Rehabilitation Protocol for Rotator Cuff Repair-Small to Medium

Sized Tears

This protocol is intended to guide clinicians and patients through the post-operative course of a rotator cuff repair.

Specific interventions should be based on the needs of the individual and should consider exam findings and clinical

decision making. If you have questions, contact the referring physician.

Considerations for the Post-operative Rotator Cuff Repair Rehabilitation Program

Many different factors influence the post-operative rotator cuff repair rehabilitation outcome, including rotator cuff tear

size, type of repair, tissue quality, number of tendons involved, and individual patient factors like age and co-morbidities

including increased BMI and diabetes. Consider taking a more conservative approach for more complex tears, including

large/massive tears (>3 cm) and >1 tendon involvement.

Post-operative Complications

If you develop a fever, unresolving numbness/tingling, excessive drainage from the incision, uncontrolled pain or any

other symptoms you have concerns about you should contact the referring physician.

PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Protect surgical repair

• Reduce swelling, minimize pain

• Maintain UE ROM in elbow, hand and wrist

• Gradually increase shoulder PROM

• Minimize muscle inhibition

• Patient education

Sling

• Neutral rotation

• Use of abduction pillow in 30-45 degrees abduction

• Use at night while sleeping

Precautions

• No shoulder AROM/AAROM

• No lifting of objects

• No supporting of body weight with hands

• Avoid scapular retraction with a teres minor repair

Intervention

Swelling Management

• Ice, compression

Range of motion/Mobility

• PROM: ER<20 scapular plane, Forward elevation <90, seated GH flexion table slide, horizontal table

slide

• AROM: elbow, hand, wrist (PROM elbow flexion with concomitant biceps tenodesis/tenotomy)

• AAROM: none

Strengthening (Week 2)

• Periscapular: scap retraction*, prone scapular retraction*, standing scapular setting, supported

scapular setting, inferior glide, low row

o *avoid with subscapularis repair and teres minor repair

• Ball squeeze

Criteria to

Progress

• 90 degrees shoulder PROM forward elevation

• 20 degrees of shoulder PROM ER in the scapular plane

• 0 degrees of shoulder PROM IR in the scapular plane

• Palpable muscle contraction felt in scapular and shoulder musculature

• No complications with Phase I

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PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Continue to protect surgical repair

• Reduce swelling, minimize pain

• Maintain shoulder PROM

• Minimize substitution patterns with AAROM

• Patient education

Sling

• Neutral rotation

• Use of abduction pillow in 30-45 degrees abduction

• Use at night while sleeping

Precautions

• No lifting of objects

• No supporting of body weight with hands

Intervention

*Continue with

Phase I

interventions

Range of motion/Mobility

• PROM: ER<20 scapular plane, Forward elevation <90

• AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch,

washcloth press, sidelying elevation to 90 degrees

Strengthening

• Periscapular: Row on physioball, shoulder extension on physioball

Criteria to

Progress

• 90 degrees shoulder PROM forward elevation

• 20 degrees shoulder PROM ER in scapular plane

• 0 degrees of shoulder PROM IR in the scapular plane

• Minimal substitution patterns with AAROM

• Pain < 4/10

• No complications with Phase II

PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Do not overstress healing tissue

• Reduce swelling, minimize pain

• Gradually increase shoulder PROM/AAROM

• Initiate shoulder AROM

• Improve scapular muscle activation

• Patient education

Sling

• Discontinue

Precautions

• No lifting of heavy objects (>10 lbs)

Intervention

*Continue with

Phase I-II

interventions

Range of motion/Mobility

• PROM: ER<30 scapular plane, Forward elevation <120

• AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall

• AROM: elevation < 120, supine flexion, salutes, supine punch, wall climbs

Strengthening

• Periscapular**: Resistance band shoulder extension, resistance band seated rows, rowing, lawn

mowers, robbery, serratus punches

• **Initiate scapular retraction/depression/protraction with subscapularis and teres minor repair

• Elbow: Biceps curl, resistance band bicep curls and triceps

Criteria to

Progress

• 120 degrees shoulder PROM forward elevation

• 30 degrees shoulder PROM ER and IR in scapular plane

• Minimal substitution patterns with AROM

• Pain < 4/10

PHASE IV: TRANSITIONAL POST-OP (9-10 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Do not overstress healing tissue

• Gradually increase shoulder PROM/AAROM/AROM

• Improve dynamic shoulder stability

• Progress periscapular strength

• Gradually return to full functional activities

Precautions

• No lifting of heavy objects (> 10 lbs)

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Intervention

*Continue with

Phase II-III

interventions

Range of motion/mobility

• PROM: ER<45 scapular plane, Forward elevation <155, ER @ 90 ABD < 60

• AROM: supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to

90 degrees elevation

Strengthening

• Periscapular: Push-up plus on knees, prone shoulder extension Is, resistance band forward punch,

forward punch, tripod, pointer

Criteria to

Progress

• 155 degrees shoulder PROM forward elevation

• 45 degrees shoulder PROM ER and IR in scapular plane

• 60 degrees shoulder PROM ER @ 90 ABD

• 120 degrees shoulder AROM elevation

• Minimal to no substitution patterns with shoulder AROM

• Performs all exercises demonstrating symmetric scapular mechanics

• Pain < 2/10

PHASE V: TRANSITIONAL POST-OP CONTD (11-12 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Restore full PROM and AROM

• Enhance functional use of upper extremity

Intervention

*Continue with

Phase II-IV

interventions

Range of motion/mobility

• PROM: Full

• AROM: Full

Stretching

• External rotation (90 degrees abduction), Hands behind head, IR behind back with towel, sidelying

horizontal ADD, sleeper stretch, triceps and lats, doorjam series

Criteria to

Progress

• Full pain-free PROM and AROM

• Minimal to no substitution patterns with shoulder AROM

• Performs all exercises demonstrating symmetric scapular mechanics

• Pain < 2/10

PHASE VI: STRENGTHENING POST-OP (13-16 WEEKS AFTER SURGERY)

Rehabilitation

Goals

• Maintain pain-free ROM

• Initiate RTC strengthening (with clearance from MD)

• Initiate motor control exercise

• Enhance functional use of upper extremity

Intervention

*Continue with

Phase II-V

interventions

Strengthening

• Rotator cuff: internal external rotation isometrics, side-lying external rotation,

Standing external rotation w/ resistance band, standing internal rotation w/ resistance band,

internal rotation, external rotation, sidelying ABD→standing ABD

• Periscapular: T and Y, “T” exercise, push-up plus knees extended, wall push up, “W” exercise,

resistance band Ws, dynamic hug, resistance band dynamic hug

• Biceps curl (begin with concomitant biceps tenodesis/tenotomy)

Motor Control

• Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)

• IR/ER and Flex 90-125 (rhythmic stabilization)

• Quadruped alternating isometrics and ball stabilization on wall

• PNF – D1 diagonal lifts, PNF – D2 diagonal lifts

• Field goals

Criteria to

Progress

• Clearance from MD and ALL milestone criteria below have been met

• Full pain-free PROM and AROM

• ER/IR strength minimum 85% of the uninvolved arm

• ER/IR ratio 60% or higher

• Negative impingement and instability signs

• Performs all exercises demonstrating symmetric scapular mechanics

• QuickDASH/PENN

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PHASE VII: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY)

Rehabilitation

Goals

• Maintain pain-free ROM

• Continue strengthening and motor control exercises

• Enhance functional use of upper extremity

• Gradual return to strenuous work/sport activity

Intervention

*Continue with

Phase II-VI

interventions

Strengthening

• Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band

standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees

Motor control

• Resistance band PNF pattern, PNF – D1 diagonal lifts w/ resistance, diagonal-up, diagonal-down

Wall slides w/ resistance band

• See specific return-to-sport/throwing program (coordinate with physician)

Criteria to

Progress

• Last stage-no additional criteria

Return-to-Sport

• For the recreational or competitive athlete, return-to-sport decision making should be individualized

and based upon factors including level of demand on the upper extremity, contact vs non-contact

sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior

to advancing to a return-to-sport rehabilitation program.

Revised June 2020

Contact

Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol

References

American Academy of Orthopaedic Surgeons. Management of Rotator Cuff Injuries Clinical Practice Guideline. https://www.aaos.org/rotatorcuffinjuriescpg

Published March 11, 2019

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