Musculoskelet Surg (2009) 93:S55S63
DOI 10.1007/s12306-009-0003-9
Post-operative rehabilitation after surgical repair
of the rotator cuff
Marco Conti Raffaele Garofalo Giacomo Delle Rose
Giuseppe Massazza Enzo Vinci Mario Randelli
Alessandro Castagna
Published online: 16 March 2009
Springer-Verlag 2009
Abstract Today advances in techniques and materials for
rotator cuff surgery allow the repair of a large variety of
types or extensions of cuff lesions in patients from a wide
range of age groups who have different kinds of jobs and
participate in different kinds of sports, and who have
widely different expectations in terms of recovery of
functions and pain relief. A large number of factors must
M. Conti ()
Via L. Settala 82, Milan, Italy
Office: Via Locatelli 6, Milan, Italy
e-mail: maconti@swissonline.ch
M. Conti G. Delle Rose M. Randelli A. Castagna arm motion in phase one, to prevent post-op stiffness. In
Shoulder Unit
IRCCS Istituto Clinico Humanitas
Rozzano (MI), Italy
R. Garofalo
Orthopaedic and Traumatologic Unit
Regional Hospital F. Miulli
Centre of Excellence
Acquaviva delle fonti (BA), Italy
G. Massazza
Orthopaedic and Traumatologic Unit and
Occupational Medicine
Medicine Faculty, University of Turin
Turin, Italy
E. Vinci
Cliniche Humanitas Gavazzeni
Bergamo, Italy
be taken into account before implementing a rehabilita-
tion protocol after rotator cuff surgery. These mainly
include the technique (materials and procedure) used by
the surgeon. Moreover, tissue quality, retraction, fatty
infiltration and time from rupture are important biologi-
cal factors while the patients work or sport or daily
activities after surgery and expectations of recovery must
also be assessed. A rehabilitation protocol should also
take into account the timing of biological healing of bone
to tendon or tendon to tendon interface, depending on the
type of rupture and repair. This timing should direct the
therapists choice of correct passive or assisted exercise
and mobilisation manoeuvres and the teaching of correct
active mobilisation movements the patient has to do.
Following accepted knowledge about the time of biolog-
ical tissue healing, surgical technique and focused reha-
bilitation exercise, a conceptual protocol in four phases
could be applied, tailoring the protocol for each patient.
It starts with sling rest with passive small self-assisted
phase two passive mobilisation by the patient dry or in
water, integrated with scapular mobilisation and stabilis-
er reinforcement, are done. Phase three consists of pro-
gressive active arm mobilisation dry or in water integrat-
ed with proprioceptive exercise and core stabilisation.
In phase four full strength recovery integrated with the
recovery of work or sports movements will complete the
protocol. Because of the multi-factorial aspects of the
problem, the best results can be obtained through a full
transfer of information from the surgeon to the therapist
to optimise timing and sizing of the individual rehabilita-
tion protocol for each patient.
Keywords Rehabilitation Rotator cuff Shoulder
Rotator cuff surgery Functional recovery Passive
motion
S56
Introduction
It is well known that rotator cuff tendon lesions are fre-
quently found in the framework of shoulder pathologies
[1], especially among patients aged over 45. However,
especially in sports and overhead working activities,
younger people are increasingly subjecting their scapu-
lar-humeral joints to significant stress and can therefore
suffer from this type of lesion. The presence of a rotator
cuff tendon lesion does not necessarily suggest the need
for surgical operations [25]. There is in fact increasing
agreement that surgery is indicated after failure of pre-
ventive rehabilitation treatment carried out for a period
of at least 34 months, or in the cases in which signifi-
cant and progressive rotator cuff tendon insufficiency
occurs [6].
Today, the surgical repair of a rotator cuff tendon tear
(RCT) can be carried out using a variety of methods,
open, mini-open and arthroscopic techniques [7], and the
post-op results are generally good and substantially com-
parable [811]. At present, one of the great topics of dis-
cussion is not therefore the surgical technique to use but
rather post-surgery recurrence. When minor re-ruptures
occur, patients may still show improvement of the clini-
cal symptoms compared with the pre-operative period,
while patients with massive re-ruptures do not benefit in
any way from the surgical operation [512]. The clinical
results therefore seem to be linked to the level of healing
of the repaired tendon [13], a factor which increasingly
appears to be the linchpin for therapeutic success. Many
factors can influence healing of the repaired tendon [14,
15]: we can in fact distinguish between surgical factors
associated with recognition of the type of lesion (forms
and number of tendons involved), the size of the lesion,
the technique as such, the mobilisation of the tendon tis-
sue it was possible to obtain intraoperatively, the tendon
quality, the degree of muscular hypo-atrophy, as well as
adequate subacromial decompression, correct prepara-
tion of the humeral tuberosity, and the anchoring and
suturing method. Then a series of factors related to the
patient such as age, lifestyle and the presence of other
shoulder complaints or systemic illnesses [7] are by no
means secondary either. In this light, the post-surgery
rehabilitative treatment assumes great importance as it
must be able to protect the repair in the early stages, to
prevent post-op stiffness and then restore the function of
the scapular-humeral joint [15, 16].
Many rehabilitation protocols have been proposed,
often based only on empirical experiences, without fully
taking into account biological aspects relative to the heal-
ing steps of the repaired tendon [1719]. Post-surgical
rehabilitation of the suture of rotator cuff tendons, fur-
thermore, can vary from patient to patient, bearing in
mind the surgical technique, the patients expectations
and functional demands, the number of tendons repaired
Musculoskelet Surg (2009) 93:S55S63
and therefore the grade of the lesion, the quality of the
tissue and any associated surgical actions [16].
Tendon healing
One of the most important aspects the rehabilitation proto-
col must take into account is biological time for the tendon
to heal. This process involves tendon healing at the bone
footprint if the tendon has been reinserted into its anatomi-
cal place using a technique with anchors and sutures or
alternatively tendon with tendon healing if a suture tech-
nique with latero-lateral stitches has been carried out.
The reparative phenomena follow a cascading series
of mechanisms in an orderly manner one after another in
healthy individuals [20] (Table 1).
The first stage is the inflammatory one: during the
first week it is characterised by inflammatory cells,
leukocytes, lymphocytes and monocytes, which release
histamine and bradykinin, which increase vascular per-
meability and therefore allow the plates to reach the level
of the repair site. The fibrin along with the fibronectin
form a fragile scar which reduces the haemorrhaging
process without any real adhesion between tendon and
bone. The inflammatory stage lasts for a period which
varies between 1and 2 weeks and which is generally
transformed into the proliferative stage.
During the proliferative stage, the inflammatory tis-
sue is gradually replaced by fibroblasts, myofibroblasts
and endothelial cells, which organise themselves with the
Table 1 Stages of the tendon healing process
Stage (duration) Evolution of the process
Inflammatory (014th day) Leucocytes, lymphocytes,
monocytes
Release of histamine and
bradykinin which increase
vascular permeability
Increase of platelets in situ
Initial scar thanks to fibrin and
fibronectin
Proliferative (2nd3rd/4th week) Inflammatory tissue replaced by
fibroblasts, myofibroblasts and
endothelial cells
Formation of granulation tissue
Tighter tendon-bone adhesion
Production of collagen III
(immature) by fibroblasts
(after 15 post-op days)
Maturation and remodelling Maturation of the scar tissue
(3rd4th week 12th/26th week) Collagen III replaced by mature
collagen I
Formation of dense connective
tissue
Integration of the tendon in the
bone
Musculoskelet Surg (2009) 93:S55S63 S57

new extracellular matrix to form a granulation tissue

which guarantees tighter adhesion between the tendon
and the bone surface. In this stage, the fibroblasts pro-
duce type III collagens, which are therefore immature,
and glycosaminoglycans; then there is significant neoan-
giogenesis. This stage lasts about 10 days and com-
mences after the first 15 days after surgical repair.
This stage is followed by maturing and remodelling,
which therefore begins around the third week and is char-
acterised by maturing of the scar tissue: the immature type
III collagen is replaced by type I with the formation of
dense connective tissue. By now the fibroblastic cells will
have replaced the inflammatory cells. The process contin-
ues during the following weeks until the tendon is com-
pletely integrated with the bone surface. Tendon healing a
studies have mainly been carried out on animal models and
therefore the remodelling and maturing stages have been
seen to vary in duration depending on the animal model
used. Some authors have described periods of 1216 weeks
for the tendon to recover its tensile strength [20], while
other authors who have studied sheep models have report-
ed times of as much as 26 weeks (4 months) [21]. These
studies obviously reveal a set of limits linked to the model
studied while, furthermore, human tendons that are rup-
tured reveal a series of degenerative alterations which can
negatively influence and therefore prolong the healing
time. The recognition of the biological timing is very
important and must be properly recognised by the doctor so
as to modulate the rehabilitative timing.

Immobilisation and sling
Bearing in mind the biological healing stages of the
repaired cuff tendon tissue, it is clear that precocious and
aggressive mobilisation or violent muscular contraction
can exceed the mechanical strength of the repair and
damage it, even though precocious mobilisation could
reduce the risks of articular stiffness. The purpose of a
reasoned rehabilitative process after a rotator cuff repair
is therefore to obtain cuff tendon healing by recovering
mobility and shoulder function gradually. From this
standpoint, an adequate immobilisation of the limb is
very important during the initial post-operative stage in
order to guarantee effective tendon healing. A study on
rats has in fact highlighted that the cuff tendons that were
immobilised after surgical suturing revealed excellent
orientation of the collagen fibres and enhanced organisa-
tion of the extracellular matrix compared with rats that
were left free after the repair [22].
Adequate immobilisation must however take into
account the vascular and biomechanical characteristics of the
rotator cuff [23]. The use of an abduction sling during the
early weeks seems capable of reducing tension at suture level
and improving vascularisation of the scar. We do in fact
b
Fig. 1a,b Sling positioning in the neutral or rest position
know that the hypovascular zone of a healthy supraspinatus
tendon is about 1.5 cm from the greater tuberosity of the
humerus and the position of the head of the humerus influ-
ences tendon vascularisation significantly [24].
Assessing tendon microcirculation in relation to the
head position, Rathbun and Macnab showed that there is
a reduction of the haematic flow to the tendon when the
arm is in a total adduction position [25]. Based on these
observations, it seems prudent to recommend post-op
immobilisation in a sling with the arm abducted at least
to 30 and an external rotation of 0 (a neutral or rest
position) for the first 46 post-operative weeks in order
to improve microcirculation and reduce the stress on the
operated tendon, especially in the case of a repair carried
out on an inveterate tendon lesion [26, 27] (Fig. 1a,b).
Continuous passive mobilisation
There are not many studies in the literature that help us
to understand if this therapeutic aid (obtained today with
S58
Fig. 2 Example of an automatic programmable CPM system
electronically controlled automatic programmable
mobilisers, see Fig. 2) can be of benefit in the rehabilita-
tion of patients operated by suturing the rotator cuff. As
a general rule this continuous passive mobilisation
(CPM) can be begun in the immediate post-op period on
condition that stress in the repair zone is kept low.
Hatakeyama et al. have shown that the safety position
after this surgery is 30 of elevation on the scapular plane
with an external rotation range between 0 and 60 [28].
In a double-blind randomised study of patients treated
with repair of the cuff and subacromial decompression,
Raab et al. [29] showed that three months after the surgi-
cal operation there were no differences in the various
scores between patients treated with physical therapy and
CPM and those treated with physical therapy only; how-
ever the range of movement and pain level were better in
patients in the first group. Recently, Michael et al. [30]
seemed to confirm these data and also showed how the
recovery of the range of movement is faster in patients
treated with CPM in the post-operative period. In another
randomised prospective study on 31 patients operated for
repair of the rotator cuff, Lastayo et al. [31] compared 2
groups, one treated with CPM in the first 4 weeks while
the other was subjected in the same period of time to a
physical therapy programme with passive recovery of
mobility. A follow-up carried out after 22 months found
that there were no statistically significant differences in
the scores of the two groups or in pain and isometric mus-
cular strength. Our figures, currently being published
[32], relating to a randomised prospective study on 100
patients seem to indicate that the precocious use of CPM
for at least two hours daily overall, for one month after the
operation, can permit better recovery of the passive ROM
in both abduction and external rotation and in forward
flexion with significant data already at two and a half
months. It therefore seems, from the analysis of the liter-
ature, that in the medium and long term, CPM succeeds in
substantially influencing the recovery of the range of
Musculoskelet Surg (2009) 93:S55S63
movement only, while it remains to be seen whether it can
have a positive effect on faster recovery of working activ-
ities or of common everyday activities. It is also not yet
known if the use of CPM can influence healing of the
repaired tendons to any extent. Certainly, however, this
method can be used in patients who have a cuff lesion
associated with adhesive capsulitis in the pre-operative
period and who can therefore benefit from a recovery, or
at least from a non-loss, of the range of movement already
gained during the surgical operation.
Post-operative functional rehabilitation
From what we have said so far, it can be deduced that the
rehabilitative management after RCT repair must take
into account multiple factors, which the surgeon and
rehabilitation therapist must share. This information is
made up of the processes and biological timing of ten-
don healing, the size of the tendon lesion treated, the
quality of the treated tendon, the type of repair made
(type of cuff suture made, if partial or total, if a mono-
or pluri-tendon suture, and if the repair is of the ten-
dontendon or tendonbone type; knowledge of the type
of implant used reabsorbable or not reabsorbable is
also important), any associated surgical actions
(acromion plastic surgery, resection of the distal clavicle
or, in younger patients, repair of an associated lesion of
the SLAP type, tenotomy or tenodesis of the long end of
the biceps and possibly knowledge of the type of tenode-
sis technique whether static or dynamic to the soft
parts of the cuff), the physiological age and expectations
of the patient, and the range of pre-op movement of the
operated shoulder.
In particular, account must be taken of the fact that
the prognosis after repair was significantly related to the
degree of fatty degeneration of the tendon and of muscu-
lar atrophy, the size of the lesion treated and the extent of
reduction of the range of movement in the pre-op period
[12, 13, 3335].
In this sense, communications and coordination
between the surgeon, physiatrist and physiotherapist are
fundamental in order to obtain an optimum result for the
patients themselves.
The current general consensus in the literature [14,
15, 19, 3639] is to subdivide the post-operative rehabil-
itative treatment into four stages, each one with different
aims (Table 2).
The aim of the first stage is to prevent articular block-
age because of post-surgical adherences by means of
exercises of the passive type which help to minimise
loading at the repair site.
The aim of the second stage is the progressive recov-
ery of the passive range of movement without scapular
compensation by means of exercises of the assist-
Musculoskelet Surg (2009) 93:S55S63
Table 2 Objectives of the various rehabilitation stages
Stage Objectives
1 Prevention of joint stiffness due to post-
operative adherences
2 Progressive recovery of the range of passive
movement without scapular compensation
3 Recovery of strength and of physiological
scapulohumeral rhythm
4 Complete the recovery of the power and
normal actions for both work and sports
ed/active type which begin gradually to apply work loads
on the repaired tendons.
The aim of the third stage is to recover strength and
physiological scapular-humeral rhythm by means of ton-
ing exercises focussing on the recovery of power and the
strength of the rotator cuff tendons.
The aim of the fourth stage is the best recovery of the
strength and normal actions for both work and sports.
These stages naturally interweave and overlap without
any break and it is possible, in the same stages, to find a
series of variables linked to all the conditions regarding
the patient and type of lesions treated and to the type of
surgical technique used.
The first rehabilitation stage runs from the immediate
post-op period until the 4th6th week. During this stage
the patient wears the abduction sling (up to 6 weeks for
complete lesions; up to 4 weeks for partial and incom-
plete lesions) and it is only removed 34 times per day to
carry out passive abduction, front flexion and external
rotation mobilisation exercises. During this stage the
loads on the repair made must be minimal and, in fact,
this stage is characterised biologically by a slight coagu-
lation of fibrin with type III collagen; therefore exercises
with active muscular contraction on the operated limb
must be avoided at this stage. The recovery of the passive
movement must be carried out inside a safety range and
the patient must work without pain and with the avoid-
ance of maximum stretching. In the event of a subscapu-
lar repair, external passive rotation must be limited to 0
and no more. Therefore patients can make active move-
ments of the wrist, hand and elbow. The active flex-
ionextension of the latter must be modulated and limit-
ed in this stage if tenodesis of the long end of the biceps
has been carried out, especially if of the dynamic type at
the rotator cuff. Pendulum exercises are useful at this
stage, to be carried out with extreme relaxation of the
musculature and with the trunk tilted 30 forward.
Furthermore, preference must be given to active and pro-
prioceptive work of the scapular/thoracic joint. Once the
suture stitches have been removed the passive mobilisa-
tion and slight stretching exercises can also be carried out
in a pool (23 times per week, for 1520 min per session)
[26]. Ice is a useful anti-inflammatory aid for use in this
stage, especially in the first 1015 days and after the
S59
physiotherapy sessions [39]. CPM can be useful in this
stage, particularly with patients who have had a reduction
of the physiological range of movement or capsulitis.
The second stage runs from the 4th6th week until
the 12th (3rd month). This is because from the 6th week
after the operation, the extent of healing of the tendon to
the bone and of the tendon to tendon begins to be suffi-
cient to allow the introduction of active movements at a
minimum load. At this stage, the mobilisation exercises
can also be carried out by a therapist and it is possible to
begin greater and greater stretching, with decoaptation of
the humeral head to prevent a subacromial iatrogenous
conflict in order to begin to recover the range of move-
ment towards the greatest angles. It is possible at this
stage to begin to use aids such as pulleys and sticks. In
this case too it is necessary to continue to maintain cer-
tain stratagems. For example, if the top fibres of the sub-
scapular muscle have been sutured, the recovery of exter-
nal rotation should preferably be obtained by means of an
abduction of the limb to 45 (and with the elbow raised
46 cm from the couch to reduce stress on the sutures to
a minimum if the execution is carried out in a supine
position). At 68 weeks it is very useful to begin the
active mobilisation exercises in water; this should be
deemed to be an active mobilisation exercise assisted in
a situation of reduced force of gravity and, as a conse-
quence, with low loading at the level of the operated ten-
don. The patient can be allowed to swim breaststroke and
when front passive flexion reaches around 130 some
modified backstroke can be added, without submerging
the limb but ending the movement at surface level. At
this stage, therefore, it is possible to start active move-
ments without forcing and therefore the use of the arm is
permitted in everyday activities. The proprioceptive exer-
cises on the scapular-thoracic joint are intensified as is
active toning of the active scapular fixator muscles.
Particularly important at this stage is the use of neuro-
muscular biofeedback systems which, though simple,
help the therapist to get the patient to relearn the abili-
ty of voluntary and coordinated control of the fundamen-
tal muscle groups for scapulohumeral stabilisation and
which, in general, have been dysfunctioning for some
time because of profound alteration of the motor patterns
induced by the cuff lesion and by the compensation
mechanisms implemented instinctively so as to permit
the spatial positioning of the hand for as long as possible
on the basis of living needs (see Fig. 3).
The third stage begins around the third month
(10th12th week) and is the muscular toning stage with
progressive functional recovery. This stage lasts until the
12th week and beyond. The start of this stage obviously
depends on various factors. As we have already said, one
of the most important factors is the type of lesion
repaired. This is because the more serious the tendon
lesion repaired, the further this stage is put back.
S60
Fig. 3 Simple neuro-muscular sound/visual biofeedback system
Fig. 4 Exercise in a closed kinetic chain
Furthermore, the start of this rehabilitation stage is sec-
ondary to recovery of a satisfactory range of active move-
ment of the operated limb, especially in terms of front
flexion and external rotation. This is because repeated
attempts to tone a shoulder which is still stiff can give
rise to pain, subacromial conflict and excess stress on the
repair itself. Patients who are unable to actively raise the
arm against gravity at this stage should begin to carry out
reinforcement exercises without resistance in a supine
position. In this position, gravity has virtually been elim-
inated and the patient begins to raise the limb over 90
and reinforce the deltoid. This exercise can be carried out
at the beginning with the elbow flexed and then gradual-
ly increasing the lever arm by extending the elbow. This
Musculoskelet Surg (2009) 93:S55S63
exercise can be carried out progressively with a small
weight in the hand or using an elastic resistance system
[40]. At this rehabilitation stage it is important to respect
the pain while the intensity of the exercises must be prop-
erly monitored. At the beginning it is possible to carry
out isometric contractions which permit the application
of controlled force through the repaired tendon. If the
supraspinatus has been repaired, toning is carried out
first in an attempt to reinforce the pair of front (subscapu-
lar) and rear (subspinatus) forces by means of exercises
with the limb abducted to 3045 and 60, so as to limit
the possibility of a subacromial conflict that can entail
pain as well as mechanical stress on the repair made.
Isometric reinforcement is followed by a reinforce-
ment stage with elastic bands and it is initially necessary
to concentrate on the execution of many repetitions with
low resistances. Remembering that muscular toning is
dependent on the articular angle, it is necessary to seek
different angular positions of the humerus at which to
carry out different exercises so that, with each exercise,
you can select in turn the subspinatus, the teres minor,
the subscapular, the deltoid, first front and then rear, the
mid and inferior parts of the trapezius and the rhom-
boideus or costoscapularis muscles. The exercises must
be modulated to spare the repaired tendon as much as
possible at the beginning. Takeda et al. [41] have shown
that with the arm abducted on the scapular plane the
supraspinatus is isolated and that this would therefore be
the ideal position for the reinforcement of this tendon.
However it is necessary to be very careful with the
humeral rotation in this position. Some NMR studies
have shown that in the abduction and internal rotation
position the subacromial space is reduced in a dynamic
manner and gives rise to stress on the repair [42], and this
is why abduction positions of less than 90 are recom-
mended if internal or external rotations are associated
with them [26]. In this rehabilitation stage it is also nec-
essary to continue to improve the range of movement
with exercises for stretching the capsulo-ligamentous
structures, in particular on the antero-inferior and pos-
tero-inferior capsule. The proprioceptive work of the
scapular stabilisers must be intensified without forgetting
core stabilisation (the muscular system of the abdomi-
nal, oblique, dorsal and gluteus muscles), fundamental
for correct positioning of the scapula.
A crucial role in progressive functional recovery is
played by proprioceptive exercises in a closed kinetic
chain first below and then above the breast (Fig. 4).
The fourth and last rehabilitation stage begins around
the 16th week and continues until the 6th month. This
stage is a progression of the third stage, and its end point
is different depending on the type of patient [43]. This is
because at this stage a patient with a low functional
demand will continue to improve in a progressive manner
in a programme of exercises prevalently at home and in
Table 3 Logical plan of the stages and contents of the rehabilitation process for post-operative rehabilitation of the rotator cuff

Stage 1 Stage 2 Stage 3 Stage 4

04th/5th week 4th/6th12th week 12th16/18th week 16th/18th 36th week

Rotator cuff suture operation Sling (Abd. 30 and ER 0) Complete return to

Passive auto-mobilisation
Passive pendular exercises
(body tilted forward 30)
Active hand-wrist mobilisation
Assisted elbow mobilisation in
case of biceps long head tenodesis
everyday activities
specific sports training
Cont. passive / assisted
mobilisation for PROM
recovery
(Max 45 ER if subscapular
suture)
Musculoskelet Surg (2009) 93:S55S63

Max 0 ER if subscapular suture

CPM (no pain range) with Possible CPM for weeks 5/6
progressive PROM increase (no pain range) with
progressive
PROM increase
Passive/assisted mobilis.
in water
Proprioceptive in closed
kinetic chain below the breast
Use of the limb for everyday
activities below the breast
No loads
No fast gestures
Scapular fixator muscle
activation
NB: biceps long head
spared if tenotomy/tenodesis
Rotator cuff suture operation
Breaststroke, plus
modified backstroke
from weeks 14/16
(see text)
Use of the limb for Use of the limb
everyday activities for everyday
also above the breast activities also
No loads above the breast
No fast gestures
Musc. isometric
reinforcement
Humeral ADD + ER + IR
(respecting the sutured
muscles more)
Active reinforcement with Functional recovery
elastic bands of the scapular specific sports training
fixator muscles
From weeks 14/16, isotonic
reinforcement with elastic bands
NB: do not stress the
supraspinatus (and biceps long
head if tenotomy or tenodesis
Proprioceptive in closed kinetic Proprioceptive in open
chain above the breast kinetic chain,
Core stabilisation: active simulating
reinforcement of the gluteus, low sports gestures
abdominal, oblique and dorsal
muscles muscular
electrostimulation
> 20th week: simulation
of sports gestures in
the gym
Recovery of work
movements (ergotherapy)
S61
S62
Fig. 5 Exercise in an open kinetic chain
an increasingly complete recovery of the normal activi-
ties of everyday life and the resumption, with great cau-
tion, of overhead activities. With regard to young patients
and athletes, these begin exercises first in an open kinet-
ic chain (Fig. 5) and then go on to specific sports recov-
ery exercises first for the gesture and then with force
applied to the specific sports gesture itself, while work-
ers begin to carry out activities which simulate the work-
ing activity in a specific and progressive manner. It may
be the therapists job to teach patients appropriate strata-
gems for limiting stress on the repaired tendon to a min-
imum during the sports or work activity. See Table 3 for
a logical-temporal diagram of the above illustrated reha-
bilitation process.
Conclusions
Evident from the analysis set out above is the consensus
about how post-operative rehabilitation constitutes a pro-
gressive, integrated and personalised process (rather than
a protocol) in which a fundamental role is played by
the passage of information between the surgeon and the
physiotherapist, as well as the sharing of knowledge
regarding the characteristics of each individual operation
both in terms of surgical technique and in terms of the
biological and anatomical characteristics of the repaired
tissues. Only through the integration of this information
with data regarding the patients lifestyle and expecta-
tions will it be possible to establish a rehabilitation pro-
gramme which, though personalised as regards the exec-
utive procedures, cannot ignore the times and processes
of biological tissue healing in order to achieve the best
possible result both in terms of functional recovery and
of management of the symptoms.
Conflict of interest The authors declare that they have no conflict of
interest related to the publication of this manuscript.
Musculoskelet Surg (2009) 93:S55S63
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