Rotator cuff injuries are the most frequent cause of shoulder problems, accounting for well over 50% of shoulder-related conditions seen by physical therapists. Risk for rotator cuff tears increases with age; in fact, 25% of individuals in their sixties and 50% of individuals in their eighties have tears.1 This means that rotator cuff tearing occurs in some part due to the natural aging process. Other risk factors that worsen underlying age-related degeneration include smoking and family history. Tears can be a result of a career of repetitive overuse, such as jobs involving overhead work, like tree trimmers, construction workers, and painters. They can also result from traumatic events, which can forcefully tear the cuff.1
The rotator cuff muscle group consists of four muscles: the subscapularis, the supraspinatus, the infraspinatus, and the teres minor (see the image below). These muscles function as the regulators of dynamic stability of the shoulder, known formally as the glenohumeral joint. The structure of the shoulder joint favors mobility at the expense of stability. When activated, these muscles provide a rigid, protective cuff around the shoulder, centering and stabilizing the head of the humerus within the shoulder and allowing full and painless ability to reach overhead during activities of daily living, like changing a lightbulb or reaching for the top shelf of a kitchen cabinet. If these muscles are compromised in any way, these simple, everyday tasks can become increasingly difficult and painful.
Symptoms of rotator cuff pathology vary from person to person. Often a person with a rotator cuff injury will complain of a dull, aching pain in the front and side of the shoulder, which can radiate into the upper arm. Symptoms often increase with overhead activity. Limited range of motion, inflammation, weakness, and compensation (such as shoulder shrugging in an attempt to reach overhead) often occur. Patients often state that they are limited in their ability to brush or wash their hair, sleep on the affected side, and drive due to shoulder pain when turning the steering wheel.
If you’ve been diagnosed with a rotator cuff tear, you should fully weigh the risks and benefits of both conservative and operative treatments before choosing a treatment option. Indications for either treatment are based on the risk for chronic rotator cuff changes associated with conservative treatment, the potential of healing based on the size of the tear, the patient’s age, the reparability of the tear, and whether the tear is chronic or acute in nature. In general, early surgical intervention is considered for individuals with large acute tears or for individuals younger than 65 years of age with full tears who are at high risk of developing irreparable rotator cuff damage.
After surgery, length of time for complete recovery and return to pre-injury/surgical activities typically takes at least six months or, for some individuals, up to one year. Below is a brief summary of what to expect from each phase of rehabilitation and a general time frame for each phase.3
Phase 1: Passive Range of Motion
The first six weeks post-surgery are known as the “healing phase.” It is critical in this phase to protect the healing repair from undue stress. You usually wear a sling at all times for approximately the first four to six weeks. In addition to wearing a sling, you will also have a firm piece of foam placed between the arm and body, which takes additional strain off the repair. Goals of this phase include reducing pain/inflammation, protecting the healing tissue, and gaining gentle range of motion while preventing scar tissue formation. Scar tissue can limit further gains with range of motion, which, during this time, is completely passive, meaning that the muscles of the shoulder are relaxed and not active.3
Phase 2: Active Range of Motion
Between six and 12 weeks after surgery, the goal is to normalize motion and activities of daily living. You can use your arm for daily activities like bathing, dressing, driving, and eating. At this time, the repair still needs to be protected, as it is about 40% as strong as a normal tendon at eight weeks and about 60% as strong at 12 weeks. For this reason, lifting anything heavier than a cup of water should be avoided as well as supporting any body weight by the recovering arm. Range of motion activities, which are done comfortably against gravity, will be prescribed by your physical therapist. During visits, the therapist will continue to progress passive range of motion to tolerance. Exercises should be done two times a day at home.3
Phase 3: Strengthening
By this phase, which covers weeks 10 to 16, full shoulder range of motion should be achieved at the onset. It is during this initial strengthening phase that shoulder strength, power, and endurance is restored slowly so you can return to normal activities of daily living, full work, and, eventually, modified recreational activities. As the tendon is still not at 100% strength, do not to lift anything heavier than five pounds and avoid sudden lifting, pushing, or jerking activities. Light free weights will be introduced during therapy, as well as elastic bands and more-aggressive stretching if you do not have full range of motion yet. Exercises should be done once a day at home and then every other day when more vigorous exercises are progressed.3
Phase 4: Return to Sport/Recreation
This last phase of therapy occurs during weeks 16 through 24 and helps transition people back to sports, hobbies, and physically intense occupations. Continue range of motion exercises and stretching to maintain motion. Progressive strengthening and endurance exercises of the shoulders are performed with an eventual transition to a weight lifting program emphasizing other larger upper extremity muscles (performed independently following formal therapy). In order to return to sport, you must gain clearance from the surgeon and the therapist. Sport-specific exercises will be developed by the therapist to ensure readiness for return to play.3
This is only a general outline of what to expect from rehabilitation following a rotator cuff repair. Treatment plans developed by your physical therapist are individualized and will depend on the extent of your injury/repair, previous level of function, and rehab protocol selected by the surgeon. The phases of rehab described above are not mutually exclusive, and transition from one phase to the other may occur earlier or later than the time frames given here, depending on recommendations from the surgeon and how well you are progressing. Working with a skilled physical therapist is paramount to this process, as he or she can select specific exercises as well as perform certain manual techniques based on your need to return to your previous level of function as quickly and as safely as possible.
1. Z. Tashjian. “Epidemiology, Natural History, and Indications for Treatment of Rotator Cuff Tears.” Clinics in Sports Medicine 31 (2012): 589–604.
2. Donald A. Neumann. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd ed. (St. Louis: Mosby/Elsevier, 2010).
3. J. Millett, R. B. Wilcox III, J. D. O’Holleran, and J. J. Warner. “Rehabilitation of the Rotator Cuff: An Evaluation-Based Approach.” Journal of American Academy of Orthopaedic Surgeons 14 (2006): 599–609.