 
Massachusetts General Brigham Sports Medicine  
 
Rehabilitation Protocol for Non-Operative Massive Rotator Cuff 
Tear(s) 
 
This protocol is intended to guide clinicians through the non-operative course of massive rotator cuff tear injury for 
individuals that are not appropriate for surgical intervention.  Massive rotator cuff tears refer to extensive tears 
involving multiple tendons of the rotator cuff in the shoulder.  Various factors, such as chronicity, poor tissue quality and 
individual patient factors may deem that patient not suitable for surgery. The goals of rehabilitation include pain 
reduction, improved range of motion, improved strength and stability, improved function and 
adaptation/compensation. 
It’s important to note that the outcomes of non-operative management may vary between individuals and patients will 
likely not achieve the same level of recovery as compared to surgical intervention.  It’s crucial to monitor the patient’s 
progress, modify the program as needed, and ensure appropriate pain management.  Collaborating with a 
multidisciplinary team is highly recommended to optimize patient outcomes. 
PHASE I: PROTECTION AND PAIN MANAGEMENT (0-4 WEEKS AFTER INJURY) 
Rehabilitation 
Goals 
• Protect the healing tissue 
• Manage pain and inflammation 
• Maintain range of motion (ROM) 
Precautions/Sling 
• Avoid heavy lifting, overhead activities and activities that cause pain 
• Use a sling for support if recommended by the healthcare professional 
Interventions 
Range of Motion 
• Passive ROM exercises for the shoulder within a pain-free range, seated GH flexion table slide, 
horizontal table slide 
o Avoid excessive force or stretching 
• Active assisted ROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external 
rotation stretch, washcloth press, sidelying elevation to 90 degrees 
 
Pain Management 
• Ice application for pain and swelling 
• Non-Steroidal anti-inflammatory drugs (NSAIDs) as prescribed 
• Steroid injection if indicated by specialist 
 
Manual Therapy 
• Gentle soft tissue mobilization and joint mobilization techniques as indicated within pain 
tolerance 
Criteria to 
Progress 
• Pain control and reduced inflammation 
• Improved PROM/AAROM 
• Basic shoulder movements without pain 
 
 
 
PHASE II: RESTORING RANGE OF MOTION (4-8 WEEKS AFTER INJURY) 
Rehabilitation 
Goals 
• Gradually improve shoulder ROM 
 
 
• Maintain pain control 
• Enhance scapular stabilization 
Additional 
Interventions 
*Continue with 
Phase I 
interventions 
Range of Motion 
• Passive and active-assisted ROM exercises for shoulder within a pain-free range, seated 
shoulder elevation with cane, seated incline table slides, ball roll on wall, supine flexion, salutes, 
supine punch, wall climbs 
• Gentle stretching exercises for the shoulder and surrounding muscles, External rotation (90 
degrees abduction), Hands behind head, IR behind back with towel, sidelying horizontal ADD, 
sleeper stretch, triceps and lats, doorjam series 
 
Strengthening 
• Anterior Deltoid Strengthening: Begin isometric exercises progressing to isotonic exercises 
using resistance bands or light dumbbells 
• Scapular Stabilization: Initiate scapular stabilization exercises, scap retraction, prone scapular 
retraction, standing scapular setting, supported scapular setting, inferior glide, low row 
• Proprioception and neuromuscular control: Include exercises that challenge balance, 
coordination and muscle control to enhance joint stability, internal and external rotation in 
scaption and Flex 90-125 (rhythmic stabilization), IR/ER and Flex 90-125 (rhythmic 
stabilization), quadruped alternating isometrics and ball stabilization on wall  
 
Manual Therapy 
• Soft tissue mobilization, joint mobilization and myofascial release techniques as indicated 
Criteria to 
Progress 
• Minimal pain during AROM exercise 
• Gradual improvement in A/PROM 
• No restrictions in daily activities 
 
PHASE III: PROGRESSIVE STRENGTHENING (8-12 WEEKS AFTER INJURY) 
Rehabilitation 
Goals 
• Improve shoulder strength and stability 
• Enhance dynamic scapular control 
• Gradually return to functional activities 
Additional 
Interventions 
*Continue with 
Phase I-II 
Interventions  
Strengthening 
• Anterior Deltoid Strengthening: Progress isotonic exercises using resistance bands or light 
dumbbells 
• Rotator Cuff Strengthening: Progressive resistance exercises for the remaining rotator cuff 
muscles using resistance bands or light dumbbells, internal external rotation isometrics, side-
lying external rotation, standing external rotation w/ resistance band, standing internal rotation 
w/ resistance band, internal  rotation, external rotation, sidelying ABD→standing ABD 
• Scapular Stabilization: Progress exercises with resistance using resistance bands or light 
dumbbells, Row on physioball, shoulder extension on physioball, Resistance band shoulder 
extension, resistance band seated rows, rowing, lawn mowers, robbery, serratus punches 
• Core and Lower Extremity Strengthening: Exercises to maintain overall body strength and 
stability 
 
• Neuromuscular control 
• Incorporate closed-chain exercises that emphasize functional movements.  Begin exercises that 
challenge dynamic stability and control with progression to addition of perturbation and 
proprioceptive training, Push-up plus on knees, prone shoulder extension Is, resistance band 
forward punch, forward punch, tripod, pointer 
 
Functional Training 
• Gradual progression of functional activities, such as reaching, lifting and carrying objects with 
proper body mechanics 
 
 
 
Manual Therapy 
• On-going soft tissue mobilization, joint mobilization and myofascial release techniques as 
indicated 
Criteria to 
Progress 
• Sustained pain-free AROM 
• Increased strength and endurance 
• Achieved specific strength and functional goals 
• Demonstrated stability and control during dynamic movements 
 
PHASE IV: RETURN TO FUNCTION (12+ WEEKS AFTER INJURY) 
Rehabilitation 
Goals 
• Maximize shoulder function 
• Improve strength and endurance 
• Return to desired activities 
Additional 
Interventions 
*Continue with 
Phase I-III 
interventions 
Strengthening 
• Continued progression of anterior deltoid, rotator cuff, scapular stabilization and 
neuromuscular control exercises, T and Y, “T” exercise, push-up plus knees extended, wall push 
up, “W” exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, External 
rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external 
rotation at 90 degrees, resistance band standing internal rotation at 90 degrees, PNF – D1 
diagonal lifts, PNF – D2 diagonal lifts, Field goals, Resistance band PNF pattern, PNF – D1 
diagonal lifts w/ resistance, diagonal-up, diagonal-down, wall slides w/ resistance band  
• Incorporation of activity-specific exercises 
Criteria to 
Progress 
• Maximal pain-free ROM and strength 
• Improved motor control during functional movements 
• Able to perform specific activities without limitations 
• Demonstrates ability to handle increased load and demands on the shoulder 
 
 
• Last stage-no additional criteria 
Revised 8/2023  
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
 
References: 
 
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