Nathan WM. Skelley, M.D.

Phase I (0 – 4 weeks)

Appointments

• Home exercise program will begin after surgery

• PT 1-3x/week.

Rehabilitation Goals

• Progression of elevation in scapular plan and ER to 20 degrees if NO subscapularis repair. If subscapularis repair, NO external rotation.

• Correct postural dysfunctions

Precautions

• Sling utilization will be determined by communication between physician and physical therapist. Typical sling use ranges from 6-8 weeks depending on surgical procedure, tissue quality, healing potential and stiffness

• No active abduction ROM for 8 weeks to protect repair and no external resistance to abduction and supraspinatus for 12 weeks

Suggested Therapeutic Exercise

• Progress forward elevation and passive ER using only exercise demonstrated to have less than 15% EMG activity level

• Supported side lying shoulder flexion

• Supine forward elevation with elastic band resistance form 90

  degrees

• Small circle (20cm) pendulums

• Scapular strengthening

• Grade I and II joint mobilizations for pain relief as needed at all

  shoulder girdle joints, GH, SC, AC, ST

• Elbow, wrist, finger AROM and light strengthening

• Ensure normal cervical spine, thoracic spine and hip mobility

  to facilitate kinetic chain upper extremity ROM

Cardiovascular exercise

• Walking and stationary bike

• Avoid running, jumping, treadmill, elliptical and Stairmaster

Progression Criteria

• At least 8 weeks post-operative

• Passive forward elevation 90 degrees

• Passive ER to 20 degrees and 45 degrees abduction

 

Phase II (weeks 8 – 3 months)

Appointments

• Rehabilitation appointments are 1-3 times per week

Rehabilitation Goals

ROM goals for approximately 9 weeks:

• Passive forward elevation to 130 degrees

• Passive ER at 20 degrees of abduction to 30 degrees.

• Passive ER at 90 degrees of abduction to 45 degrees

• Initiation and controlled progression of active assistive range of motion and AROM. AROM initiation based on PROM goals, delayed 9 weeks postoperative

• Initiate light muscle performance activities

• Correct postural dysfunctions- active elevation 80-120 degrees

  without compensation

Precautions

• Wean out of sling slowly starting postoperative weeks 6-8 based on size of tear, integrity of tissue and repair, and surgeon preference

• No active abduction ROM for 8 weeks to protect repair and no external resistance to abduction and supraspinatus for 12 weeks

Suggested Therapeutic Exercise

• Appropriate progression of upper extremity use for light ADLs in pain free ROM starting with waist level activities, progression to shoulder level

• AAROM for forward elevation and ER with exercises demonstrated to have less than 30% EMG activity level. Generally in gravity minimized positions and/or short lever arm: cane assisted forward elevation, wall ball roll, active assisted forward elevation with fingers interlaced, wall walks or slide, aquatic exercise: slow speed elevation in scapular plane

• ROM exercises in other planes can be initiated in latter half of this phase if significant ROM limitations are present (caution with passive tension over the repair): ER at progressing angles of abduction, IR, functional IR behind the back, horizontal adduction

• Progress AROM as demonstrated with good scapulothoracic mechanics and remaining pain free. Generally in upright position progressing from supported to unsupported elevation: pulley progression based on PROM and scapular control, passive progressing to active assisted elevation with active lowering, short lever arm forward elevation, ipsilateral step up shoulder flexion with a ball(both hands)k ipsilateral step up shoulder flexion with no ball

• Active shoulder flexion at the end of this phase

Cardiovascular Exercise

• Walk and stationary bike

• Avoid running and jumping, no treadmill, elliptical, or

  Stairmaster

Progression criteria

• Passive forward elevation to at least 140 degrees to full

• Passive ER at 20 degrees of abduction to at least 30 degrees to full, passive ER at 90 degrees of abduction to at least 75 degrees to full

• Active elevation to at least 120 degrees without compensation

 

Phase III (months 3 - 5)

Appointments

• Rehabilitation appointments 1-3xwk

Rehabilitation Goals

• Full P/AROM

• Gradually restore shoulder strength, power, and endurance

• Return to ADLs, work, and recreational activities that do not

  require heavy lifting, powerful movements, or repetitive

  overhead activities

• Advanced proprioceptive and dynamic neuromuscular control

  retaining

Precautions

• Post-rehabilitation soreness should alleviate within 12 hours of the activities

• No lifting of objects more than 10 pounds with short lever arm

• Lifting only light resistance with long lever arm

• No sudden lifting, jerking, or pushing movements

Suggested Therapeutic exercises

• Progress ion of strengthening with exercises demonstrated to have 30-49% EMG activity level. Generally in upright position with progression of lever arm and resistance

• Multi-plane shoulder AROM with a gradual increase in the velocity of movement while making sure to assess scapular rhythm

• ER and IR art various angles of abduction

• Prone series rowing horizontal abduction, extension

• Dynamic stabilization

• OCK proprioception awareness drills

• CKC progression

• Biceps curls, triceps extensions, lat pull downs, wrist and

  forearm strengthening

• Exercises should be progressive in terms of shoulder elevation

  range

• Rhythmic shoulder stabilizations, starting with proximal

  perturbations

• Shoulder mobilizations as needed

• Core and lower body strengthening

• Grade II and IV joint mobilizations as indicated to address

  capsular restrictions at all shoulder girdle joints GH, SC, AC, ST

Cardiovascular exercise

• Walking, stationary bike, and Stairmaster

• No treadmill or swimming

• May begin light jogging and running if the patient has normal rotator cuff strength in neutral and functional shoulder AROM

Progression Criteria

• Full shoulder AROM in all planes and multi-plane movements

• Manual muscle testing 5/5

• Pain free during strengthening exercises

• Negative impingement signs

 

Phase IV (Months 6+)

Appointments

• Rehabilitation appointments 1-3xwk

Rehabilitation Goals

• Normalize muscular strength, power and endurance

• Return to high demand activities

• Complete return to sport

• Develop strength and control for movements required for

  sport/work

• Develop work capacity cardiovascular endurance for

  sport/work

Precautions

• Post-rehabilitation soreness should alleviate within 12 hours of the activity

• Avoid activities that result in substitution patterns

• Avoid exercises that generate a large increase in load

  compared to previous exercises

Suggested Therapeutic exercises

• Continue shoulder mobilizations, stretching and PROM exercises as needed per impairments

• Rotator cuff strengthening in 90 degrees of shoulder abduction as well as positions demanded by work/sport

• Progressive return to weight lifting program starting with relatively lightweight and high repetitions. Increase weight while decreasing reps

• Core and lower body strengthening

• Throwing program, swimming program or overhead racquet

  program

• Transition to upper extremity prevention/maintenance

  program

Cardiovascular exercise

• Replicate sport or work specific energy demands

Progression Criteria

• The patient may return to sport after receiving clearance from the orthopaedic surgeon and the sports rehabilitation provider.