Brooke Army Medical Center Sports Medicine
Outpatient Rehabilitation Protocol
Arthroscopic Anterior Labral (Bankart) Repair
and/or Anterior Capsular Plication or Rotator Interval Closure
INPATIENT: Post-operative day (POD) 1 until 1st PT appointment
Goals:
Protect the anatomic repair
Prevent negative effects of immobilization
Diminish pain and inflammation
Pt indep with cryotherapy use for home at least 3 x day
PT Sessions: Afternoon visit after surgery and daily supervised sessions
Sling:
1.
2.
Exercises:
1.
2.
3.
4.
Shoulder immobilizer / abduction/IR sling (Donjoy “Ultrasling”)
Wear at all times, even when sleeping.
Remove 3x/day for PT exercises, and for personal hygiene
Grip Strength w/ foam ball, towel, putty to squeeze repetitively
Hand, wrist, elbow full active range-of-motion (AROM)
Shoulder passive pendulum exercises in sling or forearm supported
Assisted passive range-of-motion (PROM) of shoulder to maximum of
30 abduction, 45 flexion; NO extension or ER
PHASE I: Hospital d/c through Week 6 – PROTECTION PHASE
Goals:
Protect the anatomic repair
Prevent negative effects of immobilization
Promote dynamic stability
Diminish pain and inflammation
PT Sessions: 1-2 supervised sessions per week with physical therapist
Modalities:
1.
Passive modalities as needed to control pain, inflammation
2.
Biofeedback inhibition at 4-6 weeks if compensatory shoulder shrug
Weeks 0-2
Sling:
1.
2.
3.
Exercises:
1.
2.
3.
4.
5.
6.
7.
Shoulder immobilizer / abduction/IR sling (Donjoy “Ultrasling”)
Sling for 4-6 weeks (depending on quality of repair).
Wear immobilizer when sleeping for 4 weeks after surgery.
Remove sling 3x/day for home PT exercises, and for personal hygiene
Gentle PROM with goals of:
a. Flexion to 60 deg. (Week 2: flexion to 75 deg)
b. Elevation in scapular plane to 60 deg
c. ER/IR with arm in scapular plane
i. ER to 5-10 deg
ii. IR to 45 deg
**No active ER, Extension, or Abduction
Submaximal shoulder isometrics
Grip Strength w/ foam ball, towel, putty to squeeze repetitively
Hand, wrist, elbow full AROM w/ light weights (1-3 lbs.; incr. prn)
Shoulder passive pendulum exercises in sling or forearm supported
Scapular retraction; gently pinch shoulder blades together for 5 sec
Cryotherapy, modalities as indicated
Aerobic Conditioning: may ride stationary bike while wearing immobilizer
Weeks 3-4
Sling:
Begin weaning from sling after 2 weeks. Discontinue use of sling,
immobilizer at 4 weeks unless hypermobile, may need to stay in sling 6 weeks per Ortho
Exercises:
1.
2.
3.
4.
5.
6.
Continue PROM; add light AAROM exercises with goal of:
a.
Flexion to 90 deg
b.
Abd to 75-85 deg
c.
ER in scapular plane to 15-20 deg
d.
IR in scapular plane to 55-60 deg
No active ER, extension or abduction
Initiate rhythmic stabilization drills
Initiate proprioception training
Continue Isometrics
Continue use of modalities as needed
Weeks 5-6: **Note: Patients with Flexion > 150 deg and/or ER > 45 deg need to
be slowed down to protect the repair.
Exercises:
1.
Gradually improve ROM
a.
Flexion to 145 deg
b.
ER at 45 deg abduction: 25-30 deg
c.
IR at 45 deg abduction: 55-60 deg
d.
Initiate light IR/ER at 90 deg abduction
2.
Initiate gentle, global shoulder stretching
3.
4.
5.
6.
7.
Tubing IR/ER at side
PNF manual resistance
Initiate Active shoulder abduction (w/o resistance)
Initiate full can exercise (w/o resistance)
Initiate Prone rowing, Prone horizontal abduction
PHASE II: Weeks 7-14 – MODERATE PROTECTION PHASE/EARLY STRENGTHENING
GOALS:
Gradually restore full ROM (week 10)
Preserve the integrity of the surgical repair
Restore muscular strength and balance
PT Sessions: 2-3 supervised sessions per week with physical therapist
Modalities:
1.
2.
3.
4.
Cryotherapy prn
IFC prn
NMES
Biofeedback inhibition if compensatory shoulder shrug
Weeks 7-9:
Exercises:
1.
Gradually progress ROM with goals of:
a. Flexion to 160 deg
b. ER at 90 degrees abduction: 70-75 deg
c. IR at 90 deg abd: 70-75 deg
2.
Strength
a. Continue to progress isotonic/theraband strengthening program
b. Continue PNF strengthening
c. Isokinetic IR/ER at 30/30/30 at 180, 300 deg/sec
3.
Proprioception:
a. Rhythmic stabilization
b. OKC, CKC perturbation training
Aerobic Conditioning: Stationary bike or treadmill while wearing sling
Weeks 10-12:
Exercises:
1.
Progress to full functional AROM and stretching
a. Progress ER to thrower’s motion
b. ER at 90 deg abduction (110-115 in throwers)
2.
May initiate slightly more aggressive strengthening
a. Begin light serratus punches
b. Begin light chest press
c. Continue theraband,
d. Isokinetic training 30/30/30
3.
Proprioception
a. Rhythmic stabilization
b. Perturbation training
Criteria for progression to Phase III:
1.
Full non-painful ROM
2.
Satisfactory stability
3.
Muscular strength (Grade IV MMT or better)
4.
No pain or tenderness
PHASE III: Weeks 13-20 – MINIMAL PROTECTION PHASE / ADVANCED
STRENGTHENING & ENDURANCE
Goals:
Establish and maintain full ROM
Improve muscular strength, power, and endurance
Gradually initiate functional activities
PT Sessions: 1-3 supervised sessions per week with physical therapist
Weeks 13-16:
Exercises:
1.
Continue capsular stretches
2.
Continue strengthening exercises:
a. Thrower’s Ten Program
b. PNF manual resistance
c. Endurance training
d. Initiate light plyometric program
e. Restricted sport activities (light swimming, half golf swings)
f. Push-up progression (wall, on knees)
Weeks 16-20:
Exercises:
1.
Continue all exercises listed above
2.
Continue all stretching
3.
Continue Thrower’s Ten program
4.
Continue plyometric program
5.
Initiate interval sport program (throwing, etc)
6.
Progress from knee to military push-ups; AVOID anterior capsule
stretching by not dropping below the scapular plane during each rep
Aerobic Conditioning:
1.
May begin jogging in addition to bike, elliptical trainer, and stairmaster
2.
Upper body cycle up to 10-15 min forward and 10-15 min backward
Isokinetic Testing: ER/IR (30/30/30 or 90/90 if overhead athlete or laborer)
Criteria for Progression to PHASE IV:
1.
Full, painfree AROM
2.
Satisfactory static stability (MMT 4+/5) or isokinetic testing 75-80% of
uninvolved side
3.
No pain or tenderness
PHASE IV: Weeks 20-26 – ADVANCED STRENGTHENING PHASE
Goals:
Enhanced muscular strength, power, and endurance
Progress functional activities
Maintain shoulder mobility
PT Sessions: 1-2 supervised sessions per week with physical therapist
Exercises:
4. Continue flexibility exercises
5. Continue isotonic strengthening program
6. PNF manual resistance patterns
7. Plyometric strengthening
8. Progress interval sport programs
9. Continue military push-up progression
10. Isokinetic training ER/IR
11. Gradually increase weight training to maximum; must be pain free
12. Advanced pool therapy if available
Isokinetic Testing: ER/IR (30/30/30 or 90/90 if overhead athlete or laborer)
Aerobic Conditioning:
1.
Progress from jogging to running; should be painfree
Criteria for Progression to PHASE V:
1.
Full or nearly full shoulder AROM
2.
Near full strength per manual muscle testing (or 80% isokinetic testing)
3.
Pain-free basic functional training exercises
PHASE V: Months 6-9 – RETURN TO FULL DUTY/ACTIVITY
Goals:
Exercises:
1.
2.
Gradual return to sport activities
Maintain strength, mobility, and stability
Full AROM equal to opposite UE (accept 5-10 loss of ER)
Full shoulder strength per manual testing (or 90% isokinetic testing)
Able to pass APFT, including push-ups
Gradually progress sport activities to unrestrictive participation
Continue stretching and strengthening program
_______________________________
JAMES R. FICKE, MD
COL, MC
Chief, Orthopedics
______________________________
KATHLEEN S. ZURAWEL, PT, OCS
COL, SP
Chief, Physical Therapy
APPROVE / DISAPPROVE
APPROVE / DISAPPROVE
Updated 25 October 2006