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Discharge Instructions & Physical Therapy Protocol for Open Rotator Cuff 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 1st 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 1st 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.

Shoulder Open Rotator Cuff Repair Rehabilitation Program

(From The Kerlan-Jobe Orthopaedic Clinic, Department of Physical Therapy; by C.E. Brewster, MS, PT; J.L. Seto, MA, PT, and A. Lum, MA, PT)

The physical therapy rehabilitation for shoulder rotator cuff repair will vary in length depending on factors such as:

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

INITIAL - 3 WEEKS POST SURGERY

  • Patient is immobilized in sling and abductor pillow for initial 3 weeks
  • Sling may be removed for gentle passive range-of-motion (ROM) exercises (flexion, abduction, and external rotation)
  • Pendulum exercise (Codman)
  • Active range-of-motion for shoulder internal/external rotation (arms are positioned at the side with elbows extended)
  • Shoulder shrug exercises
  • Ball squeezes
  • No active shoulder flexion or abduction in the first month

3 - 5 WEEKS POST SURGERY

  • Continue use of sling, no longer required to use abductor pillow
  • Use of modalities as needed (heat, ice, electrotherapy)
  • Continue passive range-of-motion exercises. Active-assistive (wall climbs, wand) and active ROM exercises may be added
  • Add joint mobilization as needed
  • Isometric exercises - internal/external rotation, abduction, flexion, and extension
  • Active internal/external rotation exercises with rubber/surgical tubing (as tolerated)
  • 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
  • Active horizontal adduction (supine) as tolerated

6 - 8 WEEKS POST SURGERY

  • Continue shoulder ROM exercises (passive, active-assistive, and active) as needed
  • Continue active internal/external rotation exercises with rubber tubing. As strength improves, progress to free weights
    • External Rotation: May be performed lying prone with arm abducted to 90° or side lying with the arm at the side. Perform movement through available range
    • Internal Rotation: Is performed supine with the arm at the side and elbow flexed at 90°
  • Active shoulder abduction from 0° to 90°
  • Add supraspinatus strengthening exercises if adequate ROM is available (0° - 90°). The movement should be pain-free and performed in the scapular plane (approximately 20° - 30° forward of the coronal plane)
  • Active shoulder flexion through available range-of-motion (as tolerated)

2 - 3 MONTHS POST SURGERY

  • Discontinue use of sling
  • 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
  • Add shoulder bar hang exercise to increase ROM in shoulder flexion and abduction (as needed)
  • Active horizontal abduction (prone)
  • Add strengthening exercises to the elbow and wrist joint (as necessary)
  • Upper extremity PNF patterns may be added. Shoulder flexion/abduction/external rotation and extension/adduction/internal rotation diagonals are emphasized

4 MONTHS POST SURGERY

  • Add advanced capsule stretches as necessary
  • Continue to progress isotonic exercises
  • Isokinetic exercises. Isokinetic strength and endurance training (high speeds-200+ degrees/second). For shoulder, internal/external rotation (arm at side), abduction/adduction, and horizontal abduction/adduction) may be added. Pre-requisite strength requirements of the rotator cuff are 5-10 pounds for external rotation and 15-20 pounds for internal rotation
  • Add arm ergometer for endurance training
  • Add military press exercises

5 MONTHS POST SURGERY

  • Perform isokinetic strength and endurance test (as tolerated). Suggested movement patterns for testing are shoulder internal/external rotation (arm at side), abduction/adduction, and horizontal abduction/adduction. The shoulder should be pain-free and have no significant amount of swelling
  • As strength improves, continue to increase weight resistance and high-speed training with isotonic and isokinetic exercises. For shoulder internal/external rotation, gradually increase the stress to the shoulder by exercising in the functional shoulder position (progress from 0° to 45° to 80° to 90° of shoulder abduction as tolerated)
  • Continue to emphasize the eccentric phase in strengthening the rotator cuff
  • Add total body conditioning program (strength and endurance). Include flexibility exercises as needed

6 MONTHS POST SURGERY

  • Continue strengthening program. Emphasis may be placed on exercising the shoulder in positions specific to the sport. Isokinetic test results for the shoulder patterns 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)
  • Skill Mastery. Begin practicing skills specific to the activity (work, recreational activity, sport, etc.). For example, throwing athletes (e.g., pitchers) may proceed to throwing program
  • Progressive Shoulder Throwing Program. Advance through the throwing sequence as needed

Guidelines

It is important to use heat before 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 (e.g., 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 (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 not more than one-half (1/2) speed. Increase the throwing time to 20-25 minutes per session

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 2 consecutive days. Then rest the arm for 1 day.

Repeat 4 times over a 12-day period, then progress to the next step if able to complete it without pain or discomfort, i.e.

  • THROW - 2 Days
  • REST - 1 Day
  • THROW - 2 Days
  • REST - 1 Day
  • THROW - 2 Days
  • REST - 1 Day
  • THROW - 2 Days
  • REST - 1 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 2 consecutive days. Then rest the arm for 1 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 2 consecutive days. Rest the arm for 1 day.

Repeat the same routine 4 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 2 consecutive days. Rest 1 day. Repeat this step over the next 2 weeks.

11 MONTHS POST SURGERY

Step 5

Return to throwing from your normal position (i.e., mound). The throw should be at one-half (1/2) to three-fourths (3/4) speed with emphasis on technique and accuracy. Throw for 2 consecutive days, and then rest the arm for 1 day. A throwing session should not be more than 25 minutes. Repeat this step over the next 2 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-fourths to seven-eighths speed. This should be done following the same sequence, throwing for 2 consecutive days and resting for 1 day over a 12-day period. Throwing sessions should not be more than 30 minutes.

12 MONTHS POST SURGERY

Step 7

Continue to throw from your normal position at three fourths to full speed. This should be done over the next 2 weeks following the same pattern. Slowly increase the time throwing from your normal position.

12 1/2 - 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 the normal pitching regime or routine based on input from the team physician, physical therapist, athletic trainer, coach, but most important of all, the athlete.