This protocol is intended to be a general guideline. The physician staff may advance, delay, or alter this protocol based on individual patient status. If so, this should be done by direct communication with the therapist, or in writing on the therapy referral form provided to the patient or therapist.
This protocol should be modified to incorporate functional milestones for individual patient goals as indicated.
Guidelines for MD Follow-Up Visits (including telehealth)
- At two weeks post-op, patient will be seen in clinic for removal of stitches and follow up.
- At six weeks post-op, patient may be seen by physician extender through telehealth video communication during an in-clinic PT session to connect with patient and treating therapist and discuss current ROM and strength status.
- Additional follow-ups with MD and physician extender staff will be scheduled as needed.
Guidelines for Wound Care
- Original steri-strips should be left in place until stitch removal. They can be reinforced with more steri-strips if needed.
- On Day One post-op, patient can remove bulky post-op cotton and gauze dressings. Patient will be instructed to wrap shoulder in “press and seal” plastic wrap for showering until 3-5 days after stitches are removed (make sure wounds are fully healed before being exposed to water).
Week 0-2 Post-Op: General Guidelines for At-Home Recovery
Precautions: No external rotation beyond 0°
Goals: Decrease pain, allow minimal passive motion. Patient should wear immobilizer sling for first 4 weeks, or as directed by physician. Patient will not be seen in PT unless directed by physician.
- Patient may use cryotherapy several times a day for pain and inflammation control
- Emphasis on use of abduction sling, HEP compliance, and adequate use of pain medication and other modalities to control pain
- Starting on the day of surgery, patient will perform the following exercises as instructed by physician or ancillary staff: Codman’s pendulum exercises, shoulder shrugs, scapular retraction, scapular depression, elbow curls without weight, and grip strengthening
- One week after surgery, patient may begin light aerobic exercise (bike, walk) while wearing sling for cardiovascular fitness
Phase I (Week 2 – 4): Patient to be seen 2-3x/week
Goals by end of Week 4: PROM scaption to 120° supine, ER to 30° supine w/arm abducted 45 degrees, IR to 60°
Precautions: No ER beyond 30° supine
- Continue use of abduction sling as directed by physician. May remove wedge at Week 4.
- Supine PROM for flexion, scaption, ER, and IR to torso
- Supine AAROM cane exercises for scaption, flexion, and ER to 30°
- Bicep curls with no more than 3 lbs.
- Lawnmowers, table lifts
- Submaximal (20-50% effort) isometrics for shoulder musculature in standing or supine
- Soft tissue mobilization as needed for cervicoscapular muscle tension
- Scapular mobilization in sidelying to promote proper scapulohumeral rhythm
- Scapular stabilization exercises (sidelying scapular isometrics, prone shoulder retraction and extension to neutral)
- Core strengthening exercises as indicated to promote proximal stability
Phase II (Week 5-8): Patient seen 2-3x/week
Goals by end of Week 8: PROM scaption to 160°, ER to 70° supine w/arm abducted 45 degrees, IR to table in supine.
Precautions: No ER beyond 70° in supine with arm abducted to 45°
- Wean off UE sling as tolerated. Maintain use in crowds or when on slippery surfaces.
- Begin pulley exercises for AAROM in planes of flexion and scaption
- Continue above exercises, gradually increasing abduction angle with ER PROM
- When full PROM is achieved, begin AROM through full ranges of motion in gravity-neutral positions
- Progress to wall fingerwalking exercises for flexion and abduction
- Tubing exercises for shoulder retraction and IR at side
- Quadruped exercises: closed-chain weight shifting, rhythmic stabilization
- Supine serratus anterior punches
- Add sidelying ER AROM without weight
- At Week 8, begin prone middle trap and lower trap strengthening exercises
Phase III (Week 9 – 12): Patient seen 1-2x/week (or as needed to achieve ROM goals)
Goals by Week 12: Full PROM and AROM with good scapulohumeral rhythm, improved deltoid and rotator cuff strength.
Precautions: Do not begin isotonic resisted strengthening until full PROM/AROM is achieved.
- Closed-chain ball circles/bounces on wall at shoulder height
- Add weights to sidelying ER, add ER with tubing in standing
- AROM flexion, scaption, PNF D1 and D2 diagonals, progressing to free weights
- Bodyblade drills
- Tubing or pulley resisted flexion, horizontal abduction/adduction, lat pulldowns
Final Stage: (Week 12 to 6 Months Post-Op): Patient seen as needed
Phase IV (Weeks 13-20): Patient seen 1x/week or more often if needed until functional goals are achieved.
Goals for Progression to HEP and Discharge: Full strength of rotator cuff, deltoid, and periscapular muscles, full use of arm for work/recreational activity.
- Advanced deltoid, cuff, and parascapular strengthening exercises
- Add towel stretch or same-side sidelying “sleeper” stretch for IR ROM if needed
- Add UE plyometric exercises with balls
- Progressive UE closed-chain drills, planks
- Return to weightlifting equipment for bilateral upper extremities with progressive resistance
- Perform standardized functional tests for UE if applicable (UE Y Balance Test, Closed Kinetic Chain UE Stability Test, etc.) to determine readiness for RTP
- For racquet sports, initiate functional pattern exercises with tubing, pulley, free weights, etc. at 5 months post-op. Begin volleys with racquet at 6 months if ready
- For throwing sports, initiate progressive throwing program at 6 months post-op if ready (see Dr. Chams’ website for throwing protocol)
- ER stretching should never be performed past 90° by the therapist
- No incline or flat bench press
- No shoulder dips
- No behind-the-head military press or lat pull-down
- No deep pushups (only to neutral shoulder-elbow position)
Revised May 22, 2020.