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.
Therapeutic Exercises:
  • 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.

(4 weeks):

  • Discontinue routine use of sling at 4 weeks post-operatively.
  • Follow above precautions as indicated by physician.
Therapeutic Exercises:
  • 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).

(10 weeks):

  • 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.

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