6 months post-op arthroscopic rotator cuff repair problems

[artcshoulder14]

Hi,
I'm 6 mos post-op arthroscopic rotator cuff repair for a massive tear. I fell and incurred a complete tear of the rotator cuff muscle off the bone. I never had any shoulder problems and my rotator cuff muscles tendons are of good quality. I had the surgery 4 weeks after my accident. The repair surgery went well. I started physical therapy when I was 4 weeks post-op. I went thru 5 months of physical therapy and I have full flexion of 170 degrees now. However, my external rotation is only 35-40 degrees, but I can passively move to full ROM and my rotator cuff muscle is still weak. My physical therapist who was subbing for my primary PT said that the reason why my external rotation is limited and my rotator cuff muscle is still weak is because I was using other muscles to compensate when doing my exercises. I didn't know about this until I was 5 months post op. So I switched to a new PT for 6 sessions. I have finished physical therapy as of a week ago. I have been doing my hep exercises which my new PT prescribed to me for a week now. I have been very motivated and want to get better. I want to be back to my physically active lifestyle of playing tennis 3-4 times/week and softball 2x a week. My question is "Is it normal to not have full range of motion of External Rotation when you're 6 months post-op? I thought I would have attained this by now. How long does it usually take one to attain rotator cuff strength?
I read that several studies have shown that ER strength takes the longest amount of time to restore after rotator cuff repair and the longer this area is weak, the more difficult it will be to stabilize the joint. In your experience, is this true? I'm just concerned will I be able to attain the same full ER strength that I had before this injury?

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[rod physio]

You are progressing as expected. It is good you have nearly full flexion and that amount of external rotation at neutral is good. What is your range at 90 degrees of abduction?

Once you attain good rotator cuff strength you should then expect the ranges to improve further. I generally tell people that full rehab after shoulder surgery is up to 12 months. The reason you get the damage in a shoulder is because the rotator cuff is weak. Surgery makes the rotator cuff weaker so you do start quite far behind the 8 ball. And by the end of the rehab you will probably have better external rotation strength than before the surgery.

[artcshoulder14]

I don't know what my range of External Rotation is at 90 degrees of abduction. At my final Physical Therapy session, my pre-treatment Shoulder External Rotation was 36 at neutral and Post-treatment shoulder external rotation was 42 at neutral. I'm working on strengthening my external rotation and rotator cuff muscle by using the red Theraband elastic doing the Resistance shoulder External Rotation uni w/elastic exercise with my arm at side, elbow bent with elastic secured to a secure object at elbow height I will grasp elastic and move my forearm away from the elastic and then return to starting position. I'm also doing the Resistance shoulder abduction(horizontal emphasis) uni w/elastic with elastic attached to a secure object at waist level and arm at side, elbow bent and hand in front of my shoulder I reach out sideways in a straight line and then return to starting position.
How long do you think it will take to attain good rotator cuff strength after I have just started doing these 2 exercises? Of course I will also be doing my other exercises in my home exercise program.

Thanks.

[theshoulderguy]

Hi there, this article might interest you.

Prognostic Factors for Successful Recovery After Arthroscopic Rotator Cuff Repair:
A Systematic Literature Review

Click here for pdf doc:

[finchr]

It has been my experience after participating with many, many RTC repairs that ROM within 90% of expected range should occur by 3 months of time. You can increase range by working on range. Merely strengthening within a limited available range will not increase the range. Clear as mud?
There may be many factors at play, the most prevalent is what was your range going into surgery? If the external rotation (ER) was limited going in then most likely it would be coming out of surgery. It is not common to produce more inflammation by performing a partial capulosectomy.
From what I read and could understand from you note, you have full passive ER? That would be more disturbing and is a different scenario.
The problem with your condition as I understand it, requires

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It has been my experience after participating with many, many RTC repairs that ROM within 90% of expected range should occur by 3 months of time. You can increase range by working on range. Merely strengthening within a limited available range will not increase the range. Clear as mud?
There may be many factors at play, the most prevalent is what was your range going into surgery? If the external rotation (ER) was limited going in then most likely it would be coming out of surgery. It is not common to produce more inflammation by performing a partial capulosectomy.
From what I read and could understand from you note, you have full passive ER? That would be more disturbing and is a different scenario.
The problem with your condition as I understand it, requires

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My computer has been affected by voodoo or something so hopefully this works.

For me the KEY questions are;

1) Do you have full passive External Rotation(ER)?
2) If you lay on your non-involved side and passively move your affected arm out to full ER and let it go, what happens?

[artcshoulder14]

Hi,

Answers to your questions:

1) I do have full passive External Roation(ER).
2) If I lay on my non-involved side and passively move my affected arm out to full ER and let it go, my affected arm cannot stay there but moves back to where it stops its almost feels like a hinge.

So what do you think my problem is? You mentioned that if I have full passive ER that would be more disturbing and is a different scenario.

I'm doing stretching exercises along with ER strengthening exercises with theraband. What kind of stretches would you suggest?

Thanks for help.

[finchr]

In my experience, the times I have seen this has been a partial release of the tendon at the origin. It is my experience and that of of many of the top therapist's ( Kevin Wilk, DPT ) that at 6 months you should be much farther along even if there is no absolute model just " accepted "norms. From what I understand it is not a matter of having some end range weakness but absence of strength over 1/2 your range. This is not normal. I assume your surgeon has observed this. You can have a repeat MRI without harm
If this is the case, you will not be able to further strengthen. If not you should be ale to. You do not need stretches as you have full PROM, at least into ER. I would be curious to know what your scapula stabilized IR is. Look up sleeper stretch

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Please realize that when referring to strengthening I am only addressing ER.

We could always try ER isometric or eccentric. Five months of PT is more than I have ever spent except for WC heavy laborers so more of the same PT may not be the answer. I tell patients if they can and will do any exercises at home they should not do them in the clinic. This wastes your time. You should utilize the therapist for what you can not do

[artcshoulder14]

Hi finchr,

what is a partial release of the tendon? In addition to a rotator cuff repair, I also had a biceps tenodesis and subacromial compression done. Would that effect my external rotation strength? What would you look for in an MRI if I do get one?
my doctor said that my ER is not where he would expect it to be. He said that if I work on the theraband exercises that would improve my ER strength. I don't need to see him anymore for my rotator cuff unless i feel there's something wrong.

I did try isometric ER exercises but it did not work out for me because I did them incorrectly. I'm not sure if I did any eccentric ER exercises. What is the sleeper stretch for? Do I need to do it? Will it help me?

After doing the exercises with the theraband for 1 week I can see an improvement in that I can move my arm in a throwing motion and throw a tennis ball. I think my ER is getting a little better in that I feel I can move it out a little further out now before it stops than a week ago. So what do you think? Should I be alarmed about my ER strength or should I wait to see what happens after I have been strengthening my ER by using theraband whether or not ER strength comes back?

thanks a lot for your responses.

[artcshoulder14]

Hi finchr,
just a clarification on what my dr said about my ER - he said that the only thing that's not coming back as well as he would like is my ER.

Thanks,
Debbie

[finchr]

Sometimes parts of a repair can "come loose". The key to me is that it sounded like you had been attempting to strengthen your arm in ER and could get no further than 30-45 degrees. Was the therapy focusing on ER strengthening? If you can increase your ER with strengthening then there is not a problem but it is curious why it hasn't up until now. If something is working keep with it. Go on You tube. There are a lot of exercises , many by therapist
The biceps tenodesis and subacromial decompression might add a little discomfort in the 1st month or so but shouldn't affect your strength production
IR is often overlooked. This is part of the motion involved in reaching your arm up your back. The sleeper stretch stretches the posterior capsule and is used to increase the IR motion by stabilizing your scapula.

[artcshoulder14]

Hi finchr,

I was given ER exercises starting when I was 3 months post-op. I was doing isometric ER exercise, AAROM shoulder ER with elastic exercise, and many other exercises for ER. However, I was doing them incorrectly at home by overcompensating using other muscles instead of my rotator cuff and moving my body or trunk when moving my arm in ER. I thought I was strengthening my rotator cuff but I wasn't at all. So this happened for about 3.5 months into pt. I did not know about that until I saw another physical therapist who was subbing for my primary physical therapist. Thus I have been working on ER strengthening and ensuring that I am using the right muscle and not moving my trunk or body or bending my wrist when performing my ER exercises for a month. My internal rotation is fine.

Could the reason why my ER has not come back yet is because I was performing the ER exercises incorrectly by using other muscles overcompensating for a weak rotator cuff or cheating by moving my body and bending my wrist when performing them?
Hopefully my ER will becoming back soon.

thanks again for your response.

[finchr]

I really don't think that is why but time will tell. If it doesn't improve with hard work over the next 6 weeks then I would consider asking for an MRI to rule in/out
Compensation takes away from the total work of the muscle and instills incorrect movement patterns but you will still get some strengthening going on. As a therapist I expect compensatory patterns to occur in the beginning. That is why I stress form above all else, and when that is achieved it is time for that to be a home exercise only. Work hard on your ER. Focus on that 1st to make sure you get that done in case you run out of time
Do you have exercises? You can always ask for PT once a week for instruction and progression only. If it were me I would go to a new set of eyes type of PT. It is impossible to do that long distance. As we said, form is key

[artcshoulder14]

I do have exercises to do. I have ER exercises that use the red elastic theraband. I mentioned the exercises in a previous reply. I don't have anymore formal PT sessions. My Physical Therapist said that I should do those strengthening ER exercises with the theraband once every other day. What's your recommendations can I do them every day? Shouldn't one have a rest day in between strengthening or is it when you are using weights only?

What do you mean asking for an MRI to rule in/out?

Thanks again for your response.

[finchr]

Try doing multiple sets every other day. If it doesn't improve in 6 weeks then ask a 2nd opinion for possible reasons

[artcshoulder14]

Hi,

I'm doing 3 exercises given by my physical therapist using the red Theraband elastic doing the Resistance shoulder External Rotation uni w/elastic exercise with my arm at side, elbow bent with elastic secured to a secure object at elbow height I will grasp elastic and move my forearm away from the elastic and then return to starting position. I'm also doing the Resistance shoulder abduction(horizontal emphasis) uni w/elastic with elastic attached to a secure object at waist level and arm at side, elbow bent and hand in front of my shoulder I reach out sideways in a straight line and then return to starting position and where I reach upwards horizontally. He said that these exercises should increase my ER and rotator cuff muscle strength.

What other ER exercises would you recommend me doing?

Thanks again.

[finchr]

You probably need to add end range isometric and/or eccentric exercises. You need to do strengthening where you have little. There a plethora of exercises that fit this bill and can easily be shown on You Tube or Googled. It is difficult to describe and look at form via typing.

[KelcieLe]

Yea, you must search for them on YouTube. This will help you get a better insight of the exercises.