Rotator Cuff Surgery Rehab Program

Rotator cuff rehab program will focus on exercises for the next 90 days with the focus on strengthening and increasing ROM of the shoulder.  Let’s take a detailed look.

Q) ASK Ray!: Ray, I am a pitcher who just has arthroscopic rotator cuff surgery.  What can I expect in the following days and weeks?

A) Before going into the details of a postoperative rotator cuff surgery rehab program; I will first describe the makeup of the rotator cuff, rotator cuff surgery, and what you can expect in the following days, weeks, and months after surgery. Then I list the ROM (Range of Motion) exercises, modified strength exercises and a routine for a throwing athlete. Lastly I will list two published training modules for athletes that had arthroscopic rotator cuff surgery. These are examples of possible exercises programs a patient may follow by their doctor’s advice.

The Rotator Cuff and the Shoulder

The rotator cuff is the group of muscles and tendons that stabilize the shoulder joint. The shoulder joint consists of a shallow socket into which the head of the humerus fits. This ball-and-socket configuration is very weak because less than half of the head of the humerus sits inside the socket. The ball-and-socket configuration of the shoulder joint is a multiaxial joint that allows movements such as: flexion, extension, hyperextension, abduction, adduction, medial and lateral rotation, and circumduction. Because the shoulder joint is designed for mobility, it lacks the bony and ligamentous stability.

Muscles of the Shoulder Joint

The four major muscles surrounding the shoulder joint are arranged to provide the stability component. The four rotator cuff muscles are: Supraspinatus, Teres Minor, Infraspinatus, and Subscapularis. The tendons of the rotator cuff group connect the deepest layer of muscle to the humerus. Tendons are the extension of the muscle that attaches muscle to bone. Muscles move the bones by pulling on the tendons. Addition stability comes from the anterior, middle, and posterior deltoids. Further stability is offered by the biceps brachii and the triceps.

Generally, the other muscles surrounding the shoulder joint offer some stabilization, but are primarily used as the main muscles to move the arm. These primary movers of the shoulder joint are: the deltoids, coracobrachialis, pectoralis major, latissimus dorsi, teres major, the short heads of the bicep, and the long head of the triceps.

Ligaments of the Shoulder Joint

Ligaments are the soft tissue that attach bone to bone. There are four major ligaments of the shoulder joint:

1) Glenohumeral ligaments (GHL): These ligaments are the main source of stability in the shoulder joint. They connect the humerus to the glenoid. They hold the shoulder in place and keep it from dislocating.

2) Coraco-acromial ligament (CAL): These ligaments connect the coracoid to the acromion.

3) Coraco-clavicular ligaments (CCL): These ligaments attach the clavicle coracoid process of the scapula. They play an important role in keeping the scapula attached to the clavicle. They carry a massive load and are very strong.

4) Transverse Humeral ligament (THL): This ligament holds the tendon of the long head of biceps brachii muscle.

Rotator Cuff Surgery

If nonsurgical treatment has failed to improve your shoulder strength and movement, the next step is most likely rotator cuff surgery. Basic rotator cuff surgery usually involves the removal of any loose fragments of tendon, bursa, or any other debris from the space where the rotator cuff moves. The surgery will also provide more room for the rotator cuff tendon so it is not pinched. This can include shaving bone down or removing a bone spur. Lastly, the torn edges of the supraspinatus tendon will be sewn together and to the top of the humerus.

The surgery can either be “open-shoulder” or arthroscopic. With open-shoulder surgery the incision can be from 2” to 3’ long where the physician will have a direct view of the shoulder while operating. This procedure usually requires a short stay at the hospital. With arthroscopic surgery, the physician makes a small incision and operates on the shoulder by splitting the deltoid muscle. This method can reduce the problem of creating a deltoid injury.

What to Expect After Rotator Cuff Surgery

After rotator cuff surgery there will be some discomfort and pain. Your arm will be placed in a sling to prevent additional injury. Physical therapy is essential for a successful recovery. Don’t be surprised that as soon as you awake from anesthesia that you may be asked to do exercises such as flexing and extending the elbow, wrist , and hand. The next day your doctor may allow passive exercises that move your arm, and you may be asked to do them up to 3 times per day. Depending how extensive the damage to your rotator cuff, you may be able to start active exercises 6-8 weeks after surgery. A few months after your rotator cuff  surgery, your doctor may prescribe light weight bearing exercises that will progress to heavier weights.

Starting Your Postoperative Rotator Cuff Surgery Rehab Program

Now that you have an idea about the makeup of the shoulder and the rotator cuff; and what to expect after rotator cuff surgery, I will now outline what a typical rotator cuff rehab program my look like for a throwing athlete. The following are only guidelines for informational purposes only. It is suggested that you seek the advice of a professional before starting any rotator cuff rehab program.

Pitchers and Their Rotator Cuff

Due to the function of the muscles that act together to stabilize the rotator cuff, sports that require overhead movement, such as pitching; put the rotator cuff muscles under undue amounts of stress. A rotator cuff tear indicates that there is a deficiency in the tendons that hold the rotator cuff in place. These tears can occur in a single traumatic situation. However, in athletes it is more commonly seen because of the nature of repetitive tear activities where the tendons fail over time. These tears do not heal on their own and over time they will get even bigger. Left unchecked they can become impossible to repair.

The pitcher (or any athlete) with a rotator cuff tear will complain about having pain and stiffness during warm-up exercises. During the acceleration phase of throwing is when a pitcher will experience the most amount of pain. They will often complain about weakness and loss of velocity and/or the ability to control the ball.

Post Rotator Cuff Surgery Rehab Program

You have seen your doctor, came to the conclusion that you have a torn rotator cuff, and have had rotator cuff surgery. Let’s assume it is 3-4 weeks post-op and that you have had about 12 PT sessions and are now ready to start a rotator cuff rehab program. I will focus on listing the exercises for the next 3 months (12 weeks) where the focus will be on gradually strengthening and increasing the ROM of the shoulder. During this phase there will be no weight lifting using the shoulder.

Weeks 1-3

List of exercises/stretches

NOTE: PROM (Passive Range of Motion) Exercises are done for the patient by another person. Active ROM is done when the patient can do them by themselves.

The following exercises should be done twice daily:

- Hand and Wrist: Active ROM exercises without movement of the shoulder.

- Pendulum Exercises: This PROM exercise is done by carefully moving the joint in all directions as far as it can go.

- Elbow Bends: PROM up and down. This is like a standing one-arm bicep curl with no weights.

- Elbow Bends: PROM side to side. Hold arm out with palm face up at shoulder height. Bending at the elbow, the goal is to touch your fingers to your shoulder.

- Sports Massage

- Grip Strength: squeeze putty or ball.

-Lying Wand Exercise: Lying flat on your back, and keeping your elbows straight throughout, start with the wand across your pelvis. Lift the wand slowly until it is over your head. Return the wand to the starting position.

Weeks 3-6

- ROM Exercises: Active

- PROM Exercises: As needed.

- Pendulum Exercises

- Rope Pulley Exercises

- Wand Exercises in all planes

- Elbow Exercises

-Grip Exercises

- Shrugs

- Bicep Curls

- Prone Rowing

Weeks 6-9

- Continue Exercises from weeks 3-6

- Shoulder shrugs with resistance

- Shoulder retraction with resistance

- Possible push-up progression

- Triceps Exercises

Weeks 9-12

- Continue all exercises from weeks 6-9

- Horizontal Internal Rotation Exercise: without weights

- External Rotation Exercise: without weights

- Throwing Drills: (week 12 and after) Start off by throwing a small, light ball underarm against a wall. Start very gently and increase the speed and force (and so distance) you throw with. Start to use a heavier ball such as a netball. Go back to a tennis ball and start overhead throws.

TWO PUBLISHED REHAB PROTCOLS FOR POST ROTATOR CUFF SURGERY

Roator Cuff Rehab Program 1: Rotator Cuff Surgery Repair Protocol

Source: Dr. Walter R. Lowe

This rototor cuff surgury rehab protocol has been developed for the patient following a rotator cuff surgery procedure. This protocol will vary in length and aggressiveness depending on factors such as:

• Size and location of tear

• Degree of shoulder instability/laxity prior to surgery

• Acute versus chronic condition

• Length of time immobilized

• Strength/pain/swelling/range of motion status

• Rehab goals and expectations

Early passive range of motion is highly beneficial to enhance circulation within the joint to promote healing. The protocol is divided into phases. Each phase is adaptable based on the individual and special circumstances. The overall goals of the surgical procedure and rehab are to:

• Control pain, inflammation, and effusion

• Regain normal upper extremity strength and endurance

• Regain normal shoulder range of motion

• Achieve the level of function based on the orthopedic and patient

Goals

The physical therapy should be initiated within the first week and one half to two full weeks post-op. A CPM machine will be used for home range of motion prior to beginning a full therapy program. The supervised rehab program is to be supplemented by a home fitness program where the patient performs the given exercises at home or at a gym facility. Important post-op signs to monitor:

• Swelling of the shoulder and surrounding soft tissue

• Abnormal pain response, hypersensitive-an increase in night pain

• Severe range of motion limitations

• Weakness in the upper extremity musculature

Return to activity requires both time and clinical evaluation. To safely and most efficiently return to normal or high level functional activity, the patient requires adequate strength, flexibility, and endurance. Functional evaluation including strength and range of motion testing is one method of evaluating a patient’s readiness return to activity. Return to intense activities following a rotator cuff surgery repair require both a strenuous strengthening and range of motion program along with a period of time to allow for tissue healing. Symptoms such as pain, swelling, or instability should be closely monitored by the patient.

Phase 1: Week 1-3

Rotator Cuff Surgery Repair

WEEK EXERCISE GOAL

• 1-3 ROM Gradual

· Passive ROM in scapular plane

· Pendulum exercises

· Elbow (flex/ext) range of motion

· Initiate rope/pulley week 3-4 post-op

· Initiate passive ER wand exercise week 3-4

· not to exceed 45° or ER at 45° abduction

STRENGTH

· NO Active Shoulder flexion or abduction allowed in the first 3 weeks

· Grip strengthening with putty or ball

BRACE

· Brace for 3 weeks or as noted by Dr. Lowe

· Brace removed to perform exercises above

MODALITIES

· E-stim as needed

· Ice 15-20 minutes

GOALS OF PHASE:

• Promote healing of repaired rotator cuff

• Control pain and inflammation

• Gradual increase of PROM

• Independent in HEP

• Delay muscle atrophy

Phase 2: Week 3-6

Rotator Cuff Surgery

WEEK EXERCISE GOAL

• 3-6 ROM Gradual

• Continue PROM as needed

• Initiate Grade I-II joint mobilization

• Pendulum exercise

• Elbow (flex/ext) range of motion

• Rope/Pulley (flex/abd/scaption)

• Wand activities in all planes

• Initiate gentle posterior capsule stretching

• Initiate gentle IR stretching

STRENGTH

• Continue grip strengthening as needed

• Initiate submaximal isometrics at week 4

• Initiate supine AROM exercises without resistance

• Initiate UBE without resistance at week 4

• Initiate scapular stabilizer strengthening-active assisted

• Shrugs

• Shoulder retraction

• BRACE D/C wk 3-4

• Discharge brace at week 3-4

MODALITIES

• E-stim as needed

• Ice 15-20 minutes

GOALS OF PHASE:

• Control pain and inflammation

• Initiate light RC muscle contraction

• Gradual increase in ROM

• Initiate light scapular stabilizer contraction

Phase 3: Week 6-12

Rotator Cuff Surgery Repair

WEEK EXERCISE GOAL

• 6-12 ROM Full ROM

• Continue all ROM from previous phases 10-12 wk

• Posterior capsule stretching

• Initiate Grade II-IV joint mobs as needed

• Rope/Pulley (flex, abd, scaption)

• Towel stretching

• Wand activities in all planes

STRENGTH

• Continue with all strengthening from previous

• phases increasing resistance and repetition

• Manual rhythmic stabilization exercises at 90° flex

• Shoulder shrugs with resistance

• Shoulder retraction with resistance

• Supine punches with resistance

• Prone shoulder extension

• Prone rowing

• Prone ER with abduction

• Initiate forward flexion, scaption, empty can

• Sidelying ER

• Initiate D1/D2 patterns supine then standing

• Push-up progression

• UBE for endurance training

• Initiate plyotoss at chest then progress to overhead

• Bicep/Tricep work

• Isokinetic ER/IR at neutral at week 10-12

MODALITIES

• Ice 15-20 minutes

GOALS OF PHASE:

• Minimize pain and swelling

• Reach full ROM

• Improve upper extremity strength and endurance

• Enhance neuromuscular control

• Normalize arthrokinematics

Phase 4: Week 12-24

Rotator Cuff Surgery Repair

WEEK EXERCISE

• 12-24 ROM

• Continue with all ROM activities from previous phases

• Posterior capsule stretching

• Towel stretching

• Grade III-IV joint mobs as needed for full ROM

STRENGTH

• Progress strengthening program with increase in resistance and high speed repetition

• Initiate IR/ER exercises at 90° abduction

• Progress rhythmic stabilization activities to include

o standing PNF patterns with tubing

o Initiate single arm plyotoss

o Initiate military press, bench press, flys, lat pulldowns

o UBE for strength and endurance

o Initiate sport specific drills and functional activities

o Initiate interval throwing program week 16-20

o Initiate light upper body plyometric program week 16-20

o Progress isokinetics to 90° abduction at high speeds

MODALITIES

• Ice 15-20 minutes

GOALS OF PHASE:

• Full painless ROM

• Maximize upper extremity strength and endurance

• Maximize neuromuscular control

Initiate sports specific training/functional training

Rehab Program 2: Rotator Cuff Surgery Repair Protocol

Source: www.taosortho.com

Phase I: Immediate post surgical phase (day 1-10)

Goals: Maintain integrity of the repair

Gradually increase Passive ROM

Diminish pain and inflammation

Prevent muscular inhibition

Post rotator cuff surgery: Day 1-6

• Sling/Abduction brace

• Passive Supine ROM (No Pendulums)

o Flexion to tolerance 0-1400

o ER 0-400 with wand 5 times a day 20 repetitions

• Active Elbow/Wrist/Hand (E/W/H) gripping and ROM exercises

• Scapular depression and Retraction (Sitting)

• Neck/Upper quarter stretching

• Cryotherapy for pain and inflammation (ice 15-20 minutes every hour)

• Sleeping (in sling or brace)

Post rotator cuff surgery: Day 7 – 10

• Continue use of sling

• Progress passive ROM to tolerance

o Flexion to at least 1400 supine

o ER in scapular plane to 35-45 deg.

o IR in scapular plane to 35-45 deg.

• Continue Active E/W/H ROM exercises

• Neuromuscular Re-education (to prevent Shldr/Scap hiking) use mirror

• Continue Submaximal isometrics

o Flexion with bent elbow

o Extension with bent elbow

o Abduction with bent elbow

o ER/IR with arm in scapular plane

• Continue use of ice for pain control (at least 6-7 times daily)

• Sleeping (in brace)

Precautions:

1. No lifting of objects

2. No excessive shoulder extension

3. No excessive stretching of sudden movements

4. No supporting of body weight by hands **w/transfer in/out of chair/bed

5. Keep incision clean and dry

Phase II: Protection phase (day 11- week 6)

Goals: Allow healing of soft tissue

Do not overstress healing tissue

Gradually restore full passive ROM (week 4-5)

Reestablish dynamic shoulder stability

Decrease pain and inflammation

Post rotator cuff surgery: Day 11 – 14

• Continue use of sling

• Passive ROM to tolerance supine

o Flexion 0 – 170 deg.

o ER at least 45 deg. to normal for opposite side.

o IR in 45 deg. abduction to 45 deg.

• Dynamic stabilization drills; i.e., rhythmic Humeral head stabilization drills

o ER/IR in scapular plane

o Flexion/extension at 90 deg. flexion

• Continue all isometric contractions

• Overhead pulleys (Passive motion only)

• Continue use of cryotherapy as needed

• Continue all precautions

Post rotator cuff surgery: Week 3 – 4

• Patient should exhibit full passive ROM

• Continue scapular stabilization Ex and initiate scap. strengthening

o resistive retraction, rows (caution: Not if pt. had biceps tenodesis)

• Initiate Active ER supine in scapular plane using wand to stretch at terminal range

• Initiate isotonic elbow flexion

• Self capsular stretches

• Continue use of ice as needed

• May use heat prior to ROM exercises

• May use pool for light ROM exercises (passive only no resistive Ex)

• Continue sling

Post rotator cuff surgery: Week 5 – 6

• Discontinue use of sling and may use heat prior to exercise

• AAROM and stretching exercises

• AA Flex with Active Ext to neutral and AA Abduction with Active Adduction

• Initiate AROM exercises

o Shoulder flexion scapular plane

o shoulder abduction

• Active exercise program

o ER side-lying

o Side-lying IR

o Prone Rowing

o Prone horizontal abduction

o Biceps curls

o Start UBE (upper body ergometer) below 90 deg. elevation

Precautions:

1. No heavy lifting of objects

2. No excessive behind-the-back movements

3. No supporting of body weight by hands and arms

4. No sudden jerking motions

 

Phase III: Intermediate phase (week 7-14)

Goals: Full active ROM (week 8 – 10)

Dynamic shoulder stability

Gradual restoration of shoulder strength and power

Gradual return of functional activities

Post rotator cuff surgery: Week 7

• Continue stretching and ROM (as needed to maintain full ROM)

• Continue dynamic stabilization drills

• Initiate isotonic strengthening program pain-free

o ER/IR supine

o Prone rowing

o Prone horizontal abduction

o Prone extension

o Elbow flexion

o Elbow extension

Post rotator cuff surgery: Week 8 – 13

• Continue all exercise listed above

• ER side-lying

• Lateral raises*

• Full can in scapular plane*

• If physician permits, may initiate light functional activities

* Patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonics; if unable, continue humeral head/scapular stabilization Ex.

Post rotator cuff surgery: Week 14

· Continue all exercise listed above

· Progress to fundamental shoulder exercises

Phase IV: Advanced strengthening phase (week 15-22)

Goals: Maintain full non-painful ROM

Enhance functional use of UE

Improve muscular strength and power

Gradual return to functional activities

Post rotator cuff surgery: Week 15

· Continue ROM and stretching to maintain full ROM

· Continue shoulder strengthening to fundamental shoulder exercises

· Initiate interval golf program (if appropriate)

· May initiate shoulder plyometrics

Post rotator cuff surgery: Week 20

· Continue all exercises listed above

· Progress golf program to playing golf (if appropriate)

· Initiate interval tennis program