Sling
- 4 weeks elective
- Up to 6 weeks-trauma fracture or revision.
Things that can be done from day 1
- Active assisted supported movements shoulder girdle within the safe zone*
- Mobilise elbow, wrist, hand, cervical spine
- Encourage patient to remove the sling for axillary hygiene and to perform exercises
- Cryotherapy once block has worn off and MUST take pain relief as prescribed
- Safe zone is stated by the surgeon in the operation notes but a standard guideline is elevation in the scapular plane to 90* external rotation to neutral for 4 weeks and 30 thereafter
What are the Restrictions?
- Avoid active external rotation past neutral for 4 weeks and 30 for up to 6 weeks.
- No resisted internal rotation (IR) to protect subscapularis repair
- No arm behind back for 6/52
- Extension For 6/52 do not let arm fall back to rest beyond midline of body. Use a pillow
- Combined abduction/external rotation. Internal rotation and adduction
- Weight bearing through operated arm e.g. getting out of a chair/bed 12 weeks
When can strengthening commence?
- Dependent on dynamic control and range of movement, pain level and functional demand
- Elective – generally 6-12 weeks, starting with Torbay procedures
- Fracture- 12 weeks+ depending on bone status
Anterior approach or deltopectoral – the deltoid is generally intact but subscapularis requires suture repair therefore care must be taken regarding external rotation avoiding passive or active range past neutral for the first 4 weeks.
Timeframes are guidelines not specifics and should be considered on an individual patient basis dependent on potential pre-operative functional status including status of the rotator cuff particularly post trauma and other co-morbidities.
Patient Education and Advice
Prior to discharge patient must be education on joint protection along with resting and sleep positions. Safe use of walking aids, sit to standing washing dressing and axillary hygiene.
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.
Patients should be allowed to return to swimming at 4 months starting with gentle breaststroke.
Patients employed in manual jobs should avoid heavy lifting for 6 months.
Protective Phase 0-6 weeks
Goals of Rehabilitation
- Protect the prosthesis
- Reduce pain and swelling which may be a cause of muscle inhibition and delay recovery (Do not force into pain.)
- Gain and maintain the safe zone range of movement (ROM)
- Prevent compensatory movements e.g. shoulder hitching which may compromise recovery
- Re-educate optimal recruitment of the deltoid
Exercises
- Maintain hand, wrist and elbow ranges of movement
- Reinforce postural correction
- Scapula mobilisation exercises e.g. shoulder shrugs, scapula retractions and protraction
- Cuff compensation programme
- Active assisted flexion and abduction within the safe zone (e.g. table slides, ball rolls)
- Active assisted external rotation to neutral progressing to 30*
- Keep lower body active as appropriate
Criteria for progression
- Good movement quality
- Pain controlled
- Deltoid function
- No signs of instability
Middle Stage 6-12 weeks
If not already wean from sling starting in the home. Light use only at waist/chest height i.e. mug of water, plate, buttering bread, brushing teeth, washing face, writing for short periods. Pace activities.
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 developing functional use of upper limb
Exercises
- Progress active assisted to active flexion, abduction and external rotation from 6 weeks respecting pain .i.e. roll ball table, forward lean reach, hand up wall, correct scapula control during movement.
- Functional AROM; can progress range naturally, as comfort allows, if has good cuff activation and normal movement. Consider anti-gravity with forward lean reach.
- Progress to potential full passive range of movement by 8 weeks respecting pain
- Continue to progress eccentric deltoid program.
- Incorporate functional extension and hand behind back from 6 weeks
- Use clenched fist resistance through range with opposite hand to gain anterior deltoid initiation
Guidance for exercise progression
- Pain controlled
- Good movement quality
- Deltoid function through range
- Active external rotation
- Good healing around the prosthesis
Functional restoration Late Stage 12 weeks+
Progress activities above chest height as pain allows and without compensatory movements. Begin gradual weight bearing. May be able to start re-using walking aid and driving as comfort allows unless stated otherwise in operative notes
Goals of Rehabilitation
- Restore full active range of shoulder movement
- Optimise functional strength and endurance
- Return to full work/ sport and leisure activities
- Educate on long term management strategies to preserve the replacement
Exercises
- Restore full active long lever flexion and abduction and maintain full range of external rotation, incorporating abduction and external rotation and abduction internal rotation stretches
- Loaded cuff compensation programme e.g. Deltoid rehabilitation through range with weights
- Functional day to day tasks can be incorporated into the rehabilitation program
- Cuff work; progress to unsupported if able. Can begin with elbow supported against a wall / progress to un-supported through range.
- Increase power; biceps, triceps.
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.