Sling
- 4 weeks preferably in the gunslinger position
- Only removed 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 as prescribed and use of Ice therapy once block has worn off.
*Safe zone: Flexion 90 degrees in the scapular plane 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?
- Active glenohumeral joint movements until week 6
- 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
- No lifting until 8 weeks.
When can strengthening commence?
This is generally at 12 weeks but is also dependent on dynamic control and
range of movement.
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.
Patient Education and Advice
Patients should be able to return to driving within 6-12 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.
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 movement’s e.g. shoulder hitching which may compromise recovery
Exercises
- Maintain cervical spine , hand , wrist and elbow ranges of movement
- Reinforce posture correction
- Active assisted / active 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
- Scapula mobilisation exercises e.g. shoulder shrugs, scapula retractions and protractions
- Encourage early low cuff activation and proprioception in prayer position or seated / standing at a table or bench
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
- Safe zone range of movement maintained.
- Absence of significant compensatory movement patterns
Middle Stage 4- 8 weeks
Goals of Rehabilitation
- Protect the repair
- Effective pain management
- Prevent compensatory movements
- Regain range of movement
- Avoid capsular stiffness
- Re-educate cuff recruitment and scapula control through range of movement
- Optimise the kinetic chain and use functional exercises
Exercises
- From week 4 passive range of movement can gradually be progressed outside of the safe zone respecting pain aiming for full passive range by week 6.
- From week 6 progress to full active flexion, abduction and external rotation respecting pain
- Proprioception exercises , incorporate close chain exercise to enhance co contraction
- Strengthen biceps and triceps with light resistance
- Progress cuff initiation and recruitment through range
- Consider functional exercises within the limit of pain
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 8-12 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.
Goals of Rehabilitation
- Restore full active range of shoulder movement
- Prevent compensatory movements
- Prevent capsular stiffness
- Optimise cuff recruitment and scapula control through range of movement and under load
- Optimise the kinetic chain and use functional exercises
- Return to full work/ sport and leisure activities
Exercises
- Restore full active long lever flexion and abduction and maintain full range of external rotation
- Ensure regain optimal range of movement into combined positions
- Strengthen biceps , triceps and deltoid with resistance
- Progress cuff strength and endurance but not at the detriment of gaining full range of movement
- functional specific strengthening exercises
- Closed and open kinetic chain exercises with increased load
Patients returning to high level demand sports may require more advanced 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 noncompromised shoulder movement.
