Large-to-Massive Rotator Cuff Repair Protocol

Large-to-Massive Rotator Cuff Repair: Physical Therapy Protocol

General Considerations

Definition: Large-to-massive tears involve multiple tendons, significant retraction, or poor tissue quality. These repairs require a conservative approach to rehabilitation.
Factors Affecting Outcomes:
- Tear size and tissue quality.
- Number of tendons involved.
- Patient factors such as age, BMI, and comorbidities (e.g., diabetes).
- Concomitant subscapularis repair requires extra caution: No external rotation (ER) past 0° or abduction past 90° in Phase I.
Red Flags:
- For Therapists: Monitor for signs of stiffness (e.g., inability to achieve expected PROM milestones), repair failure (e.g., sharp pain, significant weakness, or clicking sensation), or excessive swelling.
- For Patients: Report the following immediately:
  - Persistent or sharp shoulder pain not improving with rest.
  - Sudden onset of weakness or inability to lift the arm.
  - Significant increase in swelling, warmth, or redness around the shoulder.

Goals:
- Protect tendon repair and promote tendon-to-bone healing.
- Minimize inflammation and pain (e.g., cryotherapy, TENS).
- Maintain mobility of the hand, wrist, and elbow.
Precautions:
- No active or passive shoulder movement.
- No weight-bearing through the surgical arm.
- No reaching overhead, behind the back, pushing, or pulling.
- If subscapularis was repaired: No ER past 0° or abduction past 90°.
Sling Use: Worn full-time (including while sleeping) with an abduction pillow (30°–45° abduction).
Interventions:
- Hand, Wrist, Elbow AROM: Avoid active elbow flexion for 4 weeks if biceps tenodesis was performed.
- Scapular Mobility: Performed within sling.
- Pain Management: Cryotherapy recommended 20 minutes, 2–3 times per day.
Criteria to Progress:
- Pain and inflammation controlled.
- Adherence to immobilization and precautions.
- No signs of repair compromise.

Goals:
- Minimize stiffness while protecting repair.
- Gradually introduce passive range of motion (PROM).
- Educate on post-operative restrictions and home exercise program (HEP).
Precautions:
- No active shoulder motion.
- Avoid painful or aggressive PROM.
- No internal rotation (IR) or reaching behind the back.
Interventions:
- PROM (With PT Assistance):
  - Forward elevation: 0°–100°.
  - External rotation (scapular plane): 0°–30°.
  - Abduction: Avoid if subscapularis was repaired.
- Gentle Scapular Exercises: Retraction, elevation, and depression without resistance.
- Table Slides and Pendulums: Avoid active shoulder muscle use.
Criteria to Progress:
- PROM: ≥120° forward elevation, ≥45° external rotation.
- Pain and inflammation controlled.
- Compliance with restrictions and HEP.

Goals:
- Initiate active-assisted range of motion (AAROM) and active range of motion (AROM).
- Normalize motion and perform daily activities.
Precautions:
- No lifting or pain-inducing activities.
- Avoid sudden, jerking motions or excessive loading.
Interventions:
- AAROM Progression:
  - Cane-assisted forward flexion and external rotation (supine to upright progression).
  - Wall slides and wall walks (starting at Week 12).
- AROM Progression (Week 14):
  - Side-lying and standing external rotation.
  - Active forward reach and shoulder elevation.
- Strengthening (Week 14): Isometrics for shoulder flexion, extension, and ER/IR (submaximal effort only).
Criteria to Progress:
- AROM without compensations.
- Functional ROM for activities of daily living (ADLs).
- Pain levels <3/10 during exercises.

Goals:
- Restore full PROM and progress strength, endurance, and power.
- Achieve ADLs and modified recreational activities without discomfort.
Precautions:
- No lifting objects heavier than 5 lbs.
- Avoid uncontrolled or overhead lifting.
Interventions:
- Stretching: Pec stretch, cross-body stretch, and gentle sleeper stretch (if tolerated).
- Strengthening:
  - Prone W, T, Y, and I.
  - Resistance band rows, shoulder ER/IR, and scapular stabilization.
  - Rhythmic stabilization drills (e.g., ball exercises on a wall or table).
Criteria to Progress:
- Full pain-free ROM.
- Strength ≥4/5 without pain.
- ADLs completed without discomfort.

Goals:
- Restore maximal strength, power, and endurance.
- Maintain full ROM and pain-free function.
Precautions:
- No lifting >10 lbs.
- Avoid painful or uncontrolled movements.
Interventions:
- Progressive Strengthening:
  - ER/IR at 45°–90° abduction.
  - Resisted diagonals (PNF D1/D2 patterns).
  - Dynamic hug and supported push-up progressions.
- Functional Training: Tailored to work, sport, or recreational activities.
Criteria to Progress:
- Full pain-free ROM with proper mechanics.
- Pain-free ADLs and strengthening.

Goals:
- Safely return to work, recreational, or athletic activities.
- Achieve shoulder strength ≥85%–90% of the contralateral side.
Precautions:
- Avoid heavy or forceful lifting.
- No painful activity progression.
Interventions:
- Conditioning: Gradual progression to general upper extremity strengthening.
- Return-to-Sport Training: Sport or activity-specific drills under therapist guidance.