Rotator cuff rehab | Drjeffkimball

Dr. Jeff Kimball, M.D.

POST-OPERATIVE ROTATOR CUFF REPAIR GUIDELINES

Sling for 4-6 weeks (based on tear size) except when showering, dressing, and doing physical therapy

NO ACTIVE shoulder ROM against gravity until 4-6 weeks after surgery (based on tear size)

Start supine passive assisted shoulder elevation to 90 degrees

Pulley exercises for shoulder flexion as tolerated

Biceps tenodesis:

No active elbow flexion for 4 weeks, weeks 4-8 begin biceps isometrics, weeks 8+ begin biceps resistance training

AROM with neutral wrist, no resisted biceps activity for 8 weeks

Phase 1: Recovery (Weeks 0- 3)

NO ACTIVE shoulder ROM against gravity until 4-6 weeks after surgery

PRECAUTIONS

Avoid weight bearing on operative upper extremity
No shoulder active range of motion (AROM)
Avoid pain during ROM exercises
No shoulder external rotation (ER) past 0°
Avoid lying on operative side
Use sling at all times except when bathing, dressing, icing or performing HEP
Use pillows to support operative arm when sitting or sleeping
If combined with biceps tenodesis, no active elbow flexion for 4 weeks, weeks 4-8 begin biceps isometrics, weeks 8+ begin biceps resistance training

SPECIAL CONSIDERATIONS

Biceps tenodesis: AROM with neutral wrist, no resisted biceps activity for 8 weeks
Massive cuff tear: delay protocol by 2 weeks unless otherwise directed by surgeon
Subscapularis repair: no flexion beyond 90° and no ER beyond 30° for 6 weeks, Weeks 0-4: no active shoulder IR, Weeks 6-12: begin active IR, Weeks 12+: begin resisted IR

ASSESSMENT

Quick Disabilities of Arm, Shoulder and Hand (Quick DASH)
American Shoulder and Elbow Surgeons Score (ASES)
Numeric Pain Rating Scale (NPRS)
Mental status
Pain
Wound status
Passive range of motion (PROM)
Static scapular assessment (Kibler grading)
Cervical mobility
Swelling
Post-anesthesia neurovascular screening
Functional status – ADLs and mobility

TREATMENT RECOMMENDATIONS

Transfer training in and out of bed and sit to stand, and stair training while

maintaining non-weight bearing on operative upper extremity

Pain-free distal AROM: note that MD may specify passive vs. active elbow flexion if

biceps tenodesis was performed

Weeks 0-1

Shoulder PROM exercises according to surgeon's preference ( Codman's,

passive ER to neutral, Passive supine elevation using the opposite hand to 90)

Beginning at 2 weeks

Pulley exercises for flexion, as tolerated. Use cane for ER; towel to increase IR.

Scapular strengthening program, in protective range

Deltoid isometrics

nstruct in semi-reclined sleeping position, avoiding lying on operative side
Educate on donning/doffing and proper positioning in sling
ADL training
Cryotherapy and elevation of upper extremity to prevent swelling
Initiate and emphasize importance of HEP to be continued until initiation of outpatient PT or OT to Elbow and wrist AROM

CRITERIA FOR ADVANCEMENT

Safely transfers unassisted
Independent with sling management, or caregiver independent in assisting
Independent with ADLs
Independent with home exercise program (HEP)
Decreasing discomfort at rest

EMPHASIZE

Pain and edema control
Proper sling positioning and compliance
Protection of repair
Independent transfers, ambulation and stair negotiation
Pain-free HEP

Phase 2 Intermediate (Weeks 4-6)

PRECAUTIONS

_ Follow precautions until cleared by MD

_ Sling to be worn at all times except when exercising, icing, dressing and showering

_ Limit shoulder PROM based on pain and MD guidelines, with emphasis on limiting ER to

protect subscapularis repair if present

_ No shoulder AROM until cleared by MD

_ Avoid severe pain with therapeutic exercise and functional activities

_ Avoid weight bearing through operative upper extremity

_ Avoid holding items greater than 1 lb.

_ Avoid prolonged sling use once discharged by surgeon. Sling will be discharged at 3-6 weeks depending on size of tear.

SPECIAL CONSIDERATIONS

_ Biceps tenodesis: AROM with neutral wrist, no resisted biceps activity for 8 weeks

_ Massive cuff tear: delay protocol by 2 weeks unless otherwise directed by surgeon

_ Subscapularis repair: no flexion beyond 90° and no ER beyond 30° for 6 weeks, Weeks 0-4: no active shoulder IR, Weeks 6-12: begin active IR, Weeks 12+: begin resisted IR

ASSESSMENT

_ Quick DASH

_ ASES

_ NPRS

_ Cervical mobility

_ Neurovascular screen

_ Shoulder PROM

_ Static scapular assessment (Kibler grading)

_ Distal AROM (PROM vs. AROM of elbow if

specified by MD due to biceps tenodesis)

TREATMENT RECOMMENDATIONS

_ PROM shoulder elevation in scapular plane

_ AAROM shoulder ER with wand in scapular plane within prescribed limits

_ Scapular mobility and stability exercises progression to manual resistance

o Manual scapular clocks

_ Codman's pendulum exercises

_ Distal AROM exercises (unless PROM specified by MD for elbow)

_ Core strengthening

_ Deltoid isometrics

_ ROM Goals (DO NOT FORCE BUT ASSESS FOR STIFFNESS)

Week 4:

_ Elevation in scapular plane: 90°

_ ER in scapular plane: 5°-15°

_ Internal rotation (IR) in scapular plane: to chest

Week 6:

_ Elevation in scapular plane: 120°

_ ER in scapular plane: 30°-45°

_ IR in scapular plane: to chest

0-6 weeks

_ Abduction 0°-90° (gentle motion)

_ Week 6: Rotator cuff (RC) isometrics

o Submaximal rhythmic stabilization ER/IR with PT

Submaximal ER/IR isometrics

MINIMUM CRITERIA FOR ADVANCEMENT

_ Swelling and pain controlled

_ Passive shoulder ER to 45° in scapular plane (remember none past 30 degrees for 6 weeks if subscapularis repair)

_ Passive shoulder elevation to 120° in scapular plane

_ Tolerance of scapular and RC exercises without discomfort

_ Independent with HEP

EMPHASIZE

_ Control swelling

_ Proper donning/doffing of sling and use per MD instruction

_ Protect surgical repair

_ Importance of patient compliance with HEP and protection during ADLs

Post-Operative Phase 3 (Weeks 7-11)

PRECAUTIONS

_ Avoid pain with ADLs and therapeutic exercise

_ No combined shoulder abduction and ER (pitch motion)

_ No lifting greater than 5 lb.

_ Avoid supporting full body weight on operative upper extremity

SPECIAL CONSIDERATIONS

_ Biceps tenodesis: AROM with neutral wrist, no resisted biceps activity for 8 weeks

_ Massive cuff tear: delay protocol by 2 weeks unless otherwise directed by surgeon

_ Subscapularis repair: no flexion beyond 90° and no ER beyond 30° for 6 weeks, Weeks 0-4: no active shoulder IR, Weeks 6-12: begin active IR, Weeks 12+: begin resisted IR

ASSESSMENT

_ Quick DASH

_ ASES

_ NPRS

_ Cervical mobility

_ Shoulder PROM

_ Static scapular assessment (Kibler grading)

_ Cervical mobility

Grip strength

TREATMENT RECOMMENDATIONS

_ D/C sling if still in use

_ Shoulder ROM exercises

o AA/PROM using wand: forward flexion and ER, abduction, extension

o Initiate AROM in all planes

o Posterior capsule stretch

_ Stabilization exercises

o Humeral head control exercises

o Closed kinetic chain exercises, e.g. ball stabilization begin week 10

o Scapular stabilization

_ Strengthening exercises

o Sub-maximal shoulder isometrics, e.g. flexion, extension, external and internal

rotation

o Multi-planar deltoid strengthening

o General upper extremity strengthening

_ Prone rows, extension

o Core strengthening

_ Cervical AROM and upper trapezius stretching

_ Upper body ergometry if motion allows

_ Reeducation of movement patterns

_ Manual therapy as needed, e.g. scapular mobilization, soft tissue mobilization

_ Functional mobility training

_ Modalities for pain and edema

_ Pool therapy if available

_ Progression of HEP

CRITERIA FOR ADVANCEMENT

_ Pain controlled

_ Shoulder AROM in plane of scapula: elevation to 150°, ER to 45°

_ Independent with HEP

_ Restore forward flexion in scapular plane to full

_ ER in scapular plane to 70°-90°

EMPHASIZE

_ Gradually restore shoulder AROM

_ Restore scapular and rotator cuff muscle balance and endurance

_ Reduce compensatory movements, e.g. overuse of upper trapezius

Post-Operative Phase 4 (Weeks 12-15)

PRECAUTIONS

_ Avoid scapular compensations with AROM

_ No painful activities

SPECIAL CONSIDERATIONS

_ Massive cuff tear- delay protocol by 2 weeks unless otherwise directed by surgeon

ASSESSMENT

_ QuickDASH

_ ASES

_ NPRS

_ Shoulder AROM and PROM

_ Static/dynamic scapular assessment

(Kibler grading)

_ Cervical and thoracic spine mobility

_ Clavicular mobility

_ UE and periscapular strength – MMT

_ Grip strength

TREATMENT RECOMMENDATIONS

_ Progress shoulder ROM and flexibility to WNL

_ Manual therapy to restore shoulder girdle ROM

_ Address flexibility of thoracic spine

_ PNF patterning

_ Progressive resistive exercises for UE, shoulder girdle and core

o Latissimus pull downs, serratus strengthening, side lying ER

_ Initiate banded ER/IR

_ Initiate closed chain upper body exercises with gradual loading (avoid full body weight)

_ Progress humeral head rhythmic stabilization exercises, e.g. closed chain, upright

position, overhead

_ Upper body ergometry and general conditioning

_ Functional training to address patient's goals

_ Progress to more advanced long term HEP

CRITERIA FOR ADVANCEMENT (OR ADVANCEMENT TO PHASE 5 IF RETURNING TO SPORT)

_ Normal/near normal shoulder motion and flexibility over 90º

_ UE and periscapular muscle strength 4+/5 for control with functional movements

_ Fully independent with ADLs with minimal pain

_ Tolerance to all exercises without discomfort

EMPHASIZE

_ Restore normal ROM and flexibility

_ Restore strength

_ Posterior capsule mobility

_ Reduce compensatory patterning

Phase 5 Return to Activity (Weeks 16+)

PRECAUTIONS

_ Avoid high impact, e.g. contact sports

_ Avoid too much too soon- monitor exercise dosing

_ Note that expert opinion varies widely on allowable sports- consult with MD

ASSESSMENT

_ QuickDASH

_ ASES

_ NPRS

_ Shoulder AROM and PROM

_ Static/dynamic scapular assessment

(Kibler grading)

_ Cervical and thoracic spine mobility

_ Clavicular mobility

_ UE and periscapular strength – MMT

_ Grip Strength

TREATMENT RECOMMENDATIONS

_ Progress humeral head control exercises in a variety of overhead positions

_ Progress isotonic exercises to higher loads as indicated

_ Sustained single arm holds with perturbations

_ Closed kinetic chain progression exercises

_ Progress cardiovascular conditioning

_ Sport-specific multidirectional core retraining

_ Dynamic balance activities

_ Neuromuscular shoulder reeducation for control with dynamic sports-specific exercises

_ Progress total body multidirectional motor control exercises to meet sport-specific

demands at 6 months if appropriate

_ Collaboration with trainer, coach or performance specialist

CRITERIA FOR RETURN TO SPORT

_ Independent in long-term sport-specific exercise program

_ Movement patterns, strength, flexibility, motion, power and accuracy to meet demands of

sport symptom free

EMPHASIZE

_ Monitor load progression and volume of exercise

_ Monitor for loss of strength and flexibility

_ Improve muscle strength and flexibility

_ Neuromuscular patterning

_ Collaboration with appropriate Sports Performance expert

Dr. Jeff Kimball, M.D.

​

Phase 1: Recovery (Weeks 0- 3)

PRECAUTIONS

SPECIAL CONSIDERATIONS

ASSESSMENT

TREATMENT RECOMMENDATIONS

CRITERIA FOR ADVANCEMENT

EMPHASIZE

Phase 2 Intermediate (Weeks 4-6)

PRECAUTIONS

SPECIAL CONSIDERATIONS

ASSESSMENT

TREATMENT RECOMMENDATIONS

MINIMUM CRITERIA FOR ADVANCEMENT

EMPHASIZE

Post-Operative Phase 3 (Weeks 7-11)

PRECAUTIONS

SPECIAL CONSIDERATIONS

ASSESSMENT

TREATMENT RECOMMENDATIONS

CRITERIA FOR ADVANCEMENT

EMPHASIZE

Post-Operative Phase 4 (Weeks 12-15)

PRECAUTIONS

SPECIAL CONSIDERATIONS

ASSESSMENT

TREATMENT RECOMMENDATIONS

CRITERIA FOR ADVANCEMENT (OR ADVANCEMENT TO PHASE 5 IF RETURNING TO SPORT)

EMPHASIZE

Phase 5 Return to Activity (Weeks 16+)

PRECAUTIONS

ASSESSMENT

TREATMENT RECOMMENDATIONS

CRITERIA FOR RETURN TO SPORT

EMPHASIZE