One of the more notable land minds for the postoperative shoulder is stiffness. If you've practiced long enough, you've probably developed some sense of what kind of patients or perioperative variables may be associated with the stiff shoulder. My running hypothesis was that it had a lot to do with preoperative stiffness and disability, much like we often see with knee arthroplasties.
Today's article, from Clinical Orthopedics and Related Research, prospectively examines the relationship between preoperative and postoperative characteristics that might predict patients more likely to become stiff following shoulder surgery.
The sample consisted of 209 patients with primary rotator cuff repairs. Operative procedures were standardized to a reasonable degree and involved subacromial decompression and rotator cuff repair. Interestingly the postoperative course was fairly well managed but did not involve supervised rehabilitation. The subjects were instructed in a 3-month home exercise program. Range of motion and manual muscle force were assessed preoperatively and at 6, 12, and 24 weeks by physical therapists. Lastly the patients were administered a Shoulder Service Questionnaire at the final postoperative follow up at a mean of 76 weeks (95% CI, 68-84 weeks).
The sample was retrospectively divided into two groups based on PROM at six weeks post-op:
- Group A (Early motion recovery): Patients who ranked in the upper quartile of ROM for at least three of the four primary measured motions of flexion, abduction, external rotation, and functional internal rotation.
- Group B (Shoulder stiffness): Patients who ranked in the lower quartile for at least three of the four motion categories
The subjects meeting the criteria for early motion recovery (39 total) and shoulder stiffness (36 total) were compared using ten descriptive and clinical characteristics. In reading the article, the progression of each characteristic is interesting to observe regardless of statistical significance. However, there were a few very interesting statistical and clinically significant findings.
- Preoperative functional IR (hand behind the back) was the best predictor for postoperative shoulder stiffness
- Age, gender, arm dominance, preoperative symptom duration, worker's compensation, type and size of tear were not predictive of shoulder stiffness
These were interesting findings of themselves but what followed really caught my attention:
- The total range of motion achieved for group A (early motion) and group B (shoulder stiffness) were remarkably similar at 76 weeks. This finding indicates a delay in regaining full shoulder ROM rather than a permanent loss in ROM as has been previously proposed.
- Although pain levels for group A were significantly better than group B, these differences only lasted up to the 12th postoperative week. After this they became remarkably similar. Again, this raises questions as to whether early postoperative pain and stiffness predicts permanent pain and disability as has been proposed.
- Postoperative pain and stiffness for group B was at its worst at the six-week point, and then steadily improved until the final follow up to be comparable to group A.
I was really impressed with this study for a few reasons. I typically push the worry button around 4-6 weeks post-op if the patient isn't' making satisfactory progress or has high pain levels. I might be inclined to loose a few less hairs now - believe me I cherish them dearly!
Secondly, this study provides some relief that postoperative stiffness may not predict long-term pain or disability. In fact many of the subjects achieved good results regardless of their early postoperative course. It will be nice to present this kind of information to patients who are struggling in the clinic next to their "group A" cohorts!
More research on this topic needs to be done as the present study does contradict some of the conventional wisdom we have in the clinic regarding postoperative shoulder stiffness. What this study does provide is very good fodder for discussion and opens up more dialogue for improving our outcomes following this fairly common procedure. Take care and talk to you soon!
Trenerry, K., Walton, J.R., Murrell, G.A. (2005). Prevention of Shoulder Stiffness after Rotator Cuff Repair. Clinical Orthopaedics and Related Research, &NA;(430), 94-99. DOI: 10.1097/01.blo.0000137564.27841.27