Shoulder rotator cuff tear, post op from arthroscopic rotator cuff repair

You have just undergone an arthroscopic (key-hole) rotator cuff tendon repair in your shoulder with Kemble. This means you had a tear of the tendon(s) of the rotator cuff. The following is a schematic diagram of such a repair (may not be exactly the same repair pattern as yours).

Postoperatively your arm will be in a sling. You can start coming out of the sling under supervision of  the physiotherapist and for prescribed exercises. However, you should remain in the sling for the majority of the time for the first 6 weeks. 

Dressing: your shoulder will have several arthroscopic key-hole portal wounds. this will have sutures holding it closed. on top of that there will be a water-proof dressing. On top of that again there will be some bulky temporary padding held with tape to decrease swelling for the first day or so. This bulky temporary padding should be removed before you are discharged from hospital. 

It is normal to have some tingling or numbness or weakness following your procedure. This is often due to a nerve block performed preoperatively to help with your pain. This will wear off in the first day or two.

The following is your physiotherapy prescription:

Weeks 0-6: Phase 1 PROM phase

 

  • Passive and active assisted ROM as tolerated; Scapular and trapezius strengthening/Scapular positioning and stability exercises

 

Weeks 7-12: Phase 2 AROM phase

 

  • Active motion, gentle strengthening

Weeks 12+: Phase 3 Strengthening phase

 

  • Full strengthening

Further details:

Phase I

(Post op week # 1 to approximately Post op week # 6)

 

General Information / Goals:

 

  • This is the “Healing phase”. The strength of the repair is initially only the strength of the sutures and anchors attaching it to the bone.

  • At 4 weeks post op the strength of the tendon repair is about 20% of a “normal” tendon attachment. Hence, prior to 6 weeks post op no active motion of the arm is permitted, as it may pull on the repair and disrupt the attachment of the tendon to the bone.

  • The goal of this phase of recovery is to protect the tendon repair while gently gaining motion and preventing formation of adhesions (scar tissue) which might limit motion.

  • Another goal during this phase is to reduce inflammation and pain.

  • The sling/abduction pillow keeps the arm in a position that takes tension off the repaired tendon.

 

Activities to Avoid:

 

  • No active range of motion (AROM) of your shoulder, even if you have minimal to no pain or other symptoms.

 

First 3 weeks of therapy

 

  • Patient education: posture, joint protection, positioning, and hygiene

  • Pendulum hangs, no active movement of shoulder

  • Elbow, wrist, and hand active range of motion (AROM), no weights

    • Only PROM of elbow if concomitant biceps tenodesis/tenotomy performed.

  • Passive forward elevation (PFE) in the plane of scapula to 90 -100 degrees

  • Passive external rotation (PER) with elbow ‘near’ the side of the body to 30 degrees. May be adjusted base on location of the tear and intraoperatively determined ‘safe zone’ of ER.

  • Begin active and manual scapula strengthening exercises

 

Weeks 3 and 4 of therapy

 

  • Progress Pendulum Hangs to Pendulum mobility, discomfort to be the guide

  • Progress scapula strengthening

  • Progress PFE and PER to tolerance

  • May begin joint mobilizations grade I & II for pain relief / relaxation as indicated for all shoulder girdle joints (GH, SC, AC, ST)

  • May allow aquatic therapy for active assisted range of motion (AAROM), if incisions well healed, no swimming strokes.

Phase II

(Approximately postop week 6 to post op week 12)

 

General Information / Goals:

 

  • You still need to allow for healing. After 4 weeks postop the tendon repair is greater than 20% of a normal shoulder which is sufficient to allow you to do assisted and active motion. This is the “active range of motion” period. We want you to normalize your motion and activities of daily living during this period.

  • After 8 weeks the tendon will be about 40% as strong as a normal tendon.

  • After 12 weeks the tendon is 60% as strong as a normal tendon.

 

Activities to Avoid:

 

  • No lifting or activities that require ROM beyond what you can do comfortably

  • No supporting of body weight by hands and arms

  • No excessive behind the back movements

  • No sudden jerking motions

 

Things you should achieve before you progress to Phase III:

 

  • Adequate ROM in all planes without pain or substitution patterns, as determined by your MD and PT. Typically greater than 140 degrees of passive forward elevation, greater than 115 degrees of active forward elevation, normal external rotation at 0 degrees of abduction.

  • Appropriate shoulder blade positioning at rest and with shoulder activity.

 

 

Additional therapist instructions, Phase II:

Week 6 thru 12 of therapy:

 

  • P/AA/AROM as needed to normalize ROM.

  • Establish basic rotator cuff and scapula neuromuscular control within available ROM.

  • Introduction of light waist level functional activities

 

ROM:

 

  • Progress joint mobilizations to grades III & IV to address capsular restrictions as indicated for all shoulder girdle joints (GH, SC, AC, ST)

  • Begin PROM in other planes (be careful to minimize direct passive tension on the repair)

  • Progress AAROM program to AROM with emphasis on good shoulder mechanics

  • Begin musculature activation exercises, which activate the shoulder girdle musculature without creating significant muscular force. (i.e. supported AROM activities, then unsupported AROM activities, then on to light resistance, including resistance to the scapula musculature)

  • Scapular/glenohumeral joint mobilization as indicated to regain full passive ROM

  • Initiate posterior capsule stretching cross body adduction stretching as indicated

  • Address scapulothoracic and trunk mobility limitations. Ensure normal cervical spine ROM and thoracic spine extension to facilitate full upper extremity ROM.

  • When appropriate (i.e. good AROM mechanics and pain free) initiate base strengthening program for deltoid, non repaired segments of rotator cuff, and scapula musculature

  • Light resistive band exercises in pain free range of motion

  • Scapula strengthening program

  • Begin low level closed chain program

Phase III

(Approximately postop week 12 to 18)

 

Activities to Avoid:

 

  • No lifting or activities that require ROM beyond what you can do comfortably

  • No supporting of body weight by hands and arms

  • No excessive behind the back movements

  • No sudden jerking motions

 

Things you should achieve before you progress to Phase III:

  • Adequate ROM in all planes without pain or substitution patterns, as determined by your MD and PT. Typically greater than 140 degrees of passive forward elevation, greater than 115 degrees of active forward elevation, normal external rotation at 0 degrees of abduction.

  • Appropriate shoulder blade positioning at rest and with shoulder activity.

 

Additional therapist instructions, Phase III:

  • Counsel in importance of gradually increasing stress to the shoulder while returning to normal ADL’s, work, and recreational activities including lifting, repetitive and overhead activities

  • Strength/ Endurance/ Power:

    • Initiate balanced rotator cuff strengthening program

    • Initially performed in a position of comfort with low stress to the surgical repair in the plane of the scapula (band or light weights)

    • Exercises should be progressive in terms of muscle demand / intensity

    • Exercises should also be progressive in terms of shoulder elevation

    • Nearly full elevation in the scapula plane should be achieved before elevation in other planes

    • Rehabilitation activities should be pain free and performed without substitutions or altered movement patterns

    • Program should focus on high repetitions (30-50 reps) and relatively low resistance (1-3 lbs.)

    • Progressive resisted exercises are needed to match/equal functional demands

    • Progress to advanced strengthening program (ASP) PRN

      • Not all patients need to progress to an ASP

      • Criteria to begin advanced strengthening

        • MMT at least 4/5

        • Painfree with basic ADLs and initial strengthening program

        • Full AROM elevation

        • Goal of returning to sports, heavy labor, or repetitive overhead activity

      • Use to following principles to develop exercises to gradually progress patient from current level of functioning to desired goals

        • Decrease amount of external stabilization provided to shoulder girdle

        • Integrate functional patterns

        • Increase speed of movements

        • Integrate kinesthetic awareness drills into strengthening activities

        • Decrease in rest time to improve endurance o

      • Sample Exercises

        • T-band standing PNF patterns

        • T-band 90/90 ER/ IR w/ or w/out arm support

        • T-band batting, golf, or tennis forehand / backhand simulation

      • Repetitions and increase weight over the course of 6-8 weeks

©2020 Kemble Wang Orthopaedics

 

Disclaimer: All information provided on this webpage should be considered as general guidelines. Actual practice and (expected) outcomes may differ in your case. The contents has been created online for information purposes only. It is not intended to be a substitute for professional medical advice.