Physical Therapy Protocol for Patients

Following Shoulder Surgery

§ Rotator Cuff Surgery

§ Shoulder Stabilization Procedures
§ Labral Repairs

General Guidelines:
§ The program is designed to take into account whether tissue has been repaired or just
arthroscopically cleaned and shaved
o If tissue was repaired then an obligatory period of protection (immobilization) is
necessary. Usually this is for no less than 4 and no more than 6 weeks.
o If no tissue has been repaired then the program is more symptom driven rather
than time dependent.
§ Once therapy begins, the patient is encouraged to get rid of the sling/immobilizer
§ Patients are counseled to avoid quick sudden movements, repetitive movements,
reaching for any weight over a pound or two and avoiding any activity that requires
force or power. Patients are discouraged from using arms (especially operated side) to
get up from chair, bed, etc.
§ Driving is not recommended until such time as the patient can safely get both hands
on the steering wheel and operate the vehicle safely.
§ Daily showers and hygiene is encouraged with the precautions already stated.

Considerations for Need for Protection Period

1. Type and size of tear
a. Partial v. complete
b. Small, medium, large or massive
2. Surgical Procedure performed
a. Arthroscopic repair
b. Mini-open (no deltoid detachment)
c. Standard open approach (deltoid detached)
d. No repair just debridement (usually for partial tears or massive irreparable
tears)
e. Need for artificial patch graft
3. Method of fixation
a. Side to side repair
b. Tendon to bone usually with anchors
4. Mobility of tissue and ease of repair
a. Tissue mobile and easily repaired
b. Tissue somewhat mobile and difficult but repaired
 c. Tissue not mobile and only partial repair achieved
d. Tissue not mobile and cuff irreparable

5. Quality of tissue
a. Good quality tissue and bone holds sutures/implants well
b. Decent quality (no significant concerns)
c. Fair to poor quality tissue

Phase I
0-2 weeks
§ Most important concern is pain control, protection and personal hygiene
§ Patients are instructed in proper showering, dressing and ADL
§ Precautions are stated in post op instructions (given to patient after surgery)
depending on what was done at surgery and the quality of the tissue/repair
§ Patients should sleep with immobilizer and not take any chances
§ Elbow, forearm, wrist and digits are mobilized to avoid stiffness and minimize edema
at the elbow and hand
§ Grip strengthening by using a “squeezy ball” keeps muscle pump going to reduce
dependent edema
§ Patients are seen at approximately 2 weeks for suture removal and wound check

2-4 weeks
§ No significant changes are made
§ Prescription is given for PT to start depending on what was done
o No tissue repair just arthroscopic debridement- start at 2 weeks
o Tissue repaired (any method) but good quality- start at 4 weeks
o Tissue repaired but concerns about tissue integrity- start physician guided
exercises at 4 weeks, formal PT at 6 weeks

Phase II
Begins when patient meets and begins working with therapist (usually at 4 weeks but may be
as much as 6 weeks post op) and lasts up till about 10-12 weeks post op
§ May discontinue sling/immobilizer unless needed out of the house or for comfort. It’s
use now becomes counter productive
§ May sleep without sling
§ May begin driving as soon as safe and confident (usually determined by patient)
§ Therapy is 3 sessions a week for 4 weeks at a time
§ Patients are encouraged and instructed in daily home stretches to assist therapist in
achieving functional ROM

Motion
§ Consists of AAROM with gentle passive assist by therapist to improve ROM and
function (therapist manually guides patient through range of motion with slow steady
stretching)
§ Directions include forward flexion, abduction, IR, ER
§ UBX, pulleys, cane stretches are all acceptable means to achieve ROM
Strengthening
§ No isometrics (they generate very high tension which may disrupt tissue repair)
§ Begin distally with grip strengthening, elbow flexion/extension PRE’s with light hand
held weights
§ For proximal muscle strengthening think 3 P’s (in sequence)
1. Primary joint stabilizers - begin at core by conditioning the cuff muscles with light
hand held weights and low resistance theraband to recover glenohumeral
stabilizers
2. Peri-scapular muscles – work on scapular retraction, protraction and elevation
3. Power movers – then lastly work on major limb positioners (pectoralis, deltoid,
latissimus)
§ Strengthening begins lightly and increases over time as tissue heals (no power activity
for at least 3 months post op)
§ Work muscle groups in proper sequence (i.e., don’t do push ups for serratus before 3
months)

Function
§ May begin using limb for ADL
§ Light desk work is OK
§ Non operative arm can be used as tolerated
§ Significant restrictions remain for operated limb
§ May do lower extremity cardiovascular type exercises

Phase III
10-12 weeks through 6 months
§ Tissue to bone healing should be almost complete
§ ROM should be approaching normal or at least making steady gains on a weekly basis
§ No sports or heavy physical work yet
§ Continue regular therapy schedule

ROM
§ Need to be more hands on for patients who are not at near functional levels
§ Encourage patients to “do what they cannot do”
o If they can’t reach behind then show them how to do this, if they can’t wash
their underarm show them how to reach for those areas with good stretches
o Use unoperated side to help get operated limb to reach for those areas that are
hard to get to

Strengthening
§ Continues as before with progression to power movers and peri-scapular muscle
strengthening
§ Anterior and middle deltoids are key to success and proper shoulder function. They
should be heavily emphasized during this time.
Function
§ No sports that require any overhead, throwing. No recreational weight training except
the exercises in PT which patient can do on non-therapy days at home
§ Golf may be tried after 4 months if no pain, good ROM, normal or near normal
strength (hit ball off tee for first month after return then resume normally)
§ Progress in work hardening type program until back to normal function
§ May do some light ground stroking for tennis players after 4 months progressing to
easy overheads at 5 months, full serve at 6 months. Try doubles first then singles.

Phase IV
6 months until back to normal
§ Throwers, overhead athletes (volleyball, tennis) and upper extremity weight bearing
athletes (gymnasts) will take longest and may continue to progress over the next few
months before full return is possible

SLAP Repair
For Patients who have undergone SLAP repair, use guidelines and timeframe for small cuff
tear with good quality repair and tissue (i.e., start formal PT at 4 weeks) with following
exceptions:
§ Avoid abduction/ER coupled motion for the first 6 weeks post-op
§ Avoid biceps resistance exercise for 8 weeks post-op

Shoulder Stabilization procedures

Capsular plications, capsular shifts, Bankharts (whether open or arthroscopic) use guidelines
and timeframe for small cuff tear with good quality repair and tissue (i.e., start formal PT at
4 weeks) with following exceptions:
§ Avoid abduction/ER-coupled motion for the first 6 weeks post-op; at 6-week point,
slowly progress this coupled movement over next 4 weeks. Full abd/ER allowed 10
weeks post-op
§ Go slow with ER at side – limit to 30 degrees at side for 6 weeks; at 6-week point,
progress ER at side over next 4 weeks
§ For open repair, must violate the subscapula, therefore, as a general principle –
protect subscapula

Kenneth A. Jurist, M.D., Joseph H. Guettler, M.D.

24255 Thirteen Mile Road, Suite 100
Bingham Farms, MI 48025
248-988-8085 Phone / 248-988-8565 Fax
“At Performance Orthopedics it’s all about You at your Peak Performance”
www.performanceorthopedics.com
 Physical Therapy Protocol for Patients
Following Distal Biceps Reinsertion at the Elbow

General Guidelines:
• The program is designed to allow early ROM but restrict resistive forces across the
elbow until the soft tissue has adequately healed to the bone
• The slow and graduated recovery of strength allows controlled tension on the repair
leading to stronger tissue/bone interface
• Once therapy begins, the patient is encouraged to get rid of the sling
• Patients are counseled to avoid quick sudden movements, repetitive movements,
reaching for any weight over a pound or two and avoiding any activity that requires
force or power. Patients are discouraged from using arms (especially operated side)
to get up from chair, bed, etc.
• Driving is not recommended until such time as the patient can safely get both hands
on the steering wheel and operate the vehicle safely.
• Daily showers and hygiene is encouraged with the precautions already stated.

Phase I
0-2 weeks
• Most important concern is pain control, protection and personal hygiene
• Patients are instructed in proper showering, dressing and ADL
• Patients shoulder sleep with splint and sling and not take any chances
• Wrist and digits are mobilized and arm is kept elevated to avoid stiffness and
minimize edema
• Gentle grip strengthening by using a “squeezy ball” keeps muscle pump going to
reduce dependent edema
• Patients are seen at approximately 2 weeks for suture removal and wound check

2-4 weeks
• No significant changes are made except that the splint is removed and ROM is
begun
• Prescription is given for PT to start at 4 weeks after surgery

Phase II
• Begins when patient meets and begins working with therapist (usually at 4 weeks
post op) and lasts until normal activities are resumed
• May begin driving as soon as safe and confident (usually determined by patient)
• Therapy is 3 sessions a week for 4 weeks at a time
• Patients are encouraged and instructed in daily home stretches to assist therapist in
achieving functional ROM
Motion
• Consists of AAROM with gentle passive assist by therapist to improve ROM and
function (therapist manually guides patient through range of motion with slow
steady stretching)
• Goal is to achieve full elbow extension, flexion, supination and pronation.

Strengthening
• Very simple therapy plan using light hand held weights in a progressive resistive
program. This is to help strengthen the tissue bone interface with light loading but
not compromising the repair by excessive loading.
• May also do some forearm grip strengthening as before using a spring loaded device
or “squeezy ball”
• All exercises are in sets of ten, with a 10 second interval up to 3 completed sets.
Weight can be adjusted as tolerated up to the limit recommended (see below).
Exercises are for elbow flexors, elbo w extensors, forearm supinators, forearm
pronators, wrist extensors, wrist flexors and grip.
o Weight limits are as follows; nothing more than a pound or two from the
time they start therapy (4 weeks post op) until 6th post op week.
o From 6th week on they can progress by 5 lbs each week until they are back to
normal weight and needs.

Functional Progression for sports/activities and return to work

• The following table is a guideline. Some patients may not need to lift this much but
these weights are also a guide for return to sport and work. Restrictions if available
will fall within these parameters. These weights describe maximums for elbow
flexion. Forearm rotators and grip strength will be far less.

Week 4-6 <5 lbs

6th week 5 lbs
7th week 10 lbs
8th week 15 lbs
9th week 20 lbs
10th week 25 lbs
11th week 30 lbs
12th week 35 lbs
13th week 40 lbs
14th week 45 lbs
15th week 50 lbs
16th week 55 lbs

Kenneth A. Jurist, M.D. and Joseph H. Guettler, M.D.

24255 Thirteen Mile Road, Suite 100
Bingham Farms, MI 48025
248-988-8085 Phone / 248-988-8565 Fax
“At Performance Orthopedics it’s all about You at your Peak Performance”
www.performanceorthopedics.com