Arthroscopic

Shoulder Anterior Stabilisation

PHYSIOTHERAPY LED POST OPERATIVE SHOULDER CLINIC

COMPILED BY: TENDAYI MUTSOPOTSI BSc. HPT (Hons) MSc. ORTHO-MED MCSP MSOM
APPROVED BY: MR ANDREW SANKEY ORTHOPAEDIC CONSULTANT SURGEON

Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Arthroscopic Anterior Stabilisation (With or Without Bankart Repair)

The purpose of this protocol is to provide the physiotherapist with a guideline for the post- operative rehabilitation course of a patient that has undergone an Arthroscopic Anterior Stabilisation (With or without Bankart repair). It is not intended to be a substitute for appropriate clinical decision-making regarding the progression of a patients post-operative course. The actual post surgical physiotherapy management must be based on the surgical approach, physical examination/findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist requires assistance in the progression of a post-operative patient they should consult with Mr. Andrew Sankey (Shoulder Consultant) or Mr. Tendayi Mutsopotsi (Specialist Shoulder Therapist) Please Note: The arthroscopic Bankart repair progresses more conservatively than an open procedure due to fixation methods that initially post-op may not be as stable. The protocol is divided into phases. Each phase is adaptable based on the individual and special circumstances. Immediately post-operatively, exercises must be modified so as not to place unnecessary stress of the anterior joint capsule of the shoulder. Early passive range of motion is highly beneficial to enhance circulation within the joint to promote healing. The overall goals of the surgical procedure and rehabilitation are to: Control pain and inflammation Regain normal upper extremity strength and endurance Regain normal shoulder range of motion Achieve the level of function based on the orthopedic and patient goals The physical therapy should be initiated within the first week and one half to two full weeks post-op. The supervised rehabilitation program is to be supplemented by a home fitness program where the patient performs the given exercises at home or at a gym facility. Important post-operative signs to monitor include: Swelling of the shoulder and surrounding soft tissue Abnormal pain response, hypersensitive-an increase in night pain Severe range of motion limitations Weakness in the upper extremity musculature Return to activity requires both time and clinical evaluation. To most safely and efficiently return to normal or high level of functional activity, the patient requires adequate strength, flexibility, and endurance. Functional evaluation including strength and range of motion testing is one method of evaluating a patients readiness to return to activity. Return to intense activities following an arthroscopic Bankart repair requires both a strenuous strengthening and range of motion program along with a period of time to allow for tissue healing. Symptoms such as pain, swelling, or instability should be monitored (advise patient accordingly).
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 PHASE I: (0-2 WEEKS) Immediate Post Surgical Phase: (Day 1 to 2 weeks) Goals: Patient Education Immobilization to protect repair Diminish pain and inflammation Precautions: Remain in body belt (2-3 weeks), only removing for showering and elbow/wrist ROM No PROM/ AROM of shoulder. Can do ER to neutral up to 4 weeks No lifting of objects with operative shoulder and Keep incisions clean and dry Week 1-3 Body belt at all times PROM/AROM elbow and wrist only + Ball squeezes Sleep with body belt supporting operative shoulder Shower with arm held at your side Cryotherapy for pain and inflammation Patient education: posture, joint protection, positioning, hygiene, etc. Begin isometrics week 3 PHASE II: (2-6 WEEKS) Protection Phase/PROM (Week 4 and 5) Goals: Gradually restore PROM of shoulder Do not overstress healing tissue Precautions: Follow surgeons specific PROM restrictions- primarily for external rotation No lifting and No PROM/stretching of the anterior capsule in the 90/90 positions. Criteria for progression to the next phase: Full flexion and internal rotation PROM PROM 30 degrees of external rotation at the side
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 Week 4-5 Continue use of sling and Pendulum exercises PROM: Full flexion, Full Internal rotation, and External rotation to 30 Continue cryotherapy as needed Continue all precautions and joint protection PHASE III: (6-12 Weeks) Intermediate phase/AROM (Week 6 and 7) Goals: Continue to increase external rotation PROM gradually Full AROM and Independence with ADLs Precautions: Wean from Sling and No lifting with affected arm Can begin gentle external rotation stretching in the 90/90 (8 weeks) Week 6 and 7 AROM of shoulder and Progress to full AROM against gravity Begin incorporating more aggressive posterior capsular stretching Cross arm stretch and Side lying internal rotation stretch Posterior/inferior gleno-humeral joint mobilization Begin gentle rhythmic stabilization techniques for rotator cuff musculature strength. Week 8 Week 12 (Strengthening Phase) Goals: Continue to increase external rotation PROM gradually Maintain full non-painful AROM Improve muscular strength, stability and endurance Gradual return to full functional activities Precautions: Be sure not to stress the anterior capsule with aggressive overhead strengthening Avoid contact sports/activities Week 8-10 Continue stretching and PROM and Initiate strengthening program (elastic resistance) ER/IR with elbow at the side of the body, Forward punch, Seated row Rhythmic stabilization exercises Initiate strengthening program (elastic resistance) Shoulder shrug, Seated row, Bicep curls, Lat pulls, Triceps extensions, Push-up plus
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 Week 10-12 Continue all exercises listed above including Continue stretching and PROM Begin gentle strengthening overhead, avoiding excessive anterior capsule stress ER/IR in the 90/90 positions, D1/D2 flexion and extension diagonals PHASE IV: Return to activity phase (12-20 WEEKS) Goal: Increase strength, endurance and ROM to the functional level required by the patient. Gradual return to strenuous work activities Gradual return to recreational activities Gradual return to sports activities Precautions: Do not begin throwing, or overhead athletic moves until 4 months post-op No exercises/activities that increase pain, cause apprehension or reinforce abnormal muscle patterning. With weight lifting: Avoid wide grip bench press and No military press or lat pulls behind the head. Be sure to always see your elbows Treatment Patient education: Encourage paced return to normal activities and lifting; encourage normal movement patterns during functional activities; advise patients of ongoing improvements for up to one year. Exercises: Full ROM with controlled stretching to achieve functional range if necessary. Advanced scapula stabiliser and rotator cuff rehabilitation through range - include speed and ballistic work as appropriate. Kinetic chain/balance work incorporating core stability and lower limbs as needed. Advanced proprioceptive work include PNF to regain rotation control through range Functional activities review functional goals; refer to Occupational Therapy if needed. Ensure sports specific/work specific activities retrained. May need to consider graduated throwing programme. Can begin golf, tennis (no serves until 4 mo.), etc. Can begin weight lifting with low weight, and high repetitions, being sure to follow weight lifting precautions. Activities: Return to moderate heavy work. May need to modify duties if requires heavy overhead work (anterior stabilisation) or heavy pushing, upper limb weight bearing (posterior stabilisation).
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 Week 16-20 May initiate interval sports program if appropriate Swimming all strokes. Return to sports e.g. football, golf, racquet sports, and martial arts at 6-8 months.
Returning to functional activities

Returning to work Driving Swimming Golf Lifting Contact Sport Sedentary job: as tolerated Manual job: 3 months About 6-8 weeks Breaststroke: 6 weeks Freestyle: 12 weeks At least 3 Months Light lifting can be started at 3 weeks. Avoid lifting heavy objects for 3 months. Such as football, racket sports, rock climbing etc: 3 months

Milestone driven These are milestone driven guidelines designed to provide an equitable rehabilitation service to all of our patients. They will also limit unnecessary visits to the outpatient clinic here at Chelsea & Westminster by helping the patient and therapist to identify when specialist review is required. If patients are progressing satisfactorily and meeting milestones, there is no need for them to attend clinic routinely. Failure to progress or variations from the norm should be the main reason for clinic attendance. Both patients and therapists can book clinic visits by contacting the numbers given further on in this document. Milestones for discharge: 1. Achieved time and patient specific functional goals. 2. Achieved 90-100% of contralateral shoulder active ROM. 3. Patient has a negative lag sign (i.e. active equals passive range) with dynamic rotation control at 0 abd, 45 abd, 90 abd. 4. Patient has no apprehension with specific movements and activities. Failure to meet milestones:
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 1. Refer to/discuss with Shoulder and Elbow Unit 2. Consider possible reasons for failure to progress and act accordingly (see below). 3. Continue with outpatient physiotherapy while patient is still making progress. Clinic follow-up schedule: 2, 6, 12, and 16-24 weeks (only if necessary) Failure to progress If a patient is failing to progress, then consider the following: Possible problem Pain inhibition Action Adequate analgesia Keep exercises pain-free Return to passive ROM if necessary until pain controlled Progressing too quickly hold back If severe night pain/resting pain refer to Shoulder Unit Increase or reduce physiotherapy/ (HEP) (max 2-4x/day) for few days/weeks and assess difference Ensure HEP focuses on key exercises and link to function Decrease activity intensity Assess and treat accordingly Passive ROM may need improving Assess and treat accordingly Ensure passive range gained first Consider isometrics through range Rotation dissociation through range with decreasing support and increasing resistance Ensure not progressing through Therabands too quickly Work on scapula stability through range without fixing with pec major/lat dorsi Work on improving core stability Maintain passive ROM as able Use physiological and accessory mobilisations, taking into account end feel and tissue healing times

Patient exercising too vigorously Patient not doing home exercise programme (HEP) regularly enough

Returned to activities too soon Cervical/thoracic pain referral Unable to gain strength Altered neuropathodynamics Poor rotator cuff control

Poor scapula control Poor core stability Secondary frozen shoulder

It is essential you contact us if you have any concerns.

Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

THE SHOULDER UNIT TEAM Shoulder Consultant: Mr. Andrew Sankey 0208 746 8545 Shoulder Therapist: Mr. Tendayi Mutsopotsi 0208 746 8404 Secretary: 0208 746 8545

Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)