These protocols were created in association with the Department of Orthopedic Surgery & Sports Medicine's Dr. Carolyn Hettrich. As with any protocol these are guidelines and mofications of patient care should be discussed with referring physician and other members of the health care team prior to making modifications.

Anterior Stabilization Therapy Protocol  

Instructions for Therapist

The MOON Shoulder Group is a collection of shoulder experts who study the best methods to treat patients after surgery for shoulder instability. Your patient is part of a group of patients being closely followed in order to determine which patients have the best and worst outcomes after surgery.

The patient is to begin therapy 2 weeks after surgery

The patient should work with therapist 1-3 x per week until released by surgeon

Do not add or skip any part of this program. If you have concerns please contact your surgeon. Carolyn Hettrich at 859-218-3054

General Instructions

• Showering: 48 Hours
• DO NOT get into a bathtub, pool, or spa until your sutures are removed and your wound is completely healed to lower the chance of skin infection. Always wash your hands before touching your wound. DO NOT use any anti‐bacterial creams on your wound.
• Deskwork: When comfortable with sling
• Driving: 6 weeks
• Using arm for Activities of Daily Living: 6 weeks
• Using arm to reach overhead: 12 weeks
• Using arm to reach behind back: 12 weeks
• Using arm to carry objects: 12 weeks
• Pushing/Pulling: 12 weeks
• Sport/Heavy Activity: When finished with therapy program

Goals

The two main goals of this physical therapy program are to:

1. Have full active and passive range of motion by 3 months after surgery
2. Return to sport by 18-24 weeks after surgery

Sling Usage

• Patients must wear their sling at all times, except when showering/bathing for 6 weeks. This does include while they are sleeping.
• A sling with a small pillow is to be worn for six weeks after surgery. The sling may be taken off for showering and therapy only. The sling should be worn when in an uncontrolled setting: sleeping, around children, pets, and crowds during these six weeks.

Ice

We encourage the use of the ice or the cryo-cuff to help control pain and inflammation after surgery.

Questions/Concerns

If you have questions or concerns, please contact the Dr. Hettrich at 859-218-0858

0-2 weeks

Wrist and elbow ROM only

2 weeks

Passive and Active assistive forward flexion to 90°

Passive/active external rotation  to neutral with arm at side

Gentle isometric (no IR or ER)

4 weeks

Passive and Active assistive forward flexion to 120°

Passive and Active assistive abduction to 90°

Passive and Active assistive external rotation to 20° with arm at side

No combined Abduction and Internal Rotation

Scapular protraction / retraction  (with arm in sling until 6 weeks post-op)

6 weeks

• May discontinue sling usage, unless in a crowd, or on slipper surface
• Unlimited Passive and Active assistive forward flexion
• May begin active motion in all planes
• Posterior glides ok if needed but no anterior glides permitted
• Resisted Isometrics – (No IR)
• Scapular stabilizers – Elevation / Depression / Retraction / Protraction

8 weeks

• Continue progressing other active motions
• Progress resistive exercises with elastic band resistance limiting motion to approximately 45-60° 3 sets of 10 repetitions using yellow or red (stay light until 12 weeks)
• Internal / External Rotation / Flexion
• Shrugs
• Avoid extension and abduction until 12 weeks to minimize stress on the anterior capsule

12 weeks

• Progress to next level of resistance (Green, Blue, Black) once patient performs all repetitions with reporting only moderately challenging
• Increase range of motion of resistive exercises as long a pain free and does not create substitution patterns
• Body weight exercise Wall -> Incline -> Knee -> Standard Push-up progression as tolerated 3 set of 10 repetitions
• Progress resistive exercise to weight resistance starting at 5 lbs progressing to approximately 15 lbs
• May begin sport specific exercise

18-24 weeks

• Return to play sports with approval of physician

Inability To lift Arm Physical Therapy Protocol (Levy Protocol)

Instructions for Therapist

The patient should work with therapist 1-3 x per week until released by surgeon

Goals

The main goals of this physical therapy program are to:

1. Have the patient regain the ability to lift their arm against gravity without pain or substitution by progressing the patients through a progression of active arm mobility from gravity minimized activities in supine to inclined to upright active arm motion.  
2. Although full motion may not be achieved by all patients the goal is to increase active arm mobility to normalize activities of daily living

Ice

We encourage the use of the ice or the cryo cuff to help control pain and inflammation if needed

Questions/ Concerns

If you have questions or concerns, please contact the patient’s physician, Carolyn Hettrick at 859-218-3054

Phase 1

• Perform exercises 5 times a day for 5-10 repetitions
• Lie on back with head on pillow for comfort
• Support or assist arm to straight up toward ceiling(90°)
  • Elbow flexed is sometimes easier
• Hold arm by itself and gradually elevate toward head and lower toward feet with ability to return to straight up, progress 1 inch at a time, to gain control of arm
  • Start using opposite hand, as you gain confidence

• Progress to performing motion without opposite hand through arc of motion (Therapist hands)

Phase 2

• Perform exercises 5 times a day for 5-10 repetitions
• Lie on back with head on pillow for comfort
• Hold a can of soup in hand (dumbbell) with arm straight up to ceiling
• Move arm through arc of motion with resistance start with 2 inch up and down but gradually increasing the arc as your strength increases

• In some patients squeezing a ball between hands (subscapularis activation) or pulling light elastic resistance apart (infraspinatus activation) will overcome sticking points in the arc of motion

Phase 3

• Perform exercises 5 times a day for 5-10 repetitions
• Lie on a wedge at 30° incline (approximately 2 pillows)
• Move arm up and down through arc of motion
  • Opposite hand supporting
  • No assistance from opposite hand
  • With a soup can through an increasing arc of motion

Phase 4

• Perform exercises 5 times a day for 5-10 repetitions
• Lie on a wedge at 60° incline (approximately 2 pillows against bead headboard or wall)
• Move arm up and down through arc of motion
  • Opposite hand supporting
  • No assistance from opposite hand
  • With a soup can through an increasing arc of motion

Phase 5

• Perform exercises 5 times a day for 5-10 repetitions
• In standing or sitting upright
• Move arm up and down through arc of motion
  • Opposite hand supporting
  • No assistance from opposite hand
  • With a soup can through an increasing arc of motion

Moon Shoulder Group Nonoperative Treatment Of Rotator Cuff Tendonopathy Physical Therapy Guidelines

From: Kuhn JE. Exercise in the treatment of rotator cuff impingement.  A systematic review and synthesized evidence-based rehabilitation protocol.  J Shoulder Elbow Surg 2009, Jan-Feb

General Instructions

This physical therapy protocol is based on the best evidence demonstrating a beneficial effect for exercise in the treatment of rotator cuff tendonitis. It is largely unknown if adding or eliminating exercises will affect the outcome. Range of motion and stretching exercises should be performed daily.  Rotator Cuff strengthening should be delayed until active range of motion is nearly pain free and mobility nearly normal. Active Elevation above 120° and Passive Internal Rotation with arm abducted should approach 50% of the opposite side are milestones suggesting nearly normal mobility. Rotator Cuff strengthening should be performed 3x/week.

Contact

Dr. Carolyn Hettrich 859-218-3054 if you have questions.

Modalities

Thermal (Heat or Cold) and electrical modalities may be used to reduce inflammatory response in high and moderately irritated tissues.1  Studies have demonstrated that ultrasound is no better than controls, and it should not be used.2

Manual Therapy

Joint and soft tissue mobilization techniques have been shown to augment the effect of the exercise program. Manual therapy techniques include joint mobilization, soft-tissue mobilization, and release techniques. Initially, supervised exercises with manual therapy is recommended. During that time patients should be instructed in a home program. Patients can move entirely to a home program when they no longer are in need of manual therapy.

Initial Goals

• Restore passive mobility of shoulder to nearly normal range
• Pain free active motion without resistance
• Reduce inflammatory symptoms, primarily pain during daily activities

Flexibility

Stretching should be performed daily and should include the following: Anterior shoulder stretching, performed by the patient in a corner or door jamb.  Posterior shoulder stretching using the crossed body adduction technique. Incorporating scapula stabilized stretching within pain tolerances is encouraged. Each stretch should be held for 30 seconds, and repeated five times with 10 seconds rest between each stretch.

Posterior Shoulder Stretch: Bring involved arm across in front of body as shown. Hold elbow with other arm. Gently flex the bent elbow which will assist in pulling the arm across chest until stretch is felt in the back of the shoulder.

Anterior Shoulder Stretch: Place hands at shoulder level on each side of a door or in a corner of a room. Gently lean forward into door or corner and hold

Sleeper Stretch: Lie on your side with a pillow supporting your head. Bring your elbow up to a comfortable position but not above your shoulder. Gently push your hand toward the surface until you feel a stretch in your shoulder without pain.

Cross Body Stretch With Scapula Stabilized: Lie on your back with arm on table. Partner or Clinician stabilizes lateral border of the scapula while the patient gently pulls the arm across the body until a stretch is felt in the shoulder without pain. Hold for 5 seconds and repeat 10 times in a row.

Range Of Motion

Patients may begin to restore their active range of motion by using active assistive devices such as a cane, pulley or the uninvolved arm. Additionally work on postural exercise, like shrugs, and shoulder retraction can be started.  Glenohumeral motion should begin with pendulum exercises, progress to active assisted motion, then to active motion as comfort dictates. Active motion may be performed in front of a mirror or using the opposite hand on the trapezius to prevent hiking of the shoulder.

Active Assisted Range Of Motion Using A Cane: Lying supine, hold the cane with both hands. Elevate the arms using the healthy arm to guide the injured arm. Increase the use of the injured arm as directed by comfort. These can be done upright when comfortable. Images demonstrate Forward Elevation, External Rotation, and Abduction. Can do standing if comfortable.

Posture Exercises: Put hands on hips, lean back and hold.

Active Training Of The Scapula Muscles - Scapular Shrugs: Pull shoulders up and back and hold.

Active Training Of The Scapula Muscles - Scapular Retraction: Pinch the back of the shoulder blades together using good posture.

Active Range Of Motion: In front of a mirror practice raising your arm in front of your body without hiking or excessively shrugging your shoulder.

Criterion To Progress To Strength Training For Shoulder

• Pain at rest below 2 out of 10
• Pain with active motion without a load below 3/10
• Nearly normal passive and active motion restored (80% of opposite side)

Strengthening Phase 1

Strengthening exercises should focus on the rotator cuff and scapula stabilizing muscles. Rotator cuff strengthening should involve the following exercises with elastic resistance bands: internal rotation with arm adducted to side, external rotation with arm adducted to side, rows, and scapular punches or press up. Each exercise should be performed as 3 sets of 10 repetitions, with increases in elastic resistance as strength improves.

External Rotation: Secure elastic at waist level. Hold elbow at 90 degrees arm at side. Pull hand away from body as shown.

Internal Rotation: Secure elastic at waist level. Hold elbow at 90 degrees arm at side. Pull hand across body as shown.

External Rotation: Lie on side, involved side up. Arm at side, elbow bent, with or without weight.

Move hand up as shown

Internal Rotation: Lie on involved side, elbow bent at 90 degrees, arm at side. With or without weight, pull hand inward across body, as shown.

Rows: Seated or standing, bend elbows and pull elastic cord back. Try to pinch your shoulder blades behind you.

Upright Row: Do one arm at a time. While standing lean over a table. Bend at waist. Pull hand weight back, pulling shoulder blade back.

Press Up: Lie on back, elbow locked straight, weights in hands. Move arm up toward ceiling as far as possible.

Criterion To Progress To Strength Training Phase 2 For Shoulder

• Pain at rest below 0 out of 10
• Pain with active motion without a load below 1 out of 10
• Nearly normal passive and active motion restored (90% of opposite side)
• Performs all Phase 1 strengthening exercises with a Red or Green (3 -5 lbs) resistance 30 repetitions without pain or substitution

Strengthening Phase 2

Strengthening exercises should continue focus on the rotator cuff and scapula stabilizing muscles but can progress to long lever arm and functional tasks for the individual demands of the patient. Incorporation of long lever arm exercise like standing scaption and prone horizontal abduction to build strength and endurance are recommended as long as there is no pain or a compensation associated with the exercise. Scapular stabilizer strengthening can progress to body weight activities such as chair and variations of push-ups. Combination strengthening while standing using elastic bands should include: forward elevation and extension. Each exercise should be performed as 3 sets of 10 repetitions, with increases in elastic resistance as strength improves.

Scaption: Hold arm 30 degrees forward, thumb up or down, raise arm. May add resistance. This exercise should be done only if there is no pain

Prone Horizontal Abduction: Lie on your stomach and squeeze your shoulder blades together as you lift your arm out to the side with your thumb up

Pushup Plus: Do a pushup (either on your hands or forearms) and then really push to bring your spine to the ceiling. You place hand on stable surface if hurts to get on your knees

Chair Press: While seated press up on chair lifting body off chair. Try to keep spine straight.

Low Trapezius: Stand upright. Grasp elastic bands. Keep elbows straight and pull. Try to reach behind you.

References

1. McClure PW, Michener LA. Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Phys Ther. 2015;95(5):791-800.
2. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons  [Et Al]. 2009;18(1):138-160.