Maximally protect the surgical repair (capsule, ligaments, labrum, sutures)

Achieve staged ROM goals. DO NOT exceed them.

Patient education in postoperative restrictions

Minimize shoulder pain and inflammatory response

Ensure adequate scapular function

Patient education regarding limited use of the arm despite lack of pain or other symptoms

Protection of repair

Achieve staged ROM goals through gentle ROM activities

Minimize inflammation

Normalize scapular position, mobility, and dynamic stability

ROM of uninvolved joints

Begin restoration of shoulder strength

Most commonly a standard sling (glenohumeral joint in IR and adduction) is used for a range of 0–4 weeks.

Explain nature of the surgery

Discuss precautions specific to the nature of the surgical repair (abduction/ER stress the anterior inferior capsule)

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  Importance of meeting staged ROM goals (especially not gaining ROM too fast)

  
  
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  Importance of tissue healing

Proper sling use (assure sling provides upward support to the glenohumeral joint).

Limiting use of arm for ADLs

Strict sling immobilization of glenohumeral joint 0–4 weeks, followed by sling use when in the community or when the patient is up for long periods of time for the remainder of phase 1.

Following the strict immobilization period begin:

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  Pendulums (unweighted)

  
  
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  Passive/active assisted forward elevation in plane of scapula (PFE) to achieve staged ROM goals listed in table 1. ROM should not be forceful

  
  
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  Passive/active assisted external rotation (PER) with the arm supported and shoulder in slight abduction to achieve staged ROM goals listed in table 1. ROM should not be forceful

  
  
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  Scapular clock exercises or alternately elevation, depression, protraction, retraction; progress to scapular strengthening as patient tolerates

Submaximal rotator cuff isometrics as tolerated

AROM of uninvolved joints

Postural awareness/education

Activity restriction

Proper fitting of sling to support arm

Scar management.

Modalities PRN

Physician prescribed or OTC medications

Achieve staged ROM goals to normalize PROM and AROM. DO NOT exceed them.

Minimize shoulder pain

Begin to increase strength and endurance

Increase functional activities

Continued patient education

P/AAROM as needed to achieve staged ROM goals. DO NOT significantly exceed them.

Establish basic rotator cuff and scapular neuromuscular control within the allowed ROM

Introduction of functional patterns of movement

Progressive endurance exercises.

Counsel about using the upper extremity for appropriate ADLs in the painfree ROM (starting with waist level activities and progressing to shoulder level and finally to overhead activities over time).

Continue education regarding avoidance of heavy lifting or quick sudden motions.

Education to avoid positions of instability during ADLs such as end range external rotation, and combined abduction/external rotation.

P/AAROM as needed to achieve staged ROM goals in all planes. Many times only light stretching or no stretching is needed.

If ROM is significantly less than staged ROM goals, gentle joint mobilizations may be performed. However they should be done only into the limited directions and only until staged ROM goals are achieved.

Address scapulothoracic and trunk mobility limitations. Ensure normal cervical spine ROM and thoracic spine extension to facilitate full upper extremity ROM.

Address abnormal scapular alignment and mobility PRN

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  Strengthen scapular retractors and upward rotators (PREs or manually resisted exercises)

  
  
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  Increase pectoralis minor flexibility if limited (manual stretching, towel mobilizations)

  
  
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  Biofeedback by auditory, visual, or tactile cues

  
  
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  Closed chain exercises may be helpful (quadruped position while working to maintain proper position of the scapula, quadruped w/scapula protraction, progressing from quadruped to tripod position, NO PUSH-UPS )

Address core stability deficits PRN

Activities to improve neuromuscular control of the rotator cuff and shoulder girdle such as use of unstable surfaces, body blade, manual exercises (PNF).

Scapula and core strengthening (PREs, manually resisted exercises, core stabilization exercises)

Balanced rotator cuff strengthening to maintain the humeral head centered within the glenoid fossa during progressively more challenging activities.

Should be initially performed in a position of comfort with low stress to the glenohumeral joint such as

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  <45° elevation in the plane of the scapula (ex: elastic band or dumbbell external rotation, internal rotation, forward flexion, shoulder extension not past the plane of the body).

  
  
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  Exercises should be progressive in terms of muscle demand/intensity. It is suggested to use activities that have documented EMG activity. 9 , 10 , 13 , 15 , 21 , 30 , 33 , 35 , 37 Resisted activities should progress from assistive exercises (ex. rope/overhead pulley and/or finger ladder) to active exercises and finally the addition of external resistance (ex. elastic bands or 1–2 lbs. weight).

  
  
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  Exercises should also be progressive in terms of shoulder elevation (ex: start w/exercises performed at waist level progressing to shoulder level and finally overhead activities).

  
  
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  Nearly full elevation in plane of the scapula should be achieved before progressing to elevation in other planes.

  
  
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  Exercises should be progressive in terms of adding incremental stress to the anterior capsule, gradually working towards a position of elevated external rotation in the coronal plane—the “90-90” position.

  
  
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  Rehabilitation activities should be pain free and performed without substitutions or altered movement patterns.

  
  
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  Rehabilitation should include both closed (ex: quadruped to tripod) and open chain activities.

  
  
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  Rehabilitation should also include both isolated and complex movement patterns.

  
  
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  Depending upon the goals of the exercise (control vs. strengthening), rehabilitation activities can also be progressive in terms of speed once the athlete demonstrates proficiency at slower speeds.

  
  
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  The rotator cuff and scapula stabilizer strengthening program should emphasize high repetitions (about 30–50 reps) and relatively low resistance (about 1–3 lbs).

  
  
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  No heavy lifting or plyometrics should be performed during this stage.

  
  
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  Elbow flexion/extension strengthening with arm at side (shoulder 0-degree elevation) can begin in this phase and progress as appropriate.

Modalities PRN

Ensure appropriate use of arm during ADLs

Ensure appropriate level of therapeutic interventions

Weaning from use of medications