Or Tho Associates - Shoulder Rehabilitation Protocols

33 Sewall Street Portland, ME 04102

(207) 828-2100

www.orthoassociates.com

ROTATOR CUFF HOME PROGRAM PHASE I

Unconditioned, imbalanced muscles of the shoulder area can cause rotator cuff injuries. As the rotator cuff fatigues from excessive use, weakness, or lack of endurance, the ball of the shoulder joint becomes more mobile and moves upward. This causes the rotator cuff tendons to come in contact with bone, which can lead to irritation of the tendon, then inflammation and pain, then ultimately an injury (shoulder tendonitis, bursitis, impingement, etc.). Along with keeping the ball firmly in its socket, the rotator cuff has functions related to performance in sports. The rotator cuff provides power and control for the golf swing, tennis stroke, baseball/softball throw and pitch, volleyball serve and spike, and swimming. The exercises described below are to help you strengthen the muscles in your shoulder (especially the muscles of the rotator cuff--the part that helps circular motion). These exercises should not cause you pain. If the exercise hurts, stop exercising. Start again with a lighter resistance.

RESISTANCE The exercises described below are designed to improve endurance of the shoulder musculature, with strength gains being secondary. Therefore the emphasis is on controlled movement with low resistance and high repetitions. The use tubing is required for several of the exercises below with the others utilizing body weight or small dumbbells. . You should strive for perfect execution throughout your routine to help restore the proper movement patterns and reduce the symptoms in your shoulder.

FREQUENCY Perform all the exercises 5 days per week, 1-2 times per day. Begin by performing 15 repetitions of each exercise for the first 3 days and then progressing to 2 sets of 15 repetitions. After 10 days progress yourself to performing 3 sets of 15 to 20 repetitions.

POSTURE Perfect posture is one of the key elements in maintaining a healthy shoulder. Think of a skeleton hanging in a classroom. Its shoulders are naturally hanging back and down, giving it perfect posture and alignment. Unfortunately, most people have a tendency to slump forward, with their shoulder blades sliding forward and up. If you spend much of your day in front of a computer, as many Americans do, you’re probably slumping over, even if you’re not conscious of it. Keep your Shoulder blades pulled Back and Down (SBD) towards your waist, as if you’re thrusting your chest up. It is important to keep your shoulders in this position throughout the exercises and in life.

EXERCISES 1. PULLDOWNS Place the band above your head so you’re pulling it down at a 45 degree angle. Standing with great posture (SBD) grab the band with both hands, elbows straight, and thumbs pointing up. Pull the band down to your pockets and about 6-8 inches away from your body. Pause for 2 seconds in this position emphasizing a squeeze between your shoulder blades. Slowly return the band to the starting position.


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2. STANDING ROWS Place the band at mid sternum height so you are pulling in a straight line. Standing with great posture (SBD) grab the band with both hands, elbows slightly bent, and thumbs pointing up. Pull the band towards your chest by contracting your shoulder blades and bending your elbows. The finish position should have a great SBD, elbows bent at 90 degrees and located at mid torso. Hold that position for 2 seconds then return to the starting position.

3. EXTERNAL ROTATION


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Place the band at mid sternum height so you are pulling in a straight line. Standing with great posture (SBD), place your elbow at your side, bent at 90 degrees and gripping the band with the thumb pointed up. Hold a towel between your elbow and your side to you remind you to maintain this position. Your forearm begins by pointing across your body. Slowly rotate your shoulder out, keeping your elbow bent, and fixed to your side. Rotate out as far as possible by limits of motion or pain. Hold that position 2 seconds and slowly return to the starting position.

4. INTERNAL ROTATION Place the band at mid sternum height so you are pulling in a straight line. Standing with great posture (SBD), place your elbow at your side, bent at 90 degrees and gripping the band with the thumb pointed up. Hold a towel between your elbow and your side. Your forearm begins by pointing away from your body. Slowly rotate your shoulder in, keeping your elbow bent, and fixed to your side. Rotate in as far as possible by limits of motion or pain. Hold that position for 2 seconds and slowly return to the starting position.


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5. STANDING HITCHHIKER Stand with perfect posture (SBD) with hand placed on your thighs and your thumbs pointed upward. While gliding your shoulder blades back and down toward your waist raise your arms up at a 45 degree angle. Raise your arms to shoulder height only and keep your elbows straight. Hold this position for 2 seconds and slowly return to the starting position. Begin this exercise with no resistance and gradually progress to 1-5lb dumbbells. Do not use weights heavier than 5lb. The smaller muscles of the rotator cuff are difficult to isolate using heavy weight.

6. BICEP CURL Stand with perfect posture (SBD). Keep your elbows next to your torso while holding a dumbbell or band. Initiate the movement by flexing your elbow and then slowly returning the starting position while maintaining good posture.


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7. TRICEP PRESS Begin the exercise with great posture (SBD), elbows by your side and bent to 90 degrees. Extend your elbows against resistance until you reach full extension. Hold this position for 2 seconds then slowly return to your starting position.

8. SERRATUS PUNCH Begin the exercise with the band wrapped around you thumb, sitting underneath your armpit, and your elbows bent to 90 degrees at your side. Extend your elbows forward until they are straight and then round your shoulders at the end of the movement. Hold this position for 2 seconds then slowly return to your starting position.


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CAUTION If any of these exercises increases your shoulder pain, stop doing that exercise and contact your physician or physical therapist.

PHASE II For those individuals requiring further strengthening to perform overhead activities should be progressed to PHASE II. Exercises for this phase require instruction from a physical therapist. See your physician or therapist for instruction on proper exercise technique and progression.


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LARGE ROTATOR CUFF REPAIR PROTOCOL

Includes Treatments for: Open Repair Large Rotator Cuff Tear Arthroscopic Repair Large Rotator Cuff Tear Post-op 0-2 Weeks Sling/swathe at all times, except for exercises

PROM limits to: 90 pure abduction, 20 extensions, 70 internal rotations (not behind back) 1. Pendulum exercises 3x/day minimum 2. PROM within pain tolerance 3. Elbow and wrist AROM 4x/day minimum 4. Cryocuff/ ice: days 1-2 as much as possible, then post activity for

pain 2-6 Weeks Sling/swathe at all times, except for exercises, bathing, or

sitting quietly. ROM limits continued. 1. PROM within limits and pain tolerance 2. Manual resistance for scapular motions 3. Postural awareness education 4. Gentle soft tissue mobilization and joint mobilization 5. Modalities as indicated for pain or inflammation

6-12 Weeks Sling for comfort, but may be discontinued. No ROM limits.

1. Initiate AAROM (wand and pulleys), unless specified by physician to progress more slowly

2. Joint mobilization for scapula and glenohumeral mobility 3. Gentle exercises for scapular stabilizers and rotator cuff, may

include sub-max isometrics, PNF, and supervised UBE 4. Progress AROM, with education for quality of motion to avoid

shoulder hiking. *Patient must be able to elevate without hiking shoulder to progress to next phase.

12-18 Weeks RESISTIVE EXERCISES HELD AS PER SURGEON’S

INSTRUCTIONS.


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MEDIUM ROTATOR CUFF REPAIR PROTOCOL

Includes Treatment for: Open Repair Medium Rotator Cuff Tear Arthroscopic Repair Small and Medium Rotator Cuff Tear Post op 0-2 Weeks Sling/swathe at all times, except for exercises.

PROM limits to: 90 pure abduction, 20 extension, 70 internal rotation (not behind back), no limitations for flexion, external rotation as tolerated (unless specified by physician) 1. Pendulum exercises 3x/day minimum 2. PROM within pain tolerance 3. Elbow and wrist AROM 4x/day minimum 4. Cryocuff ice: days 1-2 as much as possible, then post activity

for pain

2-6 Weeks Decrease use of sling during the day, except in uncontrolled situations and at night. ROM limits continued 1. PROM within limits and pain tolerance 2. Manual resistance for scapular motions 3. Postural awareness education 4. Gentle soft tissue mobilization and joint mobilization 5. Modalities as indicated for pain or inflammation

6-12 Weeks Discontinue sling at night. No ROM limits 1. Initiate AAROM/ AROM including wand and pulleys 2. Joint mobilization for scapula and glenohumeral mobility 3. Gentle exercises for scapular stabilizers and rotator cuff May include sub-max isometrics, PNF, and supervised UBE. Emphasis of strengthening on high reps and low weight with

postural awareness Goal: Involved shoulder AROM grossly WNL by 12 weeks


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12-18 Weeks 1. Resistive exercises as tolerated 2. Progress toward independent home program 3. Reinforce postural awareness, quality of exercise technique

and proper PRE progression


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OPEN SMALL ROTATOR CUFF PROTOCOL

Post-op 0-2 Weeks Sling worn for comfort

1. Pendulum exercises 3x/day minimum 2. PROM/AAROM (wand, pulley) within pain tolerance 3. Elbow and wrist AROM 3x/day minimum 4. Cryocuff/ice: days 1-2 as much as possible, then post activity for pain.

2-6 Weeks Avoid active elevation (anterior deltoid) until 6 weeks 1. Progress AAROM/AROM within pain tolerance 2. Sub-maximal isometrics for shoulder musculature, except flexion 3. Manual resistance for scapular motions 4. Postural awareness education 5. Gentle soft tissue mobilization and glenohumeral inferior glide 6. Modalities as indicated for pain or inflammation 7. May initiate UBE after 4 weeks. Goal: Involved shoulder AAROM grossly WNL by 6 weeks

6-12 Weeks 1. Progress AROM in all ranges 2. Joint mobilization for scapula and glenohumeral mobility 3. Strengthening exercises for scapular stabilizers and rotator cuff. Emphasis of strengthening on high reps and low weight, with

postural awareness. May include PRE’s, theratube/band, PNF and weight equipment

4. Progress to independent home program Goal: AROM grossly WNL without shoulder hiking by 12 weeks


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S.L.A.P. RECONSTRUCTION PROTOCOL

Post-op 0-3 Weeks PROM limited to: 90 flexion, 90 abduction, 0 external rotation and 0

extension. Avoid hyperextension of elbow. Sling worn at all times to support glenohumeral joint. 1. PROM to tolerance within limitations 2. Postural awareness education 3. Sub-maximal isometrics for shoulder musculature-avoid forward

elevations 4. Theraputty and light resisted wrist isometrics 5. Soft tissue mobilization as tolerated 6. Ice/Cryocuff as needed 7. Cardiovascular exercises-stationary bike, treadmill with arm supported

3-6 Weeks ROM limited to: 120 flexion, 120 abduction, and 30 external rotation Wean from sling-no active arm swing until after 4 weeks 1. PROM/AAROM (supine wand) to tolerance within limitations 2. Gentle manual resistance for scapula motions 3. Gentle rotator cuff strengthening 4. Gentle joint mobilization to scapula

6-8 Weeks ROM only limited to 60 external rotation 1. Progress PROM within limitations 2. AAROM/AROM within pain tolerance-seated wand, pulleys, UBE 3. Initiate light resisted elbow flexion and extension 4. Gentle open kinetic chain rhythmic stabilization exercises in supine

8-12 Weeks ROM limited to 60 external rotation 1. AROM with emphasis on quality of motion, avoid shoulder hiking with

elevation 2. Strengthening exercises for scapula stabilizers and rotator cuff May include PRE’s, eccentric rotator cuff, PNF (avoid heavy resistance

in painful end ranges), and weight equipment Emphasis of strengthening on high reps and low weight, with postural

awareness 3. Progress closed kinetic chain exercises as tolerated 4. Isokinetic at fast speeds blocking end ranges-avoid impingement Goal: Full PROM (external rotation to 60) by 12 weeks

12-24 Weeks No ROM limitations 1. Progress to independent strengthening program


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Reinforce postural awareness, quality of exercise techniques, and proper PRE progression-frequency, duration and intensity

2. Coordinate sports specific training to begin return to normal function or sport

Goals: 1. Full pain free AROM

2. Strength 95% of non-involved side 3. Return to full activity or sport without restriction by 24 weeks


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ARTHROSCOPIC ACROMIOPLASTY PROTOCOL

Includes Treatments for: Arthroscopic Acromio-Clavicular Excision Arthroscopic Partial Thickness Rotator Cuff Debridement

Post-op 0-1 Week Sling worn for comfort

1. Pendulum exercises 3x/day minimum 3. Elbow and wrist AROM 3x/day minimum 4. Cryocuff/ ice: days 1-2 as much as possible, then post activity for pain

1-2 Weeks Avoid active elevation (anterior deltoid) until 6 weeks

1. PROM/AAROM (wand, pulley) within pain tolerance 2. Sub-maximal isometrics for shoulder musculature 3. Manual resistance for scapular motions 4. Postural awareness education 5. Gentle soft tissue mobilization 6. Modalities as indicated for pain or inflammation 7. Therapist supervised UBE for motion, avoiding substitution or Impingement

2-6 Weeks 1. Progress PROM and AROM as tolerated

2. Joint mobilization for scapula and glenohumeral mobility (posterior capsule stretching) 3. Strengthening exercises for scapular stabilizers and rotator cuff. Emphasis of strengthening on high reps and low weight, with postural awareness. May include PRE’s, theratube/ band, PNF and weight equipment

Goal: Involved shoulder AROM grossly WNL without shoulder hiking by 6 weeks


(207) 828-2100


6-12 Weeks 1. Progress to independent strengthening program. 2. Reinforce postural awareness, quality of exercise techniques, and proper PRE progression.


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OPEN ACROMIOPLASTY PROTOCOL

Includes Treatments for: Open Acromio-Clavicular Excision Open Small Rotator Cuff Repair Post-op 0-2 Weeks Sling worn for comfort

1. Pendulum exercises 3x/day minimum 2. PROM/AAROM (wand, pulley) within pain tolerance 3. Elbow and wrist AROM 3x/day minimum 4. Cryocuff/ ice: days 1-2 as much as possible, then post activity for pain.

2-6 Weeks Avoid active elevation (anterior deltoid) until 6 weeks 1. Progress AAROM/AROM within pain tolerance 2. Sub-maximal isometrics for shoulder musculature, except flexion 3. Manual resistance for scapular motions 4. Postural awareness education 5. Gentle soft tissue mobilization and glenohumeral inferior glide 6. Modalities as indicated for pain or inflammation 7. May initiate UBE after 4 weeks. Goal: Involved shoulder AAROM grossly WNL by 6 weeks

6-12 Weeks 1. Progress AROM in all ranges 2. Joint mobilization for scapula and glenohumeral mobility 3. Strengthening exercises for scapular stabilizers and rotator cuff. Emphasis of strengthening on high reps and low weight, with

postural awareness. May include PRE’s, theratube/ band, PNF and weight equipment

4. Progress to independent home program. Goal: AROM grossly WNL without shoulder hiking by 12 weeks


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ARTHROSCOPIC BANKART REPAIR PROTOCOL

Post-op 0-2 Weeks Immobilization with sling/swathe on at all times, except bathing

ROM limits to: 90 flexion, 45 abduction, 0 external rotation, 20 extension 1. Elbow and wrist AROM 3x/day minimum 2. Cryocuff/ice for pain

2-6 Weeks Sling must be worn while at school, in crowds, riding in a car, and while sleeping. ROM limits to: 90 flexion, 90 pure abduction, 30 external rotation at side, 20 extension 1. PROM and AAROM (wand pulley) within pain tolerance and limits 2. Gentle rotator cuff strengthening 3. General soft tissue and joint mobilization 4. Modalities as indicated for pain or inflammation

6-12 Weeks Discontinue sling ROM limits to: 60 external rotation; full flexion, abduction, and extension 1. Progress PROM and AROM as tolerated 2. Joint mobilization for scapula and glenohumeral mobility 3. Strengthening exercises for scapular stabilizers and rotator cuff within pain-free ranges. May include PRE’s, PNF, and weight equipment. Emphasis of strengthening on high reps and low weight, with postural awareness.

12-24 Weeks 1. Range of motion-self-stretching program 2. Progress independent strengthening program 3. Reinforce postural awareness, quality of exercise technique, and proper PRE progression 4. Coordination sports specific training to begin return to normal Function

9 Months Possible return to full strength throwing and contact sport, depending on strength and physician assessment


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INFERIOR CAPSULAR SHIFT PROTOCOL

Post-op 0-4 Weeks Immobilization with sling on at all times, except distal arm

ROM and bathing 1. Elbow, wrist, and hand AROM 4x/day minimum 2. Cryocuff/ice for pain

4-6 weeks Decrease use of sling during the day except in uncontrolled

situations. Strict ROM limits to: 120 flexion, 90 abduction, 30 external rotations. 1. PROM, AAROM (wand, pulley), and AROM within pain tolerance

and limits 2. Supervised UBE within shoulder AROM within pain tolerance

and limits 3. Manual resistance for scapular motions 4. Gentle soft tissue and joint mobilization 5. Modalities as indicated for pain or inflammation

6-12 Weeks Discontinue sling at night

1. Progress AAROM and AROM as tolerated 2. Joint mobilization of scapula (gentle glenohumeral as indicated) 3. Strengthening exercises for scapula stabilizers and rotator cuff

within pain free ranges May include PRE’s, PNF, and weight equipment Emphasis of strengthening on high reps and low weight, with postural awareness

4. Progress toward independent strengthening program. Reinforce postural awareness, quality of exercise technique, and proper PRE progression.

Goal: AROM>90 percent of normal range for the involved shoulder by 12 weeks

6 Months Begin functional throwing program

1. Continue with independent program-strength, stretch, and sports specific drills.


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9 Months Possible return to full strength throwing and contact sports depending on strength and physician assessment


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TOTAL SHOULDER ARTHROPLASTY

Includes Treatment for: Hemi-Arthroplasty with intact rotator cuff

Post-op 0-3 Weeks ROM limited with external rotation to 45 Day 1 1. Pendulum exercises 3x/day minimum-taught at hospital

and reviewed in outpatient setting 2. PROM all ranges

Day 2 Phase I 1. Pulley and wand exercises 2. Manual resisted scapular motions 3. Modalities as indicated

3-4 weeks 1. Progress AAROM/AROM as tolerated 2. Isometrics for shoulder musculature 3. Scapular stabilizing exercises

4-6 Weeks Phase II 1. Initiate Theraband exercises 2. Emphasis on quality of exercise with postural Education

DISCHARGE TO INDEPENDENT PROGRAM WHEN ROM PLATEAU REACHED

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Or Tho Associates - Shoulder Rehabilitation Protocols