I have written about rotator cuff injuries in general and you can read more about it on my previous blog post. Therefore I thought I would write a blog post to follow it up on how to rehab these muscles based on the latest protocol and rehab concepts. (Van de Meijden et al 2012)
Until more recently the protocol for rehab from rotator cuff repairs has been based on clinical experience rather than expert opinion for both the timing and the actual exercises selected. There is a lot of controversy into the timing of rehab protocols to whether you should have an early rehab or delayed rehab. (Duzgen et al 2014) The research shows that starting to move your shoulder early in external rotation and flexion has significantly better results in increasing the range of movement at the joint especially in the first 6 months however it does put you at a higher risk of re-injury. However a delayed approach to movement post surgery does increases the overall healing rates. Chen et al 2015
When thinking about rehabilitation for the rotator cuff it is important to consider the shoulder blade (Scapula) mechanics as they play a huge role in the activation of the rotator cuff muscles. They will also help guide the movements at the shoulder complex, which in turn affect the rotator cuff function. The scapular movements are often affected and work the hardest in terms of compensation for a rotator cuff tear. Furthermore irritation and inflammation of the bursa can also lead to pain.
There are three phases of recovery in rotator cuff tears they are the following:
- Inflammatory Phase
- Proliferation/Repair Phase
- Remodelling phase (which is approximately 3/4 weeks after surgery this is when the scar tissue will starts to form.)
It will take around 12-16 weeks for the tendon strength to reach the max. (Murray et al 2002)
Rehabilitation of Rotator Cuff injuries:
There are four phases to exercise rehab in terms of rotator cuff tears. The aim is to increase the load and force through the shoulder gradually through each the stage. The slow progression of the exercises will help the repair process to increase the range of movement while at the same time minimizing the pain and supporting the repair process while there is still a lot of inflammation around the injury. It is important to work within a pain free range and take your time in the initial phases in order to set up the rehab effectively for the later on in the process.
There are many factors that can influence how long it will take to recovery from a roator cuff tear these include:
- Tear size
- Which rotator cuff tendon is involved
- Compensation mechanisms
- Tissue quality
- The repair method whether your had surgery or not and they type of surgery.
- Age (there is better results below 50 years)
- Previous injuries or conditions such as calcifications, adhesive capsulitis (frozen shoulder) + labral injury.
Phase 1 of Rotator cuff tears:
Aim: To protect the damaged tissue and to promote tendon healing and prevention harmful adhesions from forming.
It is normal to have initial restriction in movement post surgery and these are likely to last from 2-4 weeks. It is essential in the first phase to minimise the stress on the damaged tissues. You want to try to add passive (someone else moving your arm off weight-baring) in circles in order to minimise the joint stiffness.
You will be advised in this phase to wear a neutral sling throughout the first stage of rehab. This will try to keep the shoulder in the best position to heal. However you still want to encourage normal movement of the other surround joints (ie. the elbow, wrist, hand and neck) when possible.
Exercises- Phase 1:
Protract and retract the shoulder blade:
You can do these by focusing on your shoulder blades and trying to squeeze them together. This will help to work on the supraspinatus muscle.
This is to slowly start to increase the range of movement you only want to move the shoulder very slowly and in small circles. It will start to develop the control and stability of the supraspinatus + infraspinatus muscles.
When should you move on to Phase 2:
Once you are able to allow someone else to move your arm:
- Flexion (In front of you) to degrees,
- External rotation of shoulder blade to 75 degrees
- Internal rotation of the shoulder blade to 75 degrees,
- Abduction (arm out to the side of you) to 90 degrees
Phase 2 of Rotator cuff tears: (around 4-8 weeks post surgery)
Aim: To start to add low level impact into the routine in order to help aid the collagen fibres that will be forming in order to increase the strength the area. You also want to work on your proprioception (movement control) of the shoulder and encourage muscular balance. During this phase all exercises should be performed with the arm below the shoulder with the elbow at 90 degrees.
Rowing action using a stick or broom:
You should lie on your back with the stick and broom across your body and start to do a rowing action.
You should sit comfortably with you back straight and move your arm up towards your head like you are saluting in the army. This exercise will work on the strength on the supraspinatus muscle. You can adapt the exercise to a full can movement which is where your raise you arm above you head however it important to do this when you are lying down to add more stability. (See this picture linked with the rowing exercise).
When to progress to Phase 3:
You will be ready to progress to the next stage when you have full range of movement with no pain. It is important that you are not compensation or hitching of the shoulder blade in order to help perform the movements.
Phase 3 of Rotator cuff tears (8-12 weeks):
Aim: It start to strengthen the main rotator cuff muscles, at this point in the recovery the attachment of the tendon to the bone should have healed correctly. Therefore this phase will focus on increasing the stabilisation of the shoulder complex as well as increasing the use and muscle activation. For this phase you can start to use elastic resistance bands rather than just bodyweight. The main movements to focus on is the internal + external rotators of the shoulder.
Bear Hug test:
Attach the resistance band to something sturdy behind you and then do a punching/hugging movement while holding the band. You should stand with one foot in front of the other. You want to move you arm forward and across our body. This will work to stabilise and increase the strength of Serratus anterior, standing one foot in front of the other.
Standing sports cord row:
This time you want to have the resistance band in front of you with your arms at 90 degrees and just bring you arm straight back in line. This exercise will start to increase the strength in the trapezius particularly the lower fibres as well as the Rhomboids.
You want to hold a weight or a tin/can in your hand. Have you elbow an 90 degrees with your fingers pointing towards you and bring your arm up towards your head.
These exercise is the opposite movement to the bicep curl. Have you arm at 90 degrees and bring it back wards behind you until your elbow is straight.
When to progress to phase 4:
You should process to the next phase when you are pain free in all normal daily activities and there aren’t any movements that you can not do. You should also be able to fully tolerate all strengthening exercises without pain at all.
Phase 4 (12-16 weeks):
Aim: This phase is primarily the strengthening phase. This tendon should be completed repaired and healed with the tissue being relatively mature. This phase should move towards being sport specific and working to increase the amount of repetitions when doing strength exercises. This phase will focus on strengthening the posterior rotator cuff muscles (the muscles located on your back).
Diagonal resistance band pulls:
Attach resistance band lower down on the floor and bring you arm up in a diagonal movement to around 45 degrees, you should support your arm by placing a towel between your waist and your elbow. You can increase the intensity of the exercise by changing the angle and the height at which you attach the resistance band can modify this exercise. The aim of the exercise is to increase the stability as well as the range of movement.
Throwing ball at shoulder height:
For the exercise you can either throw the ball to a partner or against wall. To progress this exercise, modify it to throwing the ball above head level.
You want to place your hands shoulder width apart and slowly move lower your body to the ground with your body weight on your arms. You can either do this with your legs straight behind you or with you leaning on your knees. To increase the intensity of the do the push up with one hand on a box.
Returning to Sport after Rotator cuff tears:
Before you return to training for any sport you should make sure you have been cleared with your surgeon or a health professional. You want to make sure you do a full warm and take care to fully stretch before the workout. Remember to ease into training slowly there is no point doing too much too fast it will only increase your recovery time. It is also important to make sure you have a rest day in between sessions. The programme should include trying to increase you cardiovascular fitness, as this would have decreased while you have been unable to exercise. It is also important to incorporate sessions focusing on your flexibility and strength of areas including movements of the shoulder blade, rotator cuff, lower body and core.
Chen L, Peng K, Zhang D, Peng J, Xing F, Xiang Z. Rehabilitation protocol after arthroscopic rotator cuff repair: early versus delayed motion. International Journal of Clinical Experimental Medicine. 2015
Murray TF Jr, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large full-thickness rotator cuff tears: outcome at 2- to 6-year follow-up. Journal of Shoulder Elbow Surgery 2002;11:19-24.
Düzgün İ, Baltacı G, Turgut E, Atay OA. Effects of slow and accelerated rehabilitation protocols on range of motion after arthroscopic rotator cuff repair. Acta Orthopaedica Traumatologica Turcica. 2014
van der Meijden OA, Westgard P, Chandler Z, Gaskill TR, Kokmeyer D, Millett PJ. Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines. Int J Sports Phys Ther. 2012