Sling
- 6 weeks preferably in the “gunslinger position”
- Only remove for axillary hygiene and to perform exercises.
- It must be worn for bed.
- Encourage use of the hand whilst in the sling for light activities such as writing, feeding.
Things that can be done from day 1
- Active assisted supported movements within the safe zone*
- Regular pain relief must be advised as prescribed
- Advice on the safe use of ice once block has worn off
*Safe zone is elevation anterior to the scapular plane limited to 80 degrees and 50% of the external rotation (compared to the other side) respecting pain and movement pattern unless stated as otherwise by the surgeon in the operation notes.
What are the Restrictions?
- Until week 6 avoid: hand behind back or across body
- Until week 8 avoid: combined external rotation and abduction
- No forced end of range stretches
When can strengthening commence?
- This is generally at 12 weeks but is also dependent on dynamic control and range of movement
- No lifting until 12 weeks.
Patient Education and Advice
Patients should be able to return to driving around 12 weeks but this is dependent on their regained range of movement and control and on the side of the shoulder which has been operated on.
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 4-6 months starting with gentle breaststroke.
Patients employed in manual jobs should avoid heavy lifting for 6 months.
Evidence does suggest that patients will continue to potentially improve for 1-2 years following surgery.
NOTE: Following a cuff repair be mindful that tissue remodelling will not reach its maximum tensile strength until 12-16 weeks post repair and that the integrity of the repair relies essentially on the suture constraints. Smokers, diabetics, older patients, thoughts with minimal postoperative pain and > 3cm tear size have a heighted risk of re tear.
Timeframes are guidelines not specifics and should be considered on an individual patient basis.
Early Phase 0-4 weeks
Goals of Rehabilitation
- Protect the repair and optimise tissue healing
- Reduce pain and swelling which may be a cause of muscle inhibition
- Gain and maintain the safe zone of range of movement (ROM)
- Prevent compensatory movements e.g. shoulder hitching which may compromise recovery.
Exercises
- Maintain hand wrist forearm and elbow ranges of movement
- Reinforce posture correction
- Passive/ active assisted supported flexion, abduction and external rotation in sitting, standing using bench slides or gym ball rolls or in supine using the other arm +/- stick within the safe zone
- Isometric rotator cuff contractions (sub maximal <30%) however these should be pain free
- Scapula mobilisation exercises e.g. shoulder shrugs, scapula retractions
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.
Guidance for exercise progression
- Good pain control
- Progressing range of movement respectful of pain reinforcing Good movement patterns and the absence of compensatory movements such as hitching.
Middle Stage 4-12 weeks
Goals of Rehabilitation
- Protect the repair and optimise tissue healing
- Reduce pain and swelling which may be a cause of muscle inhibition
- Prevent compensatory movement’s e.g. Shoulder hitching which may compromise recovery
- Re-educate cuff recruitment and scapula control through range of movement
- Prevent capsular stiffness
- Optimise the kinetic chain and use functional exercises
NOTE: Be aware of patients who quickly progress with minimal end of range pain as these
will be the ones who are likely to load the cuff too early and run the heightened risk of retear.
Exercises
- Progress to full passive range of movement by 6 weeks respecting pain
- Progress to active short lever flexion and abduction and full range of external rotation from weeks
- Progress to active long lever flexion and abduction and maintain full range of external rotation from 8 weeks
- Strengthen biceps and triceps with light resistance
- Progress cuff initiation and recruitment through range
- Consider functional exercises within the limit of pain
- Encourage early low cuff activation and proprioception in “prayer position” or seated /standing at a table or bench
Guidance for exercise progression
- Pain free functional range of movement
- Good rotator cuff activation and control through functional range
- Good movement patterns and the absence of compensatory movements such as hitching.
Late Stage 12 weeks+
At 12-16 weeks the tissue modelling phase is almost complete and the repair will be
reaching its maximal tensile strength however patients need to be assessed regarding the
appropriateness of starting to specifically strengthen dependent upon operative findings,
tissue quality, patients age and whether the it was a primary or revision surgical procedure.
Careful progression of loading is essential to avoid compromise of the surgical repair.
Goals of Rehabilitation
- Restore full active range of shoulder movement
- Prevent compensatory movements e.g. shoulder hitching which may compromise recovery
- Optimise cuff recruitment and scapula control through range of movement and under load
- Return to full work/ sport and leisure activities
- Optimise function specific power, strength and endurance
Exercises
- Ensure regain optimal range of movement into combined positions
- Enhance neuromuscular control through range and incorporated with Kinetic chain
- Active long lever range of movement
- Strengthen biceps with resistance
- Progress cuff strengthening
- Consider functional specific strength and endurance exercises
- Closed kinetic chain exercises with increased load
Patients returning to high level demand sports may require more advanced strengthening
rehabilitation. 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 non-compromised shoulder movement.
