Initial Protective Phase (0-4 weeks post-operative):Precautions:
- No active shoulder elevation until 4 weeks post-op.
- Continue use of sling with abduction pillow unless the arm is supported while sitting.
- No shoulder horizontal adduction or horizontal abduction until 4 weeks post op.
- No passive abduction beyond 90 degrees until 4 weeks post op.
- No external rotation beyond 45 degrees at 0 degrees abduction until 4 weeks post op.
Therapeutic Exercise (0-4 weeks post-operative):
- Full AROM elbow, wrist and hand.
- Codman pendulum exercise.
- PROM/AAROM scaption to 90 degrees, ER to 45 degrees at 0 degrees ABD, flexion as tolerated.
- Light flexibility and AAROM internal rotation behind the back.
- Scapular elevation and retraction.
Intermediate Phase (4 weeks post-operative):
- Discontinue use of sling.
- PROM/AAROM scaption and flexion as tolerated.
- AROM: scaption – supine at 4 weeks, standing at 5 weeks, side- lying ER,prone row, extension at 4 weeks.
- PROM/AAROM ER at 0 abduction as tolerated.
- Progress sub maximal isometric flexion, abduction, external rotation, extension and scapular retraction.
Strength Phase (6 weeks post-operative):
- Continue progressive PROM and AAROM in all planes to achieve full shoulder ROM.
- Initiate external rotation and internal rotation ROM as tolerated at 90 degrees of abduction.
- Continue AROM exercises.
- Initiate progressive resisted exercise shoulder flexion, abduction, external and internal rotation, horizontal abduction,and adduction. Do not go beyond neutral horizontal adduction.
- Initiate rhythmic stabilization internal and external rotation at 0 degrees, 45 degrees, and 90 degrees abduction. Initiate flexion and extension rhythmic stabilization at 90 degrees flexion and horizontal abduction and adduction rhythmic stabilization 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-operative.
Advance Strength and Stabilization (weeks 8-10):
- Continue progressive resisted exercise as above.
- Initiate rotator cuff strengthening at 90 degrees of abduction.
- Progress closed chain stabilization exercise against body weight (i.e. table pushups progressing to floor, swiss ball stabilization).
Advanced Plyometric and Throwing Phase (weeks 10-12):
- Continue strengthening as above.
- Begin plyoball training.
- Begin throwing progression.
- Simulate sport specific motion for over-head athletes.