In the past decade, rotator cuff rehabilitation has developed into a science: Understand the dynamics of the tear, consider the surgical technique and employ effective treatment interventions.

Before orthopedics clearly understood the rotator cuff's role in shoulder function, it was thought that simply "covering the hole" with various techniques was the key to success.¹Today, clinicians have a better understanding of rotator cuff function and the importance of recreating the balanced force couples in the shoulder to restore maximal function.

Rotator cuff tears can result from an acute injury or a chronic, degenerative process that possesses intrinsic and extrinsic factors. Most often these intrinsic factors are associated with age degeneration, poor vascularity, overuse and calcific tendinitis. Extrinsic factors are associated with structures such as the acromial arch slope, corococlavicular ligament arch height and acromial spurs.

In sports, chronic tears are more common and usually occur from a combination of poor technique and muscular imbalances during activities that require a follow-through motion, such as repetitive throwing or overhead strokes. Pitchers, swimmers, tennis players and golfers are particularly vulnerable, as are athletes who participate in the discus, shot put and javelin. Acute tears occur when the shoulder is loaded with intense stress or pressure, such as during weightlifting.

The first line of defense is typically a non-surgical approach, which includes physical therapy. However, if function isn't regained through conservative measures, surgical intervention may be required. Although athletes are under the guidance of an orthopedic surgeon after surgery, therapists must understand the dynamics of different rotator cuff repair methods. In addition, communication between the orthopedic surgeon and treating therapist is essential to optimize outcomes.

A Clearer Picture

Before treating a rotator cuff repair, you should be aware of the following information: which rotator cuff muscles are involved, the size or location of the tear and whether the tear is partial or full thickness. This information is essential for developing the proper treatment paradigm.

Depending on the surgeon, rotator cuff tears are categorized by a small, medium, large or massive assignment system. Knowing which tendons were torn and the size of the tear impacts your exercise prescription. For example, an athlete who presents with a small supraspinatus repair should be treated differently than a patient who's recovering from a massive subscapularis repair. Although the supraspinatus and subscapularis are both rotator cuff muscles, each contributes differently to shoulder motion. Remember that the goal of any postoperative program is to regain the balanced force couples of the shoulder musculature for maximal function.

Many athletes present with multiple tendon involvement as well as secondary procedures, which alter a treatment plan. This is where close communication with the patient's surgeon is imperative. In the early stages of postop rehab, therapists can cause more harm than good if they don't have a clear picture of the athlete's past and current condition. Ask questions regarding the size of the tear, tissue quality of the repaired tendon and how confident the surgeon is with the repair. This information guides early rehab.

For example, a patient with a small-medium supraspinatus tear with good fixation can be passively ranged within the first two weeks and progressed confidently. On the other hand, a patient with a large tear and poor tissue quality should be restricted from passive motion for 4 to 6 weeks.

Different Techniques

In the advancing age of orthopedics, fewer mini-open repairs are being performed, making arthoroscopic rotator cuff repairs the standard of care. Arthroscopes give surgeons a better view of the bursal and undersurface side of the tendon to determine the complexity of tendon involvement.

Recently, comparisons of single- and double-row rotator cuff repairs have been made. A single-row rotator cuff repair is the standard method of using a single row of fixation from the tendon to the bone interface. A double-row repair uses two rows of fixation to the bone interface.

Park et al. showed significant functional and strength outcomes in double-row repairs related to massive tears.²Charousset et al. showed no functional or strength differences between double- and single-row repairs, but the double-row repairs had significantly better tendon-healing rates.³Double-row repairs may help reestablish the normal rotator cuff footprint and increase the contact area for healing. In addition, they may offer a stronger repair that allows therapists to advance patients more rapidly. This is a key advantage for athletes who need to get back in the game quickly.

Although it's too early to make these assumptions without extensive research, our facility is working on a comparative clinical outcome study that may provide more information on these techniques and show how they can alter postoperative care.

Recovery Plans

Rehab regimens consist of range of motion (ROM) and strengthening exercises. Before formulating a plan of care, always consider tendon involvement and the type of repair completed.

Progressing ROM too soon can jeopardize a repair. It takes approximately 12 weeks for adequate "pull out" strength of a repair to occur. Therefore, immobilization and passive ROM are important to initial success.

Dockery et al. showed that the best way to range a shoulder with minimal muscle activity is through passive motion in the supine position or with a continuous passive motion machine. During the early stages, use pulleys with caution since they can cause gross muscle activity throughout the shoulder girdle during attempted passive activities.⁴For most repairs, passive motion is encouraged, with a progression to active assistive ROM and then active ROM.

Exercise caution during early scapular and rotator cuff strengthening. When appropriate, initiate active isometric strengthening with resistance tubing. Fixate a fitness band to a stationary object and allow the patient to step away and elongate the band by 25 percent with each step.

Traditional isometrics are often a guessing game in determining how much muscle activity the patient is producing with a self contraction. Active isometrics using fitness bands allows you to monitor and modify the force that the patient produces. Kowalchuk et al. showed that for every 100-percent elongation of a resistance band, muscle force doubled in the external rotators (16 percent maximal voluntary contraction to 30 percent).⁵By adjusting the resistance band and percent of elongation, active isometrics allows you to control the muscle activity to which the repair will be subject.

Scapular strengthening is vital to restoring appropriate scapulohumeral rhythm and maximum shoulder function. Scapulohumeral rhythm allows appropriate space for the rotator cuff under the subacromial arch. Since rotator cuff patients tend to have scapular dyskinesia, initiate early activation of the scapular muscles with simple scapular squeezes and depression.⁶Functional variations of scapular exercises should be performed during all rehab stages to promote a return of normal scapulohumeral rhythm. Base progression on proper rotator cuff activity. When prescribing progressive exercises, consider balancing the force couples within the shoulder.

Guiding athletes with rotator cuff repairs to full functional activity can be challenging, even for veteran therapists. Take the initiative to become competent in the various forms of rotator cuff repairs, their appropriate rehab programs and published research on the subject. Open communication with your patient's orthopedic surgeon is also imperative. This communication can educate you and your patient about the surgical procedure, plan of care and prognosis.

References are available at www.advanceweb.com/pt or by request.

Michael J. Mullaney is a research associate at the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York City and co-owner of Mullaney & Associates Physical Therapy in Matawan, NJ. Christine M. Mullaney is co-owner of Mullaney & Associates Physical Therapy.