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.

Phase I – Immediate Post-Op | Weeks 0-3

Goals

  • Protect surgical repair
  • Reduce swelling, minimize pain
  • Maintain UE ROM in elbow, hand and wrist
  • Gradually increase shoulder PROM
  • Minimize muscle inhibition
  • Patient education

Sling

  • Neutral rotation
  • Use of abduction pillow in 30-45 degrees abduction
  • Use at night while sleeping

Precautions

  • No shoulder AROM/AAROM
  • No lifting of objects
  • No supporting of body weight with hands
  • Avoid scapular retraction with a teres minor repair

Intervention

Swelling Management

  • Ice, compression

Range of motion/Mobility

  • PROM: ER<20 scapular plane, Forward elevation <90, seated GH flexion table slide, horizontal table slide
  • AROM: elbow, hand, wrist (PROM elbow flexion with concomitant biceps tenodesis/tenotomy)
  • AAROM: none Strengthening (Week 2)
  • Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row
    • avoid with subscapularis repair and teres minor repair
  • Ball squeeze

Criteria to Progress

  • 90 degrees shoulder PROM forward elevation
  • 20 degrees of shoulder PROM ER in the scapular plane
  • 0 degrees of shoulder PROM IR in the scapular plane
  • Palpable muscle contraction felt in scapular and shoulder musculature
  • No complications with Phase I

Phase II – Intermediate Post-Op | Weeks 4-6

Goals

  • Continue to protect surgical repair
  • Reduce swelling, minimize pain
  • Maintain shoulder PROM
  • Minimize substitution patterns with AAROM
  • Patient education

Sling

  • Neutral rotation
  • Use of abduction pillow in 30-45 degrees abduction
  • Use at night while sleeping

Precautions

  • No lifting of objects
  • No supporting of body weight with hands

Intervention

Continue with Phase I interventions

Range of motion/Mobility

  • PROM: ER<20 scapular plane, Forward elevation <90
  • AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch,
    washcloth press, sidelying elevation to 90 degrees

Strengthening

  • Periscapular: Row on physioball, shoulder extension on physioball

Criteria to Progress

  • 90 degrees shoulder PROM forward elevation
  • 20 degrees shoulder PROM ER in scapular plane
  • 0 degrees of shoulder PROM IR in the scapular plane
  • Minimal substitution patterns with AAROM
  • Pain < 4/10
  • No complications with Phase II

Phase III – Intermediate Post-Op Continued | Weeks 7-8

Goals

  • Do not overstress healing tissue
  • Reduce swelling, minimize pain
  • Gradually increase shoulder PROM/AAROM
  • Initiate shoulder AROM
  • Improve scapular muscle activation
  • Patient education

Sling

  • Discontinue

Precautions

  • No lifting of heavy objects (>10 lbs)

Criteria to Progress

  • 120 degrees shoulder PROM forward elevation
  • 30 degrees shoulder PROM ER and IR in scapular plane
  • Minimal substitution patterns with AROM
  • Pain < 4/10

Phase IV – Transitional Post-Op | Weeks 9-10

Goals

  • Do not overstress healing tissue
  • Gradually increase shoulder PROM/AAROM/AROM
  • Improve dynamic shoulder stability
  • Progress periscapular strength
  • Gradually return to full functional activities

Precautions

  • No lifting of heavy objects (> 10 lbs)

Intervention

Continue with Phase II-III interventions

Range of motion/mobility

  • PROM: ER<45 scapular plane, Forward elevation <155, ER @ 90 ABD < 60
  • AROM: supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90 degrees elevation

Strengthening

  • Periscapular: Push-up plus on knees, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer

Criteria to Progress

  • 155 degrees shoulder PROM forward elevation
  • 45 degrees shoulder PROM ER and IR in scapular plane
  • 60 degrees shoulder PROM ER @ 90 ABD
  • 120 degrees shoulder AROM elevation
  • Minimal to no substitution patterns with shoulder AROM
  • Performs all exercises demonstrating symmetric scapular mechanics
  • Pain < 2/10

Phase V – Transitional Post-Op Continued | Weeks 11-12

Goals

  • Restore full PROM and AROM
  • Enhance functional use of upper extremity

Intervention

Continue with Phase II-IV interventions

Range of motion/mobility

  • PROM: Full
  • AROM: Full

Stretching

  • External rotation (90 degrees abduction), Hands behind head, IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats, doorjam series

Criteria to Progress

  • Full pain-free PROM and AROM
  • Minimal to no substitution patterns with shoulder AROM
  • Performs all exercises demonstrating symmetric scapular mechanics
  • Pain < 2/10

Phase VI – Strengthening Post-Op | Weeks 13-16

Goals

  • Maintain pain-free ROM
  • Initiate RTC strengthening (with clearance from MD)
  • Initiate motor control exercise
  • Enhance functional use of upper extremity

Intervention

Continue with Phase II-V interventions

Strengthening

  • Rotator cuff: internal external rotation isometrics, side-lying external rotation,
    Standing external rotation w/ resistance band, standing internal rotation w/ resistance band, internal rotation, external rotation, sidelying ABD→standing ABD
    Periscapular: T and Y, “T” exercise, push-up plus knees extended, wall push up, “W” exercise, resistance band Ws, dynamic hug, resistance band dynamic hug
    Biceps curl (begin with concomitant biceps tenodesis/tenotomy)

Motor Control

  • Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)
  • IR/ER and Flex 90-125 (rhythmic stabilization)
  • Quadruped alternating isometrics and ball stabilization on wall
  • PNF – D1 diagonal lifts, PNF – D2 diagonal lifts
  • Field goals

Criteria to Progress

  • Clearance from MD and ALL milestone criteria below have been met
  • Full pain-free PROM and AROM
  • ER/IR strength minimum 85% of the uninvolved arm
  • ER/IR ratio 60% or higher
  • Negative impingement and instability signs
  • Performs all exercises demonstrating symmetric scapular mechanics
  • QuickDASH/PENN

Phase VII – Early Return to Sport | 4-6 Months

Goals

  • Maintain pain-free ROM
  • Continue strengthening and motor control exercises
  • Enhance functional use of upper extremity
  • Gradual return to strenuous work/sport activity

Intervention

Continue with Phase II-VI interventions

Strengthening

  • Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees

Motor control

  • Resistance band PNF pattern, PNF – D1 diagonal lifts w/ resistance, diagonal-up, diagonal-down Wall slides w/ resistance band
  • See specific return-to-sport/throwing program (coordinate with physician)

Criteria to Progress

  • Last stage-no additional criteria

Return to Sport

For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc.