Sling
- Potentially upto 6 weeks consult op notes as time in the sling will be dependent on whether it is a 2,3 or 4 part fracture and the type of fixation used
- Preferably in gunslinger position
- It must be worn for bed
- Removed for axillary hygiene and to perform exercises
Things that can be done from day 1
- Active assisted/active supported movements within the safe zone*
- Mobilise elbow, wrist, hand, cervical spine and shoulder girdle
- Encourage patient to remove the sling for light activities of daily living such as washing
- their face, eating, drinking and writing.
*Safe zone is stated by the surgeon in the operation notes but a standard guideline is elevation and abduction below 90 degrees anterior to the scapular plane and external rotation to 0 degrees
What are the Restrictions?
- Avoid external rotation past neutral for 4 weeks and allow upto 30 degrees from 6 weeks onwards.
- Avoid hand behind back/extension – 6 weeks
- Avoid combined external rotation and abduction for 6 weeks
- Resisted IR for 6 Weeks
- Weight bearing through the operated arm, for example getting out of a chair/bed or pulling on the arm ascending stairs for at least 6 weeks
When can strengthening commence?
- Dependent on dynamic control and range of movement, pain level and functional demand
- Elective – generally 6-12 weeks
- Fracture-12 weeks+ depending on bone status
Patient Education and Advice
Pain relief should be taken on a regular basis to allow for good management of pain and to allow exercises to be undertaken in an effective manner. Regular application of ice packs can also be an effective source of pain relief and for swelling.
Patients should be able to return to driving within 12 weeks but this is dependent on their regained range of movement and control. Patients should be given guidance by their consultant and should also seek advice from the DVLA.
Avoid swimming for 4-6 months (Guidance to be sought from the surgeon at follow up clinic) Patients employed in manual jobs should avoid heavy lifting for 6 months.
Patient should be able to return to sporting activity at 6-9 months dependent on type of sport.
Patients will gain their maximum improvement between 12-24 months so will need to be motivated to continue their home exercise programme. Patients can expect to achieve a stable pain free shoulder facilitating light to moderate functional activity at waist level, shoulder height and overhead.
Timeframes are guidelines not specifics and should be considered on an individual patient basis dependent on pre-operative functional status including status of the rotator cuff particularly post trauma and other co-morbidities. The primary indication for surgery is pain relief.
Protective Phase 0-4 weeks
Treatment Note: Protection of subscapularis repair and greater tuberosity healing is essential in the initial post-operative phase.
Anterior approach or deltopectoral incision, the deltoid is generally intact but subscapularis requires suture repair therefore care must be taken regarding external rotation avoiding passive or active range past 0 degrees for the first 4 weeks. onsideration also needs to be mindful of the state of repair of the greater tuberosity and its stability which is usually 4-6 weeks.
Goals of Rehabilitation
- Protect the internal fixation
- Reduce pain and swelling which may be a cause of muscle inhibition and delay recovery
- Gain and maintain the safe zone of range of movement (ROM)
- Prevent compensatory movements e.g.shoulder hitching which may compromise recovery
- Re-educate optimal recruitment of the deltoid
Exercises
- Maintaincervical spine , hand, wrist and elbow active ranges of movement
- Reinforce posture correction and good movement patterns
- Scapula mobilisation exercises e.g.shoulder shrugs, scapula retractions and protractions
- Encourage use of the hand whilst in the sling for light activities such as writing, feeding
- Active assisted flexion and abduction within the safe zone (e.g. table slides, ball rolls etc.)
- Pain free isometrics rotator cuff (<30% MVC) except for internal rotation
- Reinforce pre-operative education regarding positioning and joint protection
NOTE: Research demonstrates that patients who engage their hand on the side of the operated shoulder during the immobilisation phase of rehabilitation generally have better outcomes in relation to pain and function.
Also principles of cross-education can be used with these patients in the early stages of rehab to help with facilitating muscle activation patterns and cortical representation.
Middle Stage 4-6 weeks
Goals of Rehabilitation
- Gain and maintain the functional range of movement (ROM)
- Prevent compensatory movements Optimise dynamic control through range
- Promote and facilitate movement patterns into functional activity
- Promote proprioception Exercises
- Commence Torbay type exercises starting supine short lever progressing to long lever from 4 weeks
- Progress external rotation at week 4 from 0 degrees to 30 degrees
- Encourage increasing functional activity at waist height
- Continue pain free isometrics rotator cuff (<30% MVC) Prosthesis position will be checked at clinic follow up by radiological evaluation
Guidance for exercise progression: Pain controlled functional range of movement, Good movement quality, Active external rotation, good healing around the prosthesis
Late Stage 6-12 weeks
Goals of Rehabilitation
- Progress from active assisted to full active flexion, abduction and external rotation from 6 weeks respecting pain (continue supported upper limb work until good control regained)
- No restriction regarding passive range of movement, aim to progress to full passive range of movement by 8 weeks respecting pain
- Continue pain free isometrics rotator cuff (<30% MVC) – inclusive of subscapularis from 6 weeks
- Isometric cuff strengthening through range
- Incorporate functional extension and hand behind back from 6 weeks
- Optimise functional strengthand endurance
- Return to full work/ sport and leisure activities
- Educate on long term management strategies to preserve the replacement
- Pain free well controlled functional range of movement
Exercises
- Restore full active long lever flexion and abduction and obtain full range of external rotation
- Proprioception neuromuscular facilitation exercises
- Consider functional specific strengthening exercises
- Introduce gentle rotator cuff resistance exercises (if good cuff status)
- Increase functional use of arm (respecting control/load/fatigue)
- Functional movement, re-education specific to patients functional demands
These progressions are dictated by indication that the patient is pain free with activities of daily living, can tolerate late stage rehabilitation loaded exercises without pain and have full range of noncompromised shoulder movement.