Two patients have the same shoulder arthroscopy, and on leaving hospital each has only a few tiny keyhole wounds on the shoulder, yet three months later their progress can differ by a factor of two. One can raise the arm without pain to pour tea two weeks later, while the other is still in a sling and needs help even to get dressed. This is not because the second patient is behind in rehabilitation. The two are simply on two quite different routes.
What decides the route is not how big the visible wounds are but one core question: was any tissue “repaired” during the operation? Surgery for decompression or debridement alone (such as subacromial decompression) involves no suturing, so there is no stage of waiting for tissue to heal, and the patient can be active early and take off the sling as soon as possible. Labral repair (Bankart or SLAP), by contrast, uses anchors to fix the torn labrum back in place. The repair needs time to knit firmly, and too much movement early on pulls the repair loose, so the repair must be protected and the pace slowed. The sections below use this dividing line to show step by step which rehabilitation timeline the patient is on, and when activity restrictions can be relaxed. For the whole recovery after shoulder surgery, first see the overview of physiotherapy after shoulder surgery.
Types of surgery: decompression alone and with repair
To judge how quickly recovery will go, the first task is to understand what the surgeon actually did under the arthroscope. Even when the wounds look equally keyhole, the work inside can be completely different. What decides the pace of rehabilitation is what was actually done and not how big the incision is.
Comparing the progress of decompression alone and surgery with repair
Once the type of surgery is clear, the way each route actually progresses can be seen. The table below sets decompression alone and labral repair side by side. The point is not to memorise numbers of weeks but to understand how whether tissue was repaired shapes the pace of every stage.
- Sling: mostly just for comfort early on, and it should be stopped early once pain eases and not worn for long
- Early stage: start AAROM and AROM early, within what can be tolerated, and the earlier the better
- Strengthening: added back step by step once pain and swelling have settled and range of movement has returned
- Main line: manage pain and swelling and prevent stiffness, with no stage of protecting a repair
- Sling: worn as the operation requires to protect the repair, for longer than after decompression alone
- Early stage: passive and direction-limited first (especially abduction with external rotation), to protect the repair
- Strengthening: advanced when targets are met (criterion-based), and it is right that it is slower than after decompression
- Main line: protect the sutured site while it knits firmly, since activity that is too fast can make the repair fail
The general direction of both routes is the same: first reduce pain and swelling, then restore range of movement, and finally strengthen the muscles. Labral repair, however, has an extra main line early on of protecting the repair, so every step must be taken with extra care. That said, early activity and protecting the tissue are not entirely opposed. Even when a repair needs protecting, a suitable amount of early movement still has a role. A systematic review found that early mobilisation after rotator cuff repair helps to improve short-term range of movement (Houck et al. 2017), and another meta-analysis found that early mobilisation did not significantly raise the rate of tendon retear (Mazuquin et al. 2021). Because the two studies do not give a fully consistent answer on the effect on tissue healing, clinical practice generally takes a neutral approach that depends on the individual operation: neither the more protection the better nor the earlier the movement the better, but a balance struck between protection and activity according to the quality of the repair and the surgeon’s instructions. Striking this balance is where the physiotherapist’s professional judgement is most tested.
The principle of advancing only when targets are met is in fact the direction consistently favoured by mainstream guidance for rehabilitation after shoulder surgery. A systematic review combining recommendations for rehabilitation after anatomic and reverse shoulder replacement also pointed out that rehabilitation after surgery should use a staged framework advanced according to targets achieved and not decide progress by the number of days alone (Bullock et al. 2019). The same logic suits arthroscopic labral repair too: how well the repair has healed decides how far activity restrictions can be relaxed, and the calendar does not decide it.
In summary, the core principle is that decompression alone mainly follows a “time frame” (progressing roughly by the number of weeks after surgery), while labral repair follows a “criterion frame” (specified targets of range of movement or stability must be met before the next stage is entered). So if the question is how many weeks after surgery a certain movement can be done, decompression alone usually has a clearer answer. For repair surgery only a rough range can be given, because progress depends on how well the repair has healed, and a timetable cannot be applied rigidly.
When the patient can use the arm, drive and return to work after surgery
The time to recover everyday function also follows the rule of fast after decompression and slow after repair. In practice, though, the nature of the work and the safety of the activity must be considered at the same time, and a single number of days cannot cover everything.
Light daily tasks
- Decompression alone: once the pain has eased, the arm can be used lightly within the range the patient finds acceptable.
- Labral repair: movement in particular directions is limited early on, and restrictions are relaxed slowly once targets are reached.
- Common principle: use the absence of pain as the line, and slow down as soon as it hurts.
Driving
- Wearing a sling gets in the way of control, so driving should be considered only after the sling is no longer needed.
- The arm must be able to control the steering wheel and turn safely with no pain at all.
- Research shows that the time at which patients feel they can drive is generally earlier than the time they pass an objective brake test, so never just follow another person’s number of days.
Of all the daily activities, when the patient can drive is the question patients ask most and also most often estimate wrongly. A systematic review pooling several studies found that the self-reported time to resume driving after shoulder surgery ranged from the day of surgery to about four months after surgery. Wearing a sling reduces the ability to drive, and the time at which patients feel they can drive safely is generally earlier than the time they reach the standard on an objective brake reaction test (DiSilvestro et al. 2016). Another study of driving after rotator cuff repair also found that the time to resume driving likewise ranged from the day of surgery to about four months, and that patients with remaining pain or weakness felt less safe while driving (Gholson et al. 2015). In other words, do not rashly follow others just because they can drive. The safe standard to use is that the sling has been stopped and the arm can control the steering wheel without pain. The time to return to work is the same: office workers can return earlier, but manual workers whose jobs involve lifting the arm overhead or lifting heavy loads have to wait much longer, and the time is graded according to whether the operation repaired any tissue.
Normal recovery compared with abnormal joint stiffness
Whichever route of rehabilitation the patient is on, there will be a period after surgery when the shoulder does not move smoothly, but patients must tell which signs are an expected passing stage and which are warnings that the joint is starting to stiffen. In fact, stiffness after surgery is not rare. A systematic review found that after arthroscopic repair, the overall rate of real joint stiffness was about 6.4%, and after repair of partial-thickness tears the stiffness rate was as high as 10.3%, higher than the 5.2% after repair of full-thickness tears (Baumann et al. 2023). These figures remind patients that stiffness after surgery is a real risk that needs active attention and handling. In particular, for labral repair patients following the criterion frame, if range of movement has stalled at one point with no professional to help adjust the training, it is easy for protecting the joint to turn into a stiff joint.
To tell the two apart, the broad principle is to watch the overall trend. If the range of movement gains a little each week and pain gradually lessens, this is mostly a normal course of recovery. If, by contrast, range of movement stalls or even goes backwards, passive movement is so painful that the arm cannot be moved, or the expected time has come and targets are still far from met, the patient should no longer press on blindly, because the situation may have gone from protection after surgery to secondary joint stiffness and needs reassessment as soon as possible. If the background to decompression alone is of interest (for example how subacromial impingement is treated conservatively), see the page on rotator cuff tendon tears (conservative treatment), which links the logic of treatment before and after surgery.
When is a physiotherapist needed? If any of the following applies, the patient should no longer feel the way alone: not sure whether the operation was decompression alone or a repair, range of movement still far from what is expected when the time has come, passive movement so painful that the arm cannot be moved at all, or never daring to take off the sling after decompression alone, so that the shoulder gets tighter and tighter. The home physiotherapy provided by Nova Health’s registered physiotherapists draws up a staged rehabilitation exercise plan according to the operation actually performed (decompression alone or labral repair). The therapist judges whether the present situation is a normal transitional stage or joint stiffness that needs treatment, and guides when the sling can safely be taken off and when advanced training can start, so that the patient is neither over-protective nor in too much of a hurry.