Acute Phase (0-4 weeks):Precautions:
- Avoid shoulder active range of motion (i.e.overhead activities per physician orders).
- Continue use of sling during standing activities or support arm with pillows during sitting and lying .
- Avoid AROM into IR.
- No ER beyond 45 degrees at 0 ABD and no ABD beyond 90.
- Neck flexibility.
- Elbow and forearm AROM .
- Pulley: forward flexion to tolerance and abduction limited to 90 degrees.
- Pendulum exercises.
- Gripping exercises: theraputty, balls, grippers.
- Cane AAROM: ER limited to 45 degrees at 0 ABD, FF to tolerance, scaption limited to 90 degrees.
- Table slides.
- Passive range of motion limit ER to 45 at 0 ABD and limit ABD to 90.
- Deep friction massage to scar.
- Discontinue routine use of sling at 4 weeks post-operatively.
- Follow above precautions as indicated by physician.
- Resistive elbow, wrist, and hand therapeutic exercises.
- Begin gentle isometrics: FF, ABD, ER, EXT.
- Pulleys: AAROM flexion and scaption to tolerance.
- Cane: FF, ABD, IR, and ER at 0 ABD to tolerance.
- Wall slides into FF and ABD.
- PROM to tolerance in all planes other than ER at 0 ABD only.
- Perform DFM to scar.
- Isotonic/tubing: scapular retractions.
- AROM: ER sidelying, supine FF, and side lying ABD
- AROM progress to standing FF and ABD (demonstrating good scapulohumeral rhythm/biomechanics)
- 4 weeks: begin light isotonic/tubing resistive strengthening into shoulder EXT, ADD, and ER).
- Perform rhythmic stabilization: FF/EXT (at 100 degrees of FF) and IR/ER (at 45 degrees of ABD).
Subacute Phase (6 weeks):
- PROM (achieve 80-90% of available range).
- Advance external rotation ROM as tolerated at 90 ABD.
- Continue isotonic/tubing therapeutic exercise program.
- Add IR strengthening.
- Advance strengthening (prone FF, EXT, and horizontal ABD with dumbbells; advance IR/ER strengthening to 90 degrees of ABD.
- Continue rhythmic stabilization .
- Initiate closed chain stabilization exercises in standing (i.e. wall pushups).
- PROM (full range)
- Continue isotonic strengthening rotator cuff and scapular stabilizers.
- Progress closed chain stabilization exercises against body weight (i.e. table pushups progressing to floor, swiss ball).
Dynamic Strengthening Phase/Remodeling Phase (10+ weeks):
- Advance flexibility, strength, power, and endurance training.
- PNF patterns with resistance.
- Throwers 90/90 IR and ER (slow/fast sets).
- CKC strengthening and stabilization therapeutic exercise progressions.
- At 12-15 weeks: initiate plyometrics (D2 extension plyometrics/ER and IR (at 90 degrees of ABD) plyometrics).
- Begin sports specific activities.
- Return to sports per physician’s orders.