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Narrative Review
Rotator cuff repair: considerations of surgicalcharacteristics and evidence basedinterventions for improving muscleperformance
Patrick Pabian1, Carey Rothschild1, Randy Schwartzberg2
1Department of Health Professions, University of Central Florida, Orlando, FL, USA, 2Orlando OrthopaedicCenter, Orlando, FL, USA
Background: Rotator cuff tears may lead to significant limitations in function, pain and disability. The extentof recovery from surgical intervention and subsequent rehabilitation can vary depending on the com-plexities of the tear, repair procedure, and post-operative patient management. Evidence suggests thattear and surgical characteristics will influence patient presentation in terms of strength and function, andthus need to be considered when healthcare professionals design rehabilitation programs.Objectives: The objective of this manuscript is to present evidence-based rehabilitation guidelines formanagement of patients following repair of full-thickness rotator cuff tears, while taking into considerationthe method of repair and the characteristics of the rotator cuff defect.Major findings: Many studies have examined different characteristics of rotator cuff tears, various surgicalprocedures to correct the deficits, and physical interventions that target the specific range of motion andstrength deficits post rotator cuff repair. A significant number of investigations have reported muscle activationlevels with exercises and daily activities, which may offer a prescriptive utility to the clinician providing post-operative management. However, there are insufficient evidence-based rehabilitation programs that considerthe characteristics of the rotator cuff tear defect or method of repair when addressing the post-operativeclinical presentation, related impairments, functional limitations and interventions.Conclusion: Rotator cuff tears and repairs have various characteristics that can impact patient recovery.Optimal recovery is dependent on appropriate communication among healthcare professionals and arehabilitation professional’s understanding of how the tear classifications and surgical management caninfluence the standard treatment plan for rotator cuff repair.
Keywords: Rotator cuff tear, Rotator cuff repair, Rotator cuff facilitation, Rotator cuff strength
IntroductionRotator cuff tears may result in significant shoulder
dysfunction and functional impairments. Patients
with tears can have various clinical presentations,
which are attributed to numerous factors, including
the characteristics of the rotator cuff defect. Surgical
repair of the rotator cuff aims to restore the damaged
tendon, reduce pain, and ultimately improve func-
tion. Physical therapists and other rehabilitation
professionals have examined the post-operative ma-
nagement of patients post rotator cuff repair and
developed interventions to improve function in this
population. Variables that have been shown to highly
correlate with improved function are integrity of the
repaired rotator cuff1 and strength.2 The objectives of
this manuscript are to review the outcomes of the
various methods of rotator cuff repair, identify tear
characteristics or repair procedures that could impact
rotator cuff healing and patient recovery, and to pre-
sent evidence-based rehabilitation strategies and guide-
lines for management of rotator cuff strengthening in
patients after surgical repair.
Rotator Cuff Tear CharacteristicsRotator cuff tears individually are assessed using
several parameters. These parameters include tear
size, tear shape, and tissue quality. The combination
of these elements of a rotator cuff tear makes up the
personality of that given tear. The unique personality
of a rotator cuff tear and subsequent repair are
worthy of individualized consideration in the reha-
bilitation phase. Rotator cuff tears are classified as
Correspondence to: Patrick Pabian, University of Central Florida, 4000Central Florida Blvd, HPA 1 Rm 256, Orlando, FL32816-2205, USA.Email: [email protected]
374� W. S. Maney & Son Ltd 2011DOI 10.1179/1743288X11Y.0000000044 Physical Therapy Reviews 2011 VOL. 16 NO. 5
full-thickness, or partial thickness, depending upon
depth of the defect in the tendon. This manuscript
will focus on full-thickness tears. In addition, patient
factors such as patient smoking status and medical
comorbidities should also be considered in the
evaluation of rotator cuff repair and rehabilitation.
Although outside the scope of this manuscript, it is
important to recognize that diabetes mellitus,3–5
smoking,6 and worker’s compensation3,7 all have
been correlated with poorer outcomes post rotator
cuff repair when compared to subjects without these
factors.
Rotator cuff tear size is often measured by the
maximum diameter and cross-sectional area of the
involved region of the tendon. Different diameters
have been utilized to create classifications such as
small, medium, large, and massive rotator cuff tears.
The most commonly utilized classification system
involving tear size was originated by DeOrio and
Cofield, who defined measures as small (,1 cm),
medium (1–3 cm), large (3–5 cm), and massive
(.5 cm) rotator cuff tears.8 Classifications such as
this provide descriptive size data but lack important
attributes such as tear location or degree of retrac-
tion. In this regard, a classification that examines
the degree of frontal plane retraction is the Patte
classification.9 A study examining the interrater
reliability among 12 fellowship-trained orthopedic
surgeons utilizing these classifications found a fair
agreement (k50.32) in the DeOrio and Cofield
classification and a moderate agreement (k50.54) in
the Patte classification.10 The findings of this study
suggest acceptable practical use of these classification
systems. The benefit of doing so may outweigh the
risks. Larger-sized rotator cuff tears, tears involving
multiple tendons, and increased degree of retraction
have been correlated with increased failure rates.11–15
An additional consideration related to size is the
involvement of additional tendons (or location) of the
tear. Tears involving the infraspinatus or teres minor
have been found to have a greater incidence of
re-tears1,16 and due to these tendon involvements,
require more protection and slower progression in
internal rotation range of motion and external
rotation strengthening exercises.17 Due to these find-
ings and potential changes in operative and post-
surgical management, various classification systems
involving topographic features have been proposed.18–20
The utilization of these topographic classifications
in describing rotator cuff tears could provide signifi-
cant benefit to rehabilitation professionals. Larger
rotator cuff tears carry increased risks of failure,
re-tear, and reduced functional outcome.13,15,21 There-
fore, modification of standard rehabilitation programs
to account for these topographic characteristics has
been the focus of recent literature.17,21
Rotator cuff tears have been classified further
based on their shape. Lo and Burkhart22 described
and reviewed surgical management of tears based on
these shapes. Two general categories have been
identified. First, the crescent shaped tears involve
rotator cuff tendons torn away from their humeral
head insertions (Figs. 1A, 2, and 3). Repair of these
tears involves reattachment of the tendons to their
humeral head attachments (Fig. 1B). The second
category of tears involves tearing between tendons in
addition to tendon tearing from bone. These tears
can be U-shaped (Figs. 4A and 5) or L-shaped tears
Figure 1 Crescent-shaped rotator cuff tear. (A) Superior
view of a crescent-shaped rotator cuff tear involving the
supraspinatus (SS) and infraspinatus (IS) tendons; (B)
repaired crescent-shaped tear.22 Adopted from: Lo, IK and
Burkhart, SS, American Journal of Sports Medicine (volume
31, issue 2, pp. 308–324), copyright� 2003 by SAGE
Publications. Reprinted by Permission of SAGE Publications.
Figure 2 Arthroscopic picture of crescent-shaped tear.
Figure 3 Arthroscopic picture of crescent-shaped tear.
Pabian et al. Rotator cuff repair
Physical Therapy Reviews 2011 VOL. 16 NO. 5 375
(Fig. 6A). U- and L-shaped tears require suturing of
the tendon split, often termed ‘margin convergence’,
followed by reattachment to the bone.23,24 The
biomechanics of repairing U-shaped and L-shaped
tears involves decreasing the marginal tear strains
with side-to-side suturing. This converts the tear into
a crescent shaped tear that is repaired to bone
(Figs. 4B, 4C, 6B, 6C, and 7). Although post-
operative rehabilitation implications have not been
specifically studied for repair of these different
rotator cuff tear shapes, surgical outcome studies24–
27 have been used to provide a link of these geometric
classifications to prognosis.18
Standard repair of the rotator cuff involves either
one or both of the following: tendon to bone repair or
tendon to tendon repair. Suture anchor fixation
(tendon to bone) has shown to have strong biome-
chanical properties.28,29 Side to side repairs (tendon
to tendon) have been shown to be effective in
reducing the cuff deficit and provide good patient
outcomes,30,31 but the tendon-suture interface has
often been found to be a common point of failure in
unsuccessful repairs.32 Thus, it may be prudent to
progress more cautiously in the early rehabilitation
phases with U-shaped and L-shaped tears that
necessitate tendon-to-tendon suturing.
An additional consideration of a rotator cuff tear
that impacts the complexity of the tear and sub-
sequent repair and recovery is tissue quality. Tissue
quality of tendon, muscle, and bone all need to be
Figure 4 U-shaped rotator cuff tear. (A) Superior view of a U-shaped rotator cuff tear involving the supraspinatus (SS) and
infraspinatus (IS) tendons; (B) U-shaped tears demonstrate excellent mobility from an anterior-to-posterior direction and are
initially repaired with side-to-side sutures using the principle of margin convergence; (C) the repaired margin is then repaired to
bone in a tension-free manner.22 Adopted from: Lo, IK and Burkhart, SS, American Journal of Sports Medicine (volume 31, issue
2, pp. 308–324), copyright� 2003 by SAGE Publications. Reprinted by Permission of SAGE Publications.
Figure 5 Arthroscopic picture of U-shaped tear.
Figure 6 Acute L-shaped rotator cuff tear. (A) superior view of an acute L-shaped rotator cuff tear involving the supraspinatus
tendon (SS) and rotator interval (RI); (B) the tears should be initially repaired along the longitudinal split; (C) the converged
margin is then repaired to bone. IS, infraspinatus; Sub, subscapularis tendon; CHL, coracohumeral ligament.22 Adopted from:
Lo, IK and Burkhart, SS, American Journal of Sports Medicine (volume 31, issue 2, pp. 308–324), copyright� 2003 by SAGE
Publications. Reprinted by Permission of SAGE Publications.
Pabian et al. Rotator cuff repair
376 Physical Therapy Reviews 2011 VOL. 16 NO. 5
considered. Tissue quality can be assessed through
preoperative magnetic resonance imaging (MRI),
evaluating for muscle atrophy and fatty infiltration
or degeneration. The degree of fatty degeneration has
been identified as a major prognostic factor for the
outcome of rotator cuff repair.13 Therefore, rehabi-
litation following repair should be conservative in
patients with poor tissue quality.17
Rotator Cuff Repair ConsiderationsFrom a surgical repair procedure standpoint, rotator
cuff repairs can be evaluated based on the surgical
approach (arthroscopic vs mini-open vs open) and on
the fixation method (single vs double row fixation).
Each of these variables contributes to the makeup of
a given rotator cuff repair.
Initially rotator cuff repairs were performed in an
open fashion. This approach involved the detachment
of the deltoid origin from the anterior acromion,
resection of a portion of the anterior acromion,
rotator cuff repair and reattachment of the anterior
deltoid to the remaining anterior acromion through
drill holes. Post-operative protection for the deltoid
reattachment is critical with this open approach.33
Mini-open repair was initiated to address the
needed precautions and potential failure of the deltoid
repair. During the mini-open repair procedure, the
deltoid muscle is split vertically along the orienta-
tion of the muscle fibers to allow for visualization and
repair of the torn rotator cuff tendon. Acromioplasties
performed with the mini-open approach are typically
performed arthroscopically.34 Numerous studies have
supported this procedure with good to excellent results
in approximately 90% of patients.35–38
Arthroscopic rotator cuff repair is the least invasive
surgical repair method. It involves no formal incision,
no deltoid detachment and no open deltoid split.
Arthroscopic rotator cuff repair provides the best
visualization of the rotator cuff of the three repair
methods.39,40 Studies comparing repair methods often
focus on arthroscopic versus mini-open repair. These
studies compare repair integrity through follow up
MRI, computed tomography and clinical outcomes
scores. A retrospective, study by Sauerbrey et al.41
compared 54 patients post-arthroscopic repair versus
mini-open repair at a minimum of 13 months post-op.
The groups in this study were homogenous in relation
to age (57/56 years), and tear size (2.0/2.7 cm2). This
study found no differences in pain, patient satisfaction,
or function between the mini-open and arthroscopic
procedures.
Anatomic healing of the rotator cuff is an obvious
goal of rotator cuff repair. Interestingly, some studies
have shown high clinical outcome scores despite radi-
ologically documented rotator cuff repair failures.11,42
Despite this, it is generally accepted that healed rotator
cuff repairs offer a greater chance at better clinical
outcomes in terms of pain, function, and strength.1,43
Arthroscopic rotator cuff repair healing rates have been
assessed and compared to open techniques. In a
comparison study and meta-analysis, it has been shown
that arthroscopic rotator cuff repair healing rates have
been equal to healing rates with the mini-open
techniques.41,44 Repair approaches do not correlate with
failure rate. Factors that consistently correlate with
higher rotator cuff repair failure rates include increasing
age and greater tear sizes.11,15,45
The personalities of rotator cuff repairs engender
further complexity as surgical fixation techniques are
discussed. The variety of surgical techniques involves
tendon fixation options to the humeral head inser-
tions. A landmark improvement in fixation to bone
was the development of the suture anchor. Suture
anchors are placed into bone. They have sutures in
them that pass through eyelets. The sutures are
passed through the tendon and tied to fix the tendon
to the bone. Suture anchors typify modern rotator
cuff fixation to bone.40
Suture anchor fixation methods can be divided
into single and double row repairs. Single row
repairs involve one row of anchors in an anterior
to posterior direction along the tear insertion site.
Double row repairs are defined by one row of
anchors placed along the medial margin of the tear
insertion site and another row of anchors placed
along the lateral margin of the tear insertion site
(Figs 8 and 9). Double row repairs were developed
due to the belief that single row suture anchor
techniques did not adequately restore the supraspi-
natus to its footprint insertion, leading to inadequate
healing.46,47 Double row constructs not only have
been proven to reproduce the insertion anatomy
better, but also have been shown to be biomechani-
cally superior to single row repairs.29,48,49 In addi-
tion, a systematic review examining 1252 repairs
found that double row repairs of tears greater than
1 cm have been found to have significantly lower
anatomical failure rates based on MRI and ultra-
sound evaluations.50 Despite these advantages of
Figure 7 Arthroscopic picture of margin convergence of a
U-shaped tear.
Pabian et al. Rotator cuff repair
Physical Therapy Reviews 2011 VOL. 16 NO. 5 377
double row rotator cuff repair constructs, some
studies have found that they have not been demon-
strated to result in better clinical outcomes scores
than their single row repair counterparts.51–54
Regarding post-operative rehabilitation progres-
sions for single versus double row rotator cuff
repairs, the progressions should be predicated on
characteristics other than the repair technique. The
differences in anatomical healing rates have not been
explored with use of different rehabilitation protocols
for single versus double row repairs. As previously
noted, clinical presentation may be affected by any of
the tear characteristics, surgical repair procedures, or
patient factors. Rehabilitation professionals will need
to recognize the factors making up the rotator cuff
tear personality and design the rehabilitation pro-
gram in accordance with individualized attention.
Post-operative RehabilitationThe rehabilitation program following rotator cuff
repair may be broken down into three main phases:
(1) maximum protection/passive, (2) moderate protec-
tion/active, and (3) minimum protection/resistive. The
rate at which a patient progresses through these phases
is dependent upon numerous factors related to the
patient and surgical characteristics as previously
discussed. These include the following: size, shape,
and location of the tear, surgical procedure, tissue
quality, and additional patient factors (age, co-morbid-
ities, smoking, etc.). Therefore, variance exists between
the rates at which patients can progress through the
rehabilitation programs. The authors recognize that
various rehabilitation protocols have been published
and may conflict with one another.
The goal of the first phase or rehabilitation pro-
grams for rotator cuff repair is to prevent post-operative
stiffness and scar tissue adherence while allowing for
tendon to bone healing.21 This phase typically begins
with shoulder immobilization and lasts 0–6 weeks.
Phase two progresses over weeks 7–12 and consists of
passive to active exercises for the rotator cuff
musculature and scapular stabilizers.21 The third
phase begins after week 12 and includes the addition
of strengthening exercises and progression to func-
tional activities. Various exercises have been identified
as appropriate during each of these phases post rotator
cuff repair. Naturally, with the association of poorer
outcomes with muscle atrophy of the infraspinatus
and supraspinatus,2 it is often the focus of rehabilita-
tion professionals to utilize tactics that will best
facilitate and eventually strengthen these rotator cuff
muscles. Activation and facilitation of the rotator cuff
and scapular musculature is best demonstrated
through muscle activity analysis using electromyogra-
phy (EMG). Therefore, it is our intention to provide a
comprehensive rotator cuff repair rehabilitation pro-
tocol consisting of exercises based upon EMG activity
while encouraging readers to keep in mind the con-
siderations of tear and surgical characteristics as
previously discussed. Rehabilitation guideline time-
frames are provided with the assumption of a me-
dium sized tear; smaller or larger tears will warrant
appropriate alteration of these timeframes.
The analysis of muscular activity through the use
of EMG involves the muscle’s response in relation to
its maximal voluntary isometric contraction (MVIC).
Therefore, prior to determining the effectiveness
of a particular exercise in facilitating a muscular
response, the muscle is tested for its MVIC. The
normalized mean value for a particular exercise can
be expressed as a percentage of the MVIC; the
higher the percentage, the higher muscle activity
recorded. General categories have been developed to
assist in classifying the amount of muscle activity.
McCann et al.55 suggest the following interpretation
of the percentage of MVIC: minimal activity ,20%
MVIC, moderate activity 20–50% MVIC, and
marked activity .50% MVIC. Uhl et al.56 suggest
a different scale: low activity ,20% MVIC, moder-
ate activity 20–40% MVIC; high activity 41–60%
MVIC; and very high .60% MVIC. These scales can
be useful in determining appropriateness of various
exercises and activities in each of the phases of a
rotator cuff rehabilitation program. Based on these
Figure 8 Arthroscopic picture of double row repair of a
crescent-shaped tear.
Figure 9 Arthroscopic picture of double row repair of a
U-shaped tear.
Pabian et al. Rotator cuff repair
378 Physical Therapy Reviews 2011 VOL. 16 NO. 5
findings, the authors of this manuscript recommend
the following: (1) exercises in phase one should
demonstrate minimal activity (less than 20% MVIC)
in the rotator cuff musculature; (2) exercises in phase
two should demonstrate moderate activity (20–40%
MVIC) in the rotator cuff and scapular musculature;
and (3) exercises in phase three should demonstrate
high activity (41–60% MVIC) in the rotator cuff and
scapular musculature in order to maximize gains in
returned strength.
Maximum protection phase/passive exercise(weeks 0–6)Immobilization
Shoulder immobilization is recommended in the
maximum protection phase following rotator cuff
repair regardless of the tear characteristics or method
of surgical fixation. Hatakeyama et al.57 identified
that tensile forces on the repaired rotator cuff tendon
were less at 45 and 30u compared to 15 and 0u of
shoulder abduction. Additionally, strain was lowest
in the scapular plane versus the sagittal plane for all
four abducted positions. Therefore, an abductor
pillow brace with the shoulder supported between
30 and 45uof abduction in the scapular plane is
recommended for patients following rotator cuff
repair. Immobilization has been recommended for 3
weeks and then only discontinued as determined by
the surgeon or physical therapist.17 Suggested reha-
bilitation exercises are included in Table 1, with
evidence for maximum protection phase interventions
included in Table 2.
Pendulum (Codman’s)
In addition to active movement of the hand, wrist
and elbow, the maximum protection phase usually
consists of passive movement and light activity of
daily livings (ADLs) for the operative extremity. The
pendulum exercise, also known as Codman’s, is a
typical exercise performed in this phase. Caution,
however, should be taken when performing this
exercise. Long et al.58 found that smaller pendulums
(less than 20 cm in diameter) are safer post rotator
cuff repair than larger pendulums (greater than 51 cm
in diameter) due to .20% MVIC produced in the
infraspinatus and supraspinatus muscles with the
larger motion. In addition, researchers have indicated
that even the support by the contralateral limb on the
table may cause greater than minimal supraspinatus
activity.17,58 Due to the potential for increased strain
as described, it is recommended that the pendulum
exercise be appropriately instructed and performed to
effectively protect the integrity of the healing rotator
cuff tendon regardless of tear type, tear size, or
method of fixation.
Table 1 Suggested rehabilitation exercises
Maximum protectionphase/passive exercise
Immobilization in abductor pillow brace withshoulder in 30–45u in scapular plane
(0–6 weeks) CPM machine in combined elevation and ERSupine self-assisted elevation with stick or contralateral armSupine ER/IR with stickPROM by PT: elevation (in scapular plane), ER, IRUpright pulleyUpright pendulum in small diameter ,20 cmADLs with involved arm: typingADLs with uninvolved arm: cross-body reaching, slowforward reaching and downward reachingClosed chain: Prayer and Quadruped positionsGentle scapular exercises: depression, protraction ONLYSerratus: cross-body rotations with uninvolved arm at lowerheights with/without steppingAquatic exercises: elevation in the scapular plane at slow speeds(30–45u/second); buoyancy assisted FF, ER; scapular stabilization; pendulumsAVOID AROM of the involved armAVOID isometrics during maximum protection phase55
Moderate protectionphase/active exercise
Progressive scapular exercises: inferior glide, low row, ‘Lawnmower’,‘Robbery’; (1) SL ER, (2) SL FF, (3) prone HABD, and (4) prone EXT
(7–12 weeks) Isometric exercises (5 directions) with/without NMESActive rotator cuff exercises: supine active elevation, upright elevationwith elbow bent and straight, upright abduction
Minimum protectivephase/resistive exercise
Resistive exercises with DB: (1) elevation, elbow bent and straight;(2) abduction; (3) prone ER; (4) SL ER; and (5) standing ER in scapularplane, 90u, and/or 0u (with/without towel roll)
(12 weeks and beyond) Resistive exercises with elastic bands: (1) ER elbow moving fixed; (2) IR;(3) forward elevation; and (4) EXTAdvanced scapular stabilizer exercises: push-up plus, dynamic hug,prone arm raise overhead, shoulder ABD in the plane of the scapula above 120u
Note: CPM, continuous passive motion; ER, external rotation; IR, internal rotation; PROM, passive range of motion; ADL, activity of dailyliving; FF, forward flexion; AROM, active range of motion; SL, sidelying; HABD, horizontal abduction; EXT, extension; NMES,neuromuscular electrical stimulation; DB, dumbbell.
Pabian et al. Rotator cuff repair
Physical Therapy Reviews 2011 VOL. 16 NO. 5 379
Light ADLs
The EMG activity of the rotator cuff musculature has
been studied during various ADLs deemed appropriate
in maximum protection phase. Long et al.58 deter-
mined that typing with the surgically-repaired extre-
mity required minimal activity of the supraspinatus,
infraspinatus, and deltoid muscles. However, drinking
from a cup and brushing teeth require moderate
supraspinatus activity. Therefore, it is recommended
that the uninvolved extremity complete these activities
instead. Generally, contralateral limb movements for
ADLs at self-selected speeds are unlikely to harm
healing tissue.59 However, Smith et al.59 found that
fast straightforward reaching with the uninvolved limb
Table 2 Evidence for maximum protection phase
Maximum protection phase/passive exercise
Exercise Study Comments Implications
Supine self-assisted elevation McCann et al.,55
Dockery et al.60Phase 1 exercises as described byNeer (1987): min mm activity (,20% MVIC)in infraspinatus, supraspinatus,anterior/middle/posterior deltoid, serratusanterior, middle trapezius, and biceps; supineexercises preferred over upright due tointersubject variability in this study
Considered safe in maximumprotection phaseSupine helper-assisted
elevationSupine ER with stickSupine helper-assisted ERUpright pendulumUpright pulleyCPM machine Dockery et al.60 All exercises produced low MVIC in rotator
cuff muscles (,20%) except moderate MVIC(25.2%) in deltoid with pulley exercise
CPM and PT PROM safer forpassive motion and repairprotection; all consideredsafe in this phase
PulleyPendulumSelf-assisted elevationwith other armSelf-assisted IR andER with barPT-assisted elevation inscapular plane and ER/IRPendulums Long et al.58 Larger pendulums performed incorrectly
generate more supraspinatus activity thansmaller, correctly performed pendulums;smaller pendulums (20 cm diameter) saferpost rotator cuff repair
Considered safe in maximumprotection phase, however,recommend supervisedexercise; caution: Contralaterallimb support on a table maycause supraspinatus activation58
Light ADLs withinvolved UE
Long et al.58 Typing ok Typing ok with involved UE,however, caution with drinkingand brushing teeth withpost-operative arm
Brushing teeth and drinking from a cuprequire moderate supraspinatus activity
ADLs with uninvolved UE: Smith et al.59 Avoid fast straightforwardreaching and pulling motionswith non-involved arm;cross-body reaching, slowstraightforward reaching anddownward reaching byuninvolved arm safe andactivate lower trapezius asa scapular stabilizer
1. Straightforward reaching 1. Fast straightforward reaching withnon-involved limb can cause potentialinfraspinatus stress (.20% MVIC);
2. Pulling motions 2. Resisted pulling motions with non-involvedarm (i.e. opening doors, starting lawnmowers,and pulling carts and objects) can causepotential stress to supraspinatus (.20% MVIIC);
3. Cross-body reaching 3. Cross-body reaching by uninvolved arm OKas MVC in anterior deltoid, supraspinatus,and biceps ,10% MVC;
4. Downward reaching 4. Downward reaching similar EMG activityas cross-body reaching.
Closed chain prayer andquadruped positions
Uhl et al.56 Low (,20% MVIC) of deltoidand infraspinatus
Will facilitate co-contractionearly in post-op rehab
Gentle scapular exercises Smith et al.62,64 Isolated scapular depression and protractionstanding in immobilizer sufficient to strengthenserratus anterior and trapezius while maintaining,20% MVIC in infra/supraspinatus, anteriordeltoid and biceps; avoid scapular clock,elevation, and retraction as .20% MVIC
Kinetic chain exercises Smith et al.64 Cross-body rotations at low or medium heightswill generate clinically significant EMG activityin serratus anterior while producing safe levelsof activation in supra/infraspinatus, biceps andanterior deltoid (,20% MVIC)
Better serratus anterior activatorthan scapular depressionand protraction
Aquatic exercises Kelly et al.66 Elevation in the scapular plane at slow speeds(30–45u/second) safe as MVIC in the rotatorcuff and deltoid ,20%
Elevation in the scapular plane atslow speeds (30–45u/second) safe
Aquatic exercises Brady et al.65 Accelerated restoration of PROMin FF and quality of life in landprogram with aquatic therapy
Buoyancy assisted FF, ER; scapularstabilization; pendulums are all safeand appropriate exercises
Note: CPM, continuous passive motion; ER, external rotation; IR, internal rotation; PROM, passive range of motion; ADL, activity of dailyliving; FF, forward flexion; SL, sidelying.
Pabian et al. Rotator cuff repair
380 Physical Therapy Reviews 2011 VOL. 16 NO. 5
could cause potential infraspinatus stress as shown by
.20% MVIC in EMG. This occurs as the surgically-
repaired extremity retracts and externally rotates to
counterbalance the reach. Resisted pulling motions
with the uninvolved arm (i.e. opening doors, starting
lawnmowers, and pulling carts and objects) should
also be avoided as potential stress to the supraspinatus
has been observed by EMG (.20% MVIC).59 Cross-
body reaching and downward reaching by the unin-
volved arm may be safe as minimal activity is seen in
the anterior deltoid, supraspinatus, and biceps bra-
chii.59 These activities should be safe for all tear sizes,
shapes and methods of surgical fixation as EMG
activity is minimal in the muscles involved.
Passive and active-assisted exercises
Passive range of motion (PROM) and active-assisted
exercises are also typically prescribed during the
maximum protection phase. McCann et al.55 inves-
tigated deltoid and rotator cuff muscle activity
during four supine elevation exercises: self-assisted
elevation, helper-assisted elevation, shoulder exter-
nal rotation with a stick, and helper-assisted external
rotation. All four of these exercises offer protection
of the repaired rotator cuff tendons and deltoid as
evidenced by minimal activity in the supraspinatus,
infraspinatus, anterior deltoid, and middle deltoid via
EMG. In addition, McCann et al.55 examined six
upright exercises commonly seen in this phase of
rehabilitation: forward elevation with a pulley, pendu-
lums, elevation with stick, wall slide (patient faces wall
and slides hand up the wall in the sagittal plane),
assisted extension, and assisted internal rotation
(upright position). When compared to the supine
exercises, the upright exercises demonstrated higher
activity in the rotator cuff musculature but still within
the minimal range and, thus, are safe in this phase of
rehabilitation.
Dockery et al.60 studied similar passive exercises in
addition to the effects of a continuous passive motion
machine (CPM). Electromyography analysis of the
supraspinatus, infraspinatus, anterior deltoid and
trapezius was performed during CPM use, self-
assisted exercises (pulley, pendulum, elevation with
other arm, self-assisted internal and external rota-
tion) and therapist-assisted exercises (elevation in
scapular plane, internal and external rotation). It was
determined that CPM use and therapist-assisted
PROM are safer for passive motion and repair
protection; however, all exercises resulted in low
MVIC in the rotator cuff muscles and deltoid (,20%)
and are considered safe in the maximum protection
phase of rehabilitation.60 Although patient usage of a
CPM is recommended to complement the passive
ROM by a therapist during this rehabilitation phase,
caution should be taken to avoid aggressive PROM
into internal rotation with repairs of the infraspina-
tus and into external rotation with repairs of the
subscapularis tendons.
Gentle scapular exercises (serratus anterior,
trapezius muscle group)
Exercises for the scapular stabilizers, including the
trapezius complex (upper and lower trapezius) and
the serratus anterior, may be initiated in this phase of
rehabilitation as they have a synergistic relationship
with the glenohumeral rotators.61 Early activation of
the scapular stabilizers may promote improved
scapulohumeral rhythm and functional use of the
post-surgical shoulder.61
Scapular exercises commonly performed include
retraction, protraction, elevation, depression, and the
scapular clock. Smith et al.62 studied the effects of
these scapular movements on the rotator cuff
musculature through EMG analysis. Data analysis
revealed that only isolated scapular depression and
protraction in standing while wearing an immobilizer
are safe for the repaired infraspinatus or supraspina-
tus while sufficiently activating the serratus anterior.
The scapular depression exercise activated the serra-
tus anterior more than the other motions. Should the
surgery also include the repair of the subscapularis
tendon, no scapular exercise is appropriate in this
phase as high activity (40–63% MVIC) was observed
in this muscle.62
Arm supported scapular retraction in the scapular
plane at 90 and 120u was studied by Bressel et al.63
Eelectromyography activity of the lower trapezius,
supraspinatus and infraspinatus were recorded. Results
suggest that potential neuromuscular re-education of
the lower trapezius with the arms supported at 90u are
possible early following supraspinatus repairs, but not
infraspinatus repairs as too much tension is placed on
the infraspinatus.63
An alternative method of activating the scapular
stabilizers while minimizing the activity of the rotator
cuff muscles may involve utilizing the contralateral
limb. Reaching across the body with the right arm
can activate the left lower trapezius. Smith et al.62
found significant lower trapezius activity with cross-
body forward reaching, slow straightforward reach-
ing, and downward reaching with the contralateral
upper extremity.59 In addition, kinetic chain exercises
such as cross-body rotations, which involves reaching
across the body while rotating the trunk simultaneously,
at low or medium heights will generate clinically
significant EMG activity in the serratus anterior
while producing safe levels of activation in the
supraspinatus, infraspinatus, biceps brachii, and
anterior deltoid; adding a step to the motion will
activate the serratus anterior even more selectively.
Greater serratus anterior activity was seen in the
Pabian et al. Rotator cuff repair
Physical Therapy Reviews 2011 VOL. 16 NO. 5 381
kinetic chain motions when compared to isolated
scapular elevation and depression.64 Cross-body reaches
at shoulder height with the non-involved arm effec-
tively activate the lower trapezius, the second most
important scapular stabilizer, while minimizing activ-
ity in the rotator cuff musculature.64 However, none of
these kinetic chain exercises are appropriate when the
repair includes the subscapularis tendon.64 These
activities may potentially allow reactivation of scap-
ular stabilizers in a protected environment while
minimizing activity of the healing rotator cuff, anterior
deltoid and biceps brachii.62
Aquatic therapy
Aquatic therapy is an appropriate option in the
maximum protection phase following rotator cuff
repair. Brady et al.65 found accelerated restoration of
PROM in forward flexion and improved quality of
life in subjects who underwent a land program with
the addition of aquatic therapy. Exercises performed
during the maximum protection phase included buo-
yancy assisted forward flexion and external rotation,
scapular stabilization and pendulum exercises. Buo-
yancy assisted elevation in the scapular plane at slow
speeds (30–45u/second) is safe for post-operative rota-
tor cuff repairs as the MVIC in the rotator cuff and
deltoid is minimal (,20%).66
Exercises that traditionally, on land, show higher
EMG activity of the rotator cuff musculature may be
appropriate during the maximum protection phase
when performed in the water. Water buoyancy and
shorter lever arms could help diminish tensile strain
and protect the repaired tendons. For example, active
shoulder range of motion, which may not begin until
the moderate protection phase, could be performed
earlier in the water due to the lower load environ-
ment. Aquatic therapy for repaired rotator cuff ten-
dons should begin as soon as the arthroscopic portals
or surgical incisions are completely healed or other-
wise covered with a waterproof bandage to allow for
accelerated restoration of motion.
Closed-chain activity
Uhl et al.56 examined muscle activity of the pectoralis
major, anterior deltoid, posterior deltoid, and infra-
spinatus during closed chain activities. Closed-chain
activities can be utilized to enhance proprioception of
the glenohumeral joint. Closed-chain activities in
the prayer and quadruped positions are appropriate
during the passive phase of rehabilitation as minimal
activity (,20% MVIC) of the rotator cuff and deltoid
musculature is exhibited.
Moderate protection phase/active exercise(weeks 7–12)Progression to the moderate protection/active phase
involves several factors: quality of tissue repair,
stability of fixation, and forces generated at the
surgical reconstruction.55 Typically the patient is
ready for active exercise between the sixth and
seventh post-operative weeks. Moderate activity of
the rotator cuff musculature is appropriate at this
time as the healing of the tissue repair is sufficient and
less at risk for rupture.55 Common exercises in this
phase of rehabilitation include progression of scap-
ular stabilization, isometric exercise for the rotator
cuff musculature, and active range of motion of the
glenohumeral joint. Evidence for these suggested
interventions is included in Table 3.
Progressive scapular exercises (serratus anterior,
trapezius muscle group)
Scapular stabilization is a coupled motion with
glenohumeral rotation. Therefore, at this point the
healing process should be directed at force couples
rather than isolated muscle-focused exercise. Schachter
et al.61 determined that during isolated glenohumeral
internal and external rotation, the scapular muscles
(serratus anterior and middle trapezius) are at least as
active as the glenohumeral rotators. Hence, inclusion
of scapular retraining exercises in rotator cuff rehabi-
litation programs is supported.61
Kibler et al.67 examined the EMG activity of the
lower trapezius and serratus anterior during four
scapular stabilization exercises. These exercises con-
sisted of: (1) inferior glide (isometric with humeral
head depression and scapular retraction); (2) low row
(isometric with scapular external rotation and poster-
ior tilt); (3) ‘lawnmower’ (trunk rotation with scapu-
lar retraction); and (4) ‘robbery’ (trunk extension
with scapular retraction). The ‘robbery’ exercise
begins with the subject standing with the trunk flexed
approximately 40–50u with arms forward flexed and
palms facing the thighs. With the elbows kept close
to the body, the subject moves into trunk and arm
extension and flexes elbows so palms are facing up
and away from the body while simultaneously retract-
ing the scapulae towards the back pockets. Each of
these exercises requires no more than 90u of shoulder
elevation and, therefore, is appropriate at this point in
the rehabilitation program. Moderate activity (20–
40% MVIC) of the lower trapezius and serratus
anterior was found indicating appropriateness for
retraining neuromuscular control in the active phases
of rehabilitation.67
Cools et al.68 analyzed the ratio of upper trapezius
to lower trapezius, middle trapezius, and serratus
anterior during 12 common exercises performed early
in the moderate protection/active phase of rehabi-
litation. Minimizing upper trapezius activity is an
important component in restoring appropriate sca-
pulohumeral rhythm following rotator cuff repair.
Sidelying external rotation, sidelying forward flexion,
and prone horizontal abduction were found to have
Pabian et al. Rotator cuff repair
382 Physical Therapy Reviews 2011 VOL. 16 NO. 5
low upper to lower trapezius ratios while prone
shoulder extension was found to have a low upper to
middle trapezius ratio. These findings support the
use of these four exercises in the active phase of
rehabilitation as upper trapezius activity is minimized
and scapulohumeral rhythm is improved. It was also
recommended that standing flexion movements
should be avoided if excessive shoulder girdle
elevation due to activity of the upper trapezius is
observed with this motion.68 However, if the patient
can flex the shoulder with normal scapulohumeral
rhythm and avoid excessive hiking, then this motion
should be employed during this phase. If excessive
hiking is present, then the motion can still be used,
but in a recumbent position at an angle where the
motion is demonstrated without the shoulder girdle
elevation. Mirror feedback may also be helpful
in retraining the patients’ proprioception with this
exercise.
Isometrics and neuromuscular re-education
Isometrics of the shoulder musculature are com-
monly performed during the active phase of rotator
cuff rehabilitation. McCann et al.55 performed EMG
analysis of the rotator cuff and deltoid muscles during
a 5-second isometric contraction in five directions:
external rotation, internal rotation, forward elevation,
abduction, and extension. Minimal activity of the
supraspinatus, infraspinatus and deltoids was found
with internal rotation while moderate to marked
activity was found in the other four directions. Si-
milar findings were found by Decker et al.69 support-
ing the use of shoulder internal rotation isometric
exercise to strengthen the subscapularis while eliciting
minimal activity in the supraspinatus. Shoulder
isometrics are appropriate during the moderate
protection phase/active phase, however, should be
avoided during the during the maximum protection/
passive phase as rotator cuff muscle activity is too
high.55 Submaximal isometric contractions should be
supervised in repairs of the infraspinatus and sub-
scapularis in external rotation and internal rotation,
respectively.
Neuromuscular electrical stimulation (NMES) may
be used as an adjunct treatment to enhance force
production, muscle recruitment, and improve muscle
function. Isometric contraction of the infraspinatus
assisted with NMES of the infraspinatus was studied
in patients following repair of the supraspinatus
tendon. Results showed a 22% increase in force
production by the infraspinatus regardless of age,
gender, size of tear, number of days post-op, or
intensity of NMES.70 This suggests that NMES may
be an appropriate and safe modality to enhance the
facilitation of the rotator cuff musculature during
the active phase of rehabilitation. Caution should be
taken to apply NMES to surrounding rotator cuff
Table 3 Evidence for moderate protection phase
Moderate protection phase/active exercise
Exercise Study Comments Implications
Progressive scapularexercises
Kibler et al.67 Four exercises examined by EMGfound to have moderate (20–40% MVIC)and are appropriate for retrainingneuromuscular control
Inferior glide: isometric with humeralhead depression and scapular retraction(SA and LT)Low row: isometric with scapula ERand post tilt (SA and LT)Lawnmower: included trunk rotationand scapular retraction (SA and LT)Robbery: trunk extension withscapular retraction
Progressive scapularexercises
Cools et al.68 12 trap exercises looking at low UT/LT,UT/MT, UT/SA ratios; early active rehabexercises to include (1) SL ER, (2) SL FF,(3) prone HABD, and (4) prone EXT; nos.1–3 have low UT/LT ratios and no. 4 haslow UT/MT ratio
(1) SL ER, (2) SL FF, (3) prone HABD,and (4) prone EXT appropriate in thisphase also recommended to watch forexcessive shoulder hiking with standingflexion movements and modify as needed
Isometrics with/withoutNMES
Reinold et al.70 22% increase in isometric force productionof the infraspinatus with NMES in patientspost RCR
NMES considered safe in improving ERforce production post rotator cuff repair
Active rotatorcuff exercises
McCann et al.55 Phase II exercises as described by Neer(1987): supine active elevation; uprightelevation with elbow bent and straight,upright abduction consistently showedmoderate activity (20–50%); begin uprightelevation with elbow bent then progressto elbow straight
Supine active elevation; upright elevationwith elbow bent and straight, uprightabduction all appropriate in this phase
Closed-chain tripodand pointer
Uhl et al.56 Moderate (20–40% MVIC) in posteriordeltoid and infraspinatus
Intermediate level of facilitation andco-contraction with trunk stabilization
Note: ER, external rotation; FF, forward flexion; SL, sidelying; HABD, horizontal abduction; EXT, extension; NMES, neuromuscularelectrical stimulation.
Pabian et al. Rotator cuff repair
Physical Therapy Reviews 2011 VOL. 16 NO. 5 383
muscle tendons and not directly to the repaired
tendon.
Active rotator cuff exercises
Active range of motion exercises of the glenohum-
eral joint are typically performed during the
moderate protection/active phase of rehabilitation.
McCann et al.55 analyzed the EMG activity of the
rotator cuff muscles during supine active elevation,
upright elevation with elbow bent and with elbow
straight, and upright abduction. Elevation in this
study consisted of motion of the entire shoulder
complex. Moderate activity (20–50% MVIC) of the
rotator cuff musculature was found consistently in
these exercises and are, therefore, appropriate in the
active phase of rehabilitation. It is suggested that
upright elevation begin with elbow bent then pro-
gressed to the elbow straight as increased activity of
the rotator cuff musculature is seen with the elbow
extended.55
Aquatic therapy
Aquatic exercises can also be performed during the
moderate protection/active phase of rehabilitation.
Appropriate exercises studied by Brady et al.65
include standing breaststroke, reaching the hand
behind the back, and kicking with a kickboard.
Exercises may progress in the minimal protection/
resistive phase to include resisted forward flexion and
external rotation with paddles, ball proprioception
exercises and resistance, and wall push-ups.65
Closed-chain exercise
Uhl et al.56 determined that closed chain activities in
the tripod and pointer positions are appropriate in
the active phase of rehabilitation since moderate
muscle activity (20–40% MVIC) is seen in the pec-
toralis major, anterior deltoid, posterior deltoid, and
infraspinatus muscles. For the tripod exercise, the
subject begins in the quadruped position and then
flexes one shoulder to 180u. The pointer exercise is
performed in the same position as the tripod with the
addition of contralateral hip extension to 0u. Push-
ups should be reserved for the resistive phase as
muscular activity is high in these muscles tested (41–
60% MVC).56
Minimum protection phase/resistive exercise(weeks 12z)Transition to the minimal protection phase/resistive
phase of rehabilitation typically occurs 12 weeks
post-operatively. During this phase, strengthening
Table 4 Evidence for minimum protection phase
Minimum protection phase/resistive exercise
Exercise Study Comments
Resistive exerciseswith dumbbells orelastic bands
McCann et al.55 Phase III exercises as described byNeer (1987): (1) elevation with 2.25 kg,elbow bent; (2) straight; (3) abductionwith 2.25 kg; (4) T band ER elbow moving;and (5) fixed, IR, T band forward elevation,T band extension consistently showedmoderate levels of activity in rotatorcuff and deltoid
Resistive exerciseswith dumbbells orelastic bands
Boettcher et al.71 Preferred exercises in this study:(1) pendant ER and (2) prone ER vs‘can’ exercises due to lower deltoid activity
Exercises incorporating ER are mostsuitable to strengthen supraspinatuswhile minimizing surrounding muscleactivity, especially the deltoid
ER with dumbbell Reinold et al.73 Prone HABD – high activity of middle andpost deltoid, making is less preferred if tryingto target cuff muscles; exercise in scapularplane or at 0u ABD – less mid and post deltoidthan in 90u ABDER at 90u ABD in standing insupine – mimic sporting activity but place extrastress to the inf. GH ligament complex; SL ERat 0u ABD – higher mm activity of all cuff mmsthan in standing at 0u ABD; ER in scapularplane – functional while minimizing INF GHligament stress and improving dynamicstabilization; towel roll may aid in improvedform and decreased substitution by deltoid
(1) prone HABD at 100u with full ER;(2) prone ER at 90u ABD; (3) standingER at 90u ABD; (4) standing ER inscapular plane; (5) standing ER at0u ABD; (6) standing ER at 0u ABD withtowel roll; (7) SL ER at 0u ABD
Push-up (normal, feetelevated, one-arm)
Uhl et al.56 HIGH to very HIGH (41–.60% MVC) ininfraspinatus and deltoids
Advanced co-contraction withtrunk stabilization
Advanced scapularstabilizer exercise
Decker et al.,77
Eckstrom et al.78Push-up plus and dynamic hug exerciseselicited greatest EMG activity in serratusanterior; prone arm raise overhead and shoulderabduction in scapular plane above 120u elicitedgreatest simultaneous activity of the serratusanterior and trapezius muscle group
Advanced scapular stabilizationexercises above shoulder height forimproved scapulohumeral rhythm
Note: ER, external rotation; IR, internal rotation; SL, sidelying; HABD, horizontal abduction.
Pabian et al. Rotator cuff repair
384 Physical Therapy Reviews 2011 VOL. 16 NO. 5
of the rotator cuff begins and progression to
functional lifting and sport activities are allowed
(Table 4). Sufficient healing of the rotator cuff has
completed so that moderate to high muscular activity
of the rotator cuff musculature during exercise does
not pose a great risk to rupture of the repaired
tendon. Strengthening exercises may utilize elastic
resistive bands or dumbbells with the glenohumeral
joint in various positions to strengthen the rotator
cuff muscles.
Resistive exercises
McCann et al.55 investigated seven commonly pre-
scribed exercises in this phase: shoulder elevation
with 2.25 kg with the elbow bent and straight,
shoulder abduction with 2.25 kg, external rotation,
internal rotation, forward elevation and extension
with elastic resistive bands. Each exercise consistently
showed moderate levels of activity in the rotator cuff
and deltoid muscles and are, therefore, appropriate
for the resistive phase of rehabilitation.55
Boettcher et al.71 studied five exercises typically
recommended to strengthen the rotator cuff, specifi-
cally the activity of the supraspinatus. Muscular
activity of the rotator cuff and deltoid were examined
during the following exercises: elevation in the
scapular plane with glenohumeral external rotation
(‘full can’), elevation in the scapular plane with
glenohumeral internal rotation (‘empty can’), prone
elevation (horizontal abduction), pendant external
rotation (at 0u abduction), and prone external rota-
tion. Exercises incorporating external rotation were
best for strengthening the supraspinatus while mini-
mizing surrounding muscular activity, especially the
deltoid. Pendant external rotation and prone external
rotation exercises are preferred over the elevation in
the scapular plane exercises due to lower deltoid
activity. These two exercises also highly activate the
infraspinatus, which may be advantageous in facil-
itating centralization of the humeral head in the
glenoid fossa.
Reinold et al.72 examined the activity of the sup-
raspinatus and deltoid muscles during three exercises:
elevation in the scapular plane with external rotation
(‘full can’), elevation in the scapular plane with
glenohumeral internal rotation (‘empty can’), and
prone elevation in the scapular plane with external
rotation. All exercises provided similar amounts of
supraspinatus activity (62–67% MVIC). However,
elevation in the scapular plane with glenohumeral
external rotation demonstrated the lowest middle and
posterior deltoid activity. This exercise may be best in
maximizing the amount of supraspinatus activity while
minimizing activity in the deltoid muscle.72
Seven exercises commonly used for external rota-
tion strengthening were analyzed by Reinold et al.73
These exercises utilized a dumbbell for resistance in
the following positions: prone horizontal abduction
at 100u with full external rotation, prone external
rotation at 90u abduction, standing external rotation
at 90u abduction, standing external rotation with arm
elevated 45u in the scapular plane, standing external
rotation at 0u abduction, standing external rotation
at 0u abduction with towel roll, and sidelying external
rotation at 0u abduction. Prone horizontal abduction
showed high activity of the middle and posterior
deltoid, making it less preferred when trying to target
strengthening of the rotator cuff muscles. Exercises in
the scapular plane or at 0u abduction demonstrated
less middle and posterior deltoid than in 90uabduc-
tion, but at 90u abduction, the posterior deltoid
activity may provide a compressive force and assist in
external rotation. External rotation at 90u abduction
in standing and in supine is useful in mimicking
sporting activity but places extra stress to the inferior
glenohumeral ligament complex. Sidelying external
rotation at 0u abduction results in higher muscle
activity of all rotator cuff muscles than the same
activity in standing. External rotation in the scapular
plane offers functional benefits of external rotation at
90u while minimizing inferior glenohumeral ligament
stress and maximizing the length-tension relationship
of the rotator cuff muscles for dynamic stabilization.
A towel roll may aid in improved form and decreased
substitution by the deltoid, although this study found
no significant differences.73 A limitation of this study,
however is that the researchers performed standing
external rotation with a dumbbell in hand. Therapists
do not routinely prescribe this as the resistance force
line is not in line with the rotator cuff. Additional
studies found that the placement of a towel roll in the
axilla during sidelying external rotation increased
activity of the infraspinatus by 10%,74 prevented
reduced blood flow to the supraspinatus,75 and in-
creased the subacromial space.76
Advanced training of the scapular stabilizers is
common in this phase. Decker et al.77 found that the
push-up plus and the dynamic hug exercises elicited
the greatest EMG activity in the serratus anterior
muscle. Eckstrom et al.78 identified two exercises that
produced marked (.50% MVIC) activity simulta-
neously in the serratus anterior and trapezius muscle
group: the prone arm raise overhead and shoulder
abduction in the plane of the scapula above 120u.These exercises may be effective in restoring the
scapulohumeral rhythm in the post-surgical shoulder
to return the patient to prior level of function.
ConclusionRotator cuff tear characteristics, surgical repair pro-
cedures and tactics, and patient factors can all affect
the clinical presentation as well as the overall patient
Pabian et al. Rotator cuff repair
Physical Therapy Reviews 2011 VOL. 16 NO. 5 385
outcome of rotator cuff repair. Both communication
between orthopedic surgeon and rehabilitation pro-
fessional, as well as a rehab professional’s under-
standing of the influences that these factors that can
have on patient outcome are essential in optimizing
care. Post-surgical rehabilitation after rotator cuff
repair focuses on patient function, restoration of
mobility, and return of strength. It is important for
rehabilitation professionals to recognize evidence
based tactics to restore the impairments after rotator
cuff repair, and utilize them appropriately with
consideration of the numerous variables that can
impact patient recovery. More research is warranted
to further bridge the gap between rotator cuff tear
characteristics, repair procedures, and rehabilitation
implications.
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