ACJ Stabilisation Rehabilitation Guidelines

ACJ Stabilisation Rehabilitation Guidelines

(Arthroscopic/Modified Weaver-Dunn/LARS Ligament/Surgilig procedures)

INTRODUCTION

The guidelines that follow are a framework of basic exercises and management strategies based on the patient who has had a stabilisation of the Acromioclavicular Joint (ACJ).

The physiotherapy programme will need to be individualised for each patient, all exercises should be performed without pain and the details of specific restrictions will be in the post-operative instructions. If you have not received these please ring the consultant’s secretary.

Emphasise to the patient the importance of protecting the repair to allow soft-tissue healing in the first two phases. The milestones may be used to assess whether you feel the patient is making good progress or not.

Shoulder rehabilitation is more than strength-training of the shoulder muscles alone. The (neuromuscular) rehabilitation addresses the whole shoulder girdle, upper extremity, core stability and training of the kinetic chain.

POST SURGERY

Phase 1 (1 – 14 days)

Goals:

• Maintain integrity of the repair:
  • Sling at all times except while dressing/washing or doing exercises.
  • Teach sling, dressing and personal hygiene techniques.
• Management of pain, inflammation and muscle inhibition:
  • Analgesics, NSAID’s, ice, sling, passive movement and posture.
• Teach shoulder girdle control/setting and relaxation:
  • Retraction and depression.
• Gradually increase PROM as tolerated/not into pain/do not force or stretch:
  • Pendulum.
  • ER/IR.
• Gradually introduce active assisted range of movement (AAROM) as tolerated/not into pain/do not force or stretch.
• Hand, wrist, elbow and neck range of movement (ROM) exercises as required.
• Advice on sleeping position:
  • Wearing sling, if supine use a pillow beneath the elbow to prevent the shoulder resting in extension.
• Prevent muscle atrophy:
  • Sub-maximal, pain-free isometrics in neutral (<30% Maximal Voluntary Contraction) as tolerated.

Precautions:

• Protocol:
  • Sling usually for 3-4 weeks (check post-operative note).
  • No lifting of objects.
  • No supporting of body weight on operated upper limb.
  • Keep wounds clean and dry.
  • No driving for 6 weeks.

Phase 2 (15 days – 6 weeks)

Goals:

• Allow healing of soft tissue – do not overload healing tissue.
• Continue to manage and reduce pain, inflammation and muscle inhibition:
  • As phase 1.
  • Alternate treatment strategies as appropriate e.g. manual therapy techniques, taping.
• Once stitches have been removed begin scar massage.
• Gradually restore full, pre-op PROM as tolerated/not into pain/do not force or stretch.
• Gradually progress AAROM to active range of movement (AROM) as tolerated/not into pain.
• Refer to post-op note for further specific restrictions.
• Re-establish dynamic shoulder stability:
  • Ensure good SHR through PROM and use it to guide progression of AAROM and AROM.
• Introduce lower limb and core strengthening as required.
• Gradually return to light, non-repetitive functional activities as weaning out of the sling as tolerated/not into pain.

Precautions:

• No heavy lifting of objects.
• No excessive stretching.
• No supporting of body weight by hands.
• Usually wean out of the sling after 3-4 weeks (check post-operative note).

Phase 3 (7 – 14 weeks)

Milestones:

• Pain, inflammation and muscle inhibition well managed.
• Return to pre-operative sleep patterns.
• Good scapula setting.

Milestones at 6 weeks:

• Pain, inflammation and muscle inhibition well managed.
• 75% of pre-operative elevation AROM with good SHR.
• 50% of pre-operative ER AROM.

Goals:

• Full PROM:
  • Introduce multi-directional stretching into end of range as tolerated/not into pain.
• Gradually restore pre-operative AAROM and then AROM with good SHR as tolerated/not into pain.
• Gradually introduce and progress shoulder strengthening as tolerated/not into pain:
  • Introduce scapular stabilisation exercises.
  • Introduce cuff strengthening, progressing to maximal isometrics then to isotonic strengthening.
  • Introduce proprioceptive exercises.
  • Gradually progress to shoulder and upper limb strengthening as long as the patient is able to elevate the arm without the shoulder or scapular ‘hitching’.
  • Gradually progress to dynamic and rhythmic stabilisation exercises.
• Gradually progress lower limb and core strengthening as required.
• Gradually progress functional activities.
• Gradually introduce light, early-stage sport-specific exercises.
• Return to driving.

Precautions:

• Avoid excessive loading of the shoulder:
  • No heavy lifting.
  • No prolonged, repetitive upper limb activities.

Phase 4 (3 – 6 Months)

Goals:

• Maintain full PROM:
  • Continue multi-directional stretching into end of range as tolerated/not into pain.
  • Capsular stretches (especially posterior capsule if tight).
• Full pre-operative AROM with good SHR as tolerated/not into pain.
• Progress shoulder strengthening as tolerated/not into pain:
  • Progress cuff strengthening and scapular stabilisation exercises.
  • Progress proprioceptive exercises.
  • Progress shoulder and upper limb strengthening ensuring good SHR.
  • Progress dynamic and rhythmic stabilisation exercises.
• Progress lower limb and core strengthening as required.
• Gradually progress functional activities.
• Gradually progress sport-specific exercises.

Precautions:

• Continue to avoid excessive loading of the shoulder:
  • No heavy, repetitive or prolonged overhead activities.

Milestones at 14 weeks:

• Resolved pain, inflammation and muscle inhibition.
• 100% of pre-operative elevation AROM with good SHR.
• 80% of pre-operative ER AROM.

Phase 4 (6 – 9 Months)

Goals:

• As phase 4.
• Gradual return to strenuous work activities as required.
• Gradual return to contact sports as required.

Milestones at 6 months:

• Full pain-free motion and rotator cuff strength restored.

To contact the Consultant Secretary, call 07810356433 or to contact the Physiotherapy team for Sulis Hospital call 01761 422388, for Physiotherapy Circle Health Group Bath Clinic call 01225 838767, for Physiotherapy St Joseph 01633 820321.

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