Rehabilitation after rotator cuff repair: sling, stages and return to lifting

The rotator cuff is a group of tendons that steadies the ball of the shoulder and helps lift the arm. When a torn tendon is stitched back to bone, the repair is at its weakest in the early weeks, so the first stage of rehabilitation limits how much the tendon is asked to do. At the same time the elbow, wrist and hand are kept moving, and the neck and shoulder blade are looked after, so that the whole arm does not stiffen.

The trial protocol for RaCeR 2 recruits adults awaiting arthroscopic repair of a full-thickness tear, and says that after surgery a physiotherapist advises the patient within 24 hours on how to manage the sling and begin exercises.

The standard pathway in RaCeR 2 has patients wearing the sling for 4 weeks except for eating, washing, dressing and exercises. Oxford University Hospitals gives a similar picture in patient-facing terms, and describes three phases: sling on with no movement apart from exercises, regaining everyday movements once cleared at 3 to 6 weeks, and regaining strength after 12 weeks.

The Robert Jones and Agnes Hunt leaflet says the sling is normally worn nearly all of the time for 3 to 4 weeks while the tendons heal, with pendulum-type exercises starting the day after surgery and continuing for up to 6 weeks. The Dudley Group says active therapy usually starts six weeks after surgery and formal strengthening is delayed until 12 weeks.

• Phase 1: sling on, exercises for the elbow, wrist and hand, no use of the arm for everyday tasks.

• Phase 2: regaining everyday movement under the physiotherapist's guidance.

• Phase 3: strengthening, which Oxford places after 12 weeks.

RaCeR 2 defines the exercise ladder used in standard care. Stage 1 is fully assisted movement, where someone else or the other arm moves the shoulder. Stage 2 is partly assisted movement progressing to unassisted movement. Stage 3 is static resisted work, pushing without the joint moving. Stage 4 is resisted movement through the range, within the limits of pain, progressing to functional restoration.

The protocol says patients are expected to have around five follow-up appointments with a physiotherapist across the first 12 weeks, either in person or remotely, although the number is agreed locally and not fixed.

The Oxford booklet says that for at least 3 weeks and possibly 6, depending on the repair, you should not use the arm for everyday activities, particularly those that move the elbow away from the body. For 6 weeks do not lie on the operated side. Avoid lifting any weight with the arm for 8 to 12 weeks, for example a kettle, and avoid heavier lifting such as digging or manual work for 4 to 6 months.

The Robert Jones and Agnes Hunt leaflet agrees broadly, saying you will be effectively one-handed for six weeks, cannot lift weights until about 12 weeks and should avoid anything strenuous or above head height until three months.

Office and non-manual workers can usually return three to six weeks after the operation, and manual or overhead workers at three months, according to the Robert Jones and Agnes Hunt leaflet. The same leaflet says driving usually restarts six to eight weeks after surgery, depending on regained movement and a safe emergency stop, gentle gardening is possible from six weeks, and golf from three months if movement is full and comfortable.

The Dudley Group says most day-to-day activities can begin after a few days and gives driving as four to six weeks. The difference between hospitals is a reminder that your own surgeon's instruction, which reflects the quality of your repair, overrides any leaflet.

RaCeR 2 is a UK multicentre randomised trial comparing standard rehabilitation with individualised early patient-directed rehabilitation, in which patients are advised by a physiotherapist within 24 hours to remove the sling as soon as they feel able and to start using the arm within comfortable limits. A systematic review by the same group of 20 trials found no difference in pain and disability up to 12 months between early and standard rehabilitation, but better range of movement with early rehabilitation, and no difference in repair integrity.

In the pilot, 73 patients from five NHS hospitals took part. Those in the early group reported less pain and disability, returned to driving 18 days sooner and lost four fewer days from work over 12 weeks. Re-tears were seen in 30% of the early group and 41% of the standard group. These are pilot figures from a protocol paper, and the full trial was designed to give a definitive answer, so they should not be read as proof or as a reason to change your own surgeon's plan.

Worry about re-tearing is a main reason for the cautious pathway. Increasing pain, a sudden loss of strength after a fall or strain, a wound that looks infected, a high temperature, or numbness in the hand are reasons to contact your surgical team or NHS 111. Persistent stiffness that is not improving with the programme is also worth raising at your follow-up, because the stages are meant to be adjusted for you.