Although conservative immobilization protocols are suggested after rotator cuff repair (see below), the rehabilitative team should be aware of those patients who are at high risk to develop postoperative stiffness.

Specific risk factors for postoperative stiffness include age more than 50 years, workers’ compensation payer class, adhesive capsulitis or calcific tendinitis at the time of the operation, partial articular-side tendon avulsions or single-tendon tear defects, and concurrent capsule-labral surgical repairs [1, 13].

Particular attention should be given to the conditions of compensation claims. Patients with workers’ compensation claims, in fact, tend to have poor outcomes after rotator cuff repair, which are mostly due to a very low compliance rate to postoperative immobilization and physical therapy program [14]. In this case, therefore, the risk of postoperative stiffness seems to be linked more to ineffective postoperative strategies than to intrinsic factors.

It should also be considered that “stiff” patients often display persistent postoperative pain, which might further impair functional results [15].

Obviously, the extent of stiffness varies among patients, and transitory conditions that respond to treatment must be differentiated from contractures that are resistant to multiple rehabilitation strategies, which may require surgery to restore mobility. Soft tissue mobilization and articular manual therapy represent the most important interventions for restoring mobility [16]. Moreover, attention to cervicothoracic and scapulothoracic mobility in the early phase of rehabilitation is safe and beneficial to the reestablishment of overhead mobility.

Recovery of the strength should be an important goal of postoperative rehabilitation of the rotator cuff. A functional shoulder, in fact, requires a good level of strength in the rotator cuff muscles. Approximately, it has been estimated that patients should expect 90 % of strength recovery after 12 months [17]. Noticeably, those patients who are at risk for unsuccessful healing should not be admitted to excessive load strengthening programs, thereby showing potential delays in strength gain. Risk factors for postoperative weakness are large tears [18], preoperative strength deficits in external rotation and abduction, and superior migration of the humeral head [19].

As stated above, we actually do not have any level I evidence of which is the best rehabilitative treatment in the immediate postoperative period. The dilemma is, obviously, represented by the ratio between immobilization versus mobilization strategies to adopt, in order to obtain an optimal healing and avoid stiffness. The consequences of an increased postoperative stiffness are mainly represented by functional limitations, especially in shoulder forward flexion and rotations, which may, therefore, could be seen as “complications” of shoulder surgery. On the contrary, an incomplete or inadequate healing might determine the risk of a re-rupture of the rotator cuff, representing thus a “failure” [20]. With this concept in mind, and with the exact knowledge of the biology of the healing process and of the factors affecting it, the immobilization period should be carefully scheduled in each patient to achieve healing with reasonable safety.

Parsons and colleagues [21] retrospectively evaluated 43 patients operated for arthroscopic repair of full-thickness rotator cuff tears, who underwent a 6-week full-time sling immobilization period after surgery. Despite they found ten stiff patients after surgery, at 1-year follow-up, no differences between “stiff” and “non-stiff” subjects were found in the functional outcomes measures.

In a recent prospective randomized controlled trial [22], 105 patients who underwent arthroscopic repair for small to medium-sized full-thickness rotator cuff tears were randomized to two groups, early passive motion (starting at 1st postoperative day) versus delayed immobilization (4–5 weeks postsurgery, depending on tear size). Interestingly, the authors did not find any differences at 1-year follow-up between groups in shoulder range of motion, pain, and function. They suggest that early passive motion after arthroscopic cuff repair does not guarantee early gain of range of motion or pain relief, but also does not negatively affect cuff healing, and so it should not be considered as mandatory.

Lee and colleagues (2012) compared range of motion and healing rates between an aggressive and a limited early passive exercises protocol of postoperative rehabilitation in 64 patients who received arthroscopic rotator cuff repair for the treatment of full-thickness rotator cuff tears. They concluded that, 1 year after surgery, pain, range of motion, muscle strength, and function improved in both groups, regardless of the rehabilitation protocol used. However, in the aggressive group, they could see a trend toward an increased rate of anatomic failure of the repaired cuff [23].

Therefore, it seems reasonable to avoid too aggressive mobilization strategies in the early postoperative period, in order to accomplish a good healing process. This is particularly true in the era of arthroscopic repair of rotator cuff tears, which strongly limits surgical trauma, thereby reducing the risk of postoperative stiffness.

Early postoperative mobilization, nevertheless, could be useful for certain categories of patients presenting one or more risk factors for developing shoulder stiffness [24]. In these patients, the physiatrist and the physical therapist have to interface with the surgeon to choose the best possible rehabilitation strategy. Once again, therefore, the principle of treating as necessary, according to the patient’s needs, appears to be the most rational and effective.

Hence, according to the size of the lesion, the immobilization period may last for 2–6 weeks.

The patient is usually positioned in a sling which maintains the shoulder in internal rotation. Because extreme adduction degrees worsen the microcirculation of the rotator cuff and increase the mechanical stress on tendons, a slight degree of shoulder abduction (30–40°) with neutral rotation may also be adopted, especially with those patients whose reconstruction was made applying more tension on sutured structures. The abduction position, in fact, represents the position which allows the most efficient vascularization of the rotator cuff structures, as well as the less biomechanical stress on the reconstructed tendons [25].

During this time period, passive and active exercises may be conducted to mobilize the elbow, the wrist, and the hand of the operated side, while shoulder motion exercise should not be considered as necessary. Because of the extreme frailty of the reparative tissue, during the first 4–6 weeks postsurgery, active exercise of shoulder musculature is not permitted.

When the immobilization period ends (after 25–28 days), the phase II of rehabilitative intervention may start. The patient has been restrained and only slow and limited movements of the surrounding joints have been allowed in the previous phase, so it is from this point in time that shoulder joint begins to be mobilized. The specific goal of this phase is to recover the passive range of movement of the shoulder, without compensations of scapular movements.

Although it varies from patient to patient, in consideration of the risk factors seen above, this phase approximately starts from the 4th week to the 6th week and lasts until the 12th. From a biological perspective, in this period of time, the progression of the healing process begins to be sufficient to allow the introduction of active movements with a minimum load [25].

Passive exercises should be performed with the aid of a physical therapist, who will gradually mobilize the shoulder, possibly with the patients lying supine in order to avoid scapular movements (Figs. 2 and 3a, b).

Active mobilization exercises are generally introduced starting from the 6th week to the 8th week. Tendon repairing process foresees, at this moment, the proliferative phase, in which unorganized collagen fibers constitute the reparative tissue. The small loading forces acting on repaired tendons during active exercises are useful to determine, through a gentle mechanical stimulation, a functional orientation of the fibers, that enhances the tensile strength of the repair [26]. The first step should be constituted by active-assisted exercises, including supine glenohumeral external and internal rotation as well as supine flexion with the aid of a physical therapist or of the contralateral limb (Fig. 4). Active exercises could also be introduced at this time, especially if performed in water, thereby annulling gravity. Exercises should be performed slowly (30°/s) and in the scapular plane to lessen the contraction of rotator cuff muscles [27].

A particular emphasis should be reserved in this phase to the function of the scapulothoracic joint. If the kinematics of this joint is not correctly restored, in fact, there might be the risk of development of iatrogenous subacromial impingement syndrome. Controlled mobilizations, as well as decoaptation of the humeral head, have to be used (Fig. 5). Rhomboids and trapezius muscles should gradually be reinforced, e.g., by the use of scapular retraction/depression exercises (Fig. 6). Serratus anterior may be trained by protracting the scapula from 90° of glenohumeral joint flexion.

During this phase, the rehabilitation program is not made up only of the part guided and assisted by the therapist but also of a part that includes a series of exercises performed by the patient alone, properly instructed (Fig. 7a–j). Moreover, attention has to be given to cervicothoracic and scapulothoracic rehabilitation in the early phase in order to reestablish overhead mobility.

At the end of this phase, before progressing to rotator cuff strengthening, it is important that a full glenohumeral range of motion, without pain and without scapular dyskinesia, has been achieved.

When the patient is able to achieve a full glenohumeral active and passive range of motion, the strengthening phase of rehabilitation can be started. The specific goals of this phase, generally lasting from the 8th week to the 12th week until the 16th week, are to progressively recover the muscular tone and strength of the shoulder muscles. Because the strengthening exercises might determine an excessive stress on the sutured structures of the rotator cuff, the beginning of this phase should be properly scheduled on an individual basis. Factors affecting tendon healing should be, once again, carefully checked before planning strengthening exercises.

To allow a correct reinforcement of the target muscles, it is important to consider the pain, as well as the correct execution of selected movements [25].