Anterior Stabilisation Rehabilitation Guidelines

ANTERIOR STABILISATION REHABILITATION GUIDELINES

(Arthroscopic/open, Bankart/Laterjet procedures)

INTRODUCTION

The guidelines that follow are a framework of basic exercises and management strategies based on the patient who has had an anterior stabilisation.

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.
• 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:

• Sling usually for 2-6 weeks (check post-operative note).
• Avoid combined abduction and ER usually for 6 weeks (check post-operative note).
• No lifting of objects.
• No excessive shoulder extension.
• No excessive stretching or sudden movements.
• No supporting of body weight by hands.
• Keep wounds clean and dry.
• No driving: right arm for 3 weeks, left arm for 6 weeks.

Milestones at 2 weeks:

• Pain, inflammation, and muscle inhibition well managed.
• Return to pre-operative sleep patterns.
• Good scapula setting.
• PROM: elevation in IR to 90°, ER to neutral.

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 (except ER and abduction) as tolerated/not into pain/do not force or stretch.
• Introduce active-assisted range of movement (AAROM), gradually progressing 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.

Precautions:

• Avoid combined abduction and external rotation (ER) usually for 6 weeks (check post-operative note).
• No lifting of objects.
• No excessive shoulder extension.
• No excessive stretching or sudden movements.
• No supporting of body weight on operated upper limb.
• Usually wean out of the sling after 4-6 weeks (check post-operative note).

Milestones at 6 weeks:

• Pain, inflammation, and muscle inhibition well managed.
• Pre-operative PROM except ER and abduction.
• Passive IR 25% of pre-operative range.
• Good SHR with PROM.

Phase 3 (7 – 14 weeks)

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 can elevate the arm without shoulder or scapular ‘hitching.’
  • Gradually progress to dynamic and rhythmic stabilisation exercises.
• Gradually progress lower limb and core strengthening as required.
• Gradually return to light, non-repetitive functional activities.
• Gradually introduce light, early-stage sport-specific exercises.
• Return to driving: right arm at 6 weeks, left arm at 8 weeks.

Precautions:

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

Milestones at 14 weeks:

• Resolved pain, inflammation, and muscle inhibition.
• AROM with good SHR through elevation to 100% of pre-operative range.
• Passive IR to 75% of pre-operative range.

Phase 4 (3 – 6 months)

Goals:

• Maintain full PROM:
  • Continue multi-directional stretching into end of range as tolerated/not into pain.
  • Capsular stretches.
• 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 shoulder:
  • No heavy, repetitive, or prolonged overhead activities.

Milestones at 6 months:

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

Phase 5 (6 – 12 months)

Goals:

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

To contact the Consultant Secretary, call 07810356433 or to contact the Physiotherapy team for:

• Sulis Hospital: 01761 422388.
• Physiotherapy Circle Health Group Bath Clinic: 01225 838767.
• Physiotherapy St Joseph: 01633 820321.