What is rotator cuff?
The rotator cuff is a general term for the tendon tissue covering the subscapularis, supraspinatus, infraspinatus and teres minor muscles in the anterior, superior and posterior parts of the shoulder joint. It is located below the acromion and deltoid and is closely connected to the joint capsule. The function of the rotator cuff is to bring the humeral head closer to the glenoid during upper arm abduction and to maintain a normal fulcrum joint between the humeral head and the glenoid. Rotator cuff injury will diminish or even lose this function, severely affecting upper extremity abduction function. It often occurs during repetitive sports that require extreme abduction of the shoulder joint (e.g., baseball, freestyle, backstroke and butterfly, weight lifting, racquet sports).
Conservative treatment methods include physical therapy and changes in activity patterns. If conservative treatment fails, surgical treatment is required. Statistics show that the incidence of rotator cuff tears has increased from 23.5 per 100,000 in 1995 to 83.1 per 100,000 in 2009. This is why rotator cuff repair has become the most common shoulder surgery and therefore its postoperative rehabilitation is common in clinical practice.
The surgical approach to RCR has also been improving, evolving from open surgery to small incision surgery and then to arthroscopic surgery. Arthroscopic repair has become the gold standard in the treatment of rotator cuff tears. These changes in surgical approach have also generated interest among clinicians in exploring safe postoperative rehabilitation treatment strategies.
Despite the current advances in surgical approaches, the incidence of joint stiffness and non-healing rates after RCR remain high. Joint stiffness is the most common postoperative complication, with reported rates ranging from 4.9% to 32.7%. Postoperative nonunion rates range from 20 to 94%. Factors affecting tendon healing include: age over 65 years, diabetes, osteoporosis, cardiovascular disease, smoking, extent of the tear and long-term nature of the tear. A successful postoperative rehabilitation program should take these factors into account, in addition to weighing the risk of complicating joint stiffness and repair failure.
The debate on postoperative rehabilitation continues. The main issues debated in the literature are early restriction of joint motion or early active joint motion, the use of a sling, the optimal time to start physical therapy and the appropriate amount of daily activity.
There is a prevailing view that delaying the start of joint activity is necessary to increase the healing rate. Delaying joint activity does not affect patient satisfaction and may mildly improve the healing rate after RCR. Six weeks of inactivity does not result in long-term joint stiffness and may improve tendon healing rates. It is thought that early active joint activity may increase the risk of rotator cuff retear after patients have been active and limited joint activity early in the postoperative period. Although not yet proven, early joint activity has been statistically shown to increase the rate of rotator cuff re-injury.
However, several recent studies have highlighted the benefits of early postoperative joint activity in patients. It is believed that early joint motion improves joint function and does not make a significant difference in healing, and it has also been confirmed that early joint motion does not have a detrimental effect on tendon healing.
Given the many known benefits of joint motion, postoperative rehabilitation allows for an early pain-free range of joint motion. Limiting early joint motion after surgery clearly serves to protect tendon repair. For example, at 0 to 3 weeks postoperatively, the range of forward flexion: 0 to 120 degrees and the range of internal/external rotation: 0 to 45 degrees. The physician’s prescription is the most important method of guiding the patient’s treatment, and guidelines for improving the patient’s postoperative condition should be based on the patient meeting certain conditions, not on a time-based program.
Finding the right exercises throughout the postoperative rehabilitation process is quite challenging. In the study, patients were observed in their postoperative routines, and 26 common postoperative exercises performed one to four weeks after subacromial decompression were evaluated. They concluded from electromyography that the following active exercises resulted in no greater activation of the supraspinatus than the resting state: therapist-assisted and voluntary external rotation activities, therapist-assisted elevation movements, monoswing activities, isometric internal rotation, and internal retraction. The infraspinatus muscle was activated more strongly in all active exercises than in the resting state.
1. 0 to 3 weeks
Performed in the supine position in the scapular plane
Elbow, wrist, finger joints distal to AROM
Active/stable lying side scapula
Pulling scapula in sitting position
Submaximal deltoid isometric contraction
Codman exercise
Eligible conditions for the rehab protection period include
Normal scapular motion
Full range of AROM of the distal shoulder joint
Postoperative shoulder ROM consistent with surgeon’s goals
Active assisted joint mobility training, ER external rotation, FF forward flexion, IR internal rotation, PROM passive joint mobility training
2. 3 to 7 weeks
AAROM exercises
Small range of joint activities and neuromuscular re-education by physical therapist
Joint movement with pulleys
Stabilization of the scapula
Submaximal isometric IR/ER in modified neutral position
Hydrotherapy
Airdyne dynamometer
Conditions that qualify for the early strengthening phase in rehabilitation include
AAROM
Anterior flexion in the scapular plane up to 140 degrees
Abduction to 110 degrees
Internal/external rotation to 60 degrees
Ability to bear the arm in a sling
No pain when moving rotator cuff muscles and deltoids
AAROM active assisted joint mobility training, ER external rotation, IR internal rotation.
Active assisted joint mobility training with pulleys for anterior flexion
Hydrotherapy: underwater scapular in-plane elevation
3. 7 to 13 weeks
Continued supine ROM training
Functional internal rotation activities (pass towel, tie belt)
Scapular pulling with rubber bands
Abduction of shoulder joint using rubber bands
Supine scapular anterior extension against weight
Strengthening of the rotator cuff muscles (from unilateral recumbency to standing position with the aid of an elastic band)
Active joint movement in the scapular plane
Closed chain activity
Flexion activities
Active warm-up activities prior to training
Conditions that qualify for the late strengthening phase include
Mild pain/inflammation
Full range PROM
Improved rotator cuff strength and scapular strength
Normal scapulohumeral rhythm during shoulder elevation to 90 degrees
IR internal rotation, PROM, passive joint motion
4. 14 weeks to 19 weeks
Isotonic training of peri-scapular muscles and rotator cuff muscles
Stabilize the scapula
If strength is adequate, begin below-plane strengthening exercises
Maintain posterior rotator cuff flexibility
Scapular plane (IR/ER) isotonic strength training
Eligible for return to motion phase include
Normal scapulohumeral rhythm during full range of joint motion
Scapular and humeral muscle strength at level 5
ER external rotation motion, IR,internal rotation motion.
Pulling the scapula on a seated rower
5. 20 to 24 weeks
Augmented training above horizontal position
Isotonic training of rotator cuff muscles
Isometric training and testing of internal and external rotation exercises (athletes requiring overhead movements)
Periodic and interval training for athletes requiring overhead movements
Discharge conditions include.
85% limb symmetry and ER/IR ratio near 66% of normal on isometric testing
Solo sustained strength, flexibility and neuromuscular control at home or in the gym
ER external rotation, IR internal rotation.
In conclusion, post-rehabilitation should be individualized according to the patient’s needs. Depending on the patient’s condition, rehabilitation guidelines or a time-based program are preferable, and aggressive ROM in the early postoperative phase is not conducive to safe tendon healing. Careful monitoring of exercises to avoid pain and patient education on daily living are important aspects of post-RCR rehabilitation. Performing higher levels of activity is required until pain is eliminated and return to exercise is adapted to the needs of the athlete.