Large / Massive Rotator Cuff Repair

RESTRICTIONS:

• NO shoulder motions for 3 weeks
• NO internal rotation or hyperextension for 8 weeks
• NO upper body weighted exercises for 4 months
• NO overhead weight training >20 lbs (e.g. shoulder press) for 8 months

Phase I: Protection (Weeks 0–3)

Primary Goals:

• Protect surgical repair / healing tissue
• Minimize pain and inflammation
• Prevent stiffness of adjacent joints

Precautions:

• Sling with abduction pillow x3 weeks at all times other than for hygiene
• No shoulder motion; active or passive

Interventions:

Scapular and Distal Mobility

• AROM for elbow, wrist, and hand
• Scapular retraction/depression exercises

Phase II: Protection and Early Motion (Weeks 3–8)

Primary Goals:

• Protect surgical repair / healing tissue
• Minimize pain and inflammation
• Prevent stiffness via controlled PROM
• Maintain mobility in distal joints

Precautions:

• Sling alone until post-op week 6
• No active shoulder motion
• No lifting, pushing, or pulling
• No internal rotation or hyperextension for 8 weeks

Shoulder Passive Range of Motion (PROM)

• Flexion to tolerance
• ER in scapular plane to tolerance UNLESS Subscapularis repair performed
• Gentle pendulums

Scapular and Distal Mobility

• AROM for elbow, wrist, and hand
• Scapular retraction/depression exercises

Criteria to Progress to Phase III

• Minimal pain at rest
• PROM flexion ≥120°, ER ≥30°
• Good scapular mobility without trapezial substitution

Phase III: Active Motion and Early Strengthening (Weeks 8–16)

Primary Goals:

• Gradually restore AROM
• Begin controlled rotator cuff and scapular muscle activation
• Protect repair while minimizing stiffness and atrophy

Precautions:

• Avoid lifting >1–2 lb
• No upper body weighted exercises x4 months

Interventions:

Transition to Active-Assisted → Active Motion

• AAROM with cane or pulley in pain-free range
• Progress to AROM in supine to minimize gravitational load
• Emphasize isometric and eccentric control

Scapular Stabilization

• Prone and standing scapular retraction/protraction control
• Rhomboid, lower trapezius, and serratus anterior activation
  • Exercises: wall slides with resistance

Early Rotator Cuff Activation

• Initiate isometrics (ER, IR, flexion, abduction) in neutral
• Initiate light theraband ER/IR as tolerated around ~10–12 weeks

Criteria to Progress to Phase IV

• Full, pain-free AROM
• No trapezial substitution or scapular dyskinesis
• Strength ≥4/5 for rotator cuff and scapular stabilizers

Phase IV: Strengthening and Functional Return (Weeks 16–32)

Primary Goals:

• Restore full strength and endurance of rotator cuff and scapular muscles
• Optimize dynamic stability and proprioception
• Gradually return to work/sport-specific activities

Precautions:

• Avoid overloading with fatigue or poor form
• Delay overhead or plyometric activity until baseline strength achieved
• No overhead weight training >20 lbs (e.g. shoulder press) for 8 months

Interventions:

Progressive Strengthening

• Resistance bands → free weights
• ER/IR at 0°, progress to 90° abduction positions
• Scapular plane elevation, prone horizontal abduction
• Closed-chain progression: wall push-ups → stability ball → floor

Endurance and Kinetic Chain Integration

• High-rep, low-load endurance work (15–20 reps)
• Incorporate trunk and lower extremity strength for kinetic chain contribution

Functional / Sport-Specific Drills

• Simulated ADLs, overhead reach tasks
• Return-to-sport / work test if applicable

At 8 months no formal work or lifting restrictions. Patient cleared for activity as tolerated. PT as patient desires up to 1 year.