Recovery: Anterior stablisation

The operation

In open procedures the subscapularis will have been divided to gain entry into the joint as an open procedure. There will have been some soft tissue reconstruction, such as capsular shift or Bankart repair, followed by the resuturing of the wound. In arthroscopic procedures the subscapularis is not affected.

Contraindications

The glenohumeral joint needs to be immobilised in a sling for 3 weeks.
No external rotation unless markedly reduced range (see time guidelines).
No active or passive abduction with external rotation for eight weeks.
No forceful stretching or stressing of the anterior capsule (such as forcing the arm into a horizontal extension at the end range of a conventional press up) for twelve weeks.

Three weeks post-operation

The main emphasis is on regaining flexion range of movement. External rotation is restricted.

i. Wean out of sling
ii. Mobility exercises – mainly flexion
iii. Progress to active assisted
iv. Start isometric cuff work in neutral (pain-free and scapula stable)
v. Avoid passive stretch external rotation beyond 20º
vi. Avoid combined abduction and external rotation

If the patient appears to be regaining full range of movement very quickly, stop mobility work and concentrate on cuff rehabilitation.

Six weeks post-operation

The main emphasis is on increasing muscle activity (cuff and scapula) with optimal movement patterning

i. Range of movement should be approx 75% flexion contra lateral side
ii. External rotation should be restricted still (50% contra lateral shoulder)
iii. Progress cuff activity
iv. Progress scapula muscle activity
v. Do not work or stretch into combined abduction/lateral rotation
vi. Proprioceptive work

Twelve weeks post-operation

The main emphasis is on power, endurance and proprioceptive muscle work aiming towards functional activities.

i. Progress resistance through range
ii. Stretches if necessary for functional activities, but external rotation range should remain tighter
iii. Function specific training

General guidelines for rehabilitation

There will be some variation in the ability of patients to regain movement following surgery and immobilisation. Adjust therapy input to this. Some need considerable help with mobilisation, others need ‘holding back’ with more emphasis on muscle activity.

Guidelines for returning to activities

• Driving at four to six weeks
• Swimming – breaststroke at six to eight weeks, freestyle at twelve weeks
• Return to non contact sport at twelve weeks (if range and control of movement allows)
  
• No contact sport for six months (this is a minimum and will vary depending on the sport). Contact sports include football, martial arts, racket sports, rock climbing.
  

With thanks to the Oxford Shoulder & Elbow Clinic, at the Nuffield Orthopaedic Centre for sharing their written physiotherapy guidance with us.