Rehabilitation Following Rotator Cuff Repair

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Rehabilitation Following Rotator Cuff Repair

• Kolleen Shields MS, P.T.
• 2006 Hawkeye Sports Medicine Symposium

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Terminology

• Partial Rotator Cuff Tears
• Full Rotator Cuff Tears
• Small (lt 2 cm)
• Medium (2-5 cm)
• Large (gt 5 cm)
• Massive (involves 2 or more tendons)

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Open Repairs vs. Arthroscopic

• Larger incision
• Deltoid detachment
• More post-op pain
• Inpatient stay for pain control

• Smaller incision
• Less post-op pain
• Outpatient procedure
• Pain is not a good guide for rehab

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Information essential in designing a
rehabilitation program

• Nature of injury (type of tear)
• Extent of surgical repair
• Restrictions set by physician
• Restrictions as understood by client
• Concurrent medical conditions
• Pre-op level of function and mobility

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Immediate post-operative goals (0-2 weeks)

• Control pain/swelling
• Cryotherapy
• (Speer et al. J Shoulder Elbow Surg. 1996)
• Medications as prescribed
• Use of sling to limit shoulder movement
• Sleep position

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Immediate post-operative goals (0-2 weeks)

• Early protective passive motion
• Pendulums
• Passive elevation (90-120 degrees)
• Table slides
• Pulleys
• Passive external rotation (0-20 degrees)
• Elbow, wrist, hand active motion
• Isometric grip strengthening
• Periscapular isometrics

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Early ROM Exercises
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Table Slides
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Immediate post-operative precautions

• Avoid extension movements beyond plane of body (4
  weeks)
• Avoid any active lifting of the arm
  (elevation/abduction 6 weeks)
• Avoid active external rotation (4-6 weeks)

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Posture

• Coracoacromial ligament and attachment to
  acromion form a roof under which the
  supraspinatus tendon, the biceps tendon and
  subacromial bursa must pass during elevation or
  abduction of the arm.
• At approx. 70-120 deg of active glenohumeral
  elevation, the greater tuberosity approaches the
  roof
• Rounded shoulder posture narrows potential space
  of the roof, thus making it more likely that
  impingement may occur with elevation of the arm

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Postural sets
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Progressive Rehabilitation (2-4 weeks)

• Continue pendulums and table slides
• Passive elevation (120-135 deg)
• Passive external rotation (20-35 deg)
• Initiate pulleys
• Tendon tissue healing requires the load across
  the tendon to be minimal for the first 4 weeks

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Advanced passive motion
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Progressive Rehabilitation (4-6 weeks)

• Continue passive motion exercises
  (elevation135-150 deg, external rotation30-45
  deg)
• Add bilateral extension motion with cane
• Add internal rotation for posterior capsule
  stretch

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Progressive Rehabilitation (6-8 weeks) A.A.R.O.M

• Gradually introduce controlled stretches across
  the healing tendon during the maturation process.
  Tissues need to see progressively increasing
  loads.
• A.A.R.O.M for elevation progression of wall
  walking, assisted supine cane exercises, supine
  bilateral arm raise

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Assisted wall walking
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Progressive Rehabilitation (6-8 weeks) A.A.R.O.M

• A.A.R.O.M for internal rotation cane behind
  back, towel stretch, clasp hands behind back
• A.A.R.O.M diagonal supine with cane
• A.A.R.O.M extension standing
• A.A.R.O.M for external rotation (35-55 deg)
• Continued wall walking
• Low level isometrics

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Progressive Rehabilitation (8-12 weeks)

• Continue with range of motion exercises working
  towards full functional mobility (mobilization?)
• Should be able to raise arm above head
• Add light resistance (cream/yellow) therabands
• Bilateral extension
• Bilateral forward flexion (30 deg)
• Bilateral external rotation
• Triceps
• Scapular retraction
• Unilateral internal rotation
• Abduction/Adduction

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Progressive Active Elevation
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Isometrics
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Active Assistive Range of Motion
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Progressive Theraband
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Progressive Rehabilitation (8-12 weeks)

• Side lying external rotation (light weights)
  progressing from arm at side to arm away from
  side
• Periscapular prone strengthening with weights
• Tricep strengthening
• Bicep curls

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Periscapular Strengthening
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Side Lying External Rotation
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Triceps/Biceps Strengthening
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Advanced Strengthening (12 weeks-6 months)

• Progression of theraband exercises
• Add closed chain exercises
• PREs for external rotation, elevation, abduction

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Cuff Strengthening in Abduction
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Progression of Active Exercises
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Progression of Stabilization Exercises
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Highest Level Strengthening May Include

• Full range strengthening activities
• Body blade
• Therapeutic ball activities
• Plyometric activities
• Return to sport drills

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Full Range Strengthening
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Therapuetic Ball Exercises
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Body Blade
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Plyometrics
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Rehabilitation Following Rotator Cuff Tears
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Initial Goals

• Control pain (cryotheraphy, medication, sling)
• Begin gentle, passive/active assistive range of
  motion exercises
• Sleep position
• Rest arm

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Goals of Therapeutic Exercise

• Improve strength of surrounding musculature in
  order to regain functional use of the arm
• Proceed slowly and use pain as a guide.
• Partial RCT can progress to full thickness tears.
  

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Return to function