Post-operative rehabilitation guidelines
Latissimus Dorsi Transfer to Posterosuperior Cuff
Please note that this is advisory information only. Your experiences may differ from those
described. A fully qualified Physiotherapist must demonstrate all exercises to a patient.
We cannot be held liable for the outcome of you undertaking any of the exercises
outlined here independently of direct supervision from the RNOH.
Please read these guidelines with consideration to the specific physiotherapy discharge
report that will be sent to the physiotherapist concerned. There may be individual variation
that is patient specific in which case these general guidelines will have to be modified as
appropriate by the physiotherapist.
At RNOH, our emphasis is patient-specific, not condition-specific rehabilitation which
encourages recognition of those patients who may progress slower than others. We also
want to encourage clinical reasoning based on the continuum concept of shoulder
rehabilitation i.e. similar rehabilitation tools are used for each shoulder procedure but the
time of intervention varies according to the status of the tissues at pre-op, at surgery and the
post-op restrictions.
Most of our procedures at RNOH have guidelines that fall into categories loosely based on
the Matsen classification of shoulder dysfunction rather than having specific guidelines for
each of our more established procedures – however, as this particular procedure is often
used to supplement another – it is difficult to necessarily generalise and suggest which
classification it should be in – therefore, for now, these guidelines stand alone!
Our hope is that by providing guidelines and treatment ideas, it will promote an equitable
rehabilitation service to all of our patients and improve the overall understanding of the
unique challenges that rehabilitation of the shoulder complex presents.
Milestone driven
Apart from phase one of the post-operative care which is based upon tissue healing times
and surgical opinion, these guidelines are milestone driven and designed to provide an
equitable rehabilitation service to all of our patients. The time periods documented at the
beginning of each phase are purely there as a rough guide. We hope the guidelines will limit
unnecessary visits to the outpatient clinic at the RNOH by helping the patient and therapist to
identify when specialist review is required.
If the patient and the therapist feel that rehabilitation is progressing satisfactorily and
there are no concerns, the patient may cancel and re-book their follow up for a later
date.
Failure to progress or variations from the norm should be the main reason for clinic
attendance. Both patients and therapists can book clinic visits by contacting the numbers
given in this document.
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
It is essential you contact us if you have any concerns:
Physiotherapy Team
Occupational Therapy Team
Consultant Team Secretaries
020 8909 5820/5519
020 8909 5310
020 8909 5456/5727
Surgical Indications for Latissimus Dorsi Transfer to Posterior Cuff

Inability to actively place and hold the arm in a functional position in front of the body
at waist level due to lack of active external rotation at the shoulder. - e.g. following
Brachial Plexus Injury/Neurological Compromise, Irreparable Massive Cuff Tears.
Being unable to place the arm in this position will prevent the ability to achieve the
starting positions required for an Anterior Deltoid Programme should it be required.

Inability to * “snug” the humeral head on initiation of abduction. This can lead to pain
and decreased function in elevation.
- e.g. secondary to posterosuperior cuff failure.
*“Snugging” of the humeral head is a term we often use to explain the normal subtle
movement of the humeral head as it centres towards the glenoid prior to any
movement of the GHJ. This action is normally produced by a functioning cuff. It is
tested with gently resisted abduction of the shoulder and the “down and in” motion of
the humeral head is observed.
Possible surgical complications
 Infection
 Neurovascular compromise
 Joint stiffness
 Failure of the transfer
Expected long-term outcome
When used to supplement a rotator cuff repair, expected outcome may take 9-24 months to
achieve. Post neurological injury/BPL our experience shows that changes can continue to
develop for up to 4-5 years post transfer.
For patients who have had the transfer to supplement a cuff repair, the expected long term
outcome should be similar to that of a standard cuff repair, but the time taken to achieve it
will be longer due to the early restrictions and the time taken to re-educate the function of the
Latissimus Dorsi muscle.
This operation is sometimes undertaken in conjunction with other operative
procedures such as Total Shoulder Replacements (TSR) therefore it is imperative that
all components and limitations of the surgery are taken into consideration.
A standard goal for all patients is to report a pain-free shoulder (other underlying pathology
to be considered) that can be held comfortably in neutral rotation at waist level allowing for
increased functional activity. Further progress from this stage and long-term functional
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
outcome is dependent on the underlying pathology/neuropathology/additional surgery rather
than purely the latissimus transfer itself and it is important that the patient’s goals and
expectations are realistic at the outset.
In-patient post op care plan
The RNOH Shoulder Physiotherapy Service follows this care plan prior to discharge.
Goals:
1. To educate the patient on post operative instructions and expected
outcomes following surgical procedure – this may include explaining the
purpose of an in-patient rehabilitation admission for initiating Phase 2 in the
future.
2. To explain the purpose of the patient’s specific support – ie spica or
abduction pillow and demonstrate ideal positioning/how to alter and remove
components of spica/abduction pillow for exercises - within post-operative
restrictions.
3. To ensure patient is safe mobilizing on ward with arm immobilized in spica
or abduction pillow and feels they can manage stairs/check they can
manage stairs, with arm immobilized (as appropriate).
4. To teach scapular setting and hand/wrist/elbow ROM exercises (where
appropriate).
5. To teach and ensure that the patient and/or carers are competent with the
post operative exercise programme and can maintain the programme post
discharge.
6. To ensure all patients requiring further physiotherapy are given a copy of
their outpatient referral prior to discharge and are aware that they can
contact the Shoulder Service if local services fail to provide a timely
appointment.
7. To fax/send physiotherapy referral with patient specific guidelines and
information about accessing generic guidelines to local physiotherapy team
(as appropriate).
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Initial rehabilitation phase one: For Latissimus Dorsi Transfer to
Posterosuperior Cuff
Discharge – 8 (or 12) weeks
(Dependent on patient specific post-op instructions)
If additional major surgery was carried out in conjunction with the transfer, the guidelines
may vary. The integrity and tension of the graft will drive the decisions regarding Phase
One.
Goals:
1. Ensure Wound/Tissue Healing (as able, according to method of
immobilization – ie spica or abduction pillow).
2. Encourage effective pain control.
3. Ensure patient is safe mobilizing with spica/abduction pillow.
4. Maintain/Increase Passive/Active-Assisted ROM -ranges will be
documented on patient specific referral.
5. Initiate scapular control.
6. Continue Isometrics (IR+ER) and eccentric ER -only if documented on
patient specific referral.
Restrictions:
1. The patient is not to lower the arm from the abduction pillow or remove
abduction pillow or spica.
2. No exercises to be carried out, other than those outlined in the post-op
plan, that would affect the graft.
3. Exercise should remain relatively pain-free.
Education:
Patient education on anatomy of shoulder complex, post-op restrictions,
progression of short/long term goals in conjunction with guidelines, postural
advice/retraining.
Milestones to progress to phase two:
1. Adequate pain control.
2. Adequate scapular control.
3. Achieved time specific goals specified on individual referral.
Often, to initiate this next phase, the patient will be brought into RNOH rehabilitation ward
for one week – especially if they have been immobilised in a plaster spica, if this is not
due to happen, please progress……..
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Rehabilitation phase two:
Approx weeks 8 (or 12) to 9 months
Goals:
1. To hold and maintain at least 30 degrees ER with the elbow supported
on the abduction pillow (ie with the arm resting at approx 40 degrees
scaption).
2. To be able to eccentrically control the arm from 30 degrees ER position
on abduction pillow, back to rest on abduction pillow.
3. (After achieving 1 & 2 above) To wean off the abduction pillow, deflating
it, lowering the arm on the support, whist ensuring some control is still
achievable as the abduction component decreases.
4. To start to use the arm at waist level for functional activity.
Restrictions:
1. Where possible, minimize exercises that may exacerbate pain.
2. Once in this phase, even prior to gaining control, the patient can remove
the support for washing/dressing etc, but should return to the
abducted/neutral rotation position at other times so as not to overstretch the graft, making it harder to gain activity – this resting position
can be on an armchair or table at times if the patient prefers.
3. Avoid removing the abduction pillow too quickly – even though the
patient will want to be rid of it! Continue using it for resting and
exercises until the patient is able to isometrically hold at approx 30
degrees ER so as to avoid stretching the graft and therefore
compromising the ability to recruit to the muscle.
4. Avoid GHJ stretching other than to achieve the ranges required for the
goals above.
Advice:
It is important to remember that when working through these very basic stages, the
exercises are not about just “strengthening” the muscle – the muscle/tendon transfer itself
would have been of adequate quality and strength in it’s previous position and function, and
although it has been disrupted and immoblised and therefore weakened, “strengthening” as
such, is not the main focus.
The important concept is that of developing the neuromuscular control of the muscle in its
new roles as an external rotator and posterosuperior stabilizer of the humeral head.
Latissimus Dorsi has always worked predominantly as an internal rotator and adductor of the
GHJ and as a depressor of the shoulder girdle.
In its new role, it will still depress the shoulder girdle and adduct the GHJ, but it now has to
externally rotate the shoulder and assist the remaining cuff (if applicable) to “*snug” the
humeral head onto the glenoid. You will need to initially get cognitive control of the new role
and then eventually, as neuroplasticity takes place, it will hopefully become more automatic.
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Some ideas to assist the exercise progression:










In the 40/45 degrees position on the abduction pillow, assist the ER
movement to 30/40 degrees as able and encourage “holding” with the
addition of some adduction/depression – i.e. using part of the “old” role to
activate the LD muscle, but assist the new ER position – as the patient is
able to hold it isometrically, try to decrease the active adduction component.
Don’t request a maximum contraction – it is not about “strength” but
activating the muscle appropriately – perhaps try “30%” effort as a starting
point.
Use biofeedback if you have the facility, placed on the belly of the LD
transfer, to give visual feedback as to when the transfer is working and
encourage the “holding” – even if still supported
Use FES in a similar way to the biofeedback, giving sensation feedback as
to how to activate the muscle – join in with it.
Place a hand on the area to give proprioceptive feedback so the patient
knows where the contraction should be happening and can get some
feedback.
Manually facilitate the adduction/depression component that you are trying
to activate whilst the patient “joins in”.
Repetition! Repetition! Repetition!
Use 30-40 degrees of ER as this is roughly the mid to inner range of the
transfer and therefore, from a length-tension relationship point of view, it
should be easier! However, if the patient is struggling, vary the degree of
ER.
Once you have the isometric hold, work on eccentric lowering back to
neutral rotation – i.e. back to the abduction pillow – gaining control this way
will prevent “hitching”/elevating of the scapula and it appears to gain control
more easily than working concentrically.
Hydrotherapy can be useful to assist with the upper limb control and also
with general scapulothoracic control, core stability etc
Education:
Patient education about the reasoning behind the exercises and the need for continuing
abduction/ER support, ongoing postural education.
Milestones to progress to Phase Three: (if this is much sooner than 9
months – please still progress…that is the purpose of milestones rather
than specified time periods)
1. To be able to hold the arm at approx 30 degrees ER with the arm resting at
approx 40 degrees scaption/abduction.
2. To be able to eccentrically control the arm from approx 30 degrees ER
position back to neutral when resting at approx 40 degrees
scaption/abduction.
3. To have weaned off the abduction pillow and be using arm at low level for
light activities.
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Once these milestones have been achieved, if there are no other reasons for restricting it,
driving can be restarted if the patient feels safe to do so.
Rehabilitation phase three: Approx 9 months+
(Dependent on underlying pathology and other rehab requirements)
Regardless of whatever additional operation your patient has had, the information
below incorporates the final progression of the LD transfer +/- other operations.
At this stage –if your patient has also had an additional Total Shoulder Replacement
or Rotator Cuff Repair – see “Smooth and Weak” Guidelines for more specific
guidance if required, and work through the phases according to the milestones
outlined.
Goals:
For those without an existing, functioning Rotator Cuff:
1. To restore full active range of movement (patient specific).
2. To achieve MMT grade 3/5 from an internally rotated position to neutral
rotation at 0 degrees abduction – achieving a comfortable “neutral
position”, but not necessarily being able to achieve full MMT grade 3/5
through full passive ER range.
3. To develop automatic control of ER and endurance of appropriate
muscle groups (patient specific) and relate to functional tasks.
For those without an existing, functioning Rotator Cuff, but a functioning Deltoid:
1. To restore full active range of movement (patient specific).
2. To achieve MMT grade 3/5 from an internally rotated position to neutral
rotation at 0 degrees abduction – achieving a comfortable “neutral
position”, but not necessarily being able to achieve full MMT grade 3/5
through full passive ER range.
3. To develop automatic control of ER and endurance of appropriate
muscle groups (patient specific) and relate to functional tasks.
4. To work through an Eccentric Deltoid Programme and maximize
functional range.
For those who have had the transfer to supplement an existing cuff/cuff repair:
1. To restore full active range of movement (patient specific).
2. To achieve grade MMT 3/5 through rotation range.
3. To develop automatic control of ER and endurance of appropriate
muscle groups (patient specific) and relate to functional tasks.
4. To recruit the LD transfer to achieve “snugging” of the humeral head
automatically on the initiation of abduction.
5. To progress Rotator Cuff/Transfer control initially to the exclusion of
Deltoid in varying positions through range and without inappropriate
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
muscle patterning (Pecs, Traps, etc) and then to progress control
through full functional range with addition of Deltoid.
For all patients - try to restore scapulohumeral rhythm, maintain core and postural control
and address all other aspects of the kinetic chain as required to maximize function.
Restrictions:
1. Where possible minimize exercises that may exacerbate pain.
2. If the patient has an active Rotator Cuff, ensure it is functioning well at a
low level and the humeral head is “snugging” into the glenoid prior to
progressing to active exercises above shoulder level.
Education:
Patient education around pacing of activity. Return to sporting activity – initially non contact.
Caution to be taken with previously aggravating activities. Ongoing postural education.
Normal movement with functional activities. To remind regarding the purpose of the LD
transfer for each individual patient so that expectations are realistic.
Some ideas to assist the exercise progression (as appropriate):









When stretching, start with active-assisted stretches into range –
considering the expected outcome as to how much range is going to be
needed for long term goals.
Maintain and monitor the ER control that has been gained closely as you
start to stretch the GHJ as you are now stretching the graft and could lose
control if you stretch too quickly.
Use capsular stretches as required for anterior and posterior capsule –
again, monitoring the active ER gains that have been made and ensuring
these are maintained.
Use slings and springs or hydrotherapy to offload the arm, allowing low
level cuff exercises (as appropriate), now treating the LD transfer as
posterosuperior cuff, add resistance and decrease support as control
improves. If using therabands, use a maximum strength of a yellow band if
you are trying to target just the cuff itself.
Monitor the transfer activity during exercises (with biofeedback/palpation) to
ensure that it is now activating appropriately as posterosuperior cuff.
Still use the concepts of initiating “old” functions of LD while trying to
achieve “new” functions to recruit appropriately – as in Phase Two –
assisting with manual, visual, proprioceptive feedback and facilitation where
required.
As the control improves at waist level, incorporate more functional activities
to try to make the transition from cognitive control of the graft to automatic
control.
Use a closed and open chain exercise programme.
Address and strengthen LD’s original and ongoing action of scapula
depression, GHJ adduction and extension from a flexed position
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science


For information on cuff exercises and Anterior Deltoid exercises see
“Smooth and Weak” Guidelines and exercise examples on the RNOH web
page.
Address general core control and proprioceptive deficits - consider Kibler et
al, 2001. Principles of Kinetic chain and the incorporation of lower limb
exercises.
Failure to progress:
If a patient is failing to progress, then consider the following:
Possible problem
Pain Inhibition
Action
Adequate analgesia
Maintain pain free exercises
Return to passive stretches if appropriate
Slow rehab programme
If severe night/resting pain then refer to Shoulder
Unit
Inability to gain any activity Try exercise ideas outlined in phase two and if no
in LD Graft
flicker can be elicited at all by six months, refer to
Shoulder Unit
Poor Rotator Cuff Control
once Transfer seems to be
working reasonably well in
isolation
Inability to activate Deltoid
for an Eccentric Deltoid
Programme
(having checked “Smooth
and Weak” Guidelines and
Eccentric
Deltoid
Exercises for ideas)
Ensure “snugging” is taking place ie the transfer is
working automatically as posterosuperior cuff – if
not revert back to ideas in phase three
Ensure passive range is gained
Isometrics through range
Rotation dissociation (cuff control without
additional
muscle
assistance
or
scapula
movement) through range with decreasing levels
of support and increasing resistance
Slow progression through theraband resistances
(e.g. Yellow/white tend to bias cuff and green tend
to incorporate deltoid)
Ensure there is innervation to Deltoid – i.e. check
for history of nerve damage
Try activating a static contraction at low level to
give patient feedback as to which muscle should
be working
Ensure the humeral head is located beneath the
acromion in passive elevation
Try to maximize passive ER at 90 degrees flexion,
to ensure the position is encouraging anterior
Deltoid activity
Ensure that at least 100 degrees passive flexion
can be achieved with ease, and more if possible,
as in positions lower than 90 degrees, the weight
of the limb acting through a longer lever against
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
gravity will increase the work of Deltoid
If still concerned, refer to Shoulder Unit
Poor Scapular Control
Work on scapular setting through range without
pec and/or lat overactivity
Try closed chain exercises to increase
proprioception
Consider prone lying to develop control/awareness
Poor Core Stability
Develop patient appropriate stability programme
Secondary
‘frozen’ Maintain passive ROM as able – specifically in
shoulder
flexion
Use manual mobilizations if appropriate
Patient
exercising
too Education on pacing, risks of flare-up scenario
vigorously
Poor patient compliance Set functional based goals
with HEP
Return to ADL too soon
Reduce activity levels
Cervical/thoracic referred Assess and treat
pain
Altered neurodynamics
Assess and treat
Many thanks for your help
The Shoulder Unit, RNOH
References of interest:
Iannotti J, et al (2006) ‘Latissimus Dorsi Tendon Transfer for Irreparable Posterosuperior
Rotator Cuff Tears: Factors Affecting Outcome,’ The Journal of Bone and Joint Surgery
(American);88:342-348.
- This (albeit small study) suggests that there is a better clinical result when there is
synchronous contraction of the transfer present with ER and flexion
Aoki M, et al (1996) ‘Transfer of Latissimus Dorsi for Irreparable Rotator-Cuff Tears’ The
Journal of Bone and Joint Surgery [Br];78-B:761-6.
-
Again, it is noted that the patients with the poorer results demonstrated nonsynergistic action of the transferred Latissimus Dorsi and the supraspinatus
Gerber (1992) ‘Latissimus Dorsi Transfer for the Treatment of Irreparable Tears of the
Rotator Cuff’, Clinical Orthopaedics and Related Research: 275: 152-60
Holt M, et al ‘GOST3: Guide for Orthopaedic Surgeons and Therapists’, 3rd Ed, Liverpool
Upper Limb Unit and South Manchester University Hospitals Trust, Biomet-Merck.
- Very useful resource for sample exercises especially glenohumeral rotation control
and closed kinetic chain. Contact Biomet-Merck for copies.
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Kibler W B, et al (2001) 'Shoulder rehabilitation strategies, guidelines and practice',
Orthopaedic Clinics of North America, 32, 3, 527-538.
McMullen J and Uhl T, (2000) 'A kinetic chain approach for shoulder rehabilitation', Journal
of Athletic Training, 35, 3, 329-337.
2008 Tania Douglas
Updated – May 2009 (review date May 2011)
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science