How Fast Do You Rehab Your Rotator Cuff Repair Patients?

That seems to be one of the most common questions I get regarding rehabilitation of the shoulder.  It seems like clinicians want to know how everyone else is rehabilitation their patients following rotator cuff repair surgery.  My guess is because most people feel that their physicians are too restrictive in their postoperative guidelines?  Does that sound like you?

DSC01366Unfortunately the most optimal rehabilitation progression following a cuff repair has not  been documented.  There are no research reports stating that one technique is better than another, that starting ROM immediately is better than not, or that avoiding isometrics for 12 weeks is safer for the repair than beginning immediately.

Notice above that I highlighted “optimal.”  That was a specific choice of wording.  Optimal can mean many things.  For these patients it could mean “safest rehabilitation progression” or even “most effective rehabilitation progression.”  But even those phrases are vague.

Let me ask you a question:

What is your definition of the optimal outcome following rotator cuff repair?

Is it that the patients returns to their premorbid work or athletic activity?  That the patient restores ROM and strength as quickly and safely as possible?  Or that the patient have an intact cuff repair when performing a MRI or ultrasound 2 years after surgery?

We may all have a different answer to that question, but let me share with your how I would answer.  The most optimal outcome following rotator cuff repair for me is having your patient return to their normal activities as quickly and safely as possible.  I would bet that if you asked this question to a surgeon, they would respond with the above comment regarding having the repair intact at time X after surgery.  I would also bet that if you ask the patient this same question, they would respond with something along the lines of “I want to be able to lift my arm overhead while doing [insert activity here!] without pain.”

What would you say if I told you that 35% of rotator cuff repair surgeries fail?  Again, I highlighted “fail” because I am talking about two research reports that examined the percentage of repairs that were still intact 5 years after surgery (Harryman: JBJS ‘91 & Fealy: Arthroscopy ‘02).  Here are some interesting findings:

  • 35% of all tears fail
  • 20% of supraspinatus repairs fail
  • 50% of repairs of two tendons fail
  • 68% of repairs of three tendons fail
  • 25% of repairs to people aged 34-55 fail
  • 35% of repairs to people aged 56-70 fail
  • 45% of repairs to people aged 71-85 fail

Pretty shocking, right?

This is the primary factor why I believe surgeons promote a decelerated rehabilitation approach – they do not want failure

Well how about this information, also from those studies:

  • 96% of patients with intact cuff report being satisfied
  • 87% without cuff intact are STILL satisfied

What does this mean to me?  This tells me that integrity of the repair is not the most optimal factor associated with success following rotator cuff repair.  I would argue that we should be more worried about satisfaction than integrity of the cuff

Now don’t get me wrong, I realize that if your cuff remains intact that you will likely have a better outcome.  I am just saying that I don’t believe that we need to be unnecessarily cautious and decelerate our rehabilitation approaches.

There are safe and effective ways to achieve satisfaction and integrity of the repair

Want to know how I believe we can achieve this?  Want to know how I rehabilitate my patients using what limited evidence we have?  Want to know what I do each week following surgery, and more importantly – why?

Click here to see more about how I rehabilitation rotator cuff repair patients and download free copy of my arthroscopic rotator cuff repair protocol.

Harryman DT 2nd et al (1991). Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff J Bone joint Surg, 73 (7), 982-989 DOI: 12098132

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20 Responses to “How Fast Do You Rehab Your Rotator Cuff Repair Patients?”

  1. This month’s Sports Health Journal has three docs “attempting” to state an optimal rehab protocol (or not) after a repair. Check it out and post as to why the surgeons are trying to tell us therapists the best approach to rehabbing their patients. Last I checked, we don’t tell them what the best approach to surgery is for a patient.

  2. Trevor Winnegge DPT Reply March 22, 2009 at 5:52 am

    I believe most of our RC patients had poor ER strength, poor scapular mm strength and control, and a poor ability to optimally stabilize their shoulder during normal tasks pre-operatively. This is what lead to the RC tear. Post operatively, we work a lot on these key points and really get the shoulder muscles working better than ever before. So if they do have a failure of the repair, their shoulder will still function quite well, leading to their satisfaction with the procedure, despite a failure on mri. What is an interesting question to ask here is….why do they fail? Is it because they fell again, or tried to throw a 100mph fastball in their backyard? Or did the tear occur during physical therapy-perhaps the result of an overzealous PT? Mike has already talked about the towel stretch to regain IR placing the the cuff in a less than optimal position, possibly leading to failure. Yet we still see therapists all the time use it post operatively! I have seen therapists go to the plyoback throwing exercises, throwing a medicine ball too early. If the patient can’t stabilize their scapulae in prone or standing, how can they do so throwing and catching? I am not sure if we can really ever know when the failure occured, which will forever leave us with this problem of having doctors try to tell us how to rehab their cuff patients.

  3. I completely agree Trevor. Unfortunately, most docs from group to group have their own thoughts on RTC rehabilitation often putting the therapist in an awkward position. Two pt’s from different docs but with the same surgery are often treated differently because of the doc’s philosophy.
    Most studies, including EMG studies on the RTC with pt’s performing pulleys (Dockery et al. 17.6% MVIC), L-bar, etc are not quality or are performed on non-op patients. But they are something and have guided me in the rehab of my patients. Most activities that we perform with our patients are below the 20% MVIC threshold that we consider significant. Early, controlled motion through PROM and AAROM is safe and I have seen it successful time and time again. We know that motion improves pain, places a gentle stress on the healing soft tissues, and prevents adhesion formation… among many other benefits.

  4. I need to read that article, Lenny. I glanced at it but havent had a chance yet. Funny that a main area of paper is on CPM use… has anyone used a shoulder CPM after a cuff repair in the last 2 decades?!? Disappointing that a quality journal like Sports Health would even consider publishing a paper like that. Who wants to write a paper with me on the best surgical technique to repair the cuff?

  5. Brian O'Neil, PT Reply March 23, 2009 at 6:20 am

    Hi Mike, great post. There are 5 docs in my group that do RC repairs and they are really all over the place in terms of what they want for rehab. I have been trying to gather data, research as well as pt. data to present to them to try to determine which protocol is getting the best results(based on functional outcomes). One surgeon in particular has his patients in a sling for 6 weeks, followed by 6 weeks of PROM. You can imagine a lot of post-op frozen shoulders. Another has been decelerating his protocol lately and has begun to limit ER (don’t ask me why). It would be interesting to see if there is any commonality in rehab with the patients that had 96% satisfied, and especially with the 87% with a failed cuff that are still satisfied. I completely agree with Trevor that many that fail are returning to the same activity, often with the same mechanics (poor TS extension, poor upward scap rotation). The ones that do well have been properly rehab’d. I am going to try to make the webinar tomorrow.

  6. Hi All! I’m enjoying the discussion. My partner and I share many of the frustrations you mention with the progressive deceleration of r/c repair rehab. I wonder if a few over-aggressive PTs over the years are setting us all back… The discussion of CPM is an interesting one. Mike, you ask who has used CPM s/p cuff repair in the last 20 years. Well on of our local orthopods (one that has always been pretty pro-PT and progressive interacting with us) is using a CPM chair for cuff repairs. We are planning to discuss this with him ASAP as we see it as a huge blockade for overall recovery as it is being done without any physical therapy. Is anyone else seeing this trend? Do you have any references we can dazzle our MD with?
    Thank you all for sharing your expertise.

  7. Trevor Winnegge DPT Reply March 23, 2009 at 5:56 pm

    The doc i work for is pretty aggressive-now. When our practice opened, he had poor experience with PT in north carolina. he came up here, and we all met-hired by hospital. his RC’s came to me 10 weeks post op. was awful. We sat down and went over protocols and he agrees to try 6 weeks post op. 6 weeks in sling only doing pendulums. I convinced him to compromise down to 4 weeks. Our current protocol is 4 weeks pendulums/sling, then they come to PT. If he sees them at initial post op and feels they are getting stiff (despite all his rc’s done arthroscopically) then he sends them to me at that time. i have been fortunate to work with a great doc and communicate with him on a weekly basis. We have both come to a comfortable point in our rehab approaches. He wont send them any sooner and i respect that. most of them do really well. One of the drawbacks of not working with the physician, is if you have a doc send you someone 12 weeks post op for initial Pt like Brian stated, it makes you look bad as a PT! Brian-i think the communication with the docs will be great. show them hard data. show them reinold and andrews work. askt hem to let you try your protocol on one patient and see how it goes! you may transform them! I did

  8. Christie Downing, PT, DPT Reply March 23, 2009 at 6:14 pm

    Absolutely shocking stats, Mike.

    86% are satisfied without the cuff intact? Makes me yet again realize that perhaps the pathoanatomic diagnosis of r/c tear is not that valid in the first place? To me, this suggests that PT carried over the course of 4-6 months (or at least continuation of a HEP) may be sufficient to reagain the strength and function that people desire in most cases.

    I’ve seen a lot of full thickness tears who retained ability to reach over head have very successful conservative managements.

    Makes me realize we don’t have the whole picture yet.

  9. Trevor Winnegge DPT Reply March 24, 2009 at 3:07 am

    another thing to consider is the presence of bone spurs. most of these RC patients going into surgery have some degree of spurring in the subacromial space. perhaps the reason for success after rc repair is not really the cuff repair itself, but the fact that they no longer have spurs following a decompression at the time of repair. we all know we can treat rc tears conservatively, with strengthening surrounding musculature. If there is a bone spur causing impingement, it doesn’t really matter how much exercise you do, you can’t change that impingement. Surgery fixes that and with a post operative course of stabilization/ER/scapular strengthening, the patient may do fine. let’s see if any docs are willing to do that study-every cuff tear brought to the OR, they just perform a SAD on them and leave cuff alone. See how it turns out. Probably not well but it is something to think about…..

  10. Brian O'Neil, PT Reply March 24, 2009 at 5:13 am

    Trevor, I would say that your doc is still conservative, holding PT for 1 month. Most of the Reinold/Andrews protocols begin PT week one. The benefits are well documented. However from what Mike is stating in this post, a doc will come back at me and say “There are no research reports stating that one technique is better than another, that starting ROM immediately is better than not, or that avoiding isometrics for 12 weeks is safer for the repair than beginning immediately.”(as above). Or that “96% with an intact cuff report satisfaction, so the most important factor is cuff remaining intact”. I am just playing devil’s advocate, but I think this is what we as PTs run into. Until I can show them hard research that these people actually do better, with a functional outcome tool, then my argument will fail… Trevor I agree that a primary impingement resulting in a tear can be treated well with a SAD, and often our docs will leave the cuff alone unless it is a massive tear. (I have also seen that even these people can be treated conservatively if the cuff can be strengthened to prevent humeral head migration into the spur). However with an undersurface tear they would have to fix it.

  11. Chris Goettee, DPT Reply March 24, 2009 at 12:23 pm

    The conclusion in the Sports Health Journal article that individualized PT treatment is no better than an unsupervised HEP got my attention. But, if you look into it more it’s only based on 2 studies, one which had everyone hold off on isotonics until 3 months post op and the other study compared ROM and MMTs (not the most objective measure). The mean flexion ROM at 24 weeks was 144 and ER was 43 for the HEP group and not much better for the PT group – so they concluded both tx’s were just as effective – not that suboptimal rehab is no better than the unsupervized HEP. I hope that most of us have a lot better ROM results than those. And the CPM? I don’t think I knew those existed for the shoulder.

    Lenny or Mike: since your article in that issue supports measuring IR by stabilizing the scap, do you do the same when you range or stretch someone into IR (instead of preventing anterior translation of the humeral head)?

  12. Lenny Macrina MSPT, SCS, CSCS Reply March 24, 2009 at 8:26 pm

    If I feel as if there’s compensatory motion coming from the scapula, then I’ll do my best to stabilize the scapula…although it’s difficult to do and get a stretch at the same time. Also, you may need to address a tight posterior capsule if excessive anterior translation is occurring. And as I taught you during your 3 glorious months as my student in Birmingham, we would never stretch a RTC repair too soon into IR. The motion will come, just give it time before becoming too aggressive.

  13. Trevor Winnegge DPT Reply March 25, 2009 at 2:55 am

    Brian,
    Our doc is somewhat conservative yes, but I would rather have a RC at 4 weeks instead of 12!! given that he only does arthroscopic stuff, they usually don’t have a lot of stiffness issues. he gives them home exercises to do for first 4 weeks. The stiff ones are the babies who don’t do what they are supposed to!

  14. Agree with all the comments in the discussion. Maybe this wont work with your docs, but can you try the approach of: “i know there is no research as it is challenging to design a study with enough control to address this question, but in my experience, patients that start late have a hard time with motion and returning to ADLs.” Maybe a good time would be when a patient comes to you late and is tight or has a shrug sign? I know it stinks but we are getting there…

  15. Great discussion… really enjoyed everyone’s posts. I am up in a rural community and our 3 local orthos refer anywhere from 3 days post op (wanting full PROM into flexion, abduction, and ER at 6 weeks) to 6 weeks- fortunately none making us wait until week 12! Never seen a CPM for shoulders… although I will Google that to take a look.

    I took a course from Michael Voight a couple years ago and he told a story about two elite surgeons (one was in Vail) that were getting each other’s patients 5 years post cuff repair and MRI’s showed the repair had “failed”. They eventually talked at a conference to give each other a hard time and then realized it was happening to both of them. It turned out that the failures were due to the suture anchors at the tendon-suture interface and normal shoulder function often continued despite the re-tears due to good cuff and scapular strength.

  16. Chris Goettee, DPT Reply March 25, 2009 at 4:01 pm

    Don’t worry Lenny, I haven’t forgotten your teachings.
    Chad, if it’s any consolation, I’m in the medical mecca of Boston, and still see a wide range of post op protocols. And definitely not always the for the best – recently had an ACL who wasn’t supposed to start PT until 4 weeks post op and another who was not allowed to do SLRs. It keeps things interesting at least.

  17. Christie Downing, PT, DPT Reply March 25, 2009 at 5:27 pm

    Good points about impingment and bone spurs….but yet again, there are many false positives walking around without pain.

    On one hand, I’d see no problem going in and doing a SAD as opposed to a repair…it can always be done later if needed, but then again, I often think a good course of PT will take care of the impingement anyway…bone spur or not (in many cases).

    In my experience, those who are having a SAC, DCE and R/C repair seems to do worse than any procedure in isolation…they tend to have more pain, guard more and really never get full motion or function. It just seems that they never get over the trauma of the three procedures.

    Anyone else have thoughts on this?

  18. Hi All! I am 32 days out from surgery after 2 CM tear in supraspinatus and acromion decompression and distal clavicle resection. Doing PT 3 times per week! During passive exercises on my own I noticed lots of shoulder and trapezius migration. Tried to hold shoulder down during movement and now am pretty sore. Too soon for this? Please help!!

  19. Getting better!! 7 weeks in now, start active therapy next week. BTW I am a 51 year old tennis player.

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