Therapist Protocols

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Goals & Guidelines:

Remove sling after the first postoperative day. Patients may use arm for all ADL’s. The goal of the postop rehabilitation is to maintain this ROM gained in the operating room with long slow stretches in all planes to prevent recurrence. It should be emphasized to the patient that these stretches should be performed 2-3 times daily at home. Each session should last 20 minutes. Instruct the patient on the use of heat and analgesics 30 minutes prior to stretching. Emphasize holding each stretch for at least 10 seconds. The most important time is the first 6 weeks. If the patient does not get FROM in the first 6 weeks, then it will be very difficult to obtain it thereafter. Periscapular and postural strengthening exercises may be initiated once FROM is attained. Make sure to pay close attention to diabetic patients, as they will tend to have higher recurrence rates and thus need to be especially diligent with the stretching.

0-2 weeks

• Begin passive supine FE-ER to full, AROM in all planes, ER with stick, IR behind the back and Cross body adduction
• Encourage AAROM with HOME PULLEY
• D/C sling postoperative day 1

2-6 weeks

• Begin Alternate Internal Rotation Stretch, Overhead Pulley, Sleeper stretch, Wall slide into Scaption, ER at the doorway, Hand across chest

6-12 weeks

• Start 4 way shoulder resistive band strengthening and periscapular strengthening exercises working on proper joint kinematics.

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Pathology and Treatment:  

Operative intervention is typically indicated in acute rotator cuff tears especially in younger and more active patients and in chronic tears that have failed nonoperative treatment. There are several repair techniques, but we usually repair these tears arthroscopically with a two row technique which has been shown to have improved biomechanical strength and surface area for healing. It is cliché to say that every tear is a little different, but in many respects this is true. The tendons can be torn from the bone (most common) and within its substance. The tears can also have different shapes and tissue quality.

The rotator cuff tendons are repaired to the bone and to themselves. The quality of the repair is determined by the quality of the bone and tendon tissue and dictates how and when therapy is performed. Most of the time the patient will have arthroscopic pictures of their own surgery which can be reviewed with them if desired.  

At the time of the rotator cuff repair other procedures might need to be performed. These can include a subacromial decompression which typically involves removing any bone spurring and making ample space for the rotator cuff. It can also include repairing the biceps tendon and cleaning up any other damaged tissue.

Goals & Guidelines:

Obtain range of motion (ROM) first then proceed to strengthening. In general, it takes about 6-8 weeks for the tendon tissue to heal enough to begin strengthening. Therefore we have to be careful with the range of motion exercises in that first phase of therapy which is 6-8 weeks. Remember that the goal of the first 6-8 weeks is to not re-tear the rotator cuff and get some ROM (a shoulder with an intact rotator cuff with some stiffness is easier to manage than a shoulder with re-torn rotator cuff with dysfunction). The patient is allowed to use the operative arm for waist level activities such as using a computer, countertop level activities, and personal hygiene care but is to do no lifting, pushing or pulling with the arm nor reaching behind one’s back. Shoulder immobilizer/sling needs to be worn when sleeping or when outside the home for the first 6-8 weeks. When the patient is at home, the sling should be worn when they are up and walking around but may be removed when they are seated. Most patients are more comfortable sleeping in a recliner for the first few weeks, but may sleep in a bed when comfortable. While sleeping the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). 

A multimodal approach is used to manage the discomfort which typically includes NSAID’s like ibuprofen, ice or cryotherapy, and narcotics. It is preferable to discontinue the use of narcotics as soon as possible and switch to Tylenol or other less addictive medications.

The second phase of therapy focuses on regaining the remaining range of motion deficits, including internal rotation, and the initiation of strengthening. At no point should the patient be asked to use a UBE machine or cycling with the arms because this is a repetitive activity that stresses the repair. Pain medication of some sort can be taken prior to therapy.  The patient should perform their stretching program 1 time per day for the first 6 weeks and then 2 times per day after the 6 week point until FROM is obtained. Their strengthening program should be performed every other day once it is started. Expect maximum medical improvement 5-6 months after surgery. It is important to note that everyone is not the same, nor are all rotator cuff tears the same or repaired the same fashion. Everyone progresses at different rates depending on age, past medical history, current health status, smoking, etc…These are only guidelines and not set in stone. If the patient is not progressing as he/she should, please contact us.

The patient with concomitant frozen shoulder can be a very difficult situation. This is more common in diabetics and middle aged females but can occur in males as well.  Sometimes we have to treat these shoulders in a staged fashion by performing extensive releases first and obtaining FROM and then coming back at a later date and performing the repair. If the ROM loss is severe this is probably the best option but if the ROM loss is mild, we may elect to do the releases and the repair at the same time to try to save the patient from a second operation. The only caveat is that the therapy afterward might be difficult as the patient is more prone to getting stiff again secondary to the pre-existing frozen shoulder. If this is the case, we may ask that the passive ROM be near full immediately postop but this will be relayed to you. Frozen shoulder is common in some patients and is not the fault of the patient or therapist.

0 – 2 Weeks

• Pendulum and Active ROM elbow and hand exercises only

2 -4 Weeks

• Passive Supine Forward Elevation and Passive External Rotation exercises may be performed by a therapist or family member or using the opposite arm to raise the operative arm. It is imperative that the patient and family member understands the therapy protocol and is able to demonstrate that he/she can perform the exercises, as they are responsible for performing these at home. Ten reps of each exercise is done one time per day. Stress to the patient that there should be no active use of the operative shoulder with these exercises…it is being passively stretched only.
• Start working on scapular stabilization for protraction, retraction, elevation and depression.

4-6 Weeks

• Start Supine Active Assisted Forward Elevation (SAAFE)
• Start table slides

6 – 8 Weeks

• Start internal rotation stretching behind the back.  It is easy to teach the patient how to use a belt or towel in the nonoperative arm to pull the operative arm up their back.  Pulleys can also be used for this.
• Supine Active Forward Elevation (SAFE).
• Start using pulleys for forward elevation.

8 – 12 Weeks

• Start Active forward elevation using good mechanics. Set the shoulder blades by retracting them first. Make sure the patient is not using any trapezial substitution. These should be performed with the thumb up.
• Progress to Wall Slide into Scaption (using the wall as a support). 
• Progress to Active Range of Motion in abduction, and scaption with the elbow flexed to decrease the moment arm for the deltoid and RC. If minimal to no soreness and no substitution patterns are seen you may begin strengthening with theraband.
• If good form and mechanics are observed you may begin Standing Overhead Reach.
• Progress to light dumbbell strengthening

12 – 16 Weeks

• Continue more strengthening focusing on deltoid and RC and periscapular strengthening, resisted abduction in scapular plane, and neuromuscular control.
• Continue stretching which can be more aggressive at this point.

16-20 Weeks

• Strengthening can include light bench press (being careful not to extend the shoulder). Dumbbell bench on the floor can minimize this extension. Can start lat pulls and seated rows.
• Once good strength is obtained, sport specific exercise such as concentric and eccentric resisted throwing, rebounder throwing, swimming and ground strokes can be started.
• Golfers can start swinging a golf club and work on swing mechanics
• Emphasize proper mechanics for the patient’s desired activities (golf, overhead throwing, etc.)

20 Weeks

• May return to sport and other activities.

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Pathology and Treatment:  

Massive tears are defined by the amount of tissue that is torn. There are 4 rotator cuff tendons and massive tears involve at least 2 of the 4. The repairs take more time to repair and heal. Operative intervention is typically indicated in acute tears especially in younger and more active patients and in chronic tears that have failed nonoperative treatment. There are several repair techniques, but even in massive tears, we usually repair these tears arthroscopically with a two row technique which has been shown to have improved biomechanical strength and surface area for healing. It is cliché to say that every tear is a little different, but it many respects this is true. The tendons can be torn from the bone (most common) and within its substance. The tears can also have different shapes and tissue quality. Some patients are placed on the large/massive protocol not because of tear size but because of tissue quality.

The rotator cuff tendons are repaired to the bone and to themselves. The quality of the repair is determined quality of the bone and tendon tissue and dictates how and when therapy is performed. Most of the time the patient will have arthroscopic pictures of their own surgery which can be reviewed with them if desired. 

At the time of the rotator cuff repair other procedures might need to be performed. These can include a subacromial decompression which typically involves removing any bone spurring and making ample space for the rotator cuff. It can also include repairing the biceps tendon and cleaning up any other damaged tissue.

Goals & Guidelines:

Obtain range of motion (ROM) first then proceed to strengthening. In general it takes about 8-10 weeks for the tendon tissue to heal enough to begin strengthening.  Therefore we have to be careful with the range of motion exercises in that first phase of therapy which is 8-10 weeks. Remember that the goal of the first 8-10 weeks is to not re-tear the rotator cuff and get some ROM (a shoulder with an intact rotator cuff with some stiffness is easier to manage than a shoulder with re-torn rotator cuff with dysfunction). The patient is allowed to use the operative arm for waist level activities such as using a computer, countertop level activities, and personal hygiene care but is to do no lifting, pushing or pulling with the arm nor reaching behind one’s back. Shoulder immobilizer/sling needs to be worn when sleeping or when outside the home for the first 8-10 weeks. When the patient is at home, the sling should be worn when they are up and walking around but may be removed when they are seated. Most patients are more comfortable sleeping in a recliner for the first few weeks, but may sleep in a bed when comfortable. While sleeping the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). 

A multimodal approach is used to manage the discomfort which typically includes NSAID’s like ibuprofen, ice or cryotherapy, and narcotics. It is preferable to discontinue the use of narcotics as soon as possible and switch to Tylenol or other less addictive medications.

The second phase of therapy focuses on regaining the remaining range of motion deficits, including internal rotation, and the initiation of strengthening. At no point should the patient be asked to use a UBE machine or cycling with the arms because this is a repetitive activity that stresses the repair. Pain medication of some sort can be taken prior to therapy.  The patient should perform their stretching program 1 time per day for the first 8 weeks and then 2 times per day after the 8 week point until FROM is obtained. Their strengthening program should be performed every other day once it is started. Expect maximum medical improvement 6-8 months after surgery. It is important to note that everyone is not the same, nor are all rotator cuff tears the same or repaired the same fashion. Everyone progresses at different rates depending on age, past medical history, current health status, smoking, etc…These are only guidelines and not set in stone. If the patient is not progressing as he/she should, please contact us.

0-2 Weeks

• Pendulums, Elbow and hand ROM ONLY

2-4 Weeks

• Continue Pendulum exercises, GENTLE passive supine forward elevation to 90 degrees-external rotation to 30 degrees

4-6 Weeks

• Passive Supine Forward Elevation and Passive External Rotation exercises may be performed by a therapist or family member or using the opposite arm to raise the operative arm. It is imperative that the patient and family member understands the therapy protocol and is able to demonstrate that he/she can perform the exercises, as they are responsible for performing these at home. Ten reps of each exercise is done one time per day. Stress to the patient that there should be no active use of the operative shoulder with these exercises…it is being passively stretched only.
• Start working on scapular stabilization for protraction, retraction, elevation and depression.

6-8 Weeks

• Start Supine Active Assisted Forward Elevation (SAAFE)
• Start table slides

8-10 Weeks

• Start internal rotation stretching behind the back. It is easy to teach the patient how to use a belt or towel in the nonoperative arm to pull the operative arm up their back. Pulleys can also be used for this.
• Supine Active Forward Elevation (SAFE).
• Start using pulleys for forward elevation.

10-14 Weeks

• Start Active forward elevation using good mechanics. Set the shoulder blades by retracting them first. Make sure the patient is not using any trapezial substitution. These should be performed with the thumb up.
• Progress to Wall Slide into Scaption (using the wall as a support). 
• Progress to Active Range of Motion in abduction, and scaption with the elbow flexed to decrease the moment arm for the deltoid and RC. If minimal to no soreness and no substitution patterns are seen you may begin strengthening with theraband.
• If good form and mechanics are observed you may begin Standing Overhead Reach.
• Progress to light dumbbell strengthening

14-18 Weeks

• Continue more strengthening focusing on deltoid and RC and periscapular strengthening, resisted abduction in scapular plane, and neuromuscular control.
• Continue stretching which can be more aggressive at this point.

18-22 Weeks

• Strengthening can include light bench press (being careful not to extend the shoulder). Dumbbell bench on the floor can minimize this extension.  Can start lat pulls and seated rows.
• Once good strength is obtained, sport specific exercise such as concentric and eccentric resisted throwing, rebounder throwing, swimming and ground strokes can be started.
• Golfers can start swinging a golf club and work on swing mechanics
• Emphasize proper mechanics for the patient’s desired activities (golf, overhead throwing, etc.)

24 Weeks

• May return to sport and other activities.

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Goals & Guidelines:

With stabilization surgeries, we focus on isometric strengthening and progress to isokinetic and then functional strengthening. The emphasis is not initially on ROM as much as it is with other surgeries given that the goal is to tighten up the shoulder. Shoot for about 75% of normal ROM by about 3-4 months. The protocol focuses on the operative arm but please also work on core strength and conditioning for total rehabilitation of the athlete. Patients are in an immobilizer/sling for 6 weeks. While sleeping, the arm should be kept in the plane of the body with pillows or blankets under the operative elbow. The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. The degree of allowed ER for these waist level activities is dictated by postoperative time and is delineated below. No combined ER and abduction until 6 weeks. Teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).

0 – 2 Weeks

• Start scapular depression, retraction, protraction and elevation.
• Start IR, ER and abduction isometrics
• ER limited to neutral

2 – 4 Weeks

• Supine Active Assisted Forward Elevation (SAAFE) to 120° and External Rotation with stick limited to 30°.

4 – 6 Weeks

• Start sub-maximal 4 Way Theraband Strengthening exercises.
• Increase ER to 45°.
• Increase FE to 140°.

6 – 8 Weeks

• Start Active Range of Motion in all planes except for combined abduction and ER
• Increase 4 Way Shoulder Theraband Strengthening

8 – 12 Weeks

• Patient may perform combined ER and abduction actively. Increase ER stretches of the abducted arm as tolerated.
• Begin more aggressive periscapular strengthening exercises that focus on the inferior trap and rhomboids by performing lower rows and seated rows
• Rhythmic Stabilization with Bodyblade beginning with patient’s arm at 90°. Progressions can include increase in tempo and position. Further progression would be into a PNF pattern avoiding abduction and ER. Progress to standing and move into flexion, scaption, abduction and PNF patterns.
• At 10 weeks, full active motion is encouraged again not pushing the abduction ER
• Start more aggressive strengthening exercises at 10 weeks for deltoid and rotator cuff. Avoid behind the neck lat pull downs and military presses. No heavy lifting. Do not strengthen to the point of fatigue.  Once the muscles are fatigued, they can no longer provide dynamic stability and the patient thus relies more on the static restraints that were just repaired.

12 –16 Weeks

• Push-up into wall with ball under uni-lateral hand focusing on scapular retraction. Progress to stability ball on a table while performing a push-up then. Progress to stability ball on the floor. Do not forget to set shoulder blades into the correct position.
• May start light bench press, more aggressive deltoid strengthening and lat pulls in front of body
• Continue Bodyblade endurance and proprioceptive exercises

16 – 20 Weeks

• Continue to increase the intensity of the strengthening exercises
• May start throwing program for overhead athletes.

24 Weeks

• Return to unrestricted activity

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Goals and Guidelines:

With stabilization surgeries, we focus and isometric strengthening and progress to isokinetic and then functional strengthening. The emphasis is not initially on ROM as much as it is with other surgeries as the goal is to tighten up the shoulder. Shoot for about 75% of normal ROM by about 3-4 months. The protocol focuses on the operative arm but please also work on core strength and conditioning for total rehabilitation of the athlete.  Patients are in an immobilizer/sling for 6 weeks. While sleeping, the arm should be kept in the plane of the body with pillows or blankets under the operative elbow. The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. No active internal rotation behind the back for 6 weeks to avoid stretching the posterior capsule. Teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).

0-2 weeks

• No specific therapy

2-6 weeks

• Start scapular depression, retraction, protraction and elevation.
• Start ER and abduction isometrics.  NO INTERNAL ROTATION
• Start Supine Active Assisted Forward Elevation (SAAFE) with FE no greater than 140°.
• Start External Rotation with stick to 40°.

6-12 weeks

• Transition from SAAFE to SAFE during the first 2 weeks and then progress to active ROM in all planes. No specific posterior capsular stretching until 8 weeks post op.
• Start 4 Way Theraband Strengthening
• At 8 weeks, start deltoid strengthening performing lateral and front raises and Rhythmic Stabilization with Bodyblade beginning with patient’s arm at 90°.  Progressions can include increase in tempo and position. Further progression would be into a PNF pattern. Progress to standing and move into flexion, scaption, abduction and PNF patterns.
• At 10 weeks, start more aggressive strengthening exercises. Avoid behind the neck lat pull downs and military presses.  Start TVA’s and 6 Pack Back periscapular strengthening exercises. Do not strengthen to the point of fatigue.  Once the muscles are fatigued, they can no longer provide dynamic stability and the patient thus relies more on the static restraints that were just repaired.

12-16 weeks

• Push-up into wall with ball under uni-lateral hand focusing on scapular retraction. Progress to stability ball on a table while performing a push-up then. Progress to stability ball on the floor. Do not forget to set your shoulder blades into the correct position.
• May start light bench press, more aggressive deltoid strengthening and lat pulls in front of body
• Continue Bodyblade endurance and proprioceptive exercises

16-20 weeks

• Continue to increase the intensity of the strengthening exercises
• May start throwing program for overhead athletes.

24 weeks

• Return to sport

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Goals Guidelines:

Maximize ROM while protecting subscapularis repair. Once ROM is lost, it is very hard to get it back while strengthening can be done at any point. The first phase of therapy is 6 weeks and is focused on active assisted ROM exercises only. During this time the patient may work on scapular protraction and retraction for strengthening but no strengthening exercises for deltoid or rotator cuff (RC). The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. Shoulder immobilizer only needs to be worn when outside the home for the first six weeks. If the patient feels more comfortable with the sling, then he/she may wear it at home as well but it is not necessary. For the first couple weeks, most patients are more comfortable sleeping in their sling and a recliner but they may move to a bed when comfortable.   While sleeping in bed the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). Therapists should teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).  The second phase of therapy is about 2 months and focuses on continued stretching (which can be more aggressive) and strengthening. The strengthening starts slowly and progresses to functional exercises. Whether using bands or weights, the strengthening should not be painful and focus on a resistance with which the patient can perform 10-15 reps comfortably. Most patients are able to play a round of golf at 4 months postop and are released to more aggressive activities at that point but improvements in strength and function continue for up to 2 years.

0 – 6 Weeks

• Immediately start Pendulums, Elbow and Hand ROM.Supine Active Assisted Forward Elevation (SAAFE), and External Rotation With Stick. It is imperative that the patient understands the exercises and are able to demonstrate that they can perform the exercises, as they are responsible for performing these at home. Stretching exercises should be performed 1 time per day.
• External rotation should be limited to 30 degrees for the first 4 weeks and then progressed out to 60 degrees.

6 – 8 Weeks

• Start AAROM with Home Pulley
• Start IR, ER and abduction isometric strengthening exercises. Start very slowly on the IR isometrics.
• Start Supine Active Forward Elevation (SAFE) exercises.
• Start Functional Internal Rotation using a towel or belt to pull the operative arm up behind the back.
• DC sling at 6 weeks

8 – 12 Weeks

• Should strive for FROM at this point. If not continue more aggressive stretching, including Wall Slide into Scaption, Alternate Internal Rotation Stretch, External Rotation at the doorway. Performing all forms of posterior capsule stretching exercises are appropriate.
• Start Standing Overhead Reach and 4 Way Shoulder Rubber-Band strengthening and Active Range of Motion in upright position. Make sure that the patient is not developing substitution patterns with active ROM. If the patient is developing these patterns then try Wedge Assisted Active Forward Elevation (WAFE). WAFE and stretching exercises should be performed on a daily basis and strengthening only every other day at most.

12 – 16 Weeks

• Teach continued home program for deltoid Active Range of Motion and RC strength maintenance
• Work on neuromuscular control
• Teach specific exercises and proper mechanics for specific sport such as golf, racket sports, fishing or a vocation. Throwing exercises such as concentric and eccentric resisted throwing with bands and throwers ten exercises can be started now.

16 Weeks

• Return to unrestricted activity. Impress upon the patient that heavy lifting and other weight bearing activities can lead to loosening and accelerated polyethylene/glenoid wear and thus should be avoided. 

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Goals and Guidelines:

Therapy fora reverse TSA is very similar to an anatomic TSA. The first phase of therapy is 6 weeks and is focused on active assisted ROM exercises only. During this time, the patient may work on scapular protraction and retraction for strengthening but no strengthening exercises for deltoid or remaining rotator cuff (RC). The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. Shoulder immobilizer only needs to be worn when outside the home for the first six weeks. If the patient feels more comfortable with the sling, then he/she may wear it at home as well but it is not necessary. For the first couple weeks, most patients are more comfortable sleeping in their sling and a recliner but they may move to a bed when comfortable. While sleeping in bed the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). Therapists should teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises). The second phase of therapy is about 2 months and focuses on continued stretching (unlike anatomic TSA’s, stretching should not be aggressive with a reverse TSA as the procedure is non-anatomic and reverse TSA patients tend to be more osteoporotic) and strengthening. The strengthening starts slowly and progresses to functional exercises. In many cases, the anterior cuff (subscapularis) and posterior cuff (teres minor) remain intact and can be strengthened to improve internal and external rotation function. Whether using bands or weights, the strengthening should not be painful and focus on a resistance with which the patient can perform 10-15 reps comfortably. Most patients are able to play a round of golf at 4 months postop and are released to more aggressive activities at that point but improvements in strength and function continue for up to 2 years.

0-6 weeks

• Immediately start Pendulums, Supine Active Assisted Forward Elevation (SAAFE), and External Rotation With Stick. It is imperative that the patient understands the exercises and are able to demonstrate that they can perform the exercises, as they are responsible for performing these at home. Stretching exercises should be performed 2 times per day.
• At FOUR weeks start internal rotation in the supine position. In the supine position, position the arm in about 30⁰ of abduction. External and internal rotation can be performed in this position.
• All ranges of motion should be taken to tolerance and focus on long slow stretches with appreciable gains being realized each week.

6-8 weeks

• Continue stretching but can be more aggressive. Start External Rotation Stretching in Doorway, Pulley assisted ROM,
• Start IR, ER and abduction isometric strengthening exercises. Start very slowly on the IR isometrics.
• Start Supine Active Forward Elevation (SAFE) exercises.
• Start Functional Internal Rotation using a towel or belt to pull the operative arm up behind the back.
• DC sling at 6 weeks

8-12 weeks

• Should strive to optimize the ROM. Both the therapist and patient should understand that the reverse TSA is non-anatomic procedure and as such, the ROM can be more limited.  It is important to work on scapular motion so that the acromion can be moved out of the way to achieve greater degrees of ROM.
• Start Wall Slide into Scaption, Start Standing Overhead Reach and 4 Way Shoulder Rubber-Band strengthening and Active Range of Motion in upright position.  Make sure that the patient is not developing substitution patterns with active ROM. If the patient is developing these patterns then try Wedge Assisted Active Forward Elevation (WAFE). WAFE and stretching exercises should be performed on a daily basis and strengthening only every other day at most.

12-16 weeks

• Teach continued home program for deltoid Active Range of Motion and RC strength maintenance
• Other strengthening exercises can be started such as bench press and lat pulls and military press with dumbbells or with machines as long as form is good. There should be no pain with strengthening. When bench pressing, do not let the elbows extend below the plane of the body.
• Work on neuromuscular control
• Teach specific exercises and proper mechanics for a specific sport such as golf, racket sports, fishing, or a vocation. Throwing exercises such as concentric and eccentric resisted throwing with bands and throwers ten exercises can be started now.

16 Weeks

• Return to unrestricted activity. Impress upon the patient that heavy lifting and other weight bearing activities can lead to loosening and accelerated polyethylene/ glenoid wear and thus should be avoided. 

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Goals and Guidelines: 

The goal of surgery is to anatomically reconstruct the proximal humerus and provide stable fixation to allow early ROM. The most common problems after surgery are loss of reduction and stiffness. Therefore the therapy is tailored to try to prevent these complications. The sling can be removed at home to perform waist level activities. In addition some proximal humeral fractures are associated with axillary nerve palsies. In these cases sling use might be more prolonged. 

0-2 weeks

• Supine Passive Forward Elevation to full, External Rotation with stick to the side to 30 degrees. Teach the passive to patient and family for home exercises.
• Pendulums. Active range of motion to elbow and hand.

2-6 weeks

• Continue Passive supine forward elevation and external rotation and continue to increase the degree of ROM.
• Start gently Internal rotation behind back and cross body adduction. 
• At the end of the 6 weeks supine ROM should be 75% of normal.
• Exercises are to be performed twice daily.

6-8 weeks

• Continue stretching in all planes (FE, ER, and IR). 
• Start AAROM with pulley. Patients need a pulley for home use.
• For patients with concomitant nerve palsies, Wedge Assisted Forward Elevation can be initiated.
• Younger patients can start Wall slides.

8-10 weeks

• Continue prior exercises.
• Start 4 way Resistance Band Strengthening. Internal rotation behind back stretching, and sleeper stretch.
• Stretching is performed daily and strengthening is every other day.

10-12 weeks

• Continue above exercises.
• Add more aggressive stretching in all planes. External rotation stretching at wall.

12-20 weeks

• If good ROM has been obtained the more aggressive strengthening can be started focusing on deltoid and rotator cuff and periscapular musculature.
• Teach HEP for discharge.