by Jason Boyer, M.D.
Immediate postoperative period (weeks 1 to 6)
1. Maintain / protect the integrity of repair.
2. Gradually increase PROM.
3. Diminish pain and inflammation Prevent muscular inhibition.
4. Become independent with modified ADLs.
1. Maintain arm in sling, remove only for exercise.
2. 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.
3. Keep incision clean and dry.
Criteria for Progression to Phase 2
1. Passive forward flexion to >125°.
2. Passive ER in scapular plane > 75°(if uninvolved shoulder PROM > 80°).
3. Passive IR in scapular plane to > 75°(if uninvolved shoulder PROM > 80°).
4. Passive abduction > 90°in the scapular plane.
Days 1 to 6
1. Sling at all times.
2. Pendulum exercises.
3. Finger, wrist, and elbow AROM.
4. Begin scapula musculature isometrics / sets; cervical ROM.
Days 3 to 6
1. Begin pulley exercises in forward flexion and abduction < 90°.
5. Maintain proper posture, joint protection, positioning and hygiene.
Days 7 to 28
1. Continue with sling at night and day for comfort.
2. Pendulum / pulley exercises.
3. Begin PROM to tolerance (done supine; should be pain free).
a. Flexion to 90°.
b. ER in scapular plane to 25-30°.
c. IR in scapular plane to 55-60°.
4. Continue elbow, wrist, and finger AROM / resisted.
5. Submaximal isometrics for all cuff, periscapular, and shoulder musculature.
6. Cryotherapy is needed for pain control and inflammation.
7. May resume general conditioning program (e.g., walking, stationary bike).
8. Aquatherapy / pool therapy may begin three weeks postoperative.
Protection and active motion (weeks 5-12)
1. Allow healing of soft tissue.
2. Do not overstress healing tissue.
3. Gradually restore full PROM (weeks 4-5).
4. Decrease pain and inflammation.
1. No lifting.
2. No supporting body weight with hands and arms.
3. No sudden jerking motions.
4. Avoid upper extremity bike and ergometer.
Criteria for progression to Phase 3
1. Full AROM.
1. Discontinue sling at night.
2. Between weeks 4-6, use sling for comfort only.
3. Discontinue sling at end of week 6.
4. Gradually improve PROM and AROM.
a. Flexion and elevation in the plane of the scapula to 145°.
b. Abduction to 145°.
c. External rotation 45-50° at 45° abduction.
d. Internal rotation 55-60° at 45° abduction.
e. Extension to tolerance.
5. Continue cryotherapy as needed.
6. May use heat before ROM exercises.
7. Aquatherapy OK for light AROM exercises.
8. Ice after exercise.
1. Continue AROM, AAROM, and stretching exercises.
2. Begin rotator cuff isometrics – No empty can in forward plane.
3. Continue periscapular exercises.
4. Gradually progress PROM and AROM.
a. Flexion, elevation in the plane of the scapula, and abduction to 180°.
b. External rotation 90-95° at 90° abduction.
c. Internal rotation 70-75° at 90° abduction.
d. Extension to tolerance.
Early strengthening (weeks 10-16)
1. Full AROM (weeks 10-16).
2. Maintain full PROM.
3. Dynamic shoulder stability.
4. Gradual restoration of shoulder strength, power, and endurance.
5. Optimize neuromuscular control.
6. Gradual return to functional activities.
1. No lifting objects >5 pounds, sudden lifting or pushing activities, sudden jerking motions, overhead lifting.
2. Avoid upper extremity bike and ergometer.
Criteria for progression to Phase 4
1. Ability to tolerate progression to the low level functional activities.
2. Demonstrated return of strength / dynamic shoulder stability.
3. Reestablishment of dynamic shoulder stability.
4. Demonstrated adequate strength and dynamic stability for progression to more demanding work- and sport-specific activities.
1. Continue stretching and PROM, as needed.
2. Dynamic stabilization exercises.
3. Progress ER PROM and AROM to thrower’s motion ER 110-115 at 90° abduction in throwers (weeks 10-12).
4. Progress shoulder isotonic strengthening exercises as above.
5. Continue all stretching exercises as need to maintain ROM.
6. Progress ROM to functional demands (i.e., overhead athlete).
1. Begin gentle resisted biceps isotonic strengthening at week 12.
1. Continue all exercises listed above.
2. Progress to fundamentals shoulder exercises.
Advanced strengthening (weeks 16-22)
1. Maintain full non-painful AROM.
2. Advance conditioning exercises for enhanced functional use.
3. Improve muscular strength, power and endurance.
4. Gradual return to full activities.
1. Continue ROM and self-capsular stretching for ROM maintenance.
2. Continue progression of strengthening.
3. Advance proprioceptive, neuromuscular activities.
4. Light sports (golf chipping / wedges, tennis ground strokes) if doing well.
1. Continue strengthening and stretching.
2. Continue stretching if motion is tight.
3. Initiate interval sports program (e.g., golf, doubles doubles tennis) if appropriate.
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
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