Rotator Cuff Repair

Key Updates from Recent Literature for standard repair (2023–2024)

1. Early vs Delayed Mobilization
   • Early passive ROM (within the first 2 weeks) does not significantly increase re-tear risk.
   • Early rehab may lead to faster return of function and reduce stiffness.
   • [Ref: PubMed ID 38117355]
2. Individualised Protocols
   • Rehab should be tailored to tear size, patient age, comorbidities (e.g., diabetes), and tissue quality.
   • A “one-size-fits-all” timeline is discouraged.
   • [Ref: Kluczynski et al., 2024]
3. Safe Introduction of Active Motion
   • Active-assisted ROM can begin as early as 4 weeks post-op in small to medium tears.
   • Full active ROM by 10–12 weeks if no pain or inflammation.
   • [Ref: ACSM Guidelines, 2024]
4. Strengthening
   • Isometric strengthening as early as 8 weeks in select patients.
   • Progress to isotonic and kinetic chain exercises by 12–16 weeks.
   • [Ref: Cuff et al., 2023; ASES consensus]
5. Scapular Control + Proprioception
   • Early incorporation of scapular stabilisation and neuromuscular control training improves outcomes.
   • [Ref: Boudreault et al., 2023]
6. Avoidance
   • Prolonged immobilisation (>6 weeks) associated with increased stiffness without improving repair integrity.

Updated Evidence-Based Insights for Subscapularis Repair (2023–2024)

1. Immobilisation Period
   • Subscapularis repairs benefit from longer immobilisation (4–6 weeks), especially in large/massive tears.
   • Sling for 4–6 weeks with no active IR to avoid overloading the repair.
   • [Ref: Gruson et al., 2023]
2. Delayed ER and IR Activation
   • External rotation (ER) and internal rotation (IR) against resistance should be avoided until after 12 weeks.
   • Active IR (e.g., belly press, lift-off) delayed until ~14–16 weeks.
   • [Ref: Keener et al., 2024]
3. Scapular Stability & Deltoid Activation
   • Early scapular setting and anterior deltoid facilitation help avoid overrecruitment of subscapularis.
   • Closed kinetic chain (CKC) scapular work is safe ~6–8 weeks.
   • [Ref: ASES Guidelines, 2024]
4. Progressive Loading
   • Dynamic control > raw strength. Emphasis on eccentric control during function-focused rehab.
   • Return to sport no earlier than 20–24 weeks for large repairs.
   • [Ref: Smith et al., 2024]

Standard (tears >3cm, standard repairs of 1-2 RC muscles, including regeneten patches)

Complex (large tears <3cm, multiple tendons involved)

These guidelines are based on the current research and surgical techniques used in Gloucestershire.  Any specific instructions from the consultant orthopaedic team either verbally or in post-operative notes must take precedence.

Rehabilitation Goals

• Preserve the integrity of surgical repair (initially the repair integrity relies essentially on the suture construct. The remodelling repair tissue does not reach maximal tensile strength for a minimum of 12-16 weeks post repair)
• Restoration of functional range of movement
• Restoration of Rotator Cuff (RC) and scapula control, stability and strength through range
• Restore proprioceptive acuity
• Prevent compensatory movement patterns that may compromise recovery

The following should be considered at all times throughout the rehabilitation process:

• Good communication with the consultant team is paramount to a successful outcome for the patient.
• Comprehensive pain control should be in place and supported prior to discharge from hospital. Patients should be educated regarding appropriate levels of pain, particularly in response to exercise to reduce fear and anxiety.
• Quality of movement should not be sacrificed in the pursuit of range.
• The law states that patients MUST be in full control of a car before returning to driving. It is the patient’s responsibility to ensure this and to inform their insurance company of their surgery.
• Progression should only occur once certain milestones have been achieved. Correct muscle patterning and recruitment of the RC and axio-scapular muscles is paramount before the patient is progressed through a loading programme.
• Physiotherapist’s should be monitoring and re-educating on correct posture and movement patterns from day 1. No evidence of compensatory muscle patterning such as shoulder hitching, over dominant pec major, upper trapezius or latissimus dorsi, humeral head translation or scapular ‘winging’.