I can imagine you’ve likely stumbled upon this blog post because you’ve recently had rotator cuff surgery. Or maybe you already have surgery scheduled and you’re looking to see what’s in store for you post-operatively with rotator cuff surgery rehab. Regardless of the specifics, welcome! Rest assured, you’re far from alone: rotator cuff tears are very common, affecting 30% of the population older than 60 years and 60% of the population by 80 years (1). Rotator cuff tears are one of the more publicized shoulder pathologies, often discussed in casual conversation in a frequency similar to that of ACL tears in the knee. Furthermore, as we continue to walk deeper into the current era of arthroscopic surgery, we’ve only seen a rise in the number of surgeries like yours. In the last 10 years alone, the prevalence of arthroscopic rotator cuff repairs has increased by over 600% (2).

 

You may be reading this text on screen with your shoulder secured in a sling. It’s possible that you’re very frustrated and in pain. Depending on your conversation and decision-making before surgery with your anesthetist, you may still have your nerve block. I can imagine that you’re fairly uncomfortable and a bit worried about the recovery process. But thankfully there are things you can do to help improve the likelihood of a successful outcome. Your initial post-operative journey should be threaded carefully with lots of sound advice and reassurance. More importantly, it will include a ton of rest, patience, and activity modification. Later on down the road (and when appropriate) progressive loading will become your main focus. But we’ll discuss all of these variables in detail, with timelines and the reasoning behind them.

Know that if you have access to a good physical therapist, the two of you will discuss much of what’s outlined in this article ahead. If you don’t, we have your back — we’ll outline the general themes in your recovery. Naturally, there are often some individualized decisions made in surgery that may change your rehab plan from the themes we’ll discuss here together. Many surgeons also have personal preferences based on experience that will also dictate the speed and course of your rehabilitation. (Listen to your orthopedic surgeon and physical therapist closely and appreciate their personalized insights supersede what I can offer through an online blog post.)

This all being said, get your non-surgical arm with a mouse in hand ready, strap up your sling, retract those scapulae and read on.

 

Learn How To Rehab Your Rotator Cuff On Your Own Terms

This rotator cuff program will help you regain your range of motion, basic strength, and control, allowing you to propel into latter phases of rehab, and get your shoulder back to 100%

 

What happens during rotator cuff repair surgery?

Rotator cuff repairs are now done almost entirely through arthroscopic surgery. In the past, these used to be “open” procedures, where a large incision was made over the front of the shoulder to gain access and visualization of the joint and relevant soft tissues. With arthroscopic surgery, a few small, button-sized incisions allow your surgeon access to the joint (3). Under general anesthesia, your surgeon will introduce several different tools through these incisions including an arthroscope (specialized camera to visualize the joint), a fluid pump (to distend to the joint with saline and work more easily within) and a variety of other tools including motorized shavers, forceps, probes, electrocautery, and radiofrequency instruments, etc. (4). Depending on the location and size of your rotator cuff repair, and the preferences of your surgeon, may mean you have more/less button-sized incisions than someone else with the same surgery. The number of incisions can change during surgery based on operative need (3,4). Regardless, know these are small and when healed, will generally be hard to see.

The sterilized and prepped right upper extremity of a patient in a “beach-chair” position ready for shoulder surgery. You can see the surgeon drew his/her anatomical landmarks and portal site incisions (labeled by the small letters) as part of the pre-operative prepping (5).

Your surgeon will first perform a full arthroscopic exam to assess the health of the shoulder. This is typically done to ensure your pre-operative imaging was correct and fully captured the extent of your injury. From here, the surgeon will identify what rotator cuff muscles are affected (supraspinatus, infraspinatus, teres minor or subscapularis), the thickness of tear (partial or full-thickness) the tear shape (crescent tears, U-shaped tears, and L-shaped tears) and the size of the tear (small, medium, large or massive) (6). In particular, the size of the tear is what will dictate the speed of your rehabilitation the most: especially the amount of time you spend in a sling post-operatively. Other considerations will be communicated from your surgeon to your therapist including things like tissue quality (how well the torn rotator cuff muscle could hold suture) and tissue mobility (how easy it was to manipulate and position the injured rotator cuff muscle for repair).

Your surgeon will then do his or her best to restore your torn rotator cuff to its original anatomy. This will involve attempting to restore the original “footprint” of the muscle, which is where the rotator cuff attaches to the humerus. The suture pattern choice can vary widely based on the specifics of your tear and the training of your surgeon (and far exceed the scope of this post), but If you’re trying to visualize what occurs in surgery take a look at the example illustrations below (7). On the far left is a transosseous suture repair that just uses suture. In the middle and on the far right are single-row and double-row suture anchor repairs, which are generally more common. These involve the use of a suture anchor, which roots the tendon back down into the bone (8). These anchors dissolve into the bone later on.

(Left) Transosseous suture repair, (Middle) single-row suture anchor repair, (Right) double-row suture anchor repair (7).

 

A nice visualization of suture anchors holding a rotator cuff tendon down into its original footprint (8).

 

Below is a video by a colleague, David Abassi, giving an explanation of rotator cuff surgery.

 

The days following rotator cuff surgery

You’re now over the surgical hump! While your journey is far from over, the hardest part is likely done. In the days following your rotator cuff surgery, you’ll be resting at home in a shoulder sling. There will likely be a follow-up appointment with the support staff of your surgeon for bandage changes. You may be prescribed pain medication to make it through these first days/weeks. You may have a nerve block that keeps the shoulder completely numb immediately following surgery. Depending on the preferences of your anesthetist, this can be removed at home once the medication wears off. If uncomfortable, one of the members of your medical team can remove this, including your physical therapist.

Unfortunately, the most challenging days in terms of pain are in that first week post-operatively. Generally, patients can be very uncomfortable. Follow your post-operative instructions from the surgeon, and don’t be afraid to utilize your pain medication as prescribed. Your surgeon has provided these to get you through these hard times. If you have a history of addiction or are just concerned in general with pain medication: don’t hold this to yourself. Please discuss with your surgeon in length. When it’s time to wean from them, you can do so at your convenience as the shoulder calms post-operatively.

 

Your sling

Depending on the size of your tear and the preferences of your surgeon, there will likely be a strict period of immobilization in your sling. Follow it. Despite the positive clinical results patients experience following rotator cuff surgery, reports of structural failure are quite high, ranging anywhere from 16% to 94% (9). I don’t say this to keep you up at night — rather, I caution this because now is not the time to push the limits of your shoulder. There will be a time to work later, but initially this is a time to err toward caution. For those with large rotator cuff tears, 78% of failures to heal occur within the first 3 months from your date of surgery (10). It’s in these first 3 months that people make silly decisions and put their hard work, financial investments, and time investments at risk.

READ: HOW TO OPTIMIZE RECOVERY AFTER SURGERY

Universally, a period of strict immobilization with graded rehabilitation (a.k.a. following the instructions of your surgeon and physical therapist) shows improved rates of anatomic healing without associated stiffness when compared with an approach of early, unprotected range of motion (a.k.a. doing whatever you want, as early as you want) (9). In general, most surgeons will recommend anywhere from 2 to 6 weeks in a sling. That decision will be based on how the torn rotator cuff looked in surgery and what published literature in the field recommends to us. However, there truly isn’t a universal specific number to tell you, which is quite frustrating when life is put on hold due to your arm being stuck in a sling.

If you’re getting concerned of shoulder stiffness, rest assured: taken as a whole, clinical trials comparing immediate range of motion versus delayed range of motion at 6 weeks out from surgery don’t show any meaningful differences at 1 year out (9). To be transparent, there are some mild benefits of immediate range of motion (11) but in the big picture, they’re negligible and likely place your repair at risk. Should you be a patient who struggles with some stiffness throughout your recovery, this will tend to resolve by 1 year out (9). In other words, view this post-operative journey in the big picture: focus your efforts imaging where you’ll be at a year out versus months out from date of surgery.

 

Phase 1: 0-6 weeks

Your first visit of physical therapy:

Welcome to your first day of physical therapy! You’ll have several goals to accomplish over the next 4 to 6 months including the restoration of full symmetrical passive and active motion, the balancing of glenohumeral and scapulothoracic force coupling and the restoration of pain-free function to the shoulder (9). However, during these initial first six weeks, your largest goal is a pretty low hanging fruit: maintaining the integrity of the surgery.

The preferences of your surgeon will dictate when your first session of physical therapy is. For some, it’s post-op day 1. For others, it’s post-op 2 weeks. And for some (those with large or massive rotator cuff repairs) it’s 4 or 6 weeks post-op. Generally, the earlier you begin physical therapy, the slower and more “boring” it will feel. But as a whole, there’s a guiding theme here for both you and your therapist:

Easy goes it. I’ll be straight with you: there isn’t much to accomplish at your first appointment. Your therapist should not be pushing your range of motion, prescribing complex exercises or doing anything fancy. These early days of physical therapy are not “sexy” or exciting. 

Your therapist will have a referral script which typically includes some detail about your surgery. In the best-case scenario, your surgical team has sent over an operative report which gives your therapist even more detail to help create your rehab plan. But in any case, the two of you will go over the history of your shoulder pain, the surgery itself and (the most important part) discuss your goals for the future. This first appointment will likely include lots of conversation and education from your physical therapist. 

The official recommendation by the American Society of Shoulder and Elbow Therapists (ASSET) in their 2016 consensus statement is a “2-week period of strict immobilization and a staged introduction of protected, passive range of motion starting at 2 weeks postoperatively” (9). Depending on your date of surgery, your arm will likely be passively ranged at this appointment. This means your physical therapist will carefully move your shoulder outside of the sling. You may find it challenging to relax completely and trust your therapist, but do your best; this comes with practice. To be clear, your shoulder will be moved in a very small range that will not test your end limits of motion. 

From a therapeutic exercise standpoint, you won’t be given much homework. Likely some scapular retractions, some shoulder shrugs, and possibly some wrist and grip work. You will generally be very underwhelmed, and that’s how it should be initiated. Your biggest job is to keep that shoulder quiet and remain in the sling until verbally cleared by your surgeon. Patients who exhibit poor compliance with their post-operative restrictions in the first 6 weeks show a relative risk of retear or nonhealing that is 152 times higher than that of compliant patients (12).  In other words, do what your surgeon and physical therapist tell you!

LISTEN: ROTATOR CUFF DISCUSSION WITH PREHAB

 

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American Society of Shoulder and Elbow Therapists (ASSET) Recommendations, 0-6 weeks

In general, here are some specifics that ASSET recommends in terms of passive range of motion at this stage (9). The instructions given to you by your surgical and rehab team supersede what can be offered here. However, these are great guiding recommendations. Remember, these should never be forced or painful. 

0 to 2 weeks from date of surgery: shoulder stays in sling quietly. No range of motion.

2 to 6 weeks from date of surgery: (passive forward elevation) 60 to 90° (passive external rotation at 20° of abduction) 0 to 20° (passive external rotation at 90° of abduction) none (active forward elevation) none

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Shoulder Passive Range of Motion – Flexion to 90

Sample Phase 1 Rotator Cuff Rehab Program Exercise Video

 

Shoulder Shoulder ER PROM

 

Phase 2: 6-12 weeks

The first weeks out of your sling:

You’ve been cleared from the sling! At this time, your post-op shoulder pain has likely calmed. For many, this is when they begin testing the shoulder. However, animal studies show us that the repair of your rotator cuff is likely only 19% to 30% of normal at 6 weeks (13). At a microanatomy level, healthy tendon is anchored to bone through Sharpey fibers. These fibers penetrate the periosteum (the outer layer of bone), allowing for safe and productive muscle contractions without avulsing the tendon from its anchoring. Interestingly enough, animal studies show us that Sharpey fibers are not present between 6 to 12 weeks post-operatively. So even though you’re out of that sling, you’re not in the clear yet — the repair is only a fraction of its original strength.

A simple illustration showing Sharpey fibers anchored into the periosteum of bone. This anchoring allows for a stable contraction without the muscle avulsing from the bone. Your torn rotator cuff muscle used to have this — in this current phase of healing (6 to 12 weeks post-op), it does not.

At this point, the tendon to bone healing is sufficient to withstand low levels of muscle activity or passive tension (9). But it’s not wise to shoot for lifting high loads or doing repetitious activities quite yet. I once had a mentor who used a gardening metaphor to explain this to patients. Imagine digging a fresh hole and planting a sapling inside. You fill in your hole, proud of the new addition to your yard. But instead of giving it the time it needs to grow mature roots, you wake up the next morning and begin yanking at the base of the sapling to test its strength. Naturally, it gives way pretty easily, and you’ve found yourself with a tree now leaning crooked and half uprooted. That’s exactly what happens when patients test the integrity of their shoulder too soon following rotator cuff repair. This initial and prolonged period of rest and activity modification is crucial.

In this phase of your rehab, your stretching and passive ROM exercises can be progressed. Experts of ASSET recommend following interventions based on EMG activity levels (talk to your therapist about this) which are beyond the scope of this blog, but help rehab professionals to select appropriate exercises. But for ease of discussion, this can include pulley and cane-exercises, which are big “go-to” exercises for many patients with a post-op rotator cuff (and are often used too early during weeks 0-6). You’ll also begin to explore motions in other planes of directions: external rotation into increasing angles of abduction, horizontal adduction and functional internal rotation (reaching up your back to scratch an itch). These motions are all thought to place stress directly on your repair, so your therapist will make sure you’re performing them judiciously, and likely only following the 9 week post-op mark.

From an exercise standpoint, you may now begin performing basic “muscle performance” exercises (what many will refer to as “strength” exercises, which is a fairly inappropriate term at this point). A load of these exercises will be quite low, but that’s all your repair should be subjected to at this point anyway. Initially, you’ll learn some active-assisted ROM exercises and then active ROM exercises once able. Isometrics may also be used, but maximal effort isometrics actually place more stress on the repair than most active ROM exercises at this point, so perform these submaximally (9). 4 key exercises advocated for this in phase include external rotation, internal rotation, the row, and scaption. Of course, these will all be done with light elastic resistance. (Scaption should not be performed with anything more than 2 to 3 pounds of resistance to honor the strength of your healing repair) (9). Naturally, there are a ton of different exercises appropriate for this stage. Your therapist may teach you some not mentioned in this article, and that’s likely okay. The focus of these muscle performance exercises is to impart a stimulus for tendon healing by focusing on movement quality and endurance while working against low loads (9).

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American Society of Shoulder and Elbow Therapists (ASSET) Recommendations, 6-12 weeks

In general, here are some specifics that ASSET recommends in terms of passive range of motion at this stage (9). The instructions given to you by your surgical and rehab team supersede what can be offered here. However, these are great guiding recommendations. Remember, these should never be forced or painful. 

6 to 9 weeks from date of surgery: (passive forward elevation) 90° to 120° (passive external rotation at 20° of abduction) 20° to 30° (passive external rotation at 90° of abduction) none (active forward elevation) none

9 to 12 weeks from the date of surgery: (passive forward elevation) 130° to 155° (passive external rotation at 20° of abduction) 30° to 45° (passive external rotation at 90° of abduction) 45° to 60° (active forward elevation) 80° to 120°

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Watch How To Assess Your Own Rotator Cuff

 

Shoulder ROM

Sample Rotator Cuff Rehab Program Exercise Video

This video exemplifies the shoulder active range of motion. The extent of your surgery and post-operative guidelines will dictate not only when you can start moving your arm actively, but also how far, and in what positions.

 

Shoulder Isometric

 

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Phase 3: 12-20 weeks

The bulk of your physical therapy! Things are starting to look the way you thought rehab would:

Animal studies show us that your repair has between 29% and 50% of its normal strength at 12 weeks. By 15 weeks, the bone to tendon healing is nearly mature (13, 14). As you may or may not know, you’re not a sheep or a goat (the animals used in these studies) so we won’t expect the exact same soft tissue healing times from your shoulder. But it does provide a nice framework to program from.

In general, tendon to bone healing is considered sufficient to allow strengthening between weeks 12 and 20 as long as resistance is gradually applied and appropriate for the patient’s abilities, comfort level, and long-term goals (9). Resistance can increase as appropriate for strengthening exercises below-chest level. For many, this phase of rehabilitation will conclude a patient’s time in physical therapy following rotator cuff surgery. However, a subset of patients will require further strengthening, which will focus on overhead strengthening and resisted elevation in the scapular plane (9).

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American Society of Shoulder and Elbow Therapists (ASSET) Recommendations, 12-20 weeks

In general, here are some specifics that ASSET recommends in terms of passive range of motion at this stage (9). The instructions given to you by your surgical and rehab team supersede what can be offered here. However, these are great guiding recommendations. Remember, these should never be forced or painful. 

12 weeks and on from the date of surgery: (passive forward elevation) 140° to within normal limits (passive external rotation at 20° of abduction) 30° to within normal limits (passive external rotation at 90° of abduction) 75° to within normal limits (active forward elevation) 120° to within normal limits

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Phase 4: 20-26 weeks

Polishing off the remaining deficits of your shoulder:

This final phase of rehab is appropriate only for patients whose work or recreational demands require loads or positioning not achieved in phase 3 (9). Imagine those returning to a heavy labor-based job, or someone returning to sport. Essentially think of this final phase of rehab as identifying any remaining individualized deficits and polishing off your shoulder rehab. Again, the majority of patients who undergo this surgery will find their rehab is sufficiently concluded somewhere between weeks 12 and 20 and need to consider weeks 20+ from the date of surgery. Below are some examples of exercises you may be doing in the polishing phases of rehab.

 

Split Stance Row – Band

 

Unilateral Farmer Carry – Kettlebell

Sample Rotator Cuff Rehab Program Exercise Video

You may have a weight restriction for a period of time after surgery as well depending on your post-surgical guidelines and surgeon recommendations.

 

Side Plank Row

 

Closing Thoughts

We wish you luck in your journey to recovery. The general timeline to complete a formal rehab program following arthroscopic rotator cuff surgery is somewhere between 4 to 6 months. But keep in mind, even after being discharged from rehabilitation, it will be about a year before you’re feeling true back to your old self. Be wise in choosing your orthopedic surgeon, get in touch with a great physical therapist, and set your expectations realistically for a long recovery ahead.

Initially (0 to 6 weeks) you’ll be balancing mobilization of the shoulder while avoiding excessive stress on the repair. From there, you’ll gradually introduce appropriate and progressive loads to promote healing and remodeling of the repair (6 to 12 weeks). When the repair is sufficiently strong (past the 12-week mark), resistance training will become your main focus. And finally, you’ll polish off your rehab somewhere between 4 and 6 months, focusing on individualized programming to help return you to your work, hobbies, or sport.

For more information, please refer to the consensus statement on rehabilitation following arthroscopic rotator cuff repair by The American Society of Shoulder and Elbow Therapists (9). Their insights are detailed, realistic, and backed by hard evidence in the field. Their views and opinions have largely shaped my own philosophies on post-operative care of patients with rotator cuff surgery.

 

Take Control of Your Rotator Cuff Health!

The rotator cuff is composed of 4 small muscles that work together allowing the shoulder to move with ease. They are small but generate a large amount of force to stabilize the shoulder and when they become injured they are not shy about letting you know! This program will help you recover and get your rotator cuff back stronger than ever!

 

References

1. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2016; 88: 1699-704.
2. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012; 94: 227-33.
3. Farmer KW, Wright TW. Shoulder arthroscopy: The basics. J Hand Surg Am. 2015; 40(4): 817-821.
4. Crimmins IM, Mulcahey MK, O’Brien MJ. Diagnostic shoulder arthroscopy: Surgical technique. Arthroscopy Techniques. 2019; 8(5): 443-449.
5. Higgins JD, Frank RM, Hamamoto JT, Provencher MT, Romeo AA, Verma NN. Shoulder arthroscopy in the beach chair position. Arthroscopy Techniques. 2017; 6(4): 1153-1158.
6. Morag YM, Jacobson JA, Miller B, Maeseneer MD, Girish G, Jamadar D. MR Imaging of rotator cuff injury: What the clinician needs to know. Radiographics. 2006; 26: 1045-1065.
7. Dines JS, Bedi A, Elattrache NS, Dines DM. Single-row versus double-row rotator cuff repair: Techniques and outcomes. J Am Acad Orthop Surg. 2010; 18: 83-93.
8. Denard PJ, Burkhart SS. The evolution of suture anchors in arthroscopic rotator cuff repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2013; 29(9): 1589-1595.
9. Thigpen CA, Shaffer MA, Gaunt BW, Leggin BG, Williams GR, Wilcox RB. The american society of shoulder and elbow therapists’ consensus statement on rehabilitation following arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2016; 25: 521-535.
10. Iannotti JP, Deutsch A, Green A, Rudicel S, Christensen J, Marraffino S, et al. Time to failure after rotator cuff repair: a prospective imaging study. J Bone Joint Surg Am. 2013; 95: 965-971.
11. Chang KV, Hung CY, Hans DS, Chen WS, Wang TG, Chien KL. Early versus delayed passive range of motion exercise for arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials. Am J Sports Med. 2015; 43: 1265-73.
12. Ahmad S, Haber M, Bokor DJ. The influence of intraoperative factors and postoperative rehabilitation compliance on the integrity of the rotator cuff after arthroscopic repair. J Shoulder Elbow Surg. 2015; 24: 229-35.
13. Gerber C, Schneeberger AG, Perren SM, Nyffeler RW. Experimental rotator cuff repair. A preliminary study. J Bone Joint Surg Am. 1999; 81: 1281-1290.
14. St Pierre P, Olson EJ, Elliot JJ, O’Hair KC, McKinney LA, Ryan J. Tendon-healing to cortical bone compared with healing to a cancellous trough. A biomechanical and histological evaluation in goats. J Bone Joint Surg Am. 1995; 77: 1858-1866.

 

About The Author

Christopher Lefever, PT, DPT, SCS, CSCS, USAW

[P]rehab Writer & Content Creator