Restoring range of motion after a rotator cuff repair is one of the most important factors in long-term patient satisfaction.
Internal rotation is especially important, as a loss of IR can really limit their functional movements.
There are many variables to consider when rehabbing a rotator cuff repair patient. Several factors will alter our speed of progression.
Unfortunately, protocols vary greatly. Here are our thoughts on restoring range of motion after rotator cuff repair surgery.
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#AskMikeReinold Episode 359: Restoring Range of Motion After Rotator Cuff Repair
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Show Notes
• Evaluation and Treatment of the Shoulder Masterclass
• Should You Delay Range of Motion after a Rotator Cuff Repair?
Transcript
Student:
So we have Andrew from Michigan. “When should you begin restoring internal rotation after rotator cuff repair? When researching, some protocols mentioned not passing zero degrees for the first four to six weeks, but doesn’t a sling put them into slight IR from the start?”
Mike Reinold:
I mean, this is why I picked this question this week, right? You ever read a question and you’re like, “That’s pretty funny, right?” These are the types of things we deal with with protocols and surgeons in our profession. You can’t go past zero degrees, but I want you to sit all day with 45 degrees of internal rotation with your hand on your belly in a sling. Really makes no sense. So I love how Andrew called out the hypocrisy of the concept of that, but maybe let’s dig in a little deeper.
And I will say… I’m old enough to say that I’m from the era where we had those huge pillow splints, like big braces that would actually keep them up at 45 degrees and stop them at zero degrees. And I do think some surgeons still use those, right Len? That’s not uncommon, especially with a massive repair that starts going posterior into infraspinatus and everything. But man, they used to walk around with this huge thing. You were hugging a pillow for six weeks. It was crazy, and now we’re doing the sling. So I don’t know who wants to start on this. I mean, I think there’s two questions to answer here for Andrew. How do we start range of motion after rotator cuff repair? What’s safe? What’s not safe? Dan, you want to start? I know we can all probably start, but what do you got?
Dan Pope:
Yeah, this one’s kind of tough. You’re going to get so many different opinions from different surgeons. I would say first and foremost, if you haven’t done this already, probably reach out and try to communicate with the surgeon a little bit just to pick their brain and see their thoughts. Maybe there is a reason why they’re doing this. Maybe it’s a typo. I’ve definitely had situations… I was talking to Jacob the other day, where the surgeon doesn’t even know which protocol is sent over. I know that sounds crazy. And oftentimes the protocol is just taken from the internet, so it’s not even always what the surgeon actually thinks. I would say it probably depends on which part of the cuff is repaired. Like you’re saying. So if it is infraspinatus involvement, maybe they do have a reason why they’re trying to limit that range of motion.
And then from the speed of progression standpoint, you’ll see a lot of research that talks about early range of motion versus delayed or accelerated physical therapy versus delayed. Usually, acceleration is going to be a faster range of motion. They also incorporate active range of motion versus the range of motion a little bit quicker. What I will say is it’s not a perfect science and we don’t have the best data always to guide us, although there’s a decent bit. I would say that one of the things that’s going to force you to slow down or should force you to slow down is you have an individual that has a larger or massive rotator cuff tear. I think that if you have a small or partial or moderate, there’s quite a bit of research to show you can go early range of motion, faster range of motion.
To answer your question exactly when, I’m not sure that I have that data. You’ll find some studies that have them do full range of motion like post-op day two, and some will start at week two to four and they’ll still call that early, compared to delayed, which might be six weeks or more. But if it’s a small, moderate, or partial, you could probably go faster. Probably don’t need to be super slow. Although, make sure you talk to your physician first when they’re okay with that. We have a larger, massive, any sort of retraction going on, multiple tendons, obviously then we probably do need to slow this down a little bit just because we have research to show that if you go too fast early on, so if you use early range of motion or accelerated protocol, it increases that re-tear rate.
And then other things are probably important to think about too. So, things like patient age, comorbidities… Do they smoke? If they’re unhealthy or have more comorbidities, you slow it down. If they’re young, fit, healthy, good, viable tissue, maybe it’s an acute tear, maybe we’re more comfortable going a little faster. But just a lot of variables to keep in mind. Get that post-op report, talk to the surgeon, see what the heck they’re thinking, see if they know what their protocol actually says, and then you could probably go from there and make more educated guesses on your rehab.
Mike Reinold:
Who else wants to jump in, just out of curiosity? I think the point that Dan made there was pretty nice. There’s a lot of variables. It’s really hard to say there’s one way to do a rotator cuff repair. That’s like saying what’s the best food to eat? It’s like, oh my gosh, this is just… It’s such a big conversation. It just depends on a lot of different things. But going back to your point, how to restore range? I think there’s a way you can sequentially do that for anybody, but you do have to know the variables. So Dave, do you want to jump in a little bit?
Dave Tilley:
Yeah, I just had a point to make on the surgical protocol thing. I was just talking to Lenny yesterday about this. This is a high level soccer player in college who had a Bankart repair and a remplissage. And the surgeon that we work with is one of our favorite surgeons. He’s awesome. He’s very accessible. He’s very, very talented, and the protocol that he sent me was very conservative, I would say. And then the protocol that I talked to him about on the phone… I called him real quick and he was like, “Oh yeah, yeah, actually pretty easy repair, no big deal. You can actually progress way faster.” So he was telling me to go more than what the protocol said. And then online, I looked up other protocols that we have and it was like uber slow. So I had one protocol saying go quick with strengthening, one saying stay in the middle, and one saying do it.
And you have to just follow the surgeon’s guidance there because he’s the only one who knows the tissue quality. This kid’s super young, super healthy, to Dan’s point. Super active kid going into surgery really strong. And so the doctor felt comfortable progressing a bit faster because this kid’s trying to get back to playing high level soccer this season. And so I think in all those situations, maybe you don’t have the phone call accessibility that maybe we do with some surgeons, but it’s always better to try to clarify with the surgeon or call a PA or get to them and be like, “Hey, I know the protocol says don’t squat ever, but is that really what you mean? Is there actually some things that we can do?” And oftentimes like, “Oh yeah, you’re totally fine, it wasn’t that bad. Great tissue quality, no problem at all.” So I think having as many relationships as you possibly can to clarify some of these things is really important.
Mike Reinold:
Nice. I love it. Len, anything from your extensive career? I just called you old.
Lenny Macrina:
Yeah, exactly. It’s starting to show.
Mike Reinold:
Starting to show?
Lenny Macrina:
Yeah, the question, I understand what the question is and yes, they are put into rotation and yes, they probably should be in a neutral position. They have abduction pillows that do that, and I think they’re underutilized. But I think if you think about the mechanics of what’s going on when you’re working on how we define, I think I’m imagining the person’s talking about reaching behind back. When can you start working on reaching behind back stuff?
Mike Reinold:
Yeah, I didn’t even think of that. He just said, “when do you restore,” but yeah. That’s a good point.
Lenny Macrina:
Internal rotation is, so be cautious with that motion because that’s a combined motion of extension, horizontal adduction essentially, and then internal rotation. So that I think puts a little bit more stress on a cuff repair. And I don’t do any of that stuff for probably about three months easily, depending on the person, especially if it’s what Dan mentioned, a super infra repair, which is what most of them are. That small to medium size tear is going to be super, super in infraspinatus. So internal rotation, if you’re bringing them out at 90 degrees and working on internal rotation, I’m still cautious with that for at least the first eight weeks. That’s not a motion, to me, that I struggle with down the road. It seems to come back for most people if I just give the tissue time to heal. I just don’t want to be the reason why something happens to the cuff repair.
So if we’re talking about pure internal rotation, yeah, you’re right, they’re already gaining a ton just by being in the pillow. So how much more do we need? If you’re talking about reaching behind the back, that’s a combined motion of probably at least three motions that I can come off the top of my head right now. And so I’d be cautious with that because you are extending the shoulder and having them kind of reach back. And so some people do pulleys and all that where they do a towel stretch. I would wait at least three months for something like that, just for tendon healing. The first six weeks is just tendon trying to heal to the bone. The next six weeks is going to be a good amount of tendon healing to the bone, and then after that, you can start progressing. I think it’d be a little bit more progressive or aggressive to the tendon. So I’d be cautious if that’s what we’re talking about.
Mike Reinold:
That’s a good point. I didn’t even like… That didn’t even cross my mind. I just went straight to IR. But you’re right, that’s probably a lot of people who consider reaching behind the back IR.
Lenny Macrina:
That’s always a question.
Mike Reinold:
That’s the question. And I took it very literal that it was IR and that didn’t even cross my mind. So I think that’s a big take home here, is that behind your back isn’t internal rotation. That is three multi-dimensional movements all in one, and that is probably the most aggressive position that you can put a rotator cuff repair in. That’s the most deleterious position. So just keep that in mind. To Andrew’s point, which is hilarious. I love that. We can’t go past zero, but they stay there all day at 45 degrees of IR. Just remember that at different planes of motion, that strain on the rotator cuff is different, right? 0, 45, 90, just using those three as an example, the strain on the rotator cuff’s different. What we know is that as you go into elevation and external rotation, strain is reduced on the rotator cuff repair.
So we know that biomechanically with some studies on there. So think about it. If ER reduces strain, that does mean IR increases strain. And that’s kind of the main point. Neutral position, that 45-degree position is usually where we start. Just have them go through some gentle pain-free range of motion. I don’t think, and maybe this is… I don’t think this is short-sighted. I was going to say maybe this is short-sighted. If you have no pain and IR just kind of goes in nice and easy, I don’t think you’re stressing the rotator cuff repair in any way. No pain, no resistance, nothing, and you’re just going into IR. That’s not anything different than him being in the sling all day. So I’m not necessarily against that. But you certainly don’t want to start pushing. You don’t want to have discomfort. You don’t want to feel pain in the rotator cuff insertion point where the repair was, those sorts of things.
I would just be very careful with those. But just some gentle range of motion has a ton of benefits. Nourishing the capsule, nourishing the collagen tissue by just getting some motion going and lubricating a little bit in the area. Those are all very important things for the proprioceptors, for cartilage. Everything does better with gentle range of motion. So to your point, yes, we’re not going to start pushing IR. And to Lenny’s point, we’re not going to be aggressive with a huge movement behind the back that isn’t really just IR, but just be really cautious with that, especially if they have that discomfort.
So hopefully that helps, Andrew. I know that’s kind of like a big topic. I actually like how you highlighted the hypocrisy. That’s why I liked this question. I thought that was really cool. But yeah, there’s a ton of that out there. Just be smart with your progression, and I think your patients will do better. Okay, awesome. Great question. Really appreciate it. If you like these questions, please head to mikereinold.com. You can ask away. We will answer them. And be sure to subscribe so that way you get notifications for the next episode. Thank you.
