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. presented a novel technique, the quadro-iliac plane block, involving injection of 40 mL of methylene blue with sonographic guidance along the quadratus lumborum muscle's attachment along the iliac crest within an unembalmed cadaver25. Methylene blue staining showed coverage of the lower abdomen, lumbosacral paraspinal region, and part of the lumbar plexus. The study supports the quadro-iliac plane block as an option for acute or chronic low back, lower abdominal, and hip region pain. Elite athletes require optimal spinal mobility, making motion-preserving spinal surgery such as total disc arthroplasty and microdiscectomy preferable to traditional options. In a systematic review, Reyes et al. found that, in 612 professional athletes (including those from the National Basketball Association and National Football League), return-to-play rates ranged from 75% to 100% for lumbar cases and 83% to 100% for cervical cases26. Motion-preserving spinal surgery is a feasible option for elite athletes when properly indicated. Joints Patients undergoing total joint arthroplasty face the risk of persistent opioid use, which can have a negative impact. Quaye et al. found that persistent opioid use after total joint arthroplasty in 6,432 opioid-naïve patients was associated with current smoking, depression, anxiety, substance use or behavioral disorders, chronic back pain, kidney disease, chronic obstructive pulmonary disease, diabetes, hypertension, fibromyalgia, perioperative use of certain psychotropic medications, dementia, body mass index of >40 kg/m2, and American Society of Anesthesiologists (ASA) score of 4. Regional anesthesia did not reduce long-term opioid use27. Decreasing opioid use while maintaining good postoperative pain control is somewhat of a universal goal. Wagner et al. explored the use of a postoperative methylprednisolone taper following total shoulder arthroplasty in an RCT28. Both groups received intraoperative dexamethasone, but the treatment group also received a 6-day methylprednisolone taper postoperatively. The treatment group demonstrated reductions in mean VAS pain scores up to 12 weeks postoperatively. Opioid use was significantly decreased in the treatment group. Rising obesity rates in patients undergoing TKA raise concerns about postoperative complications. Uvodich et al. utilized an institutional total joint registry and found that, although there has been a 90% increase in prevalence of Class-II obesity and a 300% increase in Class-III obesity in those undergoing TKA, the risks of reoperation, revision, or periprosthetic joint infection decreased for patients who were not obese and decreased or remained stable for patients who were obese29. Postoperative pain control following hip surgery is essential to expedite recovery and rehabilitation. Kang et al. conducted an RCT of intra-articular liposomal bupivacaine and found that it did not significantly reduce postoperative pain scores, opioid consumption, time to ambulation, or hospital length of stay compared with bupivacaine hydrochloride in patients undergoing hip hemiarthroplasty for intracapsular femoral neck fracture using a posterior approach30. Accurately assessing the risk of THA in patients with osteoarthritis is challenging because of a lack of validated methods. Xu et al. tried to fill this gap by developing a deep convolutional neural network model to predict the 9-year probability of THA and the most likely time period for THA31. The prediction model achieved an overall accuracy of 91.35%, sensitivity of 92.59%, and specificity of 86.96%. This could assist clinicians in patient counseling and decision-making. Orthobiologics Patients frequently seek injections to improve symptoms from mild to moderate carpal tunnel syndrome. The literature is inconclusive regarding the efficacy of dextrose compared with corticosteroid. Oh et al. performed a systematic review and meta-analysis comparing 5% dextrose with corticosteroid injections for mild to moderate carpal tunnel syndrome and found that, within 3 months, the dextrose group had significantly better function compared with the corticosteroid group32. Dextrose caused fewer side effects, supporting its use over corticosteroid for mild to moderate carpal tunnel syndrome. In a double-blinded RCT with 12-month follow-up, Rossi et al. found greater improvement in the VAS pain score in patients treated with platelet-rich plasma (PRP) into the subacromial bursa compared with corticosteroid33. The PRP group also scored higher in 3 other patient-reported outcomes, including the ASES score. Given the mixed results from conventional knee osteoarthritis treatments and surgical limitations from medical comorbidities in older patients, Park et al. systematically reviewed RFA and intra-articular mesenchymal stem cell injections for knee osteoarthritis34. They found RFA and mesenchymal stem cell injections to be superior to conventional treatment options at 3 and 6 months, highlighting them as reasonable treatment options for these patients. Prostheses and Orthotics In contrast to a conventional socket prosthesis, a bone-anchored prosthesis utilizes an osseointegrated implant that anchors directly into the residual bone. A Dutch study used a discrete choice experiment to assess patient preferences in discussions of bone-anchored prosthesis treatment, outcomes, and complications. The research found that patients consider long-term complications and quality of life to be the most important factors when evaluating this treatment option35. An RCT of 208 patients with lateral epicondylitis compared a 6-week wait-and-see approach to 2 splinting methods: a lateral epicondylopathy band and a wrist extension splint. Both splinting groups showed superior outcomes over education alone, with reduced pain, improved function, and higher pain thresholds. The lateral epicondylopathy band group demonstrated greater hand grip strength improvement and higher patient satisfaction36. Physiatry Societies and Upcoming Events The United States has 3 medical societies for physical medicine and rehabilitation (PM&R): the Association of Academic Physiatrists (AAP), the American Academy of Physical Medicine and Rehabilitation (AAPM&R), and the American Congress of Rehabilitation Medicine (ACRM). The 2026 AAP Annual Meeting will be in San Juan, Puerto Rico, from February 17 to 21, 2026. The 2026 AAPM&R Annual Assembly will be in Orlando, Florida, from November 11 to 14, 2026. The 2026 ACRM Annual Conference will be held in Washington, DC, from October 30 to November 2, 2026. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 4 other articles with a higher Level of Evidence grade relevant to orthopaedic rehabilitation are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Benn NL, Jervis-Rademeyer H, Souza WH, Pakosh M, Inness EL, Musselman KE. Balance interventions to improve upright balance control and balance confidence in people with motor-incomplete spinal cord injury or disease: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2025 Mar;106(3):444-58. Fall prevention is critically important for individuals with spinal cord injury who are at increased risk for falls due to decreased sensation and strength, which may cause severe injuries such as fractures. Balance interventions enhance upright balance control, decreasing fall risk. A systematic review and meta-analysis evaluated interventions for upright balance control, confidence in balance, and fall prevention in 500 adults with chronic motor-incomplete spinal cord injury. Upright balance training with visual feedback and walking interventions improved standing balance control compared with conventional physical therapy. Moreover, there was better balance confidence with walking interventions. Adverse events were minor, including fatigue and myalgia. There were insufficient data to evaluate interventions for falls. This study informs clinicians of the efficacy of fall prevention strategies for patients with motor-incomplete spinal cord injury: specifically, of upright balance training with visual feedback and walking interventions on standing balance control and of walking interventions on balance confidence. Solsona-Carcas D, Trenado-Molina J, Buesa-Estéllez A, López-Royo MP, Bellosta-López P. Physical therapist interventions versus or combined with surgical treatment in nontraumatic degenerative meniscal pathology: a systematic review and network meta-analysis. Phys Ther. 2024 May 1;104(5):pzae007. As the elderly population grows, degenerative meniscal pathologies are rising. Although arthroscopic partial meniscectomy and physical therapy are effective therapies, past reviews lacked comparisons involving combined treatments. In a systematic review and meta-analysis evaluating interventions for nontraumatic degenerative meniscal pathology involving 1,141 participants, both physical therapy and physical therapy plus arthroscopic partial meniscectomy were found to be superior to arthroscopic partial meniscectomy alone for pain at rest and knee extensor strength at 3 months. There were no differences between groups beyond 3 months. This study shows that physical therapy, alone or with arthroscopic partial meniscectomy, offers better short-term knee extensor strength and pain at rest compared with arthroscopic partial meniscectomy alone. Weninger V, Agócs G, Kovács N, Váncsa S, Hergár L, Baek CJ, Hegyi P, Holnapy G, Skaliczki G. Hyaluronate acid plus platelet-rich plasma is superior to steroids for pain relief less than 6 months using injection therapy of partial rotator cuff tears: a systematic review and network meta-analysis. Arthroscopy. 2025 Feb;41(2):304-15. Although corticosteroid injections are the standard treatment for partial-thickness rotator cuff tears, hyaluronic acid, PRP, and adipose-derived regenerative cells may be more effective alternatives. A systematic review and meta-analysis including 7 RCTs found that combining hyaluronic acid and PRP was most effective in decreasing pain at 4 weeks, followed by hyaluronic acid, PRP, saline solution, and corticosteroid. Hyaluronic acid and PRP yielded better function scores followed by hyaluronic acid, PRP, saline solution, and corticosteroid at 3 months. There was no difference between groups at 6 months, including for adipose-derived regenerative cells. This study supports the efficacy of alternative injectates, especially hyaluronic acid plus PRP, over corticosteroids for the short-term treatment of partial-thickness rotator cuff tears. Zhao L, Sun M, Yin Z, Cui J, Wang R, Ji L, Geng G, Chen J, Cai D, Liu Q, Zheng H, Liang F. Long-term effects of individualized acupuncture for chronic neck pain: a randomized controlled trial. Ann Intern Med. 2024 Oct;177(10):1330-8. Acupuncture is gaining recognition as an effective treatment for chronic neck pain, but studies are limited by substantial risk of bias and inconsistency in technique. A multicenter RCT of 659 patients found acupuncture to be effective for chronic neck pain compared with sham or no treatment, with significant improvement by week 4, which was sustained through 24 weeks. Both high-sensitivity and low-sensitivity acupoint techniques were equally effective, without a clinically important difference between groups. Despite some limitations, the study underscores acupuncture's benefit as a treatment for chronic neck pain and addresses prior research gaps.