✅ Small to Medium Tear (<3 cm, 1 tendon)
- Sling 4–6 weeks with abduction pillow
- PROM begins Week 1–2
- Active movement begins Week 7–8
- Strengthening begins Week 13–16
- Return to activity Month 4–6
⚠️ Large to Massive Tear (>3 cm, >1 tendon)
- Sling 6 weeks strict immobilisation: NO early PROM
- PROM begins Week 6 only
- Active movement begins Week 10–14
- Strengthening begins Week 18–22
- Return to activity Month 6+
Phase 1
Immediate Protection: Sling Phase
Small/Medium: Week 0–3 · Large/Massive: Week 0–6🎯 Goals
- Protect the tendon repair completely
- Control pain and swelling
- Keep elbow, wrist, and hand moving
- Begin gentle scapular activation
- Understand sling use and activity restrictions
⚠️ Precautions
- Sling with abduction pillow at 30–45°: wear day and night
- No active shoulder movement whatsoever
- No lifting any objects
- No supporting body weight through the arm
- No reaching behind back or overhead
- Keep wound clean and dry: no soaking for 2 weeks
Large/Massive Tear difference: No shoulder PROM at all for first 6 weeks: only elbow, wrist and hand movement. No pendulums. Strict immobilisation protects tendon-to-bone healing.
Exercises
- Elbow bending/straightening: slowly, full range
- Wrist circles: flex, extend, rotate
- Finger squeezes: ball or rolled cloth
- Scapular retractions: gently squeeze shoulder blades (in sling)
- Pendulums (small/medium only): lean forward, let arm hang and sway gently
- PROM shoulder flexion (small/medium, Week 2): passive elevation to 90°
- PROM external rotation (small/medium, Week 2): to 20° in scapular plane only
- Table slide (small/medium): sit at table, slide arm forward gently
- Ice: 15–20 min, 4–5 times per day
✅ Ready for Phase 2 When (Small/Medium):
- Shoulder PROM flexion to 90°
- Shoulder PROM external rotation to 20°
- Palpable muscle contraction in shoulder and scapular muscles
- No complications
Phase 2
Increasing Passive Range of Motion
Small/Medium: Week 4–6 · Large/Massive: Week 6–10🎯 Goals
- Continue protecting repair
- Gradually increase passive shoulder range
- Reduce swelling and pain
- Begin assisted shoulder movement
- Improve scapular strength
Exercises
- PROM flexion: to 90° (large/massive: 100°)
- PROM external rotation: to 20° in scapular plane
- Assisted flexion with stick/cane: supine, good arm guides bad arm
- Side-lying elevation to 90°
- Table slides: forward and sideways
- Scapular rows on exercise ball
- Continue all Phase 1 elbow/wrist exercises
Large/Massive Tear: PROM begins at Week 6. Progress elevation to 100° and ER to 30° maximum by Week 10. No active movement still: the tendon is still healing at bone. Active movement begins Week 14+.
✅ Ready for Phase 3 When:
- PROM shoulder flexion to 90° (small/medium) or 100–120° (large/massive)
- PROM external rotation to 20° (small/medium) or 25–45° (large/massive)
- Minimal substitution patterns with assisted movements
- Pain less than 4/10
Phase 3
Assisted & Active Movement Begins
Small/Medium: Week 7–10 · Large/Massive: Week 10–18🎯 Goals
- Wean off sling (small/medium: Week 7)
- Increase PROM to 120–155°
- Begin active shoulder movement carefully
- Improve scapular muscle activation
- No lifting heavy objects (>5 kg)
Exercises
- PROM elevation to 120°
- PROM ER to 30° in scapular plane
- Assisted elevation with cane/stick: supine and sitting
- Wall climbs: fingers walk up the wall
- Ball rolling on wall
- Active elevation to 120° (small/medium, Week 7–8)
- Resistance band rows, lawn mower pulls
- Serratus punches: push arm forward, protract scapula
- Biceps curls, triceps extension
Large/Massive Tear: Active movement (AROM) begins at Week 14, not Week 7. Isometrics only from Week 14. Progress to full AROM by Week 18. Do not rush: re-tear risk is highest in this phase.
✅ Ready for Phase 4 When:
- PROM elevation to 120° (small/medium) or 140° (large/massive)
- PROM ER to 30° in scapular plane
- Minimal substitution patterns with active movement
- Pain less than 4/10
Phase 4
Progressive Active Movement
Small/Medium: Week 9–12 · Large/Massive: Week 14–22🎯 Goals
- Full passive range of motion
- Active elevation to 155°+
- Normal scapular movement pattern
- Return to light daily activities
Exercises
- PROM elevation full range
- PROM ER to 45° in scapular plane
- Active shoulder elevation to 155°
- Scaption: raise arm in diagonal, thumb up
- Resistance band forward punch
- Prone shoulder extension: Is
- Push-up plus on knees
- Quadruped ball rolls
✅ Ready for Phase 5 When:
- PROM elevation to 155° (small/medium) or full range (large/massive)
- PROM ER to 45° in scapular plane
- Active elevation to 120° with good scapular mechanics
- Pain less than 2/10
- Symmetric scapular movement with all exercises
Phase 5
Full Range of Motion & Rotator Cuff Strengthening
Small/Medium: Week 11–16 · Large/Massive: Week 18–26🎯 Goals
- Full pain-free active and passive range of motion
- Begin rotator cuff strengthening (surgeon clearance)
- Enhance functional use of arm
- Good motor control throughout movement
Exercises
- Full ROM stretching: ER, IR behind back, cross-body, sleeper stretch
- Side-lying external rotation: with light weight
- Resistance band ER and IR: standing
- Prone Ts, Ws, Ys: scapular strengthening
- Side-lying abduction
- Dynamic hug with band
- Wall push-up plus
- Rhythmic stabilisation: ball on wall, quadruped
- PNF diagonal patterns: D1 and D2
✅ Ready for Phase 6 When:
- Full pain-free active and passive ROM
- ER/IR strength minimum 85% of the other arm
- Negative impingement and instability signs
- Symmetric scapular mechanics throughout movement
- Surgeon clearance obtained
Phase 6
Return to Activity
Small/Medium: Month 4–6 · Large/Massive: Month 6+🎯 Goals
- Maintain full pain-free ROM
- Gradual return to work and recreational activities
- 85–90% shoulder strength versus other arm
- Return to overhead sport with surgeon clearance
Exercises
- ER and IR at 90° abduction: progress resistance
- Resistance band PNF patterns
- Push-up progression: wall → counter → knees → full
- Upper body conditioning: general gym work
- Activity-specific training: cricket bowling, overhead sport as needed
- Home strengthening programme: 3 times/week lifelong
Activity Guide
| Activity | Allowed? | When (Small/Medium) | When (Large/Massive) | Notes |
|---|---|---|---|---|
| Sling use | REQUIRED | 4–6 weeks | 6 weeks strict | With abduction pillow; day and night |
| Elbow/wrist movement | YES | Immediately | Immediately | Keep distal joints moving at all times |
| Driving | WAIT | Week 6+ | Week 12+ | Surgeon clearance; must be off sling and strong painkillers |
| Two-wheeler | WAIT | Month 3+ | Month 4+ | Risk of fall; confirm with surgeon |
| Office/desk work | YES | Week 2–3 | Week 4–6 | Keep arm in sling; no keyboard/mouse work with operated arm initially |
| Light housework (one arm) | CAUTION | Week 6 | Week 10+ | No reaching overhead or lifting with operated arm |
| Lifting (light: <1 kg) | CAUTION | Week 12 | Week 18+ | Surgeon clearance required before any lifting |
| Swimming | WAIT | Month 4–5 | Month 6+ | No swimming until wound healed and surgeon clears |
| Cricket bowling/throwing | WAIT | Month 4–6 | Month 6–9+ | Overhead sport: surgeon clearance mandatory; avoid fast bowling early |
| Badminton / overhead sport | WAIT | Month 5–6 | Month 9+ | High demand on cuff: last activity to return |
| Heavy manual work / farming | WAIT | Month 4–6 | Month 6–9+ | Discuss with surgeon based on specific tasks |
🚨 When to Contact Us
🔴 Come to Hospital Immediately
- Sudden severe pain after a fall or twist on the arm
- High fever with wound redness, swelling or discharge
- Arm becomes cold, pale or numb
- Cannot move fingers or elbow at all
🟡 Call Clinic Within 24 Hours
- Wound not healing or looking infected
- Increasing pain not settling with rest and ice
- Sling feels uncomfortable or incorrect
- Increasing shoulder stiffness despite physio
📅 Follow-up Schedule
🗓 Clinic Reviews
- 2 weeks: Wound check, suture removal
- 6 weeks: ROM assessment, sling weaning
- 3 months: Strength and function review
- 6 months: Full functional assessment
- 12 months: Final review if needed
⚠️ Long-term Advice
- Home strengthening programme: 3x/week lifelong
- Avoid sleeping on operated shoulder for 3+ months
- Avoid overhead lifting until fully strengthened
- Warm up before any overhead sport activity
🏠 Daily Life Tips
- Sleep on back or opposite side: pillow support for arm
- Dress operated arm first, undress last
- Do not tuck shirt behind back: stresses repair
- Non-slip mat in bathroom during sling phase