Department of Rehabilitation Services 1
( ) Rehabilitation Guidelines
Department of Rehabilitation Services
Arthroscopic Shoulder Subacromial Decompression Guidelines
Indications: Subacromial decompression surgery is indicated when chronic subacromial impingement
and pain interfere with daily activities, and conservative measures are unsuccessful. Surgery is designed
to restore normal shoulder function for daily activities, work-related tasks, and sports by increasing the
subacromial space for optimal joint mechanics and muscle function. This rehabilitation program is
designed to return patients to their most challenging physical requirements for work, school, or
recreational pursuits.
Postoperative Rehabilitation:
Phase I: 0-2 weeks post-op
Treatment goals
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Patient education
Prevent effects of immobilization
Re-establish full, painless ROM
Prevent muscle atrophy
Reduce pain and inflammation
Independence in a home exercise program to
o Improve postural awareness
o Reduce postoperative pain and inflammation
o Initiate muscle function of the shoulder and upper back
o Achieve full shoulder passive range of motion in supine and/or sitting
Patient education
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Frequent icing 15-20 minutes, making sure skin has returned to normal temperature before repeat icing.
Take prescribed medications as directed for pain control and swelling. If patients experience stomach
upset, they should discontinue use and contact their physician.
Postural education and explanation of scapula and shoulder biomechanics for optimal function
postoperatively.
Sling use for 1 to 3 days postoperatively for comfort. May use sling when out in public or in a crowd to
prevent unwanted stress on shoulder from others.
No range of motion restrictions. Patient should use pain as their guide for mobility.
Avoid cross arm adduction for 6 weeks, overhead throwing for 8 weeks.
Avoid sport-related activities for 2 months.
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Therapeutic exercise -- Week 1 (performed twice daily)
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Passive range of motion pendulum exercises
Active range of motion of the elbow, forearm, wrist and hand
Supine active-assistive range of motion exercises utilizing a cane
o Includes shoulder flexion, scaption (flexion in the plane of the scapula) and external rotation
Scapular stabilization/activation exercises
o Includes scapular retraction/protraction and active scaption
Standing active-assistive range of motion exercises utilizing a towel
o Includes shoulder internal rotation behind patient’s back
Sub-maximal isometric strengthening exercises with patient’s elbow at their side
o Includes shoulder flexion, extension, abduction, internal and external rotation
Therapeutic exercise -- Week 2 (performed twice daily, in addition to Week 1 exercises)
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Scapular recruitment and impingement prevention exercise (Kibler exercises)
o Inferior glide at 90 degrees shoulder abduction
o Standing low row, neutral wrist position (elbow extended)
o Lawnmower (scapular retraction, then rowing motion in trunk flexed position)
o Robbery (standing scapular retraction with bilateral external rotation)
Upper body ergometer for active assistive range of motion.
Active-assistive range of motion for shoulder internal and external rotation performed at 90 degrees of
shoulder abduction with a cane.
Active range of motion for shoulder flexion, scaption, and abduction.
Progress sub-maximal isometric exercises to maximal resistance in all directions.
Scapular stabilization serratus anterior and lower trapezius
o Examples include prone scapular rowing, supine scapular protraction
Rhythmic stabilization exercises in supine
o Supine shoulder flexion to 90 degrees while patient receives multi-directional perturbations at
variable speeds and resistances.
Stretches for neck and chest musculature to maximize biomechanics
o Upper trapezius stretch incorporating cervical flexion, contralateral sidebending, and ipsilateral
rotation—2 reps, 30 seconds each
o Pectoralis major stretch incorporating shoulder horizontal abduction, external rotation and
multiple levels of abduction—2 reps, 30 seconds each level
Physical performance test:
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Full passive and active-assistive shoulder range of motion
Pain managed with cryotherapy and medication
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Phase II: 2-6 weeks post-op
Treatment goals
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Patient education
Manage pain and inflammation in order to complete home exercise program
Full, pain-free active range of motion in multiple planes
Recruit and improve muscular strength
Normalize joint arthrokinematics
Improve neuromuscular control of the shoulder complex
Avoid negative reaction to steadily increasing exercise volume: exercise tolerance
Independence in activities of daily living
Patient education
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Continue icing 15-20 minutes after completion of exercise program to prevent increased inflammation
Assess tolerance to exercise progression twice: once during exercise and once the morning after. This
pain assessment is done when exercises contain increased quantity, reps, or resistance.
Begin to use postoperative upper extremity for more daily activities through the arm’s full range of
motion, assessing tolerance through pain.
Modalities may be utilized if patient continues to have pain (i.e. electrical stimulation)
Joint mobilizations may be performed to improve joint arthrokinematics and modulate pain if these
impairments continue to persist.
Therapeutic exercise (stretching performed 2 times daily, strength performed 1 time daily)
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Gradually increase use of upper extremity for activities of daily living (i.e. hygiene, household chores,
etc)
Continue active range of motion exercises for shoulder motions noted above, adding gentle overpressure
for end range stretching. 10-second hold, 3 reps.
Shoulder posterior capsule stretching when patient can tolerate correct positions if indicated
o With belt/towel anchored around elbow, postoperative shoulder positioned in internal rotation
with forearm behind back, patient will apply anterior force by pulling forward on the belt/towel
while standing. Hold 10 seconds, 10 reps.
o In sidelying position, postoperative shoulder and elbow both at 90 degrees flexion, patient applies
internal rotation force to postoperative shoulder utilizing opposite hand positioned on the wrist.
Hold 10 seconds, 10 reps.
Isotonic strengthening without weight, progressing to full active ROM per patient tolerance
o Prone horizontal abduction
o Standing shoulder abduction to 90 degrees
o Sidelying shoulder internal and external rotation
Resistive isotonic dumbbell exercises beginning with 1 lb. weight (after patient is able to perform gravityresisted active range of motion exercises pain free for 1 week)
o Standing shoulder abduction and flexion to 90 degrees
o Standing shoulder scaption
o Sidelying shoulder internal and external rotation
o Seated or standing elbow flexion and extension
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Resistive isotonic theraband exercises for standing shoulder internal and external rotation with shoulder
positioned in neutral abduction/adduction, towel roll medial to the elbow.
Resistive isotonic theraband row progression.
Cardiovascular fitness exercises including stationary bike, treadmill, jogging. Begin with 10 minutes
activity if shoulder active range of motion is involved and assess exercise tolerance.
Upper body activity tolerance exercise including upper body ergometer. Begin with 5 minutes activity
and assess exercise tolerance.
Dynamic stabilization exercises
o Proprioceptive neuromuscular facilitation (PNF) flexion and extension D1 and D2 patterns
actively and with resistance utilizing theraband once able.
o Body blade (small and/or large) dynamic oscillations throughout active shoulder range of motion.
o Rhythmic stabilization tracing a light or medium-sized ball on the wall in the form of circles,
letters and/or numbers.
Scapular stabilization push-up progression.
Physical performance tests:
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Full, pain-free active ROM in multiple planes
Pain-free Phase II exercise program
Negative impingement signs
Independence with activities of daily living
Phase III: 6-12 weeks post-op
Treatment goals
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Patient education
Improve strength, power, and endurance
Improve neuromuscular control
Prepare for gradual return to functional activities (work/recreation)
Patient education
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Avoid the following weightlifting activities: bench press, deep dips and behind-the-head pull downs
Therapeutic exercise
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Same as phase II with increased speed, multiplanar activities incorporating entire kinetic chain
Continue capsular stretches
Continue end range stretching for flexion, internal and external rotation
Regular pushups with “+” (not before 2 months)
Dumbbell Matrix
o Overhead press, forward press, forward cross punch, downward cross punch, short wing
abduction, long wing abduction, 90 degree abduction with external rotation, hooking (focusing on
scapular stabilization)
Gym program, avoiding above noted exercises
2-hand Plyometrics
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o Includes chest pass, side to side throws, overhead throws forward and backward
1-hand plyometrics (begin at 9-12 weeks)
o Includes underhand throws, wall dribbles, overhead throwing progression (Rienhold)
Physical performance tests
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Pain-free phase III exercise program
5/5 manual muscle test grade of shoulder
Successful completion of the Upper Extremity Stability Test (Davies)
Phase IV: 12+ weeks post-op
Treatment recommendations
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Continue 1-hand plyometric exercises
Initiate progressive return-to-sport program/work-related activities
Progress overhead throwing for athletes
Physical performance tests
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No complaints of pain with activity or at rest
Successful completion of most demanding work/sport-specific performance test
Clearance from physician
References
1. Jackins S. Postoperative shoulder rehabilitation. Phys Med Rehabil Clin N Am. 2004;15:vi,643-82.
2. Hultenheim Klintberg I, Gunnarsson AC, Styf J, Karlsson J. Early activation or a more protective regime
after arthroscopic subacromial decompression—a description of clinical change with two different
physiotherapy treatment protocols—a prospective, randomized pilot study wit a 2 year follow-up. Clin
Rehabil. 2008;22:951-65.
3. Fyfe I, Stanish WD. The use of eccentric training and stretching in the treatment and prevention of tendon
injuries. Clin Sports Med. 1992;11:601-24.
4. Manske RC, Davies GJ. Post-rehabilitation outcomes of muscle power (torque-acceleration energy) in
patients with selected shoulder dysfunctions. J Sport Rehabil. 2003;12(3):181-98.
5. Wilk KE, Andrews JR. Rehabilitation following arthroscopic subacromial decompression. Orthopedics.
1993;16:349-58.
6. Wang CH, McClure P, Pratt N, Nobilini R. Stretching and strengthening exercises: their effect on 3dimensional scapular kinematics. Arch Phys Med Rehabil. 80. Aug 1999. 923-29.
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7. Lippitt SB, Matsen FA, Rockwood CA, Wirth MA (2009). Shoulder Arthroscopy: Arthroscopic
Management of Rotator Cuff Disease. In Fehringer EF & Sperling JW (Eds.). The Shoulder.4th ed. (pp.
961-964). Philadelphia, PA: Saunders/Elsevier.
8. Townsend H et al. Electromyographic analysis of the glenohumeral muscles during a baseball
rehabilitation program. Am J Sports Med. 1991;19(3): 264-72.
9. Moseley JB et al. EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J
Sports Med. 1992;20(2):128-34Kuhn JE. Exercise in the treatment of rotator cuff impingement: a
systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg.
2009;18(1):138-160.
10. Borstad JD, Ludewig PM. Comparison of three stretches for the pectoralis minor muscle. J Shoulder
Elbow Surg. 2006;15(3):324-330.
11. Yanai T, Fuss FK, Fukunaga T. In vivo measurements of subacromial impingement: substantial
compression develops in abduction with large internal rotation. Clin Biomech (Bristol, Avon).
2006;21(7):692-700.
12. Ekstrom RA, Donatelli RA, Soderberg GL. Surface electromyographic analysis of exercises for the
trapezius and serratus anterior muscles. J Orthop Sports Phys Ther. 2003;33(5):247-258.
13. Lombardi I Jr, Magri AG, Fleury AM, Da Silva AC, Natour J. Progressive resistance training in patients
with shoulder impingement syndrome: a randomized controlled trial. Arthritis Rheum. 2008;59(5):615622.
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