Evidence-Based Approach to Rotator Cuff Rehabilitation: What to Expect Written by physiotherapist Marine Pfeiffer

Rehabilitation following rotator cuff repair is typically guided by one of two evidence-based protocols: moderate or conservative. In the moderate protocol, passive range of motion (PROM) exercises begin on the first day after surgery and are adapted according to the patient’s pain levels. Early movement may help reduce stiffness but must be carefully monitored to avoid placing excessive stress on the repaired tissue. The conservative protocol, by contrast, delays PROM for 2 0 4 weeks post-operatively to allow for initial tissue healing and to minimise the risk of damaging the repair. The selection of protocol depends on various factors, including surgical findings - such as the size of the tear, quality of the tissue, and tendons involved - as well as patient-specific considerations such as age and comorbidities (van der Meijden et al., 2012).

A successful outcome following rotator cuff surgery relies not only on the surgical technique but also on a collaborative, evidence-based rehabilitation plan involving both the surgeon and the physiotherapist. Clear communication between medical professionals is essential to share key information about the procedure and to tailor the rehabilitation process appropriately. A structured home exercise programme (HEP), prescribed by the physiotherapist, plays a central role in supporting recovery while adhering to post-operative restrictions. This programme evolves in line with the phases of healing and may initially focus on maintaining mobility in adjacent joints such as the neck, elbow, wrist, and hand to prevent compensatory issues (van der Meijden et al., 2012).

Phases of Rehabilitation

Phase I: Protection and Early Motion (0 - 4 weeks post-op)The primary objective during this initial phase is to protect the repair while preventing post-operative stiffness. Passive range of motion exercises are carried out with careful positioning to safeguard the healing structures. Patient education is a key component at this stage, focusing on post-surgical precautions, pain management, and the overall rehabilitation journey. Cryotherapy (ice therapy) is often employed to control inflammation and pain during this period (Nikolaidou et al., 2017).

Phase II: Active-Assisted Motion and Neuromuscular Control (Weeks 4 - 8)This phase introduces active-assisted range of motion (AAROM) exercises and begins to restore neuromuscular control. The pace of progression depends on patient-specific factors such as age, the size of the tear, and overall health. Physiotherapists work with patients to retrain coordinated muscle activation around the shoulder girdle, helping to reduce the risk of complications like impingement syndrome (van der Meijden et al., 2012).

Phase III: Strengthening (Weeks 8 - 12)Once sufficient neuromuscular control has been achieved, the focus shifts towards strengthening exercises. These are individualised according to the physiotherapist’s assessment of the patient’s shoulder function and tolerance. The goal is to restore rotator cuff strength while maintaining correct scapulothoracic mechanics, which are essential for pain-free and efficient shoulder movement (van der Meijden et al., 2012).

Phase IV: Advanced Strengthening (Weeks 12 - 16+)By this stage, the repaired tissues are generally strong enough to tolerate more demanding strengthening activities. Patients should no longer experience pain during daily activities, and exercises are progressed to build endurance and improve overall shoulder function. This phase marks the transition from basic rehabilitation to higher-level physical performance (van der Meijden et al., 2012).

Return to Sport

Patients may begin sport-specific rehabilitation once clinical criteria have been met, including symmetrical shoulder strength and motion, pain-free function at rest and during activity, and normal scapulothoracic kinematics. The return-to-sport programme focuses not only on shoulder-specific tasks but also on cardiovascular fitness, core stability, flexibility, and lower limb conditioning. There is a growing amount of current research and protocol development of return to play programmes that are orientated to specific sports. Your physiotherapist can source such a programme. This comprehensive, multidisciplinary approach supports a safe and effective return to physical activity and minimises the risk of reinjury (Reinold et al., 2010).

Progression through the rehabilitation phases is based on meeting clearly defined clinical milestones rather than fixed timelines. This ensures that each patient’s recovery is appropriately paced to match their healing capacity and physical needs (Nikolaidou et al., 2017).

Conclusion

Rotator cuff rehabilitation is a carefully structured and individualised process that depends on collaboration between healthcare providers and alignment with the surgical outcome. Evidence supports a phased, criteria-based model of rehabilitation, beginning with protection and passive movement, followed by progressive active motion, strength development, and finally functional retraining and sport-specific preparation (van der Meijden et al., 2012). By adhering to these evidence-based principles and tailoring the approach to each patient, the risk of reinjury is reduced, and long-term outcomes are optimised (Thigpen et al., 2016).

References:

The creation, enrichment, and editing of this article for enhanced clarity was facilitated by the use of Perplexity Ai rewrite https://www.perplexity.ai (accessed 2025)

Boileau, P. (2005) ‘Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal?’, The Journal of Bone and Joint Surgery (American), 87(6), p. 1229. doi:10.2106/jbjs.d.02035.

Nikolaidou, O., Migkou, S. and Karampalis, C. (2017) ‘Rehabilitation after rotator cuff repair’, The Open Orthopaedics Journal, 11(1), pp. 154–162. doi:10.2174/1874325001711010154.

Reinold, M. M., Wilk, K. E., Macrina, L. C., & Andrews, J. R. (2010). Rehabilitation and Return to Play of the Athlete after an Upper Extremity Injury. Sports Health, 2(5), 426–434.

Thigpen, C. A. et al. (2016). The role of the physical therapist in the diagnosis and management of rotator cuff disorders. Journal of Orthopaedic & Sports Physical Therapy, 46(6), pp. 414–426.

sh blvan der Meijden, O. A., Westgard, P., Chandler, Z., Gaskill, T. R., Kokmeyer, D. and Millett, P. J. (2012). Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines. International Journal of Sports Physical Therapy, 7(2), pp. 197–218.