UVA SPORTS MEDICINE - PDF Document

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  1. UVA SPORTS MEDICINE 515 Ray C. Hunt Drive, Suite 1100, Charlottesville, VA 22903 Phone: 434-243-7778 Fax: 434-243-5075 David R. Diduch M.D., Mark D. Miller M.D., Eric W. Carson M.D, Stephen F. Brockmeier M.D., F. Winston Gwathmey M.D. Jennifer Hart, PA-C, Cara Garrett, PA-C, Claire Denny, PA-C Post-operative Rehabilitation Protocol Shoulder Latarjet Procedure PHASE I (weeks 1-3) - Immediate post-op phase Goals: Minimize/control shoulder inflammation and pain Protection of surgical repair Gradual restoration of shoulder PROM Adequate scapular mobility and function Patient education/precautions: NO AROM of the operative shoulder No excessive shoulder external rotation ROM/stretching. STOP at first felt end feel. WEAR SLING AT ALL TIMES. Remove only for showering with arm at side. No lifting of objects with operative shoulder/arm. Limit use of operative upper extremity. Sleep with sling supporting operative shoulder (towel placed under elbow to prevent shoulder extension) Education regarding posture, joint protection, positioning, etc. Activity PROM/AAROM/AROM of elbow, wrist, and hand. Begin shoulder PROM (PT directed/administered) Forward flexion/elevation to tolerance Abduction in scapular plane to tolerance IR to 45 degrees at 30 degrees abduction ER in scapular plane from 0-25 degrees; begin at 30-45 degrees abduction. DO NOT FORCE ANY PAINFUL MOTION. RESPECT ANTERIOR CAPSULE INTEGRITY WITH ER. Scapular clock and isometric exercises. Ball squeezes Frequent ice/cryotherapy for pain and inflammation Criteria to progress to Phase II Patient adherence to precautions and immobilization guidelines 100 degrees of passive forward elevation and 30 degrees of passive ER at 20 degrees abduction. Completion of phase I activities with minimal to no pain or difficulty. Phase II (approximately weeks 4-9) - Intermediate Phase Goals for phase II Minimize/control pain and inflammatory response Protection of surgical repair/integrity Achieve restoration of AROM gradually Wean from sling in weeks 6-7. Initiate LIGHT waist level activities.

  2. Patient education/Precautions No active shoulder movement until adequate PROM with good mechanics No lifting with operative shoulder/upper extremity No excessive ER ROM/stretching. Respect anterior capsule integrity No activities/exercises that place excessive load on anterior shoulder (push-ups, pectoralis flys, etc.) Avoid exercises that involve “empty can” /IR position in scaption due to risk of impingement. Activity Early Phase II (approx. week 4) Progress shoulder PROM (do not force any painful motion) Forward flexion/elevation to tolerance Abduction in scapular plane to tolerance IR to 45 degrees at 30 degrees of abduction ER to 0-45 degrees at 30-40 degrees abduction Glenohumeral joint mobilizations as indicated when ROM significantly less than expected. Mobilization done in direction of limitation and discontinue once adequate ROM achieved Address scapulothoracic and trunk mobility limitations. Mobilizations done in direction of limitation and discontinued when ROM achieved Introduce posterior capsule stretching as indicated Continue ice/cyrotherapy for pain and inflammation Late Phase II (approx. week 6) Progress shoulder PROM (do not force any painful motion) Forward flexion/elevation/abduction in scapular plane to tolerance IR as tolerated at multiple angles of abduction ER to tolerance at multiple angles of abduction ONCE ACHIEVE 35 DEGREES ER AT 0-40 DEGREES OF ABDUCTION. Glenohumeral and scapulothoracic joint mobilizations as indicated Progress to AAROM/AROM activities of shoulder as tolerated with good mechanics (minimal to no scapulothoracic substitution with up to 90-110 degrees of elevation) Begin rhythmic stabilization drills (IR/ER in scapular plane, flexion/extension and abduction/adduction at varying angles of shoulder elevation) Continue AROM elbow, wrist, and hand Strengthen scapular retractors and upward rotators Initiate balanced AROM/strengthening program Low dynamic positions initially Muscular endurance with high repetition (30-50), low resistance (1-3 lbs) Exercises should be progressive in terms of muscle demand/intensity, shoulder elevation, and stress on anterior joint capsule Achieve full elevation in scapular plane before beginning elevation in other planes All activities should be pain free and without substitution patterns Exercises both open and closed-chain No heavy lifting or plyometrics at this time Initiate “full can” scapular plane to 90 degrees elevation with good mechanics Initiate IR/ER strengthening with tubing at 0 degrees of abduction Sidelying ER with towel roll 2 Page

  3. Manual resistance ER in scapular plane in supine position Prone scapular exercise (30/45/90 degrees abduction) in neutral arm position Criteria to progress to phase III Forward elevation PROM at least 155 degrees and AROM 145 degrees with good mechanics ER PROM within 8-10 degrees of contralateral side at 20 degrees abduction ER PROM at least 75 degrees at 90 degrees abduction Appropriate scapular posture at rest and dynamic scapular control with ROM and functional activities. Completion of phase II activities with minimal to no pain or difficulty. PHASE III (approximately weeks 10-15) Goals Normalize strength, endurance, and neuromuscular control Return to chest level functional activities Gradual and planned progression of anterior joint capsule stress Precautions No aggressive overhead activities/strengthening that overstress anterior joint capsule Avoid contact sports/activities No strengthening or functional activities in any plane until near full ROM and strength in that plane of movement Patient education regarding gradual increase of shoulder activities Activities Continue AROM and PROM as needed/indicated Initiate biceps strengthening with light resistance, progress as tolerated Gradual progression of pectoralis major/minor (avoid positions of excessive stress to anterior joint capsule) Subscapularis strength progression (push-up plus, cross body diagonals, forward punch, IR resistance band at 0/45/90 degrees abduction, etc) Criteria to progress to phase IV PROM forward elevation within normal limits PROM ER at all angle at all angles of shoulder abduction within normal limits AROM forward elevation within normal limits with good mechanics Good rotator cuff and scapular muscular performance for chest level activities Completion of phase III activities with minimal to no pain or difficulty Phase IV (approx. weeks 16-20) Overhead activities/return to activities phase Goals Stretching and PROM as needed/indicated Maintain full non-painful AROM Return to full work activities Return to full recreational activities Precautions Excessive anterior joint capsule stress Avoidance of “triceps dips, wide grip bench press, military press, or lat pulls behind head. Always “see your elbows” when weight lifting. No throwing or overhead athletic moves until 4 months post-op or cleared by MD. Activity Continue all exercises from phase III 3 Page

  4. Overhead strengthening if ROM and strength below 90 degrees elevation is good Shoulder stretching/strengthening at least 4 x a week Return to upper extremity weight lifting program with emphasis on larger, primary upper extremity muscles (deltoids, latissimus dorsi, pectoralis major) Push-ups with elbows not flexing past 90 degrees Plyometrics/interval sports program if appropriate/cleared by PT and MD May initiate pre injury level activities/vigorous sports if appropriate/cleared by MD 4 Page