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.
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
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
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