Post op supraspinatus tear management

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I now have comprehensive content from Campbell's Operative Orthopaedics on all three protocols. Let me compile the full answer.

Post-Operative Supraspinatus (Rotator Cuff) Tear Management

Based on Campbell's Operative Orthopaedics, 15th Ed. 2026 (Tables 57.4, 57.5, 57.6)

Guiding Principles

Post-operative rehabilitation after rotator cuff repair is guided primarily by tear size. The three tiers are:

Classification	Size	Key difference
Minor	< 2 cm	Earlier progression, sport RTP at 3 months
Moderate	2-5 cm	Slower AROM progression, sport RTP at 4 months
Massive	> 5 cm	ABD pillow required, most conservative timeline

Pre-operative goals (all tear sizes): full passive ROM to prevent frozen shoulder, independent understanding of the post-op exercise program, and realistic expectations about the time frame.

MINOR TEAR (< 2 cm) — Table 57.4

Phase I - Protection & Progressive PROM

Immediately Post-op:

Sling at all times for 3 weeks, then as needed for comfort
Sutures removed at 7-10 days
Begin pendulum exercises
AROM of wrist and hand
Home exercise program (HEP) 2-3x/day

Weeks 1-3 (PT 4x/week to 3x/week):

PROM: flexion, scaption, ER, ER in available scaption
Table slides (FL, scaption)
AROM of elbow, wrist, and hand
Scapular PNF
Ice/E-stim for pain and edema
Precautions: Sling at all times except during exercises; NO active/active-assisted ROM (would jeopardize repair)

Goals by 3 weeks: PROM >150° FL, >50° ER (neutral), >140° ABD scaption

Weeks 4-6:

Wean from sling
PROM continued; add true ABD stretch and gentle IR stretch
AROM <90° (begin at week 5)
Supine TheraBand ER stretch (as needed)
Cane exercises in supine (FL, scaption, ER neutral, ER at 90° scaption)
Shoulder pulley (FL, scaption)
Grades II-III capsular mobilizations
Wall walks (FL, scaption)
Submaximal isometrics (25%) with arm at side: ER, IR, FL, ABD, EXT
Precautions: Lift nothing heavier than a coffee cup; no aggressive IR stretching

Goals by 6 weeks: PROM ≥160° FL, ≥65° ER, ≥160° scaption, max 50° IR; able to comb hair (dominant arm), open a car door, reach behind back for wallet

Phase II - Progressive AROM & Strengthening

Weeks 7-8 (PT 4x/week to 2x/week):

Progress AROM to full by week 8
Isotonics (light weight/high repetition): biceps curls, triceps extension, shoulder shrugs, supine scapular protraction, reverse Codman
Supine manual resistance PNF patterns
Functional tasks: clothespin, cupboard placing
UBE with minimal resistance
Functional exercises per patient goals

Goals by 8 weeks: A/PROM WNL for FL/ABD/ER, PROM ≥60° IR; able to lift plate to eye-level cupboard; dress with normal mechanics

Precaution: Unilateral lifting ≤3 lb; prevent posterior capsular tightness

Weeks 9-10 (PT 1x/2-3 weeks):

Isotonics: standing FL/ABD to 90°, ER/IR with tubing; prone rows, horizontal ABD (90° and 120°), extension; side-lying IR/ER with towel roll under axilla
Increased resistance on UBE
Begin wall push-ups with a plus, progressing to lower levels (table, chair, bench, floor)
Weighted PNF patterns D1 and D2

Goals by 10 weeks: MMT ≥4/5 FL, ABD, ER; MMT ≥4+/5 IR; functional reach behind back; place 2 lb in overhead cabinet; lift gallon of milk

Precaution: Unilateral lifting ≤10 lb

Phase III - Advanced Strengthening / Return to Sport

Weeks 11-16 (PT as needed):

Progress isotonic exercises
Additional isotonics (week 12): bench press (light/short range), lateral pull-downs to chest, incline chest press, short-arc high TheraBand ER/IR at 90° ABD
Plyometrics at 3 months: chest pass, Plyoball chop toss, overhead throw
Return to throwing/racquet sports at 3 months - must have normal strength, normal GH mechanics, and no pain
Isokinetic evaluation if needed

Goals by 16 weeks: MMT 5/5 for FL, ABD, ER, IR, EXT; able to place ≥10 lb in overhead cabinet

MODERATE TEAR (2-5 cm) — Table 57.5

The protocol follows the same three-phase structure but with delayed progression compared to minor tears.

Immediately Post-op: Same as minor tear (sling 3 weeks, pendulums, wrist/hand AROM, HEP 2-3x/day)

Weeks 1-3: Same PROM targets, scapular PNF, ice/E-stim

Goals: PROM >130° FL, >40° ER (neutral), >130° ABD scaption
Precautions: Sling at all times; NO A/AAROM

Weeks 4-6: Wean sling; AROM <90° at 6 weeks (1 week later than minor); cane exercises, pulley, capsular mobilizations

Precaution: Lifts ≤1 lb until 6 weeks
Goals by 6 weeks: PROM ≥160° FL, ≥65° ER, ≥160° scaption, 50° max IR; functional ADLs

Phase II (Weeks 7-8): Same progression as minor, with goal AROM ≥140° FL, ≥130° ABD, ≥60° ER

Precaution: Unilateral lifting ≤2 lb

Weeks 9-12: Same isotonic progression

Goals by 12 weeks: AROM WFL for FL/ABD/ER, MMT ≥4/5 for all; functional overhead activities
Precaution: Unilateral lifting ≤10 lb

Phase III (Weeks 11-16): Same but plyometrics delayed to 4 months and return to throwing/racquet sports at 4 months

MASSIVE TEAR (> 5 cm) — Table 57.6

The key distinction here is the use of a sling and ABD pillow with a longer immobilization period.

Immediately Post-op:

Sling AND abduction pillow for 4-6 weeks (not just 3 weeks), then as needed
Pendulums, wrist/hand AROM, HEP 2-3x/day

Weeks 1-4 (PT 4x/week to 3x/week):

PROM: FL, scaption, ER - but ER only in ≤45° scaption (restricted compared to minor/moderate)
AROM of elbow/wrist/hand
Scapular PNF; ice/E-stim
Grades II-III posterior and inferior capsular mobilizations (begin week 3)

Goals by 4 weeks: PROM ≥110° FL, ≥30° ER, ≥110° scaption

Precautions: Sling at all times except exercising; NO A/AAROM; DO NOT stretch IR

Weeks 5-8:

Wean from sling after 6 weeks
AROM limited to <60° elevation after sling removal (very conservative)
PROM continued; initiate IR without overpressure
Cane exercises: ER in 60° scaption only (vs. 90° for smaller tears)
Shoulder pulley (FL, scaption)
Submaximal (25%) isometrics with arm at side (IR, FL, ABD, EXT - NOTE: ER isometrics not initially included)
Precaution: Lifts ≤1 lb until 8 weeks

Goals by 8 weeks: PROM ≥150° FL, ≥65° ER, ≥160° scaption, max 50° IR; functional ADL tasks

Phase II begins weeks 9-12 with light isotonics; goals by 12 weeks are similar to moderate tear (MMT ≥4/5 all directions, AROM WFL)

Phase III - Return to sport and overhead activities typically 16+ weeks with the most conservative strength expectations.

Important General Principles

Sling duration scales with tear size: 3 weeks (minor), 3 weeks (moderate), 4-6 weeks (massive)
NO active ROM in the first 3-6 weeks across all protocols - active contraction jeopardizes the repair
Lifting restrictions are progressive: coffee cup only → ≤1-2 lb → ≤3 lb → ≤10 lb
Avoid aggressive IR stretching throughout early phases - posterior capsular tightness is addressed with gentle mobilization only
Scapular stabilization (PNF patterns) is initiated early across all protocols - scapular dyskinesia is common and affects healing mechanics
ABD pillow is reserved for massive tears to reduce tension at the repair site
Aquatic therapy, if available, can be introduced in phase II to facilitate AROM with gravity reduced

Campbell's Operative Orthopaedics 15th Ed. 2026, Tables 57.4, 57.5, 57.6 (pp. 3192-3195)

Recent literature note: A 2025 review on optimal techniques and rehabilitation protocols for rotator cuff repair (PMID 41127068) and a 2024 RCT exploring dry needling as an adjunct in post-repair rehab (PMID 39639410) are available in the recent literature. These do not contradict the phased Campbell's protocol but suggest that adjunct modalities like dry needling may improve early pain outcomes. A 2025 study (PMID 40297484) identifies predictors of outcomes after arthroscopic repair, with pre-op ROM and tendon tissue quality being key factors.

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