What is the recommended rehabilitation protocol after a full‑thickness rotator cuff repair?

Rehabilitation After Full-Thickness Rotator Cuff Repair

The rehabilitation protocol should progress through four distinct phases over approximately 24 weeks, beginning with immobilization and passive motion, advancing to active motion, then strengthening, and finally functional exercises, with the understanding that early passive motion improves short-term range of motion but delayed motion may improve healing rates in large tears. 1, 2

Phase 1: Immobilization and Protection (0-6 Weeks)

Immobilization Strategy

• Use either a standard sling or abduction pillow—the American Academy of Orthopaedic Surgeons found no evidence favoring one over the other, so choose based on surgeon preference and patient comfort 3, 4, 5
• The duration of immobilization remains controversial with no high-quality evidence, but conservative protocols using 6 weeks of full-time sling immobilization do not result in long-term stiffness 6
• Immobilization serves primarily for pain control and preventing further injury during acute tendon-to-bone healing 4

Pain Management Protocol

• Start scheduled acetaminophen 1000mg every 6 hours combined with an NSAID or COX-2 inhibitor for baseline pain control 4, 7
• Reserve opioids strictly for rescue analgesia only 4, 7
• Apply ice for 15-20 minutes every 2-3 hours 4, 7
• Discontinue opioids as soon as possible to allow driving and optimal function 7

Early Motion Considerations

• The timing controversy: Early passive motion (starting immediately) improves forward flexion and external rotation at short-term and mid-term follow-ups, but delayed motion (starting at 6 weeks) may result in better long-term functional scores and higher healing rates, especially in large tears 2
• For patients at high risk for stiffness (diabetes, adhesive capsulitis history, older age), consider early closed-chain overhead stretches (table slides) 8
• For standard patients, delaying overhead stretches until 6 weeks optimizes healing without increasing long-term stiffness risk 8, 6

Phase 2: Passive and Assisted Motion (6-12 Weeks)

• Begin passive mobilization by the patient, both dry and in water 9
• Integrate scapular mobilization and stabilizer muscle reinforcement 9
• Progress passive range of motion exercises for forward elevation, external rotation, and internal rotation 1
• The American Academy of Orthopaedic Surgeons cannot recommend a specific timeframe for when to start these exercises due to insufficient evidence, but biological healing principles suggest 6-12 weeks is appropriate 3

Phase 3: Active Motion and Proprioception (12-18 Weeks)

• Progress to active arm mobilization, both dry and in water 9
• Integrate proprioceptive exercises and core stabilization 9
• Continue advancing based on patient progress with communication between therapist and surgeon 1
• The optimal timing for starting resistive exercises remains controversial and lacks high-quality evidence 4

Phase 4: Strengthening and Functional Recovery (18-24 Weeks)

• Implement full strength recovery exercises 9
• Progress to work-specific or sport-specific movement patterns 9, 1
• Complete functional and sport-specific exercises as the final rehabilitation stage 1

Critical Patient-Specific Risk Factors

High-Risk Populations Requiring Modified Protocols

• Older patients have higher failure rates and poorer outcomes, requiring more conservative progression 4
• Diabetic patients and smokers may have impaired healing and need slower advancement 4
• Larger tears (especially massive tears) have less favorable outcomes and may benefit from delayed motion protocols to optimize healing 7, 2
• Workers' compensation cases have less favorable outcomes and may require extended restrictions 7

Healing Rate Evidence

• Conservative rehabilitation with 6 weeks of immobilization shows a trend toward better healing rates (70% intact vs 36% in early motion groups in one study) 6
• When examining large tears specifically, early passive motion resulted in 76.6% healing rate versus 85.9% with delayed motion 2
• The primary biologic goal is achieving tendon-to-bone healing, as intact repairs demonstrate improved outcomes over re-tears 3

Return to Activity Guidelines

Driving

• Patients may resume driving once off opioid medications and demonstrating adequate shoulder control for steering and emergency maneuvers, typically by 2-4 weeks 7

Work

• Sedentary work with restrictions: operative arm in sling except for prescribed therapy, no lifting/pushing/pulling with operative arm, may use non-operative arm for light tasks 7
• Progression depends on tear size, patient age, and occupation type 7

Common Pitfalls to Avoid

• Do not assume early stiffness means long-term stiffness—23% of patients are stiff at 6-8 weeks, but this resolves by one year without differences in final range of motion or functional scores 6
• Avoid aggressive early overhead motion in large tears, as this may compromise healing rates 2
• Do not use non-cross-linked porcine small intestine submucosal xenograft patches, which have 20-30% complication rates and worse outcomes than primary repair alone 3
• Ensure full information transfer from surgeon to therapist regarding tear size, tissue quality, and repair technique to optimize individualized protocol timing 9