1. Evidence Based Algorithm for Rehabilitation after RC Repair
Michael A. Shaffer
PT, ATC, OCS

2. Instability Guidelines NOT THIS TALK!!!
JOSPT March 2010

5. ‘Well if you think you can do better, go ahead and try.’
(paraphrasing)

6. “Patients completed a standard physical therapy program”
“S/P RCR- MOON Protocol”

7. Standard PT Program 0-2 Weeks 2-6 Weeks > 6 Weeks Pendulums
Elbow AROM
Grip Isometrics
2-6 Weeks
PROM/ AAROM
> 6 Weeks
“Strengthening”

8. Shari Shaffer’s Grandmother’s Recipe for Homemade Bread
Step 1-
“Put 2 scoops of flour
into the green bowl”
Step 2-
Keep buying bread at
the store
Normal Rockwell
Freedom from Want

9. What’s the goal? Dissect the black box of exercise prescription
Supplement the ASSET RC Guidelines
Spur discussion among “seasoned” clinicians
Serve as a guide for novice clinicians

10. Integral Features of an Algorithm
“Delayed” and Standard on same algorithm
ROM Progression Detailed
PROM, AROM
ROM “gate” to strengthening
Strengthening Progression Detailed
Dosing
Staged elevation program
End Point for Supervised Rehab
“Maintenance program”

11. A million ways to fold them… But only two ways to use them
Avoid getting lost…
Prevent the most common problems
Or after you’re lost….
Fix the problems to get back on track

12. “Typical Patient” 63 y.o. male Full thickness 3-5 cm2 SS and IS
s/p arthroscopic RCR
Immob. in standard sling or ultrasling
2 week follow up visit
Pain = 4/10 at rest. Difficulty sleeping.
PFE = 0-95°; PER = 0-10°

13. What are the rehab goals after RC Repair?
Pain controlled
Functional ROM
> 115° AFE
> 140° PFE
> 75° PER at 90°
Functional strength
Able to complete 1) ADL’s, 2) Work, 3) Hobbies
Healed repair (?)
AFE = Active Forward Elevation
PFE = Passive Forward Elevation
PER = Passive External Rotation

14. Avoid Painful – Stiff Train Wreck

15. Avoid Painful-Stiff 0-2 weeks
Start correct exercises
Identify problems early
Comprehension
Pain
ROM
Avoid Painful-Stiff 0-2 weeks

16. ** Exercise Prescription
ROM Progression
Start 0-14 days
Exercises
Pendulums
Supine PFE w/ opp. hand
Supine PER
** Exercise Prescription
Exercise Series = 2 - 4x/ day
ROM Exercises = x each w/ 10 sec hold

17. ROM Progression ROM Check If Yes If No > 80° PFE > 10° PFE Gain
Return in 2 weeks
If No
Instruct in Table Step Backs
Return within 2 days

18. Back on Track? 3-4 Weeks ROM Check If Yes If No 110° PFE 25° PER
20° PAbd.
If Yes
Remove sling as per MD
Return in 2 weeks
If No
Add OH Pulleys
Supervised Rehab 1-2x/week
PROM

19. What’s the goal of the algorithm? Assistance out of a rough spot

20. Persistent problems 3-4 weeks
Still struggling
(< 80° PFE/ <10° Gain)
Comprehension
OH Pulleys
Pain
∆ Ex. Program/ MD
ROM
Start 2-3x week PROM

21. Avoid Painful- Stiff ~ 4 Weeks
What predominates?
Pain
Pendulums only
Stiffness
Continue PROM
Increase HEP
Frequency
End range hold time

22. What Predominates? Pain Stiffness Resting pain
Pain before end range (empty end feel)
Stiffness
Pain after end range

23. Strengthening Progression
Typical protocol = 6 weeks
Clinically?
6 weeks if……..x,y,z
ROM is the gate to strengthening

24. ROM is the Gate to Strengthening

25. ROM is the Gate to Strengthening
6 Weeks
Elastic Resistance IR ER
Extension* (unilateral)
Rowing* (bilateral)
* to neutral
*THERABAND INSTRUCTION: (For each exercise/motion)
-Start with yellow Theraband (1x10 reps)
-When patient “can complete the exercise without difficulty”, then progress to 2x10 reps
-Eventually progress to 3x10 reps
-Advance to next resistance level (color) and begin with 1x10 reps
Expected recovery - Approximately 1 week/ color.

26. Other components Strengthening progressions Guide for…
9 Weeks
12 Weeks
“Advanced strengthening” (athletes, laborers)
Guide for…
Scapular hiking
Limited active elevation
Return to work, sport criteria

27. What we need to move forward Your Feedback, but…
What we need to move forward Your Feedback, but….. (Keeping in algorithmic format) NO
“I do ______ with my patients after RC surgery.”
YES
“I do ______ with my patients after RC surgery when/ if they present like ______”

28. Thank You. Brian G. Leggin PT, DPT, OCS Chuck Thigpen PhD, PT, ATC
Reg. Wilcox PT, DPT, MS, OCS