Surgery day. Rotator cuff repair is outpatient arthroscopic surgery through four or five small poke holes: you go home the same day. You are asleep for the operation, and a nerve block keeps the arm numb for one to three days. Plan for someone to drive you home and stay with you the first night. Before surgery, set up a recliner or a stack of pillows, because most patients sleep propped up for the first few weeks. Button-front shirts and slip-on shoes help too.

The sling

• Wear the sling whenever you are up and around, and while you sleep, for 6 weeks. It protects the repair while the tendon starts to heal to the bone.
• Once the nerve block wears off and you have control of the arm, you can take the sling off to sit and use a computer, watch TV, write, eat and shower. Keep the arm resting at your side, and put the sling back on when you get up.
• Being in a sling means asking other people for help, which no one enjoys. You still have one good arm and two good legs, so you can be up and around. You just aren't doing much with this arm.

Motion

Standard repair (most patients):

• No moving the shoulder for the first 2 weeks. Moving your elbow, wrist and hand is fine and encouraged.
• Gentle neck stretches and squeezing your shoulder blades back and down are fine from the start.

Massive repair (three or four tendons) or a revision repair:

• No moving the shoulder for the first 4 weeks. Moving your elbow, wrist and hand is fine and encouraged.
• Gentle neck stretches and squeezing your shoulder blades back and down are fine from the start.

Pain and swelling

• Ice the shoulder several times a day. Bruising often tracks down the arm toward the elbow; that is normal.
• You will go home with prescription pain medication. Ibuprofen and Tylenol help too; your folder explains how to combine them.
• Nights are the hardest part early on. A recliner, or pillows behind your back with one under the elbow, usually works best.

Preventing blood clots

• Take one baby aspirin daily for about 3 weeks, unless we tell you otherwise. Ankle pumps and walking help too.

Incision care

• You can shower right away. Cover the incisions for the first 3 to 5 days, then let water run over them. Do not scrub or soak them.
• If your biceps was moved through a small incision near the armpit, it has a waterproof dressing that can come off around day 3 to 5.
• Stitches come out at your first post-op visit, about 7 to 14 days after surgery.

Watch: changing your dressing at home. How to change your dressing after shoulder surgery.

Physical therapy

• Schedule PT now, even though very little is required in the first 2 weeks. Your discharge paperwork includes the prescription and your protocol.
• Early visits cover your elbow, wrist and hand, posture, and what the next stage will look like.

What's normal

• Numbness from the nerve block for a few days, then a sore, stiff shoulder.
• Sleeping a lot. Your body is using its resources to heal.
• Soreness in the muscles on top of the shoulder and in the neck. They are working overtime to cover for the arm.

Ready for the next stage when: the incisions look good at your first post-op visit and the pain is settling.

Motion

Standard repair (most patients):

• From week 2, your therapist moves the shoulder for you (passive motion). You do not lift the arm under its own power yet.
• Limits through week 6: forward reach to 120 degrees, rotation outward to 30 degrees, out to the side to 90 degrees, and rotation inward only to the belly.
• Pendulum exercises (letting the arm hang and swing gently) start around week 3. Gentle motion in a pool can start around week 5.

Massive repair (three or four tendons) or a revision repair:

• Through week 4, the shoulder stays still. From week 4, your therapist moves the shoulder for you (passive motion) within limits: forward reach to 90 degrees, rotation outward to 30 degrees, out to the side to 90 degrees, and rotation inward only to the belly.
• Pendulum exercises start around week 4. Gentle motion in a pool can start around week 5.

Daily life

• Driving: not yet. You can drive once you are out of the sling and off prescription pain medication, usually about 6 weeks.
• Work: desk work with the arm supported is fine as soon as you feel up to it. Jobs that need the arm wait.
• Travel: you can travel in the first 6 weeks. You are just traveling in a sling and asking someone else to lift the bag.
• Washing and dressing: use the other arm. Let the operated arm hang while you wash under it.

What's normal

• Stiffness, as above.
• Aching in the deltoid and the muscles on top of the shoulder, and pain that travels down toward the outside of the upper arm. That is where a sore shoulder sends its pain.
• Frustration with the sling. By the end of this stage you are through the worst part.

Ready for the next stage when: you reach 6 weeks and your post-op visit shows the shoulder moving smoothly.

At 6 weeks the sling is done. (Don't burn it; it is handy in a crowded airport.) The tendon is healed well enough to use the arm for normal things, but not well enough to load. This stage is about working the stiffness out.

What you can do

• Use the arm for everyday activities below shoulder level: dressing, eating, cooking, computer work, light chores.
• Sleep however is comfortable, without the sling. You are not harming the shoulder by sleeping on it.
• Drive once you are off prescription pain medication.
• Lift up to about 10 pounds. A gallon of milk is about 8.

What you can't do yet

• No lifting anything heavier than about 10 pounds, and nothing heavy overhead. Spring cleaning and the attic can wait.
• No pushing, pulling or catching yourself with the arm. Don't fall.

Physical therapy

• Your therapist takes the shoulder through full passive motion, then you start moving it under your own power (active motion), working up from lying on your back to sitting to standing.
• Stretching: doorway, cross-arm and sleeper stretches.
• Light isometrics (pushing against resistance without moving) start around weeks 7 to 8. Real strengthening waits for 3 months.

Golf

• No golf yet. Putting and chipping start at about 4 months, irons at about 5 months, and a full swing at about 6 months.

What's normal

• The shoulder feels good enough that you'll be tempted to do more. Don't let it fool you; the repair is still healing.
• Weakness. You haven't used these muscles in 6 weeks, and strengthening hasn't started yet.

Ready for the next stage when: you reach the 3-month mark with good motion. That is when the tendon is healed well enough to start strengthening.

At 3 months the repair is mostly healed, and at 4 months Dr. Raynor considers it fully healed. This is when strengthening begins. It starts slow and light (curling a 2-pound weight is hard at first), because the muscles have been protected for 3 months. As they get stronger, two things happen: you can lift more, and everyday life stops feeling like work.

What you can do

• All of normal life. At 3 months you are a normally functioning person; you just aren't playing competitive sports yet.
• Running is fine from about 3 months.
• Overhead activity and lifting more than 10 pounds, progressing as your therapist directs.
• Gym work on your therapist's program. Two gym rules for good: no lat pulldowns behind the neck, and no wide-grip bench press.
• Golf: putting and chipping at about 4 months, irons at about 5 months.

Physical therapy

• Resistance bands for rotation, rows, punches, biceps and triceps, then push-up progressions and stability work with the hand on a wall or table.
• Visits usually space out to once a week or less. Most of the work is yours to do at home.

What's normal

• Twinges and little stabs with new exercises. By now the repair has had months to heal, and the job is to rebuild strength. Don't grind through real pain, but don't skip work because of small aches.

Ready for the next stage when: you have full, pain-free motion and your strength is coming back, usually at about 4 to 5 months.

Full recovery is about 6 months. Return to sport comes when you have full, pain-free motion and your rotator cuff strength is back. If you are doing great at 4 months, Dr. Raynor will often release you early; after a massive tear or a revision, this stage runs longer. Golf: putting and chipping at about 4 months, irons at 5, a full swing at about 6. Overhead and throwing sports (tennis serves, volleyball, baseball) follow a throwing progression with your therapist and a check with Dr. Raynor. Contact sports and swimming return at about 6 months.

The arm keeps getting stronger for a full year. It is normal for the shoulder to look and feel slightly different from the other side for a while.

Ready when: you have full motion, full strength, and we clear you together. Then you're back, with no restrictions.

• Most repairs include moving the biceps tendon out of its groove so it stops hurting. It takes a few extra minutes in surgery and does not change your recovery calendar.
• The one extra rule: no resisted elbow bending (curls, or carrying with a bent elbow) for about 12 weeks while it heals.
• Bruising down the front of the arm is common. The biceps may sit a touch differently from the other side. That is normal and not a sign of a problem.

• Same roadmap, slower start: no motion for 4 weeks instead of 2, and strengthening progresses more gradually.
• A big repair does not have to heal completely for the shoulder to work well. Getting most of it to heal, then getting it strong, can give you a shoulder that does what you want it to do.

• Some smaller or partial tears are treated with an immediate-motion or healing-response protocol: sling for comfort for about 2 weeks, motion right away, and strengthening sooner.
• If your protocol sheet from surgery says that, follow it. The sling and motion limits on this page are more restrictive than yours.