the american society of shoulder and elbow therapists' · pdf filejournal of orthopaedic...

journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 | 155

[ clinical commentary ]

1 Director of Physical Therapy, HPRC at St Francis Rehabilitation Center, Columbus, GA. 2 Coordinator of Sports Rehabilitation University of Iowa Sports Medicine, Clinical Specialist Department of Rehabilitation Therapies University of Iowa Hospitals and Clinics, Iowa City, IA. 3 Associate Professor and Chair, Department of Interdisciplinary Health Sciences, A. T. Still University, Mesa, AZ. 4 Associate Professor Department of Physical Therapy, Virginia Commonwealth University-MCV Campus, Richmond, VA. 5 Director, St Francis Shoulder Center, St Francis Orthopaedic Institute, Columbus, GA. 6 Clinical Research Scientist, Proaxis Therapy, Greenville, SC. 7 Assistant Consulting Professor, Doctor of Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC. Address correspondence to Bryce Gaunt, HPRC at St Francis Rehabilitation Center, PO Box 8068, Columbus, GA 31908-8068. E-mail: [email protected]

Bryce W. Gaunt, PT, SCS1 • Michael a. Shaffer, MSPT, OCS, ATC2 • eric l. SauerS, PhD, ATC3 lori a. Michener, PT, PhD, ATC, SCS4 • GeorGe M. MccluSkey iii, MD5 • chuck a. ThiGpen, PT, PhD, ATC6,7

The American Society of Shoulder and Elbow Therapists’ Consensus Rehabilitation

Guideline for Arthroscopic Anterior Capsulolabral Repair of the Shoulder

the maintenance of shoulder stability is the result of a complex interplay of static and dynamic factors. Shoulder instability may require surgical stabilization to resolve the anatomical deficits causing the instability and to restore shoulder function.

A variety of surgical techniques exist. The chronicity, magnitude (dislocations or subluxations), and direction (anterior, posterior, or multidirectional) of instability are the key factors considered during preoperative planning. In addition, patient factors, such as a need for mobility in the case of an overhead athlete, must be considered.

store shoulder stability by suturing back to the glenoid the detached or unstable anterior inferior labrum, known as a Ban-kart lesion (fiGure 1). In addition to a Ban-kart repair, capsular plication is added as necessary to address permanent plastic deformation of the glenohumeral joint capsule that often accompanies recurrent anterior inferior dislocations.6,31 Rehabili-tation following the surgery must balance the restoration of motion and function with the desired result of an appropriately taut capsulolabral complex.23,34

Blackburn and Guido7 published a re-habilitation guideline in 2000 for patients following open anterior shoulder stabiliza-tion, which at the time was the most com-monly performed stabilization procedure. However, due to the less invasive nature of arthroscopic procedures, patients under-going arthroscopic repair today generally regain range of motion (ROM) more easily and with less risk of permanent restriction than patients following comparable open surgeries.23,34 In 2002, Wilk et al95 pub-lished a rehabilitation protocol follow-ing thermal-assisted capsulorraphy. Due to concerns about the long-term health of capsular tissue treated with laser- or

As the majority of patients with an-terior instability have injuries to their capsulolabral complex, the arthroscopic

anterior capsulolabral repair is a com-monly utilized procedure. Arthroscopic anterior capsulolabral repair seeks to re-

t SynopSiS: This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the reha-bilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual applica-tion of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month

period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This docu-ment represents the first consensus rehabilita-tion guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder. J Orthop Sports Phys Ther 2010;40(3):155-168. doi:10.2519/jospt.2010.3186

t key WorDS: Bankart repair, capsular plica-tion, postoperative rehabilitation, shoulder instabil-ity, therapeutic exercise

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156 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy


radiofrequency-assisted shrinkage, and the concern about the rapid restoration of ROM at the expense of long-term stability, this procedure is no longer performed reg-ularly. Although these previous guidelines exist for patients following capsulolabral repair, the rehabilitation for open stabi-lization and thermal capsulorraphy are very different, based upon the surgical ex-posure and fixation method. Furthermore, a consensus rehabilitation guideline is not available for what is now the most com-monly performed surgical procedure for anterior inferior instability, arthroscopic anterior capsulolabral repair.

aiM of The GuiDeline

this consensus rehabilitation guideline of the American Society of Shoulder and Elbow Therapists

(ASSET) was designed for use with pa-tients who have undergone arthroscopic anterior capsulolabral repair in which the detached labrum was suture anchored back to the glenoid rim and/or capsular tension is restored through suture tight-ening of the plicated capsule. This reha-bilitation guideline is not intended for use with other surgical procedures to address glenohumeral instability because of the variation in surgical approaches, initial fixation strength, and varying potential for lost ROM following the procedures. Additionally, the repair of associated le-sions, such as a rotator cuff tear or supe-rior labrum anterior-to-posterior (SLAP)

tear, would also require a different reha-bilitation program.

This consensus rehabilitation guide-line, created by the members of ASSET, is not intended to serve as the standard of medical care. Instead, this document should serve as a guideline and, as such, should be used in conjunction with a thor-ough history and physical examination of the individual patient. The rehabilitation processes described herein are designed to provide the clinician with a guide-line for rehabilitation and description of the expected outcome; however, out-come may differ for individual patients. Individual patient values, expectations, preferences, and goals should be used in conjunction with this guideline. Our guideline should evolve with advances in knowledge and technology. ASSET takes no responsibility and assumes no liability for improper use of this guideline. As the balance between mobility and shoulder stability is delicate and involves a host of anatomic, neuromuscular, and patient-centric factors, strict adherence to this guideline does not guarantee a successful outcome. In our opinion, the best chance for success is when an informed, educated patient works together with a competent, knowledgeable surgeon and rehabilita-tion specialist, who are themselves work-ing in concert to provide the patient with information and techniques which are current and grounded in science.

MeThoDS of DeVelopMenT

this guideline evolved after representatives from the American Shoulder and Elbow Surgeons Soci-

ety (ASES) approached ASSET about the need for clinical guidelines for postopera-tive rehabilitation. In response, ASSET identified a panel of members with exten-sive experience treating patients follow-ing arthroscopic capsulolabral repairs to review the literature and begin develop-ing a rehabilitation guideline. This panel included members with clinical specialty certifications and terminal research de-grees and whose members were also se-

lected to represent different geographic regions of the United States.

In the development of this guideline, our goal was to cite the best available evidence, relying on randomized con-trolled trials when available. The panel searched for clinical trials and basic sci-ence evidence from multiple databases up to August, 2009 (Cochrane, PubMed, CINAHL, SportDiscus), using only Eng-lish language articles for this guideline. Because of the paucity of randomized controlled trials comparing rehabilita-tion protocols or no treatment post-operatively, we used basic science and mechanistic studies, along with ASSET member expertise and clinical opinion, to develop this rehabilitation guideline. After initial development by the subpanel of the major principles and time frames guiding rehabilitation, the guideline was sent to all members of ASSET to review and provide feedback from which to de-velop consensus. In addition, the specifics of the guideline (ie, immobilization time frames, when to initiate active ROM, time to restore normal ROM, etc) were openly debated until consensus was reached at 2 subsequent annual meetings of ASSET. Finally, an ASES member with experi-ence performing arthroscopic anterior capsulolabral repairs was recruited to add a surgeon’s perspective. The final guide-line (appenDiX) represents an interna-tional consensus rehabilitation guideline developed by a multidisciplinary society of rehabilitation professionals (athletic trainers, occupational therapists, and physical therapists who are American or foreign members of ASSET). This is the first clinical guideline developed for the rehabilitation of patients following ar-throscopic anterior capsulolabral repair.

rehaBiliTaTion GuiDeline principleS

a successful outcome follow-ing shoulder instability surgery is defined as a pain-free and sta-

ble shoulder that has enough mobility, strength, and muscle control for a pa-

fiGure 1. A Bankart lesion.

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tient’s desired level of activity and par-ticipation. Four principles are of critical importance for the rehabilitation profes-sional to successfully apply controlled stress to the shoulder and optimize pa-tient outcome: (1) an understanding of the surgical procedure, (2) an understanding of the anatomic structures which must be protected, how they are stressed, and the rate at which they heal, (3) the identifica-tion and skilled application of techniques to impart varying levels of stress to the healing tissues, and (4) managing the ini-tial immobilization period and the rate of ROM progression (TaBle 1).

Guiding principle 1Understanding the surgical procedure is important for the rehabilitation specialist. An arthroscopic anterior capsulolabral re-pair begins with a thorough arthroscopic examination of the glenohumeral joint, which is performed to assess the extent of pathology (ie, labral detachment and capsular attenuation) and to develop a plan for restoring stability.67 During the

classic anterior-inferior traumatic gle-nohumeral dislocation, the humeral head is driven anterior-inferior and usually lodges inferior to the coracoid process in what is referred to as a subcoracoid dislo-cation.80 As the head is forced out of the glenoid socket, it detaches the anterior-inferior labrum from approximately the 3-to 6-o’clock position (ie, Bankart lesion) (fiGure 1).90 Capsular attenuation is also frequently present as the forces that drive the humeral head out of the glenoid are sufficient to cause plastic, unrecoverable deformation of the capsuloligamentous restraints.6,31 Therefore, some surgeons perform capsular plication in all pa-tients undergoing arthroscopic instabil-ity repairs.83 In patients with congenital or atraumatic instability and an intact labrum, capsular attenuation is the pri-mary pathology addressed by the surgery. Associated injuries, such as a Hill Sachs lesion, rotator cuff tears, or osteochondral injuries, may also be present.90 It is es-sential for the rehabilitation specialist to communicate with the surgeon to deter-

mine the extent of any associated injuries and if anything was done at the time of surgery to address them that may impact the rehabilitation progression.

In patients with anterior instability but without a significant labral injury, the surgeon tightens the capsule and the glenohumeral ligaments with an ar-throscopic capsular plication or capsular shift procedure.83 Either biodegradable suture anchors are placed along the anterior-inferior labral articular surface without disturbing the intact labrum or the capsule is sutured directly to the in-tact labrum without the use of suture an-chors. In either case, special instruments are used to shuttle the suture through the capsule and labrum, and a rasp or syn-ovial resector is used to lightly abrade the capsular tissue that is to be retensioned. The amount of capsular tightening or re-tensioning is based on the preoperative examination and history, the amount of laxity demonstrated during the examina-tion under anesthesia, and the pathologic findings from the diagnostic arthroscopic examination.83 In a typical capsular shift without a Bankart repair, 3 suture an-chors with a single suture in each anchor are utilized (fiGure 2), and the capsule is shifted approximately 5 to 10 mm with each suture limb from an inferior to a superior direction (fiGure 3), thus elimi-nating the capsular redundancy in the anteroinferior joint compartment.31,83

The presence of a Bankart lesion, bony Bankart lesion, or other labral injury re-quires mobilization of the capsulolabral complex from the anterior glenoid neck or rim.88,89 An arthroscopic elevator is utilized, first followed by a synovial resector or small burr to abrade the glenoid rim at the articu-lar margin, so as to promote healing of the labrum to bone after repair. It is generally not necessary to shift or tighten the capsule in a Bankart repair. The labral-capsular complex is repaired anatomically.

Guiding principle 2Understanding the anatomic structures that must be protected, how they are stressed, and the rate at which they heal

fiGure 2. Suture anchors are demonstrated in the 5-, 4-, and 3-o’clock positions during an arthroscopic capsular shift.

fiGure 3. The capsule has been shifted 5 to 10 mm superiorly with each suture limb during an arthroscopic capsular shift.

TaBle 1Guiding Principles for the Rehabilitation Specialist

1. A thorough understanding of the surgical procedure

2. A thorough understanding of the anatomic structures that must be protected, how they are stressed, and the rate at which they heal

3. Appropriate selection and skilled application techniques to impart varying levels of stress to the healing tissues

4. Appropriate management of the initial immobilization period and the rate of range-of-motion progression

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[ clinical commentary ]The rehabilitation process is divided

into 3 phases of 6 to 12 weeks in duration, because we believe these time frames co-incide with the healing and clinical mile-stones. The first 6 weeks postoperative include the inflammatory and the prolif-erative (fibroplasia and wound contrac-tion) phases and the beginning of the scar maturation phase of tissue healing.19 Scar maturation and remodeling of the tissue likely continues throughout the rehabili-tation process and may not be complete until 40 to 50 weeks after surgery.53,96

Other factors, such as the patient’s age and the presence of comorbidities, may affect tissue healing and should be considered when deciding how quickly to progress an individual patient. Diabetes mellitus, peripheral vascular disease, and connective tissue disorders may impair healing; therefore patients with these diseases may have or require a slower re-habilitation progression. No studies have examined the influence of comorbidities on shoulder function following capsulo-labral repair. Comorbidities do negatively influence outcome following rotator cuff repair and shoulder athroplasty,11,35 there-fore it is possible that comorbidities may negatively impact rehabilitation and out-comes after capsulolabral repair.

Guiding principle 3Correct selection and use of techniques to apply varying levels of stress to the sur-gical repair is important for a successful outcome. Following surgical repair, the healing capsulolabral structures require appropriate stress to stimulate optimal healing, while protecting the repair from excessive tension. The gradual applica-tion of stress is a stimulus for further proliferation and differentiation of fibro-blasts.19,35 A gradual increase in applied stress, in a process analogous to Wollf ’s law of bone healing,96 results in enhanced structural integrity of the capsulolabral complex as additional collagen fibers are laid down in response to controlled stresses. However, it is equally important to understand that with excessive stress to the capsulolabral complex, either in

terms of magnitude or timing, the tissues will be unable to adequately adapt,32,92 and damage will result to either the heal-ing tissues or the suture anchors. During rehabilitation, there are 3 mechanisms by which rehabilitation providers apply stress to the surgical repair to positively affect patient outcome: (1) absolute ROM, (2) controlled submaximal tissue loading, and (3) dynamic stabilization.

Immediately following surgery, the re-pair is completely reliant on the mechani-cal strength of the sutures and/or suture anchors. Therefore, the absolute ROM limit that is initially deemed safe is based upon the surgical fixation and structural integrity of the repair. As time passes, the repaired tissues begin to heal through fi-brous scar formation and gradually in-crease in tensile strength. In the case of a Bankart lesion, the labrum develops immature connective tissue links to the glenoid rim, and in the case of a capsu-lar plication, the plicated layers of the capsule initiate formation of immature connective tissue links to one another. Excessive stretching during ROM activi-ties may overload the structural integrity of these immature cross-links in the heal-ing tissues.30,68,81,86

Much in the same way micromotion prevents bony union during fracture healing, submaximal tissue loading also has the potential to disrupt the tenuous tissue healing bonds between the labrum and bone and between the plicated layers of the capsule.32,92 Repeated submaximal stress of a ligament plication in an ani-mal model has been shown to negatively affect mechanical resistance properties, even as late as postoperative week 12.32 While direct extrapolation cannot be made to a pathologic human condition, these findings are similar to the effects of submaximal loading in human cadavers. Repetitive submaximal loading has been shown to increase the length and decrease the subsequent load to failure of the an-terior inferior glenohumeral ligament.71 The exact effect of submaximal loading during various rehabilitation interven-tions is currently unknown. Thus, clini-

is also important before rehabilitation begins. Arthroscopic anterior capsulo-labral repair involves a direct repair of damaged capsular and labral structures. Repair is achieved via suture and/or su-ture anchor reattachment, which requires protection from excessive stresses to fa-cilitate appropriate tissue healing.62,75 It is well documented that specific portions of the capsule and labrum are selectively tensioned with specific glenohumeral motions.68,81,86 A standard anterior cap-sulolabral repair, addressing attenuation of the anterior inferior capsule, is most directly stressed by external rotation, particularly above 90° of abduction.68,86 In a cadaveric model, Itoi et al37 dem-onstrated that with the arm by the side, external rotation to 30° could safely be applied to the shoulder without separat-ing a simulated Bankart lesion.

Forward flexion stresses the inferior part of the glenohumeral joint capsule. Therefore, based on the stress to the in-ferior capsule, we recommend limiting flexion to less than 90° until 3 weeks postsurgery, then gradually increasing flexion to 135° through postoperative week 6.

During the classic open Bankart re-pair, the subscapularis is either detached or split to access the capsule and is then subsequently reattached or closed with sutures, necessitating protection from active internal rotation during the early postoperative period.39,50 However, dur-ing the standard arthroscopic anterior capsulolabral repair, the subscapularis is not detached or split, therefore it does not need specific protection from ex-cessive stress during the rehabilitation program.15

It is imperative that activities be lim-ited to those which produce less stress to the healing tissues than the failure strength of the repair.93 The challenge for guiding rehabilitation based upon the tissue healing is the limited ability for clinicians to measure tissue heal-ing. Moreover, the amount of stress im-parted by many rehabilitation activities remains unknown.

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cians should keep in mind that repeated and excessive submaximal tensioning of the repair during the remodeling phases of tissue healing may theoretically cause the capsule to heal at a longer length. Therefore, even though they are below the failure strength of the capsulolabral tissues, repetitive submaximal stresses should be carefully controlled as they pose a potential threat to capsuloliga-mentous integrity.

While excessive submaximal loading may be detrimental, dynamic stabiliza-tion or active stabilization of a joint by the muscles directly surrounding it provides protection to the surgical repair9,13,49,51 by supporting the joint capsule,14 increas-ing joint compression forces,42,49 and resisting joint displacement.55 It is vital to understand that these 3 mechanisms (absolute ROM, submaximal tissue load-ing, and dynamic stabilization) do not occur in isolation but are interrelated in all rehabilitation activities and should be the primary considerations when select-ing interventions during rehabilitation.

Guiding principle 4Appropriate management of the initial immobilization period and ROM pro-gression are also important for the reha-bilitation specialist because the tensile strength of the arthroscopic anterior capsulolabral repair is reduced through the first 12 postoperative weeks.32 There-fore, it is important to protect the surgi-cal repair from undue stress during the first 2 phases of this rehabilitation guide-line (12 weeks total) by controlling the rate at which ROM is regained. Gaining ROM too quickly can limit the normal tissue-healing process and lead to cap-suloligamentous attenuation.93 There-fore, an initial period of immobilization is common after arthroscopic anterior capsulolabral repair to facilitate healing of the surgically repaired tissues,40,45,52,65,76 theoretically allowing the surgically reat-tached labrum a chance to bind to the glenoid and the plicated layers of capsule to heal to each other.

Absolute immobilization (no gle-

nohumeral ROM exercises and constant sling use) in the first 6 weeks following arthroscopic capsulolabral repair of the shoulder was advocated during the in-fancy of these procedures,40,65 when surgi-cal techniques were rapidly evolving and failure rates were high.27 However, stud-ies advocating absolute immobilization as a means to decrease long-term failure rates utilized surgical procedures such as transglenoid sutures27,84 or staple repair40 that are no longer common. Current sur-gical methods typically employ sutures and suture anchors to repair the labrum and retension the glenohumeral liga-ments,3,10,45,52 producing outcomes similar to open instability repair.3,23,44 Therefore, the need for absolute immobilization af-ter arthroscopic Bankart repair has been reexamined in recent years.

Studies have shown short periods of absolute immobilization result in no greater recurrence rate of shoulder insta-bility and have demonstrated improved ROM over the course of recovery.3,46 In a randomized controlled trial comparing 3 weeks of absolute immobilization to im-mediate staged ROM in a select group of patients undergoing Bankart repair, Kim et al46 found that immediate ROM yielded no greater recurrence rate in dis-location, or difference in pain or function scores. These results apply to patients with recurrent (nonacute) instability brought on by a traumatic event, and a Bankart lesion only without the pres-ence of a bony fragment (bony Bankart). These results do not apply to those pa-tients actively participating in sports, or to those patients with multidirectional or posterior instability, other labral lesions, a rotator cuff tear, or a larger bony Ban-kart lesion involving greater than 30% of the glenoid. Additionally, considering that the capsulolabral complex appears to be within the safe boundaries of stress with the arm in adduction and up to 30° of external rotation,37 immediate postop-erative ROM in this range is safe.46

Based on this evidence and our sig-nificant clinical experience rehabilitat-ing patients following this surgery, we

recommend a variable period between 0 up to 4 weeks of absolute immobiliza-tion following an arthroscopic anterior capsulolabral repair, in which sutures or suture anchors are utilized. Relative immobilization (out of sling only for ROM exercises or short periods of sit-ting or standing) is recommended for 6 weeks, followed by sling use for comfort. We offer ranges of immobilization as a general guideline because we recognize that surgeon preference plays a major role in the postoperative immobilization time frames for patients undergoing this procedure and want to provide a wide range that is safe, both in terms of early motion and protecting the repair, and restricted motion in terms of preventing contractures and adhesions. Immobiliza-tion periods should be determined by the surgeon and rehabilitation provider for each individual patient, considering the extent of the pathology, the integrity or the repair, as well as the patient’s goals, age, and comorbidities.

Regardless of the period of absolute and relative immobilization, controlling the rate of ROM progression is vitally important. The integrity of the surgi-cal repair is thought to be negatively affected by the patient regaining ROM too quickly during the first 8 to 12 weeks postoperatively.32,62,75 Staged ROM goals are an effective tool to guide the rate of ROM progression.46,52 We have proposed a general guideline for staged ROM goals that we were able to achieve consensus on from our multidisciplinary team of shoul-der rehabilitation specialists (TaBle 2). As with the specific period of immobiliza-tion, ROM goals may be modified by the surgeon or rehabilitation provider, based on the individual patient. The ROM goals have the patient comfortably progressing their ROM to the specified angle. If the patient’s ROM is less than the targeted range, gentle stretching should be imple-mented to facilitate ROM gains to the targeted range and to prevent the devel-opment of contractures and adhesions. On the other hand, if the targeted ROM is easily obtained, then stretching in the

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directions in which the target motions have already been met should be avoid-ed to prevent overstressing the healing tissues.19

rehaBiliTaTion GuiDeline

the appenDiX contains ASSET’s Consensus Rehabilitation Guide-line for Arthroscopic Anterior

Capsulolabral Repair. The guideline is divided into 3 phases, based on general time frames of capsulolabral healing. In addition to time, short-term goals or milestones at each phase are used to determine progression from one phase to the next of the treatment program. Clinician-rated impairments and patient-rated outcome tools are used to judge these milestones. Goals for each phase include surgical healing, staged attain-ment of passive and/or active ROM, pain, adherence to immobilization and home exercise program, scapular posture and dynamic control during ROM and ex-ercise, and restoration of shoulder func-tion. Clinician-rated impairments and patient-rated outcomes are used to assess the achievement of these goals. Healing of the surgical repair is assessed by time frames, and adherence to the precau-tions, immobilization, and ROM guide-lines. Active and passive ROM should be measured with an inclinometer or goni-ometer. Pain should be assessed with a patient-rated numeric pain rating scale (NPRS). Scapular posture should be as-sessed visually for winging or other ab-normal motion during active elevation of the arm or as the patient completes the

supervised portion of their exercise pro-gram. Completion of strengthening pro-gram should be assessed by comparing the exercise program performed to the protocol. Finally, measurement of shoul-der functional loss or disability is best evaluated with a patient-rated outcome measure.

Both the clinical milestones and time frames should be met prior to progres-sion to the next phase. Clinician-rated impairments should be performed every 1 to 2 weeks, to closely monitor response to treatment and achievement of milestones. It is critical to use patient-rated measures of function and disability to comprehen-sively assess patient response to treat-ment. There are numerous patient-rated measures with established measurement properties available to assess shoulder function and disability. Recent studies of patient-rated measures of shoulder func-tional loss and disability in patients with instability or undergoing shoulder sur-gery indicate that one measure is likely not superior to another.69,70 The scales recommended for use are patient-rated measures specifically for instability, such as the Western Ontario Instability Index (WOSI) or a general shoulder measure such as the ASES Form patient-rated section.47,48,63

phase 1: postoperative Weeks 0 to 6The focus of phase 1 rehabilitation, which constitutes the first 6 postoperative weeks, is to maximally protect the surgical re-pair and achieve, but not to exceed, the staged ROM goals (TaBle 2), while being especially mindful to not exceed external

rotation limits. Because of the minimally invasive nature of the surgical procedure, some patients experience little pain and may be able to use their arm more than is advisable during this phase. Therefore, patient education is critical to convey the importance of staying within the pre-scribed ROM limits and not overloading the shoulder, so as to protect the healing tissues from excessive stress and possible anchor or tissue failure. Potentially in-jurious forces can be avoided by slowly progressing through staged ROM goals, controlling submaximal loading forces by limiting repetitive activity of the arm, and avoiding forces that may overstress the structural integrity of the capsulo-labral repair by not lifting heavy objects. Wetzler et al92 estimated that a shoulder would typically experience 1000 to 2000 loading cycles during the first 6 weeks of rehabilitation following capsulolabral re-pair. Based upon their analysis, the maxi-mum load any particular suture anchor could accommodate is 60 to 100 N, based upon the location of the suture anchors, with lower forces to failure on the more inferior portions of the glenoid. Addition-ally, the pull-out strength decreased pre-cipitously within the first 100 cycles until the suture anchor “settled.” Therefore, de-spite the fact that the suture anchor-bone construct is strongest initially, the loads during the first few weeks of rehabilita-tion should be minimized until the suture anchor has “settled” into its final position. Direct application of these data clinically is limited, as cadaveric specimens were used with an average age older than the typical patient undergoing arthroscopic capsulolabral repair. Still, we believe these findings provide some support for minimizing the number and amount of repetitive loads, particularly during the first phase of rehabilitation.92

Because the rotator cuff muscles are not detached during arthroscopic stabi-lization, both passive and/or active as-sistive ROM exercises are appropriate in the early stages of postoperative rehabili-tation. Therefore, unlike rehabilitation of the patient following rotator cuff repair,

TaBle 2Staged Range-of-Motion Goals Following

Arthroscopic Anterior Capsulolabral Repair

Abbreviations: Abd, abduction; AFE, active forward elevation in the scapular plane; NA, not applicable; PER, passive external rotation; PFE, passive forward elevation; POW, postoperative week; WNL, within normal limits.

pfe per at 20° abd per at 90° abd afe

POW 3 90° 10°-30° Contraindicated NA

POW 6 135° 35°-50° 45° 115°

POW 9 155° 50°-65° 75° 145°

POW 12 WNL WNL WNL WNL

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active assistive exercises can be performed immediately for the patient following ar-throscopic capsulolabral repair.

Forward elevation and external rota-tion in slight abduction within the pre-scribed ROM limits are the glenohumeral motions performed during phase 1, as they allow for glenohumeral ROM without adversely stressing the surgi-cal repair. Exercises to regain forward elevation may include rope-and-pulley-assisted elevation, self-assisted elevation in the supine position, or wand-assisted elevation in the supine position. A table step-back exercise (fiGure 4), where the patient’s hands remain stationary on a surface, while the patient slowly walks his or her body back, bending at the waist to achieve forward elevation, may be help-ful for patients who have difficulty relax-ing. To regain external rotation ROM, the clinician or family member may perform passive external rotation with the arm at the side, or the patient could perform ac-tive assisted external rotation with a cane or bar to assure that ROM limits are not exceeded and the shoulder is not posi-tioned in extension during any external rotation ROM exercise.

To protect the surgical repair, ROM should never be forceful during phase 1. During phase 1, it is recommended that stretching exercises stop at the point when the patient experiences a sensation of a light stretch, as long as the ROM is less than the staged ROM goals. If ROM exceeds the staged goals without any sensation of stretch, then the pa-tient no longer has a ROM deficit. If this circumstance occurs, ROM exercises in this plane are discontinued until ROM is consistent with the staged goals. Dur-ing phase 1, ROM exercises should not be used that stretch into end range external rotation, particularly at 90° of abduction, have the patient positioned in shoulder extension, or stretch into straight-plane abduction, with or without humeral ex-ternal rotation, because they directly stress the anterior or anterior inferior glenohumeral capsule.86

Scapular exercises and active motion

of the uninvolved joints of the upper ex-tremity, such as the elbow or wrist, are recommended during phase 1 but are considered supplementary activities. Exercises to achieve scapular control are encouraged; however, positions and exer-cises that stress the capsulolabral struc-tures should be avoided, such as scapular protraction with concomitant horizontal abduction of the shoulder. Postures or exercises that include scapular retraction should be encouraged, as scapular retrac-tion minimizes the amount of shoulder extension needed for functional tasks and therefore limits stress on the anterior-inferior capsule and labrum.91 However, even though scapular elevation and re-traction are relatively safe, these activities should only be completed with very light or no resistance.

Although the rotator cuff does not specifically require protection following arthroscopic stabilization, glenohumeral active ROM and rotator cuff strengthen-ing are purposefully de-emphasized dur-ing the early postoperative period because of the potentially detrimental effect to the healing tissues.32,92 Light strengthening and active ROM within the staged ROM goals would not likely result in excessive loading; however, in our opinion, it sends an inconsistent message to the patient during this early postoperative period that some strengthening is approved yet significant restrictions of activities of

daily living and immobilization are nec-essary. We believe this inconsistency can lead to excessive arm use, in terms of both loading and ROM, resulting in too much stress to the surgical repair. Heal-ing is the first priority in phase 1. During phase 1, the only form of strengthening recommended is submaximal isometric strengthening of the shoulder and elbow, with the arm adducted to the side in neu-tral rotation.

phase 2: postoperative Weeks 6 to 12Phase 2 begins at postoperative week 6 and after the clinical milestones identified in phase 1 (appenDiX) have been achieved. The focus of this phase is continued pa-tient education regarding postoperative activity limitations, staged ROM goals (TaBle 2), and the initiation of rotator cuff and scapular neuromuscular control activities within the allowed ROM. This is achieved by gradual increase in ROM, submaximal tissue loading, and dynamic stabilization.

The goal is to achieve full ROM in all planes at 12 weeks postoperative, with the exception of end range external rotation at 90° of abduction. The motions of forward elevation and external rotation in slight abduction remain the focus of this phase, and it is also important to measure and, if limited, begin interventions to increase glenohumeral joint horizontal adduction and internal rotation. Posterior shoulder

fiGure 4. (A) Starting position and (B) 90° of shoulder elevation for the table step back exercise.

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[ clinical commentary ]mobility is important to maintaining nor-mal arthrokinematics of the glenohumeral joint, as a tightness of the posterior shoul-der has been shown to increase superior humeral head migration, which may lead to impingement.28 Cross-body stretching has been shown to yield superior gains in internal rotation ROM when compared to a “sleeper” stretch.60

If forward elevation or external rota-tion ROM lag behind staged ROM goals, joint mobilizations or stretching can be performed. Based upon data regarding fatigue properties of suture anchors,92 rehabilitation professionals should be cautious during the use of joint mobili-zations. We recommend their use only when active assisted and passive ROM has not allowed the patient to achieve staged ROM goals.

In addition, there is an often theo-rized link between anterior glenohumer-al laxity and excessive external rotation ROM, particularly in overhead athletes. Increased laxity5,77 and greater external rotation ROM77 have been found in the dominant shoulders of professional base-ball pitchers. However, this finding is far from universal, as several authors have demonstrated no asymmetry in laxity between the dominant and nondominant shoulders of professional pitchers.12,16 The most direct evidence linking capsular loading, laxity, and ROM may have been provided by Mihata et al,64 who demon-strated a linear increase in length of the inferior glenohumeral ligament and the amount of glenohumeral anterior trans-lation as a result of a prolonged, excessive stretch into external rotation. Therefore, it is important to remember not to per-form passive stretching to gain end range external rotation or external rotation at 90° of abduction unless significant tight-ness is present, as these are the motions that impart the greatest stress to the heal-ing capsulolabral repair.68,86

As ROM targets are met, the focus of rehabilitation can shift to neuromuscu-lar retraining. A program which focuses on scapular stability and maintaining the humeral head in a centralized posi-

tion within the glenoid fossa has been shown to minimize strain on the cap-sule and thereby offers a protective ef-fect for the surgical repair.9,13,49,51 The neuromuscular retraining must be car-ried out within the staged ROM goals, and must provide a stepwise increase in muscular demand. If muscular demand is increased too quickly, abnormal move-ment patterns are likely to occur at the scapulothoracic and glenohumeral joints. We recommend exercises for which the magnitude of specific muscle activation has been documented through electro-myographic studies, to provide the clini-cian with the ability to objectively apply gradually increasing loads to specific muscles.4,8,17,18,20,22,33,36,38,43,54,57,58,66,72,73,85,87 A strengthening program that integrates the ROM progression, progressively in-creasing muscular activity levels, and re-petitive submaximal loading is detailed in the phase 2 strength and endurance section of the appendix.

Progression to active and resistive el-evation activities should be performed in phase 2. We advocate elevation in the scapular plane because, compared to frontal or sagittal plane elevation, scapular plane elevation provides mini-mal capsular stress,21 better subacromial clearance,41 and a more optimal length-tension relationship for the scapula and rotator cuff muscles.56 We advocate us-ing the thumb-up (“full can”) position for active and resisted elevation activities because it provides better subacromial clearance,25 better scapula mechanics,82 and equal rotator cuff activation8 com-pared to the thumb-down (“empty can”) position.

Exercises with weight bearing applied through the upper extremities can be help-ful to achieve correct static and dynamic scapular mechanics; however, the stresses that these exercises place on the surgical repair can be high. Appropriate weight-bearing scapular exercises during phase 2 include maintaining scapular alignment in the quadruped position progressing to 3-point and finally 2-point stabilization.87 While it is tempting to extrapolate this

information to a true push-up exercise, in our opinion, traditional push-ups are not appropriate during phase 2 because they produce relatively high loads on the shoulder and stress the anterior capsule when the arm is brought in horizontal abduction (“down position”). Push-ups performed in standing with hands placed on the wall (ie, wall push-ups, would be appropriate at this time frame). But to the best of our knowledge, the benefits of this exercise have not been quantified in published research.

Patient education regarding appropri-ate positions and loading is crucial during phase 2 so the patient understands that, even though his or her shoulder may be starting to feel much better, there should be no uncontrolled end range stretching, heavy lifting, or quick motions performed with the surgical arm. Loading of the surgical repair must be controlled dur-ing rehabilitation and during activities of daily living as well. The impact of this cannot be overstated, as the patient will spend more time performing activities of daily living than directly performing rehabilitation exercises. Patient educa-tion should stress that tissue healing is incomplete through 12 weeks32 and may not be complete until 40 to 50 weeks postoperatively.30,96

phase 3: postoperative Weeks 12 to 24Phase 3 rehabilitation begins at approxi-mately postoperative week 12, once the criteria to progress to phase 3 (appenDiX) are met. The primary focus of this final phase of rehabilitation is normalizing neuromuscular function with strength-ening, endurance, power, and dynamic stability exercises. This must be contin-ued in a way that assures gradual ad-vancement of stress to the capsulolabral structures through graded progressions of ROM, repetitive submaximal loading, and dynamic stabilization. Any remain-ing limitations in ROM should be di-rectly addressed early in phase 3 through low-load, prolonged stretching and joint mobilizations.

Time frame for the initiation of high-

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loading exercises and activities following capsular plication or labral repair have not been established.10,44,46 A 12-week pe-riod is often cited as the minimum post-operative time frame to begin vigorous activities,7,23,45,61,94 and this time frame is consistent with our review of the litera-ture for healing rates of the capsulolabral complex.19,96 No clinical trial evidence supports this recommendation, only con-sensus from a multidisciplinary group of rehabilitation specialists. Prior to initiat-ing any high-load activities, the patient should demonstrate excellent shoulder girdle strength, endurance, and neuro-muscular control.

The ultimate goal of rehabilitation is to maximize the patient’s ability to return to full activities of daily living, work, and recreational activities. Setting appropri-ate goals should occur early in the reha-bilitation process and result from a team effort between the patient, physician, and rehabilitation specialist. Because each patient’s goals are different, phase 3 interventions should be tailored to each patient. For example, an athlete who de-sires a return to competitive baseball will require a greater amount of external rota-tion ROM in the 90° abducted position, an ability to control the shoulder girdle at high speeds, and endurance and power of the entire upper extremity, torso, and lower body. In contrast, a patient who desires a return to work on an assembly line may require the ability to lift heavy loads at waist level and moderate loads repeatedly to shoulder level. A patient who desires only to return to normal dai-ly activities would not require extreme ROM and would not require high levels of strength, endurance, and neuromuscu-lar control needed for overhead sport or repetitive work demands.

Although these patients have the same entry point into this last phase of rehabili-tation, every patient is unique and will re-quire goal-specific phase 3 programs. The final rehabilitation step for the sedentary person may be establishing a home exer-cise routine consisting of selected phase 2 exercises. Rehabilitation of the assembly

line worker would emphasize endurance through general weight lifting, as well a progressive routine of functional lifting. Rehabilitation of the throwing athlete would emphasize activities with pro-gressively higher speed and multiplanar sport-specific movements. Examples in-clude exercises performed rapidly against elastic resistance (fiGure 5) and progres-sive plyometrics.24,26,29,59

Due to the extremely high sport-spe-cific stresses placed on the upper quarter with overhead activities, it is necessary to progress to sport-specific programs.1,2,74 These programs should incorporate a gradual build-up in volume and intensi-ty, and include adequate rest.1,2,74 Return to sporting activities should be made in consultation with the surgeon and pa-tient and should not occur until specific milestones are achieved. Athletes must be symptom free and should not return to sport until they have demonstrated appropriate ROM, strength, control, en-durance, and power necessary for their particular sport or activity.

concluSion

aSSET developed this consen-sus rehabilitation guideline based upon 4 critical principles (TaBle 1),

to guide the rehabilitation process and optimize patient outcome. Each funda-mental principle has been reviewed and incorporated into the development of the consensus guideline for which the staged ROM goals (TaBle 2) and time frames of this consensus guideline are based. The graded application of stress to the heal-ing capsulolabral tissues guides reha-bilitation; this stress can be modulated through absolute ROM limits, repeti-tive submaximal loading, and dynamic stabilization.

This document represents a consensus guideline for the typical patient; modifi-cations to the specific application of the guideline may be required, based on the individual patient’s pathology, goals, age, or comorbidities. Because of the wide vari-ety of patients who undergo arthroscopic capsulolabral repair, we feel that final re-

fiGure 5. (A) Starting position and (B) ending position for a high-speed elastic resistance exercise replicating the throwing motion.

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ACKNOWLEDGEMENTS: The authors would like to acknowledge the members of The Ameri-can Society of Shoulder and Elbow Thera-pists (www.asset-usa.org) for their expertise in the development this international consen-sus guideline. The authors would also like to acknowledge Carol Capers, MSMI, CMI, for creating the figures.

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55. Louie JK, Mote CD. Contribution of the muscu-lature to rotatory laxity and torsional stiffness at the knee. J Biomech. 1987;20:281-300.

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appenDiX

phase 1: poW 0 to poW 6

Goals• Maximallyprotectthesurgicalrepair(capsule,liga-

ments, labrum, sutures)• AchievestagedROMgoals.Donotsignificantlyexceed

them:- PFE: POW 3, 90°; POW 6, 135°- PER at 20° abd: POW 3, 10°-30°; POW 6, 35°-50°- PER at 90° abd: POW 3, contraindicated; POW 6, 45°- AFE: POW 3, NA; POW 6, 115°

• Patienteducationinpostoperativerestrictions• Minimizeshoulderpainandinflammatoryresponse• Ensureadequatescapularfunction

Interventions to Avoid• DonotalloworperformROM/stretchingsignificantly

beyond staged ROM goals, especially external rotation both by the side and in abduction

• Donotallowthepatienttousearmforheavyliftingorany use of the arm that requires ROM greater than the staged ROM goals

Specific InterventionsActivities of primary importance:• Patienteducationregardinglimitinguseofthearm

despite lack of pain or other symptoms• Protectionofrepair• AchievestagedROMgoalsthroughgentleROM

activities• MinimizeinflammationSupplementary activities:• Normalizescapularposition,mobility,anddynamic

stability• ROMofuninvolvedjoints• Beginrestorationofshoulderstrengththroughisomet-

ric exercisesImmobilization:• Viastandardsling• Absoluteimmobilization(noglenohumeralROM

exercises and constant sling use) for variable time of 0 up to 4 weeks, based on patient-specific factors and surgeon recommendation

• Relativeimmobilization(outofslingforROMexercises,sitting with the arm supported, and standing for short periods), starting after the period of absolute immo-bilization and continuing for the remainder of phase 1, followed by sling use for comfort

Patient education:• Explainnatureofthesurgery• Discussprecautionsspecifictothenatureofthesurgi-

cal repair

- Importance of not significantly exceeding staged ROM goals

- Importance of tissue healing- Proper sling use (assure sling provides upward sup-

port to the glenohumeral joint)- Limiting use of arm for ADLs

ROM:• Followingtheabsoluteimmobilizationperiodbegin:

- Pendulum exercises (unweighted)- Passive/active assisted forward elevation to achieve

staged ROM goals listed earlier. ROM should not be forceful

- Passive/active assisted external rotation with the shoulder in slight abduction to achieve staged ROM goals listed earlier. ROM should not be forceful

- Scapular clock exercises or alternately elevation, depression, protraction, retraction. Progress to scapular strengthening as patient tolerates78,79

• ActiveROMofuninvolvedjointsMiscellaneous:• Submaximalrotatorcuffisometricsastolerated• Posturalawareness/educationPain management:• Activityrestriction• Properfittingofslingtosupportarm• Electrophysicalagents

The aMerican SocieTy of ShoulDer anD elBoW TherapiSTS’ conSenSuS rehaBiliTaTion GuiDeline for arThroScopic anTerior capSulolaBral repair of The ShoulDer

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appenDiX (conTinueD)

• Physicianprescribedorover-the-countermedications

Milestones (Testing Criteria) to Progress to Phase 2• Appropriatehealingofthesurgicalrepairbyadhering

to the precautions and immobilization guidelines.• StagedROMgoalsachievedbutnotsignificantly

exceeded• Minimaltonopain(NPRS,0-2/10)withROM


Goals• AchievestagedROMgoalstonormalizepassiveROM

and active ROM. Do not significantly exceed:- PFE: POW 9, 155°; POW 12, WNL- PER at 20° abd: POW 9, 50°-65°; POW 12, WNL- PER at 90° abd: POW 9, 75°; POW 12, WNL- AFE: POW 9, 145°; POW 12, WNL

• Minimizeshoulderpain• Begintoincreasestrengthandendurance• Increasefunctionalactivities

Interventions to Avoid• Donotperformstretchingsignificantlybeyondstaged

ROM goals• Donotperformanystretchtogainendrangeexternal

rotation or external rotation at 90º of abduction unless significant tightness is present

• Donotallowthepatienttousearmforheavyliftingor any activities that require ROM beyond the staged ROM goals

• Donotperformanystrengtheningexercisesthatplacea large load on the shoulder in the position of horizontal abduction or the combined position of abduction with external rotation (eg, no push-ups, bench press, pectoralis flys)

• Donotperformscapularplaneabductionwithinternalrotation (empty can) at any stage of rehabilitation due to the likelihood of impingement

Specific InterventionsActivities of primary importance• Continuedpatienteducation• Passive/activeassistedROMasneededtoachievebut

not significantly exceed staged ROM goals• Establishbasicrotatorcuffandscapularneuromuscu-

lar control within the allowed ROMSupplementary activities:• Introductionoffunctionalpatternsofmovement• ProgressiveenduranceexercisesPatient education:• Counselaboutusingtheupperextremityforappropri-

ate ADLs in the pain-free ROM (starting with waist-level activities and progressing to shoulder-level and finally to overhead activities over time)

• Continueeducationregardingavoidanceofheavyliftingor quick, sudden motions

• Educationtoavoidpositionsthatplacestressontheanterior inferior capsule during ADLs

ROM:• Passive/activeassistedROMasneededtoachieve

staged ROM goals in all planes. Many times only light stretching or no stretching is needed

• IfROMissignificantlylessthanstagedROMgoals,gentle joint mobilizations may be performed. However, they should be done only into the limited directions and only until staged ROM goals are achieved

• Addressscapulothoracicandtrunkmobilitylimitations.Ensure normal cervical spine ROM and thoracic spine extension to facilitate full upper extremity ROM

Neuromuscular re-education:• Addressabnormalscapularalignmentandmobility

PRN - Strengthen scapular retractors and upward rotators

- Increase pectoralis minor flexibility if limited- Biofeedback by auditory, visual, or tactile cues- Weight-bearing exercises with a fixed distal

segment. Examples: quadruped position while working to maintain proper position of the scapula, quadruped with scapula protraction, progressing from quadruped to tripod position, no push-ups87

• AddresscorestabilitydeficitsPRN• Activitiestoimproveneuromuscularcontrolofthe

rotator cuff and shoulder girdle such as use of unstable surfaces, Bodyblade, manual resistance exercises

Strength/endurance:• Scapulaandcorestrengthening• Balancedrotatorcuffstrengtheningtomaintainthe

humeral head centered within the glenoid fossa during progressively more challenging activities- Should be initially performed in a position of com-

fort with low stress to the glenohumeral joint, such as less than 45° elevation in the plane of the scapula (eg, elastic band or dumbbell external rotation, internal rotation, forward flexion)

- Exercises should be progressive in terms of shoulder elevation (eg, start with exercises performed at waist level progressing to shoulder level and finally overhead activities)

- Exercises should be progressive in terms of muscle demand. It is suggested to use activities that have muscle activity levels documented with EMG4,8,17,18,20,

22,33,36,38,43,54,57,58,66,72,73,85,87

- Elevation activities may progress from assistive exercises (eg, rope and pulley, wall walks) to active, to resistive upright exercises, then, finally, to prone exercises

- Nearly full active elevation in the plane of the scapula should be achieved before progressing to elevation in other planes

- Exercises should be progressive in terms of adding stress to the anterior capsule, gradually working towards a position of elevated external rotation in the coronal plane, the “90-90” position PRN

- Rehabilitation activities should be pain free and per-formed without substitutions or altered movement patterns

- Rehabilitation may include both weight-bearing and non–weight-bearing activities

- Rehabilitation may include both isolated and complex movement patterns

- Depending upon the goals of the exercise (control versus strengthening), rehabilitation activities may also be progressive in terms of speed once the patient demonstrates proficiency at slower speeds

- The rotator cuff and scapula stabilizer strengthen-ing program should emphasize high repetitions (typically 30-50 reps) and relatively low resistance (typically 1-2 kg)

- No heavy lifting or plyometrics should be performed during this stage

- Elbow flexion/extension strengthening with elbow by the side can begin in this phase

Pain management:• EnsureappropriateuseofarmduringADLs• Ensureappropriateleveloftherapeuticinterventions• Electrophysicalagentsasneeded

Milestones to Progress to Phase 3• StagedactiveROMgoalsachievedwithminimaltono

pain (NPRS, 0-2/10) and without substitution patterns• Appropriatescapularpostureatrestanddynamic

scapular control during ROM and strengthening exercises

• Strengtheningactivitiescompletedwithminimaltonopain (NPRS 0-2/10)


Goals• Normalizestrength,endurance,neuromuscularcontrol,

and power• Gradualandplannedbuild-upofstresstoanterior

capsulolabral tissues• GradualreturntofullADLs,work,andrecreational

activities

Interventions to Avoid• Donotincreasestresstotheshoulderinashortperiod

or in an uncontrolled manner• Donotperformadvancedrehabilitationexercises(such

as plyometrics or exercises requiring end range ROM) if the patient does not perform these activities during ADLs, work, or recreation

• Donotprogressintoactivity-specifictraininguntilpatient has nearly full ROM and strength

• Donotperformweightliftingactivitiesthatplaceex-cessive stress on the anterior capsule. For instance, latissimus pull-downs, and military press performed with the hands behind the head stress the anterior

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appenDiX (conTinueD)

capsule with no additional benefit in terms of muscle activity. Similarly, activities which encourage end range shoulder extension, such as dips, should also be avoided

Specific InterventionsActivities of primary importance:• Progressivestrengtheningandenduranceexercises• Progressiveneuromuscularcontrolexercises• Activity-specificprogression:sport,work,hobbiesSupplementary activities:• NormalizecoreandscapularstabilityPatient education:• Counselinimportanceofgraduallyincreasingstressto

the shoulder while returning to normal ADLs, work, and recreational activities, including heavy lifting, repetitive activities, and overhead sports

ROM:• PassiveROM,stretching,andjointmobilizationsas

needed to address any remaining deficitsNeuromuscular re-education:• Addressanyremainingdeficitsoftherotatorcuff,

scapula musculature, or trunk musculatureStrength/endurance/power:• Continueshoulder-strengtheningprogramasinitiated

in phase 2, with increasing emphasis on high-speed multiplanar activities that incorporate the entire kinetic chain

• Graduallyprogressrehabilitationactivitiestoreplicatedemanding ADL/work activities

• Progressivereturntoweight-liftingprogramemphasiz-ing the larger, primary mover upper extremity muscles (deltoid, latissimus dorsi, pectoralis major)- Start with relatively lightweight and high repetitions

(sets of 15-25 repetitions), and gradually decrease repetitions and increase weight after several months

- Suggested upper extremity exercises for early phase 3 • Bicepscurls,shoulderadducted(addedin

phase 2) • Tricepspress-downsorkick-backs,shoulder

adducted (added in phase 2) • Shouldershrugs • Rows(scapularretraction),shoulderadducted • Latissimusbarpull-downs,withhandsinfront

of the head • Dumbbelloverheadshoulderpresswith

hands starting in front of the shoulders (not in the abducted/externally rotated position)

• Push-upsaslongastheelbowsdonotflex past 90º

- Suggested upper extremity exercises to be added in intermediate phase 3• Isotonicpressingactivities(eg,flatorincline

presses using machines, barbells, or dumbbells)• Dumbbellshoulderraisesto90º• Rows(scapularretraction),shoulderselevated• Machineorbarbellshoulderpressesthatdonot

require end range abduction/external rotation- Suggested upper extremity exercises to be added in

late phase 3• Overheadpresseswithshouldersinabduction

with external rotation (military press)• Pectoralismajorflys• Deadlift• Powercleans

- Upper extremity exercises that are not advisable for this patient population• Dips• Latissimuspull-downsormilitarypresswiththe

bar behind headPlyometric program (as necessary):• Criteriatoinitiateplyometricprogram

- Goals of returning to overhead athletics or other work or recreational activities requiring large amounts of upper extremity power

- Adequate strength (4+/5) of entire shoulder girdle musculature

- Pain free with basic ADLs and current strengthening program

- At least 3 weeks of tolerance to high-speed multi-planar activities that progressively mimic functional demands

• Parameters- Due to the explosive nature of this type of exercise,

emphasis of plyometrics exercises should be on quality not quantity

- Perform a few times a week and utilize moderate repetitions (eg, 3-5 sets of 15-20 repetitions)

- Begin with unweighted balls and progress to lightly weighted balls (plyoballs)

Interval sport programs for activities such as throwing, swimming, and golf, once approved by physician (usually POW 16 or longer)

Milestones to Return to Work, Hobbies, Sport• Clearancefromphysician• Nocomplaintsofpainatrestandminimaltonopain

(NPRS 0-2/10) with activities• Noorminimalsensationofinstabilitywithactivities• RestorationofsufficientROMtoperformdesiredactivi-

ties• Adequatestrengthandenduranceofrotatorcuffand

scapular muscles to perform activities with minimal to no pain (NPRS 0-2/10) or difficulty

• Ifthepatientstruggleswithconfidenceorshoulderstability, a stabilizing brace may be considered for return to activity, but is most commonly used only for collision sports

Abbreviations: Abd, abduction; ADL, activities of daily living; AFE, active forward elevation; EMG, electromyography; NPRS, numeric pain rating scale; PER, passive external rotation; PFE, passive forward elevation; POW, postoperative week; ROM, range of motion; WNL, within normal limits.

DOWNLOAD PowerPoint Slides of JOSPT Figures & Tables

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