Rotator Cuff Repairs 25

Mary Schuler Murphy

The rotator cuff is important for both mobility and stability of the gleno-
humeral joint, as well as nourishment of the articular surface of the gleno-
humeral joint. Studies have suggested that the rotator cuff provides 45% of
the power in shoulder abduction and at least 90% of the power in external
rotation.1 The rotator cuff acts as a dynamic stabilizer, allowing the power-
ful deltoid to perform as the primary mover of the glenohumeral joint.
In addition to the rotator cuff, scapulothoracic stability and mobility are
essential for normal shoulder movement. A major goal of shoulder recon-
struction is to preserve or restore the balance between the rotator cuff and
the deltoid and scapulothoracic musculature. According to Neer,2 the most
common etiological cause of rotator cuff tears is impingement (approxi-
mately 95%, primarily in those older than 40 years of age). Normal aging
of rotator cuff tendons, with decreased cellularity and vascularity, com-
bined with repetitive microtrauma, predisposes the tendons to progressive
deterioration and possible acute rupture.3 According to Neer,2 the most
common cause of impingement is decreased space beneath the anterior
acromion and acromioclavicular joint. An anterior acromioplasty is fre-
quently performed in conjunction with the rotator cuff repair to alleviate this
problem. In the presence of a massive rotator cuff tear, the coracoacromial
arch acts as a passive stabilizer against humeral head anterior and superior
subluxation. Gartsman and Burkhart4,5 advocated that acromioplasty not be
performed with rotator cuff tears that are not fully repairable.
The most common cause of rotator cuff injury in the active young adult
is instability with excessive humeral head migration into the subacromial
space.6 Strengthening of the muscle forces acts to offset this excessive
humeral head elevation.7 The role of subtle anterior shoulder instability in
internal impingement is caused by problems with the balance of the dynamic
and static stabilizers and mobilizers of the shoulder.3 Not all rotator cuff tears
are symptomatic. Tempelheh and colleagues8 studied 411 asymptomatic
shoulders using magnetic resonance imaging; 23.4% of the participants

345
346 PA R T FO U R Shoulder

were found to have a full-thickness rotator cuff tear. As indicated earlier, the
causes of shoulder impingement vary, necessitating different approaches to
the medical management. Not all rotator cuff tears require surgery. Ruotolo
and Nottage9 reported that approximately 50% of patients with rotator cuff
tears improve with nonoperative treatment. Although pain is the primary
reason for surgery, incapacitating weakness in large cuff deficits may also
be an indication. Faryniarz and Craig10 warned that some tears, in active
patients, may progress to larger tears. Furthermore, those patients who
choose nonoperative management should be monitored for decreasing
strength. Conservative management of rotator cuff tears may follow the same
type of program as described in Chapter 24 for rotator cuff tendonitis.
To understand the advancements made in the treatment of rotator cuff
repairs, the therapist must appreciate the significant advances made in the
recognition of the various causes of impingement, the recognition of dif-
ferent tear patterns with improved surgical repair techniques, and the use
of arthroscopic evaluation and repair of the rotator cuff. Arthroscopic eval-
uation has provided the surgeon with the ability to explore and find lesions
sometimes not identified with an open approach, with minimal disruption
to the deltoid. According to Lo and Burkhart,11 and others, arthroscopic
rotator cuff repairs appear to be as good if not better than open repairs.
The advantages of arthroscopic surgery include relative deltoid preserva-
tion, the identification and repair of intraarticular lesions, release of rotator
cuff adhesions, and mobilization of the retracted rotator cuff tendons.
According to Yamaguchi and colleagues,12 as arthroscopic techniques have
progressed to include large tear repairs, results are equal to or better than
with open repair techniques. They also reported on the ability to repair
massive rotator cuff tears arthroscopically using side-to-side repairs,
margin convergence, and partial repairs. Burkhart5 reported the impor-
tance of tear pattern type recognition. He maintained that most rotator
cuff tears can be classified into crescent-shaped tears and U-shaped tears.
Crescent-shaped tears do not retract far and may be directly repaired to
bone. U-shaped tears usually extend much further medially, and side-to-
side sutures of the tear are placed before attachment of tendon to bone.
Rehabilitation of the rotator cuff requires a basic understanding of the
surgical procedure and the physician’s expectation of outcome. The pro-
gression of the rehabilitation program depends on the patient’s age, com-
pliance, tissue quality, and type of tear, as well as the type of surgery
performed. Regardless of the type of repair performed, tendon healing
requires time, during which protection of the repair must be carefully
monitored to prevent damage to the repaired tendon or other structures.
Only the surgeon knows the integrity of the repair, so close communica-
tion with the surgeon is imperative to successful rehabilitation.

DEFINITION
Rotator cuff repair is the surgical repair of a partial or complete rupture of
one or several of the tendons that comprise the rotator cuff (supraspinatus,
infraspinatus, teres minor, and subscapularis).
Anterior acromioplasty is the surgical decompression of the rotator cuff
through enlargement of the supraspinatus outlet by beveling of the ante-
rior edge and the undersurface of the anterior third of the acromion and
acromioclavicular joint.
C H A P T E R 25 Rotator Cuff Repairs 347

I. Neer’s cuff tear terminology2

A. Partial tear: incomplete tear that does not extend through
the complete tendon thickness
B. Complete tear: extends through the complete thickness of
the tendon
C. Massive tear: tear of more than one rotator cuff tendon
D. Degenerative tear: nutritional or metabolic factors could be
indicated as well as wear or injury
E. Traumatic tear: implies an injury tearing a healthy tendon
F. Acute extension: implies an injury suddenly enlarging an
impingement tear
II. Esch’s categories of rotator cuff tears (according to size)13
A. Small: less than 1 cm
B. Moderate: 1 to 3 cm
C. Large: 3 to 5 cm
D. Massive: greater than 5 cm
Mini-open repair or arthroscopic-assisted open rotator cuff repair is
an arthroscopic subacromial decompression followed by an open repair
through a deltoid splitting procedure, or the arthroscope may also be used
to release adhesions and place tagging sutures with a mini-open approach
to obtain tendon-to-bone fixation. A complete arthroscopic repair is all of
the above-described procedures performed through the arthroscope.
Cuff tear arthropathy is a degeneration of the glenohumeral joint second-
ary to the effect of massive rotator cuff tears over time.
Margin convergence is the mechanical advantage that occurs with side-
to-side closure of large cuff tears, reducing strain on the repair to bone.
Crescent-shaped tears typically pull away from bone but do not retract
and are therefore repaired directly to bone with minimal tension.
U-shaped tears require side-to-side sutures that converge the free
margin of the cuff toward the bone, followed by repair to the bone with
suture anchors.

SURGICAL PURPOSE
Surgery is performed for rotator cuff tears to restore the continuity of the
tendon and relieve the subacromial impingement. This is often difficult to
achieve, and predictability of success depends on the quality of the tendon
substance, the length of time since the injury occurred, and the underlying
pathology that brought on the disruption. Successful rehabilitation of these
injuries requires full knowledge of these factors.

TREATMENT GOALS
I. Repair of incomplete or small tears (less than 1 cm) and open and
major tear repairs (1 to 5 cm)
A. Short-term goals
1. Prevent the formation of adhesions while protecting the
repair.
2. Maintain passive range of motion (PROM) within limits set
by the physician.
3. Patient education (i.e., precautions to allow for healing)
348 PA R T FO U R Shoulder

4. Maintain full active range of motion (AROM) and strength in

elbow, forearm, wrist, and hand of involved extremity.
B. Long-term goals
1. Restore full PROM.
2. Restore pain-free AROM and return to functional active
abduction and external rotation.
3. Return to preinjury activity status.
II. Massive repairs (repairs greater than 5 cm) with significant loss
of deltoid function, rotator cuff function, or bone
A. Long-term goals
1. Restore pain-free limited but functional AROM, with
emphasis on use of the extremity at the side.
2. Return to as near previous levels of functioning as possible.
3. Independent home exercise program stressing stability and
the avoidance of excessive mobility.

POSTOPERATIVE INDICATIONS/PRECAUTIONS
FOR THERAPY
I. Indications
A. A rehabilitation program is indicated for all types of repairs if
the surgeon indicates that rotator cuff quality and glenohumeral
joint stability are adequate.
II. Precautions
A. Communication with the surgeon is of paramount importance.
The therapist must know the type and quality of the repair. Severe
loss of deltoid muscle function, rotator cuff, or bone requires a
limited goal program with lesser ROM and increased stability.

POSTOPERATIVE THERAPY
I. Incomplete or small tear repairs (less than 1 cm)
A. Days 1 to 3
1. Pain management including high-voltage galvanic stimulation
(HVG) for pain and edema control. May use a sling for comfort
for approximately 1 week. When sleeping, protect with sling,
rest shoulder in approximately 45 degrees scaption on a pillow.
Either transcutaneous electrical nerve stimulation (TENS),
HVG, or an interferential unit combined with cold application
for control of pain and swelling is recommended as part of
the patient’s home program.
2. Initiate pendulum exercises (Fig. 25-1), to be performed four
to six times a day for approximately 5 minutes each session.
3. Initiate active scapulothoracic stabilization exercises, to be
performed four to six times a day for 5 minutes each session
(see Fig. 24-3, A in Chapter 24).
4. Gentle AROM and PROM at the elbow and wrist
B. Day 3 to 3 weeks
1. Pain-free PROM of shoulder, including forward elevation in
the plane of the scapula and internal and external rotation in
the scapular plane. At the end of the third week, PROM
should be within functional limits (approximately 150 degrees
flexion/scaption, 60 degrees external rotation).
C H A P T E R 25 Rotator Cuff Repairs 349

F I G . 25-1 Pendulum exercises.

2. Progress to AAROM of the shoulder in supine in

gravity-eliminated planes (e.g., place-hold in 90 degrees
flexion with assistance) (Fig. 25-2). Initiate external AAROM
rotation at the side and progress in the plane of the scapula.
3. Progress to pain-free isometric scapulothoracic stabilization
strengthening exercise (e.g., resist patient’s protracted shoulder
positioned in 90 degrees flexion in supine) (Fig. 25-3), and
pain-free submaximal rotator cuff and deltoid isometric
strengthening. Distal strengthening.
C. Weeks 3 to 6
1. Supported AROM on tabletop, progressing to unsupported
AROM (Fig. 25-4, A and B). Continue with AROM in supine,
increasing the movement out of the gravity-eliminated plane
into gravity-challenged planes. For example, the patient starts
moving out of the place-hold position of 90 degrees with
small, controlled circles, gradually increasing the size of the
circle with gains in active control (Fig. 25-5). At the end of
week 6 to 8, AROM should be within normal limits.
2. Initiate light, gentle, active internal rotation at 4 to 5 weeks.
3. Continue to progress shoulder PROM (should be within
normal limits by week 4 to 6).
D. Weeks 6 to 10
1. Initiate light isotonic strengthening to shoulder with
Theraband exercises to be performed at the side or below
90 degrees (see Fig. 24-4, A and B in Chapter 24).
350 PA R T FO U R Shoulder

F I G . 25-2 Supine active-assisted place-hold exercise in 90 degrees flexion.

F I G . 25-3 Lightly resisted protraction in 90 degrees flexion.

C H A P T E R 25 Rotator Cuff Repairs 351

F I G . 25-4 A, Supported active range of motion (AROM) on tabletop. B, Unsupported

AROM.

2. Continue to progress shoulder strengthening to include

resistive exercises in all planes. Gradually work into
proprioceptive neuromuscular facilitation (PNF) patterns
with Theraband (see Fig. 24-4, C through H in Chapter 24).
3. Terminal stretching for full ROM
II. Open, mini-open with arthroscopic assist, or arthroscopic rotator
cuff repair for major tear repairs (1 to 5 cm) and massive tear
repairs (greater than 5 cm in healthy tissue with good repair)
A. Days 1 to 10
1. Patient education in pain management, positioning of
the extremity during sleep and at rest (in approximately
45 degrees scaption with a pillow placed between the sling
352 PA R T FO U R Shoulder

F I G . 25-5 Supine controlled active and active-assisted place-hold exercise with the
therapist setting parameters with increasing gravity-resisted planes.

and trunk), and instructions in a home exercise program of

pendulum exercises
2. Cold compression and HVG for pain and edema management.
The use of TENS, HVG, or an interferential unit with cold is
recommended as part of the patient’s home program for the
control of postsurgical pain and inflammation.
3. Immobilization in a sling with removal for hygiene and
exercises. Massive tear repairs, may only be allowed to remove
the sling or brace for exercise for the first month.
4. Initiate pendulum exercises on days 3 to 7.
5. Gentle shoulder PROM exercises performed to patient’s pain
tolerance and restricted to 160 degrees elevation in the
plane of the scapula and 60 degrees external rotation in
approximately 30 degrees scaption are initiated on days 3 to 7.
Massive tear repairs are limited to 100 degrees elevation in
the scapular plane and 35 degrees external rotation in
approximately 30 degrees scaption.
6. Initiate scapular stabilization exercises with emphasis on
serratus anterior and lower trapezius muscle function
(see Fig. 24-3, A and F in Chapter 24).
7. Distal AROM and grasp strengthening, including isometric
submaximal biceps strengthening.
8. Instructions in one-handed activities of daily living (ADLs)
and the use of adaptive equipment as needed.
B. Day 10 to 4 weeks
1. Continue with exercises described previously.
C H A P T E R 25 Rotator Cuff Repairs 353

2. Gradually wean from sling. Wait 4 weeks for major and

massive tear repairs.
3. Full PROM in flexion, scaption, and external rotation to
tolerance. Wait 4 to 6 weeks for major and massive tear repairs.
4. Initiate AAROM in scapular plane in supine (e.g., practice
place-hold, placing the shoulder in a gravity-eliminated position
while the therapist directs and supports the shoulder through
very controlled patterns of movement) (see Fig. 25-5). Also
initiate tabletop AAROM that the patient can perform as part
of a home exercise program (e.g., the patient uses uninvolved
side to assist involved side in forward flexion with a rolling
pin or towel) (Fig. 25-6).
5. Submaximal isometric shoulder exercises to be progressed at
the side and advanced to positions throughout the pain-free
range (Fig. 25-7, A and B)
6. Progress scapular stabilization exercises (see Fig. 24-3, E and F
in Chapter 24).
C. Weeks 4 to 6 (wait 6 to 8 weeks for major and massive tear repairs)
1. Continue with the exercises previously described.
2. Initiate gentle passive shoulder internal rotation.

F I G . 25-6 Standing active assistive forward flexion performed using a towel on

tabletop.
354 PA R T FO U R Shoulder

A B

F I G . 25-7 Submaximal isometric shoulder exercises performed at the side; may be advanced to positions away
from the side. A, Abduction at side. B, At 45 degrees.

3. Shoulder AROM. Progress from gravity-eliminated positions

in supine with the patient now moving gradually away from
90 degrees shoulder flexion, controlling the arm in wider
circles and in short arcs of motion returning to the
gravity-eliminated position (see Fig. 25-5). Also, progress to
supported tabletop activities, including use of the involved
side only, and eventually to nonsupported tabletop activities
(e.g., inclined pegboard) (see Fig. 25-4).
4. Initiate light functional ADLs below 90 degrees.
D. Weeks 6 to 8 (wait 3 to 6 months for major and massive tear repairs)
1. Light shoulder isotonic resistive exercises (e.g., light Theraband,
rubber tubing, 1 lb weight). Progress from positioning near
side to positions throughout the pain-free range
(see Fig. 24-4, A to H in Chapter 24).
2. Progress scapular strengthening exercises (e.g., rowing, push-up
plus against wall) (see Fig. 24-3, A to H in Chapter 24).
3. Stretch tight structures.
E. Weeks 8 to 10
1. Continue to increase isotonic resistive exercises if started at
6 to 8 weeks.
2. Initiate normal use in all light ADLs. Wait 10 to 12 weeks
for major and massive tear repairs. It may take 4 to 6 months
to return to use in most functional activities and up to 6 to
8 months to return to use in strenuous work or sports activities.
C H A P T E R 25 Rotator Cuff Repairs 355

III. Massive tear limited goal exercise program: This exercise program
avoids early overhead AROM exercises and exercises extending into
full rotation. The program stresses use of the arm at the side and
stability.
A. Day 2 to 1 month
1. Proximal immobilization with a sling; an abduction pillow or
brace may be used for the first 4 to 8 weeks for protection of
the repair.
2. Passive forward flexion performed on a daily basis; may be
limited to 100 degrees depending on the repair and treatment
goals
3. Distal strengthening
4. Instructions in one-handed ADLs and the use of adaptive
equipment as needed.
B. Months 1 to 3
1. Continued passive elevation; initiate passive external rotation
with the arm at the side (this may be limited to 20 degrees
depending on the repair and treatment goals).
2. Pendulum exercises
3. Use of the sling between exercise sessions
4. AAROM, progress to AROM (overhead AROM is delayed
until 51/2 to 6 months).
C. Months 2 to 3: Discontinue sling.
D. Months 3 to 4: submaximal isometric shoulder strengthening
E. Month 5: progressive resistive exercises
F. Month 6: activities as tolerated

POSTOPERATIVE COMPLICATIONS
I. Infection
II. Failed rotator cuff repair with residual impingement
III. Decreased AROM/deltoid weakness
IV. Adhesive capsulitis
V. Postoperative hematoma
VI. Severe pain

EVALUATION TIMELINE
I. Incomplete and major tear repairs
A. Day 3: pain (pain analog scale), posture, distal AROM and grip
strength, and ADLs
B. Day 3 to 3 weeks: PROM of shoulder in scaption, flexion, and
external rotation. Wait 4 weeks for passive internal rotation.
C. Week 6: isometric shoulder strength testing
II. Massive tear repairs
A. Day 3 to 1 month: pain (pain analog scale), distal ROM and
strength, and ADL skills
B. 1 to 3 months: passive shoulder elevation to 100 degrees and
external rotation to 20 degrees
C. 4 months: isometric shoulder strength testing
356 PA R T FO U R Shoulder

OUTCOMES
In a study by Rokito and colleagues,14 30 patients (17 with a large tear and
13 with a massive tear) underwent operative rotator cuff repair including
an open procedure, anterior-inferior acromioplasty, and partial bursec-
tomy. They were evaluated by isokinetic strength testing and the University
of California Los Angeles (UCLA) shoulder score before and after surgery.
More than 1 year was needed for strength recovery of a large and massive
rotator cuff tear, and the strength achieved was not equal to that of the
unaffected shoulder. According to the UCLA shoulder score, improvement
in the areas of function, ROM, and pain was significant, with 100% patient
satisfaction rating.
In a study by Burkhart and co-workers15 of 59 shoulders repaired arthro-
scopically, 95% of the patients had good to excellent results using a modified
UCLA scoring system. The authors concluded that results were not
dependent on tear size. All patients were able to return to overhead func-
tion in an average of 4 months.
A study of 108 patients with massive rotator cuff tears by Vad and
associates16 included 40 patients treated conservatively: 32 who underwent
arthroscopic debridement and 36 who underwent primary repair. The
authors reported that poor outcomes may be related to the presence of three
or more negative prognostic factors. These factors include the presence
of glenohumeral arthritis, decreased PROM, superior migration of the
humeral head, presence of atrophy, and external rotation and abduction
strength less than 3.
Ruotolo and Nottage’s17 review of publications comparing outcome dif-
ference for operative versus nonoperative treatment of rotator cuff tears
found satisfactory relief of pain in 50% of patients but no improvement in
strength at follow-up in nonoperative patients. With operative repair, 85% of
patients had a high rate of pain relief with a better return of strength.
Watson and Sonnabend’s18 outcome study included 667 open rotator
cuff repairs; patient self-assessment of satisfaction was very high (87.5%).
Hata and associates19 compared 36 patients subjected to conventional
open rotator cuff repair and 22 patients who underwent a mini-open repair;
there was no significant difference in UCLA shoulder scores between the
two groups at 1 year after repair. The mini-open repair group did signifi-
cantly better at the 3-month and 6-month assessments, with an earlier
return to activities.
Fealy and co-workers20 reported excellent results with surgical treatment
of 75 rotator cuff tears (30 large, 35 moderate, and 10 small) using a mini-
open rotator cuff repair and a two-row fixation technique. Patient satisfaction
based on primary level of function was 92.6%.
Grondel and colleagues21 performed retrospective study of 97 rotator cuff
tears in 92 patients age 62 years and older. Seven tears were treated arthro-
scopically, and 85 tears with the mini-open technique. Results based on the
UCLA shoulder scoring system were 54% excellent, 33% good, 8% fair, and
5% poor.

REFERENCES
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WB Saunders, Philadelphia, 1994
Donatelli RA: Physical Therapy of the Shoulder. 4th Ed. Churchill Livingstone,
New York, 2004
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technique: outcomes analysis in patients with small, moderate, and large rotator cuff
tears. Arthroscopy 18:665, 2002
Fenlin JM Jr, Chase JM, Rushton SA, et al.: Tuberoplasty: creation of an acromiohumeral
articulation—a treatment option for massive, irreparable rotator cuff tears. J Shoulder
Elbow Surg 11:136, 2002
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