Phase I : Immediate Postoperative Phase- Protected Motion (0-2 Weeks) Appointments Progression Criteria 2 weeks after surgery Rehabilitation appointments begin within 7-10 days of surgery, continue 1-2 times per week. Protect healing of repaired tissues Reduce pain and swelling in the post-surgical shoulder Controlled restoration of shoulder passive range of motion Correct postural dysfunction Sling immobilization continuously, including while sleeping for 4 weeks No shoulder instability testing for 4 weeks No active extension, abduction, ER or horizontal abduction past body for 4 weeks (including reaching behind the back) Avoid long head biceps tension or AROM for 6 weeks (long lever arm SHLD flex, resisted supination or elbow flex) Avoid passive & active abd + ER at 90/90 for 6 weeks No weightbearing exercises through UE for 8 weeks Elbow/hand PROM Hand gripping Cervical spine & scapular AROM (depression, retraction) Seated thoracic extension against chair Sub-maximal isometrics (ER/IR) Passive shoulder range of motion (based on patient tolerance) o Flexion to 60-75 degrees o Elevation in scapular plane to 60 degrees o ER in scapular plane to 10-15 degrees o IR in scapular plane to 45 degrees Soft tissue mobilization to scapular muscles, deltoid/arm (avoiding incisions) Scapular mobilizations (grade II-III) Grade I-II posterior glides of humeral head for pain relief Manual lymphatic drainage as needed Desensitization techniques for axillary nerve distribution Walking and stationary bike with sling Avoid running and jumping due to the forces that can occur at landing No Treadmill No swimming, throwing or overhead sports
(3-4 Weeks) Appointments Rehabilitation appointments 1-2 times per week. Protect healing of repaired tissues Reduce pain and swelling in the post-surgical shoulder Controlled restoration of shoulder PROM & AAROM Correct postural dysfunction Promote dynamic stability Sling immobilization continuously, including while sleeping for 4 weeks No shoulder instability testing for 4 weeks No active extension, abduction, ER or horizontal abduction past body for 4 weeks (including reaching behind the back) Avoid long head biceps tension or AROM for 6 weeks (long lever arm SHLD flex, resisted supination or elbow flex) Avoid passive & active abd + ER at 90/90 for 6 weeks No weightbearing exercises through UE for 8 weeks Elbow/hand PROM Hand gripping Cervical spine & scapular AROM (depression, retraction, protraction) Seated thoracic extension/sidebending against chair Sub-maximal isometrics abd/add/er/ir Initiate rhythmic stabilization drills Initiate proprioception training Tubing ER/IR at 0 deg abduction Gradual introduction of AAROM (flex/abder/ir in protected planes) Gentle passive shoulder range of motion (based on patient tolerance) o Flexion to 90 degrees o Abduction to 75-85 degrees o ER in scapular plane to 25-30 degrees o IR in scapular plane to 55-60 degrees Massage to scapular muscles, deltoid/arm (avoiding incisions) Scapular mobilizations (grade II-III) Grade I-II posterior glides of humeral head for pain relief Desensitization techniques for axillary nerve distribution Walking and stationary bike with sling Avoid running and jumping due to the forces that can occur at landing No Treadmill No swimming, throwing or overhead sports
Progression Criteria 5 weeks after surgery Symmetrical mobility of bilateral SC, AC, scapulothoracic joints Ability to protract, retract, elevate and depress the scapula against manual resist Minimal to no pain with submaximal isometrics at 0 deg abduction (5-6 Weeks) Appointments Rehabilitation appointments 1-2 times per week. Protect healing of repaired tissues Reduce pain and swelling in the post-surgical shoulder Controlled restoration of shoulder PROM to AAROM Correct postural dysfunction Promote dynamic stability Avoid long head biceps tension or AROM for 6 weeks (long lever arm SHLD flex, supination or elbow flex) Avoid passive & active abd + ER at 90/90 for 6 weeks No weightbearing exercises through UE for 8 weeks No resisted bicep strengthening until 12 weeks Elbow/hand PROM Hand gripping Cervical spine & scapular AROM (depression, retraction, protraction) Seated thoracic extension/sidebending against chair Sub-maximal isometrics abd/add/er/ir Rhythmic stabilization drills & proprioception training Tubing ER/IR at 0 deg abduction Gradual introduction of AAROM (flex/abd/er/ir in protected planes) o Pulleys, cane elevation, pendulums Initiate active ROM at 90 degrees abduction without resistance Initiate full can exercises without resistance Initiate prone row, prone horizontal abduction Passive/active assisted shoulder range of motion (based on patient tolerance) o Flexion to 145 degrees o Abduction to 90 degrees o ER at 45 deg abduction: 45-50 degrees o IR at 45 deg abduction: 55-60 degrees Massage to scapular muscles, deltoid/arm (avoiding incisions) Initiate stretching exercises
Grade II-III posterior glides of humeral head for restricted capsule Rhythmic stabilization drills; PNF with manual resistance Desensitization techniques for axillary nerve distribution Walking and stationary bike Avoid running and jumping due to the forces that can occur at landing No Treadmill No swimming, throwing or overhead sports Progression Criteria 7 weeks after surgery Phase II: Intermediate Phase- Moderate Protection Phase (7-9 Weeks) Appointments Rehabilitation appointments are once every 1-2 weeks Preserve integrity of the surgical repair Restore muscular strength (rotator cuff strength at neutral) and balance Gradual restoration of full AROM Gradual initiation of bicep tension & AROM elbow flex/ext Avoid aggressive stretching into ER at 90deg abd No weightbearing exercises through UE for 8 weeks No resisted bicep strengthening until 12 weeks PNF/rhythmic stabilization strengthening Progress isotonic strengthening program (AROM) Proprioception training Tubing ER/IR at 0 deg abduction Active shoulder range of motion (based on patient tolerance) o Flexion to 170-180 degrees o Abduction to 90 degrees o ER at 90 deg abduction: 90-95 degrees o IR at 90 deg abduction: 70-75 degrees (avoid up the back) May begin AROM bicep Initiate Thrower s Ten Program Strengthening of external rotators & scapular stabilizers o Active sidelying SHLD flexion o Active SHLD abd in supine/prone o Scapular squeezes o Prone Row o Prone horizontal abduction
Progression Criteria 10 weeks after surgery Passive/active assisted shoulder range of motion as needed Manual posterior glides of humeral head for posterior capsule extensibility Rhythmic stabilization/manually resisted PNF patterns Walking and stationary bike without using arms (no Airdyne) No treadmill or running No swimming, throwing or overhead sports (10-12 Weeks) Appointments Rehabilitation appointments are once every 1-2 weeks Gradually restore full thrower s ROM by week 12 Preserve integrity of surgical repair Restore muscular strength and balance No resisted bicep strengthening until 12 weeks May initiate slightly more aggressive strengthening o Balance board in push up position (rhythmic stab) o Prone swiss ball walk outs o Rapid alternating movements in supine o D2 diagonal closed kinetic chain stab with narrow BOS Progress ER to Thrower s Motion o ER @ 90deg abd: 110-115 in throwers Progress isotonic strengthening exercises o Rowing with theraband or resistance machines o IR/ER strengthening at 90deg abduction (theraband, cable column, dumbbell) Dual hand plyometrics, progress to one handed plyometrics at 12 weeks Continue all stretching exercises to achieve ROM to functional demands (ie OH athlete) Continue all strengthening exercises o Prone flexion o Prone horizontal abduction o Full can exercise o D1/D2 diagonals in standing Posterior glides and sleeper stretch if posterior capsule tightness is present upon assessment Walking, biking, stairmaster and running (if phase II criteria are met) No swimming, throwing or overhead sports
Progression Criteria 12 weeks after surgery Full non-painful AROM Satisfactory stability Muscular strength (4/5 or better) No pain or tenderness Phase III: Minimal Protection Phase (12-16 Weeks) Appointments Rehabilitation appointments are 1-2 times per week Regain normal ROM for athletes through plyometric exercise Establish and maintain full PROM & AROM Improve muscular strength, power and endurance Gradually initiate functional activities All exercises and activities to remain non-provocative and low to medium velocity Avoid activities where there is a higher risk for falling or outside forces to be applied to the arm Continue all stretching exercises (capsular stretches) Maintain Thrower s Motion (especially ER) May begin resisted bicep and forearm supination exercises Continue strengthening exercises o Throwers Ten Program or Fundamental s o PNF Manual resistance o Endurance training o Light plyometric program o Restricted sport activities (ie light swimming, half golf swings) Assess posterior capsule extensibility Progression Criteria 16 weeks after surgery Walking, biking, stairmaster and running (if phase II criteria are met) No swimming for exercise
(16-20 Weeks) Appointments Rehabilitation appointments are once every 3 weeks Progression Criteria Regain normal ROM for athletes through plyometric exercise Establish and maintain full PROM & AROM Improve muscular strength, power and endurance Gradually initiate functional activities All exercises and activities to remain non-provocative and low to medium velocity Avoid activities where there is a higher risk for falling or outside forces to be applied to the arm Continue all exercises from Week 12-16 Continue all stretching Continue Thrower s Ten Program Continue Plyometric Program o Higher velocity strengthening & control, such as inertial, plyometrics and rapid exercise band drills. o Plyometrics should start with 2 hands below shoulder height and progress to overhead, then back to below shoulder with one hand, progressing again overhead Initiate interval sport program (throwing, etc) o Begin education in sport specific biomechanics with very initial program for throwing, swimming or OH sports o Dumbbell and medicine ball exercises that incorporate trunk rotation and control with rotator cuff strengthening at 90 deg abduction; begin working towards more functional activities by emphasizing core and hip strength and control with shoulder exercises Posterior glides and sleeper stretch if posterior capsule tightness is present upon assessment Walking, biking, stairmaster and running (if phase II criteria are met) No swimming 20 weeks after surgery Full non-painful AROM Satisfactory static stability Muscular strength 75-80% of contralateral side No pain or tenderness These rehabilitation guidelines were developed collaboratively by Lindsey Colbert, PT, DPT (colbertl@health.missouri.edu) and the Missouri Orthopaedic Institute physician group. These guidelines listed are just that, guides to assist the clinician in progression, but at no time are to be taken as concrete for timing or need of progression.
Each tear and repar is unique and needs to be progressed based on tissue injured, extent of injury, comorbidities and physiologic healing time frames. Updated 07/2014 References Wilk, K. E., Macrina, L. C., Cain, E. L., Dugas, J. R., & Andrews, J. R. The Recognition and Treatment of Superior Labral (SLAP) Lesions in the Overhead Athlete. International J of Sports Physical Therapy, 2013;8(5), 579-600. Barber, A., Field, L. D., & Ryu, R. K. Biceps Tendon and Superior Labrum Injuries: Decision-Making. J of Bone & Joint Surgery, 2007:89, 1844-55 Maxey, L., & Magnusson, J. Rotator Cuff Repair and Rehabilitation. Rehabilitation for the postsurgical orthopedic patient (2013). St. Louis: Elsevier Mosby Reinold, M., & Curtis, A. Microinstability of the Shoulder in the Overhead Athlete. The International Journal of Sports Physical Therapy, 2013:8(5), 601-616. Wilk, K. E., Reinold, M. M., Dugas, J. R., Arrigo, C. A., Moser, M. W., & Andrews, J. R. Current Concepts in the Recognition and Treatment of Superior Labral (SLAP) Lesions. J of Orthopaedic & Sports Physical Therapy, 2005:35(5), 273-291.