Physical Therapy after Rotator cuff Repair

[mtomaino]

Physical therapy after arthroscopic repair of a torn rotator cuff continues to be an area of interest and research. Fundamental principles continue to prevail including the need to have tendon healing prior to exposing the tendon-bone interface to loads that might jeopardize the integrity of the repair. Preoperatively, it is very helpful to be instructed in a "Scapulothoracic program" as proper scapular mechanics effectively improves subacromial space and supraspinatus force.

In that light, a typical regimen after an arthroscopic repair of a small or medium tear might look like this:

0-6 weeks: full time use of sling; passive range of motion only.
6-12 weeks: sling is discontinued; passive motion continues; active motion begins.
At 3 months: isometric exercises begin, with progression to pre's(progressive resistnce exercises).


However, concern about retear rates has led some to utilize a more conservative approach that holds off on any motion until after 6 weeks. The rationale is that it is better to have a healed tendon, and deal with a little stiffness, than to have great "early" motion, but a failed repair. In general, observations that motion typically returns by 1 year postop have led to a more conservative approach for large and massive tears.

In a large study published in Arthroscopy (2009, Aug:25(8)p880-890, Dr Burkhart reported a 4.9% incidence of stiffness after 489 consecutive rotator cuff repairs. He has advocated a more conservative postoperative PT approach except in patients at higher risk for stiffness.

He identified risk factors for the development of postoperative stiffness: calcific tendonitis, adhesive capsulitis, PASTA lesion (partial tear), single tendon repair, concomitant labral repair, age less than 50 years, and claims that involved worker's compensation.

His Conservative and Accelerated Protocols were recently published (Clin Sports Med 29; 2010: 203-211).

The "Conservative" regimen is:
1.weeks 0-6: arom hand, wrist, elbow; passive ER with arm at side; NO PROM or AAROM.
2.weeks 7-16: D/C sling; tabletop slides/pulley; NO AAROM
3.at 4 months: AAROM with elevation; IR stretching; resistance (arm at side); Scapular program
4.at 6 months: Gym/Sports

The "Accelerated" regimen is:

1.weeks 0-6: arom hand, wrist, elbow; passive ER with arm at side; table top slides (NO AAROM)
2.weeks 7-12: d/c sling; AAROM with elevation (pulleys)
3.at 3 months: IR stretching; Resistance (arm at side); scapula program
4.At 6 months; Gym/sports
Further supporting a more conservative approach are the results of a recent study by Parsons et al (2010) which showed a 56% re-tear rate at 12 months on MRI, BUT---70% of the repairs were in tact in the "stiff group" compared to 36% in the "non stiff group".

When I plan your postoperative therapy, I will take into consideration these studies as well as other variables such as tear size and chronicity, fixation method, quality of the tissue, risk factors for stiffness, your health status and functional goals.