Physiotherapy Protocols

Rehabilitation Guidelines: Latarjet Protocol

Mr. Hannan Mullett, Consultant Shoulder Surgeon

Latarjet (coracoid transfer) is a common stabilisation procedure particularly in the setting of significant bone damage. It offers a robust reconstruction, with low re-dislocation rates and fairly predictable return to play.

These guidelines are designed to aid the therapist treating the patient who had a Latarjet procedure.

Rehabilitation considerations

It will take approx. 6-8 weeks to form an osseous union of the newly reconstructed glenoid, the biceps and coracobrachialis attachment to the coracoid needs to be protected during this initial postoperative period. For this reason, shoulder extension and external rotation range of motion needs to be gradually regained in a protected fashion after surgery.

The subscapularis is split to expose the joint during the Latarjet procedure. This may result in muscle stiffness and inhibition of subscapularis. In the early phase gentle soft tissue massage and inhibitory techniques can be useful to minimise the impact of this. Once strengthening commences it is important to monitor and address any deficits in subscapularis strength.

Phase I (Weeks 0-4)

Goals:

• Protect the integrity of the surgical repair
• Minimise shoulder pain and inflammatory response
• Gradual restoration of passive range of motion
• Enhance scapular stability
• Improve proprioceptive acuity

Rehabilitation

• Sling to be worn generally apart from showering and rehab. If the arm is supported i.e. sitting on a couch or desk the arm can be gently used out of the sling. Arm below elbow can be used e.g. writing, using laptop/phone. Avoid excessive passive range of motion for first 10 days to avoid haematoma formation. Can wean out of sling after 3 weeks if comfortable
• Elbow/wrist/Hand range of motion and grip strengthening
• Begin shoulder passive range of motion; forward flexion to tolerance, abduction in the plane of the scapula to tolerance
• Avoid combined abduction / external rotation
• Avoid force end range mobilisation especially external rotation
• Closed kinetic chain / proprioceptive exercises
• Cuff facilitation exercises within range outlined
• Scapula mobilisation / facilitation exercises
• Kinetic chain exercises with arm in sling to include thoracic spine rotation
• Heat/Ice before and after PT sessions. Do not force painful motions

Phase II. (Weeks 4-10)

Goals

• Protect integrity of the surgical repair
• Minimise shoulder pain and inflammatory response
• Full functional range of motion
• Cuff recruitment and scapula control
• Wean out of sling
• Begin light active, waist level activities

Rehabilitation

• Discontinue sling immobilisation fully at 4 weeks if comfortable. (wean from 3 weeks)
• Therapeutic Exercise
• 4-6 weeks: Begin gentle AAROM exercises (supine position)
• 6-10 Weeks: Progress to active exercises using gravity as resistance, shoulder flexion from supine, with trunk flexed to 45° in upright position, to standing. Begin deltoid and biceps strengthening.
• Initiate balanced strengthening. Exercises should be progressive in terms of intensity, shoulder elevation and stress on anterior joint capsule
• Scapular stability; retractors and upward rotators
• Progress kinetic chain integration
• Isotonic ER / IR at 0 degrees of abduction and scapular plane
• Incorporate specific subscapularis re-education if required
• Rhythmical stabilization drills; ER / IR in scapular plane, Flexion / Extension and Abduction / adduction at various angles of elevation
• Modalities per PT discretion, gentle joint mobilisations (grades 1& II) if ROM is significantly less than expected.
• Do not lift objects overhead with the weight of the object going behind the head i.e. keep weight in view in front

Phase III – Strengthening (Weeks 10-16)

Goals

• Normalise strength, endurance, power and neuromuscular control
• Return to chest level full functional activities
• Gradual and planned progressive load to anterior joint capsule
• Restore optimum cuff and scapula control through range and under load

Rehabilitation

• Range of motion -progress to full AROM without discomfort
• Therapeutic Exercise
• Continue and progress with Phase II exercises
• Continue with scapular strengthening; PNF with light resistance, serratus punch plus, CKC push up plus (progress from wall, counter, knees on floor, floor)
• Preparatory and reactive stabilization drills in risk positions
• Function specific plyo-metrics

Phase IV Overhead activity / return to work and sport (Months 4-6)

Goals

• Regain full range of motion
• Return to full strenuous work and recreational activities

Rehabilitation

• Progress strengthening as tolerated through full range of motion
• Continue shoulder stretching and strengthening at least 4 times per week
• Weight training can gradually resume with caution especially with exercises such as wide grip bench press, triceps dips, pull-downs behind the neck where the arms are repeatedly placed behind patient. Be sure to always see your elbows.
• Review at 4 months check xray to check graft incorporation
• Return to sport at 4-6 months. May initiate interval programme if cleared by surgeon. Incorporate return to play / contact drills.
• If satisfactory progression most athletes return to play by 6 months

Post Operative Guidelines –

ACJ Stabilisation- Soft tissue Reconstruction using synthetic ligament

Mr.Hannan Mullett ,Consultant Shoulder Surgeon

This surgery is undertaken to stabilise a symptomatic unstable ACJ following injury. It is an open procedure and it is vital to protect the repair

Goals

• Protect surgical soft tissue repair.
• Avoid re-dislocation secondary to failure or stretching out of the synthetic device prior to adequate healing
• Gentle stretching and regaining range of motion.
• Gentle strengthening
• Return to sports

Phase I – Joint protection (0-6 weeks)

• Patients generally wear a sling for 3-week period followed by a further period of 3 weeks when patients wean out of sling but protect it against lifting etc.
• Regular cryotherapy
• Posture awareness and scapular setting.
• Patients can use the arm below the elbow e.g. using computer, reading immediately following surgery
• Active assisted flexion as comfortable.
• Active assisted ER to 30°
• Do not force or stretch

Phase II (6-12 weeks)

• Progress active assisted to active ROM. Gradually increase ROM but do not push overhead activities
• Glenohumeral stability; sub maximal isometrics rotator cuff in neutral
• Scapular stability; serratus anterior, upper and lower trapezius strength
• Proprioception through open and closed chain exercises
• Core stability

Phase III (12 weeks +)

• Progress strengthening. Isometrics in variable starting positions progressing to resisted through range strengthening
• Sport specific rehabilitation
• Plyometric and perturbation work

Functional Milestones

• Driving -depends on side and whether automatic generally after 4-6 weeks when patient has adequate control
• Swimming – 16 weeks
• Cycling – 8-12 weeks
• Golf – 16 -20. weeks
• Rugby – 4-6 months

Key Risks

• Risk of re-tear: Greatest in the first 12 weeks post-surgery. Higher risk in older patients, smokers, diabetics, those with minimal postoperative symptoms, and those with >3 cm tears.
• Risk of stiffness: Greatest in younger patients (<50 yrs.), those with PASTA type rotator cuff tears (Partial articular supraspinatus tension avulsion), those having an associated labral repair, and single tendon repairs.

Timescales are guidelines and depend on individual factors and pre-operative status. Factors that may affect progression rate:

• Pre-operative stiffness
• Age
• Tissue quality
• Associated procedures

Acute Phase (0–4 weeks)
Histology

• Peak collagen deposition and growth factors at 10 days post-op, plateau at 28–56 days.
• Requires gentle stress to guide fibre orientation but no strain.

Goals

1. Protect surgical repair and optimize tissue healing
2. Diminish pain and inflammation
3. Gentle regaining of range of motion, respecting pain and avoiding compensatory movement patterns
4. Minimise muscle inhibition

Immobilisation

• Sling worn for 2–4 weeks for comfort and to avoid stressing the repair.
• Sling removed for axillary hygiene and exercises.
• Arm can be used below the elbow (e.g. computer, reading).

Rehabilitation

• Avoid combined abduction/external rotation and forced end range stretches
• Cryotherapy as needed
• Elbow, wrist, and hand exercises
• Encourage use of hand in sling for light, unloaded, pain-free activities
• Closed kinetic chain exercises (e.g. table slides, walking away from table)
• Active assisted/active supported mobilization within pain limits
• Submaximal isometrics (<30% MVC) rotator cuff
• Active scapula exercises (e.g. shoulder shrug)

Intermediate Phase (4–8 weeks)
Histology

• Healing progressed to remodelling phase.
• Low-level force aids fibre orientation and tensile strength.

Goals

1. Preserve integrity of repair
2. Improve functional range of movement including full elevation
3. Re-educate cuff recruitment and scapula control through range
4. Improve neuromuscular control (sensorimotor/proprioceptive function)
5. Emphasize normal movement patterns

Rehabilitation

• Avoid combined abduction/external rotation
• Avoid forced end range stretches
• Avoid lifting/loading until 12 weeks
• Gentle mobilization of capsular restriction if necessary
• Progress cuff and scapula recruitment through range (short lever, supine, closed kinetic chain)
• Avoid long lever open chain exercises until 12 weeks
• Progress kinetic chain integration
• Increase function with correct movement pattern
• Closed kinetic chain work to enhance co-contraction

Late Stage (8–12 weeks)
Histology

• Tendon-to-bone healing should endure initiation of strengthening exercises.

Goals

1. Restore full active range of movement
2. Establish optimal neuromuscular control
3. Restore cuff and scapula control through range and under load
4. Optimise functional upper limb strength and endurance
5. Return to full work/sport/recreational activities

Rehabilitation

• Regain optimal range of motion including combined positions
• Strengthening of rotator cuff and scapular stabilisers through range
• Enhance neuromuscular control through range
• Closed kinetic chain exercises with increased load
• Functional strengthening and endurance exercises

Phase 4 – Advanced Strengthening (12–16 weeks)
Histology

• Remodeling phase close to completion; repaired tissue relatively mature and able to withstand greater stresses.

Goal

• Return to work/sport with optimal control and strength

Rehabilitation

• Progression of strength training with optimal control and movement pattern
• Sport-specific training
• Endurance training and fatigue resistance
• Promote concept of prevention

Return to Sport

Interval sports programme begins only after surgeon clearance, symmetric motion/strength, normal scapulothoracic kinematics, and no pain.

• Sport-specific training after cardiovascular warm-up (5–10 minutes).
• Programme: 3 times per week, with at least one rest day between sessions
• Maintenance programme: cardiovascular endurance, flexibility, scapulothoracic, rotator cuff, lower extremity, and core strength on alternate days.

Functional Milestones

• Driving: 4–6 weeks (depends on side and transmission type)
• Swimming: 12–16 weeks
• Golf: 16 weeks

Reference

Oliver A. van der Meijden et al. (2012). Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines. International Journal of Sports Physical Therapy, 7(2): 197–218

Post-Operative Guidelines –

Rotator Cuff Repair – Large tears (>3cm)

Mr.Hannan Mullett ,Consultant Shoulder Surgeon

Treatment note: Directly following the repair, integrity relies essentially on the structural construct. The conservative post-operative protocol is characterized by either a delay in the initiating of and / or restriction of passive range of motion (PROM). Remodelling repaired tissue does not reach maximal tensile strength for 12-16 weeks post repair. No formal strengthening should be performed until 12 weeks.

The risk of re-tear is greatest in the first 12 weeks post-surgery. Groups with greater risk of re-tear include older patients, smokers, diabetics, those with minimal postoperative symptoms and those with >3 cm tears.

The risk of stiffness is greatest in younger patients (<50 yrs.), those with PASTA type rotator cuff tears (Partial articular supraspinatus tension avulsion), those having an associated labral repair and single tendon repairs.

Timescales are guidelines and are dependent on individual factors and pre-operative status. Factors that may affect progression rate:

• Pre-operative stiffness
• Age
• Tissue quality
• Associated procedures

Acute protective phase (0-6 weeks)

Histology

Peak collagen deposition and growth factors 10 days post op with plateau at 28-56 days. Requires gentle stress to guide fibre orientation but no strain by limiting active motion.

Goals

1. Patient education
2. Protect surgical repair and optimize tissue healing
3. Diminish pain and inflammation
4. Prevent post-operative adhesions
5. Minimise muscle inhibition

Immobilisation

• Patients generally wear a sling for 6 weeks for comfort and to avoid stressing the repair. The sling is removed to allow axillary hygiene and when patient is performing their exercises

Rehabilitation

• Avoid active assisted or passive mobilization past 90° elevation in scapula plane, 50% of ER (compared to opposite side) respecting pain and movement pattern.
• Cryotherapy as needed
• Elbow, wrist and hand exercises.
• Simple scapula exercises e.g. shoulder shrug
• Active assisted / supported movement within the safe zone and limits of pain
• Encourage use of hand in sling for light, unloaded, pain-free activities. Patients that use the hand of the operated arm during the immobilization phase have better outcomes in terms of pain and function.
• Closed kinetic chain exercises
• low load on the shoulder and ensuring congruency scapula on thorax; e.g. table slides, walking away from the table.
• Submaximal isometrics (<30% MVC) rotator cuff
• Active scapula exercises e.g. shoulder shrug

Intermediate phase (6-12 weeks)

Histology

Inflammatory and repair phase has passed and healing progressed to remodelling phase. The application of low-level force during this time frame aids in orientation of fibres within collagen matrix and enhances tensile strength of repair.

Goals

1. Preserve integrity of repair.
2. Improve functional range of movement including full elevation
3. Re-educate cuff recruitment and scapula control through range
4. Improve neuromuscular control by re-educating sensorimotor / proprioceptive function
5. Emphasize normal patterns of movement

Rehabilitation

• Avoid forced passive stretching into combined abduction / external rotation. Active movement into this position is allowed as long as pain free and good control.
• Avoid forced end range stretches / mobilization especially ER with arm by side
• Avoid lifting / loading until 12 weeks
• Avoid weightbearing through operated arm e.g. getting out of a chair
• Avoid force hand behind back / extension
• Gentle mobilization of capsular restriction if necessary (respect restrictions)
• Progress cuff and scapula recruitment through range. Any exercise prescription should emphasis on good cuff and scapula control. Active assisted exercises progressing to active exercises-utilise short lever, supine and closed kinetic chain. Avoid long lever open chain exercises until 12 weeks
• Progress kinetic chain integration
• Increase function, emphasis on correct movement pattern
• Closed kinetic chain work to enhance co-contraction

Late stage (12 weeks to 6 months)

Histology

Tendon to bone healing should be able to endure the initiation of strengthening exercises. However, the addition of specific strengthening should be guided by preoperative findings in terms of tissue quality, patient age and whether primary or revision surgery. Careful progression of loading is essential to avoid compromise to the repair.

Goals

1. Restore full active range of movement
2. Establish optimal neuromuscular control
3. Restore optimal cuff and scapula control through range and under load
4. Optimise functional upper limb strength and endurance
5. Return to full work / sport and recreational activities

Rehabilitation

• Regain optimal range of motion including combined positions
• Strengthening and endurance exercises for rotator cuff and scapular stabilisers
• Enhance neuromuscular control through range
• Closed kinetic chain exercises with increased load
• Functional strengthening and endurance exercises

Phase 4 – advanced strengthening (6 months +)

Histology

Remodeling phase is close to completion at 4 months and the repaired rotator cuff tissue is relatively mature, therefore able to withstand greater stresses.

Goal

Patients returning to sport or with high functional demands may require more advanced strengthening to ensure they regain maximal tensile strength and functional endurance.

Rehabilitation

• Progression of strength training with optimal control and movement pattern
• Sport specific training
• Endurance training
• Promote concept of prevention

Functional Milestones

• Driving -depends on side and whether automatic generally after 8 weeks when patient has adequate control
• Swimming 16 weeks
• Golf 16 weeks

Reference

Oliver A. van der Meijden et al (2012) Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines. International Journal of Sports Physical Therapy 7(2): 197-218

Post Operative Guidelines –

Anatomical total shoulder arthroplasty is performed for patients who have end stage arthritis with an intact rotator cuff. The surgical approach involves a tenotomy of the subscapularis tendon which is subsequently repaired. It is important to protect the repair by avoiding loading the subscapularis by active internal rotation or excessive passive external rotation.

The given time frames are an approximate guide for progression, achieving the clinical criteria should guide the clinician and patient through this protocol.

Phase 1 – Joint protection

Aim to maintain integrity of joint while restoring passive range of motion.

• Education of patient regarding post-operative precautions and importance of adherence to and compliance with rehabilitation programme
• Allow healing of soft tissue
• Protect the prosthesis
• Reduce pain, inflammation and muscular inhibition
• Achieve AAROM up to 90° flexion, 90° elevation in scapula plane

Precautions

• Sling should be worn for 4 weeks. While sitting, keep the arm supported with a small pillow to prevent hyperextension.
• Patients can use the arm below the elbow e.g. using computer, reading immediately following surgery
• No lifting with the operated arm
• Avoid excessive stretching or sudden movements
• Avoid combined abduction and external rotation
• Avoid excessive shoulder motion behind back, especially into internal rotation (IR)
• No resisted Internal rotation
• No weight bearing through operated arm e.g. getting out of a chair or when using walking aids.

Week 1-3

• Educate patient in relation to timescales, precautions and sling management
• Frequent cryotherapy for pain and inflammation
• Introduce AROM elbow, wrist, hand exercises from day 1. Encourage light functional use of hand in sling.
• Introduce Shoulder Active Assisted Range of Movement; flexion in supine to tolerance.
• Introduce submaximal pain-free isometrics in scapular plane (<30% MVC) except IR
• Periscapular submaximal pain-free isometrics in scapular plane

Week 4

• Progress passive ROM as motion allows
• Begin shoulder active assisted abduction, ER and IR in scapular plane
• Ensure good scapular / glenohumeral dissociation. Correct abnormal movement patterns

Proceed to phase 2 if pain controlled, no signs of instability, no abnormal movement patterns, subscapularis integrity intact.

Phase 2 (approximately 4-8 weeks)

Goals

• Aim to restore passive ROM
• Gradually restore active motion
• Control pain and inflammation
• Re-establish dynamic shoulder stability with good movement patterns

Intervention

• Wean out of sling
• Continue to observe precautions
• While lying supine, a small pillow placed under the elbow will prevent shoulder hyperextension
• Avoid lifting anything heavier than a cup
• Avoid supporting body weight
• Avoid sudden movements
• In the presence of poor shoulder mechanics avoid repetitive AROM exercises / activity against gravity in standing
• Continue with passive ROM, AAROM
• Begin active flexion, IR, ER, abduction pain free ROM
• AAROM pulleys (flexion and abduction)
• Continue gentle isometrics (<30%) to include IR if pain free
• If pain is controlled and good quality of movement may begin HBB (do not force)
• Progression of scapular strengthening exercises
• Encourage functional use of arm at waist height for light tasks

Progress to phase III if pain free, well controlled functional AROM, good cuff (including subscapularis) and scapular function and good shoulder mechanics through available range.

Phase III

Goals

• Gradual return to functional activities
• Gradual restoration of strength, power and endurance
• Ensure good shoulder mechanics and movement patterns

Precautions

• Avoid heavy lifting
• Avoid weightbearing through the operated arm
• Avoid forced external rotation and combined abduction and external rotation and hand behind back
• Avoid forced internal rotation against resistance

Interventions

• Continue PROM as needed to maintain ROM
• Introduce rotator cuff resistance exercises through range (including subscapularis from 8 weeks) progress as comfort permits
• Consider deltoid rehab if poor cuff function
• Regain external rotation ROM (do not force)
• Enhance functional use of the upper limb
• Include closed kinetic chain exercises if appropriate
• Educate patient with regards long term management strategies

Functional Milestones

• Driving depends on side and whether automatic generally after 4-6 weeks when patient has adequate control
• Swimming 16 weeks
• Golf 16 -20 weeks

References
Bullock GS, Garrigues GE, Ledbetter L, Kennedy J (2019) A systematic review of proposed rehabilitation guidelines following anatomical and reverse shoulder arthroplasty. Journal of Orthopaedic and Sports Physical Therapy 49(5) 337- 346
Wilcox RB, Arslanian LE, Millett PJ (2005) Journal of Orthopaedic and Sports Physical Therapy 35(12) 821-836

Post Operative Guidelines –

Reverse Geometry Total Shoulder Replacement

Mr.Hannan Mullett ,Consultant Shoulder Surgeon

Reverse geometry total shoulder replacement is a reliable option for rotator cuff arthropathy, irreparable massive rotator cuff tears, glenohumeral arthritis and for some post traumatic conditions. Patients generally can expect significant reduction in their pre-operative pain levels and a functional range of motion following recovery. Internal rotation may never recover fully given this type of prosthetic design. Given that the surgery is generally performed on patients with severe rotator cuff deficiency there is likely to be a chronic deficit in rotator cuff strength. Improvement can continue for 18-24 months post-operatively.

Goals

• Protect surgical soft tissue repair.
• Avoid dislocation in the early post-operative period. In fact with the current generation of prosthesis the risk of dislocation with primary surgery is very low. It is higher in the revision setting. Mr. Mullett will advise if there is a higher rate of dislocation otherwise the risk is very low
• Gentle stretching and regaining range of motion.
• Gentle strengthening

Immobilisation

• Patients generally wear a sling for 4 week period
• Patients can use the arm below the elbow e.g. using computer, reading immediately following surgery

0-6 weeks

• Pendular exercises, active assisted ER to 30°
• Active assisted elevation as comfort allows
• Consider use of table slides
• avoiding forced internal rotation (v small risk dislocation)

6-8 weeks

• Gradually increase ER
• As ER increases gradually increase elevation ROM
• Active assisted exercises progressing to active exercises-utilise short lever, supine and closed kinetic chain-avoid long lever open chain exercises until 12 weeks

12 weeks +

• Isometrics in variable starting positions progressing to resisted through range strengthening
• Advance proprioceptive and dynamic neuromuscular control retraining

Functional Milestones

• Driving -depends on side and whether automatic generally after 4-6 weeks when patient has adequate control
• Swimming 16 weeks
• Golf 16 -20. weeks
• Light work (sedentary) 6-8 weeks

The rotator cuff muscles are a group of muscles that originate from your shoulder blade and insert into the top of your humerus. These muscles are responsible for controlling the movement of your arm into elevation. If there is a large tear of these tendons, it can be difficult to lift your arm away from the body. Fortunately, there is another large muscle called the Deltoid which can be re-educated to compensate for the torn rotator cuff.

The following exercises should be done three times a day and it may take up to 3 months to feel the benefits of the exercises. The exercises start lying down flat to reduce the work against gravity and will be progressed as the strength improves. This progression will be guided by your chartered physiotherapist

Perform these exercises 10 times, 3-5 times a day. Stop exercising if your shoulder pain increases.
You should expect to see some improvement by 6 to 12 weeks.

Pendular Exercises
The pendular exercises can be done as a warm up.

• Bend over supporting yourself with the good arm
• Start moving your affected arm in a circle 10 times
• Then move your arm backwards and forwards 10 times
• Next move your affected arm side to side 10 times

 

Stage 1

Lie down flat on your back, with a pillow supporting your head. Support the elbow of the affected arm on a rolled towel. Bend the elbow of the affected arm. Now raise our arm to 90 degrees vertical, using the stronger arm to assist if necessary. Once you have got to 90 degrees, you can straighten your elbow. Now attempt to hold your arm in this upright position with its own strength.

 

Stage 2

Slowly, with your fingers, wrist and elbow straight move the arm in small circular movements clockwise and counter clockwise. Gradually increase the circle as tolerated.

 

With your fingers, wrist and elbow straight, move the arm forwards and backwards in line with the outside leg. Start with a small arc of motion. Keep the movement smooth and continuous for 5 minutes or until fatigue.

 

As you get more confident in controlling your shoulder movement, gradually increase the range of motion until your arm will move from the side of your thigh to above your head, touching the bed and return.

 

Stage 3 – Progress to light weight

As you get more confident in controlling your shoulder movement, a light weight e.g. small paperweight, should be held in the affected hand and you repeat the movement outlined above. Once you can control the movement lying flat with a weight in your hand you can move onto stage 4.

 

Stage 4 – Progress to an inclined position

This exercise is performed sitting up in an inclined position, using a recliner chair, deck chair or simply put some pillows underneath your back to recline your position. Repeat the exercise again, starting first without any weights and progress to use the same light weight you used before in the lying flat position.

 

Subacromial Shoulder Exercises