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RotatorCuffSurgicalRepairReturntoSportProtocol
PhaseI:(Post-Opweeks1-6)Goals:
1- Protectsurgicallyrepairedtissues2- Minimizepainandinflammation3- BeginScapularstabilization-rows,lightPNFpatternsinside-lying4- Preventmuscularinhibition5- Educate/re-educatepatientonallpost-opinstructionsonprecautionsandprogressionof
activities/movements,andteachpatientahomeexerciseprogram6- PatienttobeindependentwithADL’sandmodificationswhilecontinuingtoprotectthe
integrityoftherepair
InterventionstoAvoid/Precautions:1- NoAROMoftheshoulder(Nopushing,pulling,leaningonelboworhand)2- Noliftingofobjectswiththeshoulderthatwasrepaired3- Noexcessivestretchingorsuddenmovements4- Nosupportingofbodyweightbythehandoftherepairedshoulder5- DonotpushPROMtoaggressivelytothepointofelicitingpatientguardingorpassedPROM
stagedROM’s6- Excessiveadductionorinternalrotationshouldbeavoidedasthecanplaceexcessivestress
ontherepair7- Avoidsleepingontheaffectedside
SpecificInterventions:Immobilization:ThiswillbedeterminedbytheMDdependingon;thesizeofthetear,concomitantinjuries/repairs,co-morbidities,etc.Patientmustremainintheslingasdirectedonlyremovingforbathingortoperformexercises.Patientshouldbeeducatedthattheserestrictionsneedtobeadheredtoforprotectionoftherepair,evenwithoflackofpain/symptoms.Typicallyslingiswornapproximate4-6weekspost-op.Treatment:TreatmentsshouldfocusonachievingappropriatePROMgoals;minimizinginflammation;normalizingscapularposition,mobilityandstability;andimproving/normalizingROMofuninvolvedsurroundingjointsoftheupperextremity,cervicalandthoracicspine,andribcage.PatientEducation:
1- Explainthenatureofthesurgery2- Discusstheprecautionsspecifictothenatureofthepatient’ssurgicalrepair,suchastryingto
meetthesetgoalsforPROM,andnotgainingmotiontoofast3- Theimportanceoftissuehealing4- Properwearingtimeandpositioningofthesling5- LimiteduseofupperextremityforADL’sonlyatnohigherthanwaistlevel
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TherapeuticExercises:Post-OpDays:1-10:1- AdministertheWesternOntarioRotatorCuffIndex(WORC),ShoulderPainandDisabilityIndex
(SPADI),ortheAmericanShoulderandElbowSurgeon(ASES)Formoutcomeform(s)forabaselineself-reportedoutcomesmeasurementofthepatient.ThesearebestfortheRotatorCuffandassessingshoulderinstability.
2- PatientEducationforpostureandproperpositioningoftheshoulderforjointprotectionandtoperformdailyhygieneactivities
3- Pendulumhangs,withnoactivemovementsoftheshoulder4- Cryotherapyforpainandinflammation5- AROM,withnoweights,forelbow,wrist,andhand(grip)a. OnlyPROMforelbowiftheyalsounderwentabicepstenodesis/tenotomy
6- Deltoidreflexiveisometrics-notifbicepsinvolved*seesuggestedexercisesheet7- CervicalA+PROMexercises,&manualmobilizationsandsofttissuework8- Scapularelevationsandretractionexercises-performinandoutoftheslinga. Scapularmuscleisometrics/sets
Post-OpWeeks1-3:1- Continueaboveexercises2- Moisthotpackspre-treatmenttobloodproliferation,andtissueextensibility3- PassiveForwardElevation(PFE)inplaneofthescapulatotoleranceto60°-90°4- PassiveExternalRotation(PER)(withelbownogreaterthan0°-20°ofabduction-closetothe
body)foraROMof0°-15°:ThisdirectionofPROMmaybedelayedforupto6weeks(perMD)iftenuoustissuequality,poorrepairintegrity,and/orlargetear.
5- EarlyPROMshouldonlyincludeactivitieswithlowrotatorcuffactivation,(nopulleys,canetherapeuticexercises,orselfPROMatthistime)
6- Beginmanualscapulastabilizationexercises-PNFinS/L,rib&thoracicjt.Mobs7- BeginLEstationarybike,withslingon,totrytomaintainsomeendurancelevel
Post-OpWeeks4-6:1- Progresspendulumhangstopendulummobility2- Progressscapulastrengthening-rows,scapulardepression,progressPNF3- ProgressPFEinplaneofthescapulato90°-120°,andPERat0°-20°ofabductionto20°-30°,as
patientstolerates,byweek6patientcanbeprogressedto20°-45°forERin20°ofAbduction,aswellasbeginERat90°ofabductionwithROMbetween40°-60°
4- BeginPassiveROMinotherplanes,->AAROM(Pulleys,Cane,&UERanger)a. ERPROMcanbeadvancedto45°,75°,and90°ofabductionasmotionandpatient’stolerance
willallowb. BeginHorizontalAdduction
5- MaybegingradI->IIjointmobilizationsforpainrelief/relaxation,foralljointsoftheshoulder(GH,SC,ST,AC)
6- Ifapool/aquatherapyisavailable,patientmaybeginAAROMinthepool,noswimmingstrokes7- Progresselbow,wristandfingerAROMtolightstrengthening(delayedto6weekspost-opfor
bicepstenodesis/tenotomy)8- Lightscarmobilizationassoonasthescarisfullyhealed,andmodalitiesPRN
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StagedROMGoals:Post-OpWeek RangeOfMotion(ROM)POW1-3: PROM:
-PFE:(scapularplane):60°-90°,-PER:(@0°-20°Abd):0°-15°-maybedelayedperMD,AROM:-Elbow,WristandHand(grip):OnlyPROMfortheelbowifthe
patentunderwentabicepstenotomy/tenodesis*NoHorizontalAddorIRbehindtheback
POW4-6: PROM:-PFE:(scapularplane):90°-125°,-PER(@0°-20°Abd):20°-45°,-PER(@45°,75°,&90°Abd):40°-60°-IR(scapularplane):slowlyprogressto45°,-Abd:45°-100°:progressastolerated,-MaybeginHorizontalAdductiontotoleranceAAROM:-Begininallplanes,withinstagedROMGoalsAROM:-ContinuetoprogressanyROMdeficitsintheelbow,wristand
hand-Maybewithbicepstenotomy/tenodesispatients
POW7-12: PROM:-PFE:135°-155°,-PER:(@20°-30°Abd):30°-60°,-PER(@90°Abd):50°-75°,-IR(scapularplane):60°,-Abd:slowlyprogressastolerated,AROM:ProgressAAROMtoAROM-AFE:80°-120°,-Abd:slowlyprogressastolerated,-AIR+AER:slowlyprogressastolerated
POW13-18: ROM:-PER+AER(@20°-30°Abd):80°-90°(byweek18),-PER+AER(@90°Abd):75°-90°(byweek18,110°-115°if
patientisathrowingathlete),-P+AIR(@90°Abd):30°-65°(byweek18),-AFE:mustbe180°/WNL(byweek18),-P+AAbd:mustbe180°/WNL(byweek18)
Key: POW=Post-OperativeWeek,PFE=PassiveForwardElevation,PER=PassiveExternalRotation,AFE=ActiveForwardElevation,AIR+AER=ActiveInternalandExternalRotation
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PhaseII:Post-OpWeeks7-12CriteriaforenteringPhaseII:
1- Appropriatehealingofthesurgicalrepairbyadherencetotheprecautionsandimmobilizationguidelines
2- AchievementofthePROMgoals,asstatedintheprevioussection:PassiveForwardElevation(intheplaneofthescapula)of90°-125°,PassiveExternalRotation(with20°ofabduction)of20°-45°,PassiveExternalRotation(with90°ofAbductionintheplaneofthescapula)to40°-60°,PassiveInternalRotation³45°
3- Reductioninpainto0-2/10(onaVASscale)withPROM4- MinimalDetectableChange(MDC)onoutcomeformof9.4forASES,between8-13fortheSPADI,
and7.1pointsfortheWORC
Goals:1- Continuetoallowforsofttissuehealing2- Donotoverstresshealingtissue3- RestorefullPROM(byweek12)4- NormalizeAROMmovementsandranges5- Minimizepainandinflammation6- PatientisindependentwithfunctionalADLsandlightworkactivities(Week12)7- Begintoincreasestrengthandendurance8- TocontinuallychangethescoresontheWORC,SPADIortheASESoutcomesformswithMDC
Interventionstoavoid/Precautions:1- NoliftingoractivitiesthatrequireROMbeyondwhatisstatedforacceptable/desiredROM
goals2- Nosupportingthebodyweightbythesurgicallyrepairedhandandarm3- Noexcessivebehindthebackmotions4- Nosuddenjerkingmotions5- DonotperformROM/stretchingbeyondstatedacceptableROMgoals6- Donotperformlongleverarmstrengtheningexercisefortherotatorcuffthatwillplacetoo
muchloadontherepairedtissue7- Donotperformscaptionwithinternalrotation(emptycan)atanystageofrehabilitationdueto
impingementandstressontherotatorcuffrepair
SpecificInterventions:PatientEducation:
1- Continuepatienteducationforallareasoftherapyandrecovery2- Typicallytheslingisdiscontinuedbyweeks4-6Post-Op,basedonthedemonstrationand
expressionlittletonopainandappropriatecontroloftheupperextremitywithwaistlevelADLsandisawareofthelimitationsallowed(nosuddenreaching,lifting,etc.),however,consultwithMDforD/Ctimeframe
3- Continueeducatingpatientonusingtheupperextremityinapain-freeROMforADLS,beginningandwaistlevel,thenprogressingtoshoulderlevelactivities,andfinallyoverheadactivities
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TherapeuticExercises:(SeeSuggestedExerciseSheet)1- ContinuepreviousphaseIexercises/activitiesasneeded2- ProgressPFEandPERROMasneededtoachievegoals3- ProgressPROMandbeginActiveForwardElevation(AFE)inthescapularplaneinweek9a. ROMlimitationsare:PRE:130°-155°,PER(@20°Abduction):30°-60°+,PER(@90°abduction):
50°-75°,andAFE:80°-120°4- ProgressAAROMprogressingtoAROM,forForwardElevation,FlexionAbductioninthescapular
plane,ExternalRotation,astolerated,withemphasisonpropershouldermechanics5- ProgressJointmobilizationstoGradeIII->IVtoaddresscapsularrestrictionsandregainfullpassive
ROM,ifindicated,forallshoulderjoints(GH,SC,AC,ST)6- ProgressingtoAROM,forForwardElevation,FlexionAbduction(scapularplane),External
Rotation,andfunctionalInternalrotationwithbehindthebackmotions7- Initiateposteriorcapsulestretchingcrossbodyadductionstretchingasindicated8- EstablishbasicrotatorcuffandscapulaneuromuscularcontrolwithinallowedROM9- Introducelightwaistlevelfunctionalactivities,thenprogresstolightresistanceexerciseswithin
allowableAROMwithoutcreatingsignificantforceontheshouldergirdlemusculature10- Sub-maximalisometricexternalandinternalrotationexercises11- Addressallscapulothoracicandtrunkmobilitylimitations,tofacilitatenormalmovementofthe
shoulder.FocusingespeciallyonthoracicextensionandachievingnormalcervicalROM12- Whenpain-freeAROMwithgoodshouldermechanicsisdemonstrated,beginastrengthening
programfortheDeltoid,non-repairedsegmentsoftherotatorcuff,andscapulamusculature13- Lightresistancebandstrengtheningisappropriatewithinthepatientspain-freeROM14- Beginlow-levelclosedchainstrengthening(quadruped,physioball,suspensiontrainingsystem
(ex.TRXÔsystem))andStageIUEPlyometricProtocol,oncescapularstrengthandstabilizationisachieved(*seeattachedprotocol)
*Donotinitiateabeginningstrengtheningprogramprogressionuntilpatient’spainisatanappropriatelylowlevelandthechosenexercisesdonotincreasesymptoms
PhaseIII:Post-Op3-6MonthsCriteriaforenteringPhaseIII:
1- PROMandAROMof:>155°forPFE,>120°AFE,>60°PER@20°abduction,>75°PER@90°abduction,with0-2/10painandnosubstitutionpatternswiththemovements
2- Painof<2/10withallcurrentstrengtheningexercises3- Demonstrateappropriateposition,staticallyanddynamically,ofthescapuladuringROMand
exerciseactivities4- Scoresof>/=70%ontheWORC,</=0-20ontheSPADIor</=0-12ontheASESoutcomeforms
Goals:1- AchievefullP+AROM2- Improvedynamicshoulderandscapularstability3- Graduallyfullyrestoreshoulderstrengthtobeabletoprogresspowerandendurance4- Improveneuromuscularscapular,shoulder,andtrunkcontrol5- ReturntonormalfunctionalADLs,fullwork,andmodifiedrecreationalactivities6- Evaluatefunctionalmovementswiththepatient,assoonasAROMisachieved,withtheSelective
FunctionalMovementAssessment(SFMA),ortotalbodymovementscreening,suchascervicalmobility,forwardandbackwardbending,totalbodyrotation,single-legstance,squat,etc.Makesureyouteaseoutifdysfunctionsarecausedbyamobilityorastability/motorcontrolissue!
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InterventionstoAvoid/Precautions:1- Noliftingobjectsheavierthan10lbs2- Nosuddenliftingorpushingactivities3- Nosuddenjerkingmotions4- Nouncontrolledmovements
SpecificInterventions:PatientEducation:
a. ContinuetoexpresstheimportanceofgraduallyincreasingthestresstotheshoulderwhilereturningtonormalADLs,workandlimitedrecreationalactivities
TherapeuticExercises:(SeeSuggestedExerciseSheet)1- ContinuestretchingandpassiveROMasneeded2- Patientmaystilldesire/needMoisthotpackpriortostretchingandcryotherapyposttreatment3- Nearlyfullelevationinthescapularplaneshouldbeachievedbeforeelevationintheotherplanes4- Allexercises/activitiesshouldbeperformpain-freewithoutandcompensatory/substitution/
alteredmovementpatterns5- Exercisesintensityshouldbewithhigherrepetitions(30-50repetitions)andlowerresistance6- TreatdysfunctionsfoundthroughSFMA/FunctionalMovementtesting7- ProgressNeuromuscularRe-educationwithdynamicstabilizationexercises;lightPNFtrainingfor
therotatorcuff,deltoidandscapula;closed-chainactivityprogression8- BytheendofthisPhase,evaluatepatientwiththeFunctionalMovementScreen(FMS)&Y-
Balance/CKCUTESTAssessmentsatleastonetimeforbaselinescores9- Strengthexercisesthattargetthesurgicallyrepairedrotatorcuffcanbeinitiated,withlightweight
orbandsinandpain-free,lowstressrange.Exercisesshouldbeprogressedintermsofmuscledemandandintensitytopatient’stolerance.Theyshouldalsobeprogressedintermsofshoulderelevation/leveltheexercisesareperformed(waistlevel->shoulderheight->overheadactivities)a. ERside-lyingwithatowelrollunderthehumerusb. PerformER/IRexercisesatvariousdegreesofabductionc. Fullcaninthescapularplane(avoidemptycanexerciseatalltime2°topossibleimpingement)d. Pronescapularandrotatorcuffexercises(rowing,extension,horizontalabduction,etc.)
CriteriaforProgressingtoAdvancedStrengtheningProgram:1- MMTofagradeof4/5orgreater2- Pain-freewithallbasicADLsandpreviousstrengtheningexercises3- FullAROMwithElevation4- Patienthasadesiretoreturntopre-injurylevelofsport/activity
ExerciseAdvancement:(SeeSuggestedExerciseSheet):1- Integratefunctionalpatternsthatwillbepartoftheactivities/sportpatientwillbereturning2- Increasespeedofmovements3- Decreaseresttimebetweenexercisestoimproveendurance4- BeginLEplyometricandPhaseIIUEplyometricProtocols(seeattachedsheets/protocol)5- PNFpatternswithresistancebandsinstanding6- Resistancebandexercises@90°/90°forIRandERwithandwithoutarmsupport7- Simulatedsportmovementswithresistancebands,suchas;golf,batting,andtennisswings8- BeginThrowersTenProgram(*seeattachedsheets)->AdvancedThrower’sTenProgram(*also
seeattachedsheets)
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PhaseIV(AdvancedTrainingPhase):ToprepareforReturntoSportPhase.NosettimeframeaspatientsmayprogresstothisstageatslightlydifferentratesCriteriaforenteringPhaseIV:
1- Demonstrateadequatestrengthanddynamicstabilizationforprogressiontohigherdemandsportspecificactivities
2- Appropriatescapularpositioning/controlstaticallyanddynamicallywithROMandallstrengtheningexercises
3- Scorea14or>ontheFMS,andminimalasymmetriesontheY-Balance/CKCUTESTAssessments4- WORC,SPADIorASESisreplacedbyDASH-Sport/performingArtsModuleforapatientself-
evaluationoutcomemeasurementGoals:
1- Maintainfullandnon-painfulactiveROM2- Improvemuscularstrength,power,andendurance3- Returntofunctionalactivities4- >14ontheFMS,NostatisticalasymmetrieswithY-Balance/CKCUTESTassessments5- BeabletobegintheReturntoSportSpecificProtocolafterPhaseIVcompletion
InterventionstoAvoid1- Noheavyliftinggreaterthe15-20lbs,noSuddenliftingorpushingactivities2- Nosuddenjerkingmotionsoruncontrolledmovements3- Noprogressiontoactivityspecificexercisesunlesspatienthasfullpain-freeROM&strength
withthesurgicallyrepairedshoulderSpecificInterventions:TherapeuticExercises:(SeeSuggestedExerciseSheet):
1- ContinuepassiveandactivestretchingoftheshoulderandcapsuletomaintainROM2- Addressanyremainingstrength/motorcontrol/stabilitydeficitsfortherotatorcuff,scapula,and
trunk-withemphasisonengagingtonicstabilizingtrunkandhipmuscleswhileperformingdynamicupperandlowerextremityexercises
3- Advanceproprioceptiveandneuromuscularexercises/activities4- ContinueprogressionofstrengthwiththeAdvancedThrower’sTenProgram(seeattached)5- Graduallyprogressreturntoweight-liftingprogramfocusingonlarger,primaryupperextremity
muscles-startwithlightweightandhighrepetitions(15-25perset)andgraduallydecreaserepetitionsdownto8-10)asyouincreasetohigherweightsoverthecourseor6-8weeks
6- Begin8weekUEadvancedplyometricprotocol(seeattachedprotocol)7- BeginIntervalSportProgram(Throwing,Tennis,Golf)(seeattachedprograms)
CriteriaforenteringReturntoSpecificSportProtocols:1- ClearancefromthesurgeontobegintheReturntoSportSpecificProtocol2- Nosignsofanylingeringshoulderinstabilitywithactivities3- RestorationorallROMneededtoparticipateindesiredsport4- Adequatestrengthandmuscleenduranceoftheshoulder,rotatorcuff,trunk,hip,andscapular
musculatureneededtoperformsportspecificdrills/activitieswithminimaltonopainordifficulty
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5- PatientscoresanappropriatescoreontheDASH-Sports/PerformingArtsModuleSelf-assessmentoutcomeform:(“no”–“mild”difficultyonallquestions)andtheKerlan-JobeOrthopaedicClinicShoulder&ElbowScore(KJOCScore):(³80)
6- >16onFMSandscoreontheY-BalanceofequaltopeersforsportandagethroughtheY-Balancedatabase,orCKCUTESTequaltonormative
7- Nopainwithanyofthepreviousexercises/activitiesperformed8- CompletingtheThrowersTenProgram(ifanoverheadathlete)andtheupperextremity
plyometricsprotocols9- Passingofthefunctionaltestslistedbelow:Testcanbeovermultiplesessionsa. TrunkTesting:(Seeattachedsheets)i.DeepNeckFlexorTestii.SegmentalMultifidusTestiii.TrunkCurl-upTestiv.Double-LegLoweringTestv.ProneBridgeTestvi.EnduranceofLateralFlexors(SideBridge)vii.ExtensorDynamicEnduranceTestb. UpperExtremityTesting:(Seeattachedsheets)i.AlternativePull-upTestii.Push-upTestiii.BackwardOverheadMedicineBallThrowTestiv.SidearmMedicineBallThrowTestv.SeatedShot-PutThrowTestvi.*Ifpatientisabaseballorsoft-ballpitcher/player
1. FunctionalThrowingPerformanceIndex(FTPI)Test-bestassessedwithvideoanalysis2. Baseballpitchersonly-PT/ATCfillsoutUpperExtremityThrowingAnalysisForm-to
determineareasofthethrowingmotionthatneedtobeaddressedinthesportspecific/returntobaseballpitchingprotocol
*SeeReturntoSpecificSportProtocol
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