Phase 1: Immediate postoperative period (weeks 0-6)
Goals
Maintain / protect the integrity of repair
Gradually increase PROM
Diminish pain and inflammation
Prevent muscular inhibition
Become independent with modified ADLs
Precautions
Maintain arm in KnappSak2, remove only for exercise
No shoulder AROM, lifting of objects, shoulder motion behind the back, excessive stretching or sudden movements, supporting of any weight, lifting a body weight by hands
Keep incision clean and dry
Criteria for Progression to Phase 2
Passive forward flexion to > 90°
Passive ER to 10°
Passive IR in scapular plane to > 75° (if uninvolved shoulder PROM > 80°)
Passive abduction > 90° in the scapular plane
Days 1 to 6
KnappSak2
Pendulum exercises
Finger, wrist, and elbow AROM
Begin scapula musculature isometrics / sets; cervical ROM
Cryotherapy for pain and inflammation
Days 3 to 6
Begin pulley exercises in forward flexion and abduction < 90°
Maintain proper posture, joint protection, positioning and hygiene
Days 7 to 28
Continue with KnappSak2 at night and day for comfort
Pendulum / pulley exercises
Begin PROM to tolerance (done supine; should be pain free)
Flexion to 90°
ER to 20°
IR to body / chest
Continue elbow, wrist, and finger AROM / resisted
Cryotherapy is needed for pain control and inflammation
May resume general conditioning program (e.g., walking, stationary bike) Aquatherapy / pool therapy may begin three weeks postoperative
Phase 2: Protection and active motion (weeks 6-12)
Goals
Allow healing of soft tissue
Do not overstress healing tissue
Gradually restore full PROM (weeks 4-5)
Decrease pain and inflammation
Precautions
No lifting
No supporting body weight with hands and arms
No sudden jerking motions
Avoid upper extremity bike and ergometer
Criteria for progression to Phase 3
Full AROM
Weeks 5-6
Discontinue KnappSak2 at night
Between weeks 4-6, use KnappSak2 for comfort only
Discontinue KnappSak2 at end of week 6
Initiate AAROM flexion in supine position
Progressive PROM until approximately full ROM at weeks 4-5.
Follow Flexion / ER guidelines.
Gentle scapular / glenohumeral joint mobilization to regain full PROM
Initiate prone rowing to the neutral arm position
Continue cryotherapy as needed
May use heat before ROM exercises
Aquatherapy OK for light AROM exercises
Ice after exercise
Weeks 6-8
Continue AROM, AAROM, and stretching exercises
Begin rotator cuff isometrics – No empty can in forward plane
Continue periscapular exercises
Initiate AROM exercises (flexion scapular plane, abduction, ER, IR)
* Please note: Patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonics; if unable, continue glenohumeral joint exercises
AAROM = active assisted range of motion
ADL = activity of daily living
AROM = active range of motion
ER = external rotation
IR = internal rotation
PROM = passive range of motion
ROM = range of motion
Phase 3: Early strengthening (weeks 10-16)
Goals
Full AROM (weeks 10-16)
Maintain full PROM
Dynamic shoulder stability
Gradual restoration of shoulder strength, power, and endurance
Optimize neuromuscular control
Gradual return to functional activities
Precautions
No lifting objects >5 pounds, sudden lifting or pushing activities, sudden jerking motions, overhead lifting
Avoid upper extremity bike and ergometer
Criteria for progression to Phase 4
Ability to tolerate progression to the low level functional activities
Demonstrated return of strength / dynamic shoulder stability
Reestablishment of dynamic shoulder stability
Demonstrated adequate strength and dynamic stability for progression to more demanding work- and sport-specific activities
Week 10
Continue stretching and PROM, as needed
Dynamic stabilization exercises
Initiate strengthening program
ER and IR with exercise bands / sports cord / tubing
ER side-lying (lateral decubitus)
Lateral raises *
Full can in scapular plane *
Prone rowing
Prone horizontal abduction
Prone extension
Elbow flexion
Elbow extension
Week 12
Continue all exercises listed above
Initiate light functional activities as permitted
Full can in forward plane *
Week 14
Continue all exercises listed above
Progress to fundamentals shoulder exercises
* Please note: Patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonics; if unable, continue glenohumeral joint exercises
Phase 4: Advanced strengthening (weeks 16-22)
Goals
Maintain full non-painful AROM
Advance conditioning exercises for enhanced functional use
Improve muscular strength, power and endurance
Gradual return to full activities
Week 16
Continue ROM and self-capsular stretching for ROM maintenance
Continue progression of strengthening
Advance proprioceptive, neuromuscular activities
Light sports (golf chipping / wedges, tennis ground strokes) if doing well
Week 20
Continue strengthening and stretching
Continue stretching if motion is tight
Initiate interval sports program (e.g., golf, doubles tennis) if appropriate
General Guidelines
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WEEKS
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Forward Flexion
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External Rotation
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|
0-2
|
90o
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10o
|
|
2-4
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110o
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20o
|
|
4-6
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130o
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30o
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|
6-8
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160o
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45
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8-12
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Full
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Full
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1) No pull-ups until 6 months post-op
2) Throwing activity - start at 4 to 6 months post-op. Follow function progression per SMOG program. Progress as tolerated.
3) Return to non-contact sports at 4 months post-op if PT goals have been met
4) No dips – until 6 months
5) Full return to throwing at 6-8 months
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