=21) groups. Patients in both groups were treated with the same protocol. Active range of motion
was begun at the 3rd week in the ACCEL group and the 6th week in the SLOW group. Range of motion
was recorded at postoperative weeks 3, 5, 8, 12, and 24.
Results: While active range of motion for all measurements improved across weeks, there were no dif-
ferences between groups, with the exception of active total elevation which was greater at all time point
measurements in the ACCEL group (p<0.05).
Conclusion: e early initiation of passive and gentle controlled active motion exercise following rota-
tor cuff repairs does not appear to affect range of motion in the first 6 postoperative months.
Key words: Exercise; manual therapy; rehabilitation; rotator cuff.
e indication for surgical treatment of rotator cuff tear
is a documented partial or full-thickness tear that has
not responded to conservative treatment and produces
symptoms that interfere with the patient’s normal func-
tioning.[1] Postoperative rehabilitation goals for patients
are to decrease pain, increase range of motion (ROM)
and return to normal functional activities at the earliest
time while preventing rerupturing of the repaired tissues.
Controlled and gradually increased loading of move-
ments and exercises are prerequisites for optimal tendon
healing.[2] Collagen that is stressed regains its forma-
tion and tensile strength better than collagen that is not
stressed.[3] Recent literature suggests that a period of im-
mobilization improves the quality of rotator cuff tendon
healing.[4-6] Peltz et al. reported detrimental effects on
passive shoulder mechanics of immediate postoperative
passive motion in an animal model and speculated that
decreased ROM and increased joint stiffness are caused
by increased scar formation in the subacromial space
due to passive motion.[5] However, others have suggested
that active ROM should not be initiated until the 6th
postoperative week and emphasized the importance of
Correspondence: İrem Düzgün, PT, PhD, Assoc. Prof. Hacettepe Üniversitesi Sağlık Bilimleri
Fakültesi, Fizyoterapi ve Rehabilitasyon Anabilim Dalı, 06100 Sıhhiye, Ankara, Turkey.
Tel: +90 312 – 216 26 32 e-mail: iremduzgun@hacettepe.edu.tr
Submitted: November 04, 2013 Accepted: July 06, 2014
©2014 Turkish Association of Orthopaedics and Traumatology
Available online at
www.aott.org.tr
doi: 10.3944/AOTT.2014.13.0125
QR (Quick Response) Code
Düzgün et al. Effects of slow and accelerated rehabilitation protocols on ROM after rotator cuff repair 643
passive ROM exercises within the limitation of the heal-
ing tissues and pain in the first week after rotator cuff
repair.[7-9] Passive ROM exercises initiated the first day
after surgery followed by active ROM exercises at the 4th
week was found to have no adverse effects.[10]
ese contrasting findings indicate that postopera-
tive care is not definitive, as it is unknown if earlier mo-
tion is detrimental or beneficial to the postoperative goal
of reduced pain and improved function. erefore, the
aim of this study was to determine and compare the ef-
fects of an early rehabilitation protocol on ROM and
function following arthroscopic rotator cuff repair.
Patients and methods
Forty-eight subjects with Stage 2 or 3 rotator cuff tear as
determined by MRI[11] who underwent arthroscopic ro-
tator cuff repair for a full-thickness tear were included in
the study. Patients presenting with a central nervous sys-
tem disorder (n=1) or a peripheral nerve disorder (n=
3), who were not willing to cooperate with the rehabili-
tation duration (n=1) or who self-reported psychologi-
cal disorder (n=1) were excluded. All the patients had
non-traumatic degenerative tears.
Excluding two other patients lost to follow-up, the
remaining 40 patients who underwent arthroscopic ro-
tator cuff repair and were referred for rehabilitation by
a single orthopedic surgeon to the Sports Physiotherapy
Unit were enrolled in this study. Of these, 29 subjects
were recruited directly from a previous study by Düzgün
et al.[11] and 11 from the Sports Physiotherapy Unit (Fig.
1).
Written informed consent (Hacettepe University
Ethics Committee; FON 05/15-30) was obtained from
all patients. Both rehabilitation protocols, including all
possible risks and potential advantage were explained in
detail to patients following surgery.
Patients were quasi-randomly assigned to one of the
two groups based on their year of enrollment in the study.
e 19 patients presenting in the 1st year were placed in
the accelerated (ACCEL) protocol group (17 females, 2
males) and the 21 in the 2nd year were placed in the slow
(SLOW) protocol group (17 females, 4 males). Surgery
was performed according to the procedure described by
Düzgün et al.[11] e orthopedic surgeon with 19 years
of experience was blinded to the rehabilitation protocol
until the end of the study.
Fig. 1. Flowchart diagram.
Assessed for eligibility (n=48)
Six subjects were excluded from participation: CNS disorder (n=1); Peripheral nerve
disorder (n=3); not willing to cooperate (n=1); psychological disorder (n=1)
Randomized (n=42)
(2005 through 2013)
Allocated to SLOW
(n=22)
Allocated to ACCEL
(n=20)
Analyzed: (n=19)
No exclusions from analysis
Analyzed: (n=21)
No exclusions from analysis
Lost to Follow-up: (n=1)
Only lost to 24th week follow up
Lost to Follow-up: (n=1)
Only lost to 24th week follow up
Acta Orthop Traumatol Turc644
Treatments were performed by a single physiothera-
pist (İ.D.) with 10 years of experience and who was
blinded to the patients’ rotator cuff tear size and surgical
technique. Evaluations were performed by a single phys-
iotherapist (G.B.) with 13 years of experience and who
was blinded to group membership.
Patients enrolled in the ACCEL group were given 6
weeks of preoperative rehabilitation. e ACCEL pro-
tocol was initiated at the 2nd postoperative week and in-
cluded soft tissue mobilization for the scapulothoracic
and glenohumeral joint along with motion exercises. Ac-
tive ROM exercises with scapular plane elevation, flex-
ion and abduction was initiated at the 3rd week as long
as the patient reported no pain at rest with their sur-
gically repaired shoulder. Active exercises were delayed
by 1 week in 1 patient due to pain upon removal of the
support which later resolved. Light resistive elastic re-
sistance (era-Band, red color-coded) exercises were
initiated at the 4th postoperative week.[11] e ACCEL
protocol was applied 3 days a week for 6 weeks.[9]
In the SLOW group, soft tissue mobilization for the
scapulothoracic and glenohumeral joint along with pas-
sive ROM exercises were initiated at the 4th postopera-
tive week. Active ROM in scapular plane elevation, flex-
ion and abduction was initiated at the 6th week and light
resistive elastic resistance exercises at the 8th week.[11]
e protocol was applied 3 days a week for 14 weeks.[9]
Shoulder flexion, abduction, external and internal
rotation were measured using a manual medical goni-
ometer with the patient in the supine position.[12] Active
total elevation was determined with the patient seated to
avoid spinal tilting. Reference points were the axis of the
arm and the spinous processes of the thoracic spine. Pa-
tients actively elevated their arm in the sagittal plane[13]
and active internal rotation was performed by having the
patients lift their thumb up their back. A tape measure
was draped down the spine with the zero value placed at
T5. e distance from the tip of the thumb to T5 was
recorded to the nearest centimeter. Improving internal
rotation was indicated by a decreasing value in centime-
ters.[12] All measurements were performed at the 3rd, 5th,
8th, 12th, and 24th postoperative week by the same blind-
ed physiotherapist.
Statistical analysis was performed using repeated
measures analysis of variance. Range of motion was
compared between the protocols at each time point us-
ing the Student t-test. e level of significance was set
at p<0.05.
Results
ere were no significant differences in descriptive char-
acteristics between the two groups (p≥0.05) (Table 1).
ere were no surgical complications or adverse re-
sponses reported throughout the duration of the reha-
bilitation protocol in either group.
With the exception of internal rotation, active total
elevation and active internal rotation shoulder ROMs
improved across weeks but there were no differences
between protocols by week (Figs. 2 to 7). e ACCEL
group had significantly greater internal rotation than the
SLOW group when weeks were analyzed for all time
point measurements (p<0.05) (Table 2). Peak differ-
ences between both groups in terms of internal rotation
were detected at the 8th and 12th weeks (p=0.03).
Discussion
e timing for the initiation of postoperative motion
following arthroscopic rotator cuff repair remains con-
troversial. Similar to studies on postoperative ACL re-
habilitation,[14,15] patients in the current study received
the same rehabilitation protocol with passive, active, and
resistive exercises introduced at either the earlier (AC-
CEL) or later (SLOW) postoperative period. All pa-
tients demonstrated improvement in ROM through the
course of rehabilitation.
Previous studies have shown that rotator cuff repair
followed by rehabilitation significantly relieve pain, im-
prove functional activity level and ROM between a 1 and
5 year follow-up period.[16-22] A large portion of these
studies have focused on the effect of tear size, surgery
technique or physical characteristics[16,21,23] and appear to
suggest that active motion be initiated at the 6th week be-
cause of tendon healing.[5,8,18] Fewer studies have inves-
tigated the effect of different rehabilitation protocols on
postoperative responses.[10,24] Long-term follow-up stud-
Table 1. Physical characteristics of subjects.
ACCEL (n=19) SLOW (n=21) p
Mean±SD Min.-Max. Mean±SD Min.-Max.
Age (year) 57.68±7.8 40-69 57.2±10.1 39-75 0.864
Height (m) 1.56±0.07 1.5-1.7 1.59±.08 1.5-1.8 0.294
Weight (kg) 75.05±9.45 55-92 73.72±12.17 54-100 0.702
ies have indicated the durability of surgical intervention
but are often unable to adequately represent the effects
on the patient during the first six postoperative months.
Typically, patients are treated for less than 4 months in
an outpatient orthopedic physical therapy setting fol-
lowing rotator cuff repair.[25] is early time window is
important as it has a major impact on the patient as they
are attempting to return to normal functional activities
with minimal pain without causing long-term damage to
the repaired tissues. Several surgical intervention studies
have focused on technique and results, with minimal de-
tail provided about the utilized rehabilitation protocol.
In contrast, the current study outlines the rehabilitation
protocol in detail.
Animal model studies have provided scientific evi-
dence of the beneficial effects on the structural quality
Fig. 2. ACCEL vs. SLOW exion.
180
Degrees
90
60
30
120
150
03rd week 5th week 8th week
ROM - Flexion
12th week 24th week
ACCELERATED
SLOW
Fig. 3. ACCEL vs. SLOW abduction.
180
Degrees
90
60
30
120
150
03rd week 5th week 8th week
ROM - Abduction
12th week 24th week
ACCELERATED
SLOW
Fig. 4. ACCEL vs. SLOW external rotation.
90
Degrees
30
60
03rd week 5th week 8th week
ROM - External Rotation
12th week 24th week
ACCELERATED
SLOW
Fig. 5. ACCEL vs. SLOW internal rotation.
90
Degrees
30
60
03rd week 5th week 8th week
ROM - Internal Rotation
12th week 24th week
ACCELERATED
SLOW
Fig. 6. ACCEL vs. SLOW active total elevation.
180
Degrees
90
60
30
120
150
03rd week 5th week 8th week
ROM - Active Elevation
12th week 24th week
ACCELERATED
SLOW
Fig. 7. ACCEL vs. SLOW active internal rotation.
40
Degrees
20
10
30
03rd week 5th week 8th week
ROM - Spine Level Internal Rotation
12th week 24th week
ACCELERATED
SLOW
Düzgün et al. Effects of slow and accelerated rehabilitation protocols on ROM after rotator cuff repair 645
and strength of the healing tissue of a period of immo-
bilization and that it is not detrimental to ROM.[5,6]
However, as the mechanism of tissue damage and site
are different in the animal models than human subjects,
healing processes differ. In addition, the repair procedure
is also different between animal models and human sub-
jects and both factors affect the healing process. During
passive ROM, humans do not contract the rotator cuff
musculature while animals may isotonically or eccen-
trically contract these muscles unless they are anesthe-
tized. Tendon bone healing tissue quality is improved
with decreased loading.[26] Increased collagen organiza-
tion at the insertion site has been observed after 4 weeks
of immobilization and produces superior mechanical
properties at weeks 8 and 16.[4,27] Koh et al. concluded
that 8 weeks of immobilization did not yield a higher
rate of healing of medium-sized rotator cuff tears com-
pared with 4 weeks.[28] In both protocols, a period of
7 days of immobilization was observed to protect the
newly forming network of capillaries.[9] Cold application
was applied in both groups for the first 7 postoperative
days to reduce pain and inflammation and passive ROM
exercises were then initiated. Immobilization plays a
role in allowing healing and the natural phases of in-
flammation and proliferation.[15,29] e clinical question
is when to start movement following rotator cuff sur-
gery to determine what benefits and adverse events may
occur. Neither approach has been studied in an adverse
event during the first 6 months. However, long-term
follow-up and diagnostic imaging would reveal further
information on the durability of the repaired tissue fol-
lowing each protocol.
Active ROM in our patients was greater when ex-
ercises were initiated in the early postoperative period.
is data agrees with those of Klintberg et al.,[10] who
initiated active motion at the 4th postoperative week
while it is in contrast to an animal model that initiated
passive motion following 2 weeks of immobilization.[5]
Researchers reported increased stiffness and less ROM
in those animals undergoing passive motion early com-
pared to the continuously immobilized group.[5] One
explanation for these differing results may be in the vol-
ume of exercises prescribed. ose animals undergoing
passive motion intervention underwent 300 and 600
repetitions a day applied to their limbs compared to the
continuous immobilization group. e authors suggest
that the increased stiffness and less motion observed
in the motion group were due to excessive scar matrix
formation at the tendon insertion sites.[5] In the present
clinical study, patients were only subjected to 90 repeti-
tions of movement on any one day, assuming the patient
complied with the home exercise program on the days
they visited the clinic for treatment. During the 2nd week,
this volume was doubled in the ACCEL group with the
Table 2. Mean and standard deviation values for range of motion in active elevation, spine level internal rotation, external, internal rota-
tion, abduction and exion between two rehabilitation protocols through postoperative period.
Postop weeks 3rd week 5th week 8th week 12th week 24th week
Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD
Active Elevation (degrees)
ACCEL Group 94.3±9.9 126.3±9.8 145.9±6.3 154.4±2.2 158.9±1.8
SLOW Group 70.9±17 95.6±9.2 116.4±8.3 141.4±5.9 153.7±4
Spine Level Internal
Rotation (centimeters)
ACCEL Group 33.1±2.9 29.5±2.9 19.7±2.6 13±2.9 6.3±2.2
SLOW Group 37.5±3.2 31.5±2.6 24.8±2.3 17.6±2.5 10.5±2
External Rotation (degrees)
ACCEL Group 36.5±6 48.2±5.6 55.8±6 68.3±5.3 86.3±2.4
SLOW Group 26.9±5.4 38.5±5.1 47.9±5.4 58.6±4.7 84.1±2.2
Internal Rotation (degrees)
ACCEL Group 56.9±4..3 61.3±4.3 72.7±3.7 80±3.7 88.2±2.1
SLOW Group 50.1±3.8 54.9±3.9 57.2±3.4 68.2±3.3 86.5±1.9
Abduction (degrees)
ACCEL Group 104.9±7.3 122.5±6.8 148.5±7.3 166±5.9 173.6±3.4
SLOW Group 94±6.6 108.3±6.1 126.5±6.6 151.9±5.3 171±3.1
Flexion (degrees)
ACCEL Group 134.9±8.7 150.1±5.6 159.6±5.3 171.3±3.1 175.6±1.8
SLOW Group 115.9±7.9 131.7±5 146.9±4.8 161.8±2.8 174.2±1.6
Acta Orthop Traumatol Turc646
addition of more exercises. However, the 50 to 66% in-
crease in the volume of exercise may account for the dif-
fering results of increased motions and reduced pain in
those individuals initiating early passive and active mo-
tions in the ACCEL protocol. Despite these differences,
it is important to note that by 6 months, the amount of
elevation and internal rotation were basically the same in
all patients regardless of the initial protocol. Harris et al.
showed that restoring full external rotation takes 1 year
after rotator cuff repair and full forward elevation 3 to 6
months in their study.[30] ese results may be related to
the frequency of exercises in our rehabilitation protocol.
On the other hand, patients with accelerated pro-
tocol received 18 and the patients in slow protocol 42
sessions of rehabilitation. Patients in the ACCEL group,
therefore, benefited in terms of cost-effectiveness and
such considerations maybe of importance to both the
patient and insurance.
is study had several limitations, including the lack
of baseline assessment and 1 year follow-up. e lack of
baseline assessment leaves in question whether the pro-
tocol or the individual in the groups accounted for the
differences observed. However, a preoperative baseline is
difficult to establish when performing clinical research
on rehabilitation as in clinical practice patients are not
often referred before surgery. In addition, the effect of
the two rehabilitation programs on tissue quality was
not addressed due to the lack of ultrasound or MRI
assessment. It is acknowledged that a clinical report of
good function and minimal pain does necessarily indi-
cate the absence of a re-tear of the rotator cuff.[31] Longer
term follow-up may reveal further insight on the ben-
efits and adverse effects of each protocol but were not
feasible in this study. erefore, the 6-month follow-up
duration could be considered another limitation of this
study. However, its primary aim was to report the early
results of the two different protocols.
Power characteristics of our study have shown post-
operative changes in the early period until the 24th week
(3rd, 5th, 8th, 12th, and 24th weeks). No data with such time
frame was found in the literature. Frequently performed
evaluations in this study present us the changes in ac-
tive ROM which in turn may give us an idea about the
repaired tissue.
In conclusion, in both early and late initiation of the
rehabilitation protocol, ROM eventually reaches nor-
mal values by 6 months. e initial 6 months following
surgery is critical to reestablish normal function. Re-
habilitation protocols and their effects on tissue repair
quality require further investigation to determine which
approach results in the greatest benefits.
Conflicts of Interest: No conflicts declared.
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Acta Orthop Traumatol Turc648