I. Early Protective Phase (0-5 weeks)
a. Goals:
- Protect surgical procedure
- Educate patient on procedure and therapeutic progression
- Regulate pain and control inflammation
- Initiate range of motion and dynamic stabilization
b. Treatment Plan (0-3weeks);
- Sling Immobilization for 5 weeks;
- Gripping exercises
- Elbow, wrist and hand ROM
- Pendulum exercises (weighted & unweighted)
- PROM to AAROM
- IR/ER proprioception training (controlled range)
- Initiate gentle alternating isometrics for IR/ER in scapular plane
- Initiate passive forward flexion to 900
- Initiate scapular mobility
c. Treatment Plan (3-5 weeks);
- ROM Progression
- Forward flexion to 110° - 130°
- ER in scapular plane to 45°
- IR in scapular plane to 60°
- Progress sub-maximal alternating Isometrics for IR/ER in scapular plane
- Initiate scapular strengthening
- Manual scapula retraction
- Resisted band retraction
- No shoulder extension past trunk
- Isometrics in all directions
- Continue bicep/tricep strengthening
- Initiate light band work for IR/ER
d. Milestones for progression
- Forward flexion to 110° -130°
- ER in scapular plane to 45°
- IR in scapular plane to 60°
- Tolerance of submax Isometrics
- Knowledge of home care & contraindications
- Normalize mobility of related joints (AC/SC)
II. Intermediate Phase (5 - 8 weeks)
a. Goals (general)
- Normalize arthrokinematics
- Gains in neuromuscular control
- Normalization of posterior shoulder flexibility
b. Treatment Plan
- ROM Progression
- Forward flexion to 150° -165°
- ER in scapular plane to 65°
- Full IR in scapular plane
- Initiate joint mobilizations as necessary
- Initiate posterior capsular stretching
- Progress strengthening
- IR/ER band in scapular plane
- Side lying ER
- Full can (no weight if substitution patterns)
- CW/CCW ball against wall
- Initiate PNF patterns In available range
- Body blade at neutral or rhythmic stabilization
c. Milestones for progression
- Forward flexion to 150° -165°
- ER in scapular plane to 65°
- Full IR in scapular plane
- Symmetrical posterior capsule mobility
- Progressing isotonic strength with IR/ER in available range
III. Strengthening Phase (8 - 14 weeks)
a. Goals (general)
- Normalize ROM
- Progression of strength
- Normalize scapulothoracic motion & strength
- Overhead activities without pain
b. Treatment Plan
- ROM Progression; Initiate IR/ER @90° of GH abduction
- Within 10° of full AROM in all planes
- Progression of scapular retractors & stabilizers
- Prone program; LT, MT, Rhmd
- LT: scapular depression
- Progress strengthening
- Challenging rhythmic stabilization
- UBE: forward & retro
- Bilateral ball against wall; progress w/ perturbation
- Initiate Isokinetic IR/ER in scapular plane
- Initiate IR/ER @ 90° of GH abduction
- Isotonic strengthening; flex, abd
- Closed kinetic chain (ckc) ther-ex
c. Milestones for progression
- Within 10° of full active range in scapular plane
- IR/ER <50% deficit
- <30% strength deficits; primary shoulder muscles & scapular stabilizers
IV. Advanced Strengthening Phase (14 - 24 weeks)
a. Goals (general)
- Pain free full ROM
- Improve muscular endurance
- Improve dynamic stability
b. Treatment Plan
- Maintain flexibility
- Progress strengthening
- Advanced ckc ther-ex
- Wall push-ups; w/wo ball
- Continue w/ overhead strengthening
- Continue w/ Isokinetic IR/ER strengthening; @90° of GH abduction
- Advance isotonic strengthening
- Advance rhythmic stabilization training in various ranges and positions
- Initiate Plyometric strengthening
- Chest passes
- Trunk twists
- Overhead passes
- 90°/90° single arm plyos
c. Milestones for progression
- Strength deficits < 20% for IR/ER @ 90° of GH abduction
- <20% strength deficits throughout
V. Return to Activity & Sport Phase (6 -9 months)
a. Goals (general)
- Pain free full ROM
- Normalized strength
- Return to sport/activity program
b. Treatment Plan
- Continue Isokinetic training
- Continue w/ stability training
- Advance plyometric training
- Continue w/ ckc ther-ex
c. Milestones for Activity
- Strength deficits <10% throughout
- Normalized closed kinetic chain testing
- Completion of return to sport/activity program