Some of the most common questions we get in regard to rotator cuff repair rehabilitation are when can we start range of motion and strengthening exercises.
It will depend on several factors, but there are ways to build an evidence-based rehabilitation progression.
In this episode, we talk about how we progress rotator cuff repair patients and how we determine if an exercise is safe to perform.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 327: What Exercises Are Safe After Rotator Cuff Repair
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All right, that would be me. So first question, Tiffany from Vermont asks, “I know there are a lot of different options when it comes to starting exercises after rotator cuff surgery. How do you know when to start range of motion and what exercises are safe to perform?”
Good question. I like that. Thank you Claire. And you could argue this is a double-sided question because how do you know when to start is like, is this a debate about working with physicians and their protocols and stuff like that versus what’s safe? But I like this one. This is a good one, and I think I’m going to start this episode off by saying this. I don’t think we’re ever going to necessarily know the answer, but I think as rehab professionals in the last five years or so, I think we’ve done a really, really good job trying to put together as much of the data and research that’s out there to try to help us answer this question very scientifically.
And I don’t know if the doctors have caught up to that, to be honest with you. So sorry if you’re listening and you’re a physician, right? They still almost have blind recommendations, but who would like to start this one here? Because I think there’s a few things, and we’ll keep the episode specific. They’re talking about when do we start exercises after the cuff repair? How do we know when to start range of motion in early exercises? Like what’s safe? Who wants to start? Dan?
I guess I’ll start. I did a literature review on this I would say sometime in the past year because this is a real concern. And I think the big thing that… What was the question asker’s name?
Tiffany. And I think if the listeners aren’t aware, there’s a fairly high retear rate and rotator cuff repairs for the big massive ones, upwards of 90% plus. For the smaller ones, obviously that’s much lower. And what we do from a physical therapy standpoint does seem to influence the rate of tears. So I think it’s important that we are thinking about this a little bit, and there’s a couple thoughts that go into my mind. So when you have a retear, it could be because of mechanical fixation. So essentially when the surgeon is trying to repair this and put this down on the bone, if we put too much stress in there, it may tear off. The other piece to think about in my mind is that exercise is something that promotes healing as well. And you will see protocols that lock people down for six weeks and they do nothing, and then they start physical therapy, range of motion, and everything else.
And that may be a problem too from an optimal healing perspective. So we probably want to put a little bit of stress through that area. And I guess I just wanted to also say that I think you had it right, Mike, that we don’t really fully know exactly what the best time is to introduce range of motion, strength, all of that stuff. What I will say without trudging on too long is if you have a small to medium tear, full thickness, you could probably push this a little bit faster in terms of range of motion, meaning that you could probably start range of motion passively almost immediately.
Probably the research is kind of showing a sling for the small to medium tears does not influence retear rates. But as soon as you get to the large and the massive tears, you have to delay things quite a bit more. And a lot of the accelerated protocols you’ll see out there are early range of motion for the large plus tears. That does increase retear rates slightly, although that evidence is mixed. So there’s some broad strokes there without saying too much, I guess.
I think that was great, Dan, and I think you brought up two great points that I really liked. One is the research about retears. But before we even talk about those, actually, it’s almost like saying rotator cuff tear. That’s almost saying “when do you start running after a hamstring strain?” Well, was it a grade one, a grade two, a grade three? I mean, the answer is it depends. And just saying rotator cuff tear is not fair, I think. to the patient, right? You can’t say every rotator cuff patient needs to do that, right? A thirty-five-year-old with a very small tear and quality healthy tissue is a lot different than a seventy-five-year-old with a massive tear and really poor tissue quality. And why would those two people rehab the same? Right? We don’t do that for anything else. So I like how you said that, Dan.
I also like how you talked about some of the statistics. If you look at the stats that come out here, yes, there are a lot of rotator cuff failures, but most of them happen early anyway and they probably happen regardless of the physical therapy. And if you look at some of the studies, they tore even in the groups that didn’t do the physical therapy. So it comes back down to “does rehab impact that?” It’s probably more with the large massive tears, like Dan said, than the smaller tears that we have to be a little bit cautious based on that. But I really liked how you said that, Dan. So yeah, I just want to comment on that. Dave, what do you got?
Yeah, I think this is pretty vivid to me because early in my PT career, this is actually one of the things I found you and Lenny for, because I remember distinctly not really understanding when to start exercises after a cuff repair and like flared somebody up, which I think I went a little too early. And I think the problem that I missed when I was younger is it was really, like you said Mike, lumping them all into the same bucket, not only on severity, but also the type of cuff tear and what they had done. So somebody with a supraspinatus repair is completely different than someone who has a subscap repair who has infraspinatus tendinopathy as well. And I think you have to really understand that, okay, exercise can mean passive range of motion or active assistive range of motion to one doctor, whereas exercise is like weighted cuff sidelined ER in full cans to another doctor.
So it’s really important that you understand what the doctor’s protocol is, what they consider range of motion, and what different pathologies correlate to what types of tissues. So loaded full cans with somebody who’s had a medium sized repair is completely inappropriate six weeks in. But active assisted range of motion with pulleys is also exercise to some docs. And so that’s really important.
And so with most things, I think there are general timelines that passive range of motion can start to tolerance in certain directions, if you understand what tissue you’re working with. You wouldn’t want to do IR in an infrared repair or something like that that might stress the tissue, but elevation to tolerance might be totally fine. So I think generally speaking, we could give you timelines for maybe around four to six weeks it’s this, then active assistive range of motion is a little bit farther than the isometrics at eight weeks or 12 weeks or whatever. But it’s really going to be very specific to the severity, the doctor, the type of tissue quality like you said, and also many other protocols that are changing constantly. So I think it’s really important to study those things yourself, but then also talk with the docs and ask why and what do you want to do.
I think that’s great, Dave, and a really good example of that with the doctors. I guess this does drive me crazy, but I tell this story in person all the time. I tell the same stories over and over, right? You guys at this point, we’ve all worked together for so long it’s annoying. Even the students are hearing my stories multiple times.
But anyway, I always tell the story about this one because I think it’s a great example. I had a student, this was like 20 years ago, she was doing her best. She had a post-op recheck with a rotator cuff repair, and she did a great job. She started some basic isometrics and passive range of motion that was very appropriate at the time for that person, but it was a doctor that she hasn’t worked with before that we weren’t really aware of. The person goes back for the recheck with the doctor and the doctor’s like, “You can’t do passive range of motion, that’s crazy. Why are you doing it?” Totally throws her under the bus. He’s like, “The only thing you can do is rope and pulley.” We’re like, “Well, scientifically, that doesn’t actually make sense.”
So it was a learning experience for the student because she’s like, gosh, I thought I did the right thing, which she did. Don’t tell the doctor. But it was also an experience of that this is a lot of nomenclature and a lot of misunderstanding about the doctors, but they still control the progression because the outcome is their responsibility in my mind. So something to keep in mind. So who else? Anybody else have input on that one?
Yeah, I mean, I got opinions.
Yeah, well done Len.
I verbalize these numerous times on social media. I’ve fought numerous docs about this and we get nowhere. So good luck but…
Like fist fight? Like how aggressive?
Yeah. Like fight. Yeah. I spent time in jail. No, I’m kidding. Dan did a good job summarizing. The literature does say retear rates are like 8% to 94%. So keep that in mind when you read the literature. They’re huge. And you can MRI somebody’s rotator cuff repair a year or two out, and they are fine, asymptomatic full function, and it shows a retear. So we got to be careful how we’re defining failures and everything in the literature because it’s not going to necessarily correlate with function. And so for me, who somebody growing up with Mike in the Birmingham world was very confusing because our doctors, and those guys 20 years ago we’re doing passive a range of motion right away post-op day one and did well. So when we had an outside doc send somebody with a rotator cuff repair and we used that protocol, it was always troubling to that doctor because we were being too aggressive, even though open pulleys are about 17.6% MVIC on the supraspinatus. No, I don’t want to…
Lenny with the numbers. I love it.
Right. So if you keep your MVIC numbers less than 20% roughly, which is passive range of motion, which is a little golf club or active assistive range of motion, you’re typically safe, especially for a small to medium sized tear with good tissue quality. Somebody who has diabetes, any other comorbidities, even obesity, I would probably limit what I would do with them. But range of motion right away in my experiences, if you have a good surgeon and you have a trustworthy PT who’s not ramming people’s shoulders into flexion and external rotation, especially internal rotation for a supraspinatus or an infraspinatus, then it’s typically safe. Because my 10 minutes of passive motion versus the twenty-three hours and 50 minutes that they’re living in their sling opening doors with your other hand. Now keep in mind, there are studies that show using the contralateral extremity puts stress on the surgical side, probably the same if not more than if they would doing passive motion or open pulleys.
So we’re not going to tell people to not open a door or lift a glass of water with their other side because it’s still going to stress the surgical side. So we get… If you look really at the literature, it’s all over the place as usual. But I think in the hands of a good therapist who’s respecting the tissue and respecting range of motion and respecting the doctor’s principles of the surgery and how good the surgery was, is it a double row or single row? Most doctors do double row repairs now… The tissue is going to hold up just fine. So I promote early range of motion after rotator cuff repair because I know over the last two decades people can do just absolutely fine with it. So that’s my little soap box.
I love it Len. And I think from experience too that we can say the reason why we care and the reason why we’ve been talking about this is that we think patient satisfaction and their ability to get back to their activities of daily living are better and higher. It’s not just about does an MRI show that things return. Because a lot of times they show it’s returned, but their satisfaction is up. They think it was successful still because they’ve rehabbed it so well. So sometimes we’re using the wrong metrics.
So Tiffany, I’ll wrap it up and summarize it like this, right? We’re not going to give you weeks today, right? Because that’s not fair to the person in front of you. Everybody’s a little bit different. You can’t start this week zero or four or six or whatever it is. That’s not really the purpose of this.
But I like how Lenny kind of alluded to it. Dan Pope’s had some great content on his website and social media lately on this stuff too. But think of an ordinal scale of exercises and how much stress and EMG activity they put on you. And that’s how we think of it. And remember, like Lenny said, brushing your teeth, drinking a glass of water, opening a door with your other arm while you’re in a sling, that’s more EMG activity than doing passive range of motion with your shoulder with the therapist.
So kind of keep that in mind. And I would say put those stuff together. I think that’s how you do it and that’s how you judge what’s safe is you kind of put that ordinal scale together. So check out some of those resources for that. And Tiffany really good question that I think a lot of us face. So I like questions like that. So thanks so much. If you have a question like that, head to mikereinold.com. Click on that podcast link and be sure to head to Apple and Spotify and rate, review, and subscribe and all those other cool things you do with podcasts. Thank you so much. We’ll see you on the next episode.