Subscapularis Tendon Repair

• 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 1-2 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 Subscapularis Tendon Repair

2 to 5 Weeks Post-Surgery

• Continue using sling. Use the abductor pillow at all times.
• No overhead motion during the first 5 weeks.
• LIMIT External rotation to 30 degrees for 4 weeks.
• You will begin formal physical therapy at 1 to 2 weeks post-surgery.
• Use of modalities as needed (heat, ice, electrotherapy)
• Apply ice following treatment and home exercises for a maximum of 20 minutes.
• Continue gentle pendulum exercises for the first 3 weeks.
• Continue passive range of motion exercises for the first 3 weeks but do not exceed the limits placed on you by your doctor.
• At 3 weeks begin passive range of motion exercises in all planes to an endpoint of a comfortable stretch.
• At 3 weeks active-assistive exercises (wall climbs, wand exercises) and active ROM exercises may be added.
• Isometric exercises – internal/external rotation, abduction, flexion, extension.
• Active shoulder extension lying prone or standing (bending at the waist) – avoid the shoulder extended position by preventing arm movement beyond the plane of the body.

6 to 8 Weeks Post-Surgery

• Discontinue use of sling.
• Continue shoulder ROM exercises (passive, active-assistive and active) as needed.
• Begin active internal / external rotation exercises with rubber bands / surgical tubing (as tolerated)
• As strength improves, progress to free weights with external / internal rotation:

External Rotation: perform lying prone with arm abducted to 90° or side-lying with arm at the side – perform movement through comfortable range.

Internal Rotation: perform supine with arm at the side and elbow flexed to 90°.

• Active shoulder abduction from 0°to 90°.
• Active shoulder flexion through available range of motion (as tolerated).

2 to 3 Months Post-Surgery

• Continue shoulder ROM exercises (as needed) – patient should have full passive and active ROM.
• Continue isotonic exercises with emphasis on eccentric strengthening of the rotator cuff.
• Add push-ups -- movement should be pain free. Begin with wall push-ups. As strength improves, progress to floor push-ups (modified – hands and knees, or military – hands and feet) as tolerated.
• Active horizontal abduction (prone).
• Add subscapularis specific strengthening. Begin with forward punch and progress through internal rotation (low, mid and high), dynamic hug and diagonals.
• Add upper body ergometer for endurance training.
• Add gentle plyometrics.

4 Months Post-Surgery

• Add advanced capsule stretching, as necessary.
• Continue to progress isotonic exercises.
• Add military press exercise.
• Progress in strengthening of subscapularis specific exercises.
• Add pitch-back beginning with a light ball.
• Add total body conditioning program.

5 Months Post-Surgery

• Continue strengthening program – emphasis may be placed on exercising the shoulder in positions specific to the sport.
• Continue total body conditioning program with emphasis on the shoulder (rotator cuff).
• Skill mastery – begin practicing skills specific to the activity (work, recreational activity, sports, etc.) -- for example, throwing athletes (e.g., pitchers, quarterbacks) may proceed to throwing program.

• May add progressive shoulder throwing program – advance through the throwing sequence, as needed.

Forward Punch

• Stand with back to the wall, knees slightly bent and feet shoulder width apart in a split stance.
• Grasp the resistance device with arm at the side of the body with elbow flexed to 90°, flex the shoulder, and extend the elbow until the hand reached the height of the xyphoid process with the elbow slightly flexed.
• Return to the initial position by extending the shoulder and flexing the elbow.

Internal Rotation Low / Mid / High

• To be performed at three different positions of shoulder abduction without arm support.
• Internal rotation low begins a 0°abduction with the elbow at 90° flexion, shoulder at 0° abduction, and the humerus in 70° external rotation.
• Internally rotate the humerus against elastic resistance from 70°of external rotation to 70° of internal rotation.
• Return to the starting position by externally rotating the humerus.
• The internal rotation mid is performed the same way but with the shoulder abducted 45°.
• The internal rotation high is performed the same way but with the shoulder abducted to 90°.

Dynamic Hug

• Stand with back to the wall, knees slightly bent and feet shoulder width apart.
• Grasp the elastic resistance device with elbow flexed at 45°, the arm abducted to 60°, and the shoulder internally rotated to 45°.
• Perform a hugging motion by horizontally flexing the humerus in an imaginary arc led by your hands.
• Once your hands touch together, slowly return to the starting position by following the same imaginary arc.

Diagonal

• Stand with back to the wall, knees slightly bent and feet shoulder width apart.
• Grasp the handle of the elastic resistance device at shoulder height with the elbow slightly flexed and the humerus in neutral position, abducted to 90°.
• Horizontally flex, adduct and internally rotate the humerous until the hand reaches the anterior superior iliac spine opposite to that of the resistance.
• Progressively internally rotate the humerus 90°throughout the entire movement, beginning from the initial position and ending at the moment of touching the anterior superior iliac spine.
• Once the hand touches the anterior superior iliac spine, slowly return to the starting position.