rehabilitation protocol following arthroscopic rotator cuff repair

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

There continues to be great debate over the most appropriate rehabilitation progression following rotator cuff repair. Although our surgical techniques have gradually progressed from full open repairs, to smaller mini-open repairs, to the current standard all-arthroscopic repairs, many clinicians continue to utilize the same rehabilitation guidelines from past invasive procedures.

And more confusing is the lack of consensus among surgeons regarding the optimal postoperative rehabilitation protocol following arthroscopic rotator cuff repair.  Protocols can vary as drastically as beginning gentle passive range of motion and isometric exercises post-operative week 1 to delaying 12 weeks for the initiation of similar exercises.

I want to share the postoperative protocol that I have developed with Kevin Wilk and James Andrews.

It details the postoperative guidelines that we have used since the shift to arthroscopic rotator cuff repairs several years ago. While there is still a lack of efficacy studies, these guidelines have proven to us to be both safe and effective in the rehab of 1000’s of patients at our clinics.

Before downloading the protocol, I want to explain the goals of rehabilitation and what I believe are the 3 keys to rehabilitation. These principles are the cornerstone behind the protocol you are about to download.

 

Goals of Rehabilitation Following Rotator Cuff Repair

When rehabilitating after an arthroscopic rotator cuff repair surgery, the main goals of the rehabilitation protocol should be:

  • Protect the integrity of the rotator cuff repair
  • Minimize postoperative pain and inflammation
  • Restore passive range of motion
  • Restore strength and dynamic stability of the shoulder
  • Restore active range of motion
  • Return to functional activities

Pretty simple, right?  When you lay it out like that, we simply combine those goals with what we know about the basic science of healing tissue and you can fill in the gaps and individualize a program based on the patient and your treatment preferences.

 

The 3 Most Important Keys to Rotator Cuff Repair Rehabilitation

Now that you understand the goals, I want to share what I consider the 3 most important keys to rotator cuff repair rehabilitation.  Follow the goals above and focus on these 3 keys and you’ll be well on your way to full functional recovery:

  1. shoulder-shrug-signRestore full passive ROM quickly. It is extremely easy to lose motion following surgery. In my opinion this is caused by scarring in the subacromial space as well as loss of the redundancy of the glenohumeral capsule with immobilization. This is one of the common “rookie mistakes” I see with students and new graduates. Passive range of motion should be initiated immediately following surgery in a gradual and cautious fashion. Studies have shown that passive range of motion into flexion and external rotation actually decreases strain in the rotator cuff repair (still need to be cautious with adduction, extension, and internal rotation).
  2. Restore dynamic humeral head control. This is likely the most important goal of postoperative rehabilitation, other than maintaining the integrity of the repair. What this means is to restore the rotator cuff’s ability to center the humeral head within the glenoid fossa. Have you ever seen a patient following repair that had a shoulder “shrug” sign? That is caused by the inability of the cuff to compress the humeral head and the resultant superior humeral head migration. This is why it is imperative to begin gentle isometrics, rhythmic stabilization drills, and other drills to re-educate the rotator cuff.
  3. Maximize external rotation strength. I often refer to external rotation as the key to the shoulder. Weakness of ER is common in almost every pathology and strengthening of the area is extremely important to balance the anterior and posterior balance of cuff. Several studies have shown that ER strength takes the longest amount of time to restore after rotator cuff repair. The longer this area is weak, the more difficult it will be to stabilize the joint.

 

 

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

physical therapy rehabilitation protocolsIf you are interested in using the protocols that I have helped develop with Kevin Wilk and Dr. James Andrews, we have recently revised and expanded all of our protocols and made them completely online and downloadable.  Our physical therapy rehabilitation protocols have been published in several journals over the years and based on our decades of research, scientific evidence, and experience.

They are the most widely used and respected rehabilitation protocols today.

Want to see what our protocols include?  You can download our 3 most popular protocols for FREE:

  • Accelerated rehabilitation following ACL reconstruction using a patellar tendon autograft
  • Rehabilitation following arthroscopic rotator cuff repair for a type II medium-large sized tear
  • Thrower’s ten exercise program

 

physical therapy rehabilitation protocols online accessOur entire collection includes over 175 nonoperative, preoperative, postoperative protocols for shoulder, elbow, hip, knee, foot, and ankle.  There are several variations of many protocols to account for many specific procedures and concomitant surgeries.  Plus, we have several of our exercise handouts and interval return to sport programs.

If you work in an outpatient orthopedic or sports medicine clinic, these protocols are an invaluable resource to help guide your treatment approach.

 

 

 

25 replies
  1. Chris
    Chris says:

    Hi Mike – Thanks for outlining the goals of rehabilitation following rotator cuff surgery as well as the keys to successfully rehabbing the shoulder.

    I like your simple and direct explanations – makes it easy for a layman like me.

    I'll probably cite your article on my blog (Shoulder Performance & Rehab) in the future.

    Chris Melton
    http://therotater.com

  2. Anonymous
    Anonymous says:

    Mike,

    Good post. Any indication to change the protocol based on size of tear? We have a surgical group near us who changes the protocol based on size of tear. Up to medium tears are started at week 1-2 and isometrics begin at week 6. For large to massive tears, NO therapy is started for 8 weeks! Yikes…even then, it’s only PROM to 90 degrees! Isometrics and strengthening don’t begin until week 12! UGH!

    I also find that many protocols do not address full passive extension as you mentioned, but I find this is a very imporatant technique to use and can quickly reduce pain and immediately increase ROM with FF or ABD if done just prior…but I haven’t ever used this before week 8. Is extension the “forgotten” motion?

    Christie Downing, PT

  3. Mike Reinold
    Mike Reinold says:

    @ Christie – The protocol should definitely be adjusted based on size of tear. Actually, it is a number of things including size of tear, quality of tissue, surgical technique, age, goals, etc.

    The guidelines you state are very common, unfortunately. The protocol attached is based on arthroscopic tears of small to medium size with good tissue quality.

    I actually use about 8 different rotator cuff repair protocols, depending on technique (open, mini-open, scope) and size of tear/tissue quality. Smaller tears with good tissue quality are progressed more rapidly and patients with large, retracted, difficult repairs are much more conservative. Makes communication with the physician a must, otherwise you have to treat everyone conservatively.

  4. Anonymous
    Anonymous says:

    Thanks Mike…unfortunately, our surgical group doesn’t have time to return our calls and we’re largely speaking through office staff. Ugh.

  5. Mike Reinold
    Mike Reinold says:

    That is pretty frustrating, I always wonder why some surgeons are not open with the clinicians treating their patients. In the long term it can only enhance their outcomes…sorry to hear that.

    MR

  6. Parimal
    Parimal says:

    MY DOCTOR TOLD ME TO DO PT WITHIN ONE WEEK BUT AS I HAD COVERED BY OHIP FOR THE HOSPITAL PT. I WAS WATING FOR MY TURN… MY SURGERY WAS DONE ON 6TH OF MARCH, SO IN THIS CASE WHAT I WILL DO… PLS GUIDE ME. NOTE OF MY DOCTOR’S PT IS ” INITIATE PROM NOW, INITIATE AROM 4/52

  7. bpart81
    bpart81 says:

    Mike,
    Your protocol for arthroscopic rotator cuff repair dosen't mention PROM into shoulder abduction or the scapular plane. Do you address this? If not why? Thanks for all of your hard work!
    BP

  8. Rotator Cuff Repair
    Rotator Cuff Repair says:

    BP, good question, I actually just perform scapular plane flexion, when it says flexion, consider it scaption. I rarely perform straight flexion or abduction. We talked about changing that to elevation instead of flexion but thought may be more confusing in the long run. THanks
    MR

  9. Jennifer Johndrow PT
    Jennifer Johndrow PT says:

    why did there used to be a limit on passive ER following open RC repair as well as the use of an abduction wedge? Are these still used sometimes for massive repairs? also, I was reading the comment above about not being able to speak with surgeons about their surgical procedure…I had to jump thru hoops recently to get an op report on an ACL recon with allograft to find out her intraoperative range of motion!

  10. Mike Reinold
    Mike Reinold says:

    jennifer –

    Both restrictions date back to the use of an open procedure, which involved going through the deltoid. This is minimized, and even eliminated, with the arthroscopic approach. In addition the pillow is used to limit adduction and IR, both motions that place strain on the cuff repair.

  11. Jonathan Holtz, PT
    Jonathan Holtz, PT says:

    Hi Mike,

    I Love your site and your efforts here. Just found it. I do have Kevin's book and have taken some of his courses. Your emphasis on early sub maximal isometric contractions is noted. Do you have references?I am introducing them to an orthopod to consider for his PO protocol.

    Many thanks,

  12. Anonymous
    Anonymous says:

    Im trying to recover from rotary cuff suregery.But insuerance company rehabilitation isn't needed.What can I do?

  13. BedBugsNYCc
    BedBugsNYCc says:

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  14. GreenDragon
    GreenDragon says:

    Hi Mike,

    I tried to download your protocol, however the link to SkyDrive reported “An error occurred, Please try again.”

    Irecently underwent arthroscopic repair (7 weeks out) and was interested in reading your protocol.

    Thanks!

  15. rotator cuff injury
    rotator cuff injury says:

    Great information and instruction Mike!

    I love how you have a very straightforward approach to rehab. Many patients and sufferers get confused when medical terms and jargon are thrown in.

    In the end, all they really seek is relief from their pain so they can get back to all normal everyday life and activities again.

    Thank again Mike!

  16. Jonathan
    Jonathan says:

    Hey Mike,

    Was quite interested in seeing your protocol but when I went to download it popped up with an error. Just wondering if there were any plans to make it available again?

    Thanks!

  17. Lindsey
    Lindsey says:

    Hi Mike,
    My colleagues and I are questioning the use of isometrics when in the passive range of motion phase to strengthen the muscles in the newly gained range to avoid inflammation within the sarcomere. The actual rotator cuff muscles aren’t being activated either which is why I am questioning the passive range of motion only protocol

    • Mike Reinold
      Mike Reinold says:

      Hi Lindsey, thanks for your message. Not sure what research you are reviewing that shows that rotator cuff muscles are not activated during isometrics, this is pretty well established. Can you share?

      One paper I reference often by Bitter in JSES in 2007 shows the relative contribution between the infraspinatus and deltoid muscles during ER isometrics:

      http://www.ncbi.nlm.nih.gov/pubmed/17560805

      Just an example of the cuff being active during isometrics.

      The concept of using isometrics to me is to work on active volitional control of the rotator cuff in a safe manner and to retard muscle atrophy from the immobilization or limited function phase of rehab.

      I am a believer that this is a very important concept for outcomes and patient satisfaction. In my experience, if you wait until week 12 (for example) to perform any muscle activity, you have a really weak muscle that has poor ability to fire. Then the physician says, “OK it is time for you to start doing some exercises” and they can’t. The patient shrugs, which makes them unhappy but also may cause a superior humeral head migration that can put the repair in a disadvantageous position.

      If you work on volitional cuff control during this early phase, the subsequent phases are much more effective.

      Thanks!

  18. Melissa Koehl, PT
    Melissa Koehl, PT says:

    Hi- I know this is an old thread now, but I’m wondering about your thoughts on the newer research (Lee 2012, Cuff 2012, and Parsons 2010) that seem to favor a more conservative approach in terms of when to start PROM. They found that the groups that waited 3-6 weeks to start PROM had reduced rated of re-tears and no long term difference in outcomes in terms of strength, ROM and function.

    Thanks!

    • Mike Reinold
      Mike Reinold says:

      Careful how/what you read. For example, in Lee 2012 – Early ROM group restored faster ROM first 3 months, which can really impact satisfaction and function. They found no statistically significant difference in satisfaction or re-tear rates. Yes rate was higher, but not statistically so. That being said, ROM group performed “unlimited self passive stretching.” There is a big difference between that and a controlled and gradual progression.

      Cuff rehab should be individualized. Some need to go slow, some can progress faster.

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