How long should a patient wear a sling after rotator cuff repair?

Sling Duration After Rotator Cuff Repair

Patients should wear a sling for 3-6 weeks after arthroscopic rotator cuff repair, with emerging evidence supporting shorter durations (3 weeks) or even no sling use for small to medium tears without compromising healing or outcomes.

Evidence-Based Recommendations

Standard Immobilization Duration

• The American Academy of Orthopaedic Surgeons (AAOS) guidelines acknowledge insufficient evidence to recommend for or against specific immobilization devices (abduction pillow versus standard sling) or optimal timeframes for shoulder immobilization after rotator cuff repair 1, 2

• Despite lack of definitive guideline recommendations, immobilization serves primarily for pain control and preventing further injury during the acute healing phase 1, 2

High-Quality Recent Evidence on Duration

Three weeks of immobilization is non-inferior to six weeks:

• A 2018 Level I randomized controlled trial (n=120) demonstrated that 3 weeks of simple sling immobilization produced equivalent functional outcomes and healing rates compared to 6 weeks in a brace with abduction pillow 3
  • WORC index scores at 1 year: 83% (3-week group) vs 87% (6-week group), meeting non-inferiority criteria 3
  • MRI at 1 year showed 89% healed repairs in both groups 3
  • This applies specifically to small to medium-sized tears 3

No sling may be appropriate for selected patients:

• A 2019 Level I trial (n=80) found that patients who used no sling after repair of small or medium tears had better early mobility and functional scores without compromising repair integrity 4

  • No-sling group showed significantly better external rotation and active elevation at 1.5 months 4
  • Ultrasound at 6 months revealed no difference in repair integrity between sling and no-sling groups 4
  • Multivariable analysis confirmed sling immobilization was associated with worse SANE scores and increased pain 4

• A separate 2019 Level I trial (n=206) comparing early active motion versus standard sling immobilization found no significant differences in ROM, pain, strength, or quality of life over 24 months, with similar repair integrity at 12 months 5

  • 25% overall retear rate with no difference between groups (30% early motion vs 33% standard) 5

Clinical Algorithm for Sling Duration

For small to medium tears (most common scenario):

• 3 weeks in a simple sling is sufficient and safe 3
• Consider no sling with early pain-free active motion for motivated patients 4, 5

For larger or more complex tears:

• 6 weeks of immobilization remains reasonable given expert opinion that tendon-to-bone healing is unlikely before 12 weeks postoperatively 6
• Use sling immobilization with judicious passive motion for first 6 weeks 6

Rehabilitation progression regardless of sling duration:

• Weeks 0-6: Passive range of motion (if using sling protocol) 6
• Weeks 6-12: Progressive passive to active-assisted range of motion 6
• After 12 weeks: Begin rotator cuff strengthening and active overhead use 6

Important Caveats

Risk of postoperative stiffness:

• Resistant stiffness requiring intervention occurs in only 3.3% of patients overall 7
• Immediate passive motion protocols show 1.5% stiffness rate versus 4.5% with 6-week immobilization 7
• However, delayed mobilization may be important for achieving rotator cuff healing, particularly in larger tears 7

Patient-specific factors affecting healing:

• Older age is associated with higher failure rates and poorer outcomes, potentially warranting more conservative immobilization 2
• Comorbidities such as diabetes and smoking may negatively affect healing and require longer protection periods 2

Pain management during immobilization:

• Start scheduled acetaminophen 1000mg every 6 hours combined with an NSAID or COX-2 inhibitor 2
• Reserve opioids strictly for rescue analgesia 2
• Apply ice for 15-20 minutes every 2-3 hours 2