Patient Education Arthroscopic Rotator Cuff Repair

Dr. Laith M.
Jazrawi
Chief, Division of Sports Medicine
Associate Professor Department of Orthopaedic Surgery
Rehabilitation Protocol After Arthroscopic Rotator Cuff

Repair
The anatomic configura0on of the shoulder joint (glenohumeral joint)is o8en compared to that
of a golf ball on a tee. This is because the ar0cular surface of the round humeral head is
approximately four 0mes greater than that of the rela0vely at shoulder blade face (glenoid fossa)1.
This configura0on provides less boney stability than a truer ball and socket joint, like the hip. The
stability and movement of the shoulder is controlled primarily by the rotator cuff muscles, with
assistance from the ligaments, glenoid labrum and capsule of the shoulder. The rotator cuff is a
group of four muscles: subscapularis, supraspinatus, infraspinatus and teres minor (Figure 1).
Rotator cuff tears can occur from repeated stress or from trauma. Throwing a baseball can
create up to 750 newtons of distrac0ve force on the shoulder2. This places a significant amount of
stress on the rotator cuff while trying to dissipate this force. This stress and force may be even
greater if there is improper form or mechanics while throwing. This repeated stress may lead to
rotator cuff tears. Rotator cuff trauma also may result from falling on your arm, bracing your
arm in an accident, arm tackling in football or any large sudden force applied to the arm. Most
rotator cuff tears involve the supraspinatus and/or the infraspinatus. Occasionally isolated tears of
the subscapularis can occur. This usually results from trauma rota0ng the shoulder outward.
The rotator cuff tendons also undergo some degenera0on with age. This process alone can lead
to rotator cuff tears in older pa0ents. Pa0ents over 50 years of age are more suscep0ble to
sustaining a significant rotator cuff tear from trauma3.
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Rehabilitation Protocol After Arthroscopic Rotator Cuff Repair
Rotator cuff tears can be classified in various ways. The first classifica0on is a par0al thickness or a full thickness tear.
Normal tendon thickness is 9 to 12 mm. Par0al thickness tears start on one surface of the tendon, but do not progress
through the depth of the tendon. These can be bursal surface tears or ar0cular sided tears . Figure 2 shows the normal
anatomy of the bursal and ar0cular side of the rotator cuff. Bursal surface tears occur on the outer surface of the tendon
and may be caused by repe00ve impingement. Ar0cular sided tears (Figure 3) occur on the inner surface of the tendon, and
are most o8en caused by internal impingement or tensile stresses related to overhead sports. Full thickness or complete
tears (Figure 4) extend from one surface of the tendon all the way through to the other surface of the tendon. Full thickness
tears are o8en caused by trauma, such as falling on the arm. Since a por0on of the tendon is completely disrupted, there
also will be some tendon retrac0on. Retrac0on is movement of the tendon away from its inser0on point back toward the
muscle.4 A8er determining the type of tear, a classifica0on system is used to assess the size of the tear. Type I tears are
tears less than 2 cm in width and Type II tears are greater than 2 cm.
Surgical repair of a rotator cuff tear can be done arthroscopically or with a mini- open procedure. A 2007 review
published in The Journal of Bone and Joint Surgery stated that equally successful outcomes can be a[ained from either
technique5. The primary goal of a rotator cuff repair is to restore the normal anatomy by approxima0ng the rotator cuff
tendon back to its normal a[achment site on the greater tuberosity of the humerus. This is done by passing sutures through
the tendon and then tying the tendon down to suture anchors that have been placed in the humerus. Prior to bringing the
tendon back to its inser0on, the edges of the tear may need to be brought together, referred to as side-to-side repair or
convergence (Figure 5). Not all rotator cuff tears are repairable. A tear may be un-repairable if the tear is too large, there is
too much retrac0on, or the 0ssue quality is too poor. The degree of success for tears that are repaired is related to various
factors, including tear size, the number of tendons involved, pa0ent age, associated injuries and post opera0ve
rehabilita0on 6, 7.
Rehabilita0on is vital to regaining mo0on, strength and func0on of the shoulder a8er surgery. Ini0ally pa0ents will use a
sling to protect the repair site and allow healing of the tendon back to the bone. During this 0me, passive mo0on exercises
are started to prevent the shoulder from ge^ng s0ff and losing mobility. The rehabilita0on program will gradually progress
to more strengthening and control type exercises. The rehabilita0on guidelines will vary depending on the size of the
tear and quality of the tendon. The rehabilita0on guidelines for Type I and Type II tears of the supraspinatus or
infraspinatus and isolated subscapularis tears are presented below in a criterion based progression. General 0me frames
are given for reference to the average, but individual pa0ents will progress at different rates depending on their age,
associated injuries, pre-injury health status, rehabilita0on compliance and injury severity.
Phase I (Surgery to 4 weeks after surgery)

Precautions o Sling immobilization with supporting abduction pillow to be worn at all
times except for showering and rehab under guidance of PT (if
instructed to start before 4 weeks post surgery) !
Range of Motion o True Passive Range of Motion Only to Patient Tolerance!

o Goals: 140° Forward Flexion, 40° External Rotation with elbow at side,
60-80° Abduction without rotation, Limit Internal Rotation to 40° with the
shoulder in the 60-80° abducted position !
o Maintain elbow at or anterior to mid-axillary line when patient is supine !
Therapeutic o No canes or pulleys during this phase
Exercises o Codman exercises/ pendulums
o Elbow/wrist/hand range of motion and grip strengthening
Other Suggestions o Heat/Ice before and after PT sessions
Phase II (4 weeks to 8 weeks following surgery)

Precautions o D/C sling immobilization
ROM o 4-6 weeks: Gentle passive stretch to reach ROM goals from Phas I
o 6-8 week: Begin AAROM -> AROM as tolerated
Range of Motion o Increase Forward Flexion, Internal/External Rotation to full motion as

Exercises tolerated
Therapeutic o 4-6 weeks: Begin gentle AAROM exercises (supine position), gentle joint
Exercises mobilizations (grades I and II), continue with Phase I exercises
o 6-8 weeks: Progress to active exercises with resistance, shoulder flexion
with trunk flexed to 45° in upright position, begin deltoid and biceps
strengthening
Other Suggestions o Modalities per PT discretion
Phase III (8 weeks to 12 weeks following surgery)

ROM o Progress to full AROM without discomfort
Therapeutic o Continue with scapular strengthening

Exercises o Continue and progress with Phase II exercises
o Begin internal/external rotation isometrics
o Stretch posterior capsule when arm is warmed-up
Phase IV (3 months to 6 months following surgery)

ROM o Full range of motion without discomfort
Therapeutic o Advance strengthening as tolerated: isometrics -> therabands-> light

Exercises weights (1- 5 lbs)
o 8-12 repetitions/2-3 sets for rotator cuff, deltoid and scapular stabilizers
o Return to sports at 6 months if approved
***If biceps tenodesis was performed – no biceps strengthening un0l 8 weeks post-op
References

Patient Education Arthroscopic Rotator Cuff Repair

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Dr. Laith M.

Rehabilitation Protocol After Arthroscopic Rotator Cuﬀ

Phase I (Surgery to 4 weeks after surgery)

Range of Motion o True Passive Range of Motion Only to Patient Tolerance!

Other Suggestions o Heat/Ice before and after PT sessions

Phase II (4 weeks to 8 weeks following surgery)

Range of Motion o Increase Forward Flexion, Internal/External Rotation to full motion as

Other Suggestions o Modalities per PT discretion

Phase III (8 weeks to 12 weeks following surgery)

Therapeutic o Continue with scapular strengthening

Other Suggestions o Modalities per PT discretion

Phase IV (3 months to 6 months following surgery)

Therapeutic o Advance strengthening as tolerated: isometrics -> therabands-> light

Other Suggestions o Modalities per PT discretion

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