R e habilit at i o n an d R et ur n t o

Wo r k a n d Sp o r t A f t e r
R o t a t o r C u ff
Adam Z. Khan, MDa,*, Kurt E. Stoll, MDa, Brandon J. Erickson, MDb

KEYWORDS
 Rehabilitation protocol  Rotator cuff repair  Postoperative shoulder stiffness
 Return to work  Return to sport  Professional and recreational athletes

KEY POINTS
 The goal of rehabilitation following rotator cuff repair is to minimize postoperative stiffness
while allowing adequate tendon healing.
 Customized rehab protocols for large to massive rotator cuff repairs and patients at
increased risk of stiffness should be considered.
 Patients successfully return to work between 59.5% and 97% of the time at an average of
5 to 9 months following rotator cuff repair. Heavy manual labor is a risk factor that consis-
tently has been associated with an inability to return to work and a prior level of work.
Maximal medical improvement is not reached until1 12 months after surgery.
 Return to sport following rotator cuff repair is fairly high, with approximately 85% of pa-
tients returning to some level of athletic activity at 4 to 17 months. However, not all pa-
tients are able to return to their prior level of activity.
 Overhead athletes, especially professionals, are at higher risk of not returning to their prior
level of competition.

REHABILITATION FOLLOWING ROTATOR CUFF REPAIR

Typical Rehabilitation Protocol and Timeline
As surgical techniques for rotator cuff repair continue to evolve, so do rehabilitation
(rehab) protocols. There are two primary factors that drive rehab protocols: the period
of postsurgical immobilization and the amount of early load at the repair site.1 The
goals of rehab are to allow healing of the repaired tendon while minimizing postoper-
ative stiffness.2 The development of the optimal rehab protocol involves the balance of
these factors and goals. Furthmore, the decision to emphasize certain patient factors
or rehab goals is specific to each individual patient.

a
Rothman Orthopaedic Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA;
b
Rothman Orthopaedic Institute, 645 Madison Avenue, 3rd and 4th Floor, New York, NY
10022, USA
* Corresponding author.
E-mail address: adamzkhan12@gmail.com

Clin Sports Med 42 (2023) 175–184

https://doi.org/10.1016/j.csm.2022.08.008 sportsmed.theclinics.com
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176 Khan et al

Typical rehab protocols involve the immediate use of an abduction sling following
rotator cuff repair. The sling is worn for 2 to 6 weeks depending on the surgeon and
protocol. Passive range of motion (PROM) begins within 3 weeks after surgery.
Both the therapist and patient may carry out the passive motion. Active and overhead
motion typically does not begin until after the sixth week following surgery. The use of
resistance exercises typically does not begin until at least the sixth week after surgery,
although may be prolonged depending on tear size and tissue quality. Regarding the
modalities used during rehab: elastic bands, body weight, gravity, and free weights
have all been reportedly used.3,4 Athlete and sport-specific protocols have been
proposed.

Principles of Rehab
The optimal rehab protocol remains uncertain although guidelines are available.1–9
The American Society of Shoulder and Elbow Therapists (ASSET) developed a
consensus statement with evidence-based guidelines.9 These recommendations
attempt to balance mobility with repair healing. Key recommendations were provided
and abbreviated here:6
 Protected PROM during the first 6 weeks following repair of a small to medium-
sized tear.
 Anatomic failure is associated with increasing age, poor tissue quality, fatty infil-
tration, muscle atrophy. Failure typically occurs the first 3 to 6 months after sur-
gery. This knowledge should be used when developing a rehab protocol.
 Supervised rehab should monitor external rotation (ER) in neutral abduction and
forward elevation (FE) as indicators of progress.
 Stiffness after repair at 1 year is uncommon but increased with diabetes, thyroid
disorders, preoperative adhesive capsulitis, partial tears, and acute tears. There-
fore, this population may benefit from additional focus on PROM during the early
rehab period.
 Muscle performance should begin with active range of motion (AROM) with the
extremity in a minimal gravity/stress position followed by progressive stresses.
 Patient education is important and should include short-term activity modifica-
tions and home exercises.
Furthermore, they provide a framework for a rehabilitation protocol that is broken
into phases. These phases are abbreviated as follows:9
Phase 1 (weeks 1–6)-Goal PROM
 PROM and pendulum swings.
 Therapist-assisted FE
 Self-assisted supine FE
 ER/internal rotation self-assisted with stick
Phase 2 (weeks 8–16)-Goal active assist range of motion (AAROM) and AROM
 Pulley FE
 Inclined dusting
 Ball roll on wall and upright wall slide
 FE with upright T-bar
 AAROM elevation
Phase 3 (weeks 12–20)-Goal Endurance
 Scapular rows

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 Work and Sport After Rotator Cuff 177

 Standing dumbbell ER at 0 abd, 10-rep max

 Elastic resistance shoulder flexion and elastic IR at 90
Phase 4 (>20 weeks)-Goal Strengthening
 Upright FE 3 to 4 lb, 10-rep max
 Side-lying dumbells with ER at 0
 Prone horizontal abduction and ER at 90
 Seated military press
There are several different treatment modalities used within these phases of rehab.
Type and length of immobilization after surgery remain controversial as stiffness is the
most common complication following repair.2 Animal studies show that immobilization
for at least 2 weeks results in less stiffness and increased range of motion with the the-
ory being that motion before 2 weeks results in increased scar formation.2,10
Regarding the arm position, typically an abduction sling is used with the belief that
this minimizes tension during the repair.2 Cryotherapy is often used for 2 weeks post-
operatively as it has been shown to improve pain control.2 Continuous passive motion
has also been used although no clear benefit has been shown.2

Effect of Tear Size/Repair Construction on Rehab Protocol

Customized rehabilitation protocols have been proposed.11,12 These include a more
conservative protocol for patients with large to massive rotator cuff repairs and an
accelerated program for those at an increased risk of stiffness. For the conservative
protocol, the patient remains in the sling for 7 weeks but is instructed to remove the
sling three times a day to perform the active motion of the hand, wrist, and elbow
as well as passive ER of the shoulder. Furthermore, strengthening is delayed until 3
to 4 months postoperatively. For the accelerated program the patient begins
closed-chained overhead motion immediately after surgery. Workers’ compensation
patients have worse outcomes following rotator cuff repair and can have a difficult
rehab process. Interestingly, the use of an online exercise program with a traditional
rehab program has been shown to improve outcomes and lower complication rate.9

RETURN TO WORK FOLLOWING ROTATOR CUFF REPAIR

Arthroscopic and the more traditional open rotator cuff repairs have shown excellent
outcomes and patient satisfaction in the literature.13–15 Return to work (RTW) following
rotator cuff repair is a typical topic of patient inquiry in the office setting during the pre-
operative discussion. Furthermore, in the past couple decades the incidence of rotator
cuff repair has increased drastically,16,17 with a preferential increase observed in pa-
tients aged 45 to 65,18 an age demographic that encompasses the primary family unit
income producer. Therefore, understanding the RTW timeline and factors associated
with the ability to RTW are essential for comprehensive patient counseling before ro-
tator cuff repair.
The ability to return to employment following rotator cuff repair has been quoted be-
tween 59.5% and 97% in both the US and international literature at an average time
point of 5 to 9 months.19–28 Of note, as many as 50% of patients are on light or
some form of restricted duty when they do return.26 Methodological differences, study
population heterogeneity, as well as the study length and follow-up discrepancy ac-
count for this wide variance between these quoted percentages. In addition, many
of the studies currently in the literature suffer from small study populations and poten-
tial for statistical fragility.

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178 Khan et al

Haunschild and colleagues27 performed a systematic review and meta-analysis of

13 studies that evaluated RTW following rotator cuff repair. They evaluated 1224 pa-
tients with an average age of 52.2 (standard deviation [SD] 4.9) years and found that
62.3% of patients were able to return to their prior level of employment at an average
of 8.15 (SD 2.7) months. Lower work intensity was associated with a higher likelihood
of returning to work (P < 0.001). Interestingly, there were similar RTW rates observed
between arthroscopic and open repairs (P 5 0.418). Nove-Josserand and col-
leagues28 also evaluated open versus arthroscopic repairs and found a trend toward
faster recovery in the arthroscopically repaired group (8.75 months vs 10.9 months),
but this was not found to be statistically significant.
Collin and colleagues29 evaluated RTW in 365 patients that underwent rotator cuff
repair assessing clinical as well as 6-month ultrasound outcomes. There was an
86.3% (315 of 365 shoulders) healing rate at 6 months. Interestingly, lack of tendon
healing was not a negative predictor of RTW at 6 months in this study. By 9 months,
94% of this cohort had returned to a prior level of activity and employment. Patients
that had evidence of bursitis on their 6-month ultrasound were also less likely to
RTW at that time point (P < 0.01). Factors associated with patients being unable to re-
turn to activity and work at 6 months (16.4% of patients) were female gender (P 5 0.04)
and a job involving heavy manual labor (P 5 0.04). Imai and colleagues23 reported
similar findings, showing a 66.7% RTW at 12 months postoperatively with female
gender (P 5 0.02) and physical labor (P 5 0.02) being risk factors for not returning
to prior employment.
Gowd and colleagues21 evaluated 89 patients who underwent arthroscopic rotator
cuff repair and found an average RTW of just under 7 months. Of these patients, there
was a higher rate of RTW in patients with sedentary jobs (100%) compared with pa-
tients that had light (84%), moderate (77.4%), and heavy (63.3%) duty labor. Further-
more, dominant hand injury was associated with reduced odds for RTW at full duty.
Patient’s insurance and their rotator cuff tear characteristics were not associated
with their ability to return to their prior level of employment. Poor preoperative mental
scores were a negative predictor of a patient’s ability to RTW. Singh and colleagues25
showed similar findings with an association between depression and inability to RTW
following rotator cuff repair. Few studies have evaluated this and further investigation
into the role of mental health and returning to prior employment following rotator cuff
repair is indicated.
Limited studies have evaluated acute, traumatic rotator cuff tears in isolation.
Aagaard and colleagues19 prospectively evaluated 32 consecutive patients that un-
derwent arthroscopic repair of an acute rotator cuff tear. They found that 97% (31/
32) of patients returned to work at a median of 5 months (1.1–10.5 months). On sub-
group analysis, 43.8% returned to a prior level of work and 31.3% initially altered their
work tasks but returned to their prior work level by 6 months. 21.9% of patients
returned with permanent lifting or overhead activity restrictions. Increased degree of
physical work showed a correlation with time away from work in this study. When their
dominant hand was involved, patients returned to work sooner; this findiing is in direct
contrast to other published studies.21,22
Following rotator cuff repair, patients fare similarly with regard to RTW compared
with other shoulder surgical procedures. Jayasekara and colleagues26 evaluated an
Australian database for RTW in 1773 patients in which 12 different surgical procedures
were performed. There was an overall RTW rate of 77% at 6 months postoperatively.
Of these different procedures, patients that underwent a rotator cuff repair and stabi-
lization, calcific tendonitis debridement, and bankart repair had the higher RTW at
90%, 86%, and 84%, respectively. Patients that underwent a synthetic patch

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 Work and Sport After Rotator Cuff 179

augmented rotator cuff repair or reverse shoulder arthroplasty has the lowest RTW
rates at 67% and 56%, respectively. Finally, patients that underwent an isolated rota-
tor cuff repair made up the majority of this cohort (1306 out of 1173 patients) and
matched the mean at 77% RTW at 6 months. Of the rotator cuff repair patients that
returned to work, approximately half of the patients were back to full duty, whereas
half were light duty or had work restrictions. In their risk factor analysis, younger
age, diminished preoperative stiffness and ability to work preoperatively were all pre-
dictors of successful RTW at 6 months after surgery.
There is some controversy in the literature on the effect of workers’ compensation
on a patient’s ultimate ability to RTW. In general, patients with a workers’ compensa-
tion claim that undergo rotator cuff repair do see significant improvement in their clin-
ical and functional outcomes, but this is to a lesser degree than the non-workers’
compensation population.30–32 Furthermore, a higher rate of postoperative noncom-
pliance has been reported in the workers’ compensation population.33 Gutman and
colleagues,22 however, showed excellent outcomes and an RTW rate of 84.2% in pa-
tients who underwent rotator cuff repair at an average follow-up of 5.4 years (range
2.1–8.8). Non-dominant arm injury and non-laborers had a higher likelihood of return-
ing to a prior level of employment.
In their meta-analysis, Hauschild and colleagues27 showed no significant difference
in RTW outcomes between workers’ compensation patients and the general popula-
tion. Work by Bhatia and colleagues20 was the main driver showing a high rate of RTW
in the worker’s compensation population (88.5%) with alcohol use as the only prog-
nostic factor for a return to restricted duty. However, it should be noted that the
most of the studies21,23,34,35 evaluating workers’ compensation patients show a trend
toward worse RTW outcomes compared with the general population.
In the authors’ practice, patients who perform desk work are allowed to RTW as
soon as they would like, as long as they do not have to drive themselves to work. Pa-
tients who need to lift with their operative arm and have no option for desk work are
delayed 3 months or more before they can return and are put on lifting restrictions
for the first 4 to 6 months after surgery.

RETURN TO SPORT FOLLOWING ROTATOR CUFF REPAIR

Chronic degenerative changes are the most common pathologic mechanism in pa-
tients with rotator cuff tears, yet in younger patients and athletes the injury mechanism
is typically a result of repetitive overhead activities or acute traumatic injuries. Rotator
cuff tears are not uncommon in recreational and competitive athletes alike. Among
NFL combine invites, rotator cuff tear was the third most common shoulder pathology
with a quoted 12% incidence.36 Therefore, understanding the rate of return to sport
(RTS) following rotator cuff repair in this population, and identifying factors associated
with the successful return are important for the treating surgeon to understand.
Kloche and colleagues37 performed a systematic review and meta-analysis of RTS
following rotator cuff repair. They evaluated 859 patients, 635 of which were athletes
(286 competitive/professional) and had a mean follow-up of 3.4 years (range 0.3–13.4).
Overall, there was an 84.7% RTS and 65.9% return to a prior level of play at a range of
4 to 17 months. Only 49.9% of professional and competitive athletes returned to the
same level of play.
The distinction between professional and recreational athletes and their ability to re-
turn to their prior level of sport is an important one for surgeon consideration and pa-
tient counseling. Similar to the findings of Klouche and colleagues,37 most of the
literature supports that following rotator cuff repair, fewer higher level and professional

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180 Khan et al

athletes return to their prior level of play compared with recreational athletes.38–42 Alti-
natis and colleagues43 performed a systematic review of 15 studies, including 468 pa-
tients, who underwent arthroscopic rotator cuff repair with a mean follow-up of
40.1 months (range, 18–74.4 months). Overall, there was a high rate of RTS at
85.5% with RTS at the same level or higher being 70.2%. Stratified by athlete type,
RTS at the same level or higher was 73.3% among recreational athletes and 61.5%
among competitive athletes; however, this difference was not found to be statistically
significant. Methodologically, this study included a broader definition of a competitive
athlete compared with Klouche and colleagues,37 which could potentially account for
the slight difference in findings. Professional athletes have higher physical demands
and expectations for their shoulder function, which likely accounts for the lower rates
of return to the same level of play for this population.
Antoni and colleagues44 evaluated a cohort of 76 recreational athletes following ro-
tator cuff repair. They reported an 88.2% RTS activity with 68.4% of patients returning
to their same preoperative sport at 6 months (SD 4.9 months) postoperatively. 77.6%
of patients returned to their prior or higher level of sports activity. Preoperative sports
intensity of less than 2 hours per week or pain for more than 9 months preoperatively
were negative predictors for returning to a prior level of activity.
Sport-specific considerations and demands are paramount to the evaluation of pa-
tients before consideration of rotator cuff repair surgery. Overhead athletes, especially
baseball pitchers, put supraphysiologic loads on the shoulder during competition.
Therefore, even a small loss of strength or range of motion can make a significant
impact on their ability to return to their prior level of play following surgery. In their
study evaluating RTS following rotator cuff repair, Altinas and colleagues43 evaluated
a subset of 43 baseball and softball players. In this subset, they found 79% RTS, yet
only 38% returned to a prior level of play. Erickson and colleagues38 evaluated 151
professional baseball players who underwent surgery for rotator cuff pathology. Rota-
tor cuff debridement was performed in 86% of cases and RTS was low at 50.8% in the
debridement group and 33.3% in the rotator cuff repair group. Interestingly, patients
that had a debridement performed and RTS saw a decline in performance, but rotator
cuff repair patients that successfully RTS did not see a decline in performance. It
should also be noted that most of the rotator cuff repairs were performed in outfielders
and only one pitcher had a rotator cuff repair performed. Mazoue and colleagues42 has
shown very poor outcomes and return to prior level play (8%) in professional pitchers
following rotator cuff repair.
Tennis has shown mixed results with regard to RTS following rotator cuff repair.
Sonnery-Cottet and colleagues45 evaluated 42 tennis players that underwent rotator
cuff repair and 9 that underwent debridement. At an average of 10 months, 78% of
players were able to return to tennis. Bigiliani and colleagues46 showed similarly pos-
itive results with 22 out of 23 patients (95.6%) returning to tennis at an average of
39 months follow-up with 82.6% returning to their prior level of play. In contrast, a
small series evaluating 8 professional female tennis players showed that although
87.5% were able to return to play, only 2 out of 8 (25%) were able to return to their prior
level of competition and pre-injury ranking.40
Other sports have been assessed and shown positive results with regard to RTS.
Shimada and colleagues47 evaluated 32 shoulders following rotator cuff repair in pa-
tients that were swimmers with a mean age of 65 at 47-month follow-up (range, 24–
86 months). They found a 97% return to swimming at 8 months, with only 56% return-
ing completely. There was stroke-specific discrepancy, with 97% of patients being
able to return to freestyle and only 44% of patients being able to return to butterfly.
Decreased active FE was a risk factor for the inability to return to the preinjury level

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 Work and Sport After Rotator Cuff 181

of swimming. Simon and colleagues48 evaluated 12 rock climbers that underwent

arthroscopic rotator cuff repair at an average 27-month follow-up (range 12–
72 months). 91.7% were able to return to rock climbing. In CrossFit athletes, 100%
return to participation (22 out of 22) at a mean of 8.7 months (SD 3.4 months).49
Davey and colleagues50 evaluated 20 athletes under the age of 30 that had under-
gone rotator cuff repair. They found an 85% RTS at a mean of 5.8 months (SD 2.8),
with a 50% return to the same level of competition. They also evaluated a subset of
collision athletes and interesting found a 93.3% return to play in these patients with
60% returning to their same level of competition. Bhatia and colleagues51 evaluated
outcomes following rotator cuff repair in patients over the age of 70. They found a
77% rate of RTS in this patient population. Age does not seem to be a significant
risk factor for patients with RTS following rotator cuff repair.

CLINICS CARE POINTS

 For massive rotator cuff repairs, customized rehab protocols should be considered to support
healing
 Between 59.5% and 97% of patients return to work at an average of 5 to 9 months
postoperatively; heavy manual labor is a risk factor for not returning to a prior level of work
 There is some controversy, but a general trend toward lower RTW rates in patients with a
worker’s compensation claim
 There is good return to sport rates at or more than 85% following rotator cuff repair. Not all
patients will return to a prior level of play
 Overhead athletes, especially baseball players, are at a high risk of not returning to a prior
level of play following rotator cuff repair
 Professional athletes return to their pre-injury level of play at a lower rate than recreational
athletes

DISCLOSURE

A.Z. Khan: This author, their immediate family, and any research foundation with which
they are affiliated did not receive any financial payments or other benefits from any
commercial entity related to the subject of this article. K.E. Stoll: This author, their im-
mediate family, and any research foundation with which they are affiliated did not
receive any financial payments or other benefits from any commercial entity related
to the subject of this article. B.J. Erickson: AAOS: Board or committee member Amer-
ican Orthopedic Society for Sports Medicine: Board or committee member American
Shoulder and Elbow Surgeons: Board or committee member Arthrex, Inc: Paid
consultant; Research support DePuy, A Johnson & Johnson Company: Research sup-
port Linvatec: Research support PLOS One: Editorial or governing board Smith &
Nephew: Research support. Stryker: Research support.

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