PHYSICAL THERAPY GUIDELINES FOR POST-OPERATIVE REHABILITATION OF

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					PHYSICAL THERAPY GUIDELINES FOR POST-OPERATIVE REHABILITATION OF BANKART PROCEDURES
GENERAL GOALS:
• • Protect surgical repair Promote glenohumeral joint mobility to maximize functional usage of the arm Educate patient in surgical procedure performed by physician, healing time and progression to prior level of activity

GENERAL INFORMATION:
In general arthroscopic or open Bankart repairs are designed to stabilize the shoulder joint by repairing an unstable labrum back to the glenoid, and repairing any associated capsular or bone injury. Typically patients with arthroscopic procedures have an easier time obtaining P/AAROM than comparable open surgeries without long-term loss of range of motion. If an open procedure was required, caution should be taken to protect the subscapularis muscle, which is often reflected to access the anterior aspect of the joint, and repaired following the Bankart procedure. Excessive stress to the subscapularis with early aggressive external rotation stretching and early resisted internal rotation can lead to tendon rupture following an open Bankart procedure. Specific rehabilitation interventions are usually performed by phase. Phases help define particular stressors the healing tissues may endure to minimize impairments and optimize healing. Most importantly it is important to recognize that progress will vary between individual patients and that a gradual return of mobility / motion is optimal. It has been suggested that immediate ROM and/or gaining P/AAROM too quickly may lead to an increased failure rate. Prospective studies have demonstrated good to excellent outcomes in patients following either open or arthroscopic bankart repairs, with return to sports typically within a 4-6 month timeframes. Throwing, overhead, contact sports or activities require clearance from your surgeon before initiating these activities.

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GENERAL INTERVENTION:
• • • Physical Therapy is usually initiated between two and four weeks following surgery. As in all rehabilitation, there is a strong emphasis on a home exercise regimen to be done daily by the patient in addition to attending formal physical therapy rehabilitation sessions. Patients are usually immobilized in a sling for four to six weeks, which is dictated by the surgeon. The focus of physical therapy is to protect the repaired tissues but to allow for joint mobility without excessively stressing the repair. Strength is not a consideration in therapy until there is good soft tissue healing of the repair and range of motion is adequate. Intervention should not be forceful or painful. In general, physical therapy intervention is guided by: a. Pain b. Extent and stability of repaired tissues c. Degree of joint stiffness d. Associated medical conditions e. Patient’s functional goals

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SPECIFIC INTERVENTION:
The rehabilitation process is generally divided into three basic phases based on tissue healing timeframes: PHASE I: Protected PROM phase PHASE II: AAROM/ AROM/ neuromuscular re-education PHASE III: Initial strengthening and functional integration

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PHASE I:
• • PROTECTED P/AAROM Initiated between post operative week 2 to week 6 as directed by surgeon**
**Most patients are instructed by surgeon to utilize a sling for four to six weeks. Clearance to discharge use of sling should be obtained by the surgeon.

SPECIFIC GOALS:
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Increase joint mobility without stressing the repair ROM: flexion < 140 degrees; ER < 30 degrees ACHIEVED GRADUALLY, abduction in scapular plane < 60 degrees

SPECIFIC PRECAUTIONS:
Gradual ROM improvements should be anticipated in this phase. No forceful stretching or mobilizations should be performed. Forceful stretching in abduction and combined abduction and external rotation are also avoided in this phase.

PATIENT EDUCATION
• • Explain to the patient the nature of their surgery and stress the specific precautions of their surgery Discuss that advancement is really dependant upon their physician’s guidelines. This particularly includes lifting activities and lateral overhead reaching activities. Outline the treatment plan, goals, and expected functional outcome Emphasize the need to be an active participant in the rehabilitation process. Instruct patient in home exercise regimen appropriate for their condition. It will be important to review this home program and the precautions at each visit. Instruct patient in edema and pain control measures i.e. sleeping in sling and propped in GH loose pack position. • •

JOINT MOBILITY & ROM
As directed by surgeon exercises usually begin with the pendulum exercises and can be initiated immediately post-operatively. Active-assistive range of motion in supine/sitting can be safely done in sagittal plane as comfort allows. The patient is instructed in how to utilize the other arm for guidance and support and how to isolate glenohumeral motion. The physician usually determines the amount of lateral rotation that is safe. In the first six weeks, unless instructed otherwise it is best to restrict ER to 30 degrees, and done with the arm at side not in ABD Limitations of the periscapular muscle length and trunk mobility should be addressed early in the intervention process. Frequency and intensity of exercises may be reduced if ROM returns too rapidly (as % of other side)

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NEUROMUSCULAR CONTROL
• • • Encourage good postural alignment and a normal resting position of the scapula Improving motor control is not a part of intervention in this phase Core/ Trunk Stabilization can be initiated

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PHASE II:
• • Initiated between post-operative weeks 4 – 6 as directed by the surgeon AAROM/AROM

SPECIFIC GOALS:
• • Restore glenohumeral mobility in all planes (80% PROM) and combined motions of the shoulder Improve active motor control with normal scapulohumeral rhythm

SPECIFIC PRECAUTIONS:
• • • • No forced stretching in combined external rotation with abduction of the arm at 90 degrees No lifting greater than 10lbs or vigorous ADLs that require forceful use of the involved extremity With open Bankart procedures (not arthroscopic) strengthening subscapularis is contraindicated until 12 weeks unless otherwise noted by surgeon Do not initiate strengthening exercises unless specifically directed by the surgeon

PATIENT EDUCATION
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JOINT MOBILITY
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Encourage gradual use of upper extremity with unweighted ADL’s in pain-free range Continued HEP instruction and regular review to ensure proper compliance

Less than or equal to 80% glenohumeral mobility and gentle stretching of ER with abduction is permitted to allow progress to prior activity. Slow return to activity functionally utilizing the arm in multiple planes is encouraged. Pool can be used for gravity

NEUROMUSCULAR CONTROL
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Improvement of scapulohumeral rhythm via initiation of AA/AROM exercises Balance drills for athletes should begin

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PHASE III:
• • STRENGTHENING/ENDURANCE Initiate at post op week 8-12 as directed by the surgeon

SPECIFIC GOALS:
• • • • Continued restoration of glenohumeral mobility Restore full functional use of the upper extremity for normal activities of daily living Maximize strength and endurance emphasizing the rotator cuff and progressing to scapular stabilizers and trunk Achieve full range of motion with yielding end feels in this phase of rehabilitation

SPECIFIC PRECAUTIONS: •
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Gradual progression of theraband rotator cuff emphasis progressing to weighted activities and weighted exercises in positions that stretch the repair (abduction, lateral rotation, horizontal abduction) No deep wide hand position bench press, tricep dips and deep chest flies
No plyometrics with arm away from side until patient cleared by surgeon

JOINT MOBILITY & ROM
• Normalize end range glenohumeral joint mobility to allow full return to prior activity •
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NEUROMUSCULAR CONTROL
Normalize scapulohumeral rhythm, with AROM throughout functional ranges Initiate functional patterns to prepare for return to recreational activities Balance and core exercises continue for athletic patients

STRENGTHENING PROGRAM
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PATIENT EDUCATION
• Education as to avoiding weight lifting in extension or behind frontal plane (no deep bench press, dips) Emphasis on physician’s guidelines for timeframes as to return to occupational, sports, and recreational activities and timelines for heavy lifting, throwing and contact sports. Usually full return to above activities occurs four to six months post surgery.

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Educate patient in home exercise program to improve strength and endurance of rotator cuff and periscapular musculature Initiate sport-activity specific training once cleared by surgeon Educate patient in continued modifications to weight lifting regimen and daily activities to minimize excessive anterior joint stressors (i.e. deep bench press, deep chest fly or tricep dips behind body) Strengthening can be accomplished with combination of theraband and free weights, working both concentric and eccentric progressing to scapular stabilizers and dynamic trunk/ core stabilizers

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