Multidirectional Instability

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^stpostoperative visit.

COMFORT
- Cold Therapy
  - If you elected to receive the circulating cooling device, this can be used continuously for the first 3 days, (while the initial post-op dressing is on). After 3 days, the cooling device should be applied 3 times a day for 20-30 minute intervals.
  - If you elected to receive the gel wrap, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the gel wrap.
  - If you elected to use regular ice, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the gel wrap.
- Medication
  - Pain Medication-Take medications as prescribed, but only as often as necessary. Avoid alcohol and driving if you are taking pain medication.
    - You have been provided a narcotic prescription postoperatively. Use this medication sparingly for moderate to severe pain.
    - You are allowed two (2) refills of your narcotic prescription if necessary.
    - When refilling pain medication, weaning down to a lower potency or non-narcotic prescription is recommended as soon as possible.
    - Extra strength Tylenol may be used for mild pain.
    - Over the counter anti-inflammatories (Ibuprofen, Aleve, Motrin, etc.) shoulder be avoided for the first 4 weeks following surgery.
  - Anti-coagulation medication: A medication to prevent post-operative blood clots has been prescribed (Aspirin, Lovenox, etc.) This is the only medication that MUST be taken as prescribed until directed to stop by Dr. Forsythe.
  - Nausea Medication – Zofran (Odansetron) has been prescribed for nausea. You may take this as needed per the prescription instructions.
  - Constipation Medication -Colace has been prescribed for constipation. Both your pain medication and the anesthesia can cause constipation. Take this as needed.
- 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^stpostoperative visit. The sling may be removed for exercises.
- Range-of-Motion Exercises
  - While your sling is off you should flex and extend your elbow and wrist – (3x a day for 15 repetitions) to avoid elbow stiffness
  - You can also shrug your shoulders.
  - 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
- Bathing - Tub bathing, swimming, and soaking of the shoulder should be avoideduntil allowed by your doctor - Usually 2-3 weeks after your surgery. Keep the dressing on, clean and dry for the first 3 days after surgery.
  - You may shower 3 days after surgery with band-aids on. Apply new band-aids after showering.
- Dressings - Remove the dressing 3 days after surgery. You may apply band-aids to the small incisions around your shoulder

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

CALL YOUR PHYSICIAN IF:
- Pain in your shoulder 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.
- You have a temperature elevation greater than 101°
- You have pain, swelling or redness in your arm or hand.
- You have numbness or weakness in your arm or hand.

RETURN TO THE OFFICE
- Your first return to our office should be within the first 1-2 weeks after your surgery. Call your physician’s office to make an appointment for this first post-operative visit.

REHABILITATION PROGRAM:

Arthroscopic Stabilization of Multidirectional Instability

NOTE: The following instructions are intended for your physical therapist and should be brought to your first physical therapy visit.

1 – 4 Weeks Arm held in sling, slightly abducted, neutral rotation

Gentle isometric exercises, pendulum exercises

Hand, Wrist and Elbow ROMs

Wound care and hygiene as needed

May remove sling for exercises, showering and dressing

4-12 Weeks Start Physical therapy

12 Weeks Progressive strengthening

9 – 12 Months Contact sports

0 TO 4 WEEKS POST-SURGERY

This portion of the rehab protocol is made possible with the assistance of a friend or a family member. All active range of motion exercises should be avoided. This relative immobilization period is critical for the healing of the soft tissues and promoting a shoulder without instability. Remain in the sling with abduction pillow at all times except with exercises and hygiene.
10 Days – 3 Weeks
- Gentle isometric exercising and ROM of the hand, wrist and elbow
3 – 4 Weeks
- Range of motion goals: Ext. rotation to 20°, forward elevation 110°. Isometric strengthening and ROM of the hand, wrist and elbow

4 TO 12 WEEKS POST-SURGERY

We will begin formalized physical therapy 4 weeks after surgery. The goals by the end of the second phase of the rehabilitation process is to restore range of motion of the shoulder (both active and passive) within the limits of external rotation as determined by Dr. Forsythe. The main objective is to regain motion over several months because progressing too quickly may lead to recurrent instability.

4-6 Weeks
- rotation to 30°, forward elevation 130° by the 6^th week
- Resistance exercises begun
- Active ROM against gravity is initiated
- No IR or ER resistance exercises
- Periscapular isometrics
6-8 Weeks
- rotation to 45°, forward elevation 160° by the 8^th week
- Resistance exercises
- May begin IR/ER exercises against gravity
- Periscapular isometrics
- Discontinue sling/shoulder immobilizer at 6 weeks
8-12 Weeks
- rotation – increase gradually from 45° with full forward elevation
- May start mobilizing into IR/ER with arm abducted
- Strengthening begins during this phase with arm in neutral below 90°- focus on the RTC musculature
- Continue periscapular isometrics

3 TO 6 MONTHS POST-SURGERY

This phase is the functional phase of the rehabilitation protocol. We are trying to achieve aggressive strengthening exercises for the shoulder and scapular muscles. We will progress to functional activities needed for ADL’s and sports. Functional progression is stressed during this phase.
Plyometric program
- More aggressive strengthening program with high load, low repetition as tolerated
- Overhead lifting/traction as tolerated at 4 months
- Exercises
  - No push-ups, pull-ups until 4 months postop
  - Throwing- Started between 4-6 months as determined by Dr. Forsythe
  - Return to sport at 4-6 months as determined by Dr. Forsythe

> 6 MONTHS POST-SURGERY