Phase One

At this stage, the most important goals are patient education and gentle ROM. The tissues are healing and the focus should be on positions and postures that place the least amount of stress on the tissues.

Sling: To be worn for 3 weeks at all times and for five weeks while sleeping or out in public. It may be beneficial to use a pillow for support while sleeping once the sling is removed. When your sling is off your elbow should remain by your side.

Ice: 2-3 times per day for 10-15 minutes to help decrease inflammation and pain.

Physical Therapy: Start physical therapy 1 x per week for 6 Weeks at 10-14 days postop. At 6 weeks post-op, physical therapy should be 2 x per week for 10-14 weeks.

Remember that these guidelines should take into account the patient's symptoms and one should not progress to the next phase if the patient cannot successfully complete the previous phase.

Weeks 2-4

· Small Pendulums/Tummy Rubs
· Wrist and elbow ROM
· Theraputty/gripping exercises
· Posture education/awareness
· Pulleys (flexion/scaption) o PROM (Supine)

o Flexion as-tolerated
o Abduction as tolerated
o Internal rotation 0-30 degrees in scapular plane
o External rotation as tolerated in scapular plane

Weeks 4-6

· Gradually increase ROM in all planes - Avoid extreme end range IR and adduction

o Internal Rotation to 45 only

· Continue with previous ROM exercises
· Initiate AAROM (wand or T-Bar) in supine for flex, abd, add, and IR/ER in scapular plane·
· Initiate submaximal isometrics (all planes, shoulder in neutral, elbow
  bent to 90 with bolster under arm .
· Initiate UBE for warm-up activity
· Initiate IR/ER with theraband at 0 abduction

o Perform IR from full ER to neutral
o Perform ER from neutral to full ER

· Initiate active forward flexion and scaption
· Initiate bent over rows and sidelying ER
· Begin bicep and tricep strengthening (bands, weights)
· Scapular stabilization strengthening
· Initiate Rhythmic stabilization

Phase Two (Intermediate Phase)

This phase of rehabilitation focuses on restoring full ROM, regaining normal. scapulohumeral mechanics, and restoring muscular strength and balance/proprioception.

Weeks 6-8

· Gradually increase to full ROM in all planes - continue to avoid extreme end range IR
  and adduction
· Begin weight-bearing on all fours to help facilitate neuromuscular control
· Initiate Proprioceptive Neuromuscular facilitation (PNF) patterns with manual resistance
· May initiate light stretching

Weeks 8-12

· Gradually increase to full ROM in all planes by week 12
· Initiate slightly more aggressive strengthening exercises
· Progress isotonic strengthening exercises (increase resistance and
  repetitions)
· Begin PNF patterns with bands/pulleyslweights
· Begin wall push-ups and progress to table to floor as tolerated
· Progress rhythmic stabilization throughout .entire ROM
· Progress weight bearing exercises to include unstable surfaces (Airex, Bosu ball, etc)

Phase Three (Advanced Activity and Strengthening)

The goals of phase three include maintaining full ROM; improving muscular strength, power, and endurance; introduce functional activities; and enhance neuromuscular control.

Weeks 12-16

· Continue strengthening exercises

o PNF manual resistance (increase speed as tolerated)
o Muscular Endurance training
o Increase resistance and repetitions with isotonic and band exercises
o UBE for strength and endurance

· Initiate more aggressive strengthening

o Push-ups
o Bench Press Free weights
o Seated Row
o Lat pull-downs

· Progress stretching exercises to include posterior capsule stretch and towel internal   rotation stretch
· Begin 2 handed plyometrics @ week 12

o 3-5 lb ball
o Chest pass
o Side to side throw
o Overhead soccer throw

· Progress to single hand plyometric throwing (approximately 2 weeks after initiation of 2   handed)

o 90-90 throws
o Wall dribbles

Weeks 16-22

· Continue all exercises listed above o Con fume all stretching
· Continue plyometric program
· Initiate interval sport program (throwing, etc.) at 16 weeks

Phase 4 (Return to Activity)

During the final stage of rehab, emphasis is placed on gradual return to sport activities and maintaining strength, mobility, and stability of the shoulder.

Weeks 22-26

· Emphasis is on work or sport specific exercises
· Continue stretching and strengthening in functional or sport-specific positions
· Gradually progress sport or work activities to full participation