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Rotator Cuff Surgery for the Second Time

Tom Willemann |

If you have already gone through rotator cuff surgery, the last thing you want to think about is doing it all over again. Unfortunately, many patients do suffer tears of the same tendons that caused them to need surgery in the first place. Most of the time, this is not the surgeon’s fault, nor does it mean that you didn’t follow postoperative directions properly. For example, if you are age 65 or older, your chance of a full recovery is 43%, as opposed to 95% for patients under the age of 55.

We originally wrote about this a few years ago but since then we've developed our technique based on further research. Keep reading to find how we've updated our treatment plan for those of you experiencing Rotator Cuff surgery once more. 

What You Need to Know: Updated Research on Rotator Cuff Re-tears

Rotator cuff tears are a common musculoskeletal issue, often occurring in both symptomatic and asymptomatic populations. Research has shown that rotator cuff tears are prevalent even in individuals without symptoms. A study by Tempelhof et al. (1999) found that 20% of individuals in their 60s and 50% of those in their 80s had rotator cuff tears despite having no shoulder pain. Similarly, a 2010 study by Yamamoto et al. indicated that asymptomatic rotator cuff tears can progress to symptomatic ones over time, particularly in those engaged in repetitive overhead activities.

For those experiencing symptoms, physical therapy has been shown to be highly effective in managing pain and improving function, regardless of tear severity. A systematic review by Kuhn et al. (2013) demonstrated that 75% of patients with full-thickness tears reported significant pain relief and functional improvement with structured physical therapy after one year. Another study by Kukkonen et al. (2014) compared surgical and non-surgical management of full-thickness rotator cuff tears and found no significant differences in outcomes after one year, suggesting that conservative treatment is a viable first-line approach.

If you’ve already undergone rotator cuff surgery, the last thing you want is to go through the entire process again. Unfortunately, recurrent tears of the rotator cuff are not uncommon, and in some cases, revision surgery becomes necessary.

Understanding why re-tears occur, the associated risks, and the outcomes of revision surgery is essential for making an informed decision about your shoulder health. In this article, we’ll explore current research on rotator cuff re-tears, risk factors, surgical and non-surgical options, and evidence-based rehabilitation strategies to maximize recovery.

Why Do Rotator Cuff Re-tears Happen?

Re-tears of the rotator cuff can occur for multiple reasons. Some are related to surgical techniques, while others stem from biological factors, patient-specific issues, or rehabilitation strategies. Studies have identified several key risk factors for re-tears:

  1. 1
    Age: Older patients, particularly those over 65, have a significantly lower rate of full healing after surgery. One study found that the success rate of rotator cuff repairs in patients over 65 was only 43%, compared to 95% in patients under 55 (Jeong et al., 2017).
  2. 2
    Tear Size: The larger the initial tear, the higher the likelihood of failure. Research suggests that for every centimeter increase in tear size, the risk of re-tear increases more than two-fold (Kim et al., 2014).
  3. 3
    Tissue Quality: Poor tendon quality, often associated with chronic degeneration or fatty infiltration, reduces the success of primary repairs (Neri et al., 2019).
  4. 4
    Smoking and Comorbidities: Conditions such as diabetes, obesity, and smoking have been linked to poorer healing outcomes (Galatz et al., 2004).
  5. 5
    Surgical Technique and Rehabilitation Compliance: Poor surgical technique or premature return to strenuous activities can contribute to re-tears.

How Common Are Rotator Cuff Re-tears?

Research has shown that despite advances in surgical techniques, re-tears remain a significant issue:

  • A study published in the American Journal of Sports Medicine found that 20-70% of repaired rotator cuffs re-tear within the first year (Keener et al., 2014).
  • Larger tears (greater than 5 cm) have been reported to fail in up to 90% of cases (Boileau et al., 2007).
  • A 2014 study in the Orthopaedic Journal of Sports Medicine found that revision surgeries have twice the failure rate compared to primary rotator cuff repairs (Zhang et al., 2014).

Is Revision Surgery Worth It?

While revision surgery is an option, its success rates are lower than primary surgery. Some important considerations include:

  • Patient Satisfaction: Despite higher failure rates, one study reported that 93% of patients who underwent revision surgery were satisfied with their outcomes, especially in terms of pain reduction and improved function (Neri et al., 2019).
  • Recovery Time: Healing after revision surgery is often slower. It may take longer to regain function due to scar tissue formation and compromised tendon quality.
  • Alternative Treatments: Non-surgical management, including physical therapy and corticosteroid injections, may be preferable for some patients, especially those with small, asymptomatic re-tears (Kim et al., 2018).

Physical Therapy for Recurrent Rotator Cuff Tears

Regardless of whether you choose surgery or conservative management, physical therapy is essential for maintaining shoulder function and minimizing pain. According to the Mayo clinic these tears can often be handled conservatively if catced early.  A structured rehabilitation program focuses on:

Rotator Cuff Repair Rehabilitation Protocol for Revision

Phase I – Maximum Protection

Timeline: Weeks 0 to 6

Precautions:

  • Sling: Ultra-sling with abduction pillow for 6 weeks.
  • Shoulder Motion:
  • No passive shoulder motion for the first 4 weeks.
  • No active shoulder motion throughout this phase.  
  • No loaded elbow flexion.
  • Passive Range of Motion (PROM):
  • No motion for the first 4 weeks.
  • Progressive PROM in all directions as tolerated, beginning at week 4 done by a physical therapist
  • Avoid external rotation (ER) past 20° if a subscapularis repair was performed.

Goals:

  • Reduce inflammation and pain.
  • Provide postural education and support tissue healing.

Exercise Progression:

  • Pain Management & Circulation
  • Ice & electrical stimulation for pain relief.
  • Diaphragmatic breathing for relaxation and pain control.
  • Hand, wrist, and elbow range of motion (gentle fist making, wrist flexion/extension).
  • Scapular & Cervical Exercises
  • Scapular retractions (pinching shoulder blades together without moving the arm).
  • Passive scapular mobility exercises (manual therapist-assisted or self-assisted).
  • Chin tucks & cervical retractions to maintain neck alignment and avoid compensations.
  • Upper thoracic mobility exercises (foam rolling or assisted mobilization).
  • Shoulder Mobility (Weeks 4-6)
  • Pendulum exercises (gentle circles, front-to-back and side-to-side).
  • Passive shoulder flexion with pulley (only as tolerated).
  • Table slides for flexion & abduction (allow gravity to assist movement).

Phase II – Restoring Passive Mobility & Initiating Active Use

Timeline: Weeks 6 to 12

Precautions:

  • Discontinue sling at week 6.
  • Delay rotator cuff (RC) strengthening until 10-12 weeks.
  • Avoid heavy lifting, pushing, pulling, or repetitive reaching.
  • Light ADLs (<2 lbs) permitted.

Goals:

  • Restore full PROM in all planes.
  • No compensatory arm elevation strategies (e.g., no shoulder shrugging when reaching).
  • Slowly begin active range of motion (AROM) once strength and control allow.

Exercise Progression:

  • Passive & Assisted Range of Motion
  • Wand-assisted shoulder flexion & ER (lying down or standing).
  • Wall walks (flexion & abduction).
  • Overhead pulleys (to facilitate passive movement).
  • Active Range of Motion (AROM) – Weeks 8-12
  • Supine shoulder flexion AROM (gravity-assisted).
  • Seated shoulder shrugs & controlled scapular movement.
  • Side-lying external rotation with no weight.
  • Isometric shoulder external & internal rotation (gentle, pain-free).
  • Scapular & Postural Control
  • Scapular setting drills (holding blades back and down).
  • Prone Y’s and T’s (without weight initially).
  • Seated or standing scapular protraction/retraction.
  • Cardiovascular & Lower Body Conditioning
  • Stationary cycling without excessive arm movement.
  • Treadmill walking with arm supported.
  • Core activation & balance drills (without excessive arm involvement).

Phase III – Progressive Strengthening & Functional Training

Timeline: Weeks 12 to 20

Goals:

  • Gradually restore strength and endurance for functional movement.
  • Introduce sport-specific or job-related activities (once cleared by the surgeon).
  • Continue scapular and rotator cuff control.

Exercise Progression:

  • Strengthening (Pain-Free)
  • Theraband resistance for ER & IR (light resistance).
  • Dumbbell side-lying ER (very light weight, high reps).
  • Front & lateral raises (below 90° initially).
  • Inclined prone Y-T-I exercises (light weight or no weight).
  • Closed-Chain & Functional Strengthening
  • Quadruped scapular protraction/retraction (on hands and knees).
  • Wall push-ups → Counter-height push-ups → Knee push-ups.
  • Isometric shoulder holds in various angles (against a wall or resistance band).
  • Shoulder Stability & Dynamic Control
  • Perturbation training using a stability ball or theraband (external resistance applied unpredictably).
  • Kettlebell carries (light weight, stable shoulder positioning).
  • Plank progressions (from forearms → straight arm → shoulder taps).
  • Progressive Sport or Work-Specific Training
  • Throwing progression (if applicable, after clearance).
  • Overhead work simulation (ladder drills, functional reaching).
  • Controlled plyometrics (medicine ball wall toss, overhead reaching drills, rebounder work).

Phase IV – Return to Function & Performance Training

Timeline: Months 6-12

Goals:

  • Fully restore rotator cuff strength, endurance, and stability.
  • Progress to advanced movements required for sport or job tasks.

Exercise Progression:

  • Strengthening Progressions
  • Higher resistance band training (yellow → red → green → blue).
  • Progress dumbbell strengthening (shoulder press, upright rows, bent-over flys).
  • Weighted carries (farmer’s walk, overhead carries, suitcase carry).
  • Sport-Specific Training
  • Return-to-throwing programs for overhead athletes.
  • Lifting progression (overhead press, Olympic lifts if applicable).
  • Unilateral load training (offset carries, asymmetrical resistance).
  • Plyometric & Reaction-Based Training
  • Medicine ball rotational throws.
  • Speed & agility ladder drills with upper body movement.
  • Resisted overhead rebounds (against wall or with partner).

Important Consideration: Cervical Spine Contribution to Shoulder Dysfunction

Many individuals with rotator cuff pathology also present with cervical spine involvement, which can contribute to persistent pain, scapular dyskinesis, or altered neuromuscular control. It is essential to assess and address:

  • Cervical Range of Motion & Posture: Limited cervical mobility or poor posture may alter shoulder mechanics.
  • Cervical Radiculopathy vs. Shoulder Pain: Some "shoulder pain" may actually stem from cervical nerve root compression.
  • Cervical Strength & Stability: Incorporate deep neck flexor activation (chin tucks, isometrics) and upper thoracic mobility exercises (foam rolling, gentle rotations)
  • Scapulothoracic Function: Proper scapular stabilization exercises will help prevent compensatory movement patterns related to neck dysfunction.

Addressing cervical impairments early will help optimize shoulder rehab outcomes and reduce the risk of chronic pain or reinjury.

Emerging Treatments and Research

New techniques are being developed to improve rotator cuff healing and reduce re-tear rates, including:

  • Biologic Augmentation: The use of platelet-rich plasma (PRP) and stem cell therapy to enhance tendon healing is currently being studied (Randelli et al., 2016).
  • Patch Augmentation: Synthetic or biological patches can be used to reinforce tendon repairs, particularly in cases of poor tissue quality (Millett et al., 2015).
  • Rehabilitation Innovations: Advances in neuromuscular training and biofeedback-based exercises are being explored to optimize post-surgical outcomes (Reinold et al., 2018).

Conclusion: Making the Best Decision for Your Shoulder

If you’ve suffered a re-tear of your rotator cuff, you’re not alone. While revision surgery remains an option, it is not always necessary or ideal. Research shows that conservative management through a well-designed physical therapy program can be just as effective for many patients.

If surgery is recommended, knowing that recovery may take longer and rehabilitation strategies may differ is important. By working closely with your surgeon and physical therapist, you can create a recovery plan that maximizes function while minimizing risk.

If you’re facing a decision about revision rotator cuff surgery or want to explore non-surgical rehabilitation options, consult with a qualified physical therapist to determine the best course of action for your individual needs.

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Tom Willemann

Tom Willemann

Tom Willemann is a premier physical therapist based out of Bergen County, New Jersey. He holds an MS in physical therapy from the University of Miami, is credentialed in the world-renowned McKenzie Method of Mechanical Diagnosis and Therapy (MDT), and holds an OCS (Orthopedic Clinical Specialist) certification. As of 2018, there are approximately 14,000 ABPTS certified specialists in the nation and less than 400 of them are located in the state of New Jersey. Tom is the owner and director of Apex Orthopedic Rehabilitation in Paramus. He opened the clinic, which specializes in spine and sports injury prevention, in 2004 after many years of experience in the field. Tom’s caring interest in others and his strong belief in continuity of care, combined with his clinic’s ability to find solutions for the most difficult orthopedic problems, have earned Apex Orthopedic Rehabilitation its excellent reputation with patients and medical professionals in northeastern New Jersey and beyond. A true “family man,” Tom takes pride in his clinic’s warm and welcoming environment.
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