5 Things Clinicians Commonly Overlook When Treating Rotator Cuff Repairs

My prior post on 5 Things Clinicians Commonly Overlook When Treating Post-Op ACL Patients went over well; Naturally, I thought it would be a good idea to discuss another common surgery physical therapists treat – rotator cuff repair – and what is often overlooked.

I would say that the following 5 things aren’t just limited to rotator cuff repairs, but rather any shoulder surgery (i.e. SLAP repair, sub-acromial decompression, etc.).

1. Why

I listed this first in the ACL post because I thought it was the most important thing that is commonly overlooked and I feel the same way for rotator cuff repairs (and any other non-traumatic shoulder surgery). You have to figure out why your patient suffered a rotator cuff tear in the first place. A rotator cuff tear is often a symptom of poor movement pattern(s) - this is why a vast majority of rotator cuff tears are non-traumatic (and also why surgery may not be necessary).

If you don’t address the underlying cause of why the rotator cuff repair happened in the first place, then don’t be surprised when that patient still has pain 6, 9, 12 months from the surgery.

And just like I said in the ACL post, I realize that you can’t assess all the movement patterns initially (due to surgical pain, ROM limitations) but within 2 months after surgery, you should be able to assess just about all of them.

2. Thoracic Spine Mobility

One of the common causes of dysfunctional shoulder movement and a possible “why” is limited thoracic spine mobility. Thoracic spine and rib position will affect how the scapula moves (or doesn’t move) and that ultimately dictates how the glenohumeral joint moves.

Even though I feel like thoracic spine limitations are being discussed more and more, I don’t necessarily see the same increase in actual treatment of the thoracic spine. And there are many different ways to get this area moving - you can use mobilizations, IASTM, manipulations, corrective exercises, etc.

3. Cervical Retraction with Ipsilateral Sidebending

This movement pattern is something that I started looking at after reading about it in one of Erson's blog posts a while ago. The movement was new to me but I understood the underlying principle of it and since I had success with assessing/treating sidegliding in standing, I figured I would start checking it out on my UE patients, including post-ops. And I can say that cervical retraction with ipsilateral sidebending is commonly dysfunctional and it can definitely have an effect on shoulder ROM. This effect was unexpected for me (in a good way) - both in how much and how quickly the shoulder ROM can change after doing some repeated motions.

I bet you are well aware of how common it is for your rotator cuff repair patients to have ipsilateral neck/upper trap pain from being in a sling and how sometimes doing soft tissue work in that area has only temporary effects. Take a look at cervical retraction with ipsilateral sidebending on those people and I'd say there's a good chance it will be dysfunctional.

If you use repeated motions to help correct this dysfunctional movement, you'll probably have to instruct your patients to push their head with the opposite arm (instead of the typical pull your head to that side).

Easiest Cervical Screen Ever

4. Shoulder Extension ROM

I know it may seem kinda silly saying that a specific shoulder movement/ROM may get overlooked, but I was guilty of not looking at shoulder extension for years. I underestimated its effect on all the other shoulder motions/movement patterns and was too concerned with the other typically limited motions (ER, flex, IR). Since realizing its importance and assessing it regularly, one of the most common home exercises I give these patients is repeated shoulder extensions.

I must say that you should respect the tendon repair and not push shoulder extension during the first 4-6 weeks. Many supraspinatus tears occur along the anterior portion of the tendon and you don’t want to stress those repairs unnecessarily – same for SLAP repairs. Don’t give the surgeon a reason to throw you under the bus for a patient’s continued pain.

Shoulder Reset: 3 Variations

5. Latissimus Dorsi / Teres Major

Lastly, I figured I would touch upon a soft tissue component to shoulder mobility that is often overlooked. The lats are a huge muscle that can greatly affect shoulder overhead mobility. I grouped the teres major in with the lats because it's essentially the "mini-lat" and it's hard to distinguish between the two muscles when you're doing soft tissue work along the lateral scapula/posterior axilla area.

I've been spending more and more time over the years working on soft tissue than on joint mobility. I have probably flipped the ratios around from when I first started treating. And I feel that I have better, more consistent results now.

Commonly I like to do this soft tissue work with the patient sidelying. It's also easy for patients to perform some self soft tissue work in this area with a lacrosse ball.

Keep these 5 thoughts in mind the next time you treat a patient who has undergone shoulder surgery and see what you find. Hopefully these tips help!

via Dr. Dennis Treubig - Modern Sports PT

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...