This document discusses the rehabilitation approach for patients following shoulder instability surgery. It focuses on principles such as analgesia, quality range of motion, muscle control, timing, strength goals, and patient-specific rehabilitation. The approach emphasizes avoiding immobilization to prevent deconditioning while also protecting the surgical repair site. Exercises target the rotator cuff and scapular muscles as well as proprioception and the kinetic chain. The rehabilitation progresses from an initial protection phase using range of motion and proprioceptive exercises to a functional phase incorporating strengthening, sports-specific exercises, and plyometrics.

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