After the initiation of PROM, the gradual onset of AAROM activities begins, followed by AROM. Typically, AROM commences in coordination with the transition from the proliferative phase to the remodeling phase of healing. The therapist should make sure AROM occurs with minimal substitution patterns and eliminate faulty movement patterns. Concurrently, the therapist should continue emphasizing postural correction and begin scapular isometric exercises, then progress to therapeutic exercises that emphasize proper scapulohumeral rhythm. Considering that the majority of rotator cuff tears in patients over 40 years of age are from repetitive stress often contributed to by faulty scapular mechanics, the “disadvantaged scapula,” as evidenced by scapular dyskinesis, is a key component to recognize during rehabilitation owing to the high likelihood of preoperative dysfunction. These faulty motor patterns require extensive neuromuscular reeducation and motor retraining throughout the postoperative course. Proprioceptive neuromuscular facilitation (PNF) patterns for both the scapula and glenohumeral joint are a useful technique to assist with motor retraining (Fig. 31.10).

Total body mobility and stability are also important in proper shoulder mechanics; therefore the therapist should emphasize core stability as well as thoracic mobility to assist with scapular movement patterns. Manual therapy techniques play a large role in the intermediate phases of rehabilitation with the goal of regaining full PROM. Techniques used include scapular mobility, inferior and posterior glenohumeral mobilization, STM, and pectoralis major/minor stretching, as well as subscapularis and latissimus release due to tightness from immobilization (Fig. 31.6).

Patients are progressed into the strengthening phase of rehabilitation once full PROM has been achieved. It is recommended to avoid progressive resistive exercises (PREs) until the surgical tissues have entered into the remodeling and maturation phase of healing, which typically occurs between 4 and 8 weeks after surgery and continues well into the first year. It is imperative to place the developing collagen fibers under appropriate amounts of stress in order to facilitate proper fiber alignment and prevent disorganized scarring, which increases risk for reinjury. Performing lower-extremity balance and proprioceptive exercises is also recommended, because studies have shown impaired balance during UE immobilization (Fig. 31.16). The therapist should continue to emphasize proper scapulohumeral rhythm and total body mobility, continue manual therapy techniques to prevent postoperative stiffness, and advance PNF patterns by providing increased resistance. Against-gravity activities progress to loaded-resistance exercises. As pain-free full AROM is achieved, patients may progress to weight-bearing rhythmic stabilization exercises such as those performed in quadruped to stimulate glenohumeral proprioception and stability.

As patients progress through PREs using the overload principle, they become ready to initiate early return to sport training wherein the underlying principles of strength and conditioning training should be followed. As with the earlier phases of rehabilitation, this timeline varies on the basis of several factors, including surgeon’s preference, integrity of the repair, postoperative pain and stiffness, and additional surgical procedures performed, such as labral repair. It is strongly recommended to maintain cardiovascular conditioning during the earlier phases of recovery in the athletic population in order to better prepare the athlete for return to sport training. In order to prevent reinjury as well as to maximize capillarization of the repaired and surrounding musculature, a hypertrophic strength phase should be the foundation of strength training. During this time frame, it is also imperative to engage the periscapular muscles in endurance training. This is particularly important for the overhead athlete. If the periscapular muscles are insufficient or fatigue easily, there may be proximal kinetic chain failure leading to reinjury. As the eccentric demand increases, the therapist should be cognizant of the likelihood of muscle soreness in the rotator cuff and tightness in the surrounding tissues during this phase. Emphasis on stretching and flexibility as well as postworkout recovery with modalities such as intermittent compression and/or cryotherapy is an integral component of return to sport. Total body flexibility, as well as trunk and cervical ROM, remains important, particularly for pitchers, racquet sport athletes, and golfers. Sport-specific plyometric exercises and both lower- and upper-extremity agility are also initiated during this phase. The strength phase ultimately progresses to a power phase for higher-level recreational sport patients and athletes. At this stage, strengthening emphasis transitions to power workouts focusing on primary joint movers such as the biceps, triceps, deltoid, trapezius complex, and the latissimus while the rotator cuff continues to be challenged owing to its role in glenohumeral stability. Progressive velocity throwing programs are usually held until approximately 6 months after surgery and should not be initiated without the surgeon’s clearance.

Table 31.1 outlines the postoperative rehabilitation guidelines under three different ROM scenarios: early PROM/AAROM, delayed PROM/AAROM, and delayed AROM. Thorough knowledge of the physiologic phases of healing is imperative to understand why certain exercises are implemented at different times throughout the postoperative course as the phases of protocol progression are coordinated in concert with the stages of tissue healing. Progression throughout each protocol is dependent on the patient’s response to treatment, and pain must be respected throughout the entire duration of rehabilitation. The rehabilitation team should use their clinical experience to assist with the selection of the appropriate progression for each patient on an individual basis with the ultimate goal of restoring optimal shoulder function while protecting the surgical repair.