Rehab Protocols
Rotator Cuff Repair
Most repairs are now performed arthroscopically so there is less tissue trauma and reduced risk of adhesions. Post-op stiff shoulder is now rarely a problem, so the priority is to protect the repair from breaking down. The protocols are based on maintaining range of movement in the first phase and then gradually building strength in the middle to last phase.
Always be guided by the patient’s pain. Do not force, stretch or stress the repair before 6 weeks. Protocol selection will be determined not just by the size of tear, but also the shape of the tear, strength of repair and general tissue & joint condition. If a biceps tenodesis has been performed avoid stretching into full elbow extension for 6 weeks (see protocol).
Always check the Surgical notes and post operative instructions.
Educate patients about basic rotator cuff function and lever principles to reduce the risk of stressing the repair prematurely. Advise on importance of physiotherapy rehabilitation / advice and likely future appointments.
Consideration should always be given to the individual patients’ ability. Progression should be tailored to the individual patient but the times quoted should be the earliest active movement, and strengthening exercises begins.
(1) SMALL:
Day 1 – 3 Weeks
Polysling – to be worn at all times, apart from when washing and doing specific exercises.
Elbow, wrist, hand and finger exercises
Neck ROM exercises
Initiate scapula setting
Begin pendular exercises
2 Weeks – Review by Consultant / team
3 Weeks
Commence Physiotherapy. DO NOT FORCE OR STRETCH
Wean off sling (may be delayed till 6 weeks)
Continue pendular exercises
Progress to active-assisted flexion, extension, abduction and rotation as comfortable.
Initiate gentle cuff isometric exercises as pain allows
Encourage normal function around waist level
6 Weeks
May begin active exercises if appropriate, gently progressing into range
Commence anterior deltoid exercises as range allows
Commence rotator cuff strengthening and closed chain exercises
Start gently stretching limited movements
Encourage functional movement within pain limits
Proprioceptive exercises and core stability work
(2) MEDIUM/LARGE:
Day 1 to 3 Weeks
Polysling with body belt – to be worn at all times, apart from when washing and doing specific exercises.
Elbow, wrist, hand and finger exercises
Neck ROM exercises
Initiate scapular setting
2 Weeks – Review by Consultant / team
3 Weeks
Body belt removed
Sling retained
Begin pendular exercises
6 Weeks
Wean out of sling
Commence physiotherapy. DO NOT FORCE OR STRETCH
Initiate gentle cuff isometrics as pain allows
Continue pendular exercise, progress to active-assisted flexion, extension, abduction and rotation as comfortable
Progress to active exercises, adding resistance as appropriate
Start gently stretching limited movements
Encourage functional movements at waist level
Anterior deltoid strengthening exercises as range of movement allows
Start rotator cuff strengthening progressively, dependent on pain
Add closed chain exercises
Begin proprioceptive exercises and core stability work
(3) MASSIVE
Day 1 to 3 Weeks
Polysling with body belt (+/- abduction pad) – to be worn at all times, apart from when washing and doing specific exercises.
Elbow, wrist and finger exercises
Neck ROM exercises
Initiate scapula setting
2 Weeks – Review by Consultant / team
3 Weeks
Abduction pad retained, unless otherwise stated by Consultant
Sling retained
Avoid External rotation past neutral
6 Weeks
Remove abduction pad if not already done so
Commence physiotherapy. DO NOT FORCE OR STRETCH
Wean out of sling slowly
Begin pendular exercises
Begin active-assisted exercises – initially flexion in supine
Gentle rotator cuff isometrics, pain limiting
Encourage normal function around waist level
8 Weeks
Start stretching if appropriate
Gradually progress to active exercises
Add resisted rotator cuff exercises within pain limits
Anterior deltoid strengthening as range of movement allows
Add closed chain exercises
Begin proprioceptive skills and core stability work
Encourage functional movement within pain limits
Return to Functional Activities
These are approximate and will differ depending upon the individual. However, they should be seen as the earliest that these activities may commence.
Driving
Small tear 4-6 weeks; med/large tear 8+ weeks. Patients should be able to put their hands at the ’10 to10′ position and perform an emergency break.
Swimming
Breaststroke – MINOR/MEDIUM 6 weeks, MAJOR 12 weeks
Freestyle – MINOR/MEDIUM 3 months, MAJOR unlikely to progress
Golf
3 months
Lifting
No heavy lifting for 3 months. After this be guided by the strength of patient.
Return to work
Dependent upon the patient’s occupation.
With minor and medium tears, patients in sedentary jobs may return at 6 weeks.
Major tears may take at least 8 weeks.
Manual workers should be guided by the surgeon.
Arthroscopic / Open Anterior stabilisation
The operative procedure is performed to correct recurrent dislocations and will involve soft tissue, and/or bony reconstruction.
Day 1 Post-op
Polysling with body belt attached for 2-3 weeks.
Finger, wrist and radio-ulnar and scapular movements.
Assisted elbow flexion and extension in standing (in sitting with SLAP lesion)
Neck ROM exercises
Teach axillary hygiene
Teach postural awareness
2-3 Weeks
Patient attends review and removal of stitches and body belt.
Gentle pendular exercises into flexion/extension and circumduction only
4-6 Weeks
The sling is removed and the patient begins formal physiotherapy
Regain scapular and gleno-humeral stability working for shoulder joint control.
Gradually increase range of movement – do not push external rotation.
Strengthen the rotator cuff muscles.
Increase proprioception, using open and closed chain exercise.
Incorporate core stability work as appropriate
*No abduction coupled with external rotation until 3 months.
Return to Functional Activities
Driving 8 weeks
Return to work – Light duties as tolerated after 2-4 weeks. Heavy duties at 3 months
Swimming
Breaststroke at 8 weeks
Golf – 3 months
No Contact sports for 6-9 months – Contact sport including: horse riding, rugby, football, martial arts, racquet sports, wind surfing, handgliding and rock climbing.
Total Shoulder Arthroplasty / Hemiarthroplasty of the shoulder
This operative procedure is performed in cases of severe Osteo or Rheumatoid arthritis where pain is the predominant feature. The hemi arthroplasty is the usual method of choice. Early mobilisation is encouraged.
As subscapularis is released and reattached to the anatomical neck of humerus at the end of the procedure, there should be no resisted internal rotation for the first three weeks and care should be taken with the range of external rotation.
Post op: Day 1
Polysling fitted in theatre
Cryocuff to reduce inflammation
Finger, wrist and elbow ROM exercises
Shoulder girdle exercises and postural awareness, Neck ROM exercises
Day 2 (Discharge)
Axillary hygiene taught
Pendular exercises
Passive flexion/extension in scapular plane in supine
Discharge to 3 Weeks
Remove sling when comfortable
Pendular exercises continued
Isometric strengthening exercises of all muscle groups (except IR)
Begin passive abduction (maintain shoulder in IR)
Begin passive external rotation to neutral only.
Begin active assisted flexion in supine and progress to sitting position as soon as the patient is able. Progress to active when possible.
3 Weeks – 6 Weeks
Encourage the patient to actively move into all ranges. Gentle assisted stretching exercise to increase range – do not force inner range ER
Add isometric IR – sub maximally and only if pain free
Commence isometric theraband exercises – resistance dependent on individual
N.B. Take care with IR
Encourage proprioceptive exercises-weight and non weight bearing
6 Weeks
Progress strengthening and include anterior deltoid exercises
Continue to regularly stretch the joint to end of its available range
Can begin breaststroke if pain and range of movement allows
How well the patient progresses and the outcome will depend on the condition of the joint and soft tissues preoperatively. A better outcome is expected with patients whose joint is replaced for primary OA. Improvement continues for 18 months to 2 years and the patient should continue exercising until their maximum potential has been reached. The protocol outlined applies to patients with an intact rotator cuff. If a rotator cuff repair has been carried out in addition, the therapist should adhere to the strengthening protocol for the repair.
Return to Functional Activities
These are approximate and may differ depending upon each patient’s individual achievements. However, they should be seen as the earliest that these activities may commence.
Driving After 4 weeks
Swimming: Breaststroke 6 weeks, Freestyle 3 months
Golf 3 months
Light lifting can begin at 3 weeks. Avoid lifting heavy items for 6 months.
Return to work – Dependent upon the patient’s occupation: Those with sedentary jobs may return at 6 weeks; Manual workers or those whose occupations demand excessive shoulder use should be guided by the surgeon.
Reverse Total Shoulder Replacement
The reverse total shoulder replacement is designed for shoulders that have severe arthritis with a deficient rotator cuff or following complex fractures with a deficient rotator cuff.
The design changes the mechanics of the shoulder allowing pain relief and an improvement in function and stability, particularly when using the arm in front and above shoulder level.
The operation is carried out under general anaesthetic and a nerve block, with the incision being approximately three inches long on the front-side of the shoulder. The arm is then placed in a sling with body belt.
Post Op: Day 1
Polysling fitted in theatre
Finger, wrist and elbow exercises
Shoulder Girdle exercises and postural awareness
Neck ROM exercises
Day 2 (Discharge)
Axillary hygiene taught
Maintain exercises as above
Start GENTLE pendular swinging in forward leaning
Discharge – Week 3
Start PASSIVE shoulder exercises – Flexion/extension, Int/external rotation
(Do NOT force any movement) as instructed by your physiotherapist
Use analgesia as required, regularly, to allow maximum comfort during all
arm exercises and daily functions
Week 3 – 6
Start formal physiotherapy – to increase range of motion. Start with active assisted ROM exercises
Advice on analgesia
Continue pendular exercises
Avoid forcing any movement. Do not push the shoulder into painful positions.
Start Deltoid strengthening
Wean from sling as comfortable but always wear sling when outdoors.
Continue to stretch regularly throughout the day, where possible in lying,
maintaining good range of movement in the elbow, wrist and hand.
Slowly increase the daily use of the arm, but avoid painful activities
Week 6 – 12
Continue with physiotherapy, as instructed
Increase the Deltoid regime
Stop wearing the sling
Continue stretches maximising range of motion in all directions
Use the arm and hand as fully and normally as possible, in comfortable positions
Week 12 – Clinic Review
Continue stretches maximising range of motion in all directions
Continue with physiotherapy, as instructed
Increase the Deltoid regime
Use the arm and hand as fully and normally as possible, in comfortable positions.
Biceps tenodesis and SLAP repair
The operative procedure is performed for conditions involving the long head of biceps tendon or its insertion to the labrum.
Day 1 Post-op
Polysling for 3 weeks.
Finger, wrist and radio-ulnar and scapular movements.
Assisted elbow flexion and extension in supine position. Avoid forced straightening of the elbow or heavy lifting for at least 6 weeks.
Neck ROM exercises
Teach axillary hygiene
Teach postural awareness
2 Weeks – Review by Consultant / team
Patient attends review and removal of stitches and body belt.
Gentle pendular exercises into flexion/extension and circumduction only
4 Weeks
The sling is removed and the patient begins formal physiotherapy
Gradually increase range of movement.
Muscle strengthening exercises.
Return to Functional Activities
Driving 6 weeks
Return to work
Light duties as tolerated after 6 weeks. Heavy duties at 3 months
Swimming – Breaststroke at 8 weeks
Golf – 3 months
No Contact sports for 6 months – Contact sport including: horse riding, rugby, football, martial arts, racquet sports, wind surfing, handgliding and rock climbing.
AC Joint reconstruction
This operative procedure aims to stabilise the acromio-clavicular joint.
Day 1 Post-op
Polysling and body belt for 6 weeks
Finger, wrist and Radio-ulnar ROM exercises
Supported elbow flexion and extension in standing
Teach axillary hygiene
Teach postural awareness
2 Weeks – Review by Consultant / team
3 Weeks
Retain mastersling until week 6, but the bodybelt is removed.
Start gentle pendular exercises
6 Weeks
The sling is removed and the patient begins formal physiotherapy
Avoid all range of movement above shoulder height until 12 weeks.
Aims of Physiotherapy
Regain scapular and gleno-humeral stability working for shoulder joint control rather than range
Gradually increase range of movement
Strengthen the rotator cuff muscles
Progress proprioception through open and closed chain exercises.
Incorporate core stability exercises
Return to Functional Activities
Driving 6 weeks
Return to work, light duties as tolerate heavy duties at 4 months.
Swimming: Breaststroke 8 weeks
Golf 4-6 months
Contact sport 6 months – including horse riding, football, rugby, martial arts, racquet sports, and rock climbing
Anterior Deltoid Strengthening
These exercises are often used when your rotator cuff muscles are not working due to a full or partial tear. They aim to strengthen your anterior deltoid muscle to allow you to elevated your arm, and take over the role of the ineffectual rotator cuff.
Rehabilitation is slow as it takes time to strengthen the muscles, but can often be very successful.
These exercises should not worsen pain. Speak to your physiotherapist if you feel they are aggravating / causing pain and reduce / stop the exercises in the meantime.