Intended for licensed physical therapists coordinating care with Dr. Vasileff. Defer to the operative note and the surgeon’s office for patient-specific direction.
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Shoulder · Rotator Cuff

Rotator Cuff Repair — Large (>3 cm)

Post-operative protocol · Dr. Chris Vasileff, MD
For the treating physical therapist. This protocol is a guideline; progression is criteria-based and individualized. Defer to the operative note and the surgeon’s office for patient-specific direction.

Rotator Cuff Repair (Large-Massive, >3cm)

Phase I Maximum Protection (Weeks 0 - 8)

Goals

  • Reduce inflammation
  • Decrease pain
  • Postural education
  • PROM as instructed

Exercise Progression

  • UltraSling for weeks (0-4), then regular sling for weeks (4-8)
  • Cervical ROM and basic deep neck flexor activation (chin tucks)
  • Instruction on proper head neck and shoulder (HNS) alignment
  • Active hand and wrist range of motion
  • Encourage walks and low intensity cardiovascular exercise to promote healing.
  • Ice: continue to ice on a regular basis. At least 20 minutes at a time, 4-5 times per day.
  • Shower: On post-op day 3
  • Appointment: your first therapy appointment should be within 5-7 days after your surgery.

Phase 1-0 | Quiet (Weeks 0 – 4)

  • Quiet in sling with elbow/wrist/hand
  • Begin active scapular retraction/protraction exercises with therapist cueing

Phase 1-1 | Passive (Weeks 5 – 8) | Pendulums to warm-up beginning week 5

  • Supine external rotation - 0º - 30º beginning at 5 weeks with progression to full PROM by 8 weeks
  • Supine forward elevation - 0º - 90º beginning at 5 weeks with progression to full PROM by 8 weeks
  • Progress to upright as tolerated with ER and FE

Manual Intervention

  • Scar tissue mobilization when incisions are healed
  • Graded GH mobilizations

Phase II Progressive Stretching & Active Motion (Wks 9 - 12)

Goals

  • Postural education
  • Focus on posterior chain strengthening
  • Begin Passive / Active Assisted ROM

Activities

  • Sling: Discontinue sling
  • Ice: Continue to ice on a regular basis after therapy sessions or increased exertion.
  • Use of the affected arm: You can actively use your arm for daily living: bathing, dressing, driving, typing on a computer, eating and drinking.

Exercise Progression

  • Progress to full range of motion flexion and external rotation as tolerated. Use a combination of wand, pulleys, wall walks or table slides to ensure compliance.
  • Gradual introduction to internal rotation using shoulder extensions (stick off back)
  • Serratus activation; Ceiling punch (weight of arm) many initially need assistance
  • Scapular strengthening – prone scapular series (rows and I’s). Emphasize scapular strengthening under 90°
  • External rotation on side (no resistance)
  • Gentle therapist directed CR, RS and perturbations to achieve ROM goals
  • Cervical ROM as needed to maintain full mobility
  • DNF and proper HNS alignment with all RC/SS exercises
  • Low to moderate cardiovascular work. May add elliptical but no running

Phase II-1 | Active (Week 9-12) | Pendulums to warm up and AROM w/ terminal stretch

  • Supine external rotation - after 8 weeks progress GRADUALLY to full
  • Supine forward elevation - after 8 weeks progress GRADUALLY to full
  • Begin active biceps
  • Internal rotation - full (begin behind the back)
  • Begin AROM in supine and progress to upright

Manual Intervention

  • STM – global shoulder and CT junction
  • Scar tissue mobilization.
  • Graded GH mobilizations.
  • ST mobilizations
  • Gentle CR/RS to gain ROM while respecting repaired tissue.

Phase III – Advanced Strengthening & Endurance (Wks 13 - 16)

Goals

  • 90% passive ROM, 80-90% AROM by 16 weeks. Larger tears and patients with poor tissue quality will progress more slowly.
  • Normalize GH/ST arthrokinematics.
  • Activate RC/SS with isometric and isotonic progression.
  • Continue to emphasize posterior chain strengthening but introduce anterior shoulder loading.

Exercise Progression

  • Full painless ROM
  • No pain or tenderness on examination

Phase III-1 | Resisted (Week 13) | Pendulums to warm up and continue to prior training

  • External and internal rotation
  • Standing forward punch
  • Seated rows
  • Shoulder shrugs
  • Bicep curls

Phase III-2 Weight Training (Week 16)

  • Keep hands within eyesight, keep elbows bent, no long lever arms
  • Minimize overhead activities - below shoulder
  • No military press, pull-down behind head, or wide grip bench

Manual Intervention

  • STM and Joint mobilization to CT junction, GHJ and STJ as needed
  • CR/RS to gain ROM while respecting repaired tissue
  • Manual perturbations
  • PNF patterns

Phase IV – Advanced Strengthening & Endurance (Wks 16 - 28)

PRE/PSE (weeks 16-24)

  • Full range of motion all planes – emphasize terminal stretching with cross arm, TUB, triceps, TV, sleeper and door/pec stretch.
  • Begin strengthening at or above 90° with prone or standing Y’s, D2 flexion pattern and 90/90 as scapular control and ROM permit. Patient health, physical condition and goals/objectives will determine if strengthening above 90° is appropriate.
  • Add lat pulls to gym strengthening program; very gradual progression with pressing and overhead activity.
  • Continue with closed chain quadruped perturbations; add open chain as strength permits
  • Progress closed kinetic chain program to include push-up progression beginning with counter, knee then – gradual progression to full as appropriate
  • Initiate plyometric and rebounder drills as appropriate

Return to Sport Program

  • Full painless ROM
  • No pain or tenderness on examination

Manual Intervention

  • STM and Joint mobilization to CT junction, GHJ and STJ as needed
  • CR/RS to gain ROM while respecting repaired tissue
  • Manual perturbations
  • PNF patterns

RETURN TO ACTIVITIES

Computer As soon as tolerated

Driving When no longer taking narcotics

Elliptical 2 months

Jogging 3 months

Light Swimming 4 months

Golf (Chip & Putt) 5-6 months

Golf (Irons & Driver) 7-8 months

Tennis 7-8 months

Weight training 7-8 months

Skiing 7-8 months

Contact Sports 8 months

**Heavy overhead lifting (military press), pull-down behind head, wide grip bench and dips are discouraged.

Questions about a protocol? Contact Dr. Vasileff’s office at (704) 865-0077.