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Narrative Review

Rotator cuff repair: considerations of surgicalcharacteristics and evidence basedinterventions for improving muscleperformance

Patrick Pabian1, Carey Rothschild1, Randy Schwartzberg2

1Department of Health Professions, University of Central Florida, Orlando, FL, USA, 2Orlando OrthopaedicCenter, Orlando, FL, USA

Background: Rotator cuff tears may lead to significant limitations in function, pain and disability. The extentof recovery from surgical intervention and subsequent rehabilitation can vary depending on the com-plexities of the tear, repair procedure, and post-operative patient management. Evidence suggests thattear and surgical characteristics will influence patient presentation in terms of strength and function, andthus need to be considered when healthcare professionals design rehabilitation programs.Objectives: The objective of this manuscript is to present evidence-based rehabilitation guidelines formanagement of patients following repair of full-thickness rotator cuff tears, while taking into considerationthe method of repair and the characteristics of the rotator cuff defect.Major findings: Many studies have examined different characteristics of rotator cuff tears, various surgicalprocedures to correct the deficits, and physical interventions that target the specific range of motion andstrength deficits post rotator cuff repair. A significant number of investigations have reported muscle activationlevels with exercises and daily activities, which may offer a prescriptive utility to the clinician providing post-operative management. However, there are insufficient evidence-based rehabilitation programs that considerthe characteristics of the rotator cuff tear defect or method of repair when addressing the post-operativeclinical presentation, related impairments, functional limitations and interventions.Conclusion: Rotator cuff tears and repairs have various characteristics that can impact patient recovery.Optimal recovery is dependent on appropriate communication among healthcare professionals and arehabilitation professional’s understanding of how the tear classifications and surgical management caninfluence the standard treatment plan for rotator cuff repair.

Keywords: Rotator cuff tear, Rotator cuff repair, Rotator cuff facilitation, Rotator cuff strength

IntroductionRotator cuff tears may result in significant shoulder

dysfunction and functional impairments. Patients

with tears can have various clinical presentations,

which are attributed to numerous factors, including

the characteristics of the rotator cuff defect. Surgical

repair of the rotator cuff aims to restore the damaged

tendon, reduce pain, and ultimately improve func-

tion. Physical therapists and other rehabilitation

professionals have examined the post-operative ma-

nagement of patients post rotator cuff repair and

developed interventions to improve function in this

population. Variables that have been shown to highly

correlate with improved function are integrity of the

repaired rotator cuff1 and strength.2 The objectives of

this manuscript are to review the outcomes of the

various methods of rotator cuff repair, identify tear

characteristics or repair procedures that could impact

rotator cuff healing and patient recovery, and to pre-

sent evidence-based rehabilitation strategies and guide-

lines for management of rotator cuff strengthening in

patients after surgical repair.

Rotator Cuff Tear CharacteristicsRotator cuff tears individually are assessed using

several parameters. These parameters include tear

size, tear shape, and tissue quality. The combination

of these elements of a rotator cuff tear makes up the

personality of that given tear. The unique personality

of a rotator cuff tear and subsequent repair are

worthy of individualized consideration in the reha-

bilitation phase. Rotator cuff tears are classified as

Correspondence to: Patrick Pabian, University of Central Florida, 4000Central Florida Blvd, HPA 1 Rm 256, Orlando, FL32816-2205, USA.Email: [email protected]

374� W. S. Maney & Son Ltd 2011DOI 10.1179/1743288X11Y.0000000044 Physical Therapy Reviews 2011 VOL. 16 NO. 5

full-thickness, or partial thickness, depending upon

depth of the defect in the tendon. This manuscript

will focus on full-thickness tears. In addition, patient

factors such as patient smoking status and medical

comorbidities should also be considered in the

evaluation of rotator cuff repair and rehabilitation.

Although outside the scope of this manuscript, it is

important to recognize that diabetes mellitus,3–5

smoking,6 and worker’s compensation3,7 all have

been correlated with poorer outcomes post rotator

cuff repair when compared to subjects without these

factors.

Rotator cuff tear size is often measured by the

maximum diameter and cross-sectional area of the

involved region of the tendon. Different diameters

have been utilized to create classifications such as

small, medium, large, and massive rotator cuff tears.

The most commonly utilized classification system

involving tear size was originated by DeOrio and

Cofield, who defined measures as small (,1 cm),

medium (1–3 cm), large (3–5 cm), and massive

(.5 cm) rotator cuff tears.8 Classifications such as

this provide descriptive size data but lack important

attributes such as tear location or degree of retrac-

tion. In this regard, a classification that examines

the degree of frontal plane retraction is the Patte

classification.9 A study examining the interrater

reliability among 12 fellowship-trained orthopedic

surgeons utilizing these classifications found a fair

agreement (k50.32) in the DeOrio and Cofield

classification and a moderate agreement (k50.54) in

the Patte classification.10 The findings of this study

suggest acceptable practical use of these classification

systems. The benefit of doing so may outweigh the

risks. Larger-sized rotator cuff tears, tears involving

multiple tendons, and increased degree of retraction

have been correlated with increased failure rates.11–15

An additional consideration related to size is the

involvement of additional tendons (or location) of the

tear. Tears involving the infraspinatus or teres minor

have been found to have a greater incidence of

re-tears1,16 and due to these tendon involvements,

require more protection and slower progression in

internal rotation range of motion and external

rotation strengthening exercises.17 Due to these find-

ings and potential changes in operative and post-

surgical management, various classification systems

involving topographic features have been proposed.18–20

The utilization of these topographic classifications

in describing rotator cuff tears could provide signifi-

cant benefit to rehabilitation professionals. Larger

rotator cuff tears carry increased risks of failure,

re-tear, and reduced functional outcome.13,15,21 There-

fore, modification of standard rehabilitation programs

to account for these topographic characteristics has

been the focus of recent literature.17,21

Rotator cuff tears have been classified further

based on their shape. Lo and Burkhart22 described

and reviewed surgical management of tears based on

these shapes. Two general categories have been

identified. First, the crescent shaped tears involve

rotator cuff tendons torn away from their humeral

head insertions (Figs. 1A, 2, and 3). Repair of these

tears involves reattachment of the tendons to their

humeral head attachments (Fig. 1B). The second

category of tears involves tearing between tendons in

addition to tendon tearing from bone. These tears

can be U-shaped (Figs. 4A and 5) or L-shaped tears

Figure 1 Crescent-shaped rotator cuff tear. (A) Superior

view of a crescent-shaped rotator cuff tear involving the

supraspinatus (SS) and infraspinatus (IS) tendons; (B)

repaired crescent-shaped tear.22 Adopted from: Lo, IK and

Burkhart, SS, American Journal of Sports Medicine (volume

31, issue 2, pp. 308–324), copyright� 2003 by SAGE

Publications. Reprinted by Permission of SAGE Publications.

Figure 2 Arthroscopic picture of crescent-shaped tear.

Figure 3 Arthroscopic picture of crescent-shaped tear.

Pabian et al. Rotator cuff repair

Physical Therapy Reviews 2011 VOL. 16 NO. 5 375

(Fig. 6A). U- and L-shaped tears require suturing of

the tendon split, often termed ‘margin convergence’,

followed by reattachment to the bone.23,24 The

biomechanics of repairing U-shaped and L-shaped

tears involves decreasing the marginal tear strains

with side-to-side suturing. This converts the tear into

a crescent shaped tear that is repaired to bone

(Figs. 4B, 4C, 6B, 6C, and 7). Although post-

operative rehabilitation implications have not been

specifically studied for repair of these different

rotator cuff tear shapes, surgical outcome studies24–

27 have been used to provide a link of these geometric

classifications to prognosis.18

Standard repair of the rotator cuff involves either

one or both of the following: tendon to bone repair or

tendon to tendon repair. Suture anchor fixation

(tendon to bone) has shown to have strong biome-

chanical properties.28,29 Side to side repairs (tendon

to tendon) have been shown to be effective in

reducing the cuff deficit and provide good patient

outcomes,30,31 but the tendon-suture interface has

often been found to be a common point of failure in

unsuccessful repairs.32 Thus, it may be prudent to

progress more cautiously in the early rehabilitation

phases with U-shaped and L-shaped tears that

necessitate tendon-to-tendon suturing.

An additional consideration of a rotator cuff tear

that impacts the complexity of the tear and sub-

sequent repair and recovery is tissue quality. Tissue

quality of tendon, muscle, and bone all need to be

Figure 4 U-shaped rotator cuff tear. (A) Superior view of a U-shaped rotator cuff tear involving the supraspinatus (SS) and

infraspinatus (IS) tendons; (B) U-shaped tears demonstrate excellent mobility from an anterior-to-posterior direction and are

initially repaired with side-to-side sutures using the principle of margin convergence; (C) the repaired margin is then repaired to

bone in a tension-free manner.22 Adopted from: Lo, IK and Burkhart, SS, American Journal of Sports Medicine (volume 31, issue

2, pp. 308–324), copyright� 2003 by SAGE Publications. Reprinted by Permission of SAGE Publications.

Figure 5 Arthroscopic picture of U-shaped tear.

Figure 6 Acute L-shaped rotator cuff tear. (A) superior view of an acute L-shaped rotator cuff tear involving the supraspinatus

tendon (SS) and rotator interval (RI); (B) the tears should be initially repaired along the longitudinal split; (C) the converged

margin is then repaired to bone. IS, infraspinatus; Sub, subscapularis tendon; CHL, coracohumeral ligament.22 Adopted from:

Lo, IK and Burkhart, SS, American Journal of Sports Medicine (volume 31, issue 2, pp. 308–324), copyright� 2003 by SAGE

Publications. Reprinted by Permission of SAGE Publications.


376 Physical Therapy Reviews 2011 VOL. 16 NO. 5

considered. Tissue quality can be assessed through

preoperative magnetic resonance imaging (MRI),

evaluating for muscle atrophy and fatty infiltration

or degeneration. The degree of fatty degeneration has

been identified as a major prognostic factor for the

outcome of rotator cuff repair.13 Therefore, rehabi-

litation following repair should be conservative in

patients with poor tissue quality.17

Rotator Cuff Repair ConsiderationsFrom a surgical repair procedure standpoint, rotator

cuff repairs can be evaluated based on the surgical

approach (arthroscopic vs mini-open vs open) and on

the fixation method (single vs double row fixation).

Each of these variables contributes to the makeup of

a given rotator cuff repair.

Initially rotator cuff repairs were performed in an

open fashion. This approach involved the detachment

of the deltoid origin from the anterior acromion,

resection of a portion of the anterior acromion,

rotator cuff repair and reattachment of the anterior

deltoid to the remaining anterior acromion through

drill holes. Post-operative protection for the deltoid

reattachment is critical with this open approach.33

Mini-open repair was initiated to address the

needed precautions and potential failure of the deltoid

repair. During the mini-open repair procedure, the

deltoid muscle is split vertically along the orienta-

tion of the muscle fibers to allow for visualization and

repair of the torn rotator cuff tendon. Acromioplasties

performed with the mini-open approach are typically

performed arthroscopically.34 Numerous studies have

supported this procedure with good to excellent results

in approximately 90% of patients.35–38

Arthroscopic rotator cuff repair is the least invasive

surgical repair method. It involves no formal incision,

no deltoid detachment and no open deltoid split.

Arthroscopic rotator cuff repair provides the best

visualization of the rotator cuff of the three repair

methods.39,40 Studies comparing repair methods often

focus on arthroscopic versus mini-open repair. These

studies compare repair integrity through follow up

MRI, computed tomography and clinical outcomes

scores. A retrospective, study by Sauerbrey et al.41

compared 54 patients post-arthroscopic repair versus

mini-open repair at a minimum of 13 months post-op.

The groups in this study were homogenous in relation

to age (57/56 years), and tear size (2.0/2.7 cm2). This

study found no differences in pain, patient satisfaction,

or function between the mini-open and arthroscopic

procedures.

Anatomic healing of the rotator cuff is an obvious

goal of rotator cuff repair. Interestingly, some studies

have shown high clinical outcome scores despite radi-

ologically documented rotator cuff repair failures.11,42

Despite this, it is generally accepted that healed rotator

cuff repairs offer a greater chance at better clinical

outcomes in terms of pain, function, and strength.1,43

Arthroscopic rotator cuff repair healing rates have been

assessed and compared to open techniques. In a

comparison study and meta-analysis, it has been shown

that arthroscopic rotator cuff repair healing rates have

been equal to healing rates with the mini-open

techniques.41,44 Repair approaches do not correlate with

failure rate. Factors that consistently correlate with

higher rotator cuff repair failure rates include increasing

age and greater tear sizes.11,15,45

The personalities of rotator cuff repairs engender

further complexity as surgical fixation techniques are

discussed. The variety of surgical techniques involves

tendon fixation options to the humeral head inser-

tions. A landmark improvement in fixation to bone

was the development of the suture anchor. Suture

anchors are placed into bone. They have sutures in

them that pass through eyelets. The sutures are

passed through the tendon and tied to fix the tendon

to the bone. Suture anchors typify modern rotator

cuff fixation to bone.40

Suture anchor fixation methods can be divided

into single and double row repairs. Single row

repairs involve one row of anchors in an anterior

to posterior direction along the tear insertion site.

Double row repairs are defined by one row of

anchors placed along the medial margin of the tear

insertion site and another row of anchors placed

along the lateral margin of the tear insertion site

(Figs 8 and 9). Double row repairs were developed

due to the belief that single row suture anchor

techniques did not adequately restore the supraspi-

natus to its footprint insertion, leading to inadequate

healing.46,47 Double row constructs not only have

been proven to reproduce the insertion anatomy

better, but also have been shown to be biomechani-

cally superior to single row repairs.29,48,49 In addi-

tion, a systematic review examining 1252 repairs

found that double row repairs of tears greater than

1 cm have been found to have significantly lower

anatomical failure rates based on MRI and ultra-

sound evaluations.50 Despite these advantages of

Figure 7 Arthroscopic picture of margin convergence of a

U-shaped tear.



double row rotator cuff repair constructs, some

studies have found that they have not been demon-

strated to result in better clinical outcomes scores

than their single row repair counterparts.51–54

Regarding post-operative rehabilitation progres-

sions for single versus double row rotator cuff

repairs, the progressions should be predicated on

characteristics other than the repair technique. The

differences in anatomical healing rates have not been

explored with use of different rehabilitation protocols

for single versus double row repairs. As previously

noted, clinical presentation may be affected by any of

the tear characteristics, surgical repair procedures, or

patient factors. Rehabilitation professionals will need

to recognize the factors making up the rotator cuff

tear personality and design the rehabilitation pro-

gram in accordance with individualized attention.

Post-operative RehabilitationThe rehabilitation program following rotator cuff

repair may be broken down into three main phases:

(1) maximum protection/passive, (2) moderate protec-

tion/active, and (3) minimum protection/resistive. The

rate at which a patient progresses through these phases

is dependent upon numerous factors related to the

patient and surgical characteristics as previously

discussed. These include the following: size, shape,

and location of the tear, surgical procedure, tissue

quality, and additional patient factors (age, co-morbid-

ities, smoking, etc.). Therefore, variance exists between

the rates at which patients can progress through the

rehabilitation programs. The authors recognize that

various rehabilitation protocols have been published

and may conflict with one another.

The goal of the first phase or rehabilitation pro-

grams for rotator cuff repair is to prevent post-operative

stiffness and scar tissue adherence while allowing for

tendon to bone healing.21 This phase typically begins

with shoulder immobilization and lasts 0–6 weeks.

Phase two progresses over weeks 7–12 and consists of

passive to active exercises for the rotator cuff

musculature and scapular stabilizers.21 The third

phase begins after week 12 and includes the addition

of strengthening exercises and progression to func-

tional activities. Various exercises have been identified

as appropriate during each of these phases post rotator

cuff repair. Naturally, with the association of poorer

outcomes with muscle atrophy of the infraspinatus

and supraspinatus,2 it is often the focus of rehabilita-

tion professionals to utilize tactics that will best

facilitate and eventually strengthen these rotator cuff

muscles. Activation and facilitation of the rotator cuff

and scapular musculature is best demonstrated

through muscle activity analysis using electromyogra-

phy (EMG). Therefore, it is our intention to provide a

comprehensive rotator cuff repair rehabilitation pro-

tocol consisting of exercises based upon EMG activity

while encouraging readers to keep in mind the con-

siderations of tear and surgical characteristics as

previously discussed. Rehabilitation guideline time-

frames are provided with the assumption of a me-

dium sized tear; smaller or larger tears will warrant

appropriate alteration of these timeframes.

The analysis of muscular activity through the use

of EMG involves the muscle’s response in relation to

its maximal voluntary isometric contraction (MVIC).

Therefore, prior to determining the effectiveness

of a particular exercise in facilitating a muscular

response, the muscle is tested for its MVIC. The

normalized mean value for a particular exercise can

be expressed as a percentage of the MVIC; the

higher the percentage, the higher muscle activity

recorded. General categories have been developed to

assist in classifying the amount of muscle activity.

McCann et al.55 suggest the following interpretation

of the percentage of MVIC: minimal activity ,20%

MVIC, moderate activity 20–50% MVIC, and

marked activity .50% MVIC. Uhl et al.56 suggest

a different scale: low activity ,20% MVIC, moder-

ate activity 20–40% MVIC; high activity 41–60%

MVIC; and very high .60% MVIC. These scales can

be useful in determining appropriateness of various

exercises and activities in each of the phases of a

rotator cuff rehabilitation program. Based on these

Figure 8 Arthroscopic picture of double row repair of a

crescent-shaped tear.

Figure 9 Arthroscopic picture of double row repair of a

U-shaped tear.



findings, the authors of this manuscript recommend

the following: (1) exercises in phase one should

demonstrate minimal activity (less than 20% MVIC)

in the rotator cuff musculature; (2) exercises in phase

two should demonstrate moderate activity (20–40%

MVIC) in the rotator cuff and scapular musculature;

and (3) exercises in phase three should demonstrate

high activity (41–60% MVIC) in the rotator cuff and

scapular musculature in order to maximize gains in

returned strength.

Maximum protection phase/passive exercise(weeks 0–6)Immobilization

Shoulder immobilization is recommended in the

maximum protection phase following rotator cuff

repair regardless of the tear characteristics or method

of surgical fixation. Hatakeyama et al.57 identified

that tensile forces on the repaired rotator cuff tendon

were less at 45 and 30u compared to 15 and 0u of

shoulder abduction. Additionally, strain was lowest

in the scapular plane versus the sagittal plane for all

four abducted positions. Therefore, an abductor

pillow brace with the shoulder supported between

30 and 45uof abduction in the scapular plane is

recommended for patients following rotator cuff

repair. Immobilization has been recommended for 3

weeks and then only discontinued as determined by

the surgeon or physical therapist.17 Suggested reha-

bilitation exercises are included in Table 1, with

evidence for maximum protection phase interventions

included in Table 2.

Pendulum (Codman’s)

In addition to active movement of the hand, wrist

and elbow, the maximum protection phase usually

consists of passive movement and light activity of

daily livings (ADLs) for the operative extremity. The

pendulum exercise, also known as Codman’s, is a

typical exercise performed in this phase. Caution,

however, should be taken when performing this

exercise. Long et al.58 found that smaller pendulums

(less than 20 cm in diameter) are safer post rotator

cuff repair than larger pendulums (greater than 51 cm

in diameter) due to .20% MVIC produced in the

infraspinatus and supraspinatus muscles with the

larger motion. In addition, researchers have indicated

that even the support by the contralateral limb on the

table may cause greater than minimal supraspinatus

activity.17,58 Due to the potential for increased strain

as described, it is recommended that the pendulum

exercise be appropriately instructed and performed to

effectively protect the integrity of the healing rotator

cuff tendon regardless of tear type, tear size, or

method of fixation.

Table 1 Suggested rehabilitation exercises

Maximum protectionphase/passive exercise

Immobilization in abductor pillow brace withshoulder in 30–45u in scapular plane

(0–6 weeks) CPM machine in combined elevation and ERSupine self-assisted elevation with stick or contralateral armSupine ER/IR with stickPROM by PT: elevation (in scapular plane), ER, IRUpright pulleyUpright pendulum in small diameter ,20 cmADLs with involved arm: typingADLs with uninvolved arm: cross-body reaching, slowforward reaching and downward reachingClosed chain: Prayer and Quadruped positionsGentle scapular exercises: depression, protraction ONLYSerratus: cross-body rotations with uninvolved arm at lowerheights with/without steppingAquatic exercises: elevation in the scapular plane at slow speeds(30–45u/second); buoyancy assisted FF, ER; scapular stabilization; pendulumsAVOID AROM of the involved armAVOID isometrics during maximum protection phase55

Moderate protectionphase/active exercise

Progressive scapular exercises: inferior glide, low row, ‘Lawnmower’,‘Robbery’; (1) SL ER, (2) SL FF, (3) prone HABD, and (4) prone EXT

(7–12 weeks) Isometric exercises (5 directions) with/without NMESActive rotator cuff exercises: supine active elevation, upright elevationwith elbow bent and straight, upright abduction

Minimum protectivephase/resistive exercise

Resistive exercises with DB: (1) elevation, elbow bent and straight;(2) abduction; (3) prone ER; (4) SL ER; and (5) standing ER in scapularplane, 90u, and/or 0u (with/without towel roll)

(12 weeks and beyond) Resistive exercises with elastic bands: (1) ER elbow moving fixed; (2) IR;(3) forward elevation; and (4) EXTAdvanced scapular stabilizer exercises: push-up plus, dynamic hug,prone arm raise overhead, shoulder ABD in the plane of the scapula above 120u

Note: CPM, continuous passive motion; ER, external rotation; IR, internal rotation; PROM, passive range of motion; ADL, activity of dailyliving; FF, forward flexion; AROM, active range of motion; SL, sidelying; HABD, horizontal abduction; EXT, extension; NMES,neuromuscular electrical stimulation; DB, dumbbell.



Light ADLs

The EMG activity of the rotator cuff musculature has

been studied during various ADLs deemed appropriate

in maximum protection phase. Long et al.58 deter-

mined that typing with the surgically-repaired extre-

mity required minimal activity of the supraspinatus,

infraspinatus, and deltoid muscles. However, drinking

from a cup and brushing teeth require moderate

supraspinatus activity. Therefore, it is recommended

that the uninvolved extremity complete these activities

instead. Generally, contralateral limb movements for

ADLs at self-selected speeds are unlikely to harm

healing tissue.59 However, Smith et al.59 found that

fast straightforward reaching with the uninvolved limb

Table 2 Evidence for maximum protection phase

Maximum protection phase/passive exercise

Exercise Study Comments Implications

Supine self-assisted elevation McCann et al.,55

Dockery et al.60Phase 1 exercises as described byNeer (1987): min mm activity (,20% MVIC)in infraspinatus, supraspinatus,anterior/middle/posterior deltoid, serratusanterior, middle trapezius, and biceps; supineexercises preferred over upright due tointersubject variability in this study

Considered safe in maximumprotection phaseSupine helper-assisted

elevationSupine ER with stickSupine helper-assisted ERUpright pendulumUpright pulleyCPM machine Dockery et al.60 All exercises produced low MVIC in rotator

cuff muscles (,20%) except moderate MVIC(25.2%) in deltoid with pulley exercise

CPM and PT PROM safer forpassive motion and repairprotection; all consideredsafe in this phase

PulleyPendulumSelf-assisted elevationwith other armSelf-assisted IR andER with barPT-assisted elevation inscapular plane and ER/IRPendulums Long et al.58 Larger pendulums performed incorrectly

generate more supraspinatus activity thansmaller, correctly performed pendulums;smaller pendulums (20 cm diameter) saferpost rotator cuff repair

Considered safe in maximumprotection phase, however,recommend supervisedexercise; caution: Contralaterallimb support on a table maycause supraspinatus activation58

Light ADLs withinvolved UE

Long et al.58 Typing ok Typing ok with involved UE,however, caution with drinkingand brushing teeth withpost-operative arm

Brushing teeth and drinking from a cuprequire moderate supraspinatus activity

ADLs with uninvolved UE: Smith et al.59 Avoid fast straightforwardreaching and pulling motionswith non-involved arm;cross-body reaching, slowstraightforward reaching anddownward reaching byuninvolved arm safe andactivate lower trapezius asa scapular stabilizer

1. Straightforward reaching 1. Fast straightforward reaching withnon-involved limb can cause potentialinfraspinatus stress (.20% MVIC);

2. Pulling motions 2. Resisted pulling motions with non-involvedarm (i.e. opening doors, starting lawnmowers,and pulling carts and objects) can causepotential stress to supraspinatus (.20% MVIIC);

3. Cross-body reaching 3. Cross-body reaching by uninvolved arm OKas MVC in anterior deltoid, supraspinatus,and biceps ,10% MVC;

4. Downward reaching 4. Downward reaching similar EMG activityas cross-body reaching.

Closed chain prayer andquadruped positions

Uhl et al.56 Low (,20% MVIC) of deltoidand infraspinatus

Will facilitate co-contractionearly in post-op rehab

Gentle scapular exercises Smith et al.62,64 Isolated scapular depression and protractionstanding in immobilizer sufficient to strengthenserratus anterior and trapezius while maintaining,20% MVIC in infra/supraspinatus, anteriordeltoid and biceps; avoid scapular clock,elevation, and retraction as .20% MVIC

Kinetic chain exercises Smith et al.64 Cross-body rotations at low or medium heightswill generate clinically significant EMG activityin serratus anterior while producing safe levelsof activation in supra/infraspinatus, biceps andanterior deltoid (,20% MVIC)

Better serratus anterior activatorthan scapular depressionand protraction

Aquatic exercises Kelly et al.66 Elevation in the scapular plane at slow speeds(30–45u/second) safe as MVIC in the rotatorcuff and deltoid ,20%

Elevation in the scapular plane atslow speeds (30–45u/second) safe

Aquatic exercises Brady et al.65 Accelerated restoration of PROMin FF and quality of life in landprogram with aquatic therapy

Buoyancy assisted FF, ER; scapularstabilization; pendulums are all safeand appropriate exercises

Note: CPM, continuous passive motion; ER, external rotation; IR, internal rotation; PROM, passive range of motion; ADL, activity of dailyliving; FF, forward flexion; SL, sidelying.



could cause potential infraspinatus stress as shown by

.20% MVIC in EMG. This occurs as the surgically-

repaired extremity retracts and externally rotates to

counterbalance the reach. Resisted pulling motions

with the uninvolved arm (i.e. opening doors, starting

lawnmowers, and pulling carts and objects) should

also be avoided as potential stress to the supraspinatus

has been observed by EMG (.20% MVIC).59 Cross-

body reaching and downward reaching by the unin-

volved arm may be safe as minimal activity is seen in

the anterior deltoid, supraspinatus, and biceps bra-

chii.59 These activities should be safe for all tear sizes,

shapes and methods of surgical fixation as EMG

activity is minimal in the muscles involved.

Passive and active-assisted exercises

Passive range of motion (PROM) and active-assisted

exercises are also typically prescribed during the

maximum protection phase. McCann et al.55 inves-

tigated deltoid and rotator cuff muscle activity

during four supine elevation exercises: self-assisted

elevation, helper-assisted elevation, shoulder exter-

nal rotation with a stick, and helper-assisted external

rotation. All four of these exercises offer protection

of the repaired rotator cuff tendons and deltoid as

evidenced by minimal activity in the supraspinatus,

infraspinatus, anterior deltoid, and middle deltoid via

EMG. In addition, McCann et al.55 examined six

upright exercises commonly seen in this phase of

rehabilitation: forward elevation with a pulley, pendu-

lums, elevation with stick, wall slide (patient faces wall

and slides hand up the wall in the sagittal plane),

assisted extension, and assisted internal rotation

(upright position). When compared to the supine

exercises, the upright exercises demonstrated higher

activity in the rotator cuff musculature but still within

the minimal range and, thus, are safe in this phase of

rehabilitation.

Dockery et al.60 studied similar passive exercises in

addition to the effects of a continuous passive motion

machine (CPM). Electromyography analysis of the

supraspinatus, infraspinatus, anterior deltoid and

trapezius was performed during CPM use, self-

assisted exercises (pulley, pendulum, elevation with

other arm, self-assisted internal and external rota-

tion) and therapist-assisted exercises (elevation in

scapular plane, internal and external rotation). It was

determined that CPM use and therapist-assisted

PROM are safer for passive motion and repair

protection; however, all exercises resulted in low

MVIC in the rotator cuff muscles and deltoid (,20%)

and are considered safe in the maximum protection

phase of rehabilitation.60 Although patient usage of a

CPM is recommended to complement the passive

ROM by a therapist during this rehabilitation phase,

caution should be taken to avoid aggressive PROM

into internal rotation with repairs of the infraspina-

tus and into external rotation with repairs of the

subscapularis tendons.

Gentle scapular exercises (serratus anterior,

trapezius muscle group)

Exercises for the scapular stabilizers, including the

trapezius complex (upper and lower trapezius) and

the serratus anterior, may be initiated in this phase of

rehabilitation as they have a synergistic relationship

with the glenohumeral rotators.61 Early activation of

the scapular stabilizers may promote improved

scapulohumeral rhythm and functional use of the

post-surgical shoulder.61

Scapular exercises commonly performed include

retraction, protraction, elevation, depression, and the

scapular clock. Smith et al.62 studied the effects of

these scapular movements on the rotator cuff

musculature through EMG analysis. Data analysis

revealed that only isolated scapular depression and

protraction in standing while wearing an immobilizer

are safe for the repaired infraspinatus or supraspina-

tus while sufficiently activating the serratus anterior.

The scapular depression exercise activated the serra-

tus anterior more than the other motions. Should the

surgery also include the repair of the subscapularis

tendon, no scapular exercise is appropriate in this

phase as high activity (40–63% MVIC) was observed

in this muscle.62

Arm supported scapular retraction in the scapular

plane at 90 and 120u was studied by Bressel et al.63

Eelectromyography activity of the lower trapezius,

supraspinatus and infraspinatus were recorded. Results

suggest that potential neuromuscular re-education of

the lower trapezius with the arms supported at 90u are

possible early following supraspinatus repairs, but not

infraspinatus repairs as too much tension is placed on

the infraspinatus.63

An alternative method of activating the scapular

stabilizers while minimizing the activity of the rotator

cuff muscles may involve utilizing the contralateral

limb. Reaching across the body with the right arm

can activate the left lower trapezius. Smith et al.62

found significant lower trapezius activity with cross-

body forward reaching, slow straightforward reach-

ing, and downward reaching with the contralateral

upper extremity.59 In addition, kinetic chain exercises

such as cross-body rotations, which involves reaching

across the body while rotating the trunk simultaneously,

at low or medium heights will generate clinically

significant EMG activity in the serratus anterior

while producing safe levels of activation in the

supraspinatus, infraspinatus, biceps brachii, and

anterior deltoid; adding a step to the motion will

activate the serratus anterior even more selectively.

Greater serratus anterior activity was seen in the



kinetic chain motions when compared to isolated

scapular elevation and depression.64 Cross-body reaches

at shoulder height with the non-involved arm effec-

tively activate the lower trapezius, the second most

important scapular stabilizer, while minimizing activ-

ity in the rotator cuff musculature.64 However, none of

these kinetic chain exercises are appropriate when the

repair includes the subscapularis tendon.64 These

activities may potentially allow reactivation of scap-

ular stabilizers in a protected environment while

minimizing activity of the healing rotator cuff, anterior

deltoid and biceps brachii.62

Aquatic therapy

Aquatic therapy is an appropriate option in the

maximum protection phase following rotator cuff

repair. Brady et al.65 found accelerated restoration of

PROM in forward flexion and improved quality of

life in subjects who underwent a land program with

the addition of aquatic therapy. Exercises performed

during the maximum protection phase included buo-

yancy assisted forward flexion and external rotation,

scapular stabilization and pendulum exercises. Buo-

yancy assisted elevation in the scapular plane at slow

speeds (30–45u/second) is safe for post-operative rota-

tor cuff repairs as the MVIC in the rotator cuff and

deltoid is minimal (,20%).66

Exercises that traditionally, on land, show higher

EMG activity of the rotator cuff musculature may be

appropriate during the maximum protection phase

when performed in the water. Water buoyancy and

shorter lever arms could help diminish tensile strain

and protect the repaired tendons. For example, active

shoulder range of motion, which may not begin until

the moderate protection phase, could be performed

earlier in the water due to the lower load environ-

ment. Aquatic therapy for repaired rotator cuff ten-

dons should begin as soon as the arthroscopic portals

or surgical incisions are completely healed or other-

wise covered with a waterproof bandage to allow for

accelerated restoration of motion.

Closed-chain activity

Uhl et al.56 examined muscle activity of the pectoralis

major, anterior deltoid, posterior deltoid, and infra-

spinatus during closed chain activities. Closed-chain

activities can be utilized to enhance proprioception of

the glenohumeral joint. Closed-chain activities in

the prayer and quadruped positions are appropriate

during the passive phase of rehabilitation as minimal

activity (,20% MVIC) of the rotator cuff and deltoid

musculature is exhibited.

Moderate protection phase/active exercise(weeks 7–12)Progression to the moderate protection/active phase

involves several factors: quality of tissue repair,

stability of fixation, and forces generated at the

surgical reconstruction.55 Typically the patient is

ready for active exercise between the sixth and

seventh post-operative weeks. Moderate activity of

the rotator cuff musculature is appropriate at this

time as the healing of the tissue repair is sufficient and

less at risk for rupture.55 Common exercises in this

phase of rehabilitation include progression of scap-

ular stabilization, isometric exercise for the rotator

cuff musculature, and active range of motion of the

glenohumeral joint. Evidence for these suggested

interventions is included in Table 3.

Progressive scapular exercises (serratus anterior,

trapezius muscle group)

Scapular stabilization is a coupled motion with

glenohumeral rotation. Therefore, at this point the

healing process should be directed at force couples

rather than isolated muscle-focused exercise. Schachter

et al.61 determined that during isolated glenohumeral

internal and external rotation, the scapular muscles

(serratus anterior and middle trapezius) are at least as

active as the glenohumeral rotators. Hence, inclusion

of scapular retraining exercises in rotator cuff rehabi-

litation programs is supported.61

Kibler et al.67 examined the EMG activity of the

lower trapezius and serratus anterior during four

scapular stabilization exercises. These exercises con-

sisted of: (1) inferior glide (isometric with humeral

head depression and scapular retraction); (2) low row

(isometric with scapular external rotation and poster-

ior tilt); (3) ‘lawnmower’ (trunk rotation with scapu-

lar retraction); and (4) ‘robbery’ (trunk extension

with scapular retraction). The ‘robbery’ exercise

begins with the subject standing with the trunk flexed

approximately 40–50u with arms forward flexed and

palms facing the thighs. With the elbows kept close

to the body, the subject moves into trunk and arm

extension and flexes elbows so palms are facing up

and away from the body while simultaneously retract-

ing the scapulae towards the back pockets. Each of

these exercises requires no more than 90u of shoulder

elevation and, therefore, is appropriate at this point in

the rehabilitation program. Moderate activity (20–

40% MVIC) of the lower trapezius and serratus

anterior was found indicating appropriateness for

retraining neuromuscular control in the active phases

of rehabilitation.67

Cools et al.68 analyzed the ratio of upper trapezius

to lower trapezius, middle trapezius, and serratus

anterior during 12 common exercises performed early

in the moderate protection/active phase of rehabi-

litation. Minimizing upper trapezius activity is an

important component in restoring appropriate sca-

pulohumeral rhythm following rotator cuff repair.

Sidelying external rotation, sidelying forward flexion,

and prone horizontal abduction were found to have



low upper to lower trapezius ratios while prone

shoulder extension was found to have a low upper to

middle trapezius ratio. These findings support the

use of these four exercises in the active phase of

rehabilitation as upper trapezius activity is minimized

and scapulohumeral rhythm is improved. It was also

recommended that standing flexion movements

should be avoided if excessive shoulder girdle

elevation due to activity of the upper trapezius is

observed with this motion.68 However, if the patient

can flex the shoulder with normal scapulohumeral

rhythm and avoid excessive hiking, then this motion

should be employed during this phase. If excessive

hiking is present, then the motion can still be used,

but in a recumbent position at an angle where the

motion is demonstrated without the shoulder girdle

elevation. Mirror feedback may also be helpful

in retraining the patients’ proprioception with this

exercise.

Isometrics and neuromuscular re-education

Isometrics of the shoulder musculature are com-

monly performed during the active phase of rotator

cuff rehabilitation. McCann et al.55 performed EMG

analysis of the rotator cuff and deltoid muscles during

a 5-second isometric contraction in five directions:

external rotation, internal rotation, forward elevation,

abduction, and extension. Minimal activity of the

supraspinatus, infraspinatus and deltoids was found

with internal rotation while moderate to marked

activity was found in the other four directions. Si-

milar findings were found by Decker et al.69 support-

ing the use of shoulder internal rotation isometric

exercise to strengthen the subscapularis while eliciting

minimal activity in the supraspinatus. Shoulder

isometrics are appropriate during the moderate

protection phase/active phase, however, should be

avoided during the during the maximum protection/

passive phase as rotator cuff muscle activity is too

high.55 Submaximal isometric contractions should be

supervised in repairs of the infraspinatus and sub-

scapularis in external rotation and internal rotation,

respectively.

Neuromuscular electrical stimulation (NMES) may

be used as an adjunct treatment to enhance force

production, muscle recruitment, and improve muscle

function. Isometric contraction of the infraspinatus

assisted with NMES of the infraspinatus was studied

in patients following repair of the supraspinatus

tendon. Results showed a 22% increase in force

production by the infraspinatus regardless of age,

gender, size of tear, number of days post-op, or

intensity of NMES.70 This suggests that NMES may

be an appropriate and safe modality to enhance the

facilitation of the rotator cuff musculature during

the active phase of rehabilitation. Caution should be

taken to apply NMES to surrounding rotator cuff

Table 3 Evidence for moderate protection phase

Moderate protection phase/active exercise

Exercise Study Comments Implications

Progressive scapularexercises

Kibler et al.67 Four exercises examined by EMGfound to have moderate (20–40% MVIC)and are appropriate for retrainingneuromuscular control

Inferior glide: isometric with humeralhead depression and scapular retraction(SA and LT)Low row: isometric with scapula ERand post tilt (SA and LT)Lawnmower: included trunk rotationand scapular retraction (SA and LT)Robbery: trunk extension withscapular retraction

Progressive scapularexercises

Cools et al.68 12 trap exercises looking at low UT/LT,UT/MT, UT/SA ratios; early active rehabexercises to include (1) SL ER, (2) SL FF,(3) prone HABD, and (4) prone EXT; nos.1–3 have low UT/LT ratios and no. 4 haslow UT/MT ratio

(1) SL ER, (2) SL FF, (3) prone HABD,and (4) prone EXT appropriate in thisphase also recommended to watch forexcessive shoulder hiking with standingflexion movements and modify as needed

Isometrics with/withoutNMES

Reinold et al.70 22% increase in isometric force productionof the infraspinatus with NMES in patientspost RCR

NMES considered safe in improving ERforce production post rotator cuff repair

Active rotatorcuff exercises

McCann et al.55 Phase II exercises as described by Neer(1987): supine active elevation; uprightelevation with elbow bent and straight,upright abduction consistently showedmoderate activity (20–50%); begin uprightelevation with elbow bent then progressto elbow straight

Supine active elevation; upright elevationwith elbow bent and straight, uprightabduction all appropriate in this phase

Closed-chain tripodand pointer

Uhl et al.56 Moderate (20–40% MVIC) in posteriordeltoid and infraspinatus

Intermediate level of facilitation andco-contraction with trunk stabilization

Note: ER, external rotation; FF, forward flexion; SL, sidelying; HABD, horizontal abduction; EXT, extension; NMES, neuromuscularelectrical stimulation.



muscle tendons and not directly to the repaired

tendon.

Active rotator cuff exercises

Active range of motion exercises of the glenohum-

eral joint are typically performed during the

moderate protection/active phase of rehabilitation.

McCann et al.55 analyzed the EMG activity of the

rotator cuff muscles during supine active elevation,

upright elevation with elbow bent and with elbow

straight, and upright abduction. Elevation in this

study consisted of motion of the entire shoulder

complex. Moderate activity (20–50% MVIC) of the

rotator cuff musculature was found consistently in

these exercises and are, therefore, appropriate in the

active phase of rehabilitation. It is suggested that

upright elevation begin with elbow bent then pro-

gressed to the elbow straight as increased activity of

the rotator cuff musculature is seen with the elbow

extended.55

Aquatic therapy

Aquatic exercises can also be performed during the

moderate protection/active phase of rehabilitation.

Appropriate exercises studied by Brady et al.65

include standing breaststroke, reaching the hand

behind the back, and kicking with a kickboard.

Exercises may progress in the minimal protection/

resistive phase to include resisted forward flexion and

external rotation with paddles, ball proprioception

exercises and resistance, and wall push-ups.65

Closed-chain exercise

Uhl et al.56 determined that closed chain activities in

the tripod and pointer positions are appropriate in

the active phase of rehabilitation since moderate

muscle activity (20–40% MVIC) is seen in the pec-

toralis major, anterior deltoid, posterior deltoid, and

infraspinatus muscles. For the tripod exercise, the

subject begins in the quadruped position and then

flexes one shoulder to 180u. The pointer exercise is

performed in the same position as the tripod with the

addition of contralateral hip extension to 0u. Push-

ups should be reserved for the resistive phase as

muscular activity is high in these muscles tested (41–

60% MVC).56

Minimum protection phase/resistive exercise(weeks 12z)Transition to the minimal protection phase/resistive

phase of rehabilitation typically occurs 12 weeks

post-operatively. During this phase, strengthening

Table 4 Evidence for minimum protection phase

Minimum protection phase/resistive exercise

Exercise Study Comments

Resistive exerciseswith dumbbells orelastic bands

McCann et al.55 Phase III exercises as described byNeer (1987): (1) elevation with 2.25 kg,elbow bent; (2) straight; (3) abductionwith 2.25 kg; (4) T band ER elbow moving;and (5) fixed, IR, T band forward elevation,T band extension consistently showedmoderate levels of activity in rotatorcuff and deltoid

Resistive exerciseswith dumbbells orelastic bands

Boettcher et al.71 Preferred exercises in this study:(1) pendant ER and (2) prone ER vs‘can’ exercises due to lower deltoid activity

Exercises incorporating ER are mostsuitable to strengthen supraspinatuswhile minimizing surrounding muscleactivity, especially the deltoid

ER with dumbbell Reinold et al.73 Prone HABD – high activity of middle andpost deltoid, making is less preferred if tryingto target cuff muscles; exercise in scapularplane or at 0u ABD – less mid and post deltoidthan in 90u ABDER at 90u ABD in standing insupine – mimic sporting activity but place extrastress to the inf. GH ligament complex; SL ERat 0u ABD – higher mm activity of all cuff mmsthan in standing at 0u ABD; ER in scapularplane – functional while minimizing INF GHligament stress and improving dynamicstabilization; towel roll may aid in improvedform and decreased substitution by deltoid

(1) prone HABD at 100u with full ER;(2) prone ER at 90u ABD; (3) standingER at 90u ABD; (4) standing ER inscapular plane; (5) standing ER at0u ABD; (6) standing ER at 0u ABD withtowel roll; (7) SL ER at 0u ABD

Push-up (normal, feetelevated, one-arm)

Uhl et al.56 HIGH to very HIGH (41–.60% MVC) ininfraspinatus and deltoids

Advanced co-contraction withtrunk stabilization

Advanced scapularstabilizer exercise

Decker et al.,77

Eckstrom et al.78Push-up plus and dynamic hug exerciseselicited greatest EMG activity in serratusanterior; prone arm raise overhead and shoulderabduction in scapular plane above 120u elicitedgreatest simultaneous activity of the serratusanterior and trapezius muscle group

Advanced scapular stabilizationexercises above shoulder height forimproved scapulohumeral rhythm

Note: ER, external rotation; IR, internal rotation; SL, sidelying; HABD, horizontal abduction.



of the rotator cuff begins and progression to

functional lifting and sport activities are allowed

(Table 4). Sufficient healing of the rotator cuff has

completed so that moderate to high muscular activity

of the rotator cuff musculature during exercise does

not pose a great risk to rupture of the repaired

tendon. Strengthening exercises may utilize elastic

resistive bands or dumbbells with the glenohumeral

joint in various positions to strengthen the rotator

cuff muscles.

Resistive exercises

McCann et al.55 investigated seven commonly pre-

scribed exercises in this phase: shoulder elevation

with 2.25 kg with the elbow bent and straight,

shoulder abduction with 2.25 kg, external rotation,

internal rotation, forward elevation and extension

with elastic resistive bands. Each exercise consistently

showed moderate levels of activity in the rotator cuff

and deltoid muscles and are, therefore, appropriate

for the resistive phase of rehabilitation.55

Boettcher et al.71 studied five exercises typically

recommended to strengthen the rotator cuff, specifi-

cally the activity of the supraspinatus. Muscular

activity of the rotator cuff and deltoid were examined

during the following exercises: elevation in the

scapular plane with glenohumeral external rotation

(‘full can’), elevation in the scapular plane with

glenohumeral internal rotation (‘empty can’), prone

elevation (horizontal abduction), pendant external

rotation (at 0u abduction), and prone external rota-

tion. Exercises incorporating external rotation were

best for strengthening the supraspinatus while mini-

mizing surrounding muscular activity, especially the

deltoid. Pendant external rotation and prone external

rotation exercises are preferred over the elevation in

the scapular plane exercises due to lower deltoid

activity. These two exercises also highly activate the

infraspinatus, which may be advantageous in facil-

itating centralization of the humeral head in the

glenoid fossa.

Reinold et al.72 examined the activity of the sup-

raspinatus and deltoid muscles during three exercises:

elevation in the scapular plane with external rotation

(‘full can’), elevation in the scapular plane with

glenohumeral internal rotation (‘empty can’), and

prone elevation in the scapular plane with external

rotation. All exercises provided similar amounts of

supraspinatus activity (62–67% MVIC). However,

elevation in the scapular plane with glenohumeral

external rotation demonstrated the lowest middle and

posterior deltoid activity. This exercise may be best in

maximizing the amount of supraspinatus activity while

minimizing activity in the deltoid muscle.72

Seven exercises commonly used for external rota-

tion strengthening were analyzed by Reinold et al.73

These exercises utilized a dumbbell for resistance in

the following positions: prone horizontal abduction

at 100u with full external rotation, prone external

rotation at 90u abduction, standing external rotation

at 90u abduction, standing external rotation with arm

elevated 45u in the scapular plane, standing external

rotation at 0u abduction, standing external rotation

at 0u abduction with towel roll, and sidelying external

rotation at 0u abduction. Prone horizontal abduction

showed high activity of the middle and posterior

deltoid, making it less preferred when trying to target

strengthening of the rotator cuff muscles. Exercises in

the scapular plane or at 0u abduction demonstrated

less middle and posterior deltoid than in 90uabduc-

tion, but at 90u abduction, the posterior deltoid

activity may provide a compressive force and assist in

external rotation. External rotation at 90u abduction

in standing and in supine is useful in mimicking

sporting activity but places extra stress to the inferior

glenohumeral ligament complex. Sidelying external

rotation at 0u abduction results in higher muscle

activity of all rotator cuff muscles than the same

activity in standing. External rotation in the scapular

plane offers functional benefits of external rotation at

90u while minimizing inferior glenohumeral ligament

stress and maximizing the length-tension relationship

of the rotator cuff muscles for dynamic stabilization.

A towel roll may aid in improved form and decreased

substitution by the deltoid, although this study found

no significant differences.73 A limitation of this study,

however is that the researchers performed standing

external rotation with a dumbbell in hand. Therapists

do not routinely prescribe this as the resistance force

line is not in line with the rotator cuff. Additional

studies found that the placement of a towel roll in the

axilla during sidelying external rotation increased

activity of the infraspinatus by 10%,74 prevented

reduced blood flow to the supraspinatus,75 and in-

creased the subacromial space.76

Advanced training of the scapular stabilizers is

common in this phase. Decker et al.77 found that the

push-up plus and the dynamic hug exercises elicited

the greatest EMG activity in the serratus anterior

muscle. Eckstrom et al.78 identified two exercises that

produced marked (.50% MVIC) activity simulta-

neously in the serratus anterior and trapezius muscle

group: the prone arm raise overhead and shoulder

abduction in the plane of the scapula above 120u.These exercises may be effective in restoring the

scapulohumeral rhythm in the post-surgical shoulder

to return the patient to prior level of function.

ConclusionRotator cuff tear characteristics, surgical repair pro-

cedures and tactics, and patient factors can all affect

the clinical presentation as well as the overall patient



outcome of rotator cuff repair. Both communication

between orthopedic surgeon and rehabilitation pro-

fessional, as well as a rehab professional’s under-

standing of the influences that these factors that can

have on patient outcome are essential in optimizing

care. Post-surgical rehabilitation after rotator cuff

repair focuses on patient function, restoration of

mobility, and return of strength. It is important for

rehabilitation professionals to recognize evidence

based tactics to restore the impairments after rotator

cuff repair, and utilize them appropriately with

consideration of the numerous variables that can

impact patient recovery. More research is warranted

to further bridge the gap between rotator cuff tear

characteristics, repair procedures, and rehabilitation

implications.

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