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Review Article
2025
:4;
100409
doi:
10.1016/j.jorep.2024.100409

Rehabilitation outcome domains following rotator cuff surgical repair: A systematic review

, , ,
a Degree Course in Physiotherapy, Department of Medicine and Surgery, University of Parma, Viale Abruzzo 12 B/C, 29017, Fiorenzuola d’Arda, Italy
b Azienda Usl di Piacenza, Fiorenzuola d’Arda Hospital, via Roma 33, 29017, Fiorenzuola d’Arda, PC, Italy

⁎Corresponding author: Gianluca Ciardi. gianluca.ciardi@unipr.it

Received: , Accepted: ,
The Authors
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Rotator cuff injury represents a common shoulder dysfunction, that causes significant disability to the patient; in most complex cases this condition is treated with surgery and subsequent rehabilitation. Literature does not clarify which outcome domains should be investigated by the physiotherapist after rotator cuff repair. The goal of this review work was to verify which outcome domains are relevant for physiotherapists’ evaluation.

A systematic review conform to PRISMA statement, was planned; PICO framework guided research queries. RCTs about rehabilitation following cuff rotator repair, published from 2018 to 2023, were considered suitable, without differences in terms of surgical technique. PubMed, Google Scholar, Cochrane Database, EBSCO, PEDro and Scopus were systematically screened. Critical appraisal was carried out through Jadad and Pedro scores. A data extraction table was built with author/year, country, sample, intervention, outcome/tools by included studies.

The search yielded 14,323 records, of which 12 RCTs were finally included; they all had high methodological quality. Common physiotherapy evaluations regarded pain, joint mobility, strength, and functionality. Additional outcome domains were kinesiophobia, pain catastrophizing, quality of life, patient satisfaction.

The review highlighted the need to integrate the classic assessment of shoulder through Costant-Murley Score/UCLA scale/Visual analogue scale, with that of kinesiophobia (Tampa scale), pain catastrophisation (Pain Catastrophizing Scale), patient satisfaction (0–10 scale) and quality of life (EQ-5D-5L).

Keywords

Rotator cuff tear
Physiotherapy evaluation
Outcome domains
Systematic review
1

1 Introduction

Rotator cuff injury represents the main worldwide cause of shoulder pain, and has a multifactorial aetiology.1 Among the causes are anatomical factors (CSA Critical Shoulder Angle >35°),2,3 age-related degeneration,4–6 altered tissue composition,7,8 hyperlipidemia,9 cigarette smoking,10 poor vascularization of the tendons, and mechanical stress such as injuries.11,12 Even manual daily activities, like lifting heavy loads or repetitive movements, can represent a risk factor.13,14 Rotator cuff injury has a prevalence of 20.7 %15.36 % of patients with painful shoulder symptoms present a rotator cuff injury, while 16.9 % with the same injury are asymptomatic; often, the injury becomes symptomatic after 2–3 years, concurrent with its worsening.15 Symptoms that may arise include: recurrent and persistent shoulder pain, night pain, painful and difficult shoulder abduction and external rotation16; all of this leads to a decrease in autonomy in daily life activities. The rotator cuff injury is closely related to aging, indeed, 25.6 % of patients are aged 60 years, a percentage that increases up to 50 % for the population older than 80 years.16 The diagnosis is made through a thorough clinical examination that takes into account the localization and intensity of pain, evaluates strength and active mobility, and utilizes differential tests (drop arm test, Jobe's test; Neer test; lift-off test, Belly press test).17,18 Instrumental exams that integrate the clinical evaluation such as radiography, magnetic resonance imaging, and ultrasound can be performed.19,20 Regarding treatment options, there is no single solution. Treatment should be individualized, based on various factors: the patient's age, functional demands, comorbidities, symptoms, the size and characteristics of the injury.21 For smaller-sized lesions, a conservative approach that includes physiotherapy, medications, and reduction of activities that may worsen symptoms can be considered. If this type of treatment is not effective or if the lesions are more extensive, surgical repair of the injury may be necessary.22 Following surgical repair of a rotator cuff injury, a rehabilitation process of initial immobilization and gradual recovery of shoulder mobility and strength is recommended.23–25 The patient with a rotator cuff injury thus represents a real challenge for physiotherapists, since it's not only just a local problem, but compromises quality of life, independence, and social interaction.26 Successfully addressing this complex condition requires a holistic approach, considering not only the biological healing of the tissue but also pain management, subjective fears, and emotional aspects related to pain. In this perspective, it is essential to clearly define post-surgical rehabilitative paths that are outcome-centred, capable of ensuring comprehensive patient care27; nevertheless, to date, the literature has not yet clarified which outcome domains are most significant for planning rehabilitation. Available guidelines,28,29 in fact, address the patient's care path in detail from a medical and surgical perspective, while no high quality recommendation has been formulated about post-operative rehabilitation. In particular, the most significant outcome domains for the physiotherapist, which are indispensable for planning an effective assessment and rehabilitation programme, are not precisely described. The purpose of this review, therefore, is to define all possible outcome domains used for evaluating a patient rehabilitated following surgical repair, and to formulate a proposal for rehabilitative evaluation useful for monitoring the patient's path.

2

2 Methods

The present systematic review of literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement- 2020 version. The primary goal was to understand which outcome domains were most investigated in patients who undergone physiotherapy following a rotator cuff tear surgery. Secondly, to understand which tools are most suitable for evaluating these domains, in order to formulate an evaluative proposal. Two research queries (RQ) were drawn:1.RQ1: Which outcome domains are evaluated in patients rehabilitated following rotator cuff repair surgery?2.RQ2: What tools are commonly used by physiotherapist to evaluate these outcome?

Our theoretical inclusion profile was a patient with rotator cuff injury, undergoing post-surgical rehabilitative intervention, without other shoulder's dysfunctions and without a history of other therapeutic approaches. This strategy prevented possible selection/intervention biases. To answer the research questions, a search was set up according to PICO (population, intervention, comparison, outcome) framework:•P: patients undergoing repair of a rotator cuff injury aged between 18 and 75 years; surgical repair intervention with suture of the lesion. No inclusion/exclusion criteria based on the size of the lesion were used.•I: post-surgical physiotherapeutic rehabilitation. Any type of physiotherapy intervention was considered (early mobilization, instrumental therapy, manual therapy, therapeutic exercise).•C: inactive cohorts/continuation of usual care/sham control groups•O: Outcome measures, even self-reported by the patient (questionnaires) and objective ones (administered by the physiotherapist/clinical tests).

Exclusion criteria: patients with humeral fracture, adhesive capsulitis, shoulder instability or tumors. Subjects undergoing arthroplasty or reverse shoulder arthroplasty, tendinous transposition (e.g. latissimus dorsi) or further surgical interventions were excluded. Finally, all studies with a methodological evaluation of less than 6/10 on the PEDro Score were excluded.

Randomized controlled trials in English or Italian, published in the last five years, were considered includible.

2.1

2.1 Data extraction and appraisal tools

Two independent researchers carried out electronic searches; the opinion of a third team member was required to judge inclusion for doubtful records. Search results were firstly screened by title and abstract, then by full text retrieval and reading. Data extraction was conducted on final included RCTs; first author, year, country, included sample, intervention, outcome tools and administration times were presented in tabular form and through a narrative paragraph. Included RCTs were assessed using the PEDro Scale30 and Jadad31 scores, in order to evaluate methodological quality. The search was carried out in the following database: PubMed, Medline, Cochrane Library, PEDro, EBSCO, Cinhal, and Google Scholar. Record inclusion limits: publication in the last 5 years, English/Italian language. The last access was made on September 30, 2023. Table 1 details the search strings used for the five databases.

Table 1 Search strings.
DATABASE SEARCH STRING
PUBMED ((rotator cuff injuriesMeSH Terms) OR (rotator cuff tear) OR (arthroscopic rotator cuff repair) OR (rotator cuff repair) OR (rotator cuff surgery) OR (massive rotator cuff tear)) AND ((rotator cuff rehabilitation) OR (Physical Therapy ModalitiesMeSH Terms) OR (postoperative careMeSH Terms) OR (rehabilitationMeSH Terms) OR (Physical and Rehabilitation MedicineMeSH Terms) OR (rehabilitation centerMeSH Terms))
COCHRANE LIBRARY ((rotator cuff injuries) OR (rotator cuff tear) OR (arthroscopic rotator cuff repair) OR (rotator cuff repair) OR (rotator cuff surgery) OR (massive rotator cuff tear)) AND ((rotator cuff rehabilitation) OR (Physical Therapy Modalities) OR (postoperative care) OR (rehabilitation) OR (Physical and Rehabilitation Medicine) OR (rehabilitation center))
GOOGLE SCHOLAR ((rotator cuff injuries) OR (rotator cuff tear) OR (arthroscopic rotator cuff repair) OR (rotator cuff repair) OR (rotator cuff surgery) OR (massive rotator cuff tear)) AND ((rotator cuff rehabilitation) OR (Physical Therapy Modalities) OR (postoperative care) OR (rehabilitation) OR (physiotherapy) OR (Physical and Rehabilitation Medicine))
EBSCO-CINHAL (rotator cuff injury OR dysfunction rotator cuff OR arthroscopic rotator cuff repair OR rotator cuff repair OR massive rotator cuff tear) AND physical therapy OR rotator cuff rehabilitation OR rotator cuff surgery exercises recovery OR rotator cuff physical therapy rehabilitation OR physiotherapy OR rehabilitation
PEDRO Simple search: rotator cuff tear/rotator cuff injuries/physiotherapy/rehabilitation/postoperative
3

3 Results

Following our planned search strategy among database, records were screened according to PRISMA flow diagram (Fig. 1). A total of 14,323 results emerged by the search. Duplicates (n = 4125) and unsuitable articles (n = 3275) were initially removed. By remaining 5419 articles, 4500 were excluded applying title and abstract screening; so, 919 results were searched for full-text retrieval, which was not available in 405 cases. The full text of 514 articles was examined and, of these, 286 were eliminated as they were not RCTs, a further 173 as they concerned only surgery and not physiotherapy treatment, and a 43 because did not meet the minimum PEDro score 6. Finally, 12 RCTs32–43 were included in the present review.

Records’ screening according to Prisma statement.
Figure. 1 Records’ screening according to Prisma statement.
3.1

3.1 Appraisal

As shown in Table 2, all evidence included in this review shows a high methodological quality (PEDro score ≥6).

Table 2 Appraisal of included studies.
Author PEDro Scale Jadad score
Mazuquin et al.32 7/10 3/5
Sheps et al.33 8/10 3/5
Reza Guity et al.34 8/10 3/5
Tirefort et al.35 7/10 3/5
Kjiær et al.36 7/10 3/5
Jenssen et al.37 6/10 3/5
Karppi et al.38 6/10 3/5
Coban et al.39 8/10 3/5
Shao et al.40 6/10 3/5
Abufoul et al.41 9/10 5/5
Kim et al.42 6/10 3/5
Shim et al.43 7/10 3/5

Included studies involved a total population of 905 patients, of which 461 were male and 358 were female, with an average age at the time of the study ranging between 18 and 79 years. The studies were conducted in eleven different countries: Republic of Korea, United Kingdom, China, Denmark, Iran, Turkey, Israel, Finland, Norway, Canada, and Switzerland. An in-depth report of studies’ details is provided in Table 3.

Table 3 Data extracted by included studies. Abbreviations: Exp (experimental group); Cont: (control group); Numeric Pain Rating Scale (NPRS); Visual Analogue Scale (VAS); Pain Catastrophizing Scale (PCS); Tampa Scale for Kinesiophobia (TSK); Costant Murley Score (CMS); Shoulder Pain and Disability Index (SPADI); ASES; Simple Shoulder Test (SST); American Shoulder and Elbow Surgeons (ASES); University of California at Los Angeles (UCLA); Western Ontario Rotator Cuff Index (WORC); Disabilities of the Arm, Shoulder and Hand (DASH); Oxford Shoulder Score (OSS); EuroQol 5 Dimension quality of life EQ5D5L; Short-Form 36 Item (SF-36); Short Form 12 Item (SF-12); SSV (shoulder subjective value); ESWT (extracorporeal shockwave therapy); FUSS (Fudan University shoulder score).
Author and year Country Sample Intervention Outcome, tools and timing of evaluations
Mazuquin et al.,202132 United Kingdom 20 Exp: 1–2 physiotherapy treatment/week for 3–4 monthsCont: 1–2 physiotherapy treatment/week for 3–4 monthsDifferent use of sling between Exp and Cont OSS; EQ5D5L; SHOULDER ROMOutcome were measured before surgery and at three and six months
Sheps et al.,201933 Canada 206 Exp: 6- weeks pain free active ROM exercise, the sling could be taken off at any timeCont: 6-weeks self-assisted ROM exercises; the sling was worn all time, except when performing exercise ROM; VAS; SF-36; WORC; STRENGTH EXAMINATIONShoulder ROM, pain, and HRQOL were reassessed at 6 weeks and 3, 6, 12, and 24 months postoperatively. Strength at 6, 12 and 24 months.
Reza Guity et al.,202334 Iran 56 Exp: 12 week supervised exercise, infrared therapy, transcutaneous electrical nerve stimulation. ROM exercise by the first weekCont: 12 weeks of supervised exercise, infrared therapy, transcutaneous electrical nerve stimulation. ROM exercise delayed to fourth week CMS; VAS; ROMOutcomes were measured at 3, 6 months, and 12 months.
Tirefort et al.,201935 Switzerland 80 Exp: post-surgical self-assisted ROM exercise for 4 weeks, then active exercise. They had no slingCont: same procedure than Exp, but with immobilization in sling ASES; VASPatients were evaluated at 10 days and 1.5, 3, 6 months.
Kjiær et al.,202136 Denmark 82 Exp: progressive active exercises 3 times/week for 6 weeks; supervised physiotherapy for further 6 weeksCont: supervised exercise and delayed active exercise once/week for 6 weeks; supervised physiotherapy for further 6 weeks WORC; DASH; NPRS; PROM; STRENGHTOutcome were measured before surgery to 6, 12 weeks, and 1 year after surgery.
Jenssen et al.,201837 Norway 120 Exp: simple sling for 3 weeks, then early active ROM startingCont: brace with the arm in neutral position for 6 weeks, then active ROM starting WORC; CMS; ROM; satisfaction with VASOutcome were measured before surgery, and 3, 6, and 12 months after surgery.
Karppi et al.,202038 Finland 80 Exp: 2 weeks of sling, then 5 supervised physiotherapy session until 10 weeks by the surgeryCont: self-mobilization program lasting 3 months CSM; VAS; SSVOutcomes were measured 3 months and 1 year after surgery.
Coban et al.,202239 Turkey 30 Exp: A program including fascial release, hot packages, interferential current stimulation was planned twice/week for two weeksCont: A program of passive self-administered ROM exercise, interferential current simulation and hot packages was planned twice/week for two weeks VAS (pain and satisfaction); ROM; SPADI; TSKOutcomes were measured before and after 2 weeks treatment.
Shao et al.,202340 China 38 Exp: 5 weeks of ESWT and advanced physiotherapy treatmentCont: Advanced physiotherapy program for 5 weeks VAS; CMS; ASES; UCLA; ROM; FUSS; MRI findingsOutcome measured at 3 months (baseline) and 6 months (follow-up) post repair.
Abufoul et al.,202341 Israel 50 Exp: active photobiomodulation treatments in addition to a standard physiotherapy protocol for three monthsCont: sham photobiomodulation devices in addition to a standard physiotherapy protocol for three months CMS; QuickDASH;ROM; VAS;SF-12Evaluations were conducted before the surgery (baseline) and at 1–3 and 6 months post-surgery.
Kim et al.,202242 Republic of Korea 34 Exp: 4 weeks rehabilitation protocol (manual therapy, exercises, heat or cold using) 5 times/week plus pain neuroscience education 2 timesCont: 4 weeks rehabilitation protocol alone NPRS; ROM; PCS; TSK; DASH; SPADI; SST;VAS (satisfaction)Outcome were measured four times with two-weeks interval (fourth to tenth week)
Shim et al.,202343 Republic of Korea 115 Exp: 12 weeks rehabilitation program, the sling off phase was characterized by virtual reality introductionCont: 12 weeks rehabilitation program SST; DASH; SPADI; ROM;Strength; EQ5D5LOutcomes were measured at baseline, and at 6, 12, and 24 weeks postoperatively.

All studies in this review presented similar exclusion criteria. In all studies, patients with previous surgeries on the examined limb, osteoarthritis, rheumatoid arthritis, shoulder instability, adhesive capsulitis, cancers, and neurological deficits were excluded. Sheps et al.,33 Jenssen et al.,37 Guity et al.,34 and Shao et al.,40 unlike other authors, excluded participants with a subscapularis muscle lesion, and all lesions greater than 3 cm thus of large amplitude (5 cm for Shao et al.,40 massive rotator cuff tear). Coban et al.,39 Kjaer et al.,36 and Jenssen et al.37 recruited patients all operated by the same orthopaedic surgeon, while other studies did not consider this characteristic. Regarding intervention strategies, in 4 studies the effectiveness of early rehabilitation was evaluated, anticipating active and passive mobilization without a brace.32–36 In the study by Jenssen et al.,37 outcome between two groups that used a brace for respectively 3 or 6 weeks, were compared. Krappi et al.38 studied the effectiveness of physiotherapy performed in the presence of a physiotherapist compared with a series of pre-set exercises to be performed autonomously at home. In another study, myofascial release techniques in combination with classic therapy39 were evaluated. The effectiveness of two instrumental therapies (shockwave therapy40 and laser therapy41), was also investigated. In the first case, a group of patients underwent shockwave therapy in addition to classic physiotherapy, in the second case, patients had to self-administer a session a day of laser at home. Kim and Lee38 evaluated the education on pain management by subjecting the control group to PNE once a week. Finally, one study wanted to test a tele-rehabilitation system in relation to a protocol of exercises to be performed autonomously at home.43 The domains investigated included pain, strength, mobility, functionality, kinesiophobia, pain catastrophizing, quality of life, and patient satisfaction. All authors investigated pain with the VAS and NPRS scales. Strength was studied in two studies33,36 through the use of portable dynamometers, while in all others with the Constant Murley Scale (CMS)34,37,38,40,41 or the University of California and Los Angeles Shoulder Score (UCLA).40 CMS (Constant Murley Score)44 and UCLA (The University of California and Los Angeles Shoulder Score) are widely used evaluation scales in the literature for shoulder evaluation. In addition to these, several self-administered questionnaires were given to included patients in order to evaluate pain and functionality: ASES (The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment),45 SST (Simple Shoulder Test),46 OSS (Oxford Shoulder Score),47 WORC (Western Ontario Rotator Cuff Index),48 SPADI (Shoulder Pain and Disability Index) 49, DASH (Disability of the Arm, Shoulder and Hand).50 Of these only two included items for evaluating the quality of life or the psychological aspect related to pain.48,50 The CMS and UCLA require the presence of an external operator for the evaluation of strength and mobility, while the patient can answer questions on pain and functionality; these two scales however, were the only to investigate more domains (pain, functionality, strength, and mobility), providing a single final summary score. Mobility was investigated in 11 out of 12 studies, always using the goniometer. In 5 studies, it was integrated within the CMS evaluation,34,37,38,40,41 while in another 6 studies it was evaluated separately.32,33,36,39,42 Pain catastrophizing was evaluated in a single study42 through the self-reported Pain Catastrophizing Scale (PCS). Quality of life was investigated in 4 studies: in one with the use of the Short-Form 36 scale,33 in another with a SF-1241, and in the last 2 with the EQ5D5L questionnaire.32,43 Patient satisfaction was assessed with a 0–10 points visual analogue scale in 3 out of 12 studies.37,39,42

4

4 Discussion

To date, the literature does not clarify a standardized assessment for physiotherapists dealing with surgical rotator cuff tear repair. Functional assessment is important since it's the moment when the clinician objectifies the patient's disorder and evaluate its course over time, also in relation to the rehabilitation path. So, it's essential to know which domains are essential to assess and through which tools, in order to guide the physiotherapist in a more relevant and complete evaluation.26,28,29 This systematic review was compliant to the PRISMA statement.51 A strength of the present work was the high PEDro Scale/Jadad Score evaluation of included RCTs, which indicates a high methodological quality. The profile of patients undergoing rotator cuff repair3 was very similar across all articles (age range, inclusion and exclusion criteria). Studies’ design and methodology were also extensively detailed: randomization and patients’ allocation were fully explained; treatment objectives, characteristics, and frequency were also reported. Losses to follow-up were limited, allowing for a complete analysis of treatment and outcomes. However, some limitations were present: there was a low risk of bias, due to the lack of therapists’ and patients’ blinding; this represents a common criticality in rehabilitation research. Only in the study by Abufoul et al.41 participants were truly blinded and could not know whether they were in the intervention or control group. This study indeed had the highest methodological evaluation. Our review clarified that, although there is no evaluative gold standard for the operated shoulder for rotator cuff repair, some innovative features about physiotherapists’ evaluation emerged: if on one hand there was a focus on traditional outcome, such as pain, functionality, and mobility1–12; kinesiophobia,39,42 pain catastrophizing,42 quality of life,32,33,41,43 and patient satisfaction37,39,42 represent less investigated aspects. Kinesiophobia, in particular, has significant implications surgical repair rehabilitation cares,52–54 so its evaluation should be systematic.55 Similarly, quality of life, catastrophic thoughts about pain, and patient satisfaction are crucial elements to consider. It thus appears essential to emphasize the importance of a global functional evaluation, without focusing only on disease-specific outcome measures. Based on these results, it is possible to outline an evaluation proposal that investigates all 8 described domains. The most used evaluation scale in the literature to assess a patient with a rotator cuff lesion is the Constant Murley,34,37,38,40,41 as it turned out to be the most complete and heterogeneous by investigating the domains of pain, functionality, strength, and mobility. As an alternative to CMS, the UCLA scale, which investigates the same domains with the addition of an evaluation of patient satisfaction, is recommended. Although CMS is still preferred in the literature, Moorthy et al.56 consider the UCLA the best scale to assess patients undergoing reparative arthroscopy. To these, it is recommended to combine the Western Ontario Rotator Cuff Index as it represents the only PROMs (Patient-reported outcome measurement) with psychometric indices tested on patients operated for rotator cuff tears.57 All other evaluation scales emerged in this review have excellent psychometric indices for evaluating a patient with shoulder pain or cuff disorders, but not subjected to surgical repair. Moreover, being a scale entirely self-reported by the patient, it could be used for a distant follow-up, increasing patient's adherence and eliminating the need for an in-presence re-evaluation. Kinesiophobia, pain catastrophizing, quality of life, and patient satisfaction emerge as innovative outcome domains, as they are less present in standard evaluations found in the literature.32,33,41,43 The Tampa Scale of Kinesiophobia is the best tool to assess the patient's fear of movement, just as the Pain Catastrophizing Scale for evaluating catastrophic thoughts about pain. To evaluate patient satisfaction, a visual analogue scale with a score from 0 to 10 was used in all studies. Regarding the evaluation of quality of life, the PROMs EQ-5D-5L presents excellent psychometric indices for subjects included in this review.58

5

5 Conclusion

Our review highlights the need for a broad physiotherapy evaluation of patients undergoing rotator cuff repair. Although pain, functionality, and ROM are consistently assessed, other aspects such as kinesiophobia, pain catastrophizing, quality of life, and patient satisfaction often do not receive due attention. It is also important to integrate specific evaluation tools to fully understand the effects of the rehabilitative intervention on the daily life and well-being. A comprehensive and patient-centred evaluation could improve our understanding of treatment outcome and produce more targeted therapeutic efforts.

Ethical statement

The study did not involve human subjects (being a systematic review), so no ethical issues are applicable.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Guardian patients consent

The study did not involve human subjects (being a systematic review), so no consent was needed.

CRediT authorship contribution statement

Gianluca Ciardi: Conceptualization, Methodology, Validation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Daniele Novara: Conceptualization, Validation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing, Visualization. Fabrizio Quattrini: Conceptualization, Validation, Investigation, Resources, Writing – review & editing, Visualization. Emanuela Ricci: Conceptualization, Methodology, Validation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization.

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