General Considerations

1. Quality of tissue and integrity of repair
2. Under 50 years old is usually stronger tissue
3. Acute vs. chronic tear
4. repairs before 4 months usually responding better
5. chronic tears typically more difficult to achieve range of motion
6. First vs. revision surgery
7. revisions are more prone to fibrosis and pain
8. Extent of repair
9. Chronic and/or large tears will require more caution with active range of motion and resistive exercises
10. Repairs involving more than one tendon or large tears will require more effort to achieve range of motion
11. This protocol should be considered a guideline only. Actual progression should be based on clinical presentation. Some of the exercises that are given earlier in their treatment may be appropriate throughout the rehabilitation period.
12. Early passive range of motion of glenohumeral joint is essential to prevent capsular adhesions and fibrosis. This is done in a range that SHORTENS the involved muscle(s).
13. supraspinatus: avoid passive internal rotation (past the plane of the body), horizontal adduction, and extension
14. subscapularis: avoid passive external rotation (excessive), horizontal adduction, and extension
15. Resting pain should be used to gauge progression. Overall, pain should decrease over time.
16. All active motions of the shoulder should be closely monitored for proper scapulothoracic mechanics and to minimize compensation or substitution.
17. Physical therapy will begin immediately following surgery. The early focus will be on achieving ROM before emphasizing rotator cuff resistance exercises.

0 - 2 WEEKS (M.D. visit at days 1 and 10 post-op)

Protection:	In a sling unless showering or exercises
Dressings:	Okay to shower after 2 days, sutures removed 8 - 10 days post-op
PROM:	Forward flexion and scaption (scapular plane) 2 - 3 times daily, 10 - 20  reps as tolerated, followed by icing--this can be done at therapy and independently Pendulum and pulley exercises frequently
AROM:	Ball/putty squeezes, bicep curls, cervical stretches/exs., postural exs. as tolerated
Pain control:	Soft tissue massage, modalities as needed
Isometrics:	For uninvolved tendons as tolerated (submaximal)
Other activities:	Walking, stationary cycling, stair machine without weight on arms

2 - 4 WEEKS (M.D. visit at 4 weeks)

Protection:	In a sling unless showering, meals, or exercises
PROM:	For repaired tendons in direction that shortens tendons
AROM:	For uninvolved tendons using caution to avoid stressing repair
Isometrics:	For uninvolved tendons as tolerated (submaximal to maximal)
Other activities:	Lower body conditioning, pool therapy

4 - 8 WEEKS

Protection:	None
PROM:	GENTLE passive motion into previously protected ranges (as tolerated)  Resting pain should be considerably decreased  Motion in most planes should be at least 75% of normal  * It is important to check the integrity of the glenohumeral joint at this  phase in the patient's rehabilitation in particular for signs of excessive  decrease in glenohumeral mobility.
Mobs:	Grade I - II without restrictions, Grade III cautiously until 6 weeks
AROM:	Gradually introducing against gravity active range of motion exercises into  extension, pure abduction and external rotation
Other activities:	Road cycling, stair machines with weight on arms

8 - 12 WEEKS

PROM:	Continue with passive stretching of involved tendons to pain tolerance
Mobs:	Grade I - IV as tolerated
AROM:	Progression should be high repetitions before adding resistance,  (i.e. one pound increments, attaining 50 repetitions at each weight before progressing). * It is important to closely monitor shoulder/postural mechanics and pain throughout all exercises.
Other activies:	Jogging, swimming in protected range of motion, UBE for range of motion

3 - 6 MONTHS (M.D. visit at 3 months)

Range of motion:	If motion is still limited, then emphasis remains on achieving full range.  If motion is not limited, then the emphasis shifts to strengthening.  * At 3 months, motion in most planes should be nearly full.  * More aggressive stretching and resistive exercises can  be added at 4 months as tolerated.
PNF patterns:	Can be performed cautiously, increasing as tolerated
Other activities:	Rowing, UBE for strengthening, protected range weightlifting  (be cautious not to do exercises that stress repair)

6 MONTHS (M.D. visit at 6 months)

Range of motion:	Aggressive stretching and strenuous resistive exercises can be performed.
Other activities:	Swimming, weightlifting, begin throwing progression program  (assumes adequate range of motion of 90 abduction and external rotation)