PHYSIOTHERAPY REHABILITATION GUIDELINES 2017-07-09T21:49:08+00:00

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.