Appendix: The American Society of Shoulder and Elbow Therapists’ Consensus Rehabilitation Guidelines for Arthroscopic Anterior Capsulolabral Repair of the Shoulder

Phase I

(POW 1 to ∼ POW 6)


  • 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

Interventions to Avoid

  • Do not allow or perform ROM/stretching beyond staged ROM goals, especially ER by the side and end range ER in abduction.

  • Do not allow the patient to use their arm for heavy lifting or any use of the arm which requires ROM greater than the staged ROM goals.

Specific Interventions

Activities of Primary Importance:

  • 1

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

  • 2

    Protection of repair

  • 3

    Achieve staged ROM goals through gentle ROM activities

  • 4

    Minimize inflammation

Activities of Secondary Importance:

  • 1

    Normalize scapular position, mobility, and dynamic stability

  • 2

    ROM of uninvolved joints

  • 3

    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.

Patient Education

  • Explain nature of the surgery

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

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

    • 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:

    • Pendulums (unweighted)

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

    • 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

    • 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

Pain Management

  • Activity restriction

  • Proper fitting of sling to support arm

  • Scar management.

  • Modalities PRN

  • Physician prescribed or OTC medications

Milestones to Progress to Phase II

  • 1

    Appropriate healing of the surgical repair by adhering to the precautions and immobilization guidelines.

  • 2

    Staged ROM goals met but not significantly exceeded.

  • 3

    Inflammation controlled (painfree within the allowed ROM).

Phase II

(∼POW 6–∼POW 12)


  • 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

Interventions to Avoid

  • Do not perform ROM/stretching beyond staged ROM goals.

  • Do not perform any stretch to gain end range external rotation or external rotation w/90° of abduction unless significant tightness is present.

  • Do not allow the patient to use their arm for heavy lifting or any activities which require ROM beyond the staged ROM goals

  • Do not perform any strengthening exercises that place a large load on the shoulder in the position of horizontal abduction or the combined position of abduction with external rotation (ex: NO push-ups, pec flys). This places excessive load on anterior capsular structures during this timeframe.

  • Do not perform scaption with internal rotation (empty can) at any stage of rehabilitation due to possibility of impingement.

Specific Interventions

Activities of Primary Importance

  • 1

    Continued patient education

  • 2

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

  • 3

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

Activities of Secondary Importance

  • 1

    Introduction of functional patterns of movement

  • 2

    Progressive endurance exercises.

Patient Education

  • 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.

Neuromuscular Re-education

  • Address abnormal scapular alignment and mobility PRN

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

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

    • Biofeedback by auditory, visual, or tactile cues

    • 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

    • <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).

    • 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).

    • 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).

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

    • 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.

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

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

    • Rehabilitation should also include both isolated and complex movement patterns.

    • 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.

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

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

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

Pain Management

  • Modalities PRN

  • Ensure appropriate use of arm during ADLs

  • Ensure appropriate level of therapeutic interventions

  • Weaning from use of medications

Milestones to Progress to Phase III

  • 1

    Staged AROM goals met without pain or substitution patterns.

  • 2

    Appropriate scapular posture at rest and dynamic scapular control during ROM and strengthening exercises

  • 3

    Completion of current strengthening activities without pain or difficulty

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Apr 21, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Appendix: The American Society of Shoulder and Elbow Therapists’ Consensus Rehabilitation Guidelines for Arthroscopic Anterior Capsulolabral Repair of the Shoulder

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