Rotator Cuff Repair - Large to Massive

Physical Therapy Protocol

Rotator Cuff Repair: Large to Massive Tear

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.