ARTHROSCOPIC

ROTATOR CUFF REPAIR PROTOCOL

PHYSIOTHERAPY LED POST OPERATIVE SHOULDER CLINIC

COMPILED BY: TENDAYI MUTSOPOTSI BSc. HPT (Hons) MSc. ORTHO-MED MCSP MSOM
APPROVED BY: MR ANDREW SANKEY ORTHOPAEDIC CONSULTANT SURGEON
Arthroscopic Rotator Cuff Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Arthroscopic Rotator Cuff Repair The purpose of this protocol is to provide the physiotherapist with a guideline for the post- operative rehabilitation course of a patient that has undergone an Arthroscopic Rotator cuff Repair. It is not intended to be a substitute for appropriate clinical decision-making regarding the progression of a patients post-operative course. The actual post surgical physiotherapy management must be based on the surgical approach, physical examination/findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist requires assistance in the progression of a post-operative patient they should consult with Mr. Andrew Sankey (Shoulder Consultant) or Mr. Tendayi Mutsopotsi (Specialist Shoulder Therapist) Please Note: Recovery takes 6-12 months. The protocol is divided into phases. Each phase is adaptable based on the individual and special circumstances. Immediately post-operatively, exercises must be modified so as not to place unnecessary stress to the repaired rotator cuff of the shoulder. Early passive range of motion is highly beneficial to enhance circulation within the joint to promote healing. The overall goals of the surgical procedure and rehabilitation are to: Control pain and inflammation Regain normal upper extremity strength and endurance Regain normal shoulder range of motion Achieve the level of function based on the orthopedic and patient goals The physical therapy should be initiated within the first week and one half to two weeks post-op. The supervised rehabilitation program is to be supplemented by a home exercise program where the patient performs the given exercises at home or at a gym facility. Important post-operative signs to monitor include: Swelling of the shoulder and surrounding soft tissue Abnormal pain response, hypersensitive-an increase in night pain Severe range of motion limitations Weakness in the upper extremity musculature Return to activity requires both time and clinical evaluation. To most safely and efficiently return to normal or high level of functional activity, the patient requires adequate strength, flexibility, and endurance. Functional evaluation including strength and range of motion testing is one method of evaluating a patients readiness to return to activity. Return to intense activities following an arthroscopic rotator repair requires both a graded strengthening and range of motion program along with a period of time to allow for tissue healing. Progression to the next phase based on Clinical Criteria and/or Time Frames as Appropriate.
Arthroscopic Rotator Cuff Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 Phase I: Immediate Post Surgical (Weeks 1-6): Goals: Maintain / protect integrity of repair Prevent muscular inhibition Gradually increase passive range of motion Become independent with activities of daily living with (PROM) modifications Diminish pain and inflammation Precautions: Maintain arm in polysling/ abduction sling, No lifting of body weight by hands remove only for exercise No supporting of any weight Keep incision clean and dry No shoulder motion behind back No excessive stretching or sudden movements No active range of motion (AROM) of shoulder No lifting of objects Criteria for progression to the next phase (II): Passive forward flexion to at least 125 degrees Passive external rotation (ER) in scapular plane to at least 75 degrees Passive internal rotation (IR) in scapular plane to at least 75 degrees Passive Abduction to at least 90 degrees in the scapular plane DAYS 1 TO 6: Abduction brace/polysling Begin scapula isometrics Sleeping in sling PENDULUM, cervical, finger, wrist, and elbow AROM exercises Patient Education: posture, joint protection, positioning, hygiene, etc.

Cryotherapy for pain and inflammation Day 1-2: as much as possible (20 minutes /every hour) and Day 3-6: post activity, or for pain DAYS 7 TO 28:

Continue use of abduction sling / brace and Pendulum exercises Begin passive ROM to tolerance (these should be done supine and should be pain free) -Flexion to 90 degrees and IR to body/chest ER in scapula plane up to 35 (EXCEPT SUBSCAP REPAIR) Continue Elbow, wrist, and finger AROM / resisted Cryotherapy as needed for pain control and inflammation May resume general conditioning program walking, stationary bicycle, etc.
Aquatherapy / pool therapy may begin at 3 weeks post-op
Arthroscopic Rotator Cuff Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Phase II: Protection / AAROM (weeks 4 - 10)

Goals: Allow healing of soft tissue Do not overstress healing tissue Precautions: No lifting No excessive behind the back movements Gradually restore full passive ROM (week 4-5) Decrease pain and inflammation

No supporting of body weight by hands and arms No sudden jerking motions

Avoid upper extremity bike or upper extremity ergometer at all times. Criteria for progression to the next phase (III): Full active range of motion WEEK 5-6: Continue use of sling/brace full time until end of week 4 Continue cryotherapy as needed Initiate active assisted range of motion (AAROM) flexion Discontinue sling/ brace at end of week 6 in supine position Between weeks 4 and 6 may use sling/brace for Gentle Scapular/GHJ mobilisation as indicated comfort only to regain full PROM May use pool (aquatherapy) for light AROM exercise Initiate prone rowing to neutral arm position Progressive passive ROM until approximately Full ROM at Week 4-5. Weeks 6-10 Continue active and active assisted ROM and stretching exercises Begin rotator cuff isometrics

Continue periscapular exercises Initiate active ROM exercises

Phase III: Early strengthening (weeks 10-14)

Goals: Full active ROM (week 10-12) and Maintain full passive ROM Dynamic shoulder stability Gradual restoration of shoulder strength, power, and endurance Optimize neuromuscular control Gradual return to functional activities
Arthroscopic Rotator Cuff Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Precautions: No heavy lifting of objects (no heavier than 5 lbs.) No sudden jerking motions

No overhead lifting. No sudden lifting or pushing activities

Avoid upper extremity bike or upper extremity ergometer at all times Criteria for progression to the next phase (IV): Able to tolerate the progression to low-level functional activities Demonstrates return of strength/dynamic shoulder stability Re-establish dynamic shoulder stability Demonstrates adequate strength and dynamic stability for progression to higher demanding work/sport specific activities. WEEK 10: Continue stretching and passive ROM (as needed) Dynamic stabilization exercises Initiate strengthening program External rotation (ER)/Internal rotation (IR) with therabands/sport cord/tubing ER side lying (lateral decubitus) Lateral raises* Full can in scapular plane* (avoid empty can abduction exercises at all times) Prone rowing, Prone horizontal abduction, Prone extension, Elbow flexion and Elbow extension *Patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonics and if unable, continue glenohumeral joint exercises WEEK 12: Continue all exercise listed above and initiate light functional activities as Surgeon permits WEEK 14: Continue all exercise listed above and progress to fundamental shoulder exercises

Phase IV: Advanced strengthening (weeks 16-22)

Goals: Maintain full non-painful active ROM Advance conditioning exercises for enhanced functional use Improve muscular strength, power, and endurance Gradual return to full functional activities WEEK 16: Continue ROM and self-capsular stretching for ROM maintenance Continue progression of strengthening Advance proprioceptive, neuromuscular activities Light sports (golf chipping/putting, tennis ground strokes), if doing well
Arthroscopic Rotator Cuff Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 WEEK 20: Continue strengthening and stretching May initiate interval sport program (i.e. golf, doubles tennis, etc.), if appropriate. Milestones for discharge: 1. Achieved time and patient specific functional goals. 2. Achieved 90-100% of contra lateral shoulder active ROM. 3. Patient has a negative lag sign (i.e. active equals passive range) with dynamic rotation control at 0 abd, 45 abd, 90 abd. 4. Patient has no apprehension with specific movements and activities. 1. Milestone driven These are milestone driven guidelines designed to provide an equitable rehabilitation service to all of our patients. They will also limit unnecessary visits to the outpatient clinic here at Chelsea & Westminster by helping the patient and therapist to identify when specialist review is required. If patients are progressing satisfactorily and meeting milestones, there is no need for them to attend clinic routinely. Failure to progress or variations from the norm should be the main reason for clinic attendance. Both patients and therapists can book clinic visits by contacting the numbers given further on in this document. Clinic follow-up schedule post-op: 2, 6, 12, 16-24 weeks (only if necessary) Failure to meet milestones: 1. Refer to/discuss with Shoulder and Elbow Unit 2. Consider possible reasons for failure to progress and act accordingly 3. Continue with outpatient physiotherapy while patient is still making progress.
Arthroscopic Rotator Cuff Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Failure to progress If a patient is failing to progress, then consider the following: Possible problem Pain inhibition Action Adequate analgesia Keep exercises pain-free Return to passive ROM if necessary until pain controlled Progressing too quickly hold back If severe night pain/resting pain refer to Shoulder Unit Patient exercising too vigorously Increase or reduce physiotherapy/ Patient not doing home exercise (HEP) (max 2-4x/day) for few programme (HEP) regularly enough days/weeks and assess difference Ensure HEP focuses on key exercises and link to function Returned to activities too soon Decrease activity intensity Cervical/thoracic pain referral Assess and treat accordingly Unable to gain strength Passive ROM may need improving Altered neuropathodynamics Assess and treat accordingly Poor rotator cuff control Ensure passive range gained first Consider isometrics through range Rotation dissociation through range with decreasing support and increasing resistance Ensure not progressing through Therabands too quickly Poor scapula control Work on scapula stability through range without fixing with pec major/lat dorsi Poor core stability Work on improving core stability Secondary frozen shoulder Maintain passive ROM as able Use physiological and accessory mobilisations, taking into account end feel and tissue healing times It is essential you contact us if you have any concerns. THE SHOULDER UNIT TEAM Shoulder Consultant: Mr. Andrew Sankey 0208 746 8545 Shoulder Therapist: Mr. Tendayi Mutsopotsi 0208 746 8404 Secretary: 0208 746 8545

Arthroscopic Rotator Cuff Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)