Total Shoulder Replacement Physiotherapy Protocol by jjzN44


									Arthroscopic Rotator Cuff Repair Physiotherapy

                          Rotator Cuff Repairs

Please note that the following protocol applies to rotator cuff repairs
which have been performed arthroscopically. For the appropriate
rehabilitation after open repairs please see the relevant protocol.
Regaining full movement of the shoulder as rapidly as possible is the top
priority in the rehabilitation programme after surgery. There may need to be
restrictions on certain movements for up to six weeks but in general terms it is
a mistake not to get early movement, both because it is very difficult to get it
later and because it actually results in less pain. The second priority is to
regain scapula control and normal glenohumeral rhythm. Restoring strength is
also important, but is a low priority in the early stages of rehabilitation.
The size of the rotator cuff tear and the strength of the repair of the tendon
back to the bone (greater tuberosity) vary from patient to patient. In small
tears full active movement may be possible at four weeks, but in larger tears it
may take up to six weeks before it safe to allow active movement. In the larger
tears the repair is likely to be under stress in positions of extension and
external rotation beyond neutral.
The movement of abduction is not particularly important because the most
functional movements rely on forward flexion. Activities such as driving and
cleaning the teeth do require this movement but it is almost never necessary
to go over 90º for any functional movement. Although this movement does
need to be restored and requires active input from the therapist, it should not
be introduced before four weeks post rotator cuff repair. Active abduction
must be avoided for between four and six weeks (depending on the nature of
the tear) abduction over 90º. Regaining internal and external rotation is very
important and should be done as soon as it safe. The physiotherapy
programme will need to be individualised for each patient and the details of
the restrictions will be in the post-operative instructions. If you have not
received these please ring the secretary of Mr Gregg-Smith on 01761 422257
or Mr Jennings on 01761 422259.
Authors: Mr S J Gregg-Smith Consultant Orthopaedic and Trauma
Surgeon and Mr G Jennings Consultant Orthopaedic and Trauma
Surgeon. Produced Jan 2010.
Post-Op Physiotherapy for Arthroscopic Rotator Cuff Repairs

The guidelines that follow are a frame work of basic exercises that
should be carried out at each of the three different stages of the
rehabilitation programme based on the patient who has had a large cuff
tear repaired. Patients who have had a small tear or decompression
without a repair may be progressed much faster. The milestones may be
used to assess whether you feel the patient is making good progress or

Week 1-3 Treatment and advice:

      Patient education about the type of operation and how to control pain.
      Ensure adequate and efficient pain control.
      Passive flexion i.e. pendular (cradling technique) progressing to active
       assisted in standing, sitting or lying. Maximum of 60º -90º (dependant
       on size of tear).
      Passive external rotation in lying/sitting with a stick. Range of
       movement to neutral or as per post-op note.
      Correct scapulothoracic posture, neck and thoracic posture especially.
      Correct posture while sitting i.e. check arm position.
      Give sleeping position advice.
      Ice therapy if required.
      Once stitches have been removed begin scar massage.


Milestones at the end of the third week

      Passive flexion aim to 60º -90º (dependant on size of tear).
      Passive external rotation to neutral (or as per post-operative note) as
       pain allows.
      Good scapulothoracic control.

Authors: Mr S J Gregg-Smith Consultant Orthopaedic and Trauma
Surgeon and Mr G Jennings Consultant Orthopaedic and Trauma
Surgeon. Produced Jan 2010.
Weeks 4-6 Treatment and advice:

      Increase passive flexion, work towards 90º-120º (as per post-operative
      Begin active-assisted flexion, dependant on the degree of tear and pain
      Increase passive external rotation to 30º
      Normal glenohumeral rhythm and scapular mobility.
      Isometric exercises for the rotator cuff in neutral, e.g. infraspinatus and
       subscapularis but not supraspinatus i.e. no abduction (this depends on
       the repair and the notes must be reviewed).
      Passive abduction not above 90º (not before week four).

Milestones at the end of the sixth week

      Passive flexion 90-120º.
      Passive abduction to below 90º.
      Aim to have achieved passive external rotation to 30º.
      Good lower trapezius and correct scapulothoracic rhythm.

Week 7-12 Treatment and advice:

      Full active range of movement in all directions e.g. hydrotherapy, stick
       behind the back and towel exercises, end of range exercises including
       internal and external rotation.
      Increase strength in shoulder e.g. theraband exercises.
      Core stability work e.g. gym ball etc.
      Proprioceptive exercises e.g. using a stick, gym ball etc.

Milestones at the end of the twelfth week:

      Driving when comfortable (usually 6-8 weeks for the right and 8-10 for
       the left)
      Light work at six weeks (no lifting), medium work from 12 weeks
       onwards (light lifting below shoulder level), heavy work from 3-6
       months (above shoulder level).
      Most are comfortable between 6-12 weeks.

Authors: Mr S J Gregg-Smith Consultant Orthopaedic and Trauma
Surgeon and Mr G Jennings Consultant Orthopaedic and Trauma
Surgeon. Produced Jan 2010.

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