Shoulder rehabilitation - early phases

1. REHABILITATION
FOLLOWING INSTABILITY
SURGERY
Julia Walton &Tanya Mackenzie
Clinical Specialist Shoulder Physiotherapists

2. AIMS
• Our approach to rehabilitating patients following
instability surgery
• Rehab considerations through the phases

3. POST SURGERY REHAB SIMPLY......
• Immobilisation
• Range of Motion
• Strengthening
• Return to ADLs

4. REHABILITATION PRINCIPLES
Analgesia/Education
Quality ROM
Muscle
Timing
Strength
Patient
Specific
Goal
Control

5. REHABILITATION PRINCIPLES
Analgesia/Education
Quality ROM
Muscle
Timing
Strength
Patient
Specific
Goal
Control
Avoid Deconditioning

6. REHABILITATION PRINCIPLES
Analgesia/Education
Quality ROM
Muscle
Timing
Strength
Patient
Specific
Goal
Control
Avoid Deconditioning

7. REHABILITATION REGIMES
Slow
Accelerated

8. ACCELERATED REHAB
• Higher patient satisfaction
• Lower post operative pain
• Earlier return to function
Slow Kim et al 2003
But…….

9. REHABILITATION
• ac·cel·er·ate
1. to cause faster or greater activity, development, progress, advancement, etc., in: to
accelerate economic growth.
2. to hasten the occurrence of: to accelerate the fall of a government.
3. Mechanics . to change the velocity of (a body) or the rate of (motion); cause to
undergo acceleration.
4.to reduce the time required for (a course of study) by intensifying the work,
eliminating detail, etc.

10. REHABILITATION
• What We Do...
• EARLY
• CONTROLLED
• SAFE
• HOLISTIC

11. PRE-SURGERY
• Get started!
• Patient assessment
• Global conditioning/fitness
• Education
• Familiarisation of post op rehabilitation

12. POST-SURGERY
• Operation Note
• Immediately Available
• Repair Quality
• Associated Procedures /
Findings

13. SAFE ZONE
• ROM determined Peri-Op
• Doesn’t put strain on repair
• Gives Confidence - clinician & patient

14. THE SCIENCE...
• Strict immobilisation results in functional instability with
rotator cuff inhibition, muscular atrophy, and poor
neuromuscular control.
• Get the balance right!
Killian et al 2012

15. WHAT ARE WE PROTECTING?
• The repair itself
• Sub-optimal muscle performance
• Poor neuromuscular control

16. EXERCISE CHOICES
• Consider the of the value of exercises
• ROM
• Proprioception
• Core
• Kinetic Chain

17. SUPRASPINATUS EMG
Uhl T. Dept of Rehabilitation Sciences.
University of Kentucky, 2004
Exercise Mean % SD
Supine Passive ROM 1 6
Side-Lying Elevation 2 6
Prayer Position 2 2
Wash Cloth press-up hands close 3 7
Supine press-up 4 8
Scapular Protraction on Ball 5 9
Forward Bow (Pendular) 5 6
<10% - Trace activity/background noise, 10-20% - low activity

18. ANTERIOR INSTABILITY PROTOCOL
Day 1 - 3 weeks Protection Phase
• Sling for 3 weeks
• Teach axillary hygiene
• Teach postural awareness and scapular setting
• Core stability exercises as appropriate)
• proprioceptive exercises (minimal weightbearing below 90 degrees)
• Active assisted ROM as comfortable (in 'safe zone' )
• Do not force or stretch
• No combined abduction & external rotation
6 - 12 Weeks Progress to Functional Phase/End Stage
• Regain scapula & glenohumeral stability working for
shoulder joint control rather than range
• Gradually increase ROM
• Strengthen
• Increase proprioception through open & closed chain
exercise
• Progress core stability exercises
• Ensure and treat posterior tightness, if required
• Incorporate sports-specific rehabilitation
• Plyometrics and perturbation training
3 - 6 weeks Recovery Phase
• Wean off sling
• Progress active assisted to active ROM as comfortable
• open chain gh joint ROM with RC graded strengthening through
painfree ROM
• Do not force or stretch
• No combined abduction & external rotation

19. PROTECTION PHASE
• Safe zone ROM
• Proprioception
• Re-enforcing good motor programming
• Kinetic chain involvement

20. THE BIGGER PICTURE…
•50% power from tennis serve is
generated from Lower quadrant
•Shoulder acts as a funnel to
transfer energy
•Posterior oblique sling
Kibler 1995

21. WHAT DO WE NEED FOR SUCCESS?
• Optimal biomechanics
• Flexibility
• Proprioception
• Strength
• Endurance
• Integrated into technique reproducible/learnt
Sciascia & Cromwell (2013)
Throughout
the kinetic chain

22. IF NOT…….
•Leads to increase in load/stress at the Shoulder
•Resulting in dysfunction and injury

23. KINETIC CHAIN CONSIDERATIONS
• A step increases scapulothoracic recruitment by 10%
• Rotator cuff strength improves by 24% when scapula is
retracted/stabilised
Tate et al 2008
Kibler et al 2006

24. KINETIC CHAIN CONSIDERATIONS
• Hip stiffness or weakness found in 49% of post/superior
labral tears
Sciascia et al 2012