ROTATOR CUFF REPAIR

DAVID LINTNER, MD

Melanie McNeal, PT, CSCS, CFT

The rotator cuff is the key to elevation of the upper extremity. It functions to center the humeral head in the glenoid by providing a compressive force with active movement.

Rotator cuff tears are most prevalent in the over 40 population. The repair progression is dependent on a number of factors including the patient’s age, tissue quality, size of the tear, acute vs chronic condition, strength and ROM status pre-op, ATS vs open repair procedure, and performance/activity demands. If the patient is healthy and active, a more aggressive rehab approach can be taken. On the other hand, if the patient is sedentary, disuse of the RC decreases tendon fiber strength. Because of the poor tissue status, regardless of the size of the tear and subsequent repair, a more conservative approach must be taken. An open repair is more painful for the patient and has higher chance of infection and morbidity but it is also more stable; therefore, rehab can be advanced more aggressively than if the repair was done arthroscopically.

The key following RCR is communication with the physician. It is imperative that the therapist knows the size and extent of the tear, what was done in surgery, as well as any concerns or precautions the physician may voice regarding the patient.

Rehab following RC repair must focus not only on regaining N ROM but also on regaining neuromuscular control and strength of the RC. It is imperative that coordinated firing of the RC occur and this timing of recruitment must be re-trained post-operatively. Rhythmic stabilization exercises are mandatory to achieve this goal. In regards to AROM, ER/IR strength must be regained below shoulder level before one should be expected to perform OH activities without discomfort.

Early ROM is critical for patients post-operatively to increase circulation and promote healing of soft tissues. A CPM machine will sometimes be used at home for this purpose with the shoulder in a position of neutral rotation and elevation in the scapular plane.

Initially, the therapist must closely monitor for any signs of infection. These include significant swelling in the shoulder and surrounding areas with accompanying erythema, hypersensitivity at the joint, pain at rest, and severe limitations in ROM and/or strength.

PROTOCOL

PHASE ONE (Week 1-3)

In phase one, the general goals are to protect the surgical repair, initiate ROM to prevent adhesions and increase circulation, decrease pain and inflammation, and stress emphasis of HEP.

A sling will be worn for 4 to 6 weeks unless instructed otherwise by Dr. Lintner.

The sling is to be taken off only to perform exercises.

The RC gets a better blood supply when the shoulder is slightly away from the body; therefore, advocate the use of a towel roll under the arm when in a resting position.

ROM limitations:

Passive and Passive ROM ONLY:

Flexion/scaption Progress as tolerated (slow with a massive repair)

ER in scapular plane Not to exceed 45°

IR in scapular plane as tolerated

Active wrist and elbow full ROM

EXERCISES:

ROM: Pendulums (passive, side-side)

passive abduction ( < 60° )

passive scaption ( < 60 ° )

Passive ER at side to tolerance; ER at45° abduction at 3-4 weeks

post-op

At 3-4 weeks: Initiate rope and pulley – scaption

Grade I-II g-h and scapular joint mobs and manual stretching

Strength: Hand gripping exercises - putty

NO active shoulder flexion or abduction in first 6 weeks

Submax pain-free shoulder isometrics at 0° abduction at 2-3 weeks

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE TWO (Week 3-6)

General goals in Phase Two are to gradually restore ROM, initiate active muscle contractions with a focus on regaining proper scapulo-humeral rhythm, begin to train joint proprioception, and continue with HEP.

ROM Limitations/goal:

Flexion/scapular plane: continue to increase gradually to max 90°

ER in scapular plane: progress gradually as tolerated

IR in scapular plane: continue to progress without restrictions

EXERCISES:

ROM: Continue with AAROM exercises from Phase One – pulley, add cane/wand

Posterior capsule stretch

G-H joint mobilizations emphasizing post and inf glides.

Manual stretching should be performed following mobilizations.

Strength: Initiate supine AROM with no resistance; progress to partial

sitting, sidelying, and standing

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE THREE (Week 6-12)

The goals in this phase are to restore full active ROM, progress strengthening and scapular stabilization exercises, and initiate more functional drills into rehab program.

IR with T-band (towel roll between upper arm and thorax)

Side-step holding t-band at neutral IR for isometric resistance

DB therex – flexion, scaption, empty can, deceleration

Biceps, Triceps with theraband

Rhythmic stab progressing from supine to sidelying to partial sitting to standing as tolerated

Scapular strengthening therex including T-band seated rows, shrugs, punches

PNF patterns with manual resistance

PHASE FOUR (Week 10-14)

The RC muscles are very small; therefore, we use lower intensities to isolate each muscle without recruitment from surrounding larger muscles. Focus on hypertrophy initially by high volume (V= Reps X intensity/weight). Following the hypertrophy phase, strength is the focus with lower reps and higher intensities/weight.

PHASE 4

ROM goals:

Full ROM all planes by 10-12 weeks

EXERCISES:

ROM: Continue with previous exercises to gain full ROM

May need to add chicken wing stretch for ER

Mobilizations may be more aggressive if needed

Strength: Continue with previous T-band and C. column exercises,

increasing intensity, sets, and reps as able

Continue with db therex, increasing sets and reps, intensity up

to 7 lbs max

Initiate push-up progression: wall, table/counter, knees, regular

Initiate T-band ER at 90/90 position – slow and fast reps

Initiate prone db therex including scaption at 130° with thumb up, horiz abduction with thumb up, extension with palm down, ER

Week 8:

Initiate two-handed plyometrics including ball toss –chest pass, OH pass, diagonals

Week 10:

Biodex – isokinetics for IR/ER beginning in modified neutral position, progress to 90/90 position in scapular plane

Modalities: Ice as needed

PHASE FOUR (Week 12-24)

Goals include regaining full functional strength, implementing functional or sports specific training, and establishing a progressive gym program for continued strengthening and endurance training.

*Continue as needed with ROM exercises

*UBE high resistance, for endurance

* Progress to one-handed plyos including ball toss, ball on wall

*Eccentric RC strengthening using plyoball, deceleration tosses, T-band

*Large muscle exercises including shoulder press, lat pull-downs, bench press – do not allow elbow to extend past plane of thorax

*For high school athletes: at 12 weeks, passive ER should be 100-105°; allow the athlete to gain the rest on his own.

*For college/pro athletes: at 12 weeks, active ER should be 100-105° and passive ER should be 110-115° - allow the rest to come on its own

*Initiate interval throwing program at wk 16 – consult with physician first

*Initiate sports specific/functional training

*At week 12, do a biodex test at 180°/sec and 300°/sec. – goal is for strength to be at 80% of unaffected side

*Expected Biodex results: ER/IR ratio at 180°/sec: male–66; female- 71

Peak T/BW range for ER at 180°/sec: male11-15; female 8-12

Peak T/BW range for IR at 180°/sec: male 17-23; female 13-17

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