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ROTATOR CUFF REPAIR

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Rotator cuff complex refers to the tendons of four muscles : Subscapularis, Supraspinatus, Infraspinatus and Teres minor.[1]

These four muscles originate on the scapula, cross the glenohumeral joint, then transition into tendons that insert onto the tuberosities of the proximal humerus.

Rotator cuff tears can be classified as either acute or chronic, based on their timing and as partial thickness and full thickness tears based on the depth of the tendon tear.[1]

Indications for surgery[2] – 

  1. Tears resulting from repetitive microtrauma and chronic impingement, which leads to irreversible degenerative changes in soft tissues. 

  2. Patients with severe lesions who continue to be symptomatic and have functional limitations after a trial of non-operative treatment.

  3. Acute, traumatic rupture of the rotator cuff tendons often combined with avulsion of the greater tuberosity 

  4. Labral damage 

  5. Acute dislocation of glenohumeral joint in individuals with  no history of cuff injury. 

 

[Surgical repair is not indicated in patients who are asymptomatic despite the presence of a cuff tear confirmed by imaging]

 

IMPAIRMENTS

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BODY STRUCTURES

  1. Break in continuity of skin due to incision

  2. Rotator cuff tear

  3. Splitting of deltoid muscle to reach the site

  4. Subacromial decompression

  5. Rotator cuff was resutured due to tear

  6. Muscular atrophy in the supraspinatus and infraspinatus fossa

  7. Fatty or fibrous infiltration of the rotator cuff muscles

 

BODY FUNCTIONS

  1. Pain in shoulder region

  2. Swelling

  3. Tenderness

  4. Reduced muscle strength

  5. Reduced range of motion

  6. Muscle weakness

  7. Affected activities of daily living 

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GOALS

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  • Short term 

  1. Patient and family education

  2. Ergonomic advice

  3. Reduce pain

  4. Reduce swelling

  5. Improve range of motion

  6. Improve shoulder strength

  7. Improve shoulder power and endurance

  8. Improve neuromuscular control and shoulder proprioception

  9. Achieve functional activities

  10. Prevent secondary complications

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  • Long term

  1. Maintain range of motion

  2. Maintain muscle strength

  3. Maintain upper extremity function

  4. Establish a home exercise maintenance program

 

MANAGEMENT​

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Phase 1: Weeks 0-6 

 

Restrictions –

  • No active ROM exercises

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  • Active ROM exercises initiation based on size of tear 

    • Small tears (0-1cm) – no active ROM before 4 wk.

    • Medium tears (1-3 cm)  - no active ROM before 6 wk

    • Large tears (3-5 cm) – no active ROM before 8 wk

    • Massive tears (>5 cm ROM) – no active ROM before 12 wk

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  • Delay active assisted ROM exercises for similar time periods based on size of tear.

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  • Passive ROM only 

    • 140° of forward flexion.

    • 40° of external rotation.

    • 60° - 80° of abduction without rotation.

  • No strengthening/resisted motions of the shoulder until 12wk after surgery

  • For tears with high healing potential, isometric strengthening progressing to theraband exercises may begin at 8 wk. Strengthening exercises before 12 wk should be performed with the arm at less than 45 degrees of abduction.

                        

Immobilization 

  • Type of immobilization depends on  amount of abduction required to repair rotator cuff tendons with little or no tension.

    • Use of sling- if tension of repair is minimal or none with arm at the side

      • Small tears- 1 – 3 wk 

      • Medium tears - 3-6 wk

      • Large and massive tears – 8 wk

 

  • Abduction orthosis – If tension of repair is minimal or none with the arm in 20-40 degrees of abduction.  

                       Pain Control- 

 

  • Patients treated with arthroscopic rotator cuff repair experience less post operative pain than patients treated with mini open or open repairs.

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Therapeutic modalities 

  • Ice 

  • Ultrasound

  • High voltage galvanic stimulator

  • Moist Heat before therapy

  • Ice at end of session

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Shoulder motion

  • Passive only 

    • 140° of forward flection

    • 40° of external rotation

    • 60° - 80° of abduction

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  • For patients immobilized in abduction pillow, avoid adduction(i.e. Bringing arm towards midline)

  • Exercises should begin above the level of abduction in the abduction pillow.

    • Begin pendulum exercises to promote early motion

    • Passive ROM exercises only.

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Elbow motion

  • Passive – Progress to active motion

    • 0° to 130°

  • Pronation and supination as tolerated

 

Muscle strengthening

  • Grip strengthening only in this phase

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Phase 2: Weeks 6-12

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Criteria for progression to Phase 2-

  • At least 6 wk of recovery has elapsed.

  • Painless passive ROM to 

  • 140 °of forward flexion

  • 40 ° of external rotation

  • 60-80 °of abduction

 

Restrictions

  • No strengthening/resisted motions of shoulder until 12 wk after surgery.

  • During phase 2, no active ROM exercises for patients with massive tears.

 

Immobilization

  • Discontinuation of sling or abduction orthosis.

  • Uss for comfort only.

 

Pain control

  • Modalities

    • Ice 

    • Ultrasound 

    • HVGS 

    • Moist heat before therapy

    • Ice at end of session

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Shoulder Motion

Goals –

  • 140° of forward flexion- progress to 160°

  • 40° of external rotation-progress to 60°

  • 60-80° of abduction- progress to 90°

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Exercises-

  • Continue with passive ROM exercises 

  • Begin active assisted ROM exercises

  • Progress to active ROM exercises as tolerated after full motion achieved with active assisted exercises.

  • Light passive stretching at end of ROMs

 

Muscle Strengthening

  • Begin RC and scapular stabilizer strengthening for small tears with excellent healing potential

  • Continue with grip strengthening 

 

Phase 3: Months 4-6

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Criteria for progression to phase 3-

  • Painless active ROM

  • No shoulder pain or tenderness

 

Goals-

  • Improve shoulder strength, power, endurance

  • Improve neuromuscular control and shoulder proprioception

  • Prepare for gradual return to functional activity

  • Establish a home exercise maintenance program that is performed 3 times per wk for strengthening   

  • Stretching exercises should be performed daily

 

Motion

  • Achieve motion equal to contralateral side

  • Use passive, active-assisted, active ROM exercises

  • Passive capsular stretching at end ROMs, especially cross-body (horizontal) adduction and internal rotation to stretch the posterior capsule.

 

Muscle Strengthening

  • Strengthening of rotator cuff

  • Begin with closed chain isometric strengthening

    • Internal rotation

    • External rotation

    • Abduction

    • Forward flexion

    • Extension

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  • Progress to open chain strengthening with therabands

    • Exercises with 90° elbow flexion

    • Exercises through an arc of 45° in each five planes

    • Progression to next color band occurs usually in 2-3 wks. Do not progress if there is any discomfort at present level

    • Theraband exercises permit concentric and eccentric strengthening of shoulder muscles and are a form of isotonic exercises 

  • Progress to light isotonic dumbbell exercises

    • Strengthening of deltoid (especially ant)

    • Strengthening of scapular stabilizers 

 

Closed chain strengthening

  • Scapular Retractions (rhomboids, middle trapezius)

  • Scapular Protractions (serratus ant)

  • Scapular Depression (latissimus dorsi, trapezius, serratus ant)

  • Shoulder shrugs (trapezius, levator scapulae)

 

Progress to open chain strengthening

Goals- 

  • 3 times per wk

  • Begin with 10 reps for 1 set, advance to 8-12 reps for 3 sets

  • Functional strengthening (plyometric exercises)

  • Progressive systemic interval program for returning to sports

 

Warning signs

  • Loss of motion (esp internal rotation)

  • Lack of strength progression (esp abduction)

  • Continued pain (esp at night)

 

Treatment

  • These patients may need to move back to earlier routines

  • May require increased utilization of pain control modalities 

  • May require repeat surgical intervention

 

Indications for repeat surgical intervention

  • Inability to establish more than 90° forward elevation by 3 months

  • Steady progress interrupted by a traumatic event and/or painful pop during the healing phase with a lasting loss of previously gained active motion.

  • Radiographic evidence of loosened intra-articular implants after an injury in the postoperative rehab period.  \

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REFERENCES 

S.Brent Brotzman, Kevin E. Wilk, Clinical Orthopedic Rehabilitation, 2nd Edition, Page no -168-179

Carolyn Kisner, Lynn Allen Colby, Therapeutic Exercises Foundation and Techniques, 5th Edition, Page no- 512

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