by Tyler Tice, PT, DPT, MS, ATC
The utilization of multimodal analgesia (MMA) injections during arthroscopic rotator cuff repairs has gained popularity after commonly being utilized in hip and knee surgeries. MMA injections are a mixture of analgesic (pain relieving) agents of various classes with the intention of reducing pain and improving post-operative function. One of the agents included in this MMA injection is corticosteroids due to their local anti-inflammatory effect and ability to reduce the stress response to surgery. Previous research has demonstrated utilization of an MMA injection combined with corticosteroid significantly reduced pain and patients utilized fewer opioid medications in the first 24 hours following rotator cuff surgery. In the acute stage, the utilization of corticosteroid injections to the rotator cuff are highly effective, but concern regarding infection, risk for tendon re-tear, and general long-term tendon health remains. The goal of this study was to investigate the impact of corticosteroid injections on tendon health 1 year after arthroscopic rotator cuff repair.
This study investigated 50 patients who were undergoing arthroscopic rotator cuff repair surgery. Patients were randomized into either the study group or control group. There were 25 patients in the study group and 25 patients in the control group. Inclusion and exclusion criteria for both groups can be found in the original article. Prior to surgery, all patients completed the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder score (ASES), and Simple Shoulder Test (SST) and pain levels were recorded. The study group received a periarticular injection that consisted of ropivacaine, morphine, and methylprednisolone (corticosteroid) while the control group received a saline injection. Both groups followed the same post-operative rehabilitation regime. The day after surgery patients completed passive movements and pendulum exercises. Additionally, patients wore a splint that kept the affected arm in internal rotation for the first 4 weeks post-operatively. A standardized outpatient rehab program was supervised by a physical therapist where active motion was initiated at 6 weeks and strengthening exercises were initiated at 12 weeks. Patients were able to return to heavy manual work and sports 3 months after surgery. At 12-months post-op, pain levels and functional scores were remeasured, and an MRI was completed to determine tendon integrity.
Pain levels were significantly reduced in both groups 12-months following surgery.
CMS, ASES, and SST scores significantly improved within both groups 12-months following surgery. There were no significant differences in scores between groups 12-months following surgery.
MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group.
There were no significant differences between groups in retear rates at 12-months following surgery.
Factors negatively impacting healing were determined to be advanced age, diabetes, and posterior extension of the tear. Receiving a corticosteroid injection was determined to not negatively impact healing.
Building on their previous study, the researchers of this study determined that MMA injections that included corticosteroids have no harmful effect on tendon healing and functional outcomes 1 year after surgery. However, the authors of this study noted that the potential harmful effects of corticosteroids must be balanced out when included in MMA injections as laboratory and animal studies continue to demonstrate harmful effects on tendons. Currently, there is mixed research regarding the impact of corticosteroids on tendon healing and integrity following rotator cuff surgery. Another finding from this study was that there was no significant difference between groups in functional scores at 1-year post-op. A similar result was found in a study where patients received a corticosteroid injection preoperatively or 1-month post-surgery. There were also no instances of infection in this study following the corticosteroid injection. The overall re-tear rate in this study was 14%, which is similar to re-tear rates observed in other research.
This study had a number of limitations that should be noted such as small sample size in both the study and control groups. Also, the MMA injection was a mixture of analgesics so it’s impossible to determine the sole effect of corticosteroids on tendon healing within the study, and the hyperglycemic effect of corticosteroids was no observed due to the controversial results related to type of corticosteroid, dosage, and injection site.
Take Home Messages:
While the results of this study may not appear drastically different compared to the control group, this can actually be interpreted as a good thing as the whole concern regarding the inclusion of corticosteroids in anesthetic injections is its negative impact on tendon healing. This study demonstrated virtually no differences between groups, which can be interpreted as there is no difference between receiving an MMA injection intra-operatively with or without corticosteroids. While this study did not explicitly demonstrate the effect of just corticosteroids on tendon healing when utilized intra-operatively, the results demonstrating little to no difference when it’s included in an MMA injection is positive. More research needs to be conducted regarding the effect of corticosteroids on tendon healing when individually utilized intra-operatively, but for the time being these research can put people’s minds at ease regarding the potential negative impact if received intra-operatively for rotator cuff repair surgery.
Perdreau, A., Duysens, C., & Joudet, T. (2020). How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair. Orthopaedics & traumatology, surgery & research : OTSR, 106(6), 1159–1166. https://doi.org/10.1016/j.otsr.2020.05.009
by Tyler Tice, PT, DPT, MS, ATC
After a primary anterior cruciate ligament (ACL) reconstruction surgery, 25% of patients 25 years old or younger that return to high-risk sport sustain a second ACL injury. Currently, there is conflicting evidence surround the return to sport timeline following ACL reconstruction surgery. One study demonstrated no difference in strength and hop test performance between athletes that successfully returned to sport vs. athletes that sustained a second ACL injury. Another study demonstrated that athletes that had more symmetrical quadriceps strength and returned to sport less than 9 months after surgery had an 84% reduction in knee injury rates. Due to this, many questions regarding the protective effects of delaying return to sport and achieving symmetrical muscle function remain unanswered. The goal of this study was to investigate the association between sustaining a second ACL injury and 1) time to return to sport, 2) symmetrical muscle function, and 3) symmetrical quadriceps strength.
Patient demographics and results from 5 muscle function tests were obtained from a rehabilitation registry. Inclusion and exclusion criteria can be found in the original article. The 5 muscle function tests were the following: isometric or isokinetic knee extension, isometric or isokinetic knee flexion, single-leg vertical hop, single-leg hop for distance, and single-leg side of hop. A questionnaire was sent to athletes between the ages of 15 and 30 found on the rehabilitation registry who were involved in knee-strenuous sports prior to their injury and subsequent ACL reconstruction surgery. The questionnaire was utilized to determine time of return to knee-strenuous sport. The primary outcome for this study was whether or not the athlete sustained a subsequent ACL injury following their return to sport.
In this study, 159 athletes with a mean age of 21.5 years old were included. Of the participants, 64% were female.
Athletes who sustained a new ACL injury returned to knee-strenuous sport, on average, 10.1 ± 3.3 months after ACL reconstruction, compared with 12.7 ± 4.8 months for athletes with no new ACL injury.
Ten of the 33 athletes who returned to knee-strenuous sport earlier than 9 months after reconstructions sustained a new ACL injury.
Twelve (67%) of the second ACL injuries occurred in athletes who returned to knee-strenuous sports between 8 and 9 months after ACL reconstruction.
Athletes who returned to knee-strenuous sport at 9 months or later after surgery had a lower rate of new ACL injury compared with those who returned earlier than 9 months after ACL reconstruction.
Athletes who returned to knee-strenuous sport earlier than 9 months had an approximately 7 times higher rate of new ACL injury compared with those who returned at 9 months or later after surgery.
Achieving symmetrical muscle function in 5 tests or symmetry in quadriceps strength was not associated with new ACL injury.
Athletes who returned to sport before 9 months following ACL reconstruction surgery were 7 times more likely to experience a second ACL injury compared to athletes who returned to sport at 9 months post-surgery or later. Despite some athletes returning to less knee strenuous sport, findings in this study were similar to previous research. Additionally, there was no association between symmetrical quad strength and rate of re-injury, which contradicts previous research that has demonstrated a positive relationship between muscle function and re-injury rate. A few factors that may have affected this finding is the relatively small sample size, few athletes within the sample size having symmetrical muscle function, and different athlete populations being included in the study. An explanation that may support this finding is that all athletes in this study achieved a limb symmetry index (LSI) of 90% or greater which may have been protective against a second ACL injury, which is consistent with previous research. LSI is commonly measured in ACL rehabilitation to assess symmetry of quadriceps strength.
A key limitation of this study is that only 18 athletes included sustained a second ACL injury between both groups. This makes it difficult for in-depth analysis and assessment of multiple risk factors to be made.
Take Home Messages:
As youth athletes continues to become more competitive and the number of young athletes returning to sport following ACL reconstruction surgery, more concrete evidence regarding ideal milestones and return to sport timelines is needed to reduce re-injury rates. Over the years, research has demonstrated that delaying return to sport can benefit the athlete and reduce the likelihood of re-injury following return to sport, which this study supported as athletes who returned to sport before 9 months post-surgery were 7 times more likely to sustain a second ACL injury compared to athletes who returned after 9 months. Overall, for long-term knee health and to enable young athletes to be able to participate in their chosen sport for as long as their bodies can tolerate, delaying return to sport following a major injury like an ACL tear is more favorable compared to returning to sport earlier on in the recovery timeline.
Beischer, S., Gustavsson, L., Senorski, E. H., Karlsson, J., Thomeé, C., Samuelsson, K., & Thomeé, R. (2020). Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. The Journal of orthopaedic and sports physical therapy, 50(2), 83–90. https://doi.org/10.2519/jospt.2020.9071
by Tyler Tice, PT, DPT, MS, ATC
Rotator cuff disorders have been reported to occur in 30-50% of people over the age of 50 and the number of rotator cuff repair surgeries performed each year continues to rise. The rotator cuff is comprised of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis, and plays a vital role in stabilizing the shoulder during arm movements. Previous research has demonstrated that rotator cuff healing correlates with outcome. In patients that had an intact supraspinatus had improved functional outcome scores and satisfaction, along with a reduction in osteoarthritis progression compared to those who experience a re-tear. In surgeries that were deemed to be biomechanically superior, research has demonstrated only modest improvements in healing rates. This suggests a need for further improvement in the biological environment rather than the mechanical environment to substantially improve rotator cuff healing.
Pathology of rotator cuff tendon:
Rotator cuff disease is a spectrum ranging from tendinopathy to eventual degenerative tear. One research study has suggested the gradual degeneration of the tendons occurs as a consequence of simple anatomical variation, inciting repetitive microtrauma to the rotator cuff. Because of the repetitive trauma and inefficient loading of the tendon that would assist in the natural repair process, eventual tendon failure will occur, resulting in a tear. After undergoing a surgical repair, remodeling at the site where the tendon meets the bone gradually occurs over time. Animal studies have demonstrated that following repair the tensile strength that is achieved is approximately half the amount of normal tissue, putting the individual at risk for a re-tear.
Patient factors and clinical decision making:
Prior to any surgical procedure, there is the potential to influence the biological environment and outcome of repair through clinical decision making. Patient factors to consider are history of smoking and presence of comorbidities such as Diabetes Mellitus (DM). Presence of factors like this have been shown to have negative impacts on tendon healing, which would put the patient at further risk for re-tear following repair. A patient’s BMI may also play a role in tendon healing, however there is current insufficient evidence available. History of receiving corticosteroid injections have also been shown to impact tendon healing, despite them frequently being used in the treatment of rotator cuff disease. The size and location of the rotator cuff tear as well as fatty infiltration has also been shown to impact post-repair outcomes. In animal studies, vitamin D levels have been implicated in cuff healing however there is insufficient evidence in human studies.
Growth factor/cytokine-based augmentation:
Growth factors have the potential to improve the environment in which the repair occurs.
Matrix metalloproteinase (MMP) inhibitors: One study demonstrated tendon degeneration in the presence of overactivity of MMPs or underactivity of tissue inhibitors. One animal study demonstrated the effectiveness in MMP inhibitors following repair however further research in human participants needs to be conducted.
Rotator cuff repair and platelet rich plasma (PRP): One meta-analysis demonstrated a significantly higher healing rate in small-medium and medium-large rotator cuff tears when PRP was administered at the time of surgery. Another meta-analysis demonstrated conflicting results regarding the use of PRP as both groups, control and experimental, had significant reduction in re-tears. One study proposed delayed application of PRP intra-operatively may be more beneficial and improve retention at the repair site, however no significant improvement in healing or functional outcomes was observed.
Partial thickness rotator cuff tear/tendinopathy and PRP: One meta-analysis demonstrated short-term benefit from receiving a PRP injection in the non-operative management of either partial rotator cuff tear or tendinopathy. Another study demonstrated PRP injections were only beneficial in reducing pain in rotator cuff tendinopathy after 24 weeks, however no functional improvement was observed at any point throughout the study.
Stem cell-based augmentation:
There are a number of techniques that have been developed to be utilized in treating rotator cuff tears and tendinopathies. However, research on these techniques either has shown minimal benefit in the utilization of these procedures or were tested on small sample sizes, making the application of the results difficult to the general population.
In rotator cuff repairs, scaffolds are principally used to mechanically and/or biologically augment the repair site. They improve the biomechanics of the repair site and induces a more acute inflammatory response for improved healing. Extracellular matrix (ECM) scaffolds are biocompatible as they can be derived from human or animal sources, however there is an argument that re-purposed and structurally do not resemble tendon. In two studies that utilized this type of scaffold, reduced re-tear rates were observed up to two years after the surgical procedure. Synthetic scaffolds have also been utilized and research has demonstrated reduced re-tear rates in those who receive this type of scaffold vs. control participants. Degradable synthetic scaffolds are recently emerging, however current research demonstrates high re-tear rates after 1.5 years post-surgery. Bio-inductive scaffolds that are designed to induce biological repair while having little to no mechanical support to repair construct. There is currently little research regarding this technique, however smaller studies utilizing it have produced promising results.
Take Home Message:
There are a number of biologic techniques that are available to improve tendon healing either rotator cuff tendinopathy or following rotator cuff repair. Those who are experiencing rotator cuff tendinopathy or have sustained a rotator cuff tear should look into their available options for treatment before considering surgical intervention. Keeping open communication with your doctor about different ways to manage pain and function will ultimately give you the tools to manage your diagnosis in a way that is most suitable to you.
Rohman, M. L., & Snow, M. (2021). Use of biologics in rotator cuff disorders: Current concept review. Journal of clinical orthopaedics and trauma, 19, 81–88. https://doi.org/10.1016/j.jcot.2021.05.005
by Tyler Tice, PT, DPT, MS, ATC
Tendinitis is defined as inflammation or irritation of a tendon that is generally caused by overuse. Common treatments for this condition are rest, NSAIDs, physical therapy, laser therapy, and shock wave therapy. Due to the presence of inflammation, corticosteroid injections are widely used as it can reduce the inflammation, reduce pain, and improve function. This is highly effective for short-term management of tendinitis; however, a significant side effect of corticosteroid injections are tendon degeneration and later rupture. Frequent use of corticosteroids can inhibit tendon repair, delay tendon healing, and produce tendon degeneration. Following tendon rupture, treatment consists of surgical debridement and repair. The purpose of this article is to review cases of spontaneous tendon rupture after corticosteroid use to reduce post-operative complications.
Patients were retrospectively identified who had presented to the hospital with pain or deformity after corticosteroid injection. Inclusion criteria were individuals of tendon spontaneous rupture after corticosteroid injection in the hospital. Exclusion criteria are patients had history of injury, patients were compared with type 2 diabetes, rheumatoid arthritis, or other autoimmune diseases. MRI was utilized to identify tendon injury or inflammation as well as locate the ends of the ruptured tendon before the operation. Depending on the appearance of the injured tendons, optimal surgical technique was determined for that specific patient. If the rupture was small enough (less than 0.5 cm), tendon suturing was completed. If present in the patient and if the injury was too large, the palmaris longus was utilized for tendon grafting. Following imaging, patients with suspected tendon rupture were recommended to mobilization with a splint before operation. The goal of operation was to restore hand function and return to work. Three days following surgery, patients began physical therapy and were to wear braces with the wrist in neutral for 3 weeks (if receiving tendon suture) and 6 weeks (if receiving tendon grafting).
Regardless of what tendon in the hand ruptured, all patients appeared to have significant degeneration of the tendon during operation. Common post-operative complications were tendon adhesion and tendon rupture. The two patients who sustained tendon adhesions underwent a tendon release 3 months after the first operation. The one patient that sustained a subsequent tendon re-rupture underwent another operation where they received a tendon graft. No patient in this study had complications of infection, vascular, or nerve injury.
Use of corticosteroid injections can lead to serious consequences in tendon quality. In this study, the use of pre-operative MRI to identify the injured tendons and to estimate the extent of the injury was beneficial. The one patient in this study that sustained a re-rupture following surgery may be attributed to the patient receiving a direct suture to the tendons. Following surgery, immobilization and tendon release in supplemental operation are also needed. MRI can be a valuable tool to use throughout the rehabilitation process to monitor healing quality of the repaired tendons.
The usage of corticosteroid injections for wrist and hand pain is still ambiguous. Some patients included in this study were unaware that they were receiving corticosteroid injections. Due to the lack of standardization in the application of corticosteroid injections, further standardization is needed to appropriate address the underlying risk factor of tendon spontaneous rupture. Currently, the most common reason for receiving a corticosteroid injection to the hand/wrist is tenosynovitis of the radialstyloid. Despite this, the most commonly ruptured tendon is the extensor pollicis longus. The researchers of this study hypothesized two reasons for this finding: 1) mistaken injection sites and 2) corticosteroid extravasation. In this study, the longest rupture time after injection was 32 weeks, so it is critical to touch on delayed spontaneous rupture when educating patients.
Take Home Messages:
Spontaneous tendon rupture following a corticosteroid injection to address tendinitis is a serious complication. To minimize the risk of spontaneous rupture, more standardization regarding the application of corticosteroid injections is needed. Additional, appropriate education for both the patient and the doctors administering the injections is crucial to avoid unnecessary exposure to corticosteroids. Patients should always be fully educated on the treatment that they receiving as well as any potentially harmful side effects to enable to them to make educated decisions regarding their own health. Following spontaneous tendon rupture, the use of MRI to visualize the injury as well as to monitor healing after surgery was highly beneficial.
Lu, H., Yang, H., Shen, H., Ye, G., & Lin, X. J. (2016). The clinical effect of tendon repair for tendon spontaneous rupture after corticosteroid injection in hands: A retrospective observational study. Medicine, 95(41), e5145. https://doi.org/10.1097/MD.0000000000005145
Reviewed by Mark Boyland PT, DPT, CSCS
Knee osteoarthritis is a common condition that produces pain and limits patient function. Patients are regularly referred to Physical Therapy for complaints related to knee osteoarthritis and practice guidelines indicate exercise therapy should be the primary emphasis in the treatment of knee osteoarthritis. The authors were well aware and sought to compare two exercise types and their effect on patient’s knee pain.
Patients included in the trial were of 50 years age and up, able to walk without an assistive device, and has x-ray findings noting knee osteoarthritis. The study had 86 patients complete the study. There were 42 participants who completed the hip abductor and quadriceps strengthening protocol and 44 participants in the quadriceps strengthening protocol only. Participants completed the Knee Injury and Osteoarthritis Outcomes Scores (KOOS) throughout the study.
The exercise protocol explored only two exercises. The quadriceps strengthening group performed a knee extension exercise again for 4 sets of 10 with a 10 second hold at the top of the motion, performed in the morning and in the evening. The hip abductor strengthening group performed 4 sets of 10 of sidelying hip abduction with a 10 second hold at the top as well as the quadriceps strengthening exercise, performed in the morning and in the evening. The patients added a weight as needed to increase the difficulty as directed by the study design. The patients began with 50% of their 10 rep maximum for weeks 1 and 2, 60% for weeks 2-4, 70% for weeks 4-6, 80% for weeks 6-8, and 90% weeks 8-10.
Both study groups had improvements in their KOOS scores every 2 weeks. At the 10 week mark participants had at a minimum of 9.09% of improvement on the symptoms KOOS subsection up to 27.09% improvement in regards to quality of life. On average there was a 17.98% improvement across all subsections of the KOOS regardless of the group participants were placed in.
What can this mean for my patients? I attempted the 4 sets of 10 for 10 second holds with a 3 lb ankle weight and found it relatively challenging for myself and starting with a lighter weight was likely recommended. If my patients can tolerate this exercise protocol they only need to do 1 exercise for about 20 minutes per day. If my patients crave a little more variety they could do two exercises which would take about 40 minutes per day. The authors note that further studies need to be completed and that this may have been a relatively small sample size but I think most of my patients would be quite pleased with a minimum 9% improvement in the pain, function, and quality of life with just 1 exercise even if it could take up to 10.