Orthopedic Surgery and Physical Therapy

Brooke Army Medical Center Sports Medicine Outpatient Rehabilitation Protocol

Small (< 1cm) & Medium (1-3 cm) Rotator Cuff (1 tendon) Repairs Supraspinatus or Subscapularis

Arthroscopic & Open Procedures

BAMC Ortho: 210-916-1242 BAMC PT: 210-916-1920

This Rehab Protocol is a guideline. Specific exercises and time frames may be altered depending on patient progression except italicized and bolded items.

General Rehab Considerations:  Rehab may need to be modified/slowed based on the following considerations: o Size of repair o Quality of tissue and integrity of repair (must be communicated to the therapist by the surgeon) o Age >50 o Acute vs. chronic tear o Revision surgery vs. first surgery o Pain  Early passive ROM is essential to prevent capsular adhesions and loss of motion; should be done in a manner that shortens the involved tissue o Supraspinatus: Avoid passive IR past the plane of the body, horizontal adduction, and extension for 4 weeks. May be modified based on guidance from surgeon. o Subscapularis: Avoid excessive passive external rotation (none past neutral), horizontal adduction, and extension for 6-8 weeks. May be modified based on guidance from surgeon

INPATIENT: Post-operative day (POD) 1 through discharge (d/c) from hospital

PT Sessions: Afternoon visit after surgery and daily supervised sessions

Sling: Shoulder immobilizer / abduction sling (Donjoy “Ultrasling”) 1. Wear at all times, even when sleeping for 1st 4 weeks after surgery 2. Remove 3x/day for PT exercises, and for personal hygiene

Exercises: 1. Grip Strength w/ foam ball, towel, putty to squeeze repetitively 2. Hand, wrist, elbow full active range-of-motion (AROM) 3. Shoulder passive pendulum exercises in sling or forearm supported 4. Assisted passive range-of-motion (PROM) of shoulder to maximum of 45 flexion, 30 external rotation (neutral for subscapularis), 45 abduction; NO extension 5. Pt indep with cryotherapy use at least 3 x day at home

PHASE I: Hospital d/c through Week 4 – PROTECTION PHASE

PT Sessions: 2-3 supervised sessions per week with physical therapist

Sling: Shoulder immobilizer / abduction/IR sling (Donjoy “Ultrasling”) 1. Wear at all times, even when sleeping for 1st 4 weeks after surgery 2. Remove 3x/day for home PT exercises, and for personal hygiene

Exercises: 1. Grip Strength w/ foam ball, towel, putty 2. Hand, wrist, elbow full AROM w/ light weights (1-3 lbs.; incr. prn) 3. Modified passive pendulum exercises in sling or forearm supported 4. Supine assisted PROM shoulder to tolerance (with a goal of 90 flexion, 45 external rotation(neutral for subscapularis), 90 abduction by the 4th week); NO extension 5. Scapular retraction; gently pinch shoulder blades together for 5 sec 6. Postural correction exercises

Aerobic Conditioning: may ride stationary bike while wearing immobilizer Continue Cryotherapy

PHASE II: Week 4 - 8 – EARLY STRENGTHENING & ENDURANCE

Sling: Wean shoulder immobilizer / sling

Exercises: 1. Continue grip strength exercises 2. Continue hand, wrist, elbow full AROM w/ weights 3. Passive pendulums w/ elbow extended and forearm unsupported 4. Supine and active assisted ROM to maximum tolerance; include wand/stick, pulley, wall climbs, assistance from opposite UE, etc… DO NOT PUSH THROUGH ANY SHARP OR STABBING PAIN 5. Active assisted range-of-motion (AAROM) for ER and gentle IR 6. Scapular retraction and protraction (pinch/spread shoulder blades) 7. Cross chest (posterior capsule) stretch 8. Gentle ADL’s at or below waist level; NO sudden movements

Subscapularis repairs: Neutral ER for 6-8 weeks, no active IR for 8 weeks

Small repairs: May initiate gentle AROM and RC theraband exercises if ROM goals are being met and pain is well-controlled at 4 weeks.

Medium repairs: May initiate gentle AROM and RC theraband exercises if ROM goals are being met and pain is well-controlled at 6 weeks.

Aerobic Conditioning: Stationary bike or treadmill while wearing sling

Criteria for Progression to PHASE III: 1. 90% Full PROM 2. Pain-free ADL’s up to chest height

PHASE III: Week 8 - 12 – ADVANCED STRENGTHENING & ENDURANCE

Sling: none

Exercises: 1. Continue previous grip and hand/wrist/elbow AROM exercises Progress from AAROM to AROM; emphasize terminal stretching 2. Gentle shoulder AROM and rotator cuff strengthening; use theraband 3. Moderate ADL’s from waist to shoulder; NO overhead activity 4. Subscap PROM to 30 degrees

Aerobic Conditioning: 1. Stationary bike, elliptical trainer, stairmaster 2. May walk on treadmill; NO running 3. Upper body cycle up to 5 min forward and 5 min backward

Criteria for Progression to PHASE IV: 3. 90% shoulder FAROM (except subscap repair) 4. Pain-free ADL’s up to shoulder height 5. Able to perform 5 min of upper body cycle w/o pain

PHASE IV: Week 12 - 16 – BASIC FUNCTIONAL PHASE

Exercises: 1. Continue all previous exercises 2. Address all residual strength and ROM impairments a. Capsular stretches as needed b. Progressive resistance exercises for shoulder girdle complex 3. Full ADL’s with no lifting > 10 lbs. 4. Basic aquatic (pool) therapy if available 5. Slowly advance motion into ER with subscap

Aerobic Conditioning: 1. May begin jogging (if painfree) 2. Upper body cycle up to 10-15 min forward and 10-15 min backward

Criteria for Progression to PHASE V: 1. Full or nearly full shoulder AROM 2. Near full strength per manual muscle testing 3. Pain-free basic functional training exercises

PHASE V: Week 16 - 24 (6 mo) – ADVANCED FUNCTIONAL PHASE

Exercises: 1. Full AROM exercises to fatigue 2. Gradually increase weight training to maximum; must be pain free 3. Advanced pool therapy if available

Aerobic Conditioning: 1. Progress from jogging to running prn; should be pain-free 2. Sport or activity-specific drills prn; i.e. throwing, catching, swinging

PHASE VI: 6 Months + – RETURN TO FULL DUTY PHASE

When rehabilitation goals are met: 1. Full shoulder AROM (accept 5-10 loss of ER) 2. Full strength per manual and isokinetic testing 3. Able to pass APFT, including push-ups

______JAMES R. FICKE, MD KATHLEEN S. ZURAWEL, PT, OCS COL, MC COL, SP Chief, Orthopedics Chief, Physical Therapy

APPROVE / DISAPPROVE APPROVE / DISAPPROVE

Updated 30 October 2006