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.
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 posted about this briefly while reviewing a research report on stiffness following rotator cuff repair. Unfortunately, part of the problem is the lack of randomized control trials documenting the safety and efficacy of rotator cuff repair rehabilitation guidelines.
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 posted about this briefly while reviewing a research report on stiffness following rotator cuff repair. Unfortunately, part of the problem is the lack of randomized control trials documenting the safety and efficacy of rotator cuff repair rehabilitation guidelines.
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 almost 10 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 centers.
I also am currently involved in the very early phase of the development of a consensus statement on the preferred postoperative guidelines following rotator cuff repair. This groups consists of many of the leaders of physical therapy, such as Kevin Wilk, George Davies, Todd Ellenbecker, Bob Mangine, Tim Tyler, and many, many more. Our goal is to develop and educate others, uncluding physical therapists and orthopedic surgeons, on what we have been doing for years as part of our rehabilitation programs.
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
- Protect the integrity of the rotator cuff repair
- Minimize postoperative pain and inflammattion
- Restore passive range of motion
- Restore strength and dynamic stability of the shoulder
- Restore active range of motion
- Return to functional activities
The 3 Most Important Keys to Rotator Cuff Repair Rehabilitation
- Restore 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 reduncy of the inferior 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).
- 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.
- 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.
Below is a video demonstration of some of the manual rhythmic stabilization techniques you can perform to enhance dynamic humeral head control.
This protocol is a part of a series of protocols that I have developed with Kevin Wilk and Jim Andrews with the Advanced Continuing Education Institute. If you like this protocol, there are over 80 more just like this on the Shoulder & Elbow 2nd Ed Rehabilitation Protocol CD and also video demonstrations of the surgical and rehabilitation techniques like the one above on the Interactive Protocol: Rotator Cuff Repair CD. Remember to use coupon code "Reinold" to save $10 for being a reader of my blog. In exchange, all I ask is that you subscribe to my blog and my newsletter, and you'll get my latest posts and information delivered to your email and/or RSS reader.
I would love to hear your thoughts and experiences on postoperative rotator cuff repair rehabilitation. Click the comment link above. What guidelines do you follow? What week following surgery do you see your RTC repair patients? When can you begin passive ROM? When can you begin strengthening exercises?
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
Thanks for the comments Chris, glad this was helpful.
MR
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
@ 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.
Thanks Mike...unfortunately, our surgical group doesn't have time to return our calls and we're largely speaking through office staff. Ugh.
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
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
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
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
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!
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.
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,
Im trying to recover from rotary cuff suregery.But insuerance company rehabilitation isn't needed.What can I do?