Massive irreparable rotator cuff tears can cause significant shoulder pain, disability and reduction in quality of life. Treatment approaches can be operative or non-operative. Operative approaches include reverse total shoulder arthroplasty, arthroscopic debridement, partial rotator cuff repair, subacromial balloon spacers, superior capsule reconstruction, and tendon transfer procedures. Non-operative approaches include physiotherapy exercise programs and corticosteroid injections. There are no randomized controlled trials comparing the different treatment approaches. It is therefore challenging for clinicians to advise patients on what is their best treatment pathway. Physiotherapy exercise programs are less expensive and have lower risks for patients than surgical approaches. However, the success of physiotherapy in patients with massive irreparable rotator cuff tears is highly variable with published success rates of 32–96%. Several cohort studies have sought to identify if certain factors are predictive of success with physiotherapy. Several biomechanical factors were identified as possibly being related to a successful or unsuccessful outcome following physiotherapy, with complete tear of subscapularis demonstrating the strongest evidence. However, there were no appropriately designed prognostic studies. There has been a strong emphasis on biomechanical factors. Other domains such as psychosocial factors, which are important in similar patient populations, have not been explored. We recommend that further research is needed in this area and should include randomized controlled trials comparing treatment approaches and longitudinal prospective prognostic studies to identify predictors of treatment success.

Massive irreparable rotator cuff tears can cause significant shoulder pain and disability. Treatment options include physiotherapy or surgery, with a lack of research comparing treatment options. For physiotherapy there is uncertainty about which patients will have a successful or unsuccessful response to treatment and a lack of consensus on what constitutes the best physiotherapy programme. With these significant gaps in the research, it is challenging for clinicians seeing patients with massive irreparable rotator cuff tears to advise on what is their best treatment pathway. A three round Delphi study was conducted with expert shoulder physiotherapists and orthopaedic surgeons to gain consensus on the important factors associated with response to physiotherapy in this patient population. Round 1 was an information-gathering round to identify predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears. Rounds 2 and 3 were consensus-seeking rounds on the importance and modifiability of the predictors. Consensus criteria were determined a priori using median, interquartile range, percentage agreement and Kendall’s Coefficient of Concordance. Participants were recruited April–October, 2023. 88 experts participated in Round 1 and of these, 70 completed Round 3 (79.54%). In Round 1, content analysis of 344 statements identified 45 predictors. In Round 2, 29 predictors reached consensus as important and 2 additional predictors were identified. In Round 3, of the 31 predictors from Round 2, 22 reached consensus as important and 12 of these reached consensus as modifiable by physiotherapists. Both patient factors and clinician factors from a broad range of domains reached consensus: biomechanical, psychological, social, co-morbidities, communication / healthcare interactions and pain. The results of this Delphi study suggest that clinicians assessing patients with massive irreparable rotator cuff tears should assess across all these domains and target the modifiable factors with interventions. Particular emphasis should be placed on optimising modifiable clinician factors including therapeutic alliance, comprehensive explanation of the condition and collaborative and realistic goal-setting. These in turn may influence modifiable patient factors including patient expectations, engagement with the physiotherapy programme, motivation and self-efficacy thus creating the ideal environment to intervene on a biomechanical level with exercises.

The addition of blood flow restriction therapy (BFRT) to exercise in patients with olecranon fracture treated surgically has not been described in the literature. To describe the effects and safety of BFRT exercises in the postoperative rehabilitation of a patient with olecranon fracture. A 27-year-old male with a surgically treated olecranon fracture completed a 12-week postoperative physical therapy programme. The assessment was performed at the start of rehabilitation, 4 and 12 weeks. The patient had elbow pain, decreased active range of motion (AROM), reduced handgrip strength, and limited physical function. The patient was treated with low-intensity resistance exercises with BFRT. The BFRT was applied with three exercises per stage, at 50% of the limb occlusion pressure and 75 repetitions per exercise. At discharge from physical therapy, improvements were observed in pain intensity (5.9-1.4 cm), AROM of elbow flexion (88°-137°) and extension (-22°--2°), AROM of forearm pronation (18°-68°) and supination (34°-78°), handgrip strength (8 kg-47 kg), physical function (22.9%-89.6%), and disability (72.7%-13.6%). These changes reached the minimal clinically important difference at the time of discharge for all measures, except for extension, pronation, and supination AROM. The addition of BFRT to exercise was effective in improving pain, elbow, and wrist AROM, handgrip strength, function, and disability in a patient with surgically treated olecranon fracture. Despite the inherent limitations of our design, we believe these preliminary findings are compelling to warrant future investigations.

Background: Blood flow restriction training (BFRT) is a widely studied strategy in lower limb pathology; however, BFRT research in upper limb disorders is limited. Objective: To evaluate the effectiveness of BFRT programs on skeletal muscle mass, strength, pain, and function in upper limb musculoskeletal disorders rehabilitation and to analyze the reporting quality of the exercise content. Methods: A literature search of the PubMed, Web of Science, Scopus, Scientific Electronic Library Online, SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature, and Physiotherapy Evidence Database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines from inception to May 2023. The results included randomized controlled trials (RCTs) and non‐RCTs, prospective and retrospective cohort studies, case series, and case report studies of patients with upper limb musculoskeletal disorders treated with resistance exercise enhanced with BFRT and reporting at least one outcome related to skeletal muscle mass, strength, pain or function/disability. The risk of bias of the included studies was assessed using the Risk of Bias 2.0, and the reporting quality was evaluated with the Consensus on Exercise Reporting Template (CERT). Results: Four RCTs, one case series, and four case report studies were included. Very low‐quality studies showed a pattern of clinical improvements surpassing the minimal clinically important difference in most patient‐reported outcome and physical function measures. The risk of bias in the included studies was high. The CERT revealed poor description of the BFRT programs. Conclusions: This systematic review identified limited and low‐quality evidence that BFRT is effective in the physical rehabilitation of patients with upper limb musculoskeletal disorders. Additionally, the reporting of BFRT content in patients with upper limb disorders is poor. We recommend that authors use the CERT guideline when reporting the exercise protocols and results of trials investigating BFRT interventions.