If you feel like your rotator cuff repair is not going well, you may want to read Problems After a Rotator Cuff Repair.
Rotator cuff repair surgery is very common, typically requiring six to twelve weeks of physical therapy post surgically. This article is a brief description of various aspects of the post-surgical physical therapy, and is not intended to be a replacement for physical therapy. If you have concerns about your surgery or rehabilitation process, contact your surgeon or physical therapist so that your questions can be answered. All post-operative protocols are dictated by the surgeon’s preference, so your timeline and progress may be quite a bit different than the one presented here. This discussion is limited to a simple rotator cuff repair. There are many other surgical procedures that may accompany this surgery that can increase healing time, decrease range of motion, and increase pain.
There are three main phases after a rotator cuff repair: 1. Passive range of motion 2. Active range of motion 3. Functional strengthening. The goal of stage 1 is to protect the repair while maintaining as much range of motion as possible. Stage 2 begins after the sling is removed, and the patient begins to move the arm with muscles in the shoulder rather than an outside force. Stage 3 is an ongoing strengthening process, focusing on returning the patient to the appropriate level of activities of daily living.
First two weeks:
During the first two weeks after a rotator cuff repair, the patient is in a sling, typically with a foam bolster. Most surgeons will instruct the patient to remove the sling for pendulum exercises and elbow straightening exercises only. At this point, there should be no active movement of the shoulder, and there should be nothing placed in the hand while the arm is in the sling. Patients who are compliant with the sling and range of motion exercises typically have fewer complications later in the process. Attempting to use the arm prior to being taken out of the sling is one of the main reasons that people have difficulty in the later stages of the process.
Physical therapy typically begins at about two weeks post-op, after the surgeon has rechecked the patient. Formal physical therapy in this phase should involve passive range of motion manually (by the physical therapist) or through passive exercises. Typically on day one, the patient has 90° of flexion passively, but may have more or less depending on pain. During treatment, the physical therapist will gently move the arm in different directions to facilitate the healing process. It is important to note that all of the structures that were repaired should adequate length to move through full range of motion. The shoulder won’t move through full range because of pain and muscle guarding, not because of a lack of tissue length. Therefore, range of motion should be performed in a relatively comfortable range with the patient attempting to relax. By the time the patient is at 6 weeks, range of motion should be very close to normal for all motions. There is typically a bit of stiffness at end range, which is associated with some pain. Physical therapy exercises should also include gentle range of motion of the should blade as well as the thoracic spine.
At the 6 week appointment, most patients are taken out of the sling. This does not give the patient license to use the arm for all functional activities. For the first week, the patient should not have more than a coffee cup weight in the hand. If this goes well, then the patient can increase functional activities as tolerated. Physical therapy exercises increase by adding active range of motion and strengthening as tolerated. It is important to ensure that the thoracic spine and shoulder blade are moving well, and exercises are performed to facilitate stabilization through these regions as the shoulder tolerates them. The main goal for this stage is to regain full motion, pain free, and increase strength to the point where the patient can tolerate light to moderate activities of daily living such as cooking and self care.
Formal physical therapy will end for most patients during this time. Treatment emphasis is on integration of trunk and core muscles with shoulder muscles to produce efficient movement and good stability. Progressive loading and functional exercise continues to be increased as the shoulder tolerates it. High level activities such as throwing and overhead work related activities are dictated by surgeon’s prerogative and ability to perform functional exercise. Rather than pure rotator cuff strengthening, strengthening should incorporate trunk and scapula movements in all planes of motion.