Patients who are indicated for this type of surgical procedure are usually symptomatic with for a period of 4 to 6 months. Conservative care is no longer effective for these patients and the pain interferes with daily activities or hobbies they once enjoyed.

Another indication deals with a complete tear of the rotator cuff, surgery is recommended if the tear is complete and the patient is under 50 years of age.

Tears or damage usually occur to the supraspinatus/infraspinatus tendons as they suffer wear and tear passing under the subacromial space that is sufficiently compromised allowing little movement without friction underneath the bony prominence.

The majority of surgical interventions are performed arthroscopically in order to avoid excessive amounts of pain and dissection of the deltoid muscle.

Often a Rotator Cuff Repair is accompanied by an Acromioplasty in order to maximize the amount of space under the acromion and prevent future breakdowns of the cuff tendons.

Often patients who undergo this surgery will be immobilized in an abduction orthosis to maximize the slack on the rotator cuff tendons. The amount of time to undergo immobilization depends on the size and severity of the lesion.

• Small tears: 1-3 weeks
• Medium tears: 3-6 weeks
• Large tears: 6-8 weeks

Eternal rotation is usually prohibited for the first 6 weeks after surgery. PROM has been shown to be effective by eliminating the effects of immobilization in order to prevent joint restrictions from tendon adhesion with the surrounding soft tissue structures.

Phase 1 (Day 1 to 6 Weeks)

Goals

• Improve pain level to a 5/10 and reduce inflammation
• Decrease stiffness in the cervical spine and loss of ROM
• Prevent muscle atrophy
• Protect the incision sights
• PROM should be 60-70% of the uninvolved side 3-4 weeks post surgery
• 40-45 degrees of passive external rotation, 60-80 degrees of abduction without rotation, 120-140 degrees of passive flexion
• Delay AROM based on the degree of the tear ( 4 weeks for small tears, 6 weeks for medium and 8 weeks for large tears)
• Maintain strength and ROM of the surrounding major joints (wrist, elbow, scapula )
• Intiate neuromuscular control of the scapula to provide proper stability and glenohumeral rhythm

Modalities

• Cryotherapy for pain and inflammation
• E stem for pain and edema reduction
• Non-thermal ultra sound to promote healing of the tissue

Therapeutic Exercise

• Codman’s pendulum exercises
• PROM external rotation with a cane
• Passive elevation with a table (table slides)
• Isometric Scapular pinches
• Closed Chain Weight shifts (as tolerated)
• AROM of the cervical spine
• NO ACTIVE STRENGTHENING UNTIL 8 WEEKS FOLLOWING SURGERY!

• Hand strengthening exercises
• PROM at the elbow

Cardiovascular Fitness

• Exercise bike, walking

Manual Therapy

• Soft Tissue techniques and trigger point release for spasms or restricted areas
• Joint mobilization and oscillation grade I and II to relieve pain and promote movement to involved side
• Joint mobilization grades III, IV to the cervical/thoracic spine hypo-mobile segments

Phase 2 (6-11 weeks Post Surgery)

Goals

• AROM of abduction should be above 90 degrees
• Pain 2/10
• Cervical AROM should be WNL’s
• Normal shoulder arthrokinematics should follow the capsular pattern first in one plane the multiple angles
• Pain free ADL’s such as driving, dressing, eating and so on
• Immobilization orthosis used only for comfort from pain occasionally
• PROM should progress to 160 degrees of flexion, 60 degrees of external rotation, 90 degrees of abduction

Therapeutic Exercise

• AROM should be performed in singular planes and progressed to functional planes (PNF movement patterns)
• Internal and External rotation exercise are performed with the arm at the side and elbow at 90 degrees using a towel roll for teres minor emphasis and without  for infraspinatus emphasis
• Start rotator cuff and scapular strengthening exercise
• Horizontal add/abduction in supine and prone
• Shoulder shrugs/Scapular retractions and depressions
• Continue hand strengthening exercises
• UE ergometer can be used for cardiovascular fitness and muscular endurance of the shoulder complex

Neuromuscular Retraining

• Multidirectional rocking or rhythmic stabilization in quadruped
• Medicine ball plyometrics (gently and as tolerated)
• Scapular control within PNF patterns of shoulder movement

Manual Therapy

• Continue soft tissue work as needed
• Joint mobilization in all grades as tolerated to promote functional arthrokinematics and prevent pain
• Assisted stretching by clinician with special emphasis on the posterior capsule

Phase 3 (Week 16 +)

Goals

• AROM which is pain free and 90-100% compatible to the uninvolved side
• Pain at 0/10 to 2/10 within functional activities
• MMT on shoulder musculature 4/5
• Prepare for returning to functional activities
• Provide an HEP available for progression

Therapeutic Exercise

• Emphasis should be on functional strengthening in mutliple planes using weights, medicine ball, body weight or bands
• Active exercise should be pain free and endurance should be comparable to the uninvolved side
• UE ergo meter should be progressed to longer high intensity sessions

Additional Instructions

• Patient should be advised to continue exercises of ROM and strengthening for 6 months to 1 year post discharge
• Concern should be heightened if patient begins to lose ROM on internal rotation and loses strength in abduction  or reports constant pain at night. These patients should be regressed to earlier routines and modalities used to control pain.

Use this article as a guide to formulate an appropriate plan of care for your patient. Remember each patient will progress through each stage differently so tailor the interventions individually. Never become a cookie cutter therapist!

Find all my shoulder articles in the Spotlight section on the home page.

Check out our videos on Shoulder mobilizations to refresh your mind or to check your technique!

Related Posts:

1. Shoulder Post Surgical Managment- Acromioplasty
2. Shoulder Post Surgical Management- Capsular Reconstruction
3. Shoulder Instability- Surgical Managment
4. Exercise Alone Is Effective for Atraumatic Rotator Cuff Tears
5. [Spotlight] Glenohumeral Post Surgical Interventions