Small Rotator Cuff Repair:
Physical Therapy Protocol

Definition of Small Tear

Single-tendon involvement, such as the supraspinatus only, with minimal retraction or fatty infiltration. Typically involves single-anchor repair.

Phase I: Immediate Post-Operative Protection (0–3 Weeks)

• Goals:
  • Protect surgical repair.
  • Minimize swelling and pain.
  • Maintain mobility of the wrist, hand, and elbow.
  • Begin passive range of motion (PROM) exercises.
  • Educate the patient on restrictions and care.
• Sling Use: Neutral rotation with abduction pillow at 30°–45°. Full-time, including while sleeping.
• Precautions:
  • No active range of motion (AROM) or active-assisted range of motion (AAROM).
  • No resisted elbow flexion or active biceps contractions if biceps tenodesis was performed.
  • Avoid lifting, weight-bearing through the arm, or overhead motions.
  • No scapular retraction (if teres minor repair).
• Interventions:
  • Swelling Management: Ice and compression daily.
  • PROM Restrictions:
    • Forward flexion: <90°.
    • External rotation: <20° (in scapular plane).
  • Exercises:
    • Pendulum exercises (daily, 2–3 sessions).
    • Table slides (horizontal).
    • Wrist, hand, and elbow AROM.
    • Scapular setting and retraction (if appropriate).
    • Ball squeezes.
• Criteria to Progress:
  • Forward flexion PROM: 90°.
  • External rotation PROM: 20° (scapular plane).
  • No significant pain or swelling.

Phase II: Early Post-Operative Rehabilitation (4–6 Weeks)

• Goals:
  • Continue protecting the repair.
  • Maintain PROM and introduce active-assisted range of motion (AAROM).
  • Minimize substitution patterns.
• Precautions:
  • No unsupported lifting or weight-bearing.
  • No AROM against gravity.
  • No resisted elbow flexion until Week 6 if biceps tenodesis was performed.
• PROM Progression:
  • Forward flexion: Progress to <120°.
  • External rotation: Progress to <30° (in scapular plane).
• Interventions:
  • AAROM Exercises:
    • Cane-assisted forward flexion and external rotation.
    • Wall slides.
    • Seated shoulder flexion with support.
  • Scapular Mobility:
    • Protraction, retraction, and shrugs (as tolerated).
• Criteria to Progress:
  • Forward flexion PROM: 120°.
  • External rotation PROM: 30° (scapular plane).
  • Demonstrates scapular mobility without compensations.

Phase III: Intermediate Rehabilitation (7–12 Weeks)

• Goals:
  • Transition from PROM/AAROM to AROM.
  • Improve scapular mechanics and shoulder stability.
  • Initiate light strengthening.
• Precautions:
  • Avoid heavy lifting (>10 lbs) or aggressive motions.
• Interventions:
  • AROM Progression:
    • Forward flexion and scaption to pain-free ranges (progress to full by Week 12).
    • External rotation to <45° in the scapular plane.
  • Strengthening:
    • Isometric ER/IR.
    • Resistance band rows, shoulder extension, and scaption.
    • Supine punches and wall slides.
  • Scapular Stabilization:
    • Rowing, lawnmowers, and banded exercises.
• Criteria to Progress:
  • Full PROM achieved.
  • Controlled AROM without compensations.
  • Pain levels <4/10 during activities.

Phase IV: Advanced Strengthening & Functional Progression (13–20 Weeks)

• Goals:
  • Restore full functional strength and ROM.
  • Transition to functional and sport-specific movements.
• Interventions:
  • Closed-Chain Activities:
    • Modified push-ups, wall push-ups.
  • Progressive Resistance:
    • Bands and light weights for ER/IR and scaption.
  • Functional Strengthening:
    • Plyometrics, proprioceptive drills (optional).
• Criteria to Progress:
  • Full pain-free AROM and PROM.
  • Symmetrical scapular mechanics.

Phase V: Return to Sport or Overhead Activities (20+ Weeks)

• Goals:
  • Full return to sport-specific and overhead activities.
• Interventions:
  • Sport-specific drills and overhead progression.
  • Eccentric strengthening and plyometric activities.
• Criteria:
  • Clearance from MD and physical therapist.
  • Full functional strength and endurance achieved.