Rotator Cuff Repair: Large to Massive Tear

Physical Therapy Protocol

Phase I – Immediate Post-Op: Passive Range of Motion (Weeks 1–6)

Goals:

• Protect tendon repair and promote tendon-to-bone healing
• Maintain strict immobilization (sling with abduction pillow)
• Control pain and inflammation (ice, neuromuscular stimulation)

Sling:

• Worn full-time, including while sleeping
• 30–45° abduction pillow

Precautions:

• No active or passive shoulder ROM
• No weight bearing or overhead/reaching movements
• No pushing or pulling

Therapeutic Interventions:

• AROM for hand, wrist, elbow (except elbow if biceps tenodesis: avoid for 4 weeks)
• Scapular mobility (with sling on)

Criteria to Progress:

• Controlled pain and inflammation
• Adherence to sling use and precautions
• Surgeon clearance for progression

Phase II – Intermediate Post-Op: Passive Range of Motion (Weeks 6–10)

Goals:

• Initiate gentle PROM under supervision
• Minimize stiffness while protecting repair
• Continue pain control and reinforce patient education

Sling:

• Begin weaning per surgeon approval

Precautions:

• No AROM or IR (behind back)
• No weight bearing through arm
• Avoid painful or aggressive PROM

Therapeutic Interventions:

• Passive ROM: Supine elevation (0–100°), ER (0–30°), table slides
• Shoulder pendulums (no active use)
• Scapular: Retraction, elevation, depression

Criteria to Progress:

• PROM: ≥100–120° elevation, 25–45° ER, 90° abduction
• Controlled pain/inflammation
• Compliance with home program and restrictions

Phase III – AAROM (Weeks 10–14) and AROM (Weeks 14–18)

Goals:

• Initiate AAROM → AROM
• Begin isometric strengthening (Week 14+)
• Restore motion and function for ADLs

Precautions:

• No pain-provoking activities
• No pushing, jerking, or excessive loading
• Avoid behind-the-back motions

Therapeutic Interventions:

• AAROM: Supine shoulder flexion, abduction, ER → Progress to incline → Upright
• Assisted ER (arm supported)
• Wall slides/walks (start at 12 weeks)
• AROM (14+ weeks): Standing and side-lying ER, forward reach, shoulder elevation
• Isometrics: Submaximal flexion, extension, ER, IR
• Standing rows → bent-over rows
• Manual therapy: Grade I–II mobilizations, thoracic soft tissue

Criteria to Progress:

• AROM ≥120°, PROM ≥140°, no substitution
• Appropriate scapular motion
• Tolerate ADLs and light activity below shoulder level

Phase IV – Initial Strengthening (Weeks 18–22)

Goals:

• Achieve full ROM
• Begin gradual resistance strengthening
• Progress shoulder endurance and control

Precautions:

• No lifting >5 lbs
• No jerking or overhead activities
• Avoid "empty can" or lateral raise exercises

Therapeutic Interventions:

• Stretching: Pec stretch, IR with towel, cross-body, sleeper (if tolerated)
• Strengthening:
  • Prone W, Y, T, I
  • Supine protraction, rows
  • Resisted ER/IR, side-lying ER
  • Forward punch, biceps curls, triceps extensions
  • Rhythmic stabilization (wall ball, quadruped)
• Manual therapy: Grade III–IV mobilizations

Criteria to Progress:

• Full ROM with normal mechanics
• Pain-free ADLs and strengthening

Phase V – Advanced Strengthening (Weeks 22–26)

Goals:

• Restore max strength, power, and endurance
• Advance function for sport or higher activity

Precautions:

• No overhead lifting or sudden movements
• No lifting >10 lbs

Therapeutic Interventions:

• ER at 45° and 90° abduction (progress to unsupported)
• IR at 90° abduction
• Full can in scapular plane (light weight, high reps)
• Resisted PNF D1/D2, dynamic hug
• Push-up progression: wall → counter → floor

Criteria to Progress:

• Full, pain-free ROM
• 4+/5 strength, normalized scapular mechanics
• Pain-free with basic ADLs

Phase VI – Return to Sport (Weeks 26–30+)

Goals:

• Resume sport and work activities
• Continue strength and mobility maintenance
• Achieve ≥85–90% strength (compared to opposite side)

Precautions:

• No forceful or painful activities

Therapeutic Interventions:

• Daily home stretching routine
• 3x/week strengthening + 5–10 min cardio warm-up
• Transition to general upper extremity strengthening
• Activity-specific return to sport or work drills

Return to Sport:

• Individualized decision with surgeon input based on sport demands and function

``` Let me know if you'd like a side-by-side comparison with the small-to-medium protocol, or if you want video links or QR codes added next.