Initial Protective Phase (0-4 weeks post operative):Precautions:
- Avoid active shoulder elevation.
- Continue use of sling unless the arm is supported while sitting.
- No internal rotation behind the back until 4 weeks post op.
- No shoulder horizontal adduction until 4 weeks post op.
- No elevation beyond 90 degrees until 4 weeks post op.
- Full AROM elbow, wrist and hand.
- Codman pendulum exercise.
- External rotation PROM, AAROM and AROM to tolerance at 0 and 45 degrees of abduction.
- Flexion and abduction AAROM and PROM limited to 90 degrees.
- Light sub maximal isometric abduction, external rotation, internal rotation, and extension.
Intermediate Phase (weeks 4-5)
- Discontinue use of sling.
- Progress flexion and abduction PROM, AAROM, and AROM to tolerance beyond 90 degrees elevation.
- Begin internal rotation flexibility and AAROM behind the back to tolerance.
- Start AROM to tolerance in all planes of motion beginning in gravity lessened positions and progressing against gravity as tolerated.
- Continue sub maximal isometric flexion, abduction, external rotation and extension.
- Progress PROM in all planes to full.
Strength Phase (weeks 6-9):
- Continue progressive PROM and AAROM all planes to achieve full shoulder ROM.
- Continue AROM exercises.
- Start progressive resisted exercise shoulder flexion, abduction, external and internal rotation, horizontal abduction and adduction. Do not go beyond neutral horizontal adduction.
- Start rhythmic stabilization exercise: internal and external rotation at 0 degrees, 45 degrees, and 90 degrees abduction and flexion and extension at 90 degrees flexion, horizontal abduction and adduction at 90 degrees flexion.
- Start closed chain stabilization exercise in standing (i.e. wall pushups).
- Begin horizontal adduction flexibility if needed at 8 weeks post operatively.
Advance Strength and Stabilization (weeks 10-11):
- Continue progressive resisted exercise as above.
- Start rotator cuff strengthening at 90 degrees abduction.
- Progress closed chain stabilization exercise against body weight (i.e. table pushups progressing to floor, swiss ball stabilization).
Advanced Plyometric and Throwing Phase (week 12):
- Continue strengthening as above.
- Begin plyoball training.
- Begin throwing progression.
- Simulate sport specific motion for over-head athletes.