Shawn Hennigan, MD Total Shoulder Arthroplasty Protocol. Phase 1 Maximum Protection (0-4 weeks)

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Shawn Hennigan, MD Total Shoulder Arthroplasty Protocol Goals for phase 1 Minimize Pain and inflammation Protect integrity of repair Initiate shoulder PROM Reduce muscular inhibition Maintain AROM of

1 Shawn Hennigan, MD Total Shoulder Arthroplasty Protocol Goals for phase 1 Minimize Pain and inflammation Protect integrity of repair Initiate shoulder PROM Reduce muscular inhibition Maintain AROM of elbow, wrist, and neck Criteria for progression to Phase 2 Minimal pain with phase I exercises Passive shoulder flexion 90 Passive shoulder abduction 90 Passive shoulder internal rotation at 45 abduction in scapular plane 70 Passive shoulder external rotation to 30 at 45 abduction in scapular plane (unless otherwise specified in surgical report) Other considerations Limit shoulder external rotation PROM to 30 at 45 abduction in scapular plane (unless otherwise specified in surgical report) for 6 weeks post-operatively No shoulder internal rotation strengthening for 12 weeks postoperatively No excessive shoulder motion behind back, especially into IR for 6 weeks Limit shoulder hyperextension in supine No lifting or supporting body weight with affected arm Phase 1 Maximum Protection (0-4 weeks) Immobilization Immobilization in sling for 4-6 weeks or per physician Initial Post-Op Exercises Elbow, forearm, wrist, hand (grip) AROM exercises; pendulum (Codman s) exercise; scapular squeezes; upper trap stretching; postural correction Remove sling 3 times per day for performance of HEP Cryotherapy to minimize pain and inflammation Post-Op Physical Therapy 1 st physical therapy visit to occur 4 weeks post-op o Ensure appropriate fit of sling and reinforce on proper use o Review initial post-operative exercises and reinforce proper performance o PROM Goal 90 FLEX, 30 ABD, 70 IR, 30 ER at 45 ABD Emphasis on early shoulder PROM and glenohumeral joint mobility Aquatics Utilize aquatics for patients who are significantly painful, stiff, or guarded o Initiate when surgical incisions have healed o Initiate buoyancy assisted ROM exercises within limitations o Consider alternating land- and aquatic-based physical therapy visits Initiate pain dominant glenohumeral joint mobilization (grade 1-2) Initiate scar mobilization, soft tissue mobilization, lymph edema massage Initiate other shoulder, scapular, and cervicothoracic manual therapy techniques as needed PROM Initiate manual shoulder PROM in al PROM of motion within limitations o Limit external rotation to 30 at 45 abduction in scapular plane (unless otherwise specified in surgical report) AAROM Initiate shoulder ER AAROM with wand at 45 ABD within motion restrictions Initiate shoulder FLEX and ABD AAROM o Table slides, U.E. Ranger, physioball, wand, etc. o Avoid shoulder ER AAROM greater than established limit ABD in post operative report o Utilize cryotherapy, thermotherapy, and electric modalities as needed 1160 Kepler Drive 1 P a g e

2 Goals for phase 2 Minimize Pain and inflammation Protect integrity of repair Restore full shoulder PROM all directions except ER (Limit ER to 30 unless otherwise specified by MD) Restore AROM o Do NOT exercise through shoulder shrug sign Initiate sub-maximal rotator cuff activation and neurodynamic stabilization exercises Should be able to perform many of their waist level ADL s Criteria for progression to Phase 3 No/slight pain with flexion to 140 ; abduction 120 ; Internal rotation to 70 and External rotation to 60 in the plane of the scapula at 45 ABD Active flexion to 100 w good mechanics o No evidence of shoulder shrug with elevation AROM Other considerations Can perform sustained endrange ER (once given confirmation from MD that subscapularis is stable and healed) No lifting anything heavier than a coffee cup No supporting body weight No sudden jerking motion Avoid hyperextension while supine Phase 2 Active Range of Motion (4-8 weeks) Immobilization Wean out of brace Aquatics o Continue aquatics for patients who are significantly painful, stiff, or guarded Stretching o Initiate shoulder stretching exercises in all planes of motion as tolerated Continue pain dominant glenohumeral joint mobilization (grade 1-2) Initiate stiffness dominant glenohumeral joint mobilization (grade 3-4) Continue scar mobilization, soft tissue mobilization, lymph edema massage as needed Continue other shoulder, scapular, and cervicothoracic manual therapy Perform gentle scapulothoracic joint mobilizations as needed PROM Continue manual shoulder PROM in all planes of motion as tolerated Initiate sustained end range stretching in all directions except ER AAROM (5 weeks post-operative) Continue shoulder IR, horizontal ABD, and ER AAROM with wand Progress from 45 to 60 to 90 ABD Continue shoulder FLEX, EXT and ABD AAROM Table slides, wall slides, physioball, wand (standing extension), pulleys, etc. AROM Initiate shoulder AROM in all planes of motion as tolerated (NO IR until 6 weeks) Gradually progress from gravity reduced to full gravity positions Gradually progress from below shoulder height to above shoulder height Consider single-planar and multi-planar movement patterns Strengthening Initiate sub-maximal shoulder isometrics for FLEX, ABD, EXT, IR, and ER o (NO resisted IR until 12 weeks) Initiate light isotonic scapular strengthening o Supine press, serratus press outs, prone row, etc. Initiate anti-gravity flexion and abduction (i.e. flexion with 1-3# supine) Initiate distal extremity strengthening with light resistance Initiate sub-body weight closed-chain strengthening exercises o Wall press outs, countertop press outs, etc. Avoid sub-body weight suspension training exercises o (TRX, GTS, assisted chin or dip machine, etc.) Neuromuscular Control Initiate sub-maximal glenohumeral and scapulothoracic rhythmic stabilization drills o Gradually progress shoulder FLEX from 100 to 90 to 60 to 30 o Gradually progress shoulder IR from 30 to 60 to 90 ABD; ER same once cleared NMES Utilize NMES to facilitate rotator cuff and scapular activation and strengthening Utilize cryotherapy, thermotherapy, and electrical modalities as needed 1160 Kepler Drive 2 P a g e

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4 Phase 3 Moderate Strengthening (8-12 weeks) Goals for Phase 3 Maximize functional UE use Minimize pain and inflammation Maintain full shoulder PROM and AROM Improve shoulder, scapular, rotator cuff and total arm strength Improve neurodynamic stabilization of the shoulder Return to advanced functional activities Criteria for Progression to Phase 4 Minimal pain with Phase 3 exercises Full, pain free shoulder PROM and AROM No shoulder shrug sign with strengthening exercises No/slight pain with flexion to 140 ; abduction 120 ; Internal rotation to 70 and External rotation to 60 in the plane of the scapula at 45 ABD Other considerations Strengthening for outpatient who has had a rotator cuff repair in conjunction with their TSA should not start before weeks. No heavy lifting or sudden pushing or jerking Immobilization Wean out of brace completely Stretching Continue shoulder stretching exercises as needed Continue stiffness dominant glenohumeral joint mobilization (grade 3-4) Continue other shoulder, scapular, and cervicothoracic manual therapy PROM Continue manual shoulder PROM as needed to maintain ROM Initiate end-range sustained ER stretching once subscapularis is stable and healed AAROM Initiate IR behind back (10-12 weeks) Strengthening Initiate gradual progression of isotonic rotator cuff strengthening exercises o Gradually progress from gravity reduced to full gravity positions o Gradually progress from below shoulder height to above shoulder height o Gradually progress internal and external rotation from 30 to 60 to 90 abduction and from supported to unsupported conditions o Consider single-planar and multi-planar movement patterns (i.e. UE PNF diagonals) Progress isotonic scapular strengthening exercises o Progress from isolated to functional movement patterns Progress isotonic biceps and triceps strengthening exercises o Progress from isolated to functional movement patterns Progress closed-chain strengthening exercises o Gradually progress from sub-body weight to full body weight positions o Gradually progress from stable to unstable surfaces Do NOT exercise through shoulder shrug sign Neuromuscular Control Progress rhythmic stabilization exercises to more functional positions and dynamic movement patterns o Gradually progress from mid-range to end range positions o Gradually progress from open-chain to closed-chain positions Initiate gradual progression of other neuromuscular control exercises o Body blade, wall dribbles, ball flips, plyoback, etc. NMES Utilize NMES to facilitate rotator cuff and scapular activation and strengthening Utilize cryotherapy, thermotherapy, and electrical modalities as needed 1160 Kepler Drive 4 P a g e

5 Phase 4 Advanced Strengthening (12-20 weeks) Goals for Phase 4 Minimize pain and inflammation Full pain free AROM 5/5 MMT at 90 of shoulder abduction Return to advanced functional activities as well as gardening, sports (i.e. golf and doubles tennis) Criteria for Return to Activity Minimal pain with phase 4 exercises Full, pain free PROM and AROM Successful completion of functional capacity evaluation if physical laborer Stretching Continue shoulder stretching exercises as needed Continue stiffness dominant glenohumeral joint mobilization (grade 3-4) as needed Continue other shoulder, scapular, and cervicothoracic manual therapy techniques Continue manual shoulder PROM as needed Strengthening Continue Phase 3 strengthening exercises Consider specific demands of occupational, sport, or desired activities Rotator cuff strengthening in 90 abduction and overhead Neuromuscular Control Continue Phase 3 neuromuscular control exercises Consider specific demands of occupational, sport, or desired activities Return to Activity Initiate return to activity o Gardening, golfing, doubles tennis (No treadmill or Swimming) o Suggest modifications to work, sport, or functional activities o Heavy loading activities and repetitive use above shoulder height should be avoided until 6 months post operative Weight Lifting Initiate traditional weight lifting exercises Work Specialty Rehabilitation Program Transition to work re-conditioning if physical laborer/specific occupational demands o Lifting requirements, overhead tasks, repetitive tasks, tool or machine work, etc. Utilize cryotherapy, thermotherapy, and electrical modalities as needed HEP Establish HEP for long-term self-management Suggest modifications to work, sport, or functional activities 1160 Kepler Drive 5 P a g e

6 References 1. Boardman III, D. N., M.D., Cofield, R. H., M.D., Bengtson, K. A., M.D., Little, R., M.D., Jones, M. C., P.T., & Rowland, C. M., M.S.. (2001, November 4). Rehabilitation After Total Shoulder Arthroplasty. The Journal of Arthroplasty, 16(4), Brems, J. J., MD. (2007). Rehabilitation After Total Shoulder Arthroplasty: Current Concepts. Seminars in Arthroplasty. 3. Golant, A., M.D., Christoforou, D., M.D., Zuckerman, J. D., M.D., & Kwon, Y., M.D., PhD. (2012). Return to sports after shoulder arthroplasty: a survey of surgeons' preferences. Journal of Shoulder and Elbow Surgery. 4. Hughes M, Neer CS 2d, M.D.: Glenohumeral joint replacement and postoperative rehabilitation. Phys Ther 55:850, Kelley, M. J., & Leggin, B. G. (2016). Rehabilitation after Shoulder Arthroplasty. Total Shoulder Arthroplasty: Technical Considerations. 6. Miller, S. L., M.D., Hazrati, Y., M.D., Klepps, S., M.D., Chiang, A., M.D., & Flatow, E. L., M.D. (2003, January). Loss of subscapularis function after total shoulder replacement: A seldom recognized problem., Payne, C., Jaggi, A., Le Leu, A., Garofalo, R., & Conti, M. (2015). (V) Rehabilitation for shoulder arthroplasty. Orthopedics and Trauma, 29(5). 8. Razmjou, H., Stratford, P., Kennedy, D., & Holtby, R. (2004). Pattern of recovery following total shoulder arthroplasty and humeral head replacement. BMC: Musculoskeletal Disorders, 15(306). 9. Sperling, J. W., Kaufman, K. R., Schleck, C. D., & Cofield, R. H. (2008, January). A biomechanical analysis of strength and motion following total shoulder arthroplasty. International Journal of Shoulder Surgery, 2(1). 10. Watson, J. D., M.D., & Murthi, A. M., M.D. (2008). Conventional Shoulder Arthroplasty in the Athlete. Operative Techniques in Sports Medicine, Wilcox III, R. B., Arslanian, L. E., & Millett, P. J. (2005). Rehabilitation following total shoulder arthroplasty. Journal of Orthopaedic & Sports Physical Therapy, 35(12), Wright, T., Easley, T., Bennett, J., Struk, A., & Conrad, B. (2015). Shoulder Arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics Kepler Drive 6 P a g e

Harold Schock III, MD Rotator Cuff Repair Rehabilitation Protocol

Harold Schock III, MD Rotator Cuff Repair Rehabilitation Protocol The following document is an evidence-based protocol for arthroscopic rotator cuff repair rehabilitation. The protocol is both chronologically