Rotator Cuff Repair: An Outpatient Physical Therapy Program Using

Therapeutic Exercise
Brian OMara, SPTA

Introduction
Its estimated that 4.5 million Americans come to their doctor with shoulder
pain every year (1). Rotator cuff tears specifically are considered the third
most common musculoskeletal complaint, behind back and neck pain (2).
These injuries are categorized as either full-thickness or partial-thickness
tears and generally evolve because of chronic rotator cuff impingement,
progressive tendon degeneration or traumatic injury.
The shoulder has the most range of motion of any joint in the body. The
rotator cuff comprises four muscles: supraspinatus, infraspinatus, teres
minor and subscapularis.
Rotator cuff tears usually occur among patients aged 70-79, and present with
complaints of pain, decreased range of motion, muscular weakness and loss
of function, especially in overhead activities (2). Symptoms decrease quality
of life because they interrupt the ability to complete activities of daily living,
self-care and household chores. The goal of surgery is to reduce pain, regain
normal function and improve functional abilities.
Dysfunctions with the rotator cuff can vary in severity, from the full-thickness
tears described above to functional limitations. Surgeries to repair rotator
cuff problems are increasing in the United States, and are more likely to be
arthroscopic than open, and outpatient rather than inpatient (3).
Both careful surgical technique and postoperative physical therapy are
critical to good patient outcomes. There is some disagreement about the
timing of motion after rotator cuff repair. Some studies indicate that early
range of motion is not detrimental to the recovery process and showed
similar outcomes when compared to immobilization (4).
There may be no consensus in the foreseeable future to guide the timing of
postsurgical rotator cuff rehabilitation. There is little high-level scientific
evidence available to support or contest any one physical therapy approach,
leaving the physical therapy team to rely solely on clinical experience and
expert opinion (5).
As a result, what is most important is that postoperative therapy be
individualized, based on the size of the tear, the type of repair and the
patients age, activity level and personal goals. Its critical that surgeons
educate their patients and collaborate with the physical therapy team during
all phases of rehabilitation to optimize outcomes and patient success (4).
The purpose of this case report is to describe a specific outpatient physical
therapy plan of care for a patient who has had rotator cuff repair, and is
specific to his individual needs.

Case Description
Patient
The patient was a 74-year-old white male, retired and living alone, an avid
outdoorsman who chopped wood, repaired fences and managed a ranchette.
After a fall, he had a full thickness rotator cuff tear of the supraspinatus and
infraspinatus and tore the long head of the biceps tendon of his left shoulder.
He elected to undergo an arthroscopic rotator cuff repair. By the time patient
had scheduled surgery, it was five weeks post injury and his surgeon elected
to not repair the long head of the biceps tendon. His past medical history
included diabetes, foot neuropathy, arthritis of the acromioclavicular joint,
biceps tendinitis, hernia repair, appendectomy, cholecystectomy and
orthopedic surgery on the left knee.
Examination
The following examination was performed by the physical therapist in an
outpatient orthopedic setting, 3 days after the initial surgery.
1. Range of Motion Measurements: L UE in sitting: Elevation 85
degrees, Abduction 90 degrees, IR WFL.
2. Manual Muscle Test (MMT): Not tested secondary to surgical
protocol
3. Pain Scale: 1/10 @ rest 10/10 /w movement
4. Swelling: DNT
5. Bed Mobility (Move up and down in bed, supine<>EOB): DNT
6. Transfers (Sit<>stand, bed<>w/c, w/c<> mat): Independent
7. Sitting: Independent
8. Standing: Independent
9. Ambulation: Independent
10. Stairs: DNT
11. Additional Data: QDash 75%
12. Special Tests: DNT
Interventions
After examining the patient, the patient and physical therapist discussed
therapy and patient goals. Short term and long term goals were set and
agreed upon by both the patient and the physical therapist. The patient was
first seen December 7, which was 12 weeks post surgery. Generally the
protocol for a rotator cuff repair has three phases. The first phase is the
protection phase, from one to six weeks, which is accompanied by some
mobilization. During this phase the patient is limited to passive range of
motion exercise. In the second phase the patient is progressed to Active

Assistive Range of Motion (AAROM) and Active Range of Motion (AROM). The
final phase is the strengthening phase and generally starts at week 12.
However, at 16 weeks post surgery, the patient did not have full, active
range of motion in all planes and demonstrated muscle weakness. He
demonstrated deficits in several planes of motion delineated below.
Jan. 5, 2017

PROM

AROM

STRENGTH

160

85

3-/5

Extension

50

40

4-/5

Abduction

125

85

3-/5

Adduction

40

40

4-/5

ER 90/90

80

70

3-/5

IR 90/90

50

45

3+/5

Flexion

This necessitated a step down in progression to attempt to get full range of

motion, and then provide strengthening. The PTA and PT amended the
original plan of care with the following goals specific to this patients
lifestyle.

Patient will decrease pain level to 0/10 in order to work a full day on
the ranchette in six months.
Patient will have full active range of motion in flexion, abduction,
scaption and IR/ER in order to be able to feed his livestock in six
months.
Patient will have a strength of 5/5 in flexion, extension, abduction,
adduction and ER/IR in the left upper extremity in order to a hold a 10
pound rifle steady and be able to shoot proficiently in six months.

The patient continued to be scheduled for one visit per week at the clinic,
because of the distance needed to travel from his home.
Therapeutic Exercise
The following treatment interventions were provided at 16 weeks after
surgery:
Intervention
UBE Bike/Warm-up
5 min forward/5 min

Rationale
Cardio element, and active warm-up pre
treatment instead of hot pack to maximize

backward.

therapy session in movement.

Stretching exercises pre

strengthening:

Stretching muscles prior to strengthening

important for ROM and preventing injury.

Standing Pendulums L
shoulder forward/back/side,
circles 5 min

Deltoids, supraspinatus, infraspinatus,

subscapularis.

Standing L shoulder crossover

arm stretch 3x 30 sec hold

Posterior deltoid stretch and posterior

capsule.

Standing IR stretch to L
shoulder w/ Belt 3x 30 sec
Subscapularis muscle and anterior capsule
hold.
stretch.
Standing ER with pvc/dowel to Infraspinatus, teres minor stretch
L shoulder
Strengthening Exercises:
Standing Rows w/ blue
resistance band 3 sets 10

Middle and lower trapezius plus rhomboids

for for scapular stabilization.

Standing IR/ER w/ L elbow to

side at 90 w/blue resistance
band
3 sets 10 both directions

Infraspinatus, teres minor, posterior

deltoid, along with pectoralis major and
subscapularis strengthening.

Standing ER w/ L elbow
abducted to 90 w/blue
resistance band
3 sets 10 both directions

Infraspinatus and teres minor

strengthening. Strengthening in this
position would help with holding rifle or
shotgun to shoot in abducted position.

Standing L Elbow flexion

2 lbs weight 3 sets 10

Strengthen biceps with unattached long

head . Will aid in shoulder flexion.

Prone L shoulder reach ups at

90 degrees w/ 2 lbs weight 3
sets of 10

Middle trapezius and serratus anterior

strengthening in scapular upward rotation
to steady rifle holding.

Prone L shoulder horizontal

abduction w/ 2 lbs. weight. 3
sets 10

Middle, lower and middle trap,

infraspinatus, teres minor, posterior deltoid

Supine gravity eliminated full

Supraspinatus, anterior and middle deltoid

strengthening to be able to abduct and

ROM L abduction angel wing 3 hold rifle steady.

sets of 10
Strengthening and endurance training to
hold steady while shooting.
Supine L arm flexed upward to
90 degrees hold steady w/
perturbations in all directions. Strengthening and endurance to hold
5 min
steady while shooting.
Supine L hand on ball against
wall hold steady while
applying perturbations
against ball. 5 min

Endurance and strengthening w/ rotational

element to include multi planar movement.
Shouldering and firing shotgun at moving
targets requires multi-planar movement.

Supine LUE D2 PNF pattern for

5 min
Ice/ Estim 10 min

To decrease inflammation from tx session

and decrease pain

Outcomes
The patient was seen one time each week in the clinic for three weeks. The
patient has made small gains in his passive and active range of motion. The
patient does not have full range of motion, and so the focus has not been on
strength training. The patient has made gains in gravity eliminated positions
and the focus going forward should be on achieving full ROM in all planes
prior to progressing extensive strength training.

Jan. 16, 2017

PROM

AROM

STRENGTH

172

95

3-/5

Extension

55

50

4-/5

Abduction

130

95

3-/5

Adduction

40

40

4-/5

ER 90/90

80

70

3-/5

IR 90/90

50

50

3+/5

Flexion

Discussion

The goals of physical therapy after any rotator cuff repair fall into three main
categories:
1. Reducing the patients pain.
2. Regaining normal function of the patients daily life.
3. Improve the patients functional abilities (2).
The patient claimed he was compliant with his home exercise program, along
with its standard progressions. But at the time the plan was amended, at 16
weeks, a more in-depth interview revealed that he was indeed noncompliant,
and did not understand how to properly duplicate the exercises at home,
resulting in extensive substation and non-targeting of specific muscle groups
needed for proper rehabilitation. Rigorous oversight of the patients exercise
performance to ensure that there is no substitution or guarding is essential
to quality therapeutic outcomes (4).
Another factor beyond the scope of this case study is the fact that this
patients long head of the biceps brachii was not repaired by the surgeon,
because the muscle had atrophied and the tendon had shrunk prior to the
surgical intervention. Considering the age of the patient and the rate of his
tissue healing, the surgeon elected to leave that muscle unrepaired. Perhaps
this contributed to the demonstrated patient weakness in flexion and
scaption.
For the first 12 weeks of physical therapy, this patient did not receive the
kind of care research shows is most effective (4). It was not individualized.
His original plan was adequate, but not specific to his changing needs and
didnt evolve specifically to address the three phases of tissue healing. The
physical therapy team should have collaborated with the surgeon earlier and
more often. This patient got a standard protocol, not a focused clinical effort,
and a less than optimal outcome (5).
Conclusion
Rotator cuff problems are common and surgery has become more prevalent
in recent years. Successful postoperative therapy needs to be individualized,
and the physical therapy team must work collaboratively with the surgeon
during all phases of rehabilitation to optimize outcomes and a patients
return to full function.

References
1. Mather RC, Koenig L, Acevedo D, et al. The Societal and Economic
Value of Rotator Cuff Repair. The Journal of Bone and Joint Surgery
American volume. 2013;95(22):1993-2000.
doi:10.2106/JBJS.L.01495.
2. Du Plessis M, Eksteen E, Morris L, et al. The effectiveness of continuous
passive motion on range of motion, pain and muscle strength
following rotator cuff repair: a systematic review. Clinical
Rehabilitation [serial online]. April 2011;25(4):291-302. Available
from: CINAHL Complete, Ipswich, MA. Accessed January 14, 2017.
3. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National
Trends in Rotator Cuff Repair. The Journal of Bone and Joint Surgery
American volume. 2012;94(3):227-233. doi:10.2106/JBJS.J.00739.
4. Vo A, Zhou H, Dumont G, Fogerty S, Rosso C, et al. (2013) Physical
Therapy and Rehabilitation after Rotator Cuff Repair: A Review of
Current Concepts. Int J Phys Med Rehabil 1:142. doi:10.4172/23299096.1000142
5. Van Der Meijden, Oliver AJ, Kokmeyer, Dirk, Millett, Peter, et al. (2012)
Rehabilitation after arthroscopic rotator cuff repair: Current
concepts review and evidence-based guidelines. International
Journal of Sports Physical Therapy Volume 7, Number 2, April 2012,
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