Effectiveness of early versus delayed rehabilitation following rotator cuff repair: Systematic review and meta-analyses
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Abstract
To investigate the effectiveness of early rehabilitation compared with delayed/standard rehabilitation after rotator cuff repair for pain, function, range of movement, strength, and repair integrity.
Design
Systematic review and meta-analyses.
Methods
We searched databases and included randomised controlled trials (RCTs) comparing early with delayed/standard rehabilitation for patients undergoing rotator cuff repair surgery. We assessed risk of bias of the RCTs using the Cochrane RoB 2 tool.
Results
Twenty RCTs, with 1841 patients, were included. The majority of the RCTs were of high or unclear risk of overall bias. We found substantial variations in the rehabilitation programmes, time in the sling and timing of exercise progression. We found no statistically significant differences for pain and function at any follow-up except for the outcome measure Single Assessment Numeric Evaluation at six months (MD: 6.54; 95%CI: 2.24–10.84) in favour of early rehabilitation. We found statistically significant differences in favour of early rehabilitation for shoulder flexion at six weeks (MD: 7.36; 95%CI: 2.66–12.06), three (MD: 8.45; 95%CI: 3.43–13.47) and six months (MD: 3.57; 95%CI: 0.81–6.32) and one year (MD: 1.42; 95%CI: 0.21–2.64) and similar differences for other planes of movement. In terms of repair integrity, early mobilisation does not seem to increase the risk of re-tears (OR:1.05; 95%CI: 0.64–1.75).
Discussion
Current approaches to early mobilisation, based largely on early introduction of passive movement, did not demonstrate significant differences in most clinical outcomes, although we found statistically significant differences in favour of early rehabilitation for range of movement. Importantly, there were no differences in repair integrity between early and delayed/standard rehabilitation. Most rehabilitation programmes did not consider early active movement as soon as the patient feels able. With ongoing variation in rehabilitation protocols there remains a need for large high quality RCT to inform the optimal approach to rehabilitation after rotator cuff repair surgery.
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This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/19198875.
Short Summary of Main Findings This systematic review and meta-analysis (preprint Feb 2021; published in PLOS ONE May 2021) included 20 RCTs with 1,841 patients comparing early rehabilitation (typically starting passive motion within days/weeks) versus delayed/standard rehabilitation (immobilization in sling for 4–6 weeks before active motion) after rotator cuff repair.
Key results:
No clinically or statistically meaningful differences in pain or most function outcomes at any time point (except a small benefit on Single Assessment Numeric Evaluation at 6 months: MD 6.54, 95% CI 2.24–10.84).
Range of motion recovered significantly faster with early rehab (e.g., flexion MD +7.36° at 6 …
This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/19198875.
Short Summary of Main Findings This systematic review and meta-analysis (preprint Feb 2021; published in PLOS ONE May 2021) included 20 RCTs with 1,841 patients comparing early rehabilitation (typically starting passive motion within days/weeks) versus delayed/standard rehabilitation (immobilization in sling for 4–6 weeks before active motion) after rotator cuff repair.
Key results:
No clinically or statistically meaningful differences in pain or most function outcomes at any time point (except a small benefit on Single Assessment Numeric Evaluation at 6 months: MD 6.54, 95% CI 2.24–10.84).
Range of motion recovered significantly faster with early rehab (e.g., flexion MD +7.36° at 6 weeks, +8.45° at 3 months, +3.57° at 6 months, +1.42° at 1 year), with similar small benefits in other planes.
No increased risk of re-tear (OR 1.05, 95% CI 0.64–1.75).
No differences in strength or complications.
Rehabilitation protocols varied widely, and most "early" programs still relied on cautious passive motion rather than active loading.
How This Work Has Moved the Field Forward It updated and strengthened earlier reviews by adding eight new RCTs, confirming that early mobilization leads to faster ROM recovery without compromising tendon healing. This challenged overly conservative "protect the repair" approaches and supported earlier movement, influencing post-operative guidelines and reducing unnecessary prolonged immobilization in clinical practice.
Major Issues
Most included RCTs had high or unclear risk of bias (Cochrane RoB 2).
Substantial clinical heterogeneity in rehabilitation protocols (sling time, exercise progression, passive vs active), limiting strong recommendations.
Small mean differences in ROM, unlikely to be clinically important for most patients.
No large, high-quality trials testing truly progressive early active rehabilitation.
Minor Issues
Limited data on patient-reported function at longer-term follow-up (>1 year).
Strength outcomes under-reported across studies.
No cost-effectiveness or return-to-work analysis.
Competing interests
The author declares that they have no competing interests.
Use of Artificial Intelligence (AI)
The author declares that they did not use generative AI to come up with new ideas for their review.
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