Discharge Instructions & Physical Therapy Instructions for Arthroscopic Posterior Stabilization

Initial recovery after shoulder surgery entails healing, controlling swelling and discomfort and regaining some shoulder motion. The following instructions are intended as a guide to help you achieve these goals until your 1 st postoperative visit.

Comfort

Although surgery uses only a few small incisions around the shoulder joint, swelling and discomfort can be present. To minimize discomfort, please do the following

• Ice - Ice controls swelling and discomfort by slowing down the circulation in your shoulder. Place crushed ice in plastic bag over your shoulder for no more than 20 minutes, 3 times a day
• Pain Medication - Take medications as prescribed, but only as often as necessary. Avoid alcohol and driving if you are taking pain medication
• Antibiotic Medication - If an antibiotic has been prescribed, start taking the day of your surgery. The first dose should be around dinnertime. Continue taking until the prescription is finished
• Sling - A sling has been provided for your comfort and to stabilize your shoulder for proper healing. Continue wearing the sling for a period of approximately six weeks or until Dr. Forsythe directs you to stop
• Driving -Driving is NOT permitted as long as the sling is necessary

Activities

• You are immobilized with a sling and abductor pillow, full time, for approximately the first 6 weeks. Your doctor can tell you when you can discontinue use of the sling at your 1 st postoperative visit. The sling may be removed for exercises
• Your sling may be removed for gentle PASSIVE range-of-motion (PROM) exercises. (SOMEONE ELSE MOVES YOUR SHOULDER). This should be done 3x a day /15 repetitions (ABDUCTION ONLY - away from your body)
• Active range-of motion (AROM - you move your shoulder) should be performed for shoulder internal/external rotation. Keep elbow positioned at the side and flexed at 90 ° so forearm is parallel to the floor. This should be done within a comfortable range until you feel slight pain (3x a day for 15 repetitions). You can shrug your shoulders
• While your sling is off you should flex and extend your elbow and wrist - (3x a day for 15 repetitions) to avoid elbow stiffness
• Ball squeezes should be done in the sling (3x a day for 15 squeezes)
• You may NOT move your shoulder by yourself in certain directions. NO active flexion (lifting arm up) or abduction (lifting arm away from body) until Dr. Forsythe or your therapist gives permission. These exercises must be done by someone else (Passive Range of Motion)
• Physical therapy will begin approximately 3 - 4 weeks after surgery. Make an appointment with a therapist of your choice for this period of time. You have been given a prescription and instructions for therapy. Please take these with you to your first therapy visit
• Athletic activities such as throwing, lifting, swimming, bicycling, jogging, running, and stop-and-go sports should be avoided until cleared by Dr. Forsythe

Wound Care

• Keep the dressing on, clean and dry for the first 3 days after surgery
• Remove the dressing 3 days after surgery. The steri-strips (small white tape that is directly on the incision areas) should be left on until the first office visit. You may apply band-aids to the small incisions around your shoulder
• You may shower 5 days after surgery with band-aids on. Apply new band-aids after showering
• Tub bathing, swimming, and soaking should be avoided for two weeks after your surgery

Eating

• Your first few meals after surgery should include light, easily digestible foods and plenty of liquids, as some people experience slight nausea as a temporary reaction to anesthesia

Call your physician if

• Pain persists or worsens in the first few days after surgery
• Excessive redness or drainage of cloudy or bloody material from the wounds. (Clear red tinted fluid and some mild drainage should be expected). Drainage of any kind 5 days after surgery should be reported to the doctor
• Temperature elevation greater than 101°
• Pain, swelling, or redness in your arm or hand
• Numbness or weakness in your arm or hand

Return to the office

• Your first return to the office should be within the first 1 - 2 weeks after your surgery. Call Dr. Forsythe's office to make your first postoperative appointment

Posterior Shoulder Subluxation/Dislocation Surgical Repair - Rehabilitation Program

The physical therapy rehabilitation program following shoulder posterior subluxation/dislocation surgical repair will vary in length depending on factors such as:

• Degree of shoulder instability/laxity
• Acute vs. chronic condition
• Length of time immobilized
• Strength/range-of-motion status
• Performance/activity demands

INITIAL 3 WEEKS POST SURGERY

• The patient is immobilized in a sling with abductor pillow during the initial 6 weeks post surgery
• Sling may be removed for gentle passive range-of-motion exercises for shoulder flexion, abduction, horizontal abduction and external rotation. Perform 2 times per day with emphasis on protecting the posterior joint capsule
• Ball squeezes
• No active shoulder elevation or rotation during the first month

3 - 5 WEEKS POST SURGERY

• Patient must continue to wear sling with abductor pillow
• Use of modalities as needed (heat, ice, electrotherapy)
• Continue gentle passive range-of-motion exercises. Add range-of-motion exercises for shoulder internal rotation, as needed
• Add active-assistive range-of-motion exercises (i.e., wand exercises)
• Add gentle joint mobilization, as needed
• Shoulder shrug exercises
• Isometric internal and external rotation with arm at side and elbow flexed at 90° may be added according to the patient’s tolerance
• Note: The shoulder position may be adjusted to allow a pain free muscle contraction to occur
• Isometric shoulder flexion and extension may be added as needed
• As strength improves, active external rotation may be added. Use surgical or rubber tubing for resistance. If there is pain with active movements, continue with isometric strengthening
• Active horizontal abduction - lying prone. Restrict movement from 45° of horizontal adduction to full horizontal abduction to avoid excessive stress to the posterior capsule

6 - 8 WEEKS POST SURGERY

• Discontinue shoulder sling and abductor pillow
• Continue passive and active-assistive range-of-motion exercises. May add wall climbs for shoulder flexion and abduction
• Continue mobilization, as needed
• As strength improves, progress to free weights for external rotation in prone lying position with arm abduction to 90° or side-lying with arm at side
• Prone: Perform combined movements of horizontal abduction followed by external rotation to protect the posterior capsule
• Side-lying: Limit the degrees of internal rotation to protect the posterior capsule
• Add supraspinatus exercises if movement is pain free and adequate range-of-motion is available (0° - 90°). Shoulder is positioned in the scapular plane approximately 20°-30° forward of the coronal plane
• Add active internal rotation using free weights. Movement is performed supine with the arm at the side and the elbow flexed at 90°
• Active shoulder flexion through available range-of-motion
• Active shoulder abduction to 90°

2 - 3 MONTHS POST SURGERY

• Continue range-of-motion and mobilization, as needed. Patient should have full passive and active range-of-motion
• Add shoulder stretch (i.e., anterior cuff/capsule or posterior cuff/capsule), as needed
• Add push-ups (after 3 months). Movement should be pain free with emphasis on protecting the posterior joint capsule. Shoulders are positioned in 80° to 90° of abduction. Caution is applied during the ascent phase of the push-up to avoid excessive stress to the posterior capsule. Do not raise the body beyond the scapular plane. Begin with wall push-ups. As strength improves, progress to floor push-ups (modified - hands and knees or military - hands and feet), as tolerated by the patient
• Continue isotonic strengthening with emphasis on the rotator cuff and posterior deltoid
• Active internal rotation using surgical or rubber tubing may be added. Range of movement may be limited to avoid excessive stress to the posterior joint capsule
• Proprioceptive neuromuscular facilitation (PNF) upper extremity patterns may be added. Emphasis is on the flexion/abduction/external rotation diagonal
• Starting Position: Caution is applied to protect the posterior capsule from excessive stress. Adjustments are made by starting one-quarter of the way in the diagonal
• Range-of-Movement: Movement will be limited to the latter three-quarter range in the diagonal to full flexion/abduction/external rotatio
• Horizontal abduction may be performed through an increased range (starting position at 90° of horizontal adduction, as tolerated)

4 MONTHS POST SURGERY

• Continue to progress weights, as tolerated (i.e., rotator cuff, horizontal abduction/adduction, flexion, abduction, etc.). Emphasis may be placed on the eccentric phase of contraction in strengthening the rotator cuff
• Active horizontal adduction may be added
• Add arm ergometer for endurance exercises
• Isokinetic strengthening and endurance exercises (high speeds - 200+ degrees/second) for shoulder internal/external rotation (arm at side) and horizontal abduction may be added. Prerequisite strength requirements of the rotator cuff are 5-10 pounds for external rotation and 15-20 pounds for internal rotation. The shoulder should be pain free and have no significant amount of swelling

5 MONTHS POST SURGERY

• Isokinetic Test. Perform isokinetic strength and endurance test for the following suggested movement patterns: internal/external rotation (arm at side), horizontal abduction, and abduction/adduction
• Continue to progress isotonic and isokinetic exercises
• Continue to emphasize the eccentric phase in strengthening the rotator cuff
• Isokinetic exercises for shoulder flexion/extension and abduction/adduction may be added
• Add military press. Press the weight directly over or behind the head with low wts
• Continue arm ergometer
• Add total body conditioning with emphasis on strength and endurance. Include flexibility exercises, as needed

6 MONTHS POST SURGERY

• Isokinetic Test. The second isokinetic test for shoulder internal/external rotation, horizontal abduction/adduction, and abduction/adduction is administered. For internal/external rotation, the shoulder may be tested in the functional position (80° to 90° of abduction). Test results for internal/external rotation and horizontal abduction should demonstrate at least 80% strength and endurance (as compared to the uninvolved side) before proceeding with exercises specific to the activity setting
• Continue total body conditioning program with emphasis on the shoulder (rotator cuff, posterior deltoid)
• Skill Mastery. Begin practicing skills specific to the activity (work, recreational activity, sports, etc.). For example, throwing athletes (i.e., pitchers) may proceed to throwing program

6 MONTHS CONTINUES

• Progressive Shoulder Throwing Program. Advance through the sequence, as needed
• Guidelines: It is important to use heat prior to stretching (i.e., hot pack, whirlpool, hot shower, etc.). Heat increases circulation and activates some of the natural lubricants of the body. Perform stretching exercises after applying the heat modality and then proceed with the throwing program. Use ice after throwing to reduce cellular damage and decrease the inflammatory response to microtrauma. Proceed with tossing the ball (no wind-up) on alternate days, not more than 20 feet for 10-15 minutes

6-1/2 MONTHS POST SURGERY

• Easy tossing 30 - 40 feet, no wind-up, on alternate days, for 10 - 15 minutes

7 MONTHS POST SURGERY

• Add other endurance activities (i.e., jogging, biking) to the total body conditioning program
• Continue stretching and strengthening exercises to the wrist, elbow, and shoulder
• Chin-up exercises
• Swimming may be added as part of the exercise program (the butterfly stroke is not recommended)
• Lob the ball (playing catch with an easy wind-up) on alternate days, throwing the ball not more than 30 feet. Lobbing should be limited to 2-3 times per week and 10-15 minutes per session

8 MONTHS POST SURGERY

• Increase the throwing distance to 40 feet while still lobbing the ball (easy wind-up). Alternate days for the throwing and strengthening program. Increase the throwing time to 15-20 minutes per session

8-1/2 MONTHS POST SURGERY

• Increase the throwing distance to 60 feet while still lobbing the ball with an occasional straight throw at no more than one-half speed. Increase the throwing time to 20 - 25 minutes per session

PROGRESS TO THE FOLLOWING ROUTINE

9 MONTHS POST SURGERY - STEP 1

• Perform long, easy throws from the mid-outfield (150-200 feet) getting the ball barely back to home plate on 5-6 bounces. This is to be performed for 20-25 minutes per session on two consecutive days. Then rest the arm for one day. Repeat four times over a 12 day period then progress to the next step if able to complete it without pain or discomfort, i.e.

• THROW Two Days
• REST One Day
• THROW Two Days
• REST One Day
• THROW Two Days
• REST One Day
• THROW Two Days
• REST One Day

If problems arise, contact your physical therapist, athletic trainer, or physician.

9-1/2 MONTHS POST SURGERY - STEP 2

• Long, easy throws from the deepest portion of the outfield, with the ball barely getting back to home plate on numerous bounces. This is to be performed for 25-30 minutes per session on two consecutive days. Then rest the arm for one day. Repeat the routine over a 12-day period and progress to the next step, if there is no pain or discomfort

10 MONTHS POST SURGERY - STEP 3

• Stronger throws from the mid-outfield, getting the ball back to home plate on 1-2 bounces. This should be performed approximately 30-35 minutes per session on two consecutive days. Rest the arm for one day. Repeat the same routine four times over a 12-day period. If there is no pain or discomfort, progress to the next step

10-1/2 MONTHS POST SURGERY - STEP 4

• Short, crisp throws with a relatively straight trajectory from the short outfield on one bounce back to home plate. These throws are to be performed not more than 30 minutes on two consecutive days. Rest one day. Repeat this step over the next two weeks

11 MONTHS POST SURGERY - STEP 5

• Return to throwing from your normal position (i.e., mound). The throw should be at one-half to three-quarter speed with emphasis on technique and accuracy. Throw for two consecutive days then rest the arm for one day. A throwing session should not be more than 25 minutes. Repeat this step over the next two weeks, and then advance if there is no pain or discomfort

11-1/2 MONTHS POST SURGERY - STEP 6

• Throw from your normal position at three-quarter to seven-eighths speed. This should be done following the same sequence, throwing for two consecutive days and resting for one day over a 12-day period. Session should not be more than 30 minutes

12 MONTHS POST SURGERY - STEP 7

• Continue to throw from your normal position at three-quarter to full-speed. This should be done over the next two weeks following the same pattern. Slowly increase the time throwing from your normal position

12-1/2 TO 14 MONTHS POST-SURGERY - STEP 8

• Simulate game-day situation. Warm up with appropriate number of pitches and throw for an average amount of innings taking usual rest breaks between innings. Repeat simulation a couple of times with 3 - 4 days rest. Return to normal pitching regimen or routine based on input from the team physician, physical therapist, athletic trainer, coach, and most important of all, the athlete