PT Protocols

Massive Rotator Cuff Repair

Phase I:  (Protective Phase)


  • Minimize pain and inflammatory response
  • Achieve ROM goals
  • Establish stable scapula

Weeks 0 to 8

  1. Elbow, wrist and hand AROM (EWH)
  2. Passive forward elevation in plane of scapula (PFE) (supine ) to 90 after the first 6 weeks; 10-20 reps, 2 x day. Do not begin PROM until 6 weeks post op.
  3. Supine passive external rotation (PER) to tolerance with T-stick in 0-20 degrees flexion and 20 degrees abduction; 10-20 reps, 2 x day beginning week 6.
  4. C-spine AROM
  5. Ice
  6. Positioning full time in sling with abduction pillow
  7. Shoulder shrugs and retractions (no weight)
  8. ***Pain control modalities PRN
  9. Complications/Cautions:
    1. If pain level is not dissipating, decrease intensity and volume of exercises.
    2. Assure normal neurovascular status
    3. No AAROM or AROM until 12 weeks

Weeks 8 to 12

  1. Heat/ice PRN to help obtain motion
  2. D/C sling as comfortable
  3. Progress PROM goals to full in all planes
  4. Achieve  PROM goals in ER at 20 degrees and 90 degrees abduction (full)
  5. Start AAFE and progress to AFEat 12 weeks
  6. Initiate posterior capsule stretching
  7. Isometrics, keeping elbow flexed to 90 degrees (Sub maximal, pain free)
  8. Theraband scapula retractions
  9. ***Aquatics
  10. ***Mobilizations PRN
  11. ***Trunk stabilization/strengthening
  12. Start periscapular strengthening with very low weight and high repetitions
  13. Cautions:
    1. Do not initiate rotator cuff strengthening until 16 weeks and until night pain has subsided and overallpain level is low

Phase II: (Progressive Strengthening)


  • Achieve staged ROM goals
  • Eliminate shoulder pain
  • Improve strength, endurance and power
  • Increase functional activities

Months 3 to 4

  1. Continue as above
  2. ROM should be full in all planes
  3. Progress isometrics
  4. Advance scapula strengthening
  5. ***Mobilizations PRN
  6. ***Aquatics for strengthening
  7. ***CKC activities for dynamic stability of scapula deltoid and cuff
  8. ***Trunk stabilization/strengthening
  9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold)
  10. Initiate theraband ER and IR strengthening
  11. Progressive serratus anterior strengthening (isolatedpain free, elbow by side)
  12. Progress to isotonic dumbbell exercises for deltoid,supraspinatus, up to 3 lbs max
  13. Cautions:
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain levelis low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress onlywithout signs of increasing inflammation
    4. Strengthening program should emphasizehigh repetitions, low weight and should beperformed a maximum of 2 x day

Phase III: (Return to activity/advanced conditioning)


  • Normalize strength, endurance and power
  • Return to full ADL’s and recreational activities

Month 4 to 6

  1. Stretching PRN
  2. Continue deltoid/cuff/and scapula strengthening asabove (5lbs max for isotonic strengthening) with thefollowing progressions:
    1. Prone isotonic strengthening PRN
    2. Decreasing amounts of external stabilization provided to shoulder girdle
    3. Integrate functional patterns
    4. Increase speed of movements
    5. Integrate kinesthetic awareness drills into strengthening activities
    6. Decrease in rest time to improve endurance
  3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
  4. ***Progressive CKC dynamic stability activities
  5. ***Impulse
  6. ***Initiate isokinetic strengthening
  7. ***Mobilizations PRN
  8. ***Trunk stabilization/strengthening

Month 6 to 8

  1. Stretching PRN
  2. Continue deltoid/cuff/scapula strengthening program
  3. Initiate plyometric program (if needed)
    1. Do not begin until 5/5 MMT for rotator cuffand scapula
    2. QD at most
    3. Begin with beach ball/tennis ball progressingto weighted balls
    4. 2-handed tosses – waist level
      1. -overhead
      2. -diagonal
    5. 1-handed stability drills
    6. 1-handed tosses (vary amount of abduction, UE support, amount of protectedER)
  4. May begin Interval Throwing Program after 3-6 weeks of plyometrics
  5. Initiate progressive replication of demanding ADL/work activities

Discharge/Return to sport criteria

  1. PROM WNL for ADL’s/work/sports
  2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
  3. Complete plyometric program, if applicable
  4. Complete interval return to sport program, if applicable