1-Cervical

Artificial disc protocol treatment guidelines

Phase I: Immediate post-Surgical Phase (IPSP) 0-6 weeks
Treatment Summary:
1. Education on bed mobility and transfers with proper spine positioning.
2. Reinforce basic post-op home exercise program including
a. Ankle pumps
b. Long arc and short arc quadriceps
c. Diaphragmatic breathing
d. Relaxation exercises
e. Abdominal isometric exercises
3. Increase tolerance to walking to ½ mile daily (15-30 min cardiovascular activity)
4. Reinforce sitting, standing and ADL modifications with neutral spine and proper
body mechanics.
Phase II: Initiation of OP-PT 6-9 weeks/2-3 times per week
Treatment Summary:
 Reinforce neutral spine positioning

 Body mechanics and training: Performance of functional activities with neutral spine
and protective positions
Manual Therapy:
 Grade 1 or grade 2 joint mobs for neuro-modulation of pain
 Scar tissue mobilization.
.  Soft tissue mobilization of soft tissue restrictions
Exercises:
 Train Neutral lumbar position:
Create independent movement of the pelvis and then find and maintain a neutral
position of the lumbar spine.
 Diaphragmatic breathing:
Proper breathing technique without the use of accessory respiratory muscles
 Neural mobilization exercises. Do not reproduce symptoms

 Pelvic stabilization exercises with emphasis on transverse abdominals and multifidus:

o Neuromuscular control of lumbar spine in a neutral position (abdominal drawing in
maneuver-ADIM).
Monitor with palpation or pressure biofeedback
Prone (start at 70 mm Hg and successful contraction is 6-10 mm HG decrease in
pressure and hold for 10 sec), supine maintain 40 mm Hg with ADIM. Watch for
inability to develop tension in multifidus or compensation with erector spinae (rapid
development of tension) o Co-contraction of multifidus with transverse abdominals. o
Wk 6-7: ADIM maneuver performed with gentle arm and leg exercises (back supported):
Supine heel slides, supine marches, Supine hip abduction slides, Hip horizontal
abduction, heel slides, leg slides from crook lying postures, clam shells o Wk 8-9
progress to rotatory stability of the spine, lumbopelvic control during movements and
aggravating movements: Sitting on unstable base of support exercises, co-contractions
during normal speed walking and other activities. Isometric co-contractions with
addition of heavier external loads to lumbar spine Bridging, dead bud (cycling from
supine position), leg extensions in Quadruped.  Unloaded Pelvic and Lumbar ROM
(supported): Pelvic rocks, Wig wags, Pelvic clocks. All performed in neutral and
protective positions. Flexion based program including single and double knee to chest,
seated or standing marches.  Hip and knee flexibility exercises: Decreases stress on
lumbar spine and makes it easier to maintain neutral spine. (hamstrings, piriformis,
gluteal, quads, hip flexors, gastroc, soleus etc)  Closed Chain exercises including wall
slides, wall press (supine), squat machine  Initiate acquatics (if available and indicated)
 Cardiovascular training, treadmill, UBE, stationary bike (patient must have good
pelvic control)  Initiate balance exercises (week 10-12)  Address other mechanical
restrictions as needed  Modalities for symptom modulation if needed
Phase III: Advanced PT 9-12 weeks/2-3 times per week
Treatment Summary:  Manual Therapy:  Joint mobilization of adjacent restrictions of
thoracic spine, hip/pelvis.  Soft tissue mobilization of soft tissue restrictions. 
Exercises:  Continue with ROM exercises for lumbar spine including cat/camel, seated
and standing active rotation.  Advanced balance exercises  Neural mobilization
exercises.  Advanced stabilization and proprioceptive training, Multi-plane
stabilization/mobility  Wk 9-10: Increasing complexity and load of exercises maintaining
lumbar spine stability:, bridging on unsteady surfaces, alternate arm an leg extensions in
quadruped, prone on ball leg and arm extensions (quadruped), functional cocontractions
during walking increasing speed) and other activities (kneeling, squatting, stairs etc) 
Wk 10-12: Co-ordination exercises: High level stabilization exercises on the exercise ball,
changing speeds of walking, side bridges, extension rolls, crunches, Single leg bridging
Activity specific training  Advanced cardiovascular training  Advanced Hip/Core
strengthening exercises: Functional exercises like chops/diagonal lifts, squatting, lunging
 Lifting training with proper posture. (floor to waist and waist to shoulder level)  Body
mechanics drills  FCE if appropriate
Post-operative Spine Rehab-Cervical Fusion Treatment Guideline
Phase I: Immediate post Surgical Phase (IPSP) 0-8 weeks

Treatment Summary: 1. Education on bed mobility and transfers with proper spine positioning. 2.
Reinforce basic post-op home exercise program including a. Diaphragmatic breathing b. Relaxation
exercises c. Upper extremity extension isometric exercises 3. Increase tolerance to walking (½ mile daily)
or bike (15-30 min cardiovascular activity) 4. Reinforce sitting, standing and ADL modifications with
neutral spine and proper body mechanics

Phase II: Initiation of OP-PT 8-12 weeks/2-3 times per week

Treatment Summary:  Body Mechanics Education  Anatomy, Pathology, & Biomechanics  Reinforce
neutral spine positioning  Body mechanics and training: Performance of functional activities with
neutral spine and protective positions  Manual Therapy  Grade 1 or grade 2 joint mobs for
neuromodulation of pain  Scar mobilization. Educate patient in scar mobilization.  Nerve mobilization
(nerve glides). Do not reproduce symptoms.  Exercises:  Train upright posture.  Diaphragmatic
breathing: Proper breathing technique without the use of accessory respiratory muscles  Initiate
Cervical Isometric exercises.  Initiate Cervical range of motion.  Initiate Scapular movement re-
education including shoulder shrugs, shoulder rolls, scapular mobilization exercises  Upper thoracic
mobilization exercises: cat/camel exercises, upper thoracic extension, upper thoracic rotation, arm
clocks, combined thoracic/cervical motions  Neuromuscular re-education of longus colli with pressure
biofeedback (include arm and leg movements in varying positions)  Restricted to 5 lbs with arm
exercises (below 90 elevation)  Abdominal Exercises (watch cervical spine), perform basic core
strengthening of lumbar spine. (front and side planks) at 10-12 weeks  Cardiovascular training,
treadmill, UBE, stationary bike  Address other mechanical restrictions as needed  Modalities for
symptom modulation if needed

Phase III: Advanced PT 12-18 weeks/2-3 times per week

Treatment Summary:  Body mechanics training  Posture emphasis with exercises, posture training 
Work/activity specific training  Manual Therapy  Soft tissue mobilization to decrease guarding  Joint
mobilizations over restricted joints (around fusion) to increase contribution to overall movement
(OA/AA and upper thoracic). Protect fusion.  Nerve mobilization (nerve glides). Do not reproduce
symptoms.  Exercises:  Train upright posture.  Cervical mobility exercises (AROM is
patient/physician/surgery dependent. Do not promote passive stretching).  Occulomotor training and
proprioceptive training (laser pointer)  Upper extremity strengthening (Rhythmic stabilization upper
extremity, free weight shoulder strengthening)  Scapular stabilization/strengthening exercises
(shoulder shrugs/rolls, prone scapular series)  Spinal stabilization exercises lumbar and cervical 
Continue Upper thoracic mobilization exercises  Advanced balance training exercises.  Neuromuscular
re-education of longus colli with pressure biofeedback (include arm and leg movements in varying
positions)  Cardiovascular training, treadmill, UBE, stationary bike  14-18 weeks: Initiate advanced
strengthening (chest press, seated rows, pull downs, incline push ups) and functional core strengthening
(overhead chops, lifts, diagonal lifts, push ups).

Post operative Spine Rehab-Cervical Laminoplasty/Discetomy Treatment

Guideline
Phase I: Immediate post Surgical Phase (IPSP) 0-6 weeks

Treatment Summary: 1. Education on bed mobility and transfers with proper spine positioning. 2.
Reinforce basic post-op home exercise program including a. Diaphragmatic breathing b. Relaxation
exercises c. Upper extremity extension isometric exercises 3. Increase tolerance to walking (½ mile daily)
or bike (15-30 min cardiovascular activity) 4. Reinforce sitting, standing and ADL modifications with
neutral spine and proper body mechanics

Phase II: Initiation of OP-PT 6-9 weeks/2-3 times per week

Treatment Summary:  Body Mechanics Education  Anatomy, Pathology, & Biomechanics  Reinforce
neutral spine positioning  Body mechanics and training: Performance of functional activities with
neutral spine and protective positions  Manual Therapy  Grade 1 or grade 2 joint mobs for
neuromodulation of pain  Scar mobilization. Educate patient in scar mobilization.  Nerve mobilization
(nerve glides). Do not reproduce symptoms.  Exercises:  Train Neutral lumbar position/cervical
posture: Create independent movement of the pelvis and then find and maintain a neutral position of
the lumbar spine. Maintain god neck posture  Diaphragmatic breathing: Proper breathing technique
without the use of accessory respiratory muscles  Cervical Range of motion exercises.  Cervical
Isometric exercises.  Cervical flexibility exercises: Decreases stress on cervical spine and makes it easier
to maintain neutral spine. (levator scapula, upper trapezius, pectoralis major/minor etc)  Advance
Cervical Isometric exercises.  Initiate Scapular movement re-education including shoulder shrugs,
shoulder rolls, scapular retraction/depression exercises  Upper thoracic mobilization exercises:
cat/camel exercises, upper thoracic extension, upper thoracic rotation, arm locks  Neuromuscular re-
education of longus colli with pressure biofeedback (include arm and leg movements in varying
positions).  Cervical Joint position sense with laser pointer.  Occulomotor exercises.  Restricted (to 5
lbs) arm exercises. Progress to overhead after 6 weeks  Abdominal Exercises (watch cervical spine),
perform basic core strengthening of lumbar spine. (front and side planks). Isometric co-contractions
with addition of heavier external loads to lumbar spine Bridging, dead bud (cycling from supine
position), leg extensions in Quadruped.  Cardiovascular training, treadmill, UBE, stationary bike 
Address other mechanical restrictions as needed  Modalities for symptom modulation if needed

Phase III: Advanced PT 9-12 weeks/2-3 times per week

Treatment Summary:  Body mechanics training  Posture emphasis with exercises, posture training 
Work/activity specific training  Manual Therapy  Soft tissue mobilization to decrease guarding  Joint
mobilizations over restricted joints (around fusion) to increase contribution to overall movement
(OA/AA and upper thoracic). Protect fusion.  Nerve mobilization (nerve glides).  Exercises:  Progress
Occulomotor training  Upper extremity strengthening (Rhythmic stabilization upper extremity, free
weight shoulder strengthening)  Scapular stabilization/strengthening exercises (shoulder shrugs/rolls,
chest press, seated rows, pull downs, incline push ups)  Spinal stabilization exercises lumbar and
cervical  Continue Upper thoracic mobilization exercises  Advanced balance training exercises. 
Progress with ADL and activity simulation with recruitment of longus colli/neutral spine. 
Cardiovascular training, treadmill, UBE, stationary bike

Kyphoplasty/Vertebroplasty Treatment Guideline

Phase I: Immediate post Surgical Phase (IPSP) 0-2 weeks

Treatment Summary: 1. Education on bed mobility and transfers with proper spine positioning. 2.
Reinforce basic post-op home exercise program including a. Ankle pumps b. Long arc and short arc
quadriceps c. Diaphragmatic breathing d. Relaxation exercises e. Abdominal isometric exercises 3.
Increase tolerance to walking to ½ mile daily (15-30 min cardiovascular activity) 4. Reinforce sitting,
standing and ADL modifications with neutral spine and proper body mechanics.

Phase II: Initiation of OP-PT 2-4 weeks/2-3 times per week

Treatment Summary:  Back Education Program  Anatomy, Pathology, & Biomechanics  Reinforce
neutral spine positioning  Body mechanics and training: Performance of functional activities with
neutral spine and protective positions  Manual Therapy:  Grade 1 or grade 2 joint mobs for
neuromodulation of pain  Scar tissue mobilization. Educate patient on self mobilization of scar. 
Exercises:  Train Neutral lumbar position: Create independent movement of the pelvis and then find
and maintain a neutral position of the lumbar spine.  Diaphragmatic breathing: Proper breathing
technique without the use of accessory respiratory muscles.  Pelvic stabilization exercises with
emphasis on transverse abdominals and multifidus: o Neuromuscular control of lumbar spine in a
neutral position (abdominal drawing in manever-ADIM). o Start in quadruped position then prone and
supine. o Monitor with palpation or pressure biofeedback. Prone (start at 70 mm Hg and successful
contraction is 6-10 mm HG decrease in pressure and hold for 10 sec), supine maintain 40 mmHG with
ADIM. Watch for inability to develop tension in multifidus or compensation with erector spaine (rapid
development of tension) o Co-contraction of multifidus with transverse abdominals. o Wk 2-3: ADIM
manever performed with gentle arm and leg exercises: Supine heel slides, supine leg lifts, Hip horizontal
abduction, heel slides. Initiate sitting and standing ADIM with arm movements. Progress to SLR
flexion/extension/abduction in standing. o Wk 4 progress to lumbopelvic control during movements and
aggravating movements and heavier external loads to lumbar spine: Sitting on unstable base of support
exercises, co-contractions during normal speed walking and other activities, bridging.  Knee
strengthening exercises.  Unloaded trunk ROM exercises: Lumbar spine flexion and extension in
quadruped (cat camel) Pelvic rocks, Wig wags, Pelvic clocks.  Hip and knee flexibility exercises:
Decreases stress on lumbar spine and makes it easier to maintain neutral spine. (hamstrings, piriformis,
gluteal, quads, hip flexors, gastroc, soleus etc)  Initiate acquatics (if available and indicated) 
Cardiovascular training, treadmill, UBE, stationary bike (patient must have good pelvic control)  Initiate
balance exercises sitting and standing. Progress double leg firm surface to foam surface, eyes
open/closed, single leg balance, reaching outside BOS  Gait training with or without assistive device as
needed.  Address other mechanical restrictions as needed  Modalities for symptom modulation if
needed

Phase III: Advanced PT 4-8 weeks/2-3 times per week

Treatment Summary:  Activity specific training  Exercises (Advanced strengthening); (based on
degree of bone loss, age and functional status of the individual)  Increasing complexity and load of
exercises maintaining lumbar spine stability: supine SLR all directions, single leg bridging, bridging on
unsteady surfaces, alternate arm an leg extensions in quadruped, prone on ball leg and arm extensions
(quadruped), functional co-contractions during walking increasing speed and other activities (kneeling,
squatting, stairs etc)  Advanced Hip/Core strengthening exercises: Functional exercises like
chops/diagonal lifts, squatting, lunging.  Advanced cardiovascular training  Lifting training with
proper posture. (floor to waist and waist to shoulder level)  Body mechanics drills  FCE if appropriate

Shoulder
SMALL ROTATOR CUFF REPAIR PROTOCOL
Phase 1: Passive Range of Motion 0 to 4-6 weeks

EXERCISE SUGGESTIONS: Muscle Activation General:  Posture awareness /exercises  Ball/theraputty

squeezes19 (avoid if biceps repair or tenodesis done) 21  Pendulums forward/back, side/side for pain
control and joint stiffness

Scapula: *with sling on  Elevation/depression, retraction/protraction23  Scapular orientation: ensure

patient can achieve proper scapular positioning (typically emphasize posterior tilt with some elevation
/upward rotation, external rotation/retraction) ROM Muscle activity levels during range of motion
exercise have been measured using EMG24 .Therapist assisted passive joint mobility exercises with the
patient in supine minimized muscular activity. Conversely, shoulder musculature was most active with
the rope-and-pulley ROM exercise. As a result, passive ROM exercises should be given first (in Phase I)
and progressed to active-assisted ROM exercise (i.e. pulleys) once adequate tissue healing occurs (Phase
II). Specifically, passive ROM into flexion >30 and ROM in the scapular plane has been shown to reduce
stress on the repair site. 13 Elbow & Wrist:  Active & passive - flexion/extension/pronation/supination
19 (avoid elbow flexion if biceps repair or tenodesis)21 Neck:  general ROM if needed Shoulder: 
PASSIVE motion in a supine position through a comfortable range  0-2 weeks: NO range of motion
except home exercises given by hospital PT  2-4 weeks: therapist guided supine range of motion in
therapy sessions/assistant at home  4-6 weeks: patient passive ROM with cane/stick  Passive
abduction & scaption: slowly progress ROM to active-assisted ROM painfree  Bent-arm self-assisted
scaption and forward flexion to 90°+ 19  Passive ER/IR at 30° abduction/scapular plane: 0-60° (unless
subscapularis repaired) Modalities  Ice 15 minutes every few hours23  Interferential current therapy
(pain relief)

Phase II: Active AssistedActive Range of Motion 4-6 to 10-12 weeks (3 months)

EXERCISE SUGGESTIONS: PROM & AAROM  Use cane/stick (PROM) progressions: supine 45 semi-
reclined sitting/standing pulleys(=AAROM): - Scaption & abduction and flexion above shoulder level
(as tolerated) - Continue with ER range in abduction/scapular plane >300 elevation (as tolerated) 
Hydrotherapy/Pool 25-27 = AAROM (ensure good glenohumeral movement to avoid scapular hitching)
AROM  Supine cane/stick progress to forearm wall/towel slides 19 and then to no assistance (AROM) 
Scaption /abduction & flexion 0-140 ° (or as tolerated)
Muscle Strength & Endurance General:  Continue with pendulums for pain relief if required  Posture
awareness / exercises

Sub-Maximal Isometrics: - ER/IR and adduction with arm supported in 30 abduction28 - *caution with
IR if subscapularis is repaired23 - Shoulder flexion & extension (push/pull with elbow at 90°) - Elbow
flexion (avoid if biceps tenodesis/tenotomy), extension  Light Isotonics = AROM against gravity 
Sidelying ER with pillow/towel (~30 abduction) no weight +/-muscle stimulation29 Scapula:  Continue
with protraction, retraction, elevation, depression  Manual resistance for scapular motions  Posterior
tilt of scapula  Closed chain scapulothoracic stability & proprioception at ranges below 600 of
elevation23 i.e. large theraball on floor: circles clockwise and counterclockwise +/- pushing into ball 
Prone arm raises at 00  Swiss ball slides up wall in flexion and scaption19 Mobilizations  GH
mobilizations (Grade II-III) to attain adequate GH mobility and pain control  Scar massage if incisions
completely healed Cardiovascular (as tolerated)  Stationary bicycle, treadmill, stairmaster, elliptical
trainer (no arms), walking19

Phase III: Resisted Exercises/Strengthening 10-12 to 16-18 weeks (4½ months)

EXERCISE SUGGESTIONS: AROM  Overhead wall slide/walking: forward, scaption  Ball slides/roll up
wall (90-160+ flexion/scaption/abduction) Muscle Strength & Endurance Note: Progression is
endurance then strength. Exercises should have high repetitions (4x15 or 3x30) before adding
resistance. Closely monitor shoulder/postural mechanics and pain throughout all exercises. Rotator Cuff:
 Light Isotonics - Sidelying ER with towel (30 abduction) +/-muscle stimulation progress to 1lb - Light
resistance tubing19 (red) ER/IR (30 abduction) with towel - Progress 4590° as tolerated +/- support
and then arm at side (0)(strain values highest)  Low force rhythmic stabilization spine 90° flexion and
ER/IR@45° abduction (for humeral head control) Scapula:  Supine/standing protraction/retraction +
weights/tubing  Prone/seated rowing19 progress to pulleys, tubing etc.  Prone arm raises at 900
progress to 1200  Forward punches with pulleys, tubing…  Dynamic hug  with tubing19  Light
resistance shoulder extension, adduction, flexion19 (good patterning required!!)  PNF patterning –
none to light resistance only  Closed chain proprioception progression at and above shoulder height,
i.e. Weight-bearing protraction/retraction: supine at 90, wall, plinth, hands & knees….  Ball stabilization
on wall  Wall washes19  Push-up with plus19 progress from on wall plinth  floor Mobilizations
and Stretching  GH mobilizations (Grade III – IV) for mobility  Gentle stretches if needed for19:
anterior or posterior shoulder, internal rotation Cardiovascular (as tolerated)  Continue with stationary
bicycle, treadmill, stairmaster, elliptical trainer (no arms), walking

Phase IV: Advanced Strengthening & Dynamic Stability 4½ months+

EXERCISE SUGGESTIONS: Muscle Strength & Endurance General:  Biceps/Triceps  Chest press 
Shoulder press (military press)  Flys / Reverse flys  Lat Pull downs  Full push up Rotator Cuff:  ER/IR
at side, 45, 90 – vary speed, resistance & position (sidelying, standing, prone)  Hands and knees
closed chain perturbations19 progress to hands and feet Scapula:  Continue with shoulder
strengthening program as initiated in Phase III with emphasis on faster speed, multiplanar/functional
activities which incorporate the kinetic chain  PNF diagonal patterns with bands/pulleys/manual
resistance19 : - D1 extension (high back hand to down to hitch hike position) - D1 flexion (hitch hike to
high back hand position) - D2 extension (carry tray to hand in opposite front pocket position) - D2 flexion
(hand in opposite front pocket to carry tray position)

Plyometric Program (if needed) Plyometric exercises are advanced from 2-arm, short-lever-arm activities
below 90° of arm elevation, to single-arm long-lever-arm activities above 90° of arm elevation and
should be specific to mimic a functional task/activity.21 Suggestions/ideas:  Tubing plyometrics for
ER/IR at 900 abduction with varying speeds  2 handed tosses: waist/chest level→ overhead → diagonal
(PNF pattern)  1 handed tosses: begin throw with shoulder flexion and mostly elbow extension→
progress by increasing the amount of shoulder abduction/ER  Begin with towel, beach ball, kid’s ball,
tennis ball→ progression to lightly weighted balls (plyoballs) Cardiovascular Fitness  Train specific to
demand of sport (aerobic, anaerobic)

LARGE ROTATOR CUFF REPAIR PROTOCOL

Phase 1: Passive Range of Motion 0 to 8-10 weeks

EXERCISE SUGGESTIONS: Muscle Activation General:  Posture awareness /exercises  Ball/theraputty

squeezes19 (avoid if biceps repair or tenodesis done) 21  Pendulums forward/back, side/side for pain
control and joint stiffness

Note: For passive pendulums, the arm should dangle and the muscles must be completely relaxed. Move
the arm by rocking the body forward/back, side to side or in circles NOT by moving the arm.22 Scapula:
*with sling on  Elevation/depression, retraction/protraction23  Scapular orientation: ensure patient
can achieve proper scapular positioning (typically emphasize posterior tilt with some elevation /upward
rotation, external rotation/retraction) ROM Muscle activity levels during range of motion exercise have
been measured using EMG24.Therapist assisted passive joint mobility exercises with the patient in
supine minimized muscular activity. Conversely, shoulder musculature was most active with the rope-
and-pulley ROM exercise. As a result, passive ROM exercises should be given first (in Phase I) and
progressed to active-assisted ROM exercise (i.e. pulleys) once adequate tissue healing occurs (Phase II).
Specifically, passive ROM into flexion >30 and ROM in the scapular plane has been shown to reduce
stress on the repair site.13  Elbow & Wrist: Active & passive - flexion/extension/pronation/supination
19 (avoid elbow flexion if biceps repair or tenodesis)21  Neck: general ROM if needed  Shoulder:
PASSIVE motion in a supine position through a comfortable range - 0-2 weeks: NO range of motion
except home exercises given by hospital PT - 2-6 weeks: therapist guided supine range of motion in
therapy sessions/assistant at home - 6-8 weeks: patient passive ROM with cane/stick - Passive abduction
& scaption: slowly progress ROM to active-assisted ROM painfree - Bent-arm self-assisted scaption and
forward flexion to 90°+ 19 - Passive ER/IR at 30° abduction/scapular plane: 0-60° (unless subscapularis
repaired) Modalities  Ice 15 minutes every few hours23  Interferential current therapy (pain relief)

Phase II: Active AssistedActive Range of Motion 8-10 to 14-18 weeks (4½ months)

EXERCISE SUGGESTIONS: PROM & AAROM  Use cane/stick (PROM) progressions: supine 45 semi-
reclined sitting/standing pulleys(=AAROM): - Scaption & abduction and flexion above shoulder level
(as tolerated) - Continue with ER range in abduction/scapular plane >300 elevation (as tolerated) 
Hydrotherapy/Pool 25-27 = AAROM (ensure good glenohumeral movement to avoid scapular hitching)
AROM  Supine cane/stick progress to wall/towel slides 19 and then to no assistance (AROM) -
Scaption/abduction & flexion 0-140 ° (or as tolerated) Muscle Strength & Endurance General:  Continue
with pendulums for pain relief if required  Posture awareness / exercises Note: Flexion in supine
position from 0-90° is against gravity but, flexion above 90° then becomes gravity assisted. This exercise
can be carried out at the beginning with the elbow flexed and then gradually increasing the lever arm by
extending the elbow.

Rotator Cuff: (initiate isometrics/isotonics when 80% AROM achieved)5  Sub-Maximal Isometrics: -
ER/IR and adduction with arm supported in 30 abduction28 - *caution with IR if subscapularis is
repaired23 - Shoulder flexion & extension (push/pull with elbow at 90°) - Elbow flexion (avoid if biceps
tenodesis/tenotomy), extension  Light Isotonics = AROM against gravity - Sidelying ER with pillow/towel
(~30 abduction) no weight +/-muscle stimulation29 Scapula:  Continue with protraction, retraction,
elevation, depression  Manual resistance for scapular motions  Posterior tilt of scapula  Closed chain
scapulothoracic stability & proprioception at ranges below 600 of elevation23 i.e. large theraball on
floor: circles clockwise and counterclockwise +/- pushing into ball  Prone arms raises at 00  Swiss ball
slides up wall in flexion and scaption19 Mobilizations  GH mobilizations (Grade II-III) to attain adequate
GH mobility and pain control  Scar massage if incisions completely healed Cardiovascular (as tolerated)
 Stationary bicycle, treadmill, stairmaster, elliptical trainer (no arms), walking19 MILESTONES TO
PROGRESS TO PHASE III 1. Good resting scapular posture and dynamic scapular control with ROM and
strengthening exercises. 2. Satisfactory active range of movement without pain or compensation i.e.
Flexion: 30 repetitions in standing without upper trapezius substitution, External rotation: 30 repetitions
in side-lying without weight

PhasEXERCISE SUGGESTIONS: AROM  Overhead wall slide/walking: forward, scaption  Ball slides/roll
up wall (90-160+ flexion/scaption/abduction) Muscle Strength & Endurance Note: Progression is
endurance then strength. Exercises should have high repetitions (4x15 or 3x30) before adding
resistance. Closely monitor shoulder/postural mechanics and pain throughout all exercises. Rotator Cuff:
 Light Isotonics - Sidelying ER with towel (30 abduction) +/-muscle stimulation progress to 1lb - Light
resistance tubing19 (red) ER/IR (30 abduction) with towel - Progress 4590° as tolerated +/- support
and then arm at side (0)(strain values highest)  Low force rhythmic stabilization spine 90° flexion and
ER/IR@45° abduction (for humeral head control) Scapula:  Supine/standing protraction/retraction +
weights/tubing  Prone/seated rowing19 progress to pulleys, tubing etc.  Forward punches with
pulleys, tubing…  Dynamic hug  with tubing19  Light resistance shoulder extension, adduction,
flexion19 (good patterning required!!)  PNF patterning – none to light resistance only  Closed chain
proprioception progression at and above shoulder height. i.e.Weight-bearing protraction/retraction:
supine at 90, wall, plinth, hands & knees….  Ball stabilization on wall  Wall washes19  Push-up with
plus19 progress from on wall plinth  floor Mobilizations and Stretching  GH mobilizations (Grade III
– IV) for mobility  Gentle stretches if needed for19: anterior or posterior shoulder, internal rotation
Cardiovascular (as tolerated)  Continue with stationary bicycle, treadmill, stairmaster, elliptical trainer
(no arms), walkinge III: Resisted Exercises/Strengthening 14-18 to 24 weeks (6 months)

Phase IV:Advanced Strengthening & Dynamic Stability (6 months+ up to 1 year)

EXERCISE SUGGESTIONS: Muscle Strength & Endurance General:  Biceps/Triceps  Chest press 
Shoulder press (military press)  Flys / Reverse flys  Lat Pull downs  Full push up Rotator Cuff:  ER/IR
at side, 45, 90 – vary speed, resistance & position (sidelying, standing, prone)  Hands and knees
closed chain perturbations19 progress to hands and feet Scapula:  Continue with shoulder
strengthening program as initiated in Phase III with emphasis on faster speed, multiplanar activities
which incorporate the kinetic chain  PNF diagonal patterns with bands/pulleys/manual resistance19 : 
D1 extension (high back hand to down to hitch hike position)  D1 flexion (hitch hike to high back hand
position)  D2 extension (carry tray to hand in opposite front pocket position) This end point will differ
depending on the patient. At this phase/stage a shoulder with a low functional demand may continue to
improve in a progressive manner with a home program. 9  D2 flexion (hand in opposite front pocket to
carry tray position) Plyometric Program (if needed) Plyometric exercises are advanced from 2-arm,
short-lever-arm activities below 90° of arm elevation, to single-arm long-lever-arm activities above 90°
of arm elevation and should be specific to mimic a functional task/activity.21 Suggestions/ideas: 
Tubing plyometrics for ER/IR at 900 abduction with varying speeds  2 handed tosses: waist/chest
level→ overhead → diagonal (PNF pattern)  1 handed tosses: begin throw with shoulder flexion and
mostly elbow extension→ progress by increasing the amount of shoulder abduction/ER  Begin with
towel, beach ball, kid’s ball, tennis ball→ progression to lightly weighted balls (plyoballs) Cardiovascular
Fitness  Train specific to demand of sport (aerobic, anaerobic)

ARTHROSCOPIC ANTERIOR STABILIZATION

Phase I (General timeline: 0-6 weeks)

EXERCISE SUGGESTIONS: PROM &AAROM  Elbow: Active& passive - flexion (if SLAP repair wait 6 wks)
/extension/pronation/supination  Wrist: Active & passive - flexion/extension/radial & ulnar deviation 
Neck: general ROM if needed  Shoulder: use pulleys, cane, stick, opposite arm, finger ladder (all in
scapular plane to maximize humeral head/glenoid congruency 10) - P/AAROM flexion: 45-70° (wks 1-2),
90° (wk 3), 135° (wk 6) - P/AAROM ER: 0-5°(wks 1-2), 10-30° (wk 3), 35-50° (wk 6) - P/AAROM IR: 15-20°,
hand behind back: posterior belt line (wk 5-6) Muscle Activation / Strength Maintenance General:  Ball
squeezes  Pendulums for pain control (use body sway to move extremity: forward/back, side/side) 
Posture awareness / exercises (scapular retraction, shoulder rolls)  Scar management Rotator Cuff: 
Week 2: (if pain free) Sub maximal isometrics in neutral as tolerated 10 [*caution with IR if open Bankart
with subscapularis reattached]10  Week 4: Sidelying ER with towel – no weight Scapula:  Bilateral
elevation /depression/protraction/retraction10  Supine serratus anterior protraction/retraction at 900
flexion → progress with small weights  Rhythmic stabilization supine 900 flexion submaximal resistance
on upper arm for all planes of movement5  Supine bent elbows barrel hug  Scapular clock exercises
and progress to scapular strengthening at tolerated26 5 Proprioceptive Retraining  Week 3: Upper
extremity weight-bearing exercises for scapular movements at GH angles below 60 degrees elevation10
- i.e. Standing with swiss ball on floor – hand on ball with pressure forward/backward, side to side,
circles, - Standing weight-bearing shifts with hands on bed/plinth → progress to single arm weight-
bearing27 Modalities  Ice 15 minutes every few hours for pain relief1, 10  Interferential current
therapy (pain relief) Cardiovascular Fitness  Bicycle, elliptical, stairmaster, walking

Phase II (General timeline: 6-12 weeks)

EXERCISE SUGGESTIONS: PROM & AAROM  Neck: general ROM if needed  Thoracic spine: ensure
proper extension to facilitate shoulder ROM  Shoulder P/AAROM: Use pulleys, cane, stick, opposite
arm….. - Flexion (scapular plane): 135° (wk 6), 155° (wk 9), near end range/160° (wk 12) - ER at 20°
abduction (scapular plane): 35-50° (wk 6), 50-65°(wk 9), near end range/70° (wk 12) - ER at 90°
abduction: 45° (wk 6), 75° (wk 9,), near end range/80° (wk 12)

EXERCISE SUGGESTIONS: PROM & AAROM  Neck: general ROM if needed  Thoracic spine: ensure
proper extension to facilitate shoulder ROM  Shoulder P/AAROM: Use pulleys, cane, stick, opposite
arm….. - Flexion (scapular plane): 135° (wk 6), 155° (wk 9), near end range/160° (wk 12) - ER at 20°
abduction (scapular plane): 35-50° (wk 6), 50-65°(wk 9), near end range/70° (wk 12) - ER at 90°
abduction: 45° (wk 6), 75° (wk 9,), near end range/80° (wk 12) 6 - IR at 20° abduction (scapular plane):
30-60°  IR stretches: towel/cane assisted hand behind back (combination of ext/IR/hor add), sidelying
sleeper stretch, cross arm stretch  If ROM is significantly less than goals, joint mobilizations may be
performed into the limited direction  Progress finger ladder in flexion and scaption terminal ranges 
Arm bike/ergometer no resistance Muscle Strength & Endurance Rotator Cuff:  Light isotonics with
emphasis on high repetitions (4 sets of 15-20 reps) and low resistance (1-2 lbs):  Sidelying ER with towel
→ progress to 1lb  Standing ER & IR with towel: pulleys or light resistance tubing  Rhythmic
stabilization techniques for rotator cuff strengthening (ER/IR at 45° abduction in scapular plane)5
Scapula:  Continue with shoulder retractions, shoulder rolls  Supine rhythmic stabilization 90-100
flexion / joint perturbations in randomized directions → progressions: eyes closed, holding medicine
ball27  Closed kinetic chain rhythmic stabilization:  Ball stabilization on wall  Static holds in push-up
position on ball  Light resistance extension, adduction, forward flexion (not past plane of body) 
Progress closed chain scapulothoracic mobility to shoulder level and then to overhead i.e.:  Quadruped
scapular protraction/retraction 90° progress to 120°  Quadruped to tripod ( 2 to 1 arm)  Standing short
lever (elbow flexed) slides up wall → long lever→ no wall support28  Strengthen scapular retractors
and upward rotators i.e.:  Prone arm raises at 0° progress to 90° and 120°  Prone or seated rows →
progress with resistance or weight  Strengthen serratus  Forward punch  Push up with plus progress
from wall to floor, on knees to feet  Supine protraction/retraction with heavier weights Proprioceptive
Retraining  Standing swiss ball on the wall at 90° flexion/scaption/abduction: circles, side to side, up
and down, alphabet→ progress 2 arms to 1 arm and ROM from 90° to 120°  Therapist assisted
joint/limb positioning with patient reproduction of position → mid ranges → end ranges→ progress to
eyes closed27  Weight-bearing activities on knees on unstable base i.e. Bosu, Wobble board, Airex pad,
slider board  Supine weighted ball drop at 90° shoulder flexion  Supine weighted ball throw/catch →
progress 2 arms to 1 arm  Quadruped maintain proper scapula position  Bodyblade: arm at side→ 30,
90, 120, 160° in scaption and frontal plane → progress using PNF patterning  Ball dribbles on wall To
increase proprioceptive input and difficulty, progression of exercises can be performed with eyes
closed5 7 Modalities  Ice 15-25 minutes 1  Biofeedback: auditory, visual, tactile or machine  Muscle
Stimulation for posterior rotator cuff Cardiovascular Fitness  Bicycle, elliptical, stairmaster, treadmill
jog→run, train specific to demand of sport

Phase III (General timeline: 12-24 weeks)

EXERCISE SUGGESTIONS: ROM  PROM/Stretching/Joint Mobilizations as needed to address any

remaining deficits Muscle Strength/Endurance/Power Rotator Cuff:  Progress ER/IR at side → to 45° →
eventually to 90°  Scapula:  Rhythmic stabilization / joint perturbations in positions of function and
vulnerability27  PNF diagonal patterns with bands/pulleys/manual resistance: 8  D1 extension (high
back hand to down to hitch hike position)  D1 flexion (hitch hike to high back hand position)  D2
extension (carry tray to hand in opposite front pocket position)  D2 flexion (hand in opposite front
pocket to carry tray position)  Continue with shoulder strengthening program as initiated in Phase II
with emphasis on faster speed, multiplanar activities which incorporate the kinetic chain Proprioceptive
Retraining (open and closed kinetic chain)  Weight-bearing activities on toes on unstable base i.e. Bosu,
Wobble board, Airex pad, slider board  Swiss ball prone walk out  U/E wobble board stability→
progress to small push-up on board Strength / Endurance / Power  Replicate ADL / work activities /
sport requirements  Progressive return to weight-lifting program for larger upper extremity muscles
(i.e. deltoid, lat dorsi, pec major): start with light weight / high reps (20-30 reps) → gradually increase
weight and decrease repetitions. Suggestions for early in Phase III (3-4 months): - Biceps/Triceps (arm at
side) - Shoulder shrugs - Rows (scapular retraction) - Lat pull downs (hands in front) - Shoulder press
with hands in front of shoulders (not abducted/externally rotated) - Push-up (only to 900 elbow flexion)
Suggestions to add for intermediate Phase III (4-5 months): - Chest press / incline - Machine / Barbell
shoulder press (no end range abduction/external rotation - Prone horizontal abduction - Prone ER at 900
abduction → progress weight as able Suggestions to add for late in Phase III (5-6+ months): - Military
Press - Flys / Reverse Flys - Dead Lifts - Power Cleans Plyometric Program (if needed)  Initiate in
intermediate to late phase III (5-6+ months): Suggestions/ideas: - Tubing plyometrics for ER/IR at 900
abduction with varying speeds - 2 handed tosses: waist/chest level→ overhead → diagonal - 1 handed
tosses: begin throw with shoulder flexion and mostly elbow extension→ progress by increasing the
amount of shoulder abduction/ER o Begin with towel, beach ball, kid’s ball, tennis ball→ progression to
lightly weighted balls (plyoballs) Cardiovascular Fitness  Train specific to demand of sport (aerobic,
anaerobic)

Rehabilitation Guidelines for Arthroscopic Capsular Shift

PHASE I (surgery to 6 weeks after surgery)

• Begin at 10 days post-operatively: sub-maximal, pain free shoulder isometrics at patient’s side for
shoulder IR and ER, flexion and extension and abduction and adduction • Passive ROM and active
assistive ROM for shoulder flexion and extension, as well as abduction and adduction with progression
to active ROM at week 6 • Hand gripping • Elbow, forearm and wrist active ROM • Cervical spine and
scapular active ROM • Desensitization techniques for axillary nerve distribution • Postural
exercisesWalking, stationary bike - sling on • Avoid running and jumping due to the distractive forces
that can occur at landing • No treadmill

PHASE II (begin after meeting Phase I criteria, usually 6 weeks after surgery)

• Active assistive and active ROM in all cardinal planes while assessing scapular rhythm • Rotator cuff
strengthening in non-provocative positions with the shoulder in 0-45° abduction • Scapular
strengthening and dynamic neuromuscular control • Cervical spine and scapular active ROM • Postural
exercises • Core• Walking, stationary bike, Stairmaster are ok • No swimming or treadmill • Avoid
running and jumping until the athlete has full rotator cuff strength in a neutral position due to the
distractive forces that can occur at landing strengthening

PHASE III (begin after meeting Phase II criteria, usually 12 weeks after surgery)

Motion • Gradually progress shoulder ER ROM with shoulder abduction to 90°, focusing primarily on
active motion Strength and Stabilization • Shoulder flexion in prone; shoulder horizontal abduction in
prone; full can exercise and D1 and D2 diagonals in standing • Resistive tubing, cable column and
dumbbell exercise with light resistance and high repetitions with shoulder IR and ER in 90° shoulder
abduction; rowing is ok too • Balance board in push-up position (with RS); prone Swiss ball walk-outs;
rapid alternating movements in supine D2 diagonal and closed kinetic chain stabilization with narrow
base of support Cardiovascular Exercise • Walking, biking, StairMaster and running are ok if the patient
has met Phase II criteria • No swimming

PHASE IV (begin after meeting Phase III criteria, usually 15 weeks after surgery)

Motion • Active ROM exercises to regain full functional shoulder ROM Strength and Stabilization •
Dumbbell and medicine ball exercises that incorporate trunk rotation and control with rotator cuff
strengthening at 90° shoulder abduction; begin working towards more functional activities by
emphasizing core and hip strength and control with shoulder exercises • Resistive tubing, cable column,
and dumbbell exercises with shoulder IR and ER in 90° shoulder abduction; rowing is ok too • Higher
velocity strengthening and control, such as inertial, plyometrics and rapid resistive tubing drills;
plyometrics should start with 2 hands below shoulder height and progress to overhead, then back to
below shoulder with one hand, progressing again to overhead Cardiovascular Exercise • Walking, biking,
StairMaster and running are ok if the patient has met Phase II criteria • No swimming

PHASE V (begin after meeting Phase IV criteria, usually 20 weeks after surgery)

Motion • Assess the whole upper quarter to assess for muscle imbalances that could lead to
compensatory or abnormal motion at the shoulder Strength and Stabilization • Dumbbell and medicine
ball exercises that incorporate trunk rotation and control with rotator cuff strengthening at 90° shoulder
abduction and higher velocities; begin working towards more sport specific activities • Initiate throwing,
swimming or overhead racquet program depending on the athlete’s sport • High velocity strengt

hening and dynamic control, such as inertial, plyometrics and rapid resistive tubing drills

Rehabilitation Guidelines for Anterior Shoulder Reconstruction with Arthroscopic Bankart

Repair
PHASE I (surgery to 6 weeks after surgery)

Suggested Therapeutic Exercise • Begin week 3, sub-maximal shoulder isometrics for IR and ER, flexion,
extension, adduction and abduction. Take caution to start gradually especially with IR to protect the
subscapularis repair • Active assisted and passive ROM for shoulder flexion, abduction and IR in painfree
ROM. ER to neutral. Progress to active ROM at week 5 • Hand gripping • Elbow, forearm and wrist active
ROM • Cervical spine and scapular active ROM • Desensitization techniques for axillary nerve
distribution • Postural exercises Cardiovascular Exercise • Walking, stationary bike - sling on. • No
swimming or treadmill • Avoid running and jumping due to the distractive forces that can occur at
landing

PHASE II (begin after meeting Phase I criteria, usually 6 weeks after surgery)

Suggested Therapeutic Exercise • Active assisted and active ROM in all cardinal planes – assessing
scapular rhythm. • Gentle shoulder mobilizations as needed • Rotator cuff strengthening in non-
provocative positions (0-45° abduction) • Scapular strengthening and dynamic neuromuscular control •
Cervical spine and scapular active range of motion • Postural exercises • Core strengthening
Cardiovascular Exercise • Walking, stationary bike, Stairmaster • No swimming or treadmill • Avoid
running and jumping until athlete has full rotator cuff strength in a neutral position due to the
distractive forces that can occur at landing

PHASE III (begin after meeting Phase II criteria, usually 10-11 weeks after surgery)

Suggested Therapeutic Exercise Motion • Posterior glides if posterior capsule tightness is present. More
aggressive ROM if limitations are still present Strength and Stabilization • Flexion in prone, horizontal
abduction in prone, full can exercises, D1 and D2 diagonals in standing • TheraBand/cable column/
dumbbell (light resistance/high rep) IR and ER in 90 abduction and rowing • Balance board in push-up
position (with rhythmic stabilization), prone Swiss ball walk-outs, rapid alternating movements in supine
D2 diagonal. Closed chain stabilization with narrow base of support Cardiovascular Exercise • Walking,
biking, Stairmaster and running (if Phase II criteria has been met) • No swimming