This protocol is intended to be a general outline only. The physician reserves the right to either advance or delay this protocol as deemed necessary. If so, this should be done by direct communication with the therapist, or in writing on the therapy referral form given to the patient on the day of surgery.
0-1 Weeks Post-Op: General Guidelines – 1 visit
Precautions: Protect the subscapularis, bony union of the coracoid, biceps and coracobrachialis. No aggressive shoulder extension or ER for the first 6-8 weeks. No AROM or PROM of shoulder.
- Minimize shoulder pain, decrease inflammation, protect repair.
- Patient should wear Ultrasling with abduction wedge for first 6-8 weeks.
- AAROM bicep curls without weight, and AROM grip strengthening. These should be performed supine in gravity-eliminated position with the shoulder in neutral.
- One week after surgery, patient may begin light aerobic exercise (bike, walk) while wearing sling for cardiovascular fitness
- Ice for several times/day for pain and inflammation control
Week 1-6: Patient seen 2-3 visits/week
Precautions: No AROM. No excessive ER (stop at end feel). No lifting, pushing, or pulling. Prevent shoulder extension with pillow behind elbow in supine.
Goals: Minimize shoulder pain, decrease inflammation, protect repair. There should be minimal to no pain with exercises.
PROM Goals by end of Week 6: 100° flexion, 30° ER, 45° IR, 30° abduction.
- Continue use of Ultrasling with abduction wedge. Discontinue at 6 weeks.
- Continue elbow curls without weight and ball squeezes for circulation
- Begin supported pendulum exercises, shoulder shrugs, scapular retraction, scapular depression, and lawnmowers
- Supine PROM for flexion to tolerance. ER to 30 degrees in 30 degrees of abduction. IR to 45 degrees in 30 degrees of abduction in all scapular planes.
- Cane exercises for AAROM flex and ER
- At Week 2, begin pulley exercises for additional AAROM in planes of flexion to tolerance, and AAROM scaption to 30 degrees.
- At Week 6, submaximal (20-50% effort) isometrics for shoulder musculature in standing or supine
Week 6-10: Patient seen 2-3x/week
Precautions: No Pushing Pulling or lifting. No excessive
Goals: Protect repair. Obtain full PROM by Week 10 with limits (see below).
- Discontinue sling at Week 6.
- Continue above exercises,
- At 6 weeks – Begin posterior capsule stretching
- At 8 weeks – Begin scapulothoracic and isometrics in supine.
- At 8 weeks – Begin joint mobilizations.
- At 8 weeks – Progress ER past 30° at 0-40° abduction
- At 10 weeks – Obtain full PROM with ER to 80°, 170° of elevation, full IR.
Week 10-16: Patient seen 1-2x/week
- Precautions: No above the shoulder strengthening until 4 months post-op. No pain with AROM initiated at Week 12. Continue to avoid activities that place excessive load on anterior shoulder structures.
No resisted strengthening until full PROM/AROM is achieved
Goals: Good shoulder mechanics without pain. Improve Strength and neuromuscular control.
- At 10 Weeks – begin resistive biceps strengthening
- At 12 weeks – closed-chain ball circles on wall at shoulder height, resisted rows
- At 12 weeks – begin AROM gravity neutral for flex and abd to shoulder height. Progress above shoulder height, then progress to anti-gravity AROM.
Week 16 to 6 Months Post-Op: Patient seen as needed
Begin active strengthening above shoulder at 16 weeks.
Goals for Discharge: Full strength of rotator cuff, deltoid, and periscapular muscles
- At 16 weeks – begin resisted strengthening above the shoulder
- At 16 weeks – progress elastic band or pulley-resisted flexion, horizontal abduction/adduction, lat pull-downs
- PNF D1 and D2 diagonal AROM
- Add UE plyometric exercises with balls
- Facilitate return to weightlifting equipment for bilateral upper extremities with progressive weights. Focus on pecs, lats and deltoids. Begin with light weights at higher reps, then progress weights gradually.
- Racquet sports: At 5-6 months, initiate functional pattern exercises with tubing, pulley, free weights, etc. Progressive return to sport by 6 months if pain free.
- Throwing sports: At 6 months post-op, initiate throwing program as deemed appropriate by therapist and physician.
- Contact sports: none until 9 months post-op.
Guidelines for Return to ADL’s
Patient may return to work and sport activities involving lifting at ~6 months post-op, depending on the patient’s specific work and sport requirements. Patient must achieve full rotator cuff, deltoid, and parascapular strength and demonstrate ability to perform work duties or sport activities without pain and with proper form.
- Passive ER should never be performed past 80° by the therapist
- No incline or flat bench press for 1 year
- No deep pushups (only to neutral shoulder to elbow position)
- No shoulder dips for 1 year
- No behind-the-head military press or lat pull dow – permanently restricted
Revised 5.18.13 TJB