Discharge Instructions & Physical Therapy Instructions Arthroscopic & Open Cuff Repair of Subscapularis Muscle

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
• 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
• 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
• 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)
• While your sling is off you should flex and extend your elbow and wrist - (3x a day for 15 repetitions) to avoid elbow stiffness
• 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
• 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.

Physical Therapy Instructions Following Arthroscopic or Open Repair of the Subscapularis Muscle

2 TO 5 WEEKS POST-SURGERY

• Continue using sling. Use the abductor pillow only at night
• No overhead motion during the first 5 weeks
• You will begin formal physical therapy at 3 to 4 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)
• 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°
• As strength improves, progress to free weights with external / internal rotation

• 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

Subscapularis specific exercises taken from Decker MJ, Tokish JM, Ellis HB, Torry MR, Hawkins RJ.Subscapularis Muscle Activity During Selected Rehabilitation Exercises. Am. J. Sports Med. 2003; 31; 126