Ruth Delaney | Post-Op Shoulder Rehabilitation
Post-Op Shoulder Rehabilitation

A message from Ms. Delaney about you shoulder rehab:

 

"Shoulder rehab is not easy.  It takes time, effort and dedication from you, the patient, and your physiotherapist as well as everyone around you.  Recovery is not a straight-line graph, there are ups and downs, but as long as you put in the effort you will get there in the end.  I know this, because I myself have had multiple shoulder surgeries.   Yes, that is a photo of me doing my best at my rehab.  I've been there.  I empathise with you when you are struggling and I celebrate with you when you are making great progress.

 

Ultimately, the outcome from your shoulder surgery depends on a team effort between me and you.  I will give my very best efforts in performing your surgery to the highest possible standard, and then your end of the bargain is to work as hard as you can on your post-op rehab!"

 

 

The following are Ms. Delaney's standard post-operative physiotherapy protocols, along with the physiotherapy prescription used to communicate effectively with the physiotherapist what the preferred rehabilitation is at any given stage. Each patient is an individual, and protocols will often be tailored to an individual's unique circumstances. These are a general guide to the rehabilitation process from each surgery.

Physiotherapy Prescription

Physiotherapy Prescription - Shoulder

 

Patient name:                                                            Date:                                                    .

 

Diagnosis:                                                                                                                                  .

 

Home exercise programme ( )                                                        Aquatic therapy ( ) 

 

Range of Motion:                                                                 Stretching:

Passive                                                                                   Gentle PROM ( )

None ( )                                                                                  Aggressive PROM ( )

Full ( )                                                                                    Scapular mobilization ( )

Forward Flexion ( )                                                               Other:                                         .

Scaption ( )

External Rotation ( )                                                             Strengthening:

Internal Rotation ( )                                                             Periscapular stabilisers ( )

                                                                                                Isometrics ( )

Active-assisted                                                                        Rotator cuff ( )

None ( )                                                                                            Anterior Deltoid ( )

Full ( )                                                                                   

Forward Flexion ( )                                                               Modalities:

Scaption ( )                                                                               Discretion of therapist ( )

External Rotation ( )                                                             Ultrasound ( )

Internal Rotation ( )                                                             Iontophoresis ( )

                                                            Cryotherapy ( )

                                                                                                Electric stimulation ( )

Active                                                                                      Dry needling ( )

None ( )                                                                                  Deep tissue massage ( )

Full ( )

Pendulums ( )                                                                       Sling/brace:

Forward Flexion ( )                                                               Full time ( )

Scaption ( )                                                                            When in public ( )

External Rotation ( )                                                             Comfort only ( )

Internal Rotation ( )                                                             Wean as tolerated ( )

 

Duration of therapy:                     times per week, for                         weeks

 

Signature:                                                                      .

AC Joint Reconstruction Protocol

AC Joint Reconstruction Protocol (from shoulderdoc.co.uk)

Post op

Day 1 - 3 weeks

Level 1 Exercises

Sling for 3 weeks (athletes can wean off sooner under guidance

of club therapist)

Teach axillary hygiene

Teach postural awareness and scapular setting

Core stability exercises as appropriate)

Proprioceptive exercises (minimal weightbearing below 90

degrees)

Active assisted flexion as comfortable

Active assisted external rotation as comfortable

Do not force or stretch

3 - 6 weeks

Level 2-3 exercises

Wean off sling

Progress active assisted to active ROM as comfortable

Do not force or stretch

6 - 12 Weeks

Progress Level 3+

exercises

Regain scapula & glenohumeral stability working for shoulder

joint control rather than range

Gradually increase ROM

Strengthen

Increase proprioception through open & closed chain exercise

Progress core stability exercises

Incorporate sports-specific rehabilitation

Plyometrics and pertubation training

Milestones

Week 6 Active elevation to pre op level

Week 12 Minimum 80% range of external rotation compared to

asymptomatic side

Normal movement patterns throughout range

Failure to achieve

milestones

Referral to surgeon

 

 

Return to functional activities

Return to work Sedentary job: as tolerated

Manual job: 3 months

Driving 6-8 weeks

Swimming Breaststroke: 6 weeks

Freestyle: 12 weeks

Golf 3 Months

Lifting Light lifting can begin at 3 weeks. Avoid lifting heavy

items for 3 months.

Contact Sport E.g. Horse riding, football, martial arts, racket sports

and rock climbing: 3 months

Bankart Procedure Protocol

Arthroscopic or Open Anterior Stabilisation (Bankart repair) Protocol:

 

The intent of this protocol is to provide the physiotherapist with a guideline of the post-operative rehabilitation course of a patient who has undergone an open or arthroscopic Bankart procedure. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist has a query or concern regarding the progression of a post-operative patient, he or she should consult with the referring surgeon.

Progression to the next phase is based on Clinical Criteria and/or Time Frames as Appropriate.

 

Phase I – Immediate Post Surgical Phase (Day 1-21):

 

Goals:

  • Protect the surgical repair
  • Diminish pain and inflammation
  • Enhance scapular function
  • Achieve appropriate range of motion (ROM)

 

Precautions:

  • Remain in sling, only removing for showering and elbow/wrist ROM
  • Patient education regarding avoidance of abduction / external rotation activity to avoid anterior inferior capsule stress
  • No Active Range of Motion (AROM) of shoulder
  • No lifting of objects with operative shoulder
  • Keep incisions clean and dry up until Day 14

 

Weeks 1-3:

  • Sling at all times except where indicated above
  • PROM/AROM elbow, wrist and hand only
  • Normalize scapular position, mobility, and stability
  • Sleep with sling supporting operative shoulder
  • Shower with arm held at the side in an internally rotated position (hand on belly)
  • Cryotherapy for pain and inflammation
  • Patient education: posture, joint protection, positioning, hygiene, etc.

 

Phase II – Protection Phase/PROM (Weeks 4 and 5):

 

Goals:

  • Gradually restore PROM of shoulder
  • Do not overstress healing tissue

 

Precautions:

  • Follow surgeon’s specific PROM restrictions - primarily for external rotation
  • No shoulder AROM or lifting

 

Criteria for progression to the next phase:

  • Full flexion and internal rotation PROM
  • PROM 30 degrees of external rotation at the side

 

Weeks 4-5

  • Continue use of sling until at least end of week 4 (see patient-specific instructions)
  • PROM (gentle), unless otherwise noted by surgeon
  • Full flexion and elevation in the plane of the scapula

  • Full Internal rotation

  • External rotation to 30 degrees at 20 degrees abduction, to 30 degrees at

90 degrees abduction

  • Pendulums
  • Sub maximal pain free rotator cuff isometrics in neutral
  • Continue cryotherapy as needed
  • Continue all precautions and joint protection

 

Phase III – Intermediate phase/AROM (Week 6 - Week 10):

 

Goals:

  • Continue to gradually increase external rotation
  • Full AROM
  • Independence with ADL’s

 

Precautions:

  • Wean from Sling – often by end of week 4, always by end of week 6 at latest
  • No aggressive ROM / stretching
  • No lifting with affected arm
  • No strengthening activities

 

 

Criteria for progression to the next phase:

  • Able to begin gentle external rotation stretching in the 90/90 position
  • Full ROM restored in all other planes

 

Weeks 6 - 10

  • PROM (gentle), unless otherwise noted by surgeon

    • - ER to 30-50 degrees at 20 degrees abduction,
    • - ER to 45 degrees at 90 degrees abduction
  • Begin AROM of shoulder
    • - Progress to full AROM in gravity resisted positions
  • Begin implementing more aggressive posterior capsular stretching
    • - Cross arm stretch

      • - Side lying internal rotation stretch

      • - Posterior/inferior gleno-humeral joint mobilization
    • Enhance pectoralis minor length
    • Scapular retractor strengthening
    • Continue cryotherapy as necessary

 

Phase IV - Strengthening Phase (Week 10 – Week 16)

 

Goals:

  • Continue to increase external rotation PROM gradually
  • Maintain full non-painful AROM
  • Normalize muscular strength, stability and endurance
  • Gradually progressed activities with ultimate return to full functional activities

Precautions:

  • Strengthening to begin ONLY after approval by surgeon

- timing of strengthening may vary on an individual case-by-case basis

  • Do not stress the anterior capsule with aggressive overhead strengthening
  • Avoid contact sports/activities

 

Weeks 10-12

  • Continue stretching and PROM
    • - ER to 65 degrees at 20 degrees abduction
    • - ER to 75 degrees at 90 degrees abduction, unless otherwise noted by surgeon.
  • Begin gentle isotonic and rhythmic stabilization techniques for rotator cuff musculature strengthening (open and closed chain)

Weeks 12-16

  • Continue stretching and PROM
    • - all planes to tolerance
  • Continue strengthening progression program

 

 

Phase V – Return to activity phase (Week 16 - Week 24)

 

Goals:

  • Gradual return to strenuous work activities
  • Gradual return to recreational activities
  • Gradual return to sports activities

 

Precautions:

  • Do not begin throwing, or overhead athletic moves until 6 months post-op
  • Weight lifting:

 -  Avoid wide grip bench press

 -  No military press or lat pulls behind the head. Be sure to “always see your elbows”

 

Weeks 12-16

  • Continue progressing stretching and strengthening program
  • Can begin generalized upper extremity weight lifting with low weight, and high repetitions, being sure to follow weight lifting precautions as above

 

Weeks 16-20

  • Can begin golf, tennis (no serving until 6 months.), etc.
  • May initiate interval sports program if appropriate

 

Criteria to return to sports and recreational activities:

  • Surgeon clearance
  • Pain free shoulder function without signs of instability
  • Restoration of adequate ROM for desired activity
  • Full strength as compared to the non operative shoulder (tested via hand held

dynamometry)

 

 

We have worked extensively with some very talented massage therapists who can help with myofascial pain, muscular tightness and neck and shoulder discomfort.  Peter Mathews has partnered with us to help many of our patients (as well as ourselves!).

 

Biceps Tenodesis Protocol

Modified from the protocol developed at Boston Shoulder Institute by the

Massachusetts General Hospital and Brigham & Women’s Hospital Shoulder Services.

 

Biceps Tenodesis Protocol:

The intent of this protocol is to provide the physiotherapist with a guideline of the post-operative rehabilitation course of a patient who has undergone a biceps tenodesis. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist has a query or concern regarding the progression of a post-operative patient, he or she should consult with the referring surgeon.

A patient may undergo a biceps tenodesis in conjunction with another procedure such as rotator cuff repair or shoulder arthroplasty – in that case, the more conservative rehabilitation protocol overrides this isolated biceps tenodesis protocol.

If a subacromial decompression is performed with a biceps tenodesis, again the more conservative rehabilitation protocol is used, which in that case is this biceps tenodesis protocol.

Progression to the next phase based on Clinical Criteria and/or Time Frames as appropriate.

 

Phase I – Passive Range of Motion Phase

(start at 2 weeks post-operatively)

 

Goals:

 

  • Minimize shoulder pain and inflammatory response
  • Achieve gradual restoration of passive range of motion (PROM)
  • Enhance/ensure adequate scapular function

 

Precautions:

 

  • No active range of motion (AROM) of the elbow
  • No excessive external rotation range of motion (ROM) / stretching. Stop when

you feel the first end feel.

  • Use of a sling at all times until 3 weeks post-operatively to minimize activity of biceps
  • Ace wrap upper forearm as needed for swelling control
  • No lifting of objects with operative shoulder
  • Keep incisions clean and dry
  • No friction massage to the proximal biceps tendon / tenodesis site
  • Patient education regarding limited use of upper extremity despite the potential

lack of or minimal pain or other symptoms

 

Activity:

 

  • Shoulder pendulum hang exercise
  • PROM elbow flexion/extension and forearm supination/pronation
  • AROM wrist/hand
  • Begin shoulder PROM all planes to tolerance /do not force any painful motion
  • Scapular retraction and clock exercises for scapula mobility progressed to

scapular isometric exercises

  • Ball squeezes
  • Sleep with sling as needed supporting operative shoulder, place a towel under the

elbow to prevent shoulder hyperextension

  • Frequent cryotherapy for pain and inflammation
  • Patient education regarding postural awareness, joint protection, positioning,

hygiene, etc.

 

Criteria for Progression to Next Phase (II):

 

  • Appropriate healing of the surgical incision
  • Full PROM of shoulder and elbow
  • Completion of phase I activities without pain or difficulty

Phase II – Active Range of Motion Phase

(start approximately post op week 4)

 

Goals:

 

  • Minimize shoulder pain and inflammatory response
  • Achieve gradual restoration of AROM
  • Begin light waist level functional activities
  • Wean out of sling by the end of the 2-3 postoperative week
  • Return to light computer work

 

 

Precautions:

 

  • No lifting with affected upper extremity
  • No friction massage to the proximal biceps tendon / tenodesis site

 

Activity:

 

  • Begin gentle scar massage of anterior axillary incision
  • Progress shoulder PROM to active assisted range of motion (AAROM) and

AROM all planes to tolerance

  • Lawn chair progression for shoulder
  • Active elbow flexion/extension and forearm supination/pronation (No resistance)
  • Glenohumeral, scapulothoracic, and trunk joint mobilizations as indicated (Grade

I - IV) when ROM is significantly less than expected. Mobilizations should be

done in directions of limited motion and only until adequate ROM is gained.

  • Begin incorporating posterior capsular stretching as indicated
  • Cross body adduction stretch
  • Side lying internal rotation stretch (sleeper stretch)
  • Continued Cryotherapy for pain and inflammation
  • Continued patient education: posture, joint protection, positioning, hygiene, etc.

 

Criteria for Progression to Next Phase (III):

 

  • Restore full AROM of shoulder and elbow
  • Appropriate scapular posture at rest and dynamic scapular control with ROM and

functional activities

  • Completion of phase II activities without pain or difficulty

 

Phase III - Strengthening Phase

(start at approximately post-op week 8)

 

Goals:

 

  • Normalize strength, endurance, neuromuscular control
  • Return to chest level full functional activities

 

Precautions:

 

  • Do not perform strengthening or functional activities in a given plane until the

patient has near full ROM and strength in that plane of movement

  • Patient education regarding a gradual increase in shoulder activities
  • No resisted biceps curls or resisted supination until Phase IV/10 weeks

 

 

Activity:

 

  • Continue A/PROM of shoulder and elbow as needed/indicated
  • Begin rhythmic stabilization drills
  • External rotation (ER) / Internal Rotation (IR) in the scapular plane
  • Flexion/extension and abduction/adduction at various angles of elevation
  • Initiate balanced strengthening program
  • Initially in low dynamic positions
  • Gain muscular endurance with high repetition of 30-50, low resistance (1-3 lbs)
  • Exercises should be progressive in terms of muscle demand / intensity,

shoulder elevation, and stress on the anterior joint capsule

  • Nearly full elevation in the scapula plane should be achieved before

beginning elevation in other planes

  • All activities should be pain free and without compensatory/substitution

patterns

  • Exercises should consist of both open and closed chain activities
  • No heavy lifting should be performed at this time
    • Initiate full can scapular plane raises with good mechanics
    • Initiate ER strengthening using exercise tubing at 30° of abduction     (use towel roll)
    • Initiate sidelying ER with towel roll
    • Initiate manual resistance ER supine in scapular plane (light resistance)
    • Initiate prone rowing at 30/45/90 degrees of abduction to neutral arm position
    • Begin subscapularis strengthening to focus on both upper andlower segments
  • Push up plus (wall, counter, knees on the floor, floor)
  • Cross body diagonals with resistive tubing
  • IR resistive band (0, 45, 90 degrees of abduction
  • Forward punch
  • Continued cryotherapy for pain and inflammation as needed

 

Criteria for Progression to Next Phase (IV):

 

  • Appropriate rotator cuff and scapular muscular performance for chest level

activities

  • Completion of phase III activities without pain or difficulty

 

Phase IV – Advanced Strengthening Phase

(start at approximately post-op week 10)

 

Goals:

 

  • Continue stretching and PROM as needed/indicated
  • Maintain full non-painful AROM
  • Return to full strenuous work activities
  • Return to full recreational activities

 

Precautions:

 

  • Avoid excessive anterior capsule stress
  • With weight lifting, avoid military press and wide grip bench press.

 

Activity:

 

  • Continue all exercises listed above
  • Initiate biceps curls with light resistance, progress as tolerated
  • Initiate resisted supination/pronation
  • Progress isotonic strengthening if patient demonstrates no compensatory

strategies, is not painful, and has no residual soreness

  • Strengthening overhead if ROM and strength below 90 degree elevation is good
  • Continue shoulder stretching and strengthening at least four times per week
  • Progressive return to upper extremity weight lifting program emphasizing the

larger, primary upper extremity muscles (deltoid, latissimus dorsi, pectoralis

major)

  • Start with relatively light weight and high repetitions (15-25)
  • May initiate pre injury level activities/ vigorous sports if appropriate / cleared by

surgeon

 

Criteria for return to overhead work and sport activities:

 

  • Clearance from surgeon
  • No complaints of pain
  • Adequate ROM, strength and endurance of rotator cuff and scapular musculature

for task completion

• Compliance with continued home exercise programme

Latarjet Procedure Protocol

Modified from the protocol developed at Boston Shoulder Institute by the

Massachusetts General Hospital and Brigham & Women’s Hospital Shoulder Services.

 

Latarjet Procedure (open anterior glenoid reconstruction) Protocol:

The intent of this protocol is to provide the physiotherapist with a guideline of the post-operative rehabilitation course of a patient who has undergone a Latarjet procedure. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist has a query or concern regarding the progression of a post-operative patient, he or she should consult with the referring surgeon.

Progression to the next phase based on Clinical Criteria and/or Time Frames as appropriate.

 

Phase I – Immediate Post Surgical Phase

(Weeks 1- 3)

 

Goals:

 

  • Minimize shoulder pain and inflammatory response
  • Protect the integrity of the surgical repair
  • Achieve gradual restoration of passive range of motion (PROM)
  • Enhance/ensure adequate scapular function

 

Precautions:

 

  • No active range of motion (AROM) of the operative shoulder
  • No excessive external rotation range of motion (ROM) / stretching. Stop at first

end feel felt

  • Remain in sling, only removing for showering. Shower with arm held at side
  • No lifting of objects with operative shoulder
  • Keep incisions clean and dry
  • Patient education regarding limited use of upper extremity despite the potential

lack of or minimal pain or other symptoms

Activity:

 

  • Arm in sling except when performing distal upper extremity exercises
  • (PROM)/Active-Assisted Range of Motion (AAROM)/ (AROM) elbow and

wrist/hand

  • Begin shoulder PROM at 2 weeks (do not force any painful motion)
  • Forward flexion and elevation to tolerance
  • Abduction in the plane of the scapula to tolerance
  • Internal rotation (IR) to 45 degrees at 30 degrees of abduction
  • External rotation (ER) in the plane of the scapula from 0-25 degrees; begin at

30-40 degrees of abduction; respect anterior capsule tissue integrity with ER

range of motion

  • Scapular clock exercises progressed to scapular isometric exercises
  • Ball squeezes
  • Sleep with sling supporting operative shoulder, place a towel under the elbow to

prevent shoulder hyperextension

  • Frequent cryotherapy for pain and inflammation
  • Patient education regarding posture, joint protection, positioning, hygiene, etc.

 

Criteria for progression to next phase (II):

 

  • Adherence to the precautions and immobilization guidelines
  • Achieved at least 100 degrees of passive forward elevation and 30 degrees of

passive external rotation at 20 degrees abduction

  • Completion of phase I activities without pain or difficulty

 

Phase II – Intermediate Phase/ROM

(approximately Week 4-9)

 

Goals:

 

  • Minimize shoulder pain and inflammatory response
  • Protect the integrity of the surgical repair
  • Achieve gradual restoration of (AROM)
  • To be weaned from the sling by the end of week 4
  • Begin light waist level activites

 

Precautions:

 

  • No active movement of shoulder till adequate PROM with good mechanics
  • No lifting with affected upper extremity
  • No excessive external rotation ROM / stretching
  • Do not perform activities or strengthening exercises that place an excessive load

on the anterior capsule of the shoulder joint (i.e. no pushups, pec flys, etc..)

  • Do not perform scaption with internal rotation (empty can) during any stage of

rehabilitation due to the possibility of impingement

Early Phase II (approximately week 4):

 

  • Progress shoulder PROM (do not force any painful motion)
  • Forward flexion and elevation to tolerance
  • Abduction in the plane of the scapula to tolerance
  • IR to 45 degrees at 30 degrees of abduction
  • ER to 0-45 degrees; begin at 30-40 degrees of abduction; respect anterior

capsule tissue integrity with ER range of motion; seek guidance from

intraoperative measurements of external rotation ROM)

  • Glenohumeral joint mobilizations as indicated (Grade I, II) when ROM is

significantly less than expected. Mobilizations should be done in directions of

limited motion and only until adequate ROM is gained.

  • Address scapulothoracic and trunk mobility limitations. Scapulothoracic and

thoracic spine joint mobilizations as indicated (Grade I, II, III) when ROM is

significantly less than expected. Mobilizations should be done in directions of

limited and only until adequate ROM is gained.

  • Begin incorporating posterior capsular stretching as indicated
  • Cross body adduction stretch
  • Continued Cryotherapy for pain and inflammation
  • Continued patient education: posture, joint protection, positioning, hygiene, etc.

 

Late Phase II (approximately Week 6):

 

  • Progress shoulder PROM (do not force any painful motion)
  • Forward flexion, elevation, and abduction in the plane of the scapula to

tolerance

  • IR as tolerated at multiple angles of abduction
  • ER to tolerance; progress to multiple angles of abduction once >/= 35 degrees

at 0-40 degrees of abduction

  • Glenohumeral and scapulothoracic joint mobilizations as indicated (Grade I-IV as

appropriate)

  • Progress to AA/AROM activities of the shoulder as tolerated with good shoulder

mechanics (i.e. minimal to no scapulathoracic substitution with up to 90-110

degrees of elevation.)

  • Begin rhythmic stabilization drills
  • ER/IR in the scapular plane
  • Flexion/extension and abduction/adduction at various angles of elevation
  • Continue AROM elbow, wrist, and hand
  • Strengthen scapular retractors and upward rotators
  • Initiate balanced AROM / strengthening program
  • Initially in low dynamic positions
  • Gain muscular endurance with high repetition of 30-50, low resistance 1-3 lbs)
  • Exercises should be progressive in terms of muscle demand / intensity, shoulder elevation, and stress on the anterior joint capsule
    • Nearly full elevation in the scapula plane should be achieved before beginning elevation in other planes
    • All activities should be pain free and without substitution patterns
    • Exercises should consist of both open and closed chain activities
    • No heavy lifting or plyometrics should be performed at this time
  • Initiate full can scapular plane raises to 90 degrees with good mechanics
  • Initiate ER/IR strengthening using exercise tubing at 0° of abduction (use towel roll)
  • Initiate sidelying ER with towel roll
  • Initiate manual resistance ER supine in scapular plane (light resistance)
  • Initiate prone rowing at 30/45/90 degrees of abduction to neutral arm position
  • Continued cryotherapy for pain and inflammation
  • Continued patient education: posture, joint protection, positioning, hygiene, etc.

 

Criteria for progression to next phase (III):

 

  • Passive forward elevation at least 155 degrees
  • Passive external rotation within 8-10 degrees of contralateral side at 20 degrees

abduction

  • Passive external rotation at least 75 degrees at 90 degrees abduction
  • Active forward elevation at least 145 degrees with good mechanics
  • Appropriate scapular posture at rest and dynamic scapular control with ROM and

functional activities

  • Completion of phase II activities without pain or difficulty

 

Phase III - Strengthening Phase

(approximately Week 10 – Week 15)

 

Goals:

 

  • Normalize strength, endurance, neuromuscular control
  • Return to chest level full functional activities
  • Gradual and planned buildup of stress to anterior joint capsule

 

Precautions:

 

  • Do not overstress the anterior capsule with aggressive overhead activities /

strengthening

  • Avoid contact sports/activities until at least week 16
  • Do not perform strengthening or functional activities in a given plane until the

patient has near full ROM and strength in that plane of movement

  • Patient education regarding a gradual increase to shoulder activities

 

Activity:

 

  • Continue A/PROM as needed/indicated
  • Initiate biceps curls with light resistance, progress as tolerated
  • Initiate gradually progressed strengthening for pectoralis major and minor; avoid

positions that excessively stress the anterior capsule

  • Progress subscapularis strengthening to focus on both upper and lower segments
  • Push up plus (wall, counter, knees on the floor, floor)
  • Cross body diagonals with resistive tubing
  • IR resistive band (0, 45, 90 degrees of abduction
  • Forward punch

 

Criteria for progression to next phase (IV):

 

  • Passive forward elevation is within normal range
  • Passive external rotation at all angles of abduction is within normal range
  • Active forward elevation is within normal range with good mechanics
  • Appropriate rotator cuff and scapular muscular performance for chest level

activities

  • Completion of phase III activities without pain or difficulty

 

Phase IV - Overhead Activities Phase / Return to activity phase

(approximately Week 16-20)

 

Goals:

 

  • Continue stretching and PROM as needed/indicated
  • Maintain full non-painful AROM
  • Return to full strenuous work activities
  • Return to full recreational activities

 

Precautions:

 

  • Avoid excessive anterior capsule stress
  • With weight lifting, avoid tricep dips, wide grip bench press; no military press

or lat pulls behind the head. Be sure to “always see your elbows”

  • Do not begin throwing, or overhead athletic moves until 4 months post-op or

cleared by surgeon

 

Activity:

 

  • Continue all exercises listed above
  • Progress isotonic strengthening if patient demonstrates no compensatory

strategies, is not painful, and has no residual soreness

  • Strengthening overhead if ROM and strength below 90 degree elevation is good
  • Continue shoulder stretching and strengthening at least four times per week
  • Progressive return to upper extremity weight lifting program emphasizing the

larger, primary upper extremity muscles (deltoid, latissimus dorsi, pectoralis

major)

  • Start with relatively light weight and high repetitions (15-25)
  • May do pushups as long as the elbows do not flex past 90 degrees
  • May initiate plyometrics/interval sports program if appropriate/cleared by physio and surgeon
  • Can begin generalized upper extremity weight lifting with low weight, and high

repetitions, being sure to follow weight lifting precautions.

  • May initiate pre injury level activities/ vigorous sports if appropriate / cleared by surgeon

 

Criteria to return to overhead work and sport activities:

 

  • Clearance from surgeon
  • No complaints of pain or instability
  • Adequate ROM for task completion
  • Full strength and endurance of rotator cuff and scapular musculature for task

completion

  • Regular completion of continued home exercise programme

 

Pectoralis Major Repair Protocol

 

Pectoralis Major Repair Protocol:

From www.shoulderdoc.co.uk

Pre-op

  • ROM Exercises; should have full range of motion pre-op • Maximise shoulder strength of deltoid, intact cuff muscles and scapula stabilisers.

 

Day 1 - 3 weeks

  • Shoulder immobiliser
  • Closed chain exercise as tolerated
  • Passive / Active Assisted ROM in safe zone (30 degree lateral rotation, 90 flxn, no extn) as tolerated • Do not force or stretch • Avoid pendular exercises and stick exercises • Wrist/hand/finger exercises • Elbow flex/ext, pro/supination • Scapula setting exercises • (Level 1 Exercises)

 

3-6 weeks:

  • Do not force or stretch
  • Gentle isometric exercises in neutral as pain allows • Wean off sling • Progress to Open Chain Exercises in  safe zone (30 degree lateral rotation, 90 flexion, no extension)  as tolerated • Do not force or stretch

 

 

6 weeks +:

 

  • Progress to open chain exercises in all ranges as tolerated • motor control prior to any progressive graded resistance • sports-specific rehabilitation • Avoid hyperextending in bench press or flys or pec-deck.
  • Avoid high weights with low reps and warm up slowly •  (Level 3 Exercises)

Shoulder Replacement Protocol

Modified from the protocol developed at Boston Shoulder Institute by the

Massachusetts General Hospital and Brigham & Women’s Hospital Shoulder Services.

 

Total Shoulder Arthroplasty/Hemiarthroplasty Protocol:

The intent of this protocol is to provide the physiotherapist with a guideline of the post-operative rehabilitation course of a patient who has undergone an anatomic total shoulder arthroplasty or a hemiarthroplasty. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist has a query or concern regarding the progression of a post-operative patient, he or she should consult with the referring surgeon.

Progression to the next phase based on Clinical Criteria and/or Time Frames as appropriate.

 

Passive Range of Motion (PROM): PROM for all patients having undergone a TSA/HHR should be defined as ROM that is provided by an external source (therapist, instructed family member, or other qualified personnel) with the intent to gain ROM without placing undue stress on either soft tissue structures and/or the surgical repair.

PROM is not stretching!!!

Phase I – Immediate Post Surgical Phase:

 

Goals:

 

  • Allow healing of soft tissue
  • Maintain integrity of replaced joint
  • Gradually increase passive range of motion (PROM) of shoulder; restore active range of motion (AROM) of elbow/wrist/hand
  • Reduce pain and inflammation
  • Reduce muscular inhibition
  • Independent with activities of daily living (ADLs) with modifications while maintaining the integrity of the replaced joint.

 

 

Precautions:

 

  • Sling should be worn continuously for 4 weeks
  • While lying supine, a small pillow or towel roll should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule stretch / subscapularis stretch. When lying supine patient should be instructed to always be able to visualize their elbow. This ensures they are not extending their shoulder past neutral. This should be maintained for 6-8 weeks post-operatively.
  • Avoid shoulder AROM.
  • No lifting of objects
  • No excessive shoulder motion behind back, especially into internal rotation (IR)
  • No excessive stretching or sudden movements (particularly external rotation (ER))
  • No supporting of body weight by hand on involved side
  • Keep incision clean and dry (no soaking for 2 weeks)
  • No driving for 4 weeks

 

 

Post-Operative Day (POD) #1 (in hospital):

 

  • Passive forward flexion in supine to tolerance
  • Gentle ER in scapular plane to available PROM (as documented in operative note) – usually around 30°

(Attention:DO NOT produce undue stress on the anterior joint capsule, particularly with shoulder in extension)

  • Passive IR to chest
  • Active distal extremity exercise (elbow, wrist, hand)
  • Pendulum exercises
  • Frequent cryotherapy for pain, swelling, and inflammation management
  • Patient education regarding proper positioning and joint protection techniques

 

Early Phase I (out of hospital):

 

  • Continue above exercises
  • Begin scapula musculature isometrics / sets (primarily retraction)
  • Continue active elbow ROM
  • Continue cryotherapy as much as able for pain and inflammation management

 

Late Phase I:

 

  • Continue previous exercises
  • Continue to progress PROM as motion allows
  • Begin assisted flexion, elevation in the plane of the scapula, ER, IR in the scapular plane
  • Progress active distal extremity exercise to strengthening as appropriate

 

 

 

Criteria for progression to the next phase (II):

 

If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.

 

  • Tolerates PROM program
  • Has achieved at least 90° PROM forward flexion and elevation in the scapular plane.
  • Has achieved at least 30° PROM ER in plane of scapula
  • Has achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction

 

 

Phase II – Range of Motion, Scapular Strengthening Phase:

 

(Not to begin before 4-6 Weeks post-surgery to allow for appropriate soft tissue healing)

 

Goals:

 

  • Restore full passive ROM
  • Gradually restore active motion
  • Control pain and inflammation
  • Allow continue healing of soft tissue
  • Do not overstress healing tissue
  • Re-establish dynamic shoulder stability

 

Precautions:

 

  • Wean from sling at 4 weeks post-op
  • While lying supine a small pillow or towel should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule stretch
  • In the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/activity against gravity in standing.
  • No heavy lifting of objects (no heavier than coffee cup)
  • No supporting of body weight by hand on involved side
  • No sudden jerking motions

 

Early Phase II:

 

  • Continue with PROM, active assisted range of motion (AAROM)
  • Begin active flexion, IR, ER, elevation in the plane of the scapula pain free ROM
  • AAROM pulleys (flexion and elevation in the plane of the scapula) – as long as greater than 90° of PROM
  • Begin shoulder sub-maximal pain-free shoulder isometrics in neutral
  • Scapular strengthening exercises as appropriate
  • Begin assisted horizontal adduction
  • Gentle glenohumeral and scapulothoracic joint mobilizations as indicated
  • Initiate glenohumeral and scapulothoracic rhythmic stabilization
  • Continue use of cryotherapy for pain and inflammation.

 

Late Phase II:

 

• Progress scapular strengthening exercises

 

Criteria for progression to the next phase (III):

 

If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.

  • Tolerates P/AAROM, isometric program
  • Has achieved at least 140° PROM forward flexion and elevation in the scapular plane.
  • Has achieved at least 60+° PROM ER in plane of scapula
  • Has achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction
  • Able to actively elevate shoulder against gravity with good mechanics to 100°

 

 

Phase III – Early Strengthening:

 

(Not to begin before 8 Weeks post-surgery to allow for appropriate soft tissue healing and to ensure adequate ROM)

 

Goals:

 

  • Gradual restoration of shoulder strength, power, and endurance
  • Optimize neuromuscular control
  • Gradual return to functional activities with involved upper extremity

 

Precautions:

 

  • No heavy lifting of objects (no heavier than 3 kg.)
  • No sudden lifting or pushing activities
  • No sudden jerking motions

 

Early Phase III:

 

  • Progress AROM exercise / activity as appropriate
  • Advance PROM to stretching as appropriate

• Continue PROM as needed to maintain ROM

  • Initiate assisted shoulder IR behind back stretch
  • Resisted shoulder IR, ER in scapular plane
  • Begin light functional activities
  • Begin progressive supine active elevation strengthening (anterior deltoid) with light weights (0.5-1.5 kg) at variable degrees of elevation.

 

Late Phase III:

 

  • Resisted flexion, elevation in the plane of the scapula, extension (therabands/sport cords)
  • Continue progressing IR, ER strengthening
  • Progress IR stretch behind back from AAROM to AROM as ROM allows

(Pay particular attention as to avoid stress on the anterior capsule.)

 

Criteria for progression to the next phase (IV):

 

If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.

 

  • Tolerates AA/AROM/strengthening
  • Has achieved at least 140° AROM forward flexion and elevation in the scapular planesupine.
  • Has achieved at least 60+° AROM ER in plane of scapula supine
  • Has achieved at least 70° AROM IR in plane of scapula supine in 30° of

abduction

  • Able to actively elevate shoulder against gravity with good mechanics to at least 120°.

 

Note:(If above ROM are not met then patient is ready to progress if their ROM has plateaued is consistent with outcomes for patients with the given underlying pathology).

 

 

Phase IV – Advanced Strengthening:

 

(Not to begin before 12 Weeks to allow for appropriate soft tissue healing and to ensure adequate ROM, and initial strength)

 

Goals:

 

  • Maintain non-painful AROM
  • Enhance functional use of upper extremity
  • Improve muscular strength, power, and endurance
  • Gradual return to more advanced functional activities
  • Progress weight bearing exercises as appropriate

 

 

Precautions:

 

  • Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures. (Example: no combined ER and abduction above 80° of abduction.)
  • Ensure gradual progression of strengthening

 

Early Phase IV:

 

  • Typically patient is on a home exercise program by this point, to be performed 3-4 times per week.
  • Gradually progress strengthening program
  • Gradual return to moderately challenging functional activities.

 

Late Phase IV (Typically 4-6 months post-op):

  • Return to recreational hobbies, gardening, sports, golf, doubles tennis

Criteria for discharge from supervised physiotherapy:

 

  • Patient able to maintain non-painful AROM
  • Maximized functional use of upper extremity
  • Maximized muscular strength, power, and endurance
  • Patient has returned to advanced functional activities

Reverse Shoulder Replacement Protocol

Modified from the protocol developed at Boston Shoulder Institute by the

Massachusetts General Hospital and Brigham & Women’s Hospital Shoulder Services.

 

Reverse Shoulder Arthroplasty (RSA) Protocol:

General Information:

Reverse or Inverse Total Shoulder Arthroplasty (RSA) is designed specifically for the treatment of: glenohumeral (GH) arthritis when it is associated with irreparable rotator cuff damage or with glenoid morphology that precludes implantation of a conventional or anatomic Total Shoulder Arthroplasty (TSA); complex fractures; revision of a previously failed TSA in which the rotator cuff tendons are deficient or glenoid bone stock is inadequate for implantation of an anatomic glenoid component.

 

The rotator cuff is either absent or minimally involved with the RSA function; therefore, the rehabilitation for a patient following the RSA is different than the rehabilitation following a traditional TSA. The surgeon, physiotherapist and patient need to take this into consideration when establishing the postoperative treatment plan.

 

Important rehabilitation management concepts to consider for a postoperative physical therapy RSA program are:

  • Joint protection: Avoidance of shoulder extension past neutral and the combination of shoulder adduction and internal rotation should be avoided for 6-8 weeks postoperatively to minimise the risk of dislocation.
  • Patients with RSA don’t dislocate with the arm in abduction and external

rotation. They typically dislocate with the arm in internal rotation and

adduction in conjunction with extension. As such, tucking in a shirt or

performing bathroom / personal hygiene with the operative arm / pushing up out of a chair with the operative arm are especially dangerous activities particularly in the immediate peri-operative phase.

  • Deltoid function: Stability and mobility of the shoulder joint is now dependent

  upon the deltoid and periscapular musculature. This concept becomes the

  foundation for the postoperative physical therapy management for a patient who

  has undergone RSA.

  • Function: As with a conventional TSA, maximize overall upper extremity function,

while respecting soft tissue constraints.

  • ROM: Expectation for range of motion gains should be set on a case-by-case basis

depending upon underlying pathology. Normal/full active range of motion of the shoulder joint following RSA is not typically expected

 

The intent of this protocol is to provide the physiotherapist with a guideline of the post-operative rehabilitation course of a patient who has undergone a reverse shoulder arthroplasty (RSA). It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist has a query or concern regarding the progression of a post-operative patient, he or she should consult with the referring surgeon.

 

The scapular planeis defined as the shoulder positioned in 30 degrees of abduction and forward flexion with neutral rotation. ROM performed in the scapular plane should enable appropriate shoulder joint alignment.

 

Shoulder Dislocation Precautions:

  • No shoulder motion behind back. (NO combined shoulder adduction, internal

rotation, and extension.)

  • No glenohumeral (GH) extension beyond neutral.

*Precautions should be implemented for 6-8 weeks postoperatively unless the surgeon specifically advises patient or therapist differently.

 

Surgical Considerations:

  • The surgical approach needs to be considered when devising the postoperative plan of care.
    • Traditionally the RSA procedure is done via a typical deltopectoral approach, which minimizes surgical trauma to the anterior deltoid.
    • Some surgeons perform this procedure via a superior approach, retracting the anterior deltoid from the anterior lateral one third of the clavicle. This allows for superior exposure to the GH joint between the retracted anterior deltoid and the clavicle. Upon surgical closure the anterior deltoid is sutured back to its anatomical location. In these cases early deltoid activity is contraindicated. A variation of the below protocol is recommended for patients who have had a superior approach. These patients should use a sling for 4-6 weeks, should not begin deltoid isometrics for at least four weeks postoperatively, should not begin active range of motion (AROM) flexion for at least six weeks, and should not begin deltoid strengthening for at least 12 weeks post operatively.

 

 

The start of this protocol is delayed 3-4 weeks following RSA for a revision

and/or in the presence of poor bone stock based on the surgeon's assessment of the integrity of the surgical repair. In the case of a delayed start to physical

therapy adjust below timeframes so that day 1 is the first day of physical therapy.

 

Progression to the next phase based on Clinical Criteria and/or Time Frames as appropriate.

 

Phase I – Immediate Post Surgical Phase/Joint Protection (Day 1-6 weeks)

 

Goals:

 

  • Patient and family independent with:
  • Joint protection
  • Passive range of motion (PROM)
  • Assisting with putting on/taking off sling and clothing
  • Assisting with home exercise program (HEP)
  • Cryotherapy
  • Promote healing of soft tissue / maintain the integrity of the replaced joint.
  • Enhance PROM.
  • Restore active range of motion (AROM) of elbow/wrist/hand.
  • Independent with activities of daily living (ADL’s) with modifications.
  • Independent with bed mobility, transfers and ambulation or as per pre-admission status.

 

Phase I Precautions:

 

  • Sling is worn for 4 weeks postoperatively and only removed for exercise and bathing once able. The use of a sling often may be extended for a total of 6 weeks, if the current RSA procedure is a revision surgery.
  • While lying supine, the distal humerus / elbow should be supported by a pillow or towel roll to avoid shoulder extension. Patients should be advised to “always be able to visualize their elbow while lying supine.”
  • No shoulder AROM.
  • No lifting of objects with operative extremity.
  • No supporting of body weight with involved extremity.
  • Keep incision clean and dry (no soaking for 2 weeks)

 

Acute Care Therapy (Day 1 to 4):

 

  • Active/Active Assisted ROM (A/AAROM) of cervical spine, elbow, wrist, and hand
  • Continuous cryotherapy for first 72 hours postoperatively, then frequent application (4-5 times a day for about 20 minutes).
  • Ensure patient is independent in bed mobility, transfers and ambulation
  • Ensure proper sling fit/alignment/ use.
  • Instruct patient in proper positioning, posture, initial home exercise program
  • Provide patient/ family with written home program including exercises and protocol information.

 

Day 5 to 28:

  • Continue all exercises as above
  • Begin pendulums at 2 weeks
  • Begin PROM in supine at 3 weeks
  • Forward flexion and elevation in the scapular plane in supine to 90 degrees.
  • External rotation (ER) in scapular plane to available ROM as indicated by operative findings. Typically around 20-30 degrees.
  • No Internal Rotation (IR) range of motion
  • Frequent (4-5 times a day for about 20 minutes) cryotherapy.

 

Week 5 to 6:

 

  • Begin sub-maximal pain-free deltoid isometrics in scapular plane (avoid shoulder

extension when isolating posterior deltoid.)

  • Progress PROM:
  • Forward flexion and elevation in the scapular plane in supine to 120 degrees.
  • ER in scapular plane to tolerance, respecting soft tissue constraints.
  • Gentle resisted exercise of elbow, wrist, and hand.
  • Continue frequent cryotherapy.

 

Criteria for progression to the next phase (Phase II):

 

  • Tolerates shoulder PROM and isometrics; and, AROM- minimally resistive program for elbow, wrist, and hand.
  • Demonstrates the ability to isometrically activate all components of the deltoid

and periscapular musculature in the scapular plane.

 

Phase II –Active Range of Motion Phase (Week 6 to 12):

 

Goals:

 

  • Continue progression of PROM (full PROM is not expected).
  • Gradually restore AROM.
  • Control pain and inflammation.
  • Allow continued healing of soft tissue / do not overstress healing tissue.
  • Re-establish dynamic shoulder and scapular stability.

 

Precautions:

 

  • Due to the potential of an acromion stress fracture one needs to continuously monitor the exercise and activity progression of the deltoid. A sudden increase of deltoid activity during rehabilitation could lead to excessive acromion stress. A gradually progressive, pain-free programme is essential.
  • Continue to avoid shoulder hyperextension.
  • In the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/activity.
  • Restrict lifting of objects to no heavier than a coffee cup.
  • No supporting of body weight by involved upper extremity.

 

Week 6 to Week 8:

 

  • Continue with PROM programme.
  • At 6 weeks post-op start PROM IR to tolerance (not to exceed 50 degrees) in the scapular plane.
  • Begin shoulder AA/AROM as appropriate.
  • Forward flexion and elevation in scapular plane in supine with progression

       to sitting/standing.

  • ER and IR in the scapular plane in supine with progression to

       sitting/standing.

  • Initiate gentle scapulothoracic rhythmic stabilization and alternating isometrics in supine as appropriate. Minimize deltoid recruitment during all activities / exercises.
  • Progress strengthening of elbow, wrist, and hand.
  • Gentle glenohumeral and scapulothoracic joint mobilizations as indicated (Grade I and II).
  • Continue use of cryotherapy as needed.
  • Patient may begin to use hand of operative extremity for feeding and light activities of daily living including dressing, washing.

 

Week 9 to Week 12:

 

  • Continue with above exercises and functional activity progression.
  • Begin gentle glenohumeral IR and ER sub-maximal pain free isometrics.

 

Criteria for progression to the next phase (Phase III):

 

  • Improving function of shoulder.
  • Patient demonstrates the ability to isotonically activate all components of the

   deltoid and periscapular musculature and is gaining strength.

 

Phase III – Early/Moderate Strengthening (Week 12 +)

 

Goals:

 

  • Enhance functional use of operative extremity and advance functional activities.
  • Enhance shoulder mechanics, muscular strength and endurance.

 

 

Precautions:

 

  • No lifting of objects heavier than 2.7 kg (6 lbs) with the operative upper extremity
  • No sudden lifting or pushing activities.

 

Week 12 to Week 16:

 

  • Begin gentle periscapular and deltoid sub-maximal pain free isotonic strengthening exercises. Begin AROM supine forward flexion and elevation in the plane of the scapula with light weights (1-3lbs. or 0.5-1.4 kg) at varying degrees of trunk elevation as appropriate. (i.e. supine lawn chair progression with progression to sitting/standing).
  • Progress to gentle glenohumeral IR and ER isotonic strengthening exercises in sidelying position with light weight (1-3lbs or 0.5-1.4kg) and/or with light resistance resistive bands or sport cords.
  • Progress to gentle resisted flexion, elevation in standing as appropriate.

 

Phase IV – Continued Home Program (Typically 4 + months post-op):

 

  • Typically the patient is on a home exercise program at this stage to be performed 3-4 times per week with the focus on:
  • Continued strength gains
    • Continued progression toward a return to functional and recreational activities within limits as identified by progress made during rehabilitation and outlined by surgeon and physiotherapist.

 

Criteria for discharge from supervised therapy:

 

  • Able to maintain pain free shoulder AROM demonstrating proper

shoulder mechanics. (Typically 80 – 120 degrees of elevation with functional ER

of about 30 degrees.)

  • Typically able to complete light household and work activities.

 

Rotator Cuff Repair Protocol

 

Modified from the protocol developed at Boston Shoulder Institute by the

Massachusetts General Hospital and Brigham & Women’s Hospital Shoulder Services.

 

Arthroscopic Rotator Cuff Repair Protocol:

The intent of this protocol is to provide the physiotherapist with a guideline of the post-operative rehabilitation course of a patient who has undergone an arthroscopic rotator cuff repair. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist has a query or concern regarding the progression of a post-operative patient, he or she should consult with the referring surgeon.

Progression to the next phase based on Clinical Criteria and/or Time Frames as Appropriate.

 

Phase I – Immediate Post Surgical Phase (Weeks 1-4):

Goals:

  • Maintain integrity of repair
  • Diminish pain and inflammation
  • Prevent muscular inhibition
  • Independent for ADL’s with modifications, while maintaining integrity of

 

Precautions:

  • No active range of motion (AROM) of Shoulder
  • Maintain arm in sling, remove only for exercise
  • No lifting of objects
  • No shoulder motion behind back
  • No excessive stretching or sudden movements
  • No supporting of body weight by hands
  • Keep incision clean and dry

 

Criteria for progression to the next phase (II):

 

  • Passive range of motion (PROM) Flexion to at least 100 degrees
  • PROM ER in scapular plane to at least 45 degrees
  • PROM IR in scapular plane to at least 45 degrees
  • PROM Abduction to at least 90 degrees in the scapular plane

 

DAY 1 TO 6:

  • Abduction brace / sling
  • Sleep in brace / sling
  • Begin scapula musculature isometrics / sets; cervical ROM
  • Patient education: posture, joint protection, positioning, hygiene, etc.
  • Cryotherapy for pain and inflammation

-Day 1-2: as much as possible -Day 3-6: post activity, or for pain

 

DAY 7 TO 28:

  • Continue use of brace / sling
  • Pendulum Exercises

   - to begin 14 days after surgery, no pendulums before this time

  • Start passive ROM to tolerance (at 21 days)

-Flexion


-Abduction in the scapular plane

-ER in scapular plane


-IR in scapular plane

- Encourage pool sessions as much as possible

(supervised hydrotherapy or self-directedPROM in swimming pool)

  • Continue Elbow, wrist, and finger AROM
  • Cryotherapy as needed for pain control and inflammation

 

 

Phase II – Protection Phase (Week 4-10):

Goals:

  • Allow healing of soft tissue
  • Do not overstress healing tissue
  • Gradually restore full passive ROM (week 4-5)
  • Decrease pain and inflammation Precautions:
  • No lifting
  • No supporting of body weight by hands and arms
  • No excessive behind the back movements
  • No sudden jerking motions

Criteria for progression to the next phase (III):

 

  • Full AROM

WEEK 5-6:

  • Continue use of brace / sling full time until end of week 4*
  • Between weeks 5 and 6 may use brace / sling for comfort only
  • Discontinue brace / sling at end of week 6 at the latest

* may continue sling to end of week 6 in certain cases, depending on tear size, revision repair, tendon quality & surgeon satisfaction with repair – see specific post-op instructions/physiotherapy request form for individual patient

 

  • Initiate active assisted range of motion (AAROM) flexion in supine position
  • Progressive passive ROM until approximately Full ROM at Week 4-5.
  • This ROM should be PAIN FREE
  • Gentle Scapular/glenohumeral joint mobilization as indicated to regain full

passive ROM

  • Continue previous exercises in Phase I as needed
  • Continue all precautions
  • Initiate prone rowing to neutral arm position
  • Continue cryotherapy as needed
  • May use heat prior to ROM exercises
  • Continue to encourage pool work for ROM exercises
  • Ice after exercise

 

WEEK 6-8:

  • Continue AAROM and stretching exercises
  • Begin rotator cuff isometrics
  • Initiate active ROM exercises

-Forward flexion

-Scaption/flexion in scapular plane

 

Phase III – Intermediate phase (week 10-14):

Goals:

  • Full AROM (week 10-12)
  • Maintain Full PROM
  • Dynamic Shoulder Stability
  • Gradual restoration of shoulder strength, power, and endurance (after week 12)
  • Optimize neuromuscular control
  • Gradual return to functional activities

 

Precautions:

 

  • No heavy lifting of objects (no heavier than 5 lbs.)
  • No sudden lifting or pushing activities
  • No sudden jerking motions

Criteria for progression to the next phase (IV):

 

  • Able to tolerate the progression to low-level functional activities
  • Demonstrates return of strength / dynamic shoulder stability
  • Re-establish dynamic shoulder stability
  • Demonstrates adequate strength and dynamic stability for progression to higherdemand work/sport-specific activities.

 

WEEK 10:

  • Continue stretching and passive ROM
  • Dynamic stabilization exercises
  • No strengthening before week 12, and then only on approval of referring surgeon

 

WEEK 12:

  • Initiate strengthening program

ONLY when full ROM regained and ONLY on approval of referring surgeon

(exact timing of introduction of strengthening may vary for individual patients)

-External rotation (ER)/Internal rotation (IR) with therabands/sport cord/tubing

-ER Sidelying


-Lateral Raises*


-Full Can in Scapular Plane* (avoid empty can abduction exercises at all times)

-Prone Rowing

-Prone Horizontal Abduction

-Prone Extension


-Elbow Flexion


-Elbow Extension

*Patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonics; if unable, continue glenohumeral joint exercises.

  • Initiate light functional activities

 

WEEK 14:

  • Continue all exercises listed above
  • Progress to fundamental shoulder exercises

 

                                          

Phase IV – Advanced strengthening phase (week 16-22):

 

Goals:

 

  • Maintain full non-painful active ROM
  • Advance conditioning exercises for enhanced functional use of upper extremity
  • Improve muscular strength, power, and endurance
  • Gradual return to full functional activities

 

WEEK 16:

  • Continue ROM and self-capsular stretching for ROM maintenance
  • Continue progression of strengthening
  • Advance proprioceptive, neuromuscular activities

WEEK 20:

  • Continue all exercises listed above
  • Continue ROM and self-capsular stretching for ROM maintenance

 

Phase V – Return to activity phase (week 20-26):

 

Goals:

  • Gradual return to strenuous work activities
  • Gradual return to recreational activities
  • Gradual return to sport activities

 

WEEK 23:

  • Continue strengthening and stretching

 

WEEK 26:

  • May initiate interval sport program (i.e. golf, tennis etc.), if appropriate

 

Superior Capsular Reconstruction Protocol  

Rehabilitation Guidelines following Superior Capsule Reconstruction (SCR) of the Shoulder.

 

The following is Ms Ruth Delaney’s standard post-operative rehabilitation guideline for patients following superior capsule reconstruction (SCR) of the shoulder. This guideline is based on the latest research and the specific criteria of the referring surgeon.

The intent of this guideline is to provide the clinician with information, instruction and rehabilitation guidelines for patients following superior capsule reconstruction (SCR). The physiotherapist must exercise their best professional judgement to determine how to integrate this guideline into an appropriate treatment plan. Close communication with the surgeon is an essential component in ensuring a successful post-operative outcome.

This protocol is divided into four phases that will last up to 12 months post-operatively. Phase 1 is the protective phase, Phase 2 is the intermediate phase, Phase 3 is the strengthening phase and Phase 4 is the advanced rehabilitation phase.

Please refer to patients discharge letter for specific instructions regarding the extent of the rotator cuff repair done in conjunction with the SCR. This information will need to be taken into consideration when progressing the patient through the phases of rehabilitation.

 

 

General considerations for the rehabilitation of patients following superior capsule reconstruction (SCR) of the shoulder:

 

What is a superior capsule reconstruction (SCR) of the shoulder?

A superior capsule reconstruction (SCR) of the shoulder is an anatomic reconstruction of the superior capsule of the shoulder.(Mihataet al.2012). It is considered suitable for patients with irreparable tears of the rotator cuff where a defect in the superior capsule can also be found. It has been suggested that a SCR can restore gleno-humeral kinematics, rebalancing the force couples necessary for dynamic shoulder function without sacrificing future treatment options. (Tokish and Beicker 2015). During the surgery to reconstruct the superior capsule, an attempt is also made to repair as much of the rotator cuff as possible to aid in the balancing of the aforementioned force couples. Although the rotator cuff is the key to the restoration of complete strength, initial clinical studies following this surgical procedure have shown that most patients have had a significant reduction in pain, improvement in function and few complications. (Mihataet al.2013).

The graft:

In Europe, an acellular porcine dermal extracellular matrix is currently being used as the biologic scaffold to repair the superior capsule of the shoulder. (Arthrex 2017)Biological scaffolds are preferred over synthetic scaffolds as the grafts are composed of collagen that support the natural cell interactions such as proliferation and migration. (Valentinet al.2006)

Following the surgery a series of complex events unfolds and when thoroughly understood will help guide the physiotherapist in the post-operative rehabilitation process. The healing process consists of the initial inflammatory phase where fibroblasts must penetrate the collagen matrix within the biologic scaffold. Following fibroblast penetration of the collagen the proliferative or degradation phase will occur, which is accepted as essential to host acceptance of the biological scaffold. The final phase of healing is the remodelling or maturation phase. This involves cellularity, vascularity and collagen organisation where the fibres are aligned along different tension lines to achieve overall tensile strength of the graft. Studies suggest that if the remodelling phase does not occur properly, tissue degradation and rejection could occur. (Hogansonet al.2010, Hackettet al.2011)

Key principles of rehabilitation:

There are three key principles of rehabilitation that need to be considered for a patient following a SCR. These are optimise graft healing as part of a conservative rehabilitation approach, deltoid re-education and collaborative working between the surgeon, therapist and patient.

Optimise graft healing: A recent study looked at the current perceptions in the post-operative rehabilitation of patients following SCR and highlighted the need for a conservative rehabilitation approach. The results of the study emphasised that slow and steady was the key to a successful post-operative outcome with strength being a long-term goal. (Noonan-Tayloret al.2017)Clinical trials using acellular porcine dermal matrix on humans are lacking however a canine model evaluating acellular dermal allografts in the shoulder suggest that these grafts undergo significant remodelling and become weaker before they get stronger which would also support a slow and conservative rehabilitation program. (Adamset al.2006)

Deltoid re-education: The deltoid muscle is considered to play a key role in the rehabilitation of patients following SCR, as it is deemed the prime mover of the arm in the absence of a fully functioning rotator cuff. (Levyet al.2008, Noonan-Tayloret al.2017). In some patients with symptomatic, full-thickness tears of the rotator cuff, the humeral head may migrate superiorly in the glenoid during arm elevation. This disrupts the force couple that exists between the deltoid and the rotator cuff and can present clinically as the patient “hitching” their shoulder, causing pain and loss of function. (Meyeret al.2013)Initial results are showing that a SCR can restore shoulder kinematics, establishing a stable fulcrum that allows the deltoid and remaining rotator cuff to function more effectively. (Mihataet al.2013).

 

Collaborative working between surgeon, therapist and patient:Close communication with the surgeon is essential for a successful post-operative outcome. (Noonan-Tayloret al.2017)Clinicians also need to constantly monitor patient`s expectations by explaining the timeframes for the expected benefits and recovery to occur. (Jordan et al 2010).

 

Phase 1:Protective phase: 0-6 weeks in a sling, coincides with the initial inflammatory phase of healing of the graft.

Goals:

  • Achieve fine balance between protecting the graft and reducing post-op stiffness.
  • Optimise tissue healing with compliance of sling and home exercise program.
  • Ensure patient is comfortable and sleeping well.
  • Patient should have a clear understanding on the rationale behind the surgery and the rehabilitation process.

Precautions:

  • No active range of movement of the shoulder. No hand behind back or across body.
  • Keep arm in the sling, remove only for home exercises, washing and dressing.
  • No supporting of body weight with hands.
  • Limit passive external rotation to neutral (0 degrees) for first 6 weeks. 
  • No driving.

Treatment:

  • Absorbable stitches are used for this surgical procedure, review with surgeon 2 weeks post-operative for wound check and physiotherapy instructions.
  • Patients to remain in a protective sling for 6 weeks following the surgery.
  • Patient education: Explaining the timeframes for when expected benefits and recovery should occur.
  • Ice packs (10 minutes 3-5 times a day) and pain relief as prescribed.
  • PROM may commence before 6 weeks if the patient is showing signs of post-operative stiffness. Please refer to patient discharge notes for further information.

 

Treatment tips:

  • Sensorimotor control should start early in the rehab and progress through the phases.
  • Check for pectoralis dominance: patients will often be in a protracted shoulder position and have an observable or palpable increase in resting tone in the pectoralis muscles.

 

Phase 2:Intermediate phase, 6 weeks to 4 months, coincides with graft incorporation and revascularisation.

Goals:

  • To establish basic rotator cuff and scapular neuromuscular control within a pain free range.
  • To restore functional active range of movement.

Precautions:

  • No supporting of body weight by hands or arms.
  • No bands, heavy lifting or weights to be used for first 12 weeks.
  • No specific rotator cuff strengthening exercises for first 12 weeks.
  • No exercise or activity that increase pain levels.

Treatment:

  • Regular physiotherapy required to guide patients through this phase of the rehabilitation program.
  • Start with AAROM and progress to AROM through range with attention to scapular control.
  • Patient can commence external rotation: caution with patients who have had a subscapularis repair in conjunction with SCR.
  • Commence an evidence-based phased anterior deltoid re-education program.
  • Commence rotator cuff isometric exercises below shoulder height.
  • Closed chain stability exercises can start with wall push-ups.
  • Weight shifts and perturbations in quadruped position will improve static control through compressive forces acting through the glenohumeral joint.
  • Serratus anterior: in supine, patient moves into full scapular protraction with glenohumeral joint at 90 degrees elevation.
  • Glenohumeral joint and scapular mobilisations as indicated to regain range of movement.
  • Encourage pool sessions: supervised hydrotherapy or self-directed PROM in the pool after 12 weeks.
  • Review with surgeon 12 weeks post-operatively.

 

Milestones to progress to Phase 3:

  • Minimal pain, sleeping well.
  • Back to light to moderate functional activity at waist and shoulder height.

Treatment tips:

  • Re-education of the deltoid: Comparisons can be drawn from the literature on the rehabilitation of patients following reverse shoulder arthroplasty where the deltoid acts as the prime mover in the absence of a fully functioning rotator. (Boudreauet al.2007)Some patients may experience some difficulty in recruiting the deltoid as the prime mover of the shoulder. The routine use of biofeedback, surface electromyography, verbal and tactile cues, and tape is recommended to assist patients in learning recruitment strategies.
  • An example of a phased deltoid re-education program can be found on shoulderdoc.co.uk/article/1028. This evidence-based exercise program, based on the study by Levy et al, 2008, starts with the patient in supine doing active assisted elevation and progresses the patient into a semi-seated position using a light weight or resistance from the unaffected limb.
  • Look up shouldercommunity.com, this website is run by Dr Karen McCreesh in the University of Limerick and has a wide range of shoulder rehabilitation exercises. You will find exercises on how to improve sensorimotor control, exercises to depress the humeral head and rehabilitation ideas to activate serratus anterior.
  • Ensure exercises are goal orientated and have a proprioceptive, functional and dynamic element.

 

Phase 3: Strengthening phase, 4 to 6 months, coincides with the remodelling phase of healing where collagen fibres are laid down to achieve the overall tensile strength of the graft. 

Goals:

  • To design a structured and progressive strengthening program for the deltoid, remaining rotator cuff and scapular stabilisers. (Noonan-Tayloret al.2017)
  • Patients return to more physically demanding work and hobbies.

Precautions:

  • No heavy lifting of objects.
  • No unsupervised strengthening exercises. No contact sport.

Treatment:

  • Progress the phased re-education program for the deltoid.
  • Activate posterior cuff through available range with theraband. Start supine, progress to standing.
  • Integration of the kinetic chain into home exercise program.
  • Progress strengthening program with free weights, theraband and body weight.
  • Commence biceps and triceps exercises.
  • Progress closed chain exercises with Swiss Ball and Pilates Ball.
  • Serratus anterior: “Dynamic Bear Hug” with theraband.
  • Trapezius and rhomboids: The standing sport cord row exercise.
  • Progress sensorimotor control exercises.
  • Thoracic extension exercises: sternal lift: progress to foam roller if suitable.
  • Promote concept of injury prevention and the benefits of regular cardio-vascular exercise.
  • Review with the surgeon at 6 months post-operatively.

Treatment tips:

  • Integrate the kinetic chain in assessments and treatment plans: Whole body screening tool can be downloaded from Dr Jeremy Lewis`s website at LondonshoulderClinic.com.
  • Try facilitating weight transference on to the affected side. Progress the exercise by integrating the kinetic chain into the sequence, this allows the patient to elongate through the lateral trunk and activate trunk segmental extension.
  • Closed kinetic chain exercises with a Swiss Ball can facilitate co-contraction of the deep stabilisers and improve dynamic shoulder stability and scapular control.
  • Encourage good posture and maintain available range of thoracic extension: 15 degrees of thoracic extension are required for pain free shoulder elevation.

 

Phase 4: Advanced rehabilitation, 6-12 months.

Goals:

  • To motivate our patients to continue exercising up to 12 months post-operatively and beyond.
  • To design an individualised rehabilitation program for enhanced functional use of the upper limb.

 

Treatment:

  • Advanced strengthening exercises for return to full functional activities.
  • Advanced proprioceptive and neuromuscular control program.
  • Exercises progressing to overhead position.
  • “Push-up Plus” for progression of Serratus anterior.
  • Phone or email contact with the patient at 12 and 24 months for collection of post-operative outcome scores.

 

 
 

 

 

 

 

 

 

 

References:

 

Adams, J. E., Zobitz, M. E., Reach, J. S., Jr., An, K. N. and Steinmann, S. P. (2006) 'Rotator cuff repair using an acellular dermal matrix graft: an in vivo study in a canine model', Arthroscopy, 22(7), 700-9.

 

Arthrex (2017) [online], available: http://www.arthrex.com[accessed 6 April].

 

Boudreau, S., Boudreau, E. D., Higgins, L. D. and Wilcox, R. B., 3rd (2007) 'Rehabilitation following reverse total shoulder arthroplasty', J Orthop Sports Phys Ther, 37(12), 734-43.

 

Hackett, E. S., Harilal, D., Bowley, C., Hawes, M., Turner, A. S. and Goldman, S. M. (2011) 'Evaluation of porcine hydrated dermis augmented repair in a fascial defect model', J Biomed Mater Res B Appl Biomater, 96(1), 134-8.

 

Hoganson, D. M., O'Doherty, E. M., Owens, G. E., Harilal, D. O., Goldman, S. M., Bowley, C. M., Neville, C. M., Kronengold, R. T. and Vacanti, J. P. (2010) 'The retention of extracellular matrix proteins and angiogenic and mitogenic cytokines in a decellularized porcine dermis', Biomaterials, 31(26), 6730-7.

 

Levy, O., Mullett, H., Roberts, S. and Copeland, S. (2008) 'The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears', Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons ... [Et Al.], 17(6), 863-870.

 

Meyer, D. C., Rahm, S., Farshad, M., Lajtai, G. and Wieser, K. (2013) 'Deltoid muscle shape analysis with magnetic resonance imaging in patients with chronic rotator cuff tears', BMC Musculoskeletal Disorders, 14(1), 1-7.

 

Mihata, T., Lee, T. Q., Watanabe, C., Fukunishi, K., Ohue, M., Tsujimura, T. and Kinoshita, M. (2013) 'Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears', Arthroscopy: The Journal Of Arthroscopic & Related Surgery: Official Publication Of The Arthroscopy Association Of North America And The International Arthroscopy Association, 29(3), 459-470.

 

Mihata, T., McGarry, M. H., Pirolo, J. M., Kinoshita, M. and Lee, T. Q. (2012) 'Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study', Am J Sports Med, 40(10), 2248-55.

 

Noonan-Taylor, F., Langford, C., O'Leary, H., Kingston, R. and Delaney, R. (2017) Superior Capsule Reconstruction (SCR) of the shoulder: Clinical relevance and current perceptions in the post-operative rehabilitation., unpublished thesis (MSc Advanced Healthcare Practice), University of Limerick.

 

Tokish, J. M. and Beicker, C. (2015) 'Superior Capsule Reconstruction Technique Using an Acellular Dermal Allograft', Arthrosc Tech, 4(6), e833-9.

 

Valentin, J. E., Badylak, J. S., McCabe, G. P. and Badylak, S. F. (2006) 'Extracellular matrix bioscaffolds for orthopaedic applications. A comparative histologic study', J Bone Joint Surg Am, 88(12), 2673-86.

 

 

 

 

 

 

 

 

 

 

 

Fiona Noonan-Taylor, BSc (Hons) Physio,

MSc (Advanced Healthcare Practice).

CORU No: PT030515.

West Limerick Physiotherapy Clinic,

Killeline, Newcastle West,Co. Limerick.

Tel: 06977700

www.westlimerickphysio.com

Email: fiona@westlimerickphysio.com

© 2020 Fiona Noonan-Taylor, BSc (Hons) Physio, MSc, MISCP.

 

 

Subacromial Decompression Protocol

Modified from the protocol developed at Boston Shoulder Institute by the

Massachusetts General Hospital and Brigham & Women’s Hospital Shoulder Services.

 

Arthroscopic Subacromial Decompression Protocol:

 

The intent of this protocol is to provide the physiotherapist with a guideline of the post-operative rehabilitation course of a patient who has undergone an arthroscopic subacromial decompression. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist has a query or concern regarding the progression of a post-operative patient, he or she should consult with the referring surgeon.

Phase 1: (1-2 weeks)

 

Goals:

  • Restore non-painful range of motion (ROM)
  • Minimize muscular atrophy
  • Decrease pain/inflammation
  • Improve postural awareness
  • Minimize stress to healing structures
  • Independent with activities of daily living (ADLs)
  • Prevent muscular inhibition
  • Wean from sling

 

Precautions:

  • Care should be taken with abduction (with both active range of motion (AROM and passive range of motion (PROM) to avoid unnecessary compression of subacromial structures
  • Avoid creating or reinforcing poor movement patterns, such as excessive

    scapulothoracic motion with upper extremity elevation

 

Range of Motion:

  • PROM (non-forceful flexion and abduction)
  • Active assisted range of motion (AAROM)
  • AROM
  • Pendulums
  • Pulleys
  • Cane exercises
  • Self stretches
  • Proprioceptive Neuromuscular Facilitation (PNF)

 

Strengthening:

  • Isometrics: scapular musculature, deltoid, and rotator cuff as appropriate
  • Isotonic: theraband internal and external rotation in 0 degrees abduction

 

Modalities:

  • Cryotherapy
  • Electrical stimulation-inferential current to decrease swelling and pain (as

indicated and/or needed)

 

Criteria for progression to phase 2:

  • Full active and passive ROM
  • Minimal pain and tenderness

 

Phase 2: Intermediate Phase (2-6 Weeks)

 

Goals:

  • Regain and improve muscular strength
  • Normalize arthrokinematics
  • Improve neuromuscular control of shoulder complex

 

Exercises:

  • Initiate isotonic program with dumbbells and/or resistance bands
  • Strengthen shoulder musculature- isometric, isotonic
  • Strengthen scapulothoracic musculature- isometric, isotonic
  • Initiate upper extremity endurance exercises

 

Manual Treatment:

  • Joint mobilization to improve/restore arthrokinematics if indicated
  • Joint mobilization for pain modulation

 

Modalities:

  • Cryotherapy
  • Electrical stimulation - inferential current to decrease swelling and pain (as

indicated and/or needed)

 

Criteria for Progression to Phase 3:

  • Full painless ROM
  • No pain or tenderness on examination

 

 

 

Phase 3: Dynamic (Advanced) Strengthening Phase: (6 weeks and beyond)

 

Goals:

  • Improve strength, power, and endurance
  • Improve neuromuscular control
  • Prepare athlete to begin to throw, and perform similar overhead activities or other sport specific activities

 

Emphasis of Phase 3:

  • High speed, high energy strengthening exercises
  • Eccentric exercises
  • Diagonal patterns

 

Exercises:

  • Continue dumbbell strengthening (rotator cuff and deltoid)
  • Progress theraband exercises to 90/90 position for internal rotation and external rotation (slow/fast sets)
  • Theraband exercises for scapulothoracic musculature and biceps
  • Plyometrics for rotator cuff
  • PNF diagonal patterns
  • Isokinetics
  • Continue endurance exercises  

If you or your physiotherapist have any questions or concerns during your post-operative rehabilitation, please do not hesitate to contact us.

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