The timing of rotator cuff repair referrals on work rehabilitation program outcomes

Abstract

Background

Rotator cuff repairs are common among working-age adults and often require a lengthy rehabilitation process. Return to work (RTW) outcomes are often influenced by injury severity, job demands, and rehabilitation timing. Previous research suggests participation in work rehabilitation programs improves RTW outcomes; however, optimal timing for initiating these programs remains unclear.

Objective

To determine whether early versus typical referral to a work rehabilitation program following rotator cuff repair affects work rehabilitation program outcomes.

Methods

A retrospective analysis of 147 patients who underwent rotator cuff repair from 2014–2023 was conducted. Patients were categorized into early (n = 84) or typical (n = 63) referral groups based on surgical protocol-defined timelines by tear type. Statistical comparisons used non-parametric and categorical tests with significance set at p ≤ 0.05.

Results

Early referrals resulted in significantly fewer acute therapy visits (Mdn = 22.0 vs. 32.0; p < 0.001) and decreased time from surgery to work rehabilitation admission (Mdn = 18.0 vs. 24.0 weeks; p < 0.001) and discharge (Mdn = 22.0 vs. 29.0 weeks; p < 0.001). No significant differences were observed in RTW status (p = .327), percentage of job demands met, or number of work rehabilitation visits.

Conclusions

Early referral to a work rehabilitation program following rotator cuff repair leads to reduced therapy visits without compromising RTW outcomes. Findings from this study support an earlier transition to work rehabilitation programs from traditional outpatient therapy as a cost-effective and time-saving strategy to support the injured workers’ resumption of work tasks.

Keywords

workers compensation return to work processes and best practice occupational therapy physical therapy work rehabilitation rehabilitation processes

Background

Rotator cuff repairs are a common occurrence within the working-age population, with greater than 250,000 individuals requiring rotator cuff repairs each year in the United States.¹ Rotator cuff tears that require surgery occur due to some form of trauma, whether macro or micro. Macro trauma, such as a fall on a slippery floor at work, results in an acute injury and an acute tendon tear.² Micro-trauma can occur from repetitive motion, such as continuous overhead painting at work, which creates degenerative changes in the tendon and inadequate healing, potentially leading to a full-thickness rotator cuff tear.^2,3 Following the diagnosis of a rotator cuff tear, there are a variety of treatment options available, whether that surgical intervention or conservative management.

Following surgical intervention, the trajectory of outpatient therapy has multiple variables to consider when progressing the injured worker. The early stages of post-surgical rehabilitation emphasize a reduction in inflammation in addition to the management of pain.⁴ A recommended period of immobilization occurs for the first few weeks following the surgical intervention to protect the repair.⁵ Following immobilization, shoulder mobility should be addressed, progressing from passive, to active-assisted, to active.⁴ The repaired rotator cuff tendon should not have excessive stress and force placed upon it until 12 weeks post-operatively.⁴ The implementation of high-level activity, such as the replication of strenuous work tasks, is typically implemented near the 4- to 5-month post-operative mark, although current post-operative protocols do demonstrate quite a bit of variance.⁵

Following completion of acute therapeutic management for both nonoperative and operative rotator cuff injuries, a work rehabilitation program is then indicated once the injured worker reaches the appropriate timeframe in their recovery process to begin replicating higher level work-related tasks in a controlled, therapeutic environment. Work rehabilitation is an interdisciplinary program consisting of the replication of job tasks, cardiovascular conditioning, individualized treatment planning, and continuation of acute interventions to support the transition back to work at full duty without restrictions with the goal of providing a safe, efficient and effective return to work.⁶ Work rehabilitation programs are especially important following surgical procedures, such as a rotator cuff repair, to ensure the injured worker can return to work at the highest functional level possible through graded activities to maximize functional use, decrease underlying kinesiophobia and maximizing job demand performance.⁶ Through the literature, work rehabilitation programs have been identified as improving the injured worker's job status upon discharge, making this aspect of care an integral aspect of rehabilitation to maximize worker potential post-injury.

Research does provide insight on the impact of returning to work following a rotator cuff repair. Literature has previously identified that most injured workers return to their previous level of work around eight months, following a rotator cuff repair, however greater than 35 percent of these injured workers who have undergone the procedure are unable to return to their previous level of work.^1,7 Another study demonstrated the impact of physically demanding jobs and returning to work; the increase in physical demands increase the amount of rehabilitation required, worse levels of employment following injury, and higher levels of job loss are found.⁸ In addition, the impact of experiencing an injury while at work and receiving worker's compensation appears to negatively affect the expectation for individuals returning to work to attain previous levels of job demands.⁹

While previous literature demonstrates the impact of return to work following a rotator cuff repair, there is limited research identifying the most appropriate timing on the transition to a work rehabilitation program under these circumstances. Currently, there is a consensus statement from the American Society of Shoulder and Elbow Therapists, however this does not provide quantitative analysis further examining the specific timing, but rather general guidelines, leading to continued ambiguity in regards to appropriate transition periods.⁵ As identified in LaFrance et al.¹⁰ key components associated with resumption of work tasks through work rehabilitation programming consists of a clear description of mandated worker duties, realistic and attainable work-based goals, early identification of potential candidates who would benefit, reassessment of interventions and goals and ongoing communication with all parties involved in rehabilitation process. Literature also suggests that delaying outpatient therapy has negative effects on the outcomes of patients and leads to higher costs associated with the patient's overall care.¹¹ The current retrospective study aims to identify how the time of entry into a work rehabilitation program impacts the outcomes of the program following a rotator cuff repair.

The research study was guided by the following primary research question:

Does the timing of work rehabilitation intervention (early referral or typical referral) impact return to work status following a rotator cuff repair surgery?

The secondary research questions included the following:

Does the timing of work rehabilitation program intervention (early referral or typical referral) impact the percentage of job demands met following a rotator cuff repair surgery?

Does the type of tear and therapy protocol followed (small, medium, or large) influence return to work status following a rotator cuff repair surgery?

Does the type of tear and therapy protocol followed (small, medium, or large) influence the percentage of job demands met following a rotator cuff repair surgery?

Methods

A retrospective analysis of the work rehabilitation program database was conducted from 2014 to 2023 with rotator cuff repairs identified by tear severity. All patients within the work rehabilitation program had coverage through a worker's compensation claim. The data was extracted from the database and the timing of the evaluation was identified from the surgical date, with an early or typical connotation added to it. The current protocols followed by the facility have specific criteria regarding when the patients can transition to the work rehabilitation program depending on the severity of the rotator cuff tear and surgeon preference. The post-operative rotator cuff protocols were developed by the facility utilizing available evidence to support the progress of post-operative care.^12–17 A type 1 tear was classified as a tear less than 1 centimeter with good tissue quality, a type 2 tear was a medium tear of 1 to 3 centimeters and fair to good tissue quality, while a type 3 tear was a large tear greater than 3 centimeters or having poor tissue quality. The rate of progression for the different types varies, with type 1 first able to initiate work rehabilitation at 18 weeks, type 2 at 20 weeks, and type 3 at 22 weeks.^12–17

The timing of the entry into the work rehabilitation program was classified as early or typical based on the surgeon protocol. The early designation was based upon the protocol and calculated in weeks from the surgery to the evaluation in the work rehabilitation program. Type 1 was classified as early if it was less than 18 weeks, type 2 was early if less than 20 weeks, and type 3 was early if less than 22 weeks post-operatively.^12–17

The sample included 147 patients (Early Referral = 84 and Typical Referral = 63) who underwent rotator cuff repair surgery between 2014–2023. The data was collected from a single-site outpatient rehabilitation facility. The Shapiro-Wilk test was used to check normality for the distribution of the continuous variables, and all were nonnormally distributed. Descriptive and frequency statistics were used to summarize the characteristics of the study population. Median and range are reported for the non-normally distributed continuous variables. Counts and percentages are reported for categorical variables. Mann-Whitney U tests were used to compare group differences for non-normally distributed continuous variables between two groups. The Kruskal-Wallis H test was used to determine group differences for the non-normally distributed continuous variables between three or more groups. Chi-square or Fisher's exact (cell size < 5) tests were used to determine group differences for categorical variables. A p-value of ≤ 0.05 was considered statistically significant. The statistical analysis was performed using SPSS statistical software (version 29; IBM Corp., Armonk, NY).

Results

The outcomes of the study were analyzed, identifying various trends. The median age was 53 years (IQR = 15), and the majority of patients were Caucasian (84.4%) and male (73.5%). (Table 1) The majority of patients in both categories were the medium size tear, with no significant difference found between any of the rotator cuff tear types and the early and typical categories. (Table 2) Out of the 147 patients in the study, 84 (57.1%) received an early referral to a work rehabilitation program and 63 (42.9%) received a typical referral. Results indicated the number of acute visits for those who received an early referral (Mdn = 22.0) was statistically significantly lower than those who received a typical referral (Mdn = 32.0) to the work rehabilitation program (U = 804.0, p < 0.001). (Table 3) The number of weeks between surgery and admission to the work rehabilitation program for those who received an early referral (Mdn = 18.0) was statistically significantly lower than those who received a typical referral (Mdn = 24.0) following a rotator cuff repair surgery (U = 123.0, p < 0.001). The number of weeks between surgery and discharge from the work rehabilitation program for those who received an early referral (Mdn = 22.0) was statistically significantly lower than those who received a typical referral (Mdn = 29.0) following a rotator cuff repair surgery (U = 841.5, p < 0.001). No other statistically significant differences were found among the study variables for the early and typical referral groups, including job demands met at admission and discharge and work status upon admission and discharge. (Table 4)

Table 1.

Characteristics of the study population (N = 147).

	Total	Early	Normal
Characteristic	n (%)	84 (57.1)	63 (42.9)	P-value
Age*	53.0 (15.0)	54.0 (13.0)	52.0 (16.0)	0.361
Gender				0.518
Male	108 (73.5)	60 (71.4)	48 (76.2)
Female	39 (26.5)	24 (28.6)	15 (23.8)
Race				0.535
Caucasian	124 (84.4)	72 (85.7)	52 (82.5)
Hispanic	22 (15.0)	11 (13.1)	11 (17.5)
Asian	1 (0.7)	1 (1.2)	-

*Median (IQR)

Table 2.

Type of rotator cuff repair (N = 147).

	Total	Early	Normal
Characteristic	n (%)	84 (57.1)	63 (42.9)	P-value
Type of Rotator Cuff Tear				0.897
Small	30 (20.4)	18 (21.4)	12 (19.0)
Medium	82 (55.8)	47 (56.0)	35 (55.6)
Large	35 (23.8)	19 (22.6)	16 (25.4)

Table 3.

Visits and timing (N = 147).

	Total	Early	Normal
Characteristic	n (%)	84 (57.1)	63 (42.9)	P-value
Number of Acute Visits*	25.0 (10.0)	22.0 (6.0)	32.0 (9.0)	<0 . 001
Weeks Between Surgery and Admission*	20.0 (7.0)	18.0 (4.0)	24.0 (5.0)	<0 . 001
Weeks Between Surgery and Discharge*	25.0 (8.0)	22.0 (6.0)	29.0 (7.0)	<0 . 001

*Median (IQR)

Table 4.

Work rehabilitation program outcomes (N = 147).

	Total	Early	Normal
Characteristic	n (%)	84 (57.1)	63 (42.9)	P-value
Number of Work Conditioning Visits*	11.0 (8.0)	11.0 (7.0)	12.0 (9.0)	0.772
Days Off Work*	0.0 (54.0)	0.0 (40.0)	0.0 (108.0)	0.258
Job Demands Met Upon Admission (%)*	40.0 (30.1)	42.0 (29.8)	33.3 (26.0)	0.068
Job Demands Met Upon Discharge (%)*	100.0 (0.0)	100.0 (0.0)	100.0 (0.0)	0.147
Change in Job Demands Met (%)*	55.3 (34.5)	51.7 (32.9)	58.9 (45.5)	0.524
Work Status Upon Admission				0.960
Not Working	51 (34.7)	29 (34.5)	22 (34.9)
Working	96 (65.3)	55 (65.5)	41 (65.1)
Work Status Upon Discharge				0.327
Not Working	10 (6.8)	4 (4.8)	6 (9.5)
Working	137 (93.2)	80 (95.2)	57 (90.5)

*Median (IQR)

Discussion

While many physicians are cautious to refer prematurely for a post-operative rotator cuff repair to transition to a work rehabilitation program, the results of this study demonstrated the effectiveness of the early return to work and its limited impact on the job status. Conclusions can be drawn based upon the lack of change variance between the work status and percentage of job demands at discharge between the two groups, which supports the positive outcome of an early referral to the work rehabilitation program, as it does not change the return to work status or affect the percentage of job demands met upon discharge. Therefore, it may be beneficial to begin higher-level strengthening tasks related to the injured worker's job demands prior to the typical 20-week post-operative mark that was utilized at the site.

The early and typical work rehabilitation groups had considerable differences in the timing related to the work rehabilitation program. A significant difference occurred between the groups from the length of time between surgery to discharge from the program (p < 0.001). An approximate 7-week difference between the two groups occurred, with the typical referral group requiring an additional 7 weeks of therapy compared to the early referral group. This has a positive impact on both the injured worker and the worker's compensation providers. The decreased time spent in therapy with an earlier referral following a rotator cuff repair can further translate into greater cost savings for worker's compensation providers as fewer visits would need to be utilized. This may also decrease the potential for loss of company revenue at the expense of the injured worker. The employer would also further benefit from this improvement as the employee would be able to resume their job sooner, possibly requiring less overtime from other employees covering the workload in their absence.

The greatest impact of early referrals to work rehabilitation programs can be seen within the context of the overall course of care for the management of post-operative rotator cuff repairs. Results of this study demonstrated 10 fewer acute therapy visits utilized with the early referral compared to the standard referral therapy visit count (p < 0.001). Regarding work rehabilitation program participation specifically, there was no statistical difference between the number of work rehabilitation visits when comparing the early and typical referrals (p = .772). Analyzing this further, this can demonstrate a quicker return to work for surgical rotator cuff repair patients as work status was also comparable between the two groups (p = .327). This is in contrast to other published studies, which attributed a much longer recovery period for rotator cuff repairs and the ability to return to work in general.¹

The type of protocol followed, which was based on the tear size and tissue integrity, which demonstrated limited changes between the two groups. Previous studies have demonstrated poorer clinical outcomes and higher chances of re-tears with larger tears.¹⁸ The current analysis demonstrated no significant differences amongst the varying types of tears (p = .897), indicating the size of the tear may not be predictive of the ability to return to work and ability to meet job demands following a work rehabilitation program. Previous literature does confirm that rotator cuff tear size may not be a prognostic indicator for a poorer return to work outcome.¹⁹ This can also be suggestive of a faster progression throughout acute rehabilitation and progressing to work rehabilitation for the injured worker, improving the return-to-work timeframe.

The current study can assist in guiding future research directions which may include exploring if an early referral to a work rehabilitation program would decrease therapy costs associated with the plan of care, and ultimately overall care costs for the worker's compensation claim. A longitudinal study identifying if there was a reoccurrence of the rotator cuff tear over the course of 1, 3, and 5 years would also allow for the appropriate identification of any safety considerations with beginning a work rehabilitation program earlier than standard care has typically recommended. The lack of a longitudinal study does not allow for the conclusion to be made that it decreases any specific injury concerns that are present with the early referral. Further analysis can also be completed to determine the most effective timeframe on admission to a work rehabilitation program as well. Stratification based on strength levels required for the injured worker's job would also be important in future studies, as other literature has reported higher strength requirements leads to poorer outcomes.⁸ However, manual laborers were generally found to have an effective return to work rate.^19,20 Further emphasis on stratification could provide further clarity on the effect of the strength requirements for work.

Limitations do exist within the current study. The study was completed at one site, and these results may not extrapolate across multiple work rehabilitation programs. Work rehabilitation programs are also individualized, so the course of care for each participant was different based on their specific limitations and return to work demands. There were also no specific differences mentioned between the rotator cuff strength of the injured worker prior to the start of the work rehabilitation program. In addition, acute management of the post-operative rotator cuff did not follow a standardized progression, again due to the individualized experience and needs of the injured worker. Other factors may have contributed to the outcome as well, including the strength level required for returning to work without restrictions, as participants in the program ranged from light, lifting 11lbs to 25lbs to very heavy work, lifting greater than 100lbss.²¹ Selection bias may have also occurred in assigning the early and typical patients, however this was largely due to the referral process established by the facility, so this may have been minimal as individual patients were not selected by the work rehabilitation program.

Conclusion

The findings of the study suggest the positive impact of the early referral to a work rehabilitation program following rotator cuff repair. Early referral to a work rehabilitation program did not negatively affect the job status or percentage of job demands met at discharge, indicating a positive outcome for this group. The early work rehabilitation program group did have a decrease in the number of acute therapy visits, as well as a reduction in time between surgery and discharge from the work rehabilitation program. While there was no statistical difference in the number of work rehabilitation visits in the early group, there were seemingly limited negative effects of the early admission to the work rehabilitation program.

Footnotes

Acknowledgements

Not applicable

ORCID iDs

Mitchell Voss

Jennifer K Homa-Bonell

Ethical considerations

This study was approved by the Aurora Health Care IRB (IRB # 00106690) and deemed exempt due to IRB review due to the retrospective nature of the study on 8/20/2018.

Informed consent

Informed consent for information published in this article was not obtained due to the retrospective nature of the study.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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