title: Prevention and management of stiffness after arthroscopic rotator cuff repair: systematic review and implications for rotator cuff healing.
abstract: OBJECTIVE
  To define the incidence of stiffness after arthroscopic rotator cuff repair (ARCR) and address the prevention and management of postoperative stiffness.
  
  
  METHODS
  A PubMed search was performed using the combined terms "rotator cuff and stiffness," "shoulder and capsular release," and "capsular release and stiffness." Inclusion criteria were (1) primary outcome of postoperative shoulder stiffness, (2) Levels I to IV evidence, and (3) entirely arthroscopic technique for rotator cuff repair.
  
  
  RESULTS
  Seven articles met our inclusion criteria. Two articles discussed the management of preoperative stiffness and ARCR. These articles managed preoperative stiffness differently, preventing an adequate comparison to provide recommendations. Three articles described both the incidence of and risk factors for postoperative stiffness after ARCR. The incidence of transient stiffness responsive to nonoperative management was 10%. The incidence of resistant stiffness that was permanent or required capsular release was 3.3%. Several risk factors for stiffness were identified in this review. Two articles focused on postoperative rehabilitation protocols and stiffness after ARCR. Overall, resistant postoperative stiffness was reported in 1.5% of patients with an immediate passive range-of-motion protocol, 4.5% of patients in a 6-week sling-immobilization protocol, and 0% of patients with a modified protocol. Three articles, all among the above mentioned articles, reported that arthroscopic capsular release for stiffness after ARCR improved motion to a level comparable to that in patients who did not require reoperation.
  
  
  CONCLUSIONS
  The studies in this systematic review indicate that with ARCR, postoperative stiffness resistant to nonoperative management is uncommon despite an initial immobilization period. In the setting of resistant postoperative stiffness, arthroscopic capsular release can successfully restore range of motion. ARCR allows a delayed mobilization protocol that may be important in achieving rotator cuff healing. The optimal management of preoperative stiffness in patients undergoing ARCR is inconclusive based on this review.
  
  
  METHODS
  Level IV, systematic review of Level III and IV studies.
authors.affiliation: The San Antonio Orthopaedic Group, San Antonio, Texas, USA.
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Denard
authors.forename: Alexandre
authors.initials: A
authors.lastname: Lädermann
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Burkhart
mesh_terms: D001182:Arthroscopy / Q000009:adverse effects*; D003286:Contracture / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006801:Humans; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D020127:Recovery of Function; D017006:Rotator Cuff / Q000503:physiopathology / Q000601:surgery*; D000070636:Rotator Cuff Injuries; D012782:Shoulder / Q000503:physiopathology / Q000601:surgery; D000070599:Shoulder Injuries; D016896:Treatment Outcome