Anterior Stabilization / Latarjet

(Adapted from Wilk/Andrews/Neer/Jobe)

Note: This pathway is designed to serve as a guide to rehabilitation. Indications for progression should be based on patient’s complete operative procedure, functional capacity and response to treatment.

General Considerations:

Guidelines for progression depending on healing timeframe for anatomic repair and performance of any concomitant procedures and/or co-morbidities (RCR/biceps repair)

Restrictive Phase

Weeks 0-3

Goals: Protect anatomic repair, prevent deleterious effects of immobilization, decrease pain and inflammation.

  • Gentle PROM flexion 0-60° week 2, 60-75° week 3
  • Elevation in scapular plane to 60°
  • ER in scapular spine to <15°
  • IR in scapular plane to <45°
  • May initiate grade I/II scapular mobilization in all plans
  • Elbow/Hand AROM and gripping activities
  • No AROM or isolated biceps activation
  • Sling to be utilized 24 hours a day, first 4 weeks

Modalities:

  • Cryotherapy
  • Pulsed US/phonophoresis
  • IFC?HVGS, MHP

Moderate Protective Phase

Weeks 4-6

May discontinue use/wean off sling during the day.

Continue to wear sling at night until 6 weeks post-op.

ROM: PROM/AAROM

  • Flexion/Scaption
    • Week 4: 0-90°
    • Week 5: 0-120°
    • Week 6: 0-150°
  • External rotation (ER)
    • Week 4: 0-30°
    • Week 5: 0-45°
    • Week 6: 0-60°
  • Abduction
  • Internal rotation (IR) in scapular plane, as tolerated
  • Elbow and wrist full ROM

Therapeutic Exercises:

  • ROM
    • Pendulums
    • Pulleys (flexion and caption)
    • Wand exercises into flexion, ER per ROM units
    • Supine post cuff stretch into horizontal adduction
    • Gentle Grade I/II glenohumeral and scapular joint mobs
    • Manual stretching per ROM limits
  • Strengthening
    • Sub-maximal isometrics for IR/ER week 4, progressing to light Theraband IR/ER at neutral abduction by week 6
    • No restricted elbow flexion or resisted shoulder flexion for 6 weeks
    • Periscapular stabilization (H/M/L rows, prone rows, prone horizontal abduction)
    • Initiate dynamic stabilization/proprioceptive activity
    • No isolated biceps contraction

Minimally Protective Phase

Weeks 7-12

Goals: Gradually restore full ROM, preserve anatomic repair, improve muscle recruitment, normalize scapula-humeral rhythm, enhance joint proprioception.

  • ROM:
    • Flexion/Scaption – 150° progressing to full PROM by weeks 7-9
    • Full PROM in ER in scapular plane, progressing to 90/90 position
    • IR full by week 7-9
    • Grade III scapular mobilizations, all ranges
    • Grade III-IV, GH posteroinferior glides
  • Strengthening:
    • IR/ER with elastic resistance in neutral abduction (use a towel roll between the upper arm and side)
    • Dumbbell isotonic exercises: flexion, scaption (full can), deceleration in sidelying (Thrower’s Ten)
    • Rhythmic stabilization/contract-relax
    • UBE (upper body ergometry)
    • Scapular stabilization (H/M/L rows, shrugs, serrates punches)
    • PNF (proprioceptive neuromuscular facilitation) with light manual resistance
    • Bicep curls initiated at 6 weeks. Start with 3-5 pounds, progress cautiously
    • Week 8 initiate chest pass plyometrics, progressing to overhead pass and diagnostics

Functional Phase

Weeks 12-16

Goals: Maintain full active ROM, progress strengthening and stabilization program and to prepare for specific functional drills.

  • Continue previous ROM and mobilization technique to maintain full ROM
  • Continue with elastic IR/ER resistance exercises, progressing reps, intensity and sets
  • Progress from neutral to scapular to the 90/90 position
  • Initiate rhythmic stabilization to the 90/90 position as patient progresses
  • Progress dumbbell program (up to 5 pounds) progressing to move difficult positions (prone caption thumb up, horizontal abduction thumb up, extension palm down and ER in horizontal abduction)
  • Continue with scapular strengthening/stabilization, progressing the push-up plus program
  • Week 10 gradually progress to single arm throw, elbow extend, arm straight overhead, progressing slowly to “cocked” position

Weeks 12-24

  • Strengthening and condition, as tolerated
  • Sports specific exercises
  • Overall-be smart about biceps work – don’t overload

Return to Functional Activities (Use as guide as progress allows)

  • Sedentary job – 3 weeks
  • Manual job within reason – 3 months
  • Driving – 6-8 weeks
  • Golf – 3 months
  • Lifting – avoid heavy lifting minimum 3 months
  • Contact sports – 3 months minimum
  • Overhead lifting/traction activities – as tolerated, 4 months, include pull-ups
  • Throwing activity – 4 months post-op, follow appropriate return to throwing programming
  • Dips – 4 months, as tolerated
  • Return to sport – 4 months
  • Return to full throwing – 5-6 months