REHABILITATION AFTER ARTHROSCOPIC ROTATOR CUFF REPAIR

The senior author (SSB) has long believed that early range of motion after rotator cuff repair is contraindicated in most cases.  This belief was based on personal observations of intraoperative knot failure during open rotator cuff repair when the patient had his shoulder taken through a range of motion.  In fact, at the time of open repair, if the surgeon takes the patient’s arm up to 180 degrees of elevation six or seven times in a row, the last throw of the knot will typically come untied due to generation of large torsional forces within the knot.  If the arm is then taken through another six or seven overhead elevations, the second throw of the knot will come untied and the knot will sequentially fail in this manner.  Furthermore, if one looks arthroscopically at a single-row repair in which the rotator cuff is nicely apposed to the rotator cuff footprint with the arm at the side, and then the surgeon brings the arm into overhead elevation, he will see that the medial portion of the footprint lifts off the prepared greater tuberosity bone bed.  If this is occurring repetitively, there is no chance for healing at this interface due to the continual motion between tendon and bone.  Therefore, we have generally attempted to immobilize our rotator cuff repairs for the first six weeks after surgery in order to achieve secure biologic healing before starting range of motion.

More recently, there has been additional basic science information suggesting that immobilization is beneficial to rotator cuff healing.  Soslowsky and his associates have presented information that there are significant increases in strain at the rotator cuff repaired margin if the arm is brought passively into the overhead position (personal communication). 

A recent study by Gerber and associates showed that, with early passive motion after rotator cuff repair, the collagen fibers tended to align in a rather random fashion, whereas with immobilization for several weeks the collagen fibers aligned in a parallel array, giving stronger resistance to applied forces (1).  Based on the above studies, it seems evident that a period of immobilization to allow healing of the rotator cuff to bone would be beneficial.

 One of the most appealing features of shoulder arthroscopy in comparison to open surgery is the fact that there is very little scarring between the deltoid and underlying tissues with the arthroscopic approach.  For that reason, immobilization for six weeks can be carried out without the rather extreme stiffness that would occur with a similar period of immobilization after open repair.

 In general, following arthroscopic rotator cuff repair, our rehabilitation protocol is as follows:
 

1.                  The first 6 weeks – The patient wears a sling and does passive external rotation stretches as tolerated, and the patient is encouraged to achieve at least 45 degrees of external rotation (Fig. 1).  The exception to this protocol is in the patient with a subscapularis repair.  If the subscapularis is repaired as a part of the overall cuff repair, external rotation is restricted to 0 degrees for the first six weeks, and then is progressed as tolerated after that.

2.                  Week seven through twelve – The patient begins passive elevation as tolerated using a rope and pulley (Fig. 2) as well as supine overhead stretches using the opposite arm (Fig. 3).  The patient also continues with passive external rotation stretches.

3.                  Thirteenth week and thereafter – The patient begins a strengthening program using Thera-Band with our standard “four-pack” exercises (Fig. 4).  The four-pack includes resisted external rotation, resisted internal rotation, one-armed row, and biceps curl.  The patient starts with the smallest diameter Thera-Band, which is a red Thera-Band, and is encouraged to do four sets of ten repetitions twice a day.  The patient progresses up to the green Thera-Band and then the blue Thera-Band as tolerated.

4.                  In the case of a revision rotator cuff repair or repair of a rotator cuff tear that is greater than 5 cm in diameter, we do not begin strengthening until seventeen weeks (4 months) postop.  The reason for this more extended period of immobilization is that we believe that more time is needed for vascular ingrowth in these massive and revision repairs than in smaller repairs to achieve strong mechanical healing before stressing this repair.

5.                  Six months and thereafter -- The patient may resume full unrestricted activities if this is a primary repair that is less than 5 cm in diameter.  If it is a revision repair or has a diameter greater than 5 cm, then we have the patient wait until 12 months postop to resume full unrestricted activities, which would include golf or overhead sports.

Currently, there are two exceptions to the initial six week period of immobilization that we employ in our practice.  The first exception is the patient with calcific tendinitis.  We have observed that such patients are likely to develop rather profound chemical synovitis and chemical bursitis from the calcific deposits after the surgery, and if early stretching is not instituted they tend to become very stiff postoperatively.  Therefore, we start immediate postoperative stretching, including passive elevation with a rope and pulley as well as passive external and internal rotation.  The other exception is the patient who has a small rotator cuff tear (less than 3 cm diameter) in association with a SLAP lesion that is repaired at the same time.  We have found in our practice that this combination is also prone to stiffness if early passive stretching is not begun, so we now start immediate passive forward elevation as well as passive external and internal rotation.  In general, these small rotator cuff tears are amenable to double row fixation and we have a great deal of confidence in starting early passive range of motion because of the high fixation strength of this double row repair.

In general, for all categories of rotator cuff tear, internal rotation stretching is begun at six weeks postop but is not particularly emphasized.  We simply have the patient begin to stretch the hand up behind the back as much as possible, and then do a reverse rope and pulley stretch beginning at about eight to ten weeks postop.  Typically, restoration of internal rotation lags behind the restoration of the other ranges of motion.