Exercise

• Short but frequent exercise sessions (four or five times per day).
• Low number of repetitions per exercise.
• Only passive or assisted shoulder ROM exercises and only within the “safe” limits of ranges noted during surgery. Absolutely no end-range stretching.
• Passive external rotation to neutral or to less than 30° to avoid excessive stress to the subscapularis muscle, which was incised for surgical exposure and then repaired or lengthened if a preoperative contracture limited external rotation.
• During passive or assisted shoulder rotation with the patient lying supine, position the humerus slightly anterior to the midline of the body (by placing the arm on a folded towel) to avoid excessive stress to the anterior capsule and suture line.
• No hyperextension or horizontal abduction (beyond neutral) of the shoulder to avoid stress to the anterior capsule.
• If an overhead rope-pulley system is used for assisted elevation of the arm, initially have the patient face the doorway and pulley apparatus so shoulder elevation occurs only within a limited range.
• Maintain an erect trunk during passive or assisted elevation of the arm while sitting or standing to avoid subacromial impingement of soft tissues.
• In most instances no active (unassisted), antigravity, dynamic shoulder exercises, particularly resisted internal rotation.
• No resistance (strengthening) exercises.
• In general, a more gradual progression of exercises for a patient with a severely damaged and repaired or an irreparable rotator cuff mechanism than a patient with a preoperatively intact cuff.

Activities of Daily Living

• Limit activities to those that can be performed with the elbow at waist level, such as eating or writing.
• Avoid reaching behind the back.
• Avoid weight bearing (leaning) on the operated extremity, such as pushing during transfers or when moving in bed, especially the first week after surgery.
• Avoid lifting objects.
• Support the arm in a sling during extended periods of standing or walking.
• Wear the sling while sleeping or outside in crowded areas.
• No driving for several weeks.

Goals and interventions. The first phase of rehabilitation includes the following.

• Control pain and inflammation.

• Use of a sling or splint for comfort.
• Use of prescribed analgesic and anti-inflammatory medication.
• Use of cryotherapy, especially after exercise.

• Maintain mobility of adjacent joints.

• Active movements of the neck and scapula (while wearing the shoulder immobilizer and after it can be removed for exercise) to maintain normal motion and minimize muscle guarding and spasm. Incorporate “shoulder rolls” by elevating, adducting, and then relaxing the scapulae to reinforce an erect posture of the trunk. Emphasize active scapular retraction and spinal extension.
• Active ROM of the hand, wrist, and elbow when the arm can be removed from the sling.

• Restore shoulder mobility.

• Passive or therapist-assisted shoulder motions within the safe limits determined during surgery. With the patient lying supine and the arm slightly away from the side of the trunk on a folded towel and the elbow flexed, perform forward elevation of the arm in the plane of the scapula to tolerance, external rotation to no more than 30° to 45°, and internal rotation until the forearm rests on the chest.
• Pendulum (Codman’s) exercises with the elbow flexed (for a shorter moment arm). Encourage the patient to periodically remove the sling and gently swing the arm during ambulation at home.
• Later during this phase, progress to self-assisted shoulder ROM (elevation and rotation) in the supine position initially by assisting with the sound hand and later using a wand or dowel rod. Add horizontal abduction to neutral and adduction across the chest holding a wand.
• Self-assisted shoulder ROM in a sitting position or standing with a wand by performing “gear shift” exercises, resting the arm on a table and sliding it forward, or use of an overhead rope-pulley system to lessen the weight of the arm. Remind the patient to maintain an erect trunk when performing assisted shoulder motions while seated or standing.
• Self-assisted reaching movements (to the nose, forehead, or over the head as comfort allows) to simulate functional movements.
• In selected patients, transition to active (unassisted) shoulder ROM is often possible by 4 weeks.
• Functional activities with the elbow at waist level, such as hand to face and writing, are permissible.

• Minimize muscle inhibition, guarding, and atrophy.

• Gentle muscle-setting of shoulder musculature (excluding the internal rotators) with the elbow flexed and the shoulder in the plane of the scapula or neutral. Teach these exercises prior to discharge from the hospital by having the patient practice isometrically contracting the muscles of the sound shoulder. Postpone setting exercises (light isometrics) of the operated shoulder until about 4 to 6 weeks after surgery.
• Scapular stabilization exercises in non-weight-bearing positions. Target the serratus anterior and trapezius muscles.

NOTE: For a patient who underwent repair of a large tear or rupture of a rotator cuff tendon or other soft tissue reconstruction, it may not be permissible to begin ROM exercises immediately after surgery. When the sling or splint can be removed for exercise, perform only passive or assisted ROM throughout the first phase of rehabilitation. The range of shoulder elevation and external rotation initially permitted may be less than for shoulders that did not require cuff repair. Postpone active (unassisted), antigravity ROM and light isometrics until the next phase (until about 6 weeks postoperatively, when repaired soft tissues are reasonably well healed).

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