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Rehabilitation Following Rotator Cuff Repair
(Modified from Rehabilitation of the Rotator Cuff: J Am Acad Orthop Surg 2006)

Rotator Cuff Problems

What is the rotator cuff?

The rotator cuff is a group of tendons that lies in a small bone tunnel between the point of the shoulder and the humerus. The tendon is fixed to the humerus and passes through the tunnel. It helps you lift your arm away from your body.

what is rotator cuff disease?

The rotator cuff can be damaged by an accident, or more often, becomes worn as it passes through a narrowed tunnel. Early on, the bone presses on the rotator cuff causing inflammation and pain (impingement).  With time, the rotator cuff is permanently damaged and eventually becomes worn and may even tear.


What are the symptoms?

Shoulder pain: is the most common symptom and is often worse at night. Pain may also be felt on the outer side of the upper arm and neck. The pain may follow an injury such as a fall or a period of increased activity with the arm at or above shoulder height.Loss of movement: may occur if the rotator cuff tears. This usually happens later and reduces movement of the arm away from the body.

What tests are needed?

Shoulder X-rays can show a narrowing of the tunnel space through which the rotator cuff passes. They may show calcification of the tendon or arthritis of the shoulder joint.
Sometimes special tests may be necessary such as an MRI scan.

What are the treatments for rotator cuff problems?

Physiotherapy: Many patients respond to treatment with a physiotherapist and oral medications including painkillers and an anti-inflammatory.

Corticosteroid injection: If pain is troublesome, then an injection of a local anaesthetic and steroid may be needed. This injection sometimes worsens the pain for a short time before it settles. A maximum of three injections may be given into the shoulder in any one year.

Surgery: involves trimming the bone of the canal allowing the tendon to move more freely. This is done using key-hole (arthroscopic) surgery. If the rotator cuff is torn, this may be fixed using sutures. If badly torn, repair may not be possible and full strength and movement may never return. Surgery usually requires a general anaesthetic and two days in hospital. After surgery, physiotherapy is required to regain movement in the shoulder.

What are the risks?

There are risks with the surgery and general anaesthetic. Infection and nerve irritation are rare but can occur with the surgery. Movement may not return fully after surgery, especially if the rotator cuff was badly torn before surgery.

The risks of the general anaesthetic should be discussed with the anaesthetist.

Phase 1: Immediate postoperative period (weeks 0-6)

Avoid:

  1. Shoulder AROM.
  2. Lifting objects.
  3. Shoulder motion behind back.
  4. Excessive stretching or sudden movements.
  5. Supporting any weight including body weight.

Keep incision clean and dry for first two weeks.

Exercises:

  1. Finger, wrist, and elbow AROM.
  2. Begin scapula musculature isometrics & cervical ROM.
  3. Ice for pain and inflammation.
  4. Begin PROM to tolerance, should be reasonably pain free.
  5. May do general conditioning program, i.e. walking, stationary bicycle, etc.
  6. Hydrotherapy/pool therapy may begin 3‐4 weeks post-operatively.
  7. Sling/ abduction brace:
    1. Continue full‐time until end of week 4.
    2. Between weeks 4 and 6, use for comfort only.
    3. Discontinue at end of week 6.

Minimal Tension Repair:

  • Sling may be removed 3‐5 times per day for exercises and while resting
  • Commence gentle passive elevation using the opposite hand to support the limb. Aim for full elevation of the arm by week 4
  • Gentle passive external and internal rotation aiming for 50% of range by week 4 and 100% by week 6
  • NO repetitive pendulum. Perform pendulums for washing your underarm, drying yourself etc
  • NO abduction or extension strengthening exercises
  • Active elbow flexion/ extension strengthening exercises unless biceps surgery is performed

Cuff Repair Under Tension (Patient immobilised in an abduction brace)

  • Brace must NOT be removed at any time in the first 3 weeks
  • Continue with full‐time sling/brace until end of week 6
  • Patient may commence gentle passive elevation of the operated limb above the level of the pillow, aiming for full arm elevation by the end of Week 6
  • May also undertake gentle passive external rotation
  • Active elbow flexion/extension strengthening exercises unless biceps surgery is performed

Phase 2: Protection and active motion (weeks 6-12)

Avoid:

  1. Lifting from the shoulder.
  2. Supporting body weight with hands and arms.
  3. Sudden jerking motions.
  4. Excessive behind the back movements.

Exercises:

  1. Begin AAROM flexion in supine position.
  2. Continue PROM until approximately full.
  3. Gentle scapular/glenohumeral joint mobilisation as indicated to regain full PROM.
  4. Initiate prone rowing to neutral arm position.
  5. Continue ice as needed.
  6. Hydrotherapy OK for light AROM exercises.

Minimal Tension Repair:

  • Patient may remove sling for increasing periods through the day as tolerated, and eventually discard it
  • Continue range of motion program for elevation, external and internal rotation, beginning with gravity eliminated and progressing to work against gravity
  • Gentle abduction exercises only. Full abduction is not important at this stage

Cuff Repair Under Tension:

  • Abduction pillow is gradually removed for increasing periods during the day from about four weeks. Initially done with the patient supine and, when the arm is comfortable at the side, then patient may sit or stand
  • Continue range of motion program for elevation and external rotation
  • When arm is able to be left out of pillow, then begin passive internal rotation
  • At about 8 weeks introduce active assisted movement in elevation and internal/external rotation
  • NO abduction exercises, active or passive

Phase 3: Early strengthening (weeks 10-16)

Avoid:

  1. Sudden lifting or pushing activities, sudden jerking motions, overhead lifting exercises

Exercises

  1. Dynamic stabilisation exercises.
  2. Start strengthening program.
  3. ER and IR with exercise bands.

Minimal Tension Repair:

  • Work towards full active range of elevation, external and internal rotation.
  • Continue terminal stretching and introduce the full cuff stretching programme including posterior and inferior stretches gradually.
  • Begin resistance strengthening.
  • Avoid repetitive overhead use of the arm.
  • Gentle active abduction but no resistance work in this arc.

Cuff Repair Under Tension:

  • Work toward a full range of active elevation, external and internal rotation.
  • Continue terminal stretching and introduce the full cuff stretching programme including posterior and inferior stretches gradually.
  • Begin resistance at strengthening using Theraband. (Yellow, Green, Black).
  • Avoid repetitive overhead use of the arm.
  • Gentle active abduction but no resistance work in this arc.

Phase 4: Advanced strengthening (weeks 16-22)

Exercises:

  1. Continue stretching if motion is tight.
  2. Continue progression of strengthening.
  3. Advance proprioceptive, neuromuscular activities.
  4. Light sports (golf- chipping/putting, tennis ground strokes) if doing well.
Dr.Christopher Pullen Orthopaedic Surgeon Shoulder Elbow Trauma Blackburn South VIC
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