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RotatorCuffSurgicalRepairReturntoSportProtocol

PhaseI:(Post-Opweeks1-6)Goals:

1- Protectsurgicallyrepairedtissues2- Minimizepainandinflammation3- BeginScapularstabilization-rows,lightPNFpatternsinside-lying4- Preventmuscularinhibition5- Educate/re-educatepatientonallpost-opinstructionsonprecautionsandprogressionof

activities/movements,andteachpatientahomeexerciseprogram6- PatienttobeindependentwithADL’sandmodificationswhilecontinuingtoprotectthe

integrityoftherepair

InterventionstoAvoid/Precautions:1- NoAROMoftheshoulder(Nopushing,pulling,leaningonelboworhand)2- Noliftingofobjectswiththeshoulderthatwasrepaired3- Noexcessivestretchingorsuddenmovements4- Nosupportingofbodyweightbythehandoftherepairedshoulder5- DonotpushPROMtoaggressivelytothepointofelicitingpatientguardingorpassedPROM

stagedROM’s6- Excessiveadductionorinternalrotationshouldbeavoidedasthecanplaceexcessivestress

ontherepair7- Avoidsleepingontheaffectedside

SpecificInterventions:Immobilization:ThiswillbedeterminedbytheMDdependingon;thesizeofthetear,concomitantinjuries/repairs,co-morbidities,etc.Patientmustremainintheslingasdirectedonlyremovingforbathingortoperformexercises.Patientshouldbeeducatedthattheserestrictionsneedtobeadheredtoforprotectionoftherepair,evenwithoflackofpain/symptoms.Typicallyslingiswornapproximate4-6weekspost-op.Treatment:TreatmentsshouldfocusonachievingappropriatePROMgoals;minimizinginflammation;normalizingscapularposition,mobilityandstability;andimproving/normalizingROMofuninvolvedsurroundingjointsoftheupperextremity,cervicalandthoracicspine,andribcage.PatientEducation:

1- Explainthenatureofthesurgery2- Discusstheprecautionsspecifictothenatureofthepatient’ssurgicalrepair,suchastryingto

meetthesetgoalsforPROM,andnotgainingmotiontoofast3- Theimportanceoftissuehealing4- Properwearingtimeandpositioningofthesling5- LimiteduseofupperextremityforADL’sonlyatnohigherthanwaistlevel

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TherapeuticExercises:Post-OpDays:1-10:1- AdministertheWesternOntarioRotatorCuffIndex(WORC),ShoulderPainandDisabilityIndex

(SPADI),ortheAmericanShoulderandElbowSurgeon(ASES)Formoutcomeform(s)forabaselineself-reportedoutcomesmeasurementofthepatient.ThesearebestfortheRotatorCuffandassessingshoulderinstability.

2- PatientEducationforpostureandproperpositioningoftheshoulderforjointprotectionandtoperformdailyhygieneactivities

3- Pendulumhangs,withnoactivemovementsoftheshoulder4- Cryotherapyforpainandinflammation5- AROM,withnoweights,forelbow,wrist,andhand(grip)a. OnlyPROMforelbowiftheyalsounderwentabicepstenodesis/tenotomy

6- Deltoidreflexiveisometrics-notifbicepsinvolved*seesuggestedexercisesheet7- CervicalA+PROMexercises,&manualmobilizationsandsofttissuework8- Scapularelevationsandretractionexercises-performinandoutoftheslinga. Scapularmuscleisometrics/sets

Post-OpWeeks1-3:1- Continueaboveexercises2- Moisthotpackspre-treatmentto­bloodproliferation,andtissueextensibility3- PassiveForwardElevation(PFE)inplaneofthescapulatotoleranceto60°-90°4- PassiveExternalRotation(PER)(withelbownogreaterthan0°-20°ofabduction-closetothe

body)foraROMof0°-15°:ThisdirectionofPROMmaybedelayedforupto6weeks(perMD)iftenuoustissuequality,poorrepairintegrity,and/orlargetear.

5- EarlyPROMshouldonlyincludeactivitieswithlowrotatorcuffactivation,(nopulleys,canetherapeuticexercises,orselfPROMatthistime)

6- Beginmanualscapulastabilizationexercises-PNFinS/L,rib&thoracicjt.Mobs7- BeginLEstationarybike,withslingon,totrytomaintainsomeendurancelevel

Post-OpWeeks4-6:1- Progresspendulumhangstopendulummobility2- Progressscapulastrengthening-rows,scapulardepression,progressPNF3- ProgressPFEinplaneofthescapulato90°-120°,andPERat0°-20°ofabductionto20°-30°,as

patientstolerates,byweek6patientcanbeprogressedto20°-45°forERin20°ofAbduction,aswellasbeginERat90°ofabductionwithROMbetween40°-60°

4- BeginPassiveROMinotherplanes,->AAROM(Pulleys,Cane,&UERanger)a. ERPROMcanbeadvancedto45°,75°,and90°ofabductionasmotionandpatient’stolerance

willallowb. BeginHorizontalAdduction

5- MaybegingradI->IIjointmobilizationsforpainrelief/relaxation,foralljointsoftheshoulder(GH,SC,ST,AC)

6- Ifapool/aquatherapyisavailable,patientmaybeginAAROMinthepool,noswimmingstrokes7- Progresselbow,wristandfingerAROMtolightstrengthening(delayedto6weekspost-opfor

bicepstenodesis/tenotomy)8- Lightscarmobilizationassoonasthescarisfullyhealed,andmodalitiesPRN

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StagedROMGoals:Post-OpWeek RangeOfMotion(ROM)POW1-3: PROM:

-PFE:(scapularplane):60°-90°,-PER:(@0°-20°Abd):0°-15°-maybedelayedperMD,AROM:-Elbow,WristandHand(grip):OnlyPROMfortheelbowifthe

patentunderwentabicepstenotomy/tenodesis*NoHorizontalAddorIRbehindtheback

POW4-6: PROM:-PFE:(scapularplane):90°-125°,-PER(@0°-20°Abd):20°-45°,-PER(@45°,75°,&90°Abd):40°-60°-IR(scapularplane):slowlyprogressto45°,-Abd:45°-100°:progressastolerated,-MaybeginHorizontalAdductiontotoleranceAAROM:-Begininallplanes,withinstagedROMGoalsAROM:-ContinuetoprogressanyROMdeficitsintheelbow,wristand

hand-Maybewithbicepstenotomy/tenodesispatients

POW7-12: PROM:-PFE:135°-155°,-PER:(@20°-30°Abd):30°-60°,-PER(@90°Abd):50°-75°,-IR(scapularplane):60°,-Abd:slowlyprogressastolerated,AROM:ProgressAAROMtoAROM-AFE:80°-120°,-Abd:slowlyprogressastolerated,-AIR+AER:slowlyprogressastolerated

POW13-18: ROM:-PER+AER(@20°-30°Abd):80°-90°(byweek18),-PER+AER(@90°Abd):75°-90°(byweek18,110°-115°if

patientisathrowingathlete),-P+AIR(@90°Abd):30°-65°(byweek18),-AFE:mustbe180°/WNL(byweek18),-P+AAbd:mustbe180°/WNL(byweek18)

Key: POW=Post-OperativeWeek,PFE=PassiveForwardElevation,PER=PassiveExternalRotation,AFE=ActiveForwardElevation,AIR+AER=ActiveInternalandExternalRotation

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PhaseII:Post-OpWeeks7-12CriteriaforenteringPhaseII:

1- Appropriatehealingofthesurgicalrepairbyadherencetotheprecautionsandimmobilizationguidelines

2- AchievementofthePROMgoals,asstatedintheprevioussection:PassiveForwardElevation(intheplaneofthescapula)of90°-125°,PassiveExternalRotation(with20°ofabduction)of20°-45°,PassiveExternalRotation(with90°ofAbductionintheplaneofthescapula)to40°-60°,PassiveInternalRotation³45°

3- Reductioninpainto0-2/10(onaVASscale)withPROM4- MinimalDetectableChange(MDC)onoutcomeformof9.4forASES,between8-13fortheSPADI,

and7.1pointsfortheWORC

Goals:1- Continuetoallowforsofttissuehealing2- Donotoverstresshealingtissue3- RestorefullPROM(byweek12)4- NormalizeAROMmovementsandranges5- Minimizepainandinflammation6- PatientisindependentwithfunctionalADLsandlightworkactivities(Week12)7- Begintoincreasestrengthandendurance8- TocontinuallychangethescoresontheWORC,SPADIortheASESoutcomesformswithMDC

Interventionstoavoid/Precautions:1- NoliftingoractivitiesthatrequireROMbeyondwhatisstatedforacceptable/desiredROM

goals2- Nosupportingthebodyweightbythesurgicallyrepairedhandandarm3- Noexcessivebehindthebackmotions4- Nosuddenjerkingmotions5- DonotperformROM/stretchingbeyondstatedacceptableROMgoals6- Donotperformlongleverarmstrengtheningexercisefortherotatorcuffthatwillplacetoo

muchloadontherepairedtissue7- Donotperformscaptionwithinternalrotation(emptycan)atanystageofrehabilitationdueto

impingementandstressontherotatorcuffrepair

SpecificInterventions:PatientEducation:

1- Continuepatienteducationforallareasoftherapyandrecovery2- Typicallytheslingisdiscontinuedbyweeks4-6Post-Op,basedonthedemonstrationand

expressionlittletonopainandappropriatecontroloftheupperextremitywithwaistlevelADLsandisawareofthelimitationsallowed(nosuddenreaching,lifting,etc.),however,consultwithMDforD/Ctimeframe

3- Continueeducatingpatientonusingtheupperextremityinapain-freeROMforADLS,beginningandwaistlevel,thenprogressingtoshoulderlevelactivities,andfinallyoverheadactivities

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TherapeuticExercises:(SeeSuggestedExerciseSheet)1- ContinuepreviousphaseIexercises/activitiesasneeded2- ProgressPFEandPERROMasneededtoachievegoals3- ProgressPROMandbeginActiveForwardElevation(AFE)inthescapularplaneinweek9a. ROMlimitationsare:PRE:130°-155°,PER(@20°Abduction):30°-60°+,PER(@90°abduction):

50°-75°,andAFE:80°-120°4- ProgressAAROMprogressingtoAROM,forForwardElevation,FlexionAbductioninthescapular

plane,ExternalRotation,astolerated,withemphasisonpropershouldermechanics5- ProgressJointmobilizationstoGradeIII->IVtoaddresscapsularrestrictionsandregainfullpassive

ROM,ifindicated,forallshoulderjoints(GH,SC,AC,ST)6- ProgressingtoAROM,forForwardElevation,FlexionAbduction(scapularplane),External

Rotation,andfunctionalInternalrotationwithbehindthebackmotions7- Initiateposteriorcapsulestretchingcrossbodyadductionstretchingasindicated8- EstablishbasicrotatorcuffandscapulaneuromuscularcontrolwithinallowedROM9- Introducelightwaistlevelfunctionalactivities,thenprogresstolightresistanceexerciseswithin

allowableAROMwithoutcreatingsignificantforceontheshouldergirdlemusculature10- Sub-maximalisometricexternalandinternalrotationexercises11- Addressallscapulothoracicandtrunkmobilitylimitations,tofacilitatenormalmovementofthe

shoulder.FocusingespeciallyonthoracicextensionandachievingnormalcervicalROM12- Whenpain-freeAROMwithgoodshouldermechanicsisdemonstrated,beginastrengthening

programfortheDeltoid,non-repairedsegmentsoftherotatorcuff,andscapulamusculature13- Lightresistancebandstrengtheningisappropriatewithinthepatientspain-freeROM14- Beginlow-levelclosedchainstrengthening(quadruped,physioball,suspensiontrainingsystem

(ex.TRXÔsystem))andStageIUEPlyometricProtocol,oncescapularstrengthandstabilizationisachieved(*seeattachedprotocol)

*Donotinitiateabeginningstrengtheningprogramprogressionuntilpatient’spainisatanappropriatelylowlevelandthechosenexercisesdonotincreasesymptoms

PhaseIII:Post-Op3-6MonthsCriteriaforenteringPhaseIII:

1- PROMandAROMof:>155°forPFE,>120°AFE,>60°PER@20°abduction,>75°PER@90°abduction,with0-2/10painandnosubstitutionpatternswiththemovements

2- Painof<2/10withallcurrentstrengtheningexercises3- Demonstrateappropriateposition,staticallyanddynamically,ofthescapuladuringROMand

exerciseactivities4- Scoresof>/=70%ontheWORC,</=0-20ontheSPADIor</=0-12ontheASESoutcomeforms

Goals:1- AchievefullP+AROM2- Improvedynamicshoulderandscapularstability3- Graduallyfullyrestoreshoulderstrengthtobeabletoprogresspowerandendurance4- Improveneuromuscularscapular,shoulder,andtrunkcontrol5- ReturntonormalfunctionalADLs,fullwork,andmodifiedrecreationalactivities6- Evaluatefunctionalmovementswiththepatient,assoonasAROMisachieved,withtheSelective

FunctionalMovementAssessment(SFMA),ortotalbodymovementscreening,suchascervicalmobility,forwardandbackwardbending,totalbodyrotation,single-legstance,squat,etc.Makesureyouteaseoutifdysfunctionsarecausedbyamobilityorastability/motorcontrolissue!

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InterventionstoAvoid/Precautions:1- Noliftingobjectsheavierthan10lbs2- Nosuddenliftingorpushingactivities3- Nosuddenjerkingmotions4- Nouncontrolledmovements

SpecificInterventions:PatientEducation:

a. ContinuetoexpresstheimportanceofgraduallyincreasingthestresstotheshoulderwhilereturningtonormalADLs,workandlimitedrecreationalactivities

TherapeuticExercises:(SeeSuggestedExerciseSheet)1- ContinuestretchingandpassiveROMasneeded2- Patientmaystilldesire/needMoisthotpackpriortostretchingandcryotherapyposttreatment3- Nearlyfullelevationinthescapularplaneshouldbeachievedbeforeelevationintheotherplanes4- Allexercises/activitiesshouldbeperformpain-freewithoutandcompensatory/substitution/

alteredmovementpatterns5- Exercisesintensityshouldbewithhigherrepetitions(30-50repetitions)andlowerresistance6- TreatdysfunctionsfoundthroughSFMA/FunctionalMovementtesting7- ProgressNeuromuscularRe-educationwithdynamicstabilizationexercises;lightPNFtrainingfor

therotatorcuff,deltoidandscapula;closed-chainactivityprogression8- BytheendofthisPhase,evaluatepatientwiththeFunctionalMovementScreen(FMS)&Y-

Balance/CKCUTESTAssessmentsatleastonetimeforbaselinescores9- Strengthexercisesthattargetthesurgicallyrepairedrotatorcuffcanbeinitiated,withlightweight

orbandsinandpain-free,lowstressrange.Exercisesshouldbeprogressedintermsofmuscledemandandintensitytopatient’stolerance.Theyshouldalsobeprogressedintermsofshoulderelevation/leveltheexercisesareperformed(waistlevel->shoulderheight->overheadactivities)a. ERside-lyingwithatowelrollunderthehumerusb. PerformER/IRexercisesatvariousdegreesofabductionc. Fullcaninthescapularplane(avoidemptycanexerciseatalltime2°topossibleimpingement)d. Pronescapularandrotatorcuffexercises(rowing,extension,horizontalabduction,etc.)

CriteriaforProgressingtoAdvancedStrengtheningProgram:1- MMTofagradeof4/5orgreater2- Pain-freewithallbasicADLsandpreviousstrengtheningexercises3- FullAROMwithElevation4- Patienthasadesiretoreturntopre-injurylevelofsport/activity

ExerciseAdvancement:(SeeSuggestedExerciseSheet):1- Integratefunctionalpatternsthatwillbepartoftheactivities/sportpatientwillbereturning2- Increasespeedofmovements3- Decreaseresttimebetweenexercisestoimproveendurance4- BeginLEplyometricandPhaseIIUEplyometricProtocols(seeattachedsheets/protocol)5- PNFpatternswithresistancebandsinstanding6- Resistancebandexercises@90°/90°forIRandERwithandwithoutarmsupport7- Simulatedsportmovementswithresistancebands,suchas;golf,batting,andtennisswings8- BeginThrowersTenProgram(*seeattachedsheets)->AdvancedThrower’sTenProgram(*also

seeattachedsheets)

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PhaseIV(AdvancedTrainingPhase):ToprepareforReturntoSportPhase.NosettimeframeaspatientsmayprogresstothisstageatslightlydifferentratesCriteriaforenteringPhaseIV:

1- Demonstrateadequatestrengthanddynamicstabilizationforprogressiontohigherdemandsportspecificactivities

2- Appropriatescapularpositioning/controlstaticallyanddynamicallywithROMandallstrengtheningexercises

3- Scorea14or>ontheFMS,andminimalasymmetriesontheY-Balance/CKCUTESTAssessments4- WORC,SPADIorASESisreplacedbyDASH-Sport/performingArtsModuleforapatientself-

evaluationoutcomemeasurementGoals:

1- Maintainfullandnon-painfulactiveROM2- Improvemuscularstrength,power,andendurance3- Returntofunctionalactivities4- >14ontheFMS,NostatisticalasymmetrieswithY-Balance/CKCUTESTassessments5- BeabletobegintheReturntoSportSpecificProtocolafterPhaseIVcompletion

InterventionstoAvoid1- Noheavyliftinggreaterthe15-20lbs,noSuddenliftingorpushingactivities2- Nosuddenjerkingmotionsoruncontrolledmovements3- Noprogressiontoactivityspecificexercisesunlesspatienthasfullpain-freeROM&strength

withthesurgicallyrepairedshoulderSpecificInterventions:TherapeuticExercises:(SeeSuggestedExerciseSheet):

1- ContinuepassiveandactivestretchingoftheshoulderandcapsuletomaintainROM2- Addressanyremainingstrength/motorcontrol/stabilitydeficitsfortherotatorcuff,scapula,and

trunk-withemphasisonengagingtonicstabilizingtrunkandhipmuscleswhileperformingdynamicupperandlowerextremityexercises

3- Advanceproprioceptiveandneuromuscularexercises/activities4- ContinueprogressionofstrengthwiththeAdvancedThrower’sTenProgram(seeattached)5- Graduallyprogressreturntoweight-liftingprogramfocusingonlarger,primaryupperextremity

muscles-startwithlightweightandhighrepetitions(15-25perset)andgraduallydecreaserepetitionsdownto8-10)asyouincreasetohigherweightsoverthecourseor6-8weeks

6- Begin8weekUEadvancedplyometricprotocol(seeattachedprotocol)7- BeginIntervalSportProgram(Throwing,Tennis,Golf)(seeattachedprograms)

CriteriaforenteringReturntoSpecificSportProtocols:1- ClearancefromthesurgeontobegintheReturntoSportSpecificProtocol2- Nosignsofanylingeringshoulderinstabilitywithactivities3- RestorationorallROMneededtoparticipateindesiredsport4- Adequatestrengthandmuscleenduranceoftheshoulder,rotatorcuff,trunk,hip,andscapular

musculatureneededtoperformsportspecificdrills/activitieswithminimaltonopainordifficulty

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5- PatientscoresanappropriatescoreontheDASH-Sports/PerformingArtsModuleSelf-assessmentoutcomeform:(“no”–“mild”difficultyonallquestions)andtheKerlan-JobeOrthopaedicClinicShoulder&ElbowScore(KJOCScore):(³80)

6- >16onFMSandscoreontheY-BalanceofequaltopeersforsportandagethroughtheY-Balancedatabase,orCKCUTESTequaltonormative

7- Nopainwithanyofthepreviousexercises/activitiesperformed8- CompletingtheThrowersTenProgram(ifanoverheadathlete)andtheupperextremity

plyometricsprotocols9- Passingofthefunctionaltestslistedbelow:Testcanbeovermultiplesessionsa. TrunkTesting:(Seeattachedsheets)i.DeepNeckFlexorTestii.SegmentalMultifidusTestiii.TrunkCurl-upTestiv.Double-LegLoweringTestv.ProneBridgeTestvi.EnduranceofLateralFlexors(SideBridge)vii.ExtensorDynamicEnduranceTestb. UpperExtremityTesting:(Seeattachedsheets)i.AlternativePull-upTestii.Push-upTestiii.BackwardOverheadMedicineBallThrowTestiv.SidearmMedicineBallThrowTestv.SeatedShot-PutThrowTestvi.*Ifpatientisabaseballorsoft-ballpitcher/player

1. FunctionalThrowingPerformanceIndex(FTPI)Test-bestassessedwithvideoanalysis2. Baseballpitchersonly-PT/ATCfillsoutUpperExtremityThrowingAnalysisForm-to

determineareasofthethrowingmotionthatneedtobeaddressedinthesportspecific/returntobaseballpitchingprotocol

*SeeReturntoSpecificSportProtocol

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