This article will discuss some of the potential problems that can happen after a rotator cuff repair. It is not intended to replace medical advice from your surgeon or physical therapist, but may offer a jump off point for you to start a conversation with your practitioner. There are many potential problems that will not be addressed by this article. If you feel that your post operative process is not going well, contact your surgeon so that you can make sure that there is not a major medical issue. Good communication with your medical providers is a major key to success after a rotator cuff repair. Post surgical rehabilitation of a rotator cuff repair is much more a character building exercise than a physical task. You must allow the shoulder to heal while appropriately stressing those healing tissues with very specific exercises and activity modification.
Surgical protocols are dictated by the surgeon and can vary depending on surgical technique, size of tear, quality of bone/soft tissues, and accompanying procedures such as a distal clavicular resection, subacromial decompression, or labral repair. This discussion is limited to a simple repair, so if you had a capsular shift , labral repair, or other procedures, there may be range of motion restrictions that your surgeon will dictate. For an overview of the normal post operative course, please refer to the article “What to Expect After a Rotator Cuff Repair.”
A rotator cuff surgery is a major surgical intervention in the shoulder, and the reason that there is pain after surgery is the amount of normal surgical trauma. Cutting, drilling, cauterizing, and suturing tissues create pain and inflammation. One of the most important things to remember about your post operative course is that you need to allow your shoulder to heal. The shoulder will continue to heal over the next six to twelve months.
Problems in the early phase (0-2 weeks)
The first two weeks after a rotator cuff repair are all about trying to find a comfortable position for the shoulder in the sling during sleep and wakeful times. I find that sling position is critical. Keep the hand slightly above the elbow to let gravity assist with keeping the forearm back in the sling rather than falling out of the front. The elbow should be as far back into the bend of the sling as possible to suppor the forearm. Most surgical protocols demand that you wear the sling full time, even when sleeping. Many patients tell me that they are more comfortable sleeping in a recliner for the first month or so. Even though the hand is exposed from the end of the sling, it is not to be used for any activities while the arm is in the sling.
It is tempting to use the hand to stabilize something that is being carried in the other hand, or hold something like a coffee cup or purse in this hand. Remember that any time the hand is in use, the shoulder muscles are contracting in anticipation of performing a reaching task. Every time you use the hand, you are contracting muscles that were just sutured down, thus irritating those structures. The only exception to this rule is squeezing a foam ball to keep the hand moving. If the shoulder is well supported and the ball is essentially weightless, you will not irritate your shoulder. Driving is not allowed until cleared to do so by your surgeon.
Typically, the only exception to the sling rule is the pendulum exercise. Most surgeons will have patients perform the pendulum exercise two to three times per day. This should be a passive movement, meaning that the shoulder muscles are relaxed, and the gentle sway of the body moves the arm in a swinging motion. At this point, there should be no active movement of the shoulder, meaning that you should not be reaching in any direction with the arm. Failure to adhere to this type of passive range of motion can result in re-tearing the repair. The major goal of this stage is to allow the shoulder to heal and perform your pendulum exercise as directed.
If your incisions are red, swollen, and oozing colorful discharge, and especially if you have a fever, contact your surgeon to ensure that there has not been any type of infection.
Problems in phase 2 (3-6 weeks)
Typically, formal physical therapy will start between 2-4 weeks after your surgery. Remember that you are still required to wear your sling full time until your surgeon tells you to remove it, with the exception of your physical therapy range of motion. It is important to note that all of the repaired structures in a standard rotator cuff repair have sufficient length to move through full range of motion. At this point, If you were under anesthesia, your shoulder would likely have little to no range of motion restriction. On day one of physical therapy, your therapist will likely take you through passive range of motion, and it is normal to have about ½ of your normal motion, and it is normal for it to be accompanied by some discomfort.
Most surgeons will take the arm through full motion during the surgery after the repair is completed to ensure that all of the structures have the length necessary to perform full range of motion. The reason that your arm will not go through full range of motion early on is pain and muscle guarding. It is important to think of your range of motion exercises not as a stretch, which implies a need to lengthen a tight structure, but as taking the shoulder through available range of motion to allow the brain to recognize that this motion is not injuring the shoulder. Think about trying to relax into the shoulder’s normal end range rather than push into painful tightness.
As the shoulder calms down, your PT should be introducing gentle motion of the thoracic spine and shoulder blade as movement in these regions are very important for a long term outcome.
Failure to perform your range of motion exercises at this stage can have dramatic effects in the later process. Conversely, patients who allow their shoulder to heal in the sling while performing their range of motion exercises as directed will likely have little pain and almost full motion into forward flexion at the six week follow up.
Problems in phase 3 (6-12 weeks)
Patients who continue to have significant pain at rest and range of motion restriction generally have quite a bit of upper quarter restriction separate from the ball and socket joint of the shoulder. The shoulder is really made up of 7 regions: ball and socket, scapula on ribs, scapula on collar bone, collar bone on sternum, lower cervical spine, upper thoracic spine, ribs 1-3 on thoracic spine. All of these regions must be moving properly to allow the shoulder to move into all directions appropriately.
At six weeks, with a normal rotator cuff repair, the surgeon will likely allow you to remove the sling. Sometimes this timeframe is extended because of a large tear or poor bone integrity. The arm can now be used for light activities of daily living and typically I like to have a 5 pound weight limit. It is a good idea to wear the sling out in the community or at social events where people may want to give you a heartfelt punch in the arm.
Having the sling off does not give you license to finish that drywall project in the basement or scrub the kitchen floor on your hands and knees. Try to allow your arm to swing normally during walking, and use it for gentle tasks. Your ability to increase loading of the shoulder will be determined by what you are able to do in the PT gym. As you successfully move through the exercise protocol, you can increase your activity level. Loading exercises must not produce an inflammatory process in the shoulder. If you are having pain at the front of your shoulder during exercise, there is likely some impingement at the shoulder that is caused by restriction at one or more of the seven areas. This restriction must be resolved to have a successful outcome, and attempting to strengthen through an impingement situation will likely be unsuccessful.
Problems in phase 4 (13-24 weeks)
The emphasis on this phase is integrating active movement and loading of the shoulder to the rest of the body. As stated before the shoulder blade and thoracic spine must be able to move appropriately during overhead activities so that loads can be transferred from the hand to the shoulder into the blade and then to the spine. Restriction at the upper thoracic spine and shoulder blade can cause the rotator cuff to be placed at a disadvantage during overhead and forward reaching activities. Repetitive loading in a disadvantageous position is a recipe for inflammation and pain.
Return to sport is determined by the surgeon but is generally at six months for activities such as golf and throwing. Make sure that if you are returning to sports such as these that you work slowly into the process. For golf I like to have people chip for a few weeks, then half shot, then 75% effort full shot, then full shot over a 6-8 week timeframe.
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