● Initiate glenohumeral and scapulothoracic rhythmic stabilization. ● Continue use of cryotherapy for pain and inflammation. Late Phase II ● Progress scapular strengthening exercises. Criteria for progression to Phase III ● Tolerates PROM, AAROM, and isometric program. ● Achieves at least 140 degrees PROM flexion. ● Achieves at least 120 degrees PROM abduction. ● Achieves at least 60 degrees ER in plane of scapula. ● Achieves at least 70 degrees IR in plane of scapula measured at 30 degrees of abduction. ● Able to actively elevate shoulder against gravity with good mechanics to 100 degrees. PHASE III: MODERATE STRENGTHENING (Not to begin before six weeks postsurgery to allow for appropriate healing and to ensure adequate ROM.) Goals ● Gradual restoration of shoulder strength, power, and endurance. ● Optimize neuromuscular control. ● Gradual return to functional activities with involved upper extremity. Precautions ● No heavy lifting of objects—no heavier than 3 kg (6 lb., 9 oz. ● No sudden lifting or pulling activities. ● No sudden jerking motions. Early Phase III ● Progress AROM exercises and activity as appropriate. ● Advance PROM to stretching as appropriate. ● Continue PROM as needed to maintain ROM. ● Initiate assisted shoulder IR behind back stretch. ● Resisted shoulder IR, ER in scapular plane. ● Begin progressive supine active elevation strengthening (anterior deltoid) with light weights—0.5 kg–1.5 kg (1 lb., 2 oz.–3 lb., 5 oz.)—at variable degrees of elevation. Late Phase III ● Resisted flexion, abduction, and extension (TheraBands/sport cords). ● Continue progressing IR, ER strengthening. ● Progress IR behind back from AAROM to AROM as ROM allows. ● Continue to pay attention to avoid stress on the anterior capsule. Criteria for Progression to Phase IV ● Tolerates AAROM, AROM, and strengthening. ● Achieves at least 140 degrees AROM flexion supine. ● Achieves at least 120 degrees AROM abduction supine. ● Achieves at least 60 degrees AROM ER in plane of scapula supine. ● Achieves at least 70 degrees AROM IR in plane of scapula supine in 30 degrees of abduction. ● Able to actively elevate shoulder against gravity with good mechanics to at least 120 degrees. ● If previous ROM is not met, then patient is ready to progress when patient’s ROM is consistent with outcomes for patients with given underlying pathology. PHASE IV: ADVANCED STRENGTHENING PHASE (Not to begin before 12 weeks to allow for appropriate soft tissue healing and to ensure adequate ROM and initial strength.) Goals ● Maintain nonpainful AROM. ● Begin light functional activities. ● Wean from sling completely. ● Enhance functional use of involved upper extremity. ● Improve muscular strength, power, and endurance. ● Gradual return to more advanced functional activities.
Postsurgery day 1 (in hospital) ● Passive forward flexion in supine to tolerance. ● Gentle ER in scapular plane to available PROM, as documented in operative note, usually around 30 degrees. Do not produce undue stress on the anterior joint capsule, particularly with shoulder in extension. ● Passive IR to chest. ● Active distal extremity exercise—elbow, wrist, and hand. ● Pendulum exercises. ● Frequent cryotherapy for pain, swelling, and inflammation management. ● Patient education regarding proper positioning and joint protection techniques. Early Phase I (at home) ● Continue previous exercises. ● Begin scapula musculature isometrics and sets, primarily retraction. ● Continue active elbow ROM. ● Continue cryotherapy as much as able for pain and inflammation management. Late Phase I ● Continue previous exercises. ● Continue to progress PROM as motion allows. ● Begin assisted flexion, abduction, ER, and IR in the scapular plane. ● Progress active distal extremity exercise to strengthening as appropriate. Criteria for progression to Phase II ● Tolerates PROM program. ● Achieves at least 90 degrees PROM flexion. ● Achieves at least 90 degrees PROM abduction. ● Achieves at least 45 degrees PROM ER in plane of scapula. ● Achieves at least 70 degrees PROM IR in plane of scapula measured at 30 degrees abduction. PHASE II: EARLY STRENGTHENING PHASE (Not to begin before four to six weeks postsurgery to allow for appropriate soft tissue healing.) Goals ● Restore full PROM. ● Gradually restore AROM. ● Control pain and inflammation. ● Allow continuing healing of soft tissue. ● Do not overstress healing tissue. ● Re-establish dynamic shoulder stability. Precautions ● Sling should be used only for sleeping and removed gradually over the course of the next two weeks for periods throughout the day. ● While the patient is supine, use a small pillow behind the elbow to avoid shoulder hyperextension and anterior capsule stretch. ● In the presence of poor shoulder mechanics, avoid repetitive shoulder AROM and activity against gravity in standing. ● No heavy lifting of objects—no heavier than a coffee cup. ● No supporting of body weight by hand on the involved side. ● No sudden jerking motions. Early Phase II ● Continue with PROM and AAROM. ● Begin active flexion, IR, ER, and abduction pain-free ROM. ● AAROM pulleys (flexion and abduction) as long as greater than 90 degrees PROM. ● Begin shoulder submaximal pain-free shoulder isometrics in neutral. ● Scapular strengthening exercises as appropriate. ● Begin assisted horizontal adduction. ● Progress distal extremity exercises with light resistance as appropriate. ● Gentle glenohumeral and scapulothoracic joint mobilizations as indicated.
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