What’s New in Orthopaedic Rehabilitation

This editorial highlight key articles, mostly from March 2024 to February 2025, reflecting the ongoing synergy between orthopaedic surgery and rehabilitation. Sources include the American Journal of Physical Medicine & Rehabilitation; The American Journal of Sports Medicine; Clinical Journal of Sports Medicine; Archives of Physical Medicine and Rehabilitation; The BMJ (British Medical Journal); The Journal of Bone & Joint Surgery; JAMA (The Journal of the American Medical Association); Journal of Rehabilitation Medicine; Journal of Shoulder and Elbow Surgery; The New England Journal of Medicine; Pain Medicine; PM&R: The Journal of Injury, Function and Rehabilitation; Regional Anesthesia & Pain Medicine; and The Spine Journal. Shoulder The current literature lacks consensus on mobilization protocols following arthroscopic rotator cuff repair with biceps rerouting. A new study included 101 patients with large posterosuperior rotator cuff tears treated with arthroscopic rotator cuff repair with biceps rerouting randomized to early (starting postoperative day 1) or delayed (postoperative week 4) motion rehabilitation1. There was no difference in active range of motion between the groups with regard to function or healing at 3, 6, and 12 months, and both groups had similar retear rates. There was significant improvement in the visual analog scale (VAS) pain score, University of California Los Angeles shoulder score, and acromiohumeral interval as measured by radiographs, without between-group differences. A prospective randomized controlled trial (RCT) involving 72 nonoperatively treated 2-part displaced proximal humeral fractures evaluated a 10-week daily home-based exercise program with weekly physiotherapist-supervised exercises compared with an unsupervised program. No difference was found at 3 and 12 months in the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Constant-Murley score, the 15D instrument, the VAS pain score, the General Self-Efficacy Scale, or the Pain Catastrophizing Scale2. Orthopaedic surgeons are the third highest opioid prescribers in the United States, prompting research into minimal effective postoperative doses. Kishan et al. conducted a prospective RCT comparing opiate usage following shoulder arthroplasty, arthroscopic rotator cuff repair, or other arthroscopic shoulder procedures3. All 74 enrolled patients followed a multimodal pain control program but were randomized to treatment arms that were prescribed 7, 15, or 23 tablets of 5-mg oxycodone postoperatively. There was lower opiate use within the 7-tablet group compared with the other treatment arms, with no difference in American Shoulder and Elbow Surgeons (ASES) pain scores, the volume of refill requests, or contact with the physician office. Reverse total shoulder arthroplasty is commonly performed for substantial shoulder pain and dysfunction due to large rotator cuff tears and glenohumeral arthropathy. Vandenbosch et al. conducted a cross-sectional study of electromyographic (EMG) activity in the trapezius, serratus anterior, deltoid, latissimus dorsi, and pectoralis major during commonly used rehabilitation exercises in 50 shoulder girdles 12 weeks after reverse total shoulder arthroplasty4. Horizontal-plane exercises showed low muscle activity, whereas vertical closed-chain and open-chain exercises against gravity increased EMG activity, especially in the deltoid and upper trapezius. This supports rehabilitation progression from the horizontal plane to vertical-plane closed-chain exercises and then to open-chain exercises. Scapular mechanics are relevant to optimal upper-extremity function and are often a target for upper-limb rehabilitation programs, particularly for the shoulder. Mendez-Rebolledo et al. compared surface EMG characteristics of shoulder-stabilizing muscles among 5 common rehabilitative exercises (wall slide, wall push-up plus, prone horizontal abduction with external rotation, external rotation in side lying, and low row) in 27 healthy subjects5. Prone horizontal abduction with external rotation showed optimal scapular neuromuscular control. Although external rotation in side lying, low row, and wall slide did not meet all criteria associated with optimal scapular neuromuscular control, there was early activation of scapula-stabilizing muscles, supporting the clinical utility of those exercises in the early stages of shoulder rehabilitation. Some studies have suggested that corticosteroid injections into the rotator cuff interval have superior outcomes compared with corticosteroid injections into other locations in treating adhesive capsulitis. Arrambide-Garza et al. conducted a meta-analysis comparing the efficacy of ultrasound-guided corticosteroid injections into the glenohumeral joint via the rotator interval or a posterior approach6. Five of 991 reviewed studies were included for meta-analysis. There was a significant difference favoring the rotator interval approach in the VAS pain score, function, abduction, and internal and external rotation up to 12 weeks after injection. Elbow Lateral epicondylopathy is a common cause of lateral elbow pain, often affecting function and grip strength. A systematic review and meta-analysis assessed the effectiveness of trigger-point dry needling in treating lateral epicondyle pain, including 17 RCTs with a total of 979 participants. Findings suggested that dry needling effectively reduces pain intensity, improves elbow function, and enhances grip strength, with the most benefits observed in the short term, within 1 week of treatment7. An anatomic study of 12 digitized upper extremities identified distinct innervation patterns of the posterior elbow capsule, with key nerves supplying specific regions. The superoposterior capsule is supplied by the ulnar collateral nerve and lateral branch to the triceps, the lateral capsule by the nerve to the anconeus (sometimes with input from the extensor carpi ulnaris), and the medial capsule by direct branches from the ulnar nerve and forearm flexors, with medial and posterior antebrachial cutaneous nerves supplying the epicondylar regions. Ultrasound landmarks such as the epicondyles, olecranon, and triceps margins may guide targeted denervation or nerve blocks for elbow pain, pending clinical validation8. Hand Surgery for Dupuytren contracture carries risks of neurovascular injury and a high recurrence rate, whereas extracorporeal shock-wave therapy (ESWT), a noninvasive modality used to treat various musculoskeletal conditions, offers a noninvasive alternative. In a systematic review of 6 studies, Yazdani et al. found that ESWT provides pain relief, improves finger and hand function, and yields generally high patient satisfaction in Dupuytren disease, although benefits may diminish over time. Ultrasonographic evidence has suggested possible reduction in nodule size, but the durability of these effects and optimal treatment protocols require further investigation9. Scaphoid nonunion can lead to development of scaphoid nonunion advanced collapse arthritis, a progressive degenerative condition. White et al. conducted a multicenter, double-blinded RCT of low-intensity pulsed ultrasound (LIPUS) as adjunctive therapy after surgical fixation of established scaphoid nonunions10. LIPUS did not reduce time to union or increase union rates compared with sham treatment, after controlling for surgical technique, fracture classification, and device compliance. Serial computed tomographic scans were used for follow-up. Ultrasound optimizes the accuracy of corticosteroid injections in de Quervain tenosynovitis due to the frequent occurrence of an intracompartmental septum in the first dorsal compartment. In a prospective RCT, Kuo et al. compared ultrasound-guided corticosteroid injections with palpation-guided corticosteroid injections in 49 patients with de Quervain tenosynovitis and found improvements with both techniques but no difference in the QuickDASH (abbreviated version of the DASH) score or the VAS pain score at 1 week after injection11. There was no difference in the VAS pain score, patient satisfaction, and adverse effects at 3 and 6 months. The palpation-guided group showed a nonsignificant trend toward higher recurrence and skin side effects than the ultrasound-guided group. Ultrasound is an emerging complementary tool to EMG in the diagnosis of carpal tunnel syndrome. A retrospective cohort study found a significant association between increasing electrodiagnostic severity of carpal tunnel syndrome and both the median nerve cross-sectional area at the wrist and the wrist-to-forearm ratio on neuromuscular ultrasound12. These ultrasound parameters increased proportionally with greater electrodiagnostic severity, supporting their utility in assessing carpal tunnel syndrome severity. Hip Patients with femoroacetabular impingement syndrome may have more pain with increased duration and intensity of physical activity. Grosklos et al. explored the link between physical activity and pain in femoroacetabular impingement syndrome using accelerometry and an ecological momentary pain assessment survey13. Sedentary time above an individual’s personal average was associated with lower pain levels. Increased duration and intensity of physical activity, specifically light physical activity and moderate-to-vigorous physical activity above an individual’s average in the 90 minutes preceding the survey, were associated with increased hip pain intensity. Fluctuations in either light physical activity or moderate-to-vigorous physical activity alone did not influence pain unless an individual was more active at both intensity levels within the same 90-minute period. Hip arthroscopy in patients ≥40 years of age is controversial. A single-surgeon, parallel RCT of 97 patients ≥40 years of age with symptomatic acetabular labral tears secondary to femoroacetabular impingement compared arthroscopic surgery with postoperative physical therapy and physical therapy alone14. Arthroscopic surgery with postoperative physical therapy resulted in superior patient-reported outcomes and pain reduction at 24 months compared with physical therapy alone. Most patients assigned to physical therapy alone crossed over to surgery because of unsatisfactory improvement, and then achieved improvements similar to those who underwent primary surgery. The rate of conversion to total hip arthroplasty (THA) was similar between groups. Knee Recurrent patellar dislocations can be treated with tibial tubercle osteotomy and medial patellofemoral ligament reconstruction, followed by rehabilitation. In a randomized trial of 50 patients, Zhang et al. found early rapid rehabilitation to be safe and effective15. Early rapid rehabilitation showed early benefits, but both groups had similar outcomes at 24 months, although patella baja occurred in 17% of the conservative rehabilitation group and 0% in the early rapid rehabilitation group. Blood flow restriction training induces temporary hypoxia and metabolic stress to promote muscle growth and strength, although results have been mixed. Colombo et al. performed a systematic review involving 5 studies on rehabilitation with and without blood flow restriction training after anterior cruciate ligament (ACL) reconstruction16. The authors concluded that blood flow restriction training has an unclear effect on muscle strength and size of the knee extensors and flexors after ACL reconstruction but may improve knee-specific physical function and patient-reported outcome measure scores. Weight loss is a common treatment recommendation for obese patients with symptomatic knee osteoarthritis. A double-blinded, randomized, placebo-controlled trial on 407 obese patients (body mass index of ≥30 kg/m2) with symptomatic moderate knee osteoarthritis showed that 2.4-mg semaglutide was superior to placebo in achieving weight loss17. The semaglutide group also had a 41.7-point change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores compared with 27.5 points in the placebo group and better improvement in function. Adverse events were higher in the semaglutide group, mostly consisting of gastrointestinal disorders. Cooled and conventional radiofrequency ablation (RFA) methods targeting the genicular nerves of the knee are used to treat chronic knee pain after total knee arthroplasty (TKA) and/or symptomatic osteoarthritis. A multicenter, double-blinded RCT of 41 patients found that both cooled and conventional RFA groups had ≥50% relief in pain at 1 year18. The group treated with cooled RFA had better pain outcomes, and cooled RFA was found to be cost-effective for patients with a history of TKA compared with conventional RFA. No differences in outcomes were found in patients with knee pain due to osteoarthritis. Foot and Ankle Chronic ankle instability is frequently associated with limited dorsiflexion. Joint mobilization and uphill running can help to restore motion. In this 4-week study on chronic ankle instability, 58 participants received 1 of 4 interventions (combined uphill running and joint mobilization, uphill running alone, joint mobilization alone, and control) 3 times weekly19. The combination of uphill running and joint mobilization appeared to be superior to uphill running alone or joint mobilization alone for increased non-weight-bearing ankle dorsiflexion as measured by a goniometer. All 3 interventions had significant improvements in the outcomes compared with the control group. In a study of 67 patients with treatment-resistant plantar fasciopathy, Kruse and Volfson found that ultrasonic fasciotomy significantly improved pain and function by 12 weeks, with sustained results at 52 weeks, no complications, and a 94% satisfaction rate20. Plantar fasciitis with a calcaneal spur is a common cause of chronic heel pain. Pulsed RFA of the tibial nerve under ultrasound guidance delivers short bursts of high-voltage electrical current to the tibial nerve just proximal to the tarsal tunnel, creating a nonthermal effect that modulates the transmission of pain signals. Intralesional RFA under fluoroscopic guidance places the needle at the tip of the calcaneal spur. A continuous current heats the target tissue, causing coagulation that can promote thinning of hard tissues such as calcaneal spurs and plantar fascia. In a prospective randomized study of 49 patients, Yildiz et al. found that both tibial nerve pulsed RFA and intralesional RFA at the calcaneal spur significantly reduced pain at 1 and 3 months, with no difference between groups21. Transient side effects included paresthesia, numbness, and pain. Spine Outcomes regarding physical activity following lumbar spinal fusion can be influenced by biopsychosocial factors, leading to continued sedentary behavior postoperatively. Tegner et al. performed an RCT of 144 patients with chronic low back pain undergoing lumbar spinal fusion. Early postsurgical graded activity and pain education (GAPE) did not reduce sedentary time at 3 months compared with usual care, but improved kinesiophobia. At 12 months, GAPE led to a modest but significant reduction in sedentary behavior22. Insurance and financial factors limit extensive implementation of conservative non-pharmacological management for chronic low back pain. Maddox et al. reported durable benefit following an 8-week, self-administered, skills-based virtual reality program for chronic low back pain, incorporating cognitive-behavioral therapy techniques, mindfulness, and pain education. At 18 months after treatment, participants sustained reductions in mean pain, pain-related stress, pain interference with activity, and sleep disturbance, and improved physical function, supporting long-term efficacy23. In a large cohort study conducted by Sung et al. of >207,000 patients >50 years of age undergoing elective lumbar fusion, preoperative acupuncture performed within any time interval prior to surgery was not associated with increased early postoperative infection risk. Epidural steroid injection was linked to higher infection risk only if performed within 2 weeks before the surgery; this association was not seen when epidural steroid injection or acupuncture occurred >2 weeks preoperatively. These findings suggest that acupuncture is safe with respect to infection risk, although epidural steroid injection should be avoided within 2 weeks prior to surgery24. The quadratus lumborum muscle has been the focus of multiple different regional interventions for low back and abdominal pain. Tulgar et al. a technique, the plane involving injection of of with guidance the quadratus lumborum the within an showed of the lower and of the lumbar The study supports the plane as an for or chronic low lower and hip pain. require optimal spinal spinal surgery such as total arthroplasty and to In a systematic et al. found in those from the and rates from to for lumbar and to for spinal surgery is a for when Patients undergoing total joint arthroplasty the risk of opioid can have a et al. found that opioid use after total joint arthroplasty in patients was associated with current use or chronic back pain, disease, chronic disease, use of mass index of and American of score of Regional did not reduce long-term opioid opioid use postoperative pain control is of a et al. explored the use of a postoperative following total shoulder arthroplasty in an groups received but the treatment group also received a postoperatively. The treatment group reductions in mean VAS pain scores up to 12 weeks postoperatively. use was significantly in the treatment group. rates in patients undergoing TKA postoperative et al. an total joint and found although there has been a increase in of and a increase in in those undergoing the risks of or joint infection for patients who were not obese and or for patients who were pain control following hip surgery is to and rehabilitation. et al. conducted an RCT of and found that did not significantly reduce postoperative pain scores, opioid time to or of compared with in patients undergoing hip for fracture using a posterior assessing the risk of in patients with osteoarthritis is because of a of et al. to this by a to the of and the most time for The achieved an accuracy of of and of This in patient and Patients frequently injections to improve from to moderate carpal tunnel syndrome. The literature is regarding the efficacy of compared with et al. performed a systematic review and meta-analysis comparing with corticosteroid injections for to moderate carpal tunnel syndrome and found within 3 months, the group had significantly better function compared with the corticosteroid side supporting use over corticosteroid for to moderate carpal tunnel syndrome. In a double-blinded RCT with et al. found greater improvement in the VAS pain score in patients treated with into the compared with The group also higher in 3 other patient-reported outcomes, including the the results from conventional knee osteoarthritis and surgical from in patients, et al. reviewed RFA and injections for knee found RFA and injections to be superior to conventional treatment at 3 and 6 months, as treatment for these and In to a conventional a an that into the A study used a to patient in of treatment, outcomes, and The research found that patients long-term and of to be the most factors when this treatment An RCT of patients with lateral compared a approach to 2 a lateral epicondylopathy and a wrist groups showed superior outcomes over education alone, with reduced pain, improved function, and higher pain The lateral epicondylopathy group greater hand grip strength improvement and higher patient and The United has 3 for physical and rehabilitation the of the American of Physical Medicine and Rehabilitation and the American of Rehabilitation Medicine The be in from February 17 to The be in from to The be in from to The editorial of reviewed a large of studies to the musculoskeletal that received a higher of In to in this 4 other with a higher of relevant to orthopaedic rehabilitation are to this review after the with a to help guide further in an in this interventions to improve control and in with spinal injury or a systematic review and meta-analysis. is for with spinal injury who are at increased risk for due to and strength, may cause such as interventions control, risk. A systematic review and meta-analysis evaluated interventions for control, in and in with chronic spinal training with visual and interventions improved control compared with conventional physical there was better with Adverse events were including and There were to interventions for This study of the efficacy of for patients with spinal of training with visual and interventions on control and of interventions on Physical interventions or with surgical treatment in degenerative a systematic review and meta-analysis. 2024 the degenerative are Although arthroscopic and physical therapy are effective involving In a systematic review and meta-analysis interventions for degenerative involving both physical therapy and physical therapy arthroscopic were found to be superior to arthroscopic alone for pain at and knee extensor strength at 3 months. There were no differences between groups 3 months. This study that physical alone or with arthroscopic offers better knee extensor strength and pain at compared with arthroscopic alone. is superior to for pain relief than 6 months using injection therapy of rotator cuff a systematic review and meta-analysis. Although corticosteroid injections are the treatment for rotator cuff and may be more effective A systematic review and meta-analysis including RCTs found that and was most effective in pain at 4 weeks, followed by and and better function scores followed by and corticosteroid at 3 months. There was no difference between groups at 6 months, including for This study supports the efficacy of especially over for the treatment of rotator cuff effects of acupuncture for chronic a randomized controlled 2024 is as an effective treatment for chronic pain, but studies are limited by substantial risk of and in A RCT of patients found acupuncture to be effective for chronic pain compared with sham or no treatment, with significant improvement by week was sustained 24 and techniques were without a difference between groups. the study benefit as a treatment for chronic pain and prior research

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