Arthroscopic Rotator Cuff Repair Protocol: Medium to Large Tear Size

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This protocol was developed to provide the rehabilitation professional with a guideline of postoperative rehabilitation course for a patient who has undergone an arthroscopic medium to large size rotator cuff tear repair. It should be stressed that this is only a protocol and should not be a substitute for clinical decision making regarding a patient’s progression.

 

Actual progression should be individualized based upon your patient’s physical examination, individual progress, and the presence of any postoperative complications. The rate limiting factor in arthroscopic rotator cuff repair is the biologic healing of the cuff tendon to the humerus, which is thought to be a minimum of 8 to 12 weeks.

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Progression of AROM against gravity and duration of sling use is predicated both on the size of tear and quality of tissue and should be guided by referring physician. Refer to initial therapy referral for any specific instructions.

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Phase I: Immediate Post Surgical Phase (Weeks 0–6)

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Phase I

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GOALS

• Maintain/protect integrity of repair

• Gradually increase passive range of motion (PROM)

• Diminish pain and inflammation

• Prevent muscular inhibition

• Independence in modified activities of daily living

PRECAUTIONS

• No active range of motion (AROM) of shoulder

• No lifting of objects, reaching behind back, excessive stretching, or sudden movements

• Maintain arm in brace, sling; remove only for exercise

• Sling use for 6 weeks; medium to large tear size

• No support of body weight by hands

• Keep incisions clean and dry

DAYS 1 TO 6

• Use of abduction brace/sling (during sleep also); remove only for exercise

• Passive pendulum exercises (three times a day minimum)

• Finger, wrist, and elbow AROM (three times a day minimum)

• Gripping exercises (putty, handball)

• Cervical spine AROM

• Passive shoulder (PROM) done supine for more patient relaxation

• Flexion to 110 degrees

• External rotation/internal rotation (ER/IR) in scapular plane < 30 degrees

• Educate patient on posture, joint protection, importance of brace/sling, pain medication use early, hygiene

• Cryotherapy for pain and inflammation

• Days 1 to 3: as much as possible (20 minutes/hour)

• Days 4 to 7: postactivity or as needed for pain

DAYS 7 TO 42

• Continue use of abduction sling/brace until the end of week 6

• Pendulum exercises

• Begin PROM to tolerance (supine and pain free)

• May use heat prior to ROM

• Flexion to tolerance

• Continue elbow, hand, forearm, wrist, and finger AROM

• Begin resisted isometrics/isotonics for elbow, hand, forearm, wrist, and fingers

• Begin scapula muscle isometrics/sets, AROM

• Cryotherapy as needed for pain control and inflammation

• May begin gentle general conditioning program (walking, stationary bike) with caution if unstable from pain medications

• No running or jogging

• Aquatherapy may begin approximately 6 weeks postoperatively if wounds healed

CRITERIA FOR PROGRESSION TO NEXT PHASE (II)

• Passive forward flexion to ? 125 degrees

• Passive ER in scapular plane to ?60 degrees (if uninvolved shoulder PROM > 80 degrees)

• Passive IR in scapular plane to ?60 degrees (if uninvolved shoulder PROM > 80 degrees)

• Passive abduction in scapular plane to ? 90 degrees

• No passive pulley exercise

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Phase II: Protection and Protected Active Motion Phase (Weeks 7–12)

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Phase II

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GOALS

• Allow healing of soft tissue

• Do not overstress healing soft tissue

• Gradually restore full passive ROM (approximately week 8)

• Decrease pain and inflammation

PRECAUTIONS

• No lifting

• No supported full body weight with hands or arms

• No sudden jerking motions

• No excessive behind back motions

• No bike or upper extremity ergometer until week 8

WEEKS 7 TO 9

• Continue with full time use of sling/brace until end of week 6

• Continue periscapular exercises

• Gradually wean from brace starting several hours a day out progressing as tolerated

• Use brace sling for comfort only until full DC by end of week 7

• Initiate AAROM shoulder flexion from supine position weeks 6 to 7

• Progressive PROM until full PROM by week 8 (should be pain free)

• May require use of heat prior to ROM exercises/joint mobilization

• Can begin passive pulley use

• May require gentle GH or scapular joint mobilization as indicated to obtain full unrestricted ROM

• Initiate prone rowing to a neutral arm position

• Continue cryotherapy as needed post-therapy or -exercise

WEEKS 9 TO 12

• Continue AROM, AAROM, and stretching as needed

• Begin IR stretching, shoulder extension, and cross body, sleeper stretch to mobilize posterior capsule (if needed)

• Begin gentle rotator cuff submaximal isometrics (weeks 7–8)

• Begin glenohumeral submaximal rhythmic stabilization exercises in “balance position (90–100 degrees of elevation) in supine position to initiate dynamic stabilization

• Continue periscapular exercises progressing to manual resistance to all planes

• Seated press-ups

• Initiate AROM exercises (flexion, scapular plane, abduction, ER, IR); should be pain free; low weight; initially only weight of arm

• Do not allow shrug during AROM exercises

• If shrug exists continue to work on cuff and do not reach/lift AROM over 90-degree elevation

• Initiate limited strengthening program

• *Remember rotator cuff (RTC) and scapular muscles small and need endurance more than pure strength

• ER and IR with exercise bands/sport cord/tubing

• ER isotonic exercises in side lying (low-weight, high-repetition) may simply start with weight of arm

• Elbow flexion and extension isotonics

CRITERIA FOR PROGRESSION TO PHASE III

• Full AROM

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Phase III: Early Strengthening (Weeks 12–18)

 

Phase III

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GOALS

• Full AROM (weeks 12–14)

• Maintain full PROM

• Dynamic shoulder stability (GH and ST)

• Gradual restoration of GH and scapular strength, power, and endurance

• Optimize neuromuscular control

• Gradual return to functional activities

PRECAUTIONS

• No lifting objects >5lbs, no sudden lifting or pushing

• Exercise should not be painful

WEEK 12

• Continue stretching, joint mobilization, and PROM exercises as needed

• Continue periscapular exercises

• Dynamic strengthening exercises

• Initiate strengthening program

• Continue exercises as in weeks 7 to 12

• Scapular plane elevation to 90 degrees (patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonic exercises. If unable then continue cuff/scapular exercises)

• Full can (no empty can abduction exercises)

• Prone rowing

• Prone extension

• Prone horizontal abduction

WEEK 14

• Continue all exercise listed

• May begin BodyBlade, Flexbar, Boing below 45 degrees

• Begin light isometrics in 90/90 or higher supine, PNF D2 flexion/extension patterns against light manual resistance

• Initiate light functional activities as tolerated

WEEK 16

• Continue all exercises listed

• Progress to fundamental exercises (bench press, shoulder press)

• Initiate low level plyometrics (two-handed, below chest level, progressing to overhead and finally one-handed drills)

• CRITERIA FOR PROGRESSION TO PHASE IV

• Ability to tolerate progression to low-level functional activities

• Demonstrate return of strength/dynamic shoulder stability

• Reestablishment of dynamic shoulder stability

• Demonstrated adequate strength and dynamic stability for progression to more demanding work and sport-specific activities

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Phase IV: Advanced Strengthening Phases (Weeks 18–24)

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Phase IV

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GOALS

• Maintain full nonpainful AROM

• Advanced conditioning exercise for enhanced functional and sports specific use

• Improve muscular strength, power, and endurance

• Gradual return to all functional activities

WEEK 18

• Continue ROM and self-capsular stretching for ROM maintenance

• Continue periscapular exercises

• Continue progressive strengthening

• Advanced proprioceptive, neuromuscular activities

• Light isotonic strengthening in 90/90 position

• Initiation of light sports (golf chipping/putting, tennis ground strokes) if satisfactory clinical examination

WEEK 24

• Continue strengthening and stretching

• Continue joint mobilization and stretching if motion is tight

• Initiate interval sports program (e.g., golf, doubles tennis) if appropriate