Post-Operative Therapy Rotator Cuff Tears

 

Note: This pathway is designed to serve as a guide to rehabilitation. Indications for progression should be based on patient’s complete operative procedure, functional capacity and response to treatment.

Phase I – Immediate Post-Op | Weeks 0-3

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
  • 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

Phase II – Intermediate Post-Op | Weeks 4-6

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 Continued | Weeks 7-8

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)

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 | Weeks 9-10

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)

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 Continued | Weeks 11-12

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 | Weeks 13-16

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

Phase VII – Early Return to Sport | 4-6 Months

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.