Return to Sport Protocol Following Shoulder …...(860) 549-8210 • oahct.com Return to Sport...
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(860) 549-8210 • oahct.com Return to Sport Protocol Following Shoulder Capsulolabral Repair With and Without Bankart Lesion Immediately Post-OP: - Sling up to 7 days: If patient is deemed eligible for accelerated protocol: D/C of sling 3 days only, then sling is only worn for sleeping and in public for 1-2 weeks if patient is not confident or pain persists. Ensure proper fit of sling - Patient given Home Exercise Program before leaving recovery with instructions on Care and Exercises until patient is first seen in for Physical Therapy (See Attached HEP/Care Instruction Sheet) o Cryotherapy to control pain and swelling o Pendulums o Ball Squeezes o Wrist and Elbow Flexion and Extension movements o Picture of ADL’S under surgically repaired arm Phase I: Protection/ ROM Phase: (Approximately weeks 1-6) Goals: 1- To protect the surgical repair (labrum, capsule, ligaments, etc) 2- Follow Staged ROM Goals to ensure adequate progression, within protection parameters 3- Minimize pain and Inflammation 4- Initiate/ ensure scapular functioning 5- Prevent muscular inhibition 6- Educate patient on post-op precautions and limitations, progression of activities/movements, & teach patient their Home Exercise Program 7- Begin to restore strengthening with isometric exercises 8- Patient fills out initial ASES, DASH, and/or WOSI evaluation forms Interventions to Avoid/ Precautions: 1- Passive home exercises are limited to Passive Forward Elevation and Passive External Rotation, as well as, AAROM & AFE, following Staged ROM Goals 2- Patient should not force or perform ROM/stretching exercises to the point of greatly exceeding Staged ROM Goals (especially ER in both ROM’s of Abduction) 3- Patient should not perform IR behind there back, Horizontal Adduction, active reaching/activities outside the Staged ROM Goals, reaching overhead, or heavy lifting with the surgically repaired arm. 4- No supporting patient’s body weight with the hand of the surgically repaired shoulder 5- Avoid sleeping of the affected shoulder Staged ROM Goals: Post-Op Week Range Of Motion (ROM) POW 1-3: PROM: - PFE: 125°, - PER: (@20°-30° Abd): 10°-40°, - IR (scapular plane): 45°, AAROM: once PFE to 110° is met without increased pain - AAFE: limit to tolerance *No Horizontal Add or IR behind the back POW 4-6: PROM: - PFE: 145°- 160°, - PER (@20°-30° Abd): 40°-50°,
Transcript of Return to Sport Protocol Following Shoulder …...(860) 549-8210 • oahct.com Return to Sport...
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ReturntoSportProtocolFollowingShoulderCapsulolabralRepairWithandWithoutBankartLesion
ImmediatelyPost-OP:- Slingupto7days:Ifpatientisdeemedeligibleforacceleratedprotocol:D/Cofsling3daysonly,thenslingisonly
wornforsleepingandinpublicfor1-2weeksifpatientisnotconfidentorpainpersists.Ensureproperfitofsling- PatientgivenHomeExerciseProgrambeforeleavingrecoverywithinstructionsonCareandExercisesuntilpatientis
firstseeninforPhysicalTherapy(SeeAttachedHEP/CareInstructionSheet)o Cryotherapytocontrolpainandswellingo Pendulumso BallSqueezeso WristandElbowFlexionandExtensionmovementso PictureofADL’Sundersurgicallyrepairedarm
PhaseI:Protection/ROMPhase:(Approximatelyweeks1-6)Goals:
1- Toprotectthesurgicalrepair(labrum,capsule,ligaments,etc)2- FollowStagedROMGoalstoensureadequateprogression,withinprotectionparameters3- MinimizepainandInflammation4- Initiate/ensurescapularfunctioning5- Preventmuscularinhibition6- Educatepatientonpost-opprecautionsandlimitations,progressionofactivities/movements,&teachpatienttheir
HomeExerciseProgram7- Begintorestorestrengtheningwithisometricexercises8- PatientfillsoutinitialASES,DASH,and/orWOSIevaluationforms
InterventionstoAvoid/Precautions:
1- PassivehomeexercisesarelimitedtoPassiveForwardElevationandPassiveExternalRotation,aswellas,AAROM&AFE,followingStagedROMGoals
2- PatientshouldnotforceorperformROM/stretchingexercisestothepointofgreatlyexceedingStagedROMGoals(especiallyERinbothROM’sofAbduction)
3- PatientshouldnotperformIRbehindthereback,HorizontalAdduction,activereaching/activitiesoutsidetheStagedROMGoals,reachingoverhead,orheavyliftingwiththesurgicallyrepairedarm.
4- Nosupportingpatient’sbodyweightwiththehandofthesurgicallyrepairedshoulder5- Avoidsleepingoftheaffectedshoulder
StagedROMGoals:Post-OpWeek RangeOfMotion(ROM)POW1-3: PROM:
-PFE:125°,-PER:(@20°-30°Abd):10°-40°,-IR(scapularplane):45°,AAROM:oncePFEto110°ismetwithoutincreasedpain-AAFE:limittotolerance*NoHorizontalAddorIRbehindtheback
POW4-6: PROM:-PFE:145°-160°,-PER(@20°-30°Abd):40°-50°,
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-PER(@90°Abd):45°,-IR(scapularplane):slowlyprogress,-Abd:limitto90°,AROM:-AFE:115°
POW7-8: PROM:-PFE:160°-WNL,-PER:(@20°-30°Abd):60°-80°,-PER(@90°Abd):60°,-IR(scapularplane):60°,-Abd:slowlyprogressastolerated,AROM:-AFE:155°,-Abd:slowlyprogressastolerated,-AIR+AER:slowlyprogressastolerated
POW9-12: ROM:-PER+AER(@20°-30°Abd):80°-90°(byweek12),-PER+AER(@90°Abd):75°-90°(byweek12,110°-115°ifpatientisa
throwingathlete),-P+AIR(@90°Abd):30°-65°(byweek12),-AFE:mustbe180°/WNL(byweek12),-P+AAbd:mustbe180°/WNL(byweek12)
Key: POW=Post-OperativeWeek,PFE=PassiveForwardElevation,PER=PassiveExternalRotation,AFE=ActiveForwardElevation,AIR+AER=ActiveInternalandExternalRotation
SpecificInterventions:PatientEducation:
1- Explainthenature/answeranyquestionaboutthesurgicalprocedure2- Patientshouldbeeducatedonallprecautionsandlimitationstoprotecttherepairandensure/encourageproper
healingofrepairedtissues3- Instructpatientonproperslingusage4- Educatepatientonminimaluseofsurgicallyrepairedarm,atwaist-level,forlightADL’s,andworkascomfortable-
Ensurepatient’spainleveldoesnotincreasewhileperformingtheseactivities=excessiveuseofthearmModalities:PRN:
-Cryotherapy(icepacks,icemassage):tocontrolpainandinflammation-ScarMobilization-Kinesiotaping(basketweave):todecreaseswellingandeccymosisifpresent
Exercises:(SeeattachedSpecificExerciseSheets)
1- Pendulums-initially1-3weeks2- ElbowandWristROMexercises-Noweights3- BallSqueezes&Deltoidisometricexercise(patientsqueezestheballandsimultaneouslyflexeselbow,thisisheldfor
2-3seconds,thenpatientreleasestheballsqueezeastheslowlylowertheirforearm,andrepeatsfor10repetitions)4- StandingScapularMobility:a) Alternatingelevation,depression,protraction,retraction(noresistanceinitially)inoroutofslingb) *ClinicianmaybeginSide-LyingscapularandshoulderRhythmicStabilizationexercisesaroundweek2,as
tolerated*
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5- CliniciandrivenPassiveROMstretches/exercises:withForwardElevation,ER(@20°-30°Abd),IR(planeofscapula),followingStagedROMGoals.ROMshouldneverbeforcedinthisphase.c) Also,SC&ACjointmobilization,thoracic,ribs,andcervicalmobility-passivestretchesandjointmobilization(P/A
Mobs,MET,Mulligan,etc.)6- PatientdrivenPassiveROMstretches/exercises:
d) Passiveexternalrotationwalkaroundexercise:Patientisstandingorsittingonrollingstoolwithforearmarmrestingontheendcornerofthetable,theyproceedtomovearoundthecornerofthetablesoastopassivelybringtheirarmintoER,leavingtheforearminthesamepositionuntilamildstretchandlittletonodiscomfortisfelt.Theyholdthispositionfor5-10seconds.Patientperforms5-10repetitions,2-3timesperday.
e) Passiveforwardflexiontableslides/tablestepbackexercises:Patientissittingonarollingstool,orstandingwiththeirhandsrestingonthetable.Patientthenrollsthestoolorstepsbackwardastheybendatthewaistleavingtheirhandsonthetable.Theyholdthispositionfor5-10seconds.Patientperforms5-10repetitions,2-3timesperday.
1. *OncethepatientisabletoperformPFEto110°,withoutincreasedpain,patientisallowedtobeginsupineAAROMwithcane/pulley/otherUEassist
2. Side-lying(gravityeliminated)AFEprogresstoStagedROMGoalastolerated,sidingonatable/board3. Standingslidingupaninclineboardatvaryingheight4. ProgresssupinefromAA-AROMnoresistancetoStagedROMGoals
f) Cervicalmodifiedstretches(don’tinvolvesurgicallyrepairedUEoverhead),&thoracicmobilitystretches7- Sub-maximalshoulderisometrics:IRandER(beginweek2-3)8- ScapularClockExercises:(aroundpost-opweek2-3)SeedescriptioninSpecificSuggestedExercises9- Stationarybike,Walking:(notonatreadmill)withtheirslinginitially,forcardiovascularconditioning,LE
strengtheningexercises-nojumping10- AquaticTherapy:Gentlepain-freeAAROM(noswimmingstrokes),oncetheincisionhashealedcanbeinitiated
CriteriatoProgresstoPhaseII:1- Score>/=MDContheASES(9.4),DASH(10.5),&/orWOSI(339.3)2- ReachedStagedROMGoalsforPOW4-63- MinimaltonopainwithallpassiveROMandcurrentexercises4- Nopersistenceofswelling/inflammation5- Noapprehensionorimpingementsigns
PhaseII:StrengtheningPhase:(ApproximatelyWeeks6-12)Goals:
1- FollowweeklystagedROMGoals,however,restoreactiveandpassivenormalROMandGlenohumeraljointarthrokinematicsinallcardinalplanesbytheendofthisphase
2- -Minimizeshoulderpain,ifpresent3- Addressanyabnormalscapularalignment/mobility,anddemonstraterotatorcuffandscapularneuromuscular
controlwithintheweeklyallowedROMwithexercises4- Begintoincreaseshoulder,scapular,&corestrengthandendurance5- Improvedynamicstabilityoftheshoulderandscapula6- Increaseallowedfunctionalactivities7- Progressexerciseendurance,difficulty,andaddlight-moderateresistance8- GetabaselineSFMAandY-Balance(LEonly)assessmentscore(at9weekspost-op)
InterventionstoAvoid/Precautions:
1- DoNotExceedStagedROMGoals,unlessMDallows2- AvoidextremeendrangeforcedstretchingintoERat30°orat90°ofAbduction3- Patientcontinuestoberestrictedfromheavyliftingwiththesurgicallyrepairarm.4- Avoidliftingintostrictlyabductionorstraightcoronalplane5- Avoidpositions/exercisesofstressedhorizontalAbductionorcombinedwithER(push-ups,benchpress,pectoral
flys)6- DonotperformexercisesofscapularplaneIRsuchasthe“EmptyCan”exercise2°possibleimpingementatany
phaseofrehabilitation7- Noheavyliftingorplyometricsshouldbeperformedinthisphase
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SpecificInterventions:PatientEducation:
1- EducatepatientonallPrecautionsandLimitationswithinthisphaseofrehabilitation2- Postureawarenessandscapularpositionneedstobeemphasizeswithpatients3- PatientshouldbeinstructedthattheymayusetheirUEforADL’sonlythroughpain-freeROM4- PatientshouldbeeducatedtoavoidimpingementandendrangepositionsofERandcombinedAbductionwithER
ModalitiesPRN:1- Cryotherapy,moisthotpacks,taping,etc
Exercises:(SeeattachedSpecificExercisesSheets):
1- Continueanyexercisesfromthepreviousphaseforimpairmentsthatstillpersista) Ensureadequatescapulothoracic,trunk,andcervicalmobilityisachieved/maintainedb) Openandclose-chainexercisesmaybeperformed(weight-bearingandnon-weight-bearing)c) Allexercisesshouldbepain-freeandperformedwithoutanysubstitutionsoralteredmovements
2- Stretches&ROM:a) HorizontalAdduction/CrossArmStretch,andStarryNightStretch(unilateralorbilateral)stretchesmaybebegunb) Towel/strap/pulleystretchbehindthebackcanbebegunbetween7-8weeksc) DynamicStretches:SeeSheets(Injuryprevention->Sport&AdvancedPerformance)d) ProgressAROMforforwardelevation
i. Horizontalforwarddustingonthetable:straightinfrontand/or20°mediallyorlaterallyii. ProgressinclineUEslidingatvariousanglesprogressingallthewayupverticaltowardtheceilingiii. ProgresssupineAFEtoholdingasmall1-2poundweightiv. ResistanceBand:oppositehandholdingyellowresistancebandreachinginitiallyto90°progressingtofull
AFEv. Side-lyingERwithsmallweightorlightresistancebandvi. AFEagainstgravity:shouldbeachievedintheplaneofthescapulabeforeprogressingtofullelevationin
otherplanesvii. WallslidesandOverheadWallTapsviii. WallSlidesforSerratusAnteriorActivation/strengthening:Patientfacesthewallwithastaggeredstance,
withthedominantfootagainstthebaseofthewall.Theulnarborderoftheirforearmsareagainstthewallandshouldersandelbowsat90°.Theshouldersareelevatedinthescapularplane,andpatientshouldbeinstructedtoleanintothewallasthearmsgohigher,transferringtheirweightfromthenon-dominantbackfoottotheforwardfoot.Theathleteshouldalsobegivenverbalcuesof“bringyourshoulderbladesoutandaroundasyouslideupthewall”topromotenormalscapularmovement.Theyshouldalsobeinstructednottoallowshouldshruggingtooccur.
e) Progressive,Core,Scapular&NeuromuscularStrengtheningexercises:i. Closed-chainexercisesmaybebegun:Quadrupedinitiallyteachingpatienttomaintain/stabilizescapularand
shoulderposition,thenprogressingtoweightshifts->scapularprotractions->UEreachingexercises->planks(Proneandside-lying)->wallpush-ups->wallpush-upsPlus*(NoPush-Upsonthefloor)1. Quadruped->Tripod->Two-Point(contralateralandipsilateral)positionprogression2. Otheralternativeareusingaphysioball,orsuspensiontrainingsystem,suchasTRXÔsystem
ii. Progressfunctionalmovementandpatterns:1. Exercisestoimproverotatorcuffandshouldergirdleneuromuscular,progressingwithunstable
surfaces,manualresistance,bodybladeÒ,PNFpatterns,etciii. CoreExercisescanbeinitiatedtoaddressanylimitations:
1. Halfkneeling->doublekneelingpositions,onstableandunstablesurfaces,holdingarmsextendedwith/withoutsmallweightormedicineball,with/withoutexternalperturbations.Progressaspatienttolerates
2. LEcoreexercises:LEPilatesstyleexercises(supine,side-lying,prone)f) Strengthening/EnduranceExercises:Itisimportanttoperformsomescapularstrengtheningexercisesbilaterallyto
preventpoorpostureandscapularasymmetriesi. RotatorCuffStrengthening:toensureproperpositioningofthehumeralheadintheglenoidfossa,aswell
as,abilitytoperformprogressivelydifficultfunctionalandathleticmovementswithoutriskofre-injuryorimpingement
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ii. Progressivelight-moderateresistanceband(beginwithyellowandprogressastolerated)ordumbbellexercisesforIR,ER,Forwardreaching,scapularretraction(theseexercisesareperformedbelowshoulderlevelandfocusonmaintainingscapularposition/stabilizationandgoodposturethroughouttheexercises,thencanbeprogressedtoshoulderheight,90/90position,andfinallyoverhead)1. Highrepetitions:progressto30-60repetitions2. Emphasisshouldbeonscapularretraction,upwardrotationandposteriortilt3. Aspatientprogressesinthemidtolaterstagesofthisphase,exercisescanbeprogressedtoinclude:
a. SittingorstandingresistancebandERat45°ofAbductionb. ProneHorizontalAbduction,ER,andRows
4. Resistancescanbeincreasedtotolerances,speedofmovements,andmulti-directionalmovementscanbegraduallyprogressed(withabilitytomaintainscapularstabilization)
iii. ElbowFlexion/Extension(Biceps&Triceps)strengtheningmaybeinitiatedinthisphasewiththearmbythepatient’sside(armadducted)bicepcurls,andTricepspull-downsandkickbacks
iv. Throwers’TenProgrammaybebegunaroundpost-opweek10,whenableprogresstoAdvancedThrower’sTenProgram(seeattachedsheets)
v. Enduranceexercisesshouldcontinue:Stationarybicycle,Elliptical,Treadmillwalking(runningmaybebegunat9weekspost-op)
vi. Aquatictherapy:maybeprogressedAAROM,AROM,Lightstrengtheninginitially,thenprogressedtoincludelightbreaststrokingatapproximately9weekspost-op
vii. IntervalGolfprogression:Patientmaybeginlightchippingandputtingatapproximately9weekspost-op,progressingtohalfswingsby12weekspost-op(seeattachedsheet)
CriteriatoprogresstoPhaseIII:
1- MinimaltonopainwithROM,Strength,andfunctionalexercises2- AchieveFullROMGoalswithoutpainorsubstitutions3- Demonstrateproperscapularposition/controlatrestandwithalldynamicactivities/exercises4- Strengthtestingof70-80%ofthecontralateral/uninvolvedside5- PatientdemonstratesdecreaseinthemajordysfunctionsontheSFMA,andnoasymmetriesontheY-Balance(LE)
assessment6- Improveswith>/=MDContheDASH,ASES,&/orWOSIoutcomeforms
PhaseIII:AdvancedPhase:(ApproximatelyWeeks12-24):Goals:
1- Tonormalizeshoulderstrength,endurance,neuromuscularcontrol,andbeginexercisestoimprovepower2- GraduallyreturntoallADL’s,work,fitness/recreationalactivities(notreturntosport,however,discussplan)3- AdministertheDASHsports/artsmodule4- Beginmoresportskilltraining5- Beginplyometrictraining(phasesI-II,&possiblyIIIifpatientcanprogresstothatlevelinthistimeframe)6- GetbaselineFMSandY-balanceUEassessmentscores/orCKCUTESTiftheY-balanceassessmenttoolisnotavailable
InterventionstoAvoid/Precautions:1- Donotprogressadvancedrehabilitationexercises(suchasplyometricsorsportskilltraining)untilthepatienthasfull
ROMandStrength,andcanperformthemwithoutincreasedsymptoms2- Donotperformweightliftingexercisesthatputexcessivestressontheanteriorshouldercapsule,suchastricepdips,
orlatissimuspull-downsandmilitarypressexercisesbehindtheheada. Graduallyincreasethestressontheanteriorshouldercapsuleinanappropriatemannerwithotherexercises
SpecificInterventions:
Modalities:PRNExercises:(SeealsoattachedSpecificExercisesSheets)
1- Continueanyexercisesfromthepreviousphaseforimpairmentsthatstillpersist2- Stretches&ROM:a. ContinuestretchesandROMexercisesofpersistentrestrictionandtomaintainROMb. ContinueDynamicStretchespre-training,ProgresstoSportSpecificDynamicStretches
3- Strength/Endurance/Powerexercises:
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a. Progressstrengthening,neuromuscularcontrolandenduranceexercisesfrompreviousphaseb. Normalizecoreandscapularstabilizationc. Progressshoulderstrengtheningfromthepreviousphasewithemphasisonhigh-speed,multi-planar,entirekinetic
chainmovementsi. Patientcanuseresistancebandstosimulatebatting,oragolfortennisswing(forehandsandbackhands)
d. Advancedweightliftingprogramtoimprovelargeprimemovermuscleslikethedeltoid,latissimusdorsi,andpectoralismajor(mid-PhaseIII)
i. Beginwithlighterweightsathighrepetitionsandgraduallydecreaserepetitionsasyouincreasetheweightoverthenext10-12weeks
ii. Shouldershrugswithweightsiii. Latissimuspull-downsinfrontofthebodyiv. Inclinechestpressv. Shoulderlateral(abduction)raises:cable,dumbbell,bandsvi. PectoralisFlysvii. Rowswithshouldersabductedviii. Deadliftsix. Powercleansx. Inclinepush-ups,andpush-upsplus(withscapularprotraction,notshoulderelevation)
e. PlyometricPhaseI,IIandIIIprogressionmaybebeguninthisphasemeetingcriterialistedabove.Patientmaybegintheseprotocolsoncetherapistsisconfidentwithpatient’sstrength,endurance,andtimingwiththeexerciseslisteddirectlyabove(Seeattachedsheetsforprotocols)
i. Earlyintheprotocol,patientmaybeginwithatennisorbeachballandprogressiontoweightedballsii. Two-handed->one-handedthrows/tossesiii. OncePlyometricphasesI-IIarecompletedpatientmaybeginphaseIintervalsportprogramsforThrowing
andTennis
CriteriaforenteringReturntoSpecificSportProtocols:1- ClearancefromthesurgeontobegintheReturntoSportSpecificProtocol2- Nosignsofanylingeringshoulderinstabilitywithactivities3- RestorationorallROMneededtoparticipateindesiredsport4- Strengthtestingof>/=90%comparedtocontralateral/uninvolvedside5- Adequatestrengthandmuscleenduranceoftheshoulder,rotatorcuff,trunk,hip,andscapularmusculatureneeded
toperformsportspecificdrills/activitieswithminimaltonopainordifficulty6- PatientscoresanappropriatescoreontheDASH-Sports/PerformingArtsModuleSelf-assessmentoutcomeform:
(“no”–“mild”difficultyonallquestions),ASESand/orWOSI7- >14onFMSandscoreontheY-BalanceofequaltopeersforsportandagethroughtheY-Balancedatabase,or
CKCUTESTequaltonormative8- Nopainwithanyofthepreviousexercises/activitiesperformed9- CompletingtheThrowersTenProgram(ifanoverheadathlete)andtheupperextremityplyometricsprotocols10- Passingofthefunctionaltestslistedbelow:Testcanbeovermultiplesessionsa. TrunkTesting:(Seeattachedsheets)
i. DeepNeckFlexorTestii. SegmentalMultifidusTestiii. TrunkCurl-upTestiv. Double-LegLoweringTestv. ProneBridgeTestvi. EnduranceofLateralFlexors(SideBridge)vii. ExtensorDynamicEnduranceTest
b. UpperExtremityTesting:(Seeattachedsheets)i. AlternativePull-upTestii. Push-upTestiii. BackwardOverheadMedicineBallThrowTestiv. SidearmMedicineBallThrowTestv. SeatedShot-PutThrowTestvi. *Ifpatientisabaseballorsoft-ballpitcher/player
1. FunctionalThrowingPerformanceIndex(FTPI)Test-bestassessedwithvideoanalysis
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2. Baseballpitchersonly-PT/ATCfillsoutUpperExtremityThrowingAnalysisForm-todetermineareasofthethrowingmotionthatneedtobeaddressedinthesportspecific/returntobaseballpitchingprotocol
*SeeReturntoSpecificSportProtocol
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