Rotator Cuff Repair

The intent of this protocol is to provide the therapist and patient with guidelines for the post-operative rehabilitation course after arthroscopic rotator cuff repair. This protocol is based on a review of the best available scientific studies regarding shoulder rehabilitation. It is by no means intended to serve as a substitute for one’s clinical decision making regarding the progression of a patient’s post-operative course. It should serve as a guideline based on the individual’s physical exam/findings, progress to date, and the absence of post-operative complications. If the therapist requires assistance in the progression of a post-operative patient they should consult with Dr. Fullick.

Progression to the next phase based on Clinical Criteria and/or Timeframes as appropriate.

Phase I – Immediate Post Surgical (Weeks 1-6):

Goals:

• Maintain / protect integrity of repair
• Gradually increase passive range of motion (PROM)
• Diminish pain and inflammation
• Prevent muscular inhibition
• Become independent with activities of daily living with modifications

Precautions:

• Maintain arm in abduction sling / brace, remove only for exercise
• No active range of motion (AROM) of shoulder
• No lifting of objects
• No shoulder motion behind back
• No excessive stretching or sudden movements
• No supporting of any weight
• No lifting of body weight by hands
• Keep incisions clean and dry Criteria for progression to the next phase (II):
• Passive forward flexion to at least 125 degrees
• Passive external rotation (ER) in scapular plane to at least 75 degrees
• Passive internal rotation (IR) in scapular plane to at least 75 degrees
• Passive Abduction to at least 90 degrees in the scapular plane

DAYS 1 TO 6:

• Abduction brace/sling
• Pendulum exercises
• Finger, wrist, and elbow AROM
• Begin scapula musculature isometrics / sets; cervical ROM
• Cryotherapy for pain and inflammation -Day 1-2: as much as possible (20 minutes of every hour)
• Day 3-6: post activity, or for pain
• Sleeping in abduction sling
• Patient Education: posture, joint protection, positioning, hygiene, etc.

DAYS 7 TO 28:

• Continue use of abduction sling / brace
• Pendulum exercises
• Begin passive ROM to tolerance (these should be done supine and should be pain free)
  • Flexion to 90 degrees
  • ER in scapular plane to at least 35 degrees
  • IR to body/chest
• Continue Elbow, wrist, and finger AROM / resisted
• Cryotherapy as needed for pain control and inflammation
• May resume general conditioning program – walking, stationary bicycle, etc.
• Aquatherapy / pool therapy may begin at 3 weeks postop

Phase II – Protection / Active motion (weeks 5 - 10):

Goals:

• Allow healing of soft tissue
• Do not overstress healing tissue
• Gradually restore full passive ROM (week 4-5)
• Decrease pain and inflammation

Precautions:

• No lifting
• No supporting of body weight by hands and arms
• No sudden jerking motions
• No excessive behind the back movements
• Avoid upper extremity bike or upper extremity ergometer at all times.

Criteria for progression to the next phase (III): Full active range of motion

WEEK 5-6:

• Continue use of sling/brace full time until end of week 4
• Between weeks 4 and 6 may use sling/brace for comfort only
• Discontinue sling/ brace at end of week 6
• Initiate active assisted range of motion (AAROM) flexion in supine position
• Progressive passive ROM until approximately Full ROM at Week 4-5. -Gentle Scapular/glenohumeral
• joint mobilization as indicated to regain full passive ROM
• Initiate prone rowing to neutral arm position
• Continue cryotherapy as needed
• May use heat prior to ROM exercises
• May use pool (aquatherapy) for light active ROM exercises
• Ice after exercise

Weeks 6-8

• Continue active and active assisted ROM and stretching exercises
• Begin rotator cuff isometrics
• Continue periscapular exercises
• Initiate active ROM exercises
  • flexion scapular plane
  • abduction
  • external rotation
  • internal rotation

Phase III – Early strengthening (weeks 10-14):

Goals:

• Full active ROM (week 10-12)
• Maintain full passive ROM
• Dynamic shoulder stability
• Gradual restoration of shoulder strength, power, and endurance
• Optimize neuromuscular control
• Gradual return to functional activities

Precautions:

• No heavy lifting of objects (no heavier than 5 lbs.)
• No sudden lifting or pushing activities
• No sudden jerking motions
• No overhead lifting
• Avoid upper extremity bike or upper extremity ergometer at all times.

Criteria for progression to the next phase (IV):

• Able to tolerate the progression to low-level functional activities
• Demonstrates return of strength/dynamic shoulder stability
• Re-establish dynamic shoulder stability
• Demonstrates adequate strength and dynamic stability for progression to higher demanding work/sport specific activities.

WEEK 10:

• Continue stretching and passive ROM (as needed)
• Dynamic stabilization exercises
• Initiate strengthening program
  • External rotation (ER)/Internal rotation (IR) with therabands/sport cord/tubing
  • ER side-lying (lateral decubitus)
  • Full can in scapular plane* (avoid empty can abduction exercises at all times)
  • Prone rowing
  • Prone horizontal abduction
  • Prone extension
  • Elbow flexion
  • Elbow extension

Patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonics; if unable, continue glenohumeral joint exercises

WEEK 12:

• Continue all exercise listed above
• Initiate light functional activities as Dr. Millett permits

WEEK 14:

• Continue all exercise listed above
• Progress to fundamental shoulder exercises

Phase IV – Advanced strengthening (weeks 16-22):

Goals:

• Maintain full non-painful active ROM
• Advance conditioning exercises for enhanced functional use
• Improve muscular strength, power, and endurance
• Gradual return to full functional activities

WEEK 16:

• Continue ROM and self-capsular stretching for ROM maintenance
• Continue progression of strengthening
• Advance proprioceptive, neuromuscular activities
• Light sports (golf chipping/putting, tennis ground strokes), if doing well

WEEK 20:

• Continue strengthening and stretching
• Continue stretching, if motion is tight
• May initiate interval sport program (i.e. golf, doubles tennis, etc.), if appropriate.