Postoperative Rehabilitation Protocol Rotator Cuff Repair (Massive)

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Arthroscopic Rotator Cuff Repair of Massive(Large) Type tear.  It is by no means intended to replace or substitute the clinical decision making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

*This protocol applies to Massive Rotator Cuff Tear (3+ cm tear pattern).  If Standard Rotator Cuff repair is performed the therapist should utilize that specific protocol.  There are many variables which can influence how conservative or aggressive the patient may be rehabilitated.  These include but are not limited to the following: Quality of tissue and integrity of repair, acute vs chronic tears, primary vs revision repair, and additional procedures (such as biceps tenodesis, distal clavicle excision, subscapularis tendon repair, etc).   

*Return to work/activity will be based on the individual patient's profession and workplace demands, ability of employer to accommodate restrictions, and postoperative progress.

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

*A word about “pain” and management of anticipated discomfort following arthroscopic rotator cuff surgery...

  • Adequate management of pain is essential to progressing the patient’s mobility, strength, range of motion, and independence.  However, pain is a subjective measure and should be expected for weeks to months after surgery.  A divergence between the subjective complaints and objective findings observed by an experienced therapist should arouse concern and potential need for further consultation/evaluation.  



Phase I- Early Post-Operative Phase (Post-op Day 0-14)

The goal of physical therapy intervention during the early post-operative phase is to achieve progressive improvement in PROM (Passive Range of Motion) to prevent capsular adhesions and fibrosis.  Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential.  Recovery of strength is correlated to tear size and therefore massive tears can take much longer to rehabilitate that small or standard tears. 

Goals: 

  1. PROM only: 90 degrees flexion, 45 degrees ER, 20 degrees extension, 90 degrees ABDuction 
  2. Full AROM/PROM elbow/wrist/hand
  3. Proper posture, joint protection/positioning, don/doff sling appropriately
  4. Improve scapular mobility
  5. Implement use of nonpharmacologic modalities to control pain and swelling such as circulating cryotherapy pumps, manual massage, elevation of the extremity, etc

Assessment by Therapist:

  1. Assess surgical wounds for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess pre-treatment and post-treatment PROM
  5. Assess for signs of large intra-articular effusion, DVT/PE (pulmonary embolism), Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Grip strengthening
  2. Codman's (Pendulum) Exercises
  3. Core and Low Back Exercises
  4. Scapular elevation/depression, retraction/protraction
  5. Scapular orientation (emphasize posterior tilt)

Precautions:

  1. USE OF SLING!!!! Abduction pillow necessary (except when bathing) until 6 weeks post-op to reduce potential strain on the repair.  
  2. Avoid all AAROM/AROM
  3. Avoid lifting >5lbs
  4. Avoid any resisted supination if biceps tenodesis

*Patient may progress to Phase II after Phase I goals completed and minimum of 2 weeks post-op

Phase II (Post-op Week 2-8)

Goals:

  1. Unsupervised PROM only until end of Phase II: MAX-130 degrees flexion, 60 degrees ER, 20 degrees extension, 90 degrees ABDuction
  2. May only begin AAROM at 6 weeks post-op if supervised by PT (pulley, wand, supine assisted ROM exercises)
  3. Encourage home exercises to be performed 3X/day 
  4. Decrease swelling/inflammation (Ice, TENS unit, Dry Needling, Cupping, etc)

Assessment by Therapist:

  1. Assess frequency of narcotic and non-narcotic analgesic use 
  2. Assess pre-treatment and post-treatment PROM 


Therapeutic Exercises:

Week 2-6

  1. Continue Phase I Therapeutic exercises 
  2. Incorporate Neck ROM exercises as necessary
  3. Advance Posterior capsule mobilizations, avoid stretch of anterior capsule

Week 6-8

  1. Increase unresisted ER to tolerance up to 60 degrees
  2. May begin AAROM only when supervised by PT and able to demonstrate acceptable glenohumeral ROM in flexion, scaption/abduction, ER, and pain sufficiently controlled

Precautions:

  1. Sling should be used unless patient is bathing, performing exercises at home, or under direct supervision by physical therapist.  Patient may remove the sling at home for brief periods while the arm is supported in slight abduction (approximately 30 degrees), such as sitting on the couch or in a recliner, and when able to demonstrate to therapist ability to perform strict PROM movements.  
  2. No Lifting > 5 lbs
  3. No resisted supination if biceps tenodesis performed

*Patient may progress to Phase III after achieving PROM 0-130 degrees flexion and pain is considerably decreased 

 

Phase III (Post-op Week 8-12)

Goals:

  1. End of Phase III goals: FF 150 degrees, ABDuction 135 degrees, ER 90 degrees
  2. Wean use of sling and analgesics 
  3. Continue PROM/AAROM and progress to active ROM with minimal or no scapular compensation
  4. Establish baseline humeral head control 
  5. Initiation of ADLs and proprioception exercises below shoulder level
  6. No pain at rest

Therapeutic Exercises:

  1. Continue Phase I and Phase II exercises
  2. Cane (stick, PVC, etc.) PROM/AAROM Progressions (supine-->reclined-->standing) 
  3. Begin resistive/strengthening exercises for scapular stabilizers 
  4. Wall walks/slides, pulley exercises 
  5. Initiate Sub-maximal Rotator Cuff Isometrics when 80% AROM achieved
    1. Use Caution with IR if subscapularis repair performed

Precautions:

  1. No lifting > 5lbs 
  2. No pushing, pulling, loading
  3. No rapid movements (excessive/forceful muscle contractions) 
  4. Avoid movements resulting in subacromial impingement pain 

Phase IV (Post-op Week 12-16)

Goals:

  1. Full PROM and AROM without pain 
  2. Continue Phase I, II and III exercises
  3. Progressive strengthening and complete functional activities/heavier ADLs below shoulder height
    1. Progress endurance before strength (ie. higher reps before adding resistance)

Therapeutic Exercises:

  1. Begin isotonics = AROM against gravity 
  2. Continue scapular protraction/retraction/elevation/depression
    1. OK for manual resistance scapular motions
  3. Swiss ball slides up wall in flexion and scaption
  4. Latissimus eccentrics
  5. GH stabilization/mobilization exercises
  6. OK for cycling/running

Precautions:

  1. May discontinue elbow flexion and forearm supination restriction for biceps tenodesis 
  2. OK to progress resisted IR if subscapularis repaired
  3. No overhead loading if any pain
  4. Avoid long lever exercises 

Phase V (Post-op Week 16+)

Goals:

  1. Maintain full ROM
  2. Achieve strength measurements comparable to contralateral extremity by 24-36 weeks post-op 

Therapeutic Exercises:

*Start Rotator Cuff Isotonics with low/light resistance and progress as patient demonstrates efficiency/strength and dynamic humeral head control

  1. Sidelying ER with increasing weight (start at 1 lb)
  2. Resisted IR/ER with theraband, progress to dumbell or machine 
  3. Weighted scapular exercises (weights, tubing, seated row)
  4. Forward punches with pulley/band
  5. Dynamic Hug with bands
  6. Wall washes
  7. Push up (progressive: wall-->incline-->floor)
  8. Introduce and advance overhead weighted exercises and begin plyometrics if indicated

Precautions: 

Do not advance strengthening exercises if patient experiencing painful response.  Goal is maximize endurance of movements before increasing loads