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CASE SUMMARY & PHYSIOTHERAPY PROTOCOL

PATIENT PROFILE

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MECHANISM OF INJURY

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DIAGNOSIS

• ICD Codes: S40.012A / M75.112 / M75.4
• Pre-op imaging: X-Ray left shoulder - within normal limits (no bony injury)
• ECG: Normal sinus rhythm

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SURGICAL PROCEDURE (4 June 2026)

1. Rotator Cuff Repair (Supraspinatus repair)
2. Subacromial Decompression (SAD)

• Admission: 3 June 2026 | Discharge: 6 June 2026
• Discharged with shoulder immobiliser

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CURRENT STATUS (at time of physiotherapy referral - 3 July 2026)

• Post-op day: ~29 (approx. 4 weeks post-surgery)
• Doctor's advice: Elbow ROM exercises, Pendulum exercises, Passive and Active ROM left shoulder
• Immobiliser: Continues to use CT Shoulder Immobiliser
• Medications: Flamchek-P (NSAID), Plugmax Cap (Calcium+D3+K2), Todotendo Tab (Collagen+Hyaluronate)

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ADDITIONAL CASE (For reference - Document 1)

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PHYSIOTHERAPY REHABILITATION PROTOCOL

Post-Arthroscopic Rotator Cuff Repair + Subacromial Decompression

Left Shoulder - Mr. Rohit Vilasrao Deshmukh

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Protocol Basis: Evidence-based post-arthroscopic rotator cuff repair rehabilitation. Timelines are based on biological tissue healing of the supraspinatus repair. PEEK anchors (VIMFIX-PK) allow early passive mobilization. Three PEEK anchors were used indicating a moderate-sized tear - guard against aggressive early active loading.

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PHASE 0 - IMMEDIATE POST-OP (Week 1-2 | Completed in hospital)

• Protect surgical repair
• Manage post-op pain and swelling
• Prevent DVT and disuse complications
• Maintain elbow, wrist, hand mobility

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PHASE 1 - PROTECTION & PENDULUM PHASE

(Weeks 2-6 | Current Phase as of 3 July 2026)

• Protect repaired supraspinatus
• Initiate pendulum exercises (gravity-assisted ROM)
• Maintain elbow/wrist/hand ROM
• Reduce pain and swelling
• Prevent shoulder stiffness / capsular adhesions

• Shoulder immobiliser worn at all times except during exercise sessions
• No active shoulder elevation against gravity
• No lifting, pushing, pulling with left arm
• Sleep with immobiliser in sling position or supine with pillow under arm

EXERCISES:

• Lean forward 90° at hip, arm hangs freely
• Allow gravity to distract the glenohumeral joint
• Gentle circles: clockwise 10 reps, counter-clockwise 10 reps
• Forward-backward pendulum: 10 reps
• Side-to-side pendulum: 10 reps
• No active shoulder muscle contraction - pure gravity swing
• Progress circle diameter gradually over weeks

• No internal rotation behind back at this stage
• No overpressure. Pain-free range only.

• Gentle cervical ROM (flexion, extension, rotation, lateral flexion) - 10 reps each direction, 2x daily - prevents referred pain and cervicogenic muscle guarding

• Gentle scapular retraction (isometric squeeze) - 5 seconds hold x 10 reps - arm in sling position
• Prevents scapular dyskinesia and upper trapezius dominance

MODALITIES (in clinic):

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PHASE 2 - EARLY ACTIVE PHASE

(Weeks 7-12 | ~mid August to late September 2026)

• Gradually wean from immobiliser
• Restore active-assisted and active ROM
• Begin rotator cuff activation (pain-free isometrics)
• Correct scapulothoracic biomechanics

• Immobiliser used during outdoor activity, crowds, sleep until Week 8
• No resisted external rotation against bands/weights until Week 10
• No overhead activity against resistance

EXERCISES:

• Active forward flexion: Supine first (gravity eliminated), then seated, then standing
• Active abduction in scapular plane (scaption): Thumb up, 0-90° first then progress to 120°
• Active external rotation: Arm at side, elbow 90°, no weight

• Scapular clocks: 10 reps each direction
• Prone scapular retraction (no arm elevation): 3 x 15
• Serratus anterior activation: Wall push-plus (bilateral), hands on wall, protract scapula - 3 x 15
• Low row with band (bilateral): elbow at 90°, retract scapulae - 3 x 15

• Thoracic extension over foam roller (thoracic spine mobilization) - 1 min daily
• Pectoral stretching against doorframe (arm at 90°) - 30 sec x 3 - ensures full forward flexion is not blocked by tight anterior structures
• Upper trapezius stretch - 30 sec x 3

MODALITIES:

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PHASE 3 - STRENGTHENING PHASE

(Weeks 13-20 | ~October - November 2026)

• Full pain-free ROM restoration
• Progressive rotator cuff strengthening
• Full scapulothoracic stabilizer strengthening
• Return to daily activities and light occupational tasks

• No heavy overhead lifting (>2 kg) until Week 16
• No behind-the-back internal rotation (hand-to-spine position) until Week 14-16
• Avoid contact sport / high-velocity overhead activity until Week 20+

EXERCISES:

• Dumbbell overhead press: Bilateral → Unilateral, starting at 1 kg, progressing by 0.5 kg each week
• Shoulder flexion full range (180°) with dumbbell: 0.5 kg → 2 kg
• Functional reaching patterns: Simulated daily activities (reaching shelves, carrying bags)

• Proprioceptive exercises on unstable surface (wobble board - upper limb weight bearing with caution)
• Rhythmic stabilization in multiple angles
• Closed-chain shoulder exercises: Wall slides, floor bear-weight positions (Week 18+)

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PHASE 4 - RETURN TO FUNCTION

(Weeks 20-26 | ~December 2026 - January 2027)

• Full functional shoulder strength symmetric with right side (target: >80% symmetry)
• Return to full occupational activities
• Return to recreational activities / sport (if applicable)
• Full overhead and behind-back ROM

EXERCISES:

• Sport/occupation-specific training
• Plyometric shoulder exercises (if physically active): Wall ball throws, overhead throws with light ball
• Speed and power progressions for overhead activities
• Full strengthening program maintenance (3x per week)

Discharge Criteria:

• Pain-free full ROM in all planes
• Strength deficit < 20% compared to contralateral side on manual testing or dynamometry
• No impingement signs (Hawkins-Kennedy negative, Neer negative)
• Patient confident in functional use of limb

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OUTCOME MEASURES (Track at each phase transition)

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PHYSIOTHERAPY FREQUENCY SCHEDULE

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RED FLAGS - REFER BACK TO SURGEON IMMEDIATELY IF:

• Sudden increase in pain after a period of improvement
• Palpable "pop" or "give way" sensation during exercise
• Increasing swelling or warmth over shoulder joint
• Fever or wound discharge
• Complete loss of movement that was previously achieved
• Neurological symptoms: numbness, tingling down arm

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NOTES FOR THERAPIST

1. Anchor Awareness: Three PEEK knotless anchors (VIMFIX) were used for supraspinatus repair. This indicates a moderate-to-large tear footprint. Do NOT rush to resistive exercises before Week 10. Tendon-to-bone healing at anchor sites takes 8-12 weeks minimum.
2. Immobiliser Weaning: Wean progressively - first remove during structured exercise, then during awake hours at home, then during outdoor activity - never abruptly stop immobiliser use.
3. Subacromial Decompression: SAD was performed alongside the repair. This reduces the need for excessive anti-impingement precautions but does not eliminate them - maintain scapular upward rotation mechanics during elevation exercises.
4. Bursitis component: Subdeltoid bursitis was present pre-op. Expect some residual subacromial sensitivity especially with overhead loading in early phases - use cryotherapy liberally post-session.
5. Current medications (Collagen, Hyaluronate, Calcium): Support tendon healing - compliance is important and complements physiotherapy.
6. Follow-up: Next surgical follow-up is 11 July 2026 - physiotherapist should send a progress note to Dr. Ajankar before this date.

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