RevisedJuly 2007

CONSENSUSREHABILITATION GUIDELINES ArthroscopicAnteriorStabilization withorwithout BankartRepair

GENERALINFORMATION
SurgicalProcedure:
o Familiaritywiththesurgicalprocedureandunderstandingitseffectonrehabilitationisvital. o ArthroscopicBankartrepairsaddressshoulderinstabilitybyrepairinganunstablelabrumback to theglenoid 2,27,32 34,42 throughtheuseofsutures orsutureanchors . Earlyproceduresutilizedstaplestosecurethelabrumwhich 21,30 resultedinhighrecurrenceratesandpostoperativecomplications. Historically manyofthearthroscopic techniquesdid notadequatelyaddressconcomitantcapsularlaxity leadingtohigherrecurrenceratescomparedto 6,9,10,20,24,29,36 thetraditionalopen Bankartrepairs. o Currently,arthroscopicplicationsofthecapsuleareperformedmorereadilyduring arthroscopicBankartrepairto 1,4,8,15,16 takeupredundancyintheglenohumeraljointcapsule. Thecapsulecanbefoldedontoitselfand/or 12,15,38 stabilizedtothelabrum. o TheadditionofcapsularplicationtothearthroscopicBankartrepairhasresulted inareductionin recurrencerates 1,4,39 ofarthroscopicshoulderstabilizationprocedures. Inmanyseries,failureratesarenowsimilartoopensurgical 7,17,19,22 procedures. o Historically patientsrecovering fromarthroscopicsurgeryhaveaneasiertimeregaining P/AAROMthan 7,13 comparableopensurgerieswithoutsignificantlongtermROMloss. 4,14,23,25,37 o Surgicalproceduresandindicationsare rapidlyevolving.

StructuresWhichRequireProtectionDuringRehabilitation:
o Duetothearthroscopicnatureofthesesurgeries,therotatorcuffisnotsignificantlydisturbed.ThereforeAROM, dynamicstabilityactivities,andstrengthening doesnotneedtobedelayedtoprotecttherotatorcuff. o However,sutures,anchors,capsule,ligaments,andlabrum need significantprotectionfromunduestressfora 26,33 periodoftime(usuallyatleast6weeks)tofacilitateappropriatetissuehealing. Thereforeclosecommunication withthephysicianisvitallyimportanttodiscussassociatedlesions,tissuequality,fixationmethodandposition. Baseduponthisinformation,ROMandstrengtheningactivitieswillbeslowlyincreased duringtheinitialpost operative timeperiod toensureadequatehealing

CriticalRehabilitationPrinciples
11,17,43 o Historically,24weeksofimmobilizationiscommonafterarthroscopicinstabilityrepair .However,thereis evidencethatimmediatestagedROMissafeandmayprovideanearlierreturntofunctionalactivityandROM 18 althoughlongtermresultsarenotsignificantlydifferent .Therefore,weadvocate 04weeksofimmobilization dependenton factorssuchasthe patientsspecificinjury/pathology,comorbidities,amountofnaturallaxity,past surgicalhistory,specificsurgicaltechnique(includingtypeoffixationandarmpositionatthetimeofcapsular plication),andphysicianphilosophy. o BalancingthespeedofP/AAROMgainsisvitallyimportanttoadequatelyprotectthesurgicalrepairandtoassure ROMisnotgainedtooquicklyortooslowly.GainingROMtooquickly (especiallyER)isamorecommon problem and mayresultin recurrentlaxity,whilegainingROMtoo slowlymayresultin residual stiffness.

18,43 o BalancingthespeedofP/AAROMgainscanbeaccomplishedthroughtheuseofstagedROMgoals. The optimalspeedofP/AAROMgainsisdifferentforeachpatientandbasedonfactorssuchastheirspecificinjury/ pathology,comorbidities,amountofnaturallaxity,pastsurgicalhistory,specificsurgicaltechnique (including typeoffixationand armpositionatthetimeofcapsularplication),andphysicianphilosophy. o o StagedROMgoalscanbedeterminedatleasttwoways: * Passive ForwardElevationinthescapularplane & Passive ExternalRotation 1. Physicianpreferencebasedonthefactorsabove. # Active ForwardElevationinthescapularplane 2. Ifguidanceisnotgivenbythephysician, abdAbduction thenthefollowingtablecanbeusedasageneralguideline: * PFE 90 135 155 WNL & PER at20abd 1030 3550 5065 WNL

POW3 POW6 POW9 POW12

PERat90abd contraindicated 45 75 WNL

# AFE NA 115 145 WNL

o PROMgreaterthanthemotionslistedaboveshould beavoided. o Interventionsshouldnotbeforcefulorpainful.

Precautions/Contraindications:
o Adequateprotectionofthesurgicalrepairforatleastthefirstsixweeksisvital. Duringthisearlytimeperiod ROM/ stretchingintoendrangepositions,especially endrange ERbytheside and endrangeERinabduction shouldNOTbe performedasthesemotionsplacetensionontheanteroinferiorshouldercapsule. o Becauseoftheminimallyinvasivenatureoftheseprocedures,thepainthatsome patientsexperienceisminimal allowingforgreateruseoftheirarm thanisadvisable.Therefore,extensivepatienteducationisvitalto convey the importance ofprotecting thesurgicalrepair. HeavyliftinganduseofthearminpositionsrequiringendrangeROM arenotallowedintheearlypostoperativeperiod(<POW6).

SPECIFICREHABILITATIONGUIDELINES Phase1 (POW1to ~POW6)

GOALS: o Maximallyprotectthesurgicalrepair(capsule,ligaments,labrum,sutures) o AchievestagedROMgoals.DONOTexceedthem. o Patienteducationinpostoperative restrictions o Minimize shoulderpainandinflammatoryresponse

o Ensureadequatescapularfunction
INTERVENTIONSTOAVOID Donotalloworperform ROM/stretchingbeyondstagedROMgoals,especiallyERbythesideandendrange ERinabduction. DonotallowthepatienttousetheirarmforheavyliftingoranyuseofthearmwhichrequiresROMgreater thanthestaged ROMgoals. SPECIFICINTERVENTIONS ActivitiesofPrimaryImportance: 1) Patienteducationregarding limited useofthearmdespitelackofpainorothersymptoms 2) Protectionofrepair 3) AchievestagedROMgoalsthroughgentleROMactivities 4) Minimizeinflammation

ActivitiesofSecondaryImportance: 1) Normalizescapularposition,mobility,anddynamicstability 2) ROMofuninvolvedjoints 3) Beginrestorationofshoulderstrength

Immobilization
o Strictslingimmobilizationofglenohumeraljoint04weeks,followedbyslingusewheninthecommunityorwhenthe patientisupforlongperiodsoftimefortheremainderofphase1. o Mostcommonly astandardsling(glenohumeraljointinIRandadduction)isused through arangeof24weeks.

PatientEducation
Explainnatureofthesurgery Discussprecautionsspecifictothenatureofthesurgicalrepair(abduction/ERstresstheanteriorinferiorcapsule) ImportanceofmeetingstagedROMgoals(especiallynotgainingROMtoofast) Importanceoftissuehealing Properslinguse (assureslingprovidesupwardsupporttotheglenohumeraljoint). LimitinguseofarmforADLs ROM Following thestrictimmobilization periodbegin: Pendulums(unweighted) Passive/activeassisted forwardelevationinplaneofscapula(PFE)toachievestagedROMgoals(ex:selfassist exercisewand/oppositehand,familyortherapistassist,ropeand overhead pulley,tableslideswithinvolvedarm onatowelonatableorcountertopwith assistanceprovidedbythe uninvolvedarm). ROMshouldnotbeforceful Passive /activeassisted externalrotation(PER)withthearmsupportedandshoulderinslightabduction toachieve stagedROMgoals(ex:familyortherapistassist,selfassistwith lbar).ROMshouldnotbeforceful Scapularclockexercisesoralternately elevation,depression,protraction,retraction progresstoscapular strengthening aspatienttolerates(Smithetal2006). Submaximal rotatorcuffisometricsastolerated AROMofuninvolvedjoints Posturalawareness/education

PainManagement
Activityrestriction Properfittingofslingtosupportarm Scarmanagement. ModalitiesPRN MDprescribedorOTCmedications

MILESTONESTOPROGRESSTOPHASEII 1) Appropriatehealingofthesurgical repairbyadhering to the precautionsandimmobilization guidelines. 2) StagedROMgoalsmetbutnotsignificantlyexceeded. 3) Inflammationcontrolled (painfreewithintheallowedROM).

Phase2 (~POW6~POW12)
GOALS AchievestagedROMgoalstonormalizePROMandAROM.DONOTexceedthem. Minimizeshoulderpain Begintoincreasestrengthandendurance Increase functionalactivities INTERVENTIONSTOAVOID Donotperform ROM/stretchingbeyondstagedROMgoals. Donotperformanystretchtogainendrangeexternalrotationorexternalrotationw/90ofabductionunless significanttightnessispresent. Donotallowthepatienttousetheirarmforheavylifting oranyactivitieswhich requireROMbeyond the staged ROMgoals Donotperformanystrengtheningexercisesthatplacealargeloadontheshoulderinthepositionofhorizontal abductionorthecombinedpositionofabductionwithexternalrotation(ex:NOpushups,pecflys). Thisplaces excessiveloadonanteriorcapsularstructuresduringthistimeframe. Donotperformscaptionwithinternalrotation(emptycan)atanystageofrehabilitation duetopossibilityof impingement. SPECIFICINTERVENTIONS ActivitiesofPrimaryImportance: 1) ContinuedPatientEducation 2) P/AAROMasneeded toachievestagedROMgoals.DONOTsignificantlyexceedthem. 3) Establish basicrotatorcuffandscapularneuromuscularcontrolwithintheallowedROM ActivitiesofSecondaryImportance: 1) Introductionoffunctionalpatternsofmovement 2) Progressiveenduranceexercises.

PatientEducation
Counsel aboutusing theupperextremityforappropriateADLsinthepainfreeROM(startingwithwaistlevel activitiesandprogressingtoshoulderlevelandfinallyto overheadactivitiesovertime). Continueeducationregardingavoidanceofheavylifting orquicksudden motions. EducationtoavoidpositionsofinstabilityduringADLssuchasend rangeexternalrotation,andcombinedabduction/ externalrotation. ROM P/AAROMasneeded toachievestagedROMgoalsin allplanes. Many timesonlylightstretching ornostretching is needed. IfROMissignificantlylessthanstagedROMgoals,gentle jointmobilizationsmaybeperformed.Howeverthey shouldbedoneonlyintothelimiteddirectionsandonlyuntilstagedROMgoalsareachieved. Addressscapulothoracicandtrunkmobilitylimitations.EnsurenormalcervicalspineROMandthoracicspine extensiontofacilitatefullupperextremityROM.

NeuromuscularReeducation
Addressabnormal scapularalignmentandmobility PRN o Strengthenscapularretractorsandupwardrotators(PREsormanuallyresistedexercises) o Increasepectoralisminorflexibilityiflimited(manualstretching,towelmobilizations) o Biofeedbackbyauditory,visual,ortactilecues o Closedchainexercisesmaybe helpful (quadruped positionwhileworking tomaintainproperposition of thescapula,quadruped w/scapulaprotraction,progressingfrom quadruped totripod position,NOPUSH UPS)

 Addresscorestability deficitsPRN Activitiestoimproveneuromuscularcontrol ofthe rotatorcuffandshouldergirdlesuchasuseofunstablesurfaces, bodyblade,manualexercises(PNF).

Strength /Endurance
Scapulaand corestrengthening(PREs,manuallyresistedexercises,corestabilizationexercises) Balancedrotatorcuffstrengthening to maintain thehumeralhead centeredwithintheglenoidfossaduringprogressively more challenging activities. o Shouldbeinitiallyperformedinapositionofcomfortwith lowstresstotheglenohumeraljointsuchas <45elevationintheplaneofthescapula(ex:elasticbandordumbbellexternalrotation,internalrotation, forwardflexion,shoulderextensionnotpasttheplaneofthebody). o Exercisesshouldbeprogressiveintermsofmuscledemand/intensity. Itissuggestedtouseactivitiesthat havedocumentedEMGactivity (SpecificGuidelinesReferences).Resistedactivitiesshouldprogressfrom assistiveexercises(ex.rope/overheadpulleyand/orfingerladder)toactiveexercisesandfinallythe additionofexternalresistance(ex.elasticbandsor12lbs.weight). o Exercisesshould also beprogressiveintermsofshoulderelevation (ex: startw/exercisesperformedat waistlevelprogressingtoshoulderleveland finally overheadactivities). o Nearlyfullelevationinplaneofthescapulashouldbeachievedbeforeprogressingtoelevationinother planes. o Exercisesshouldbeprogressiveintermsofaddingincrementalstresstotheanteriorcapsule,gradually workingtowardsapositionofelevatedexternalrotationinthecoronalplane the9090position. o Rehabilitationactivitiesshouldbe painfree and performed withoutsubstitutionsoralteredmovement patterns. o Rehabilitationshouldincludebothclosed (ex: quadruped totripod)andopenchainactivities. o Rehabilitationshouldalsoincludebothisolatedand complexmovementpatterns. o Dependinguponthegoalsoftheexercise (controlvs.strengthening),rehabilitationactivitiescanalsobe progressiveintermsofspeedoncetheathletedemonstratesproficiencyatslowerspeeds. o The rotatorcuffandscapulastabilizerstrengtheningprogramshouldemphasizehighrepetitions(about30 50reps)andrelativelylowresistance (about13lbs). o Noheavyliftingorplyometricsshouldbeperformedduringthisstage. o Elbowflexion/extensionstrengtheningwitharmatside(shoulder0elevation)canbegininthisphase and progressasappropriate.

PainManagement
ModalitiesPRN Ensure appropriateuseofarmduringADLs Ensure appropriateleveloftherapeuticinterventions Weaningfromuseofmedications

MILESTONESTOPROGRESSTOPHASEIII 1) StagedAROMgoalsmetwithoutpainorsubstitutionpatterns. 2) Appropriatescapularposture atrestand dynamicscapularcontrol during ROMandstrengtheningexercises 3) Completionofcurrentstrengtheningactivitieswithoutpainordifficulty

Phase3 (~POW 12~POW 24)

GOALS Normalizestrength,endurance,neuromuscularcontrol,andpower Gradualandplannedbuildupofstressto anteriorcapsuleand labraltissues GradualreturntofullADLs,work,andrecreationalactivities INTERVENTIONSTOAVOID Donotincreasestresstotheshoulderinashortperiodoftimeorinanuncontrolledmanner. Donotperformadvancedrehabilitationexercises(suchasplyometricsorexercisesatendrangeabduction/ER) ifthepatientdoesnotperform theseactivitiesduringADLs,work,orrecreation. DonotprogressintoactivityspecifictraininguntilpatienthasnearlyfullROMandstrength. Donotperformweightliftingactivitieswhichplaceexcessivestressontheanteriorcapsule.Forinstance,lat. pulldownsand militarypressperformed withthehandsbehindthehead stresstheanteriorcapsulewithno additional benefitintermsofmuscleactivity. Similarlyactivitieswhichencourageshoulderhyperextension such asdipsshouldalsobeavoided. SPECIFICINTERVENTIONS ActivitiesofPrimaryImportance: 1) Progressivestrengtheningandenduranceexercises 2) Progressiveneuromuscularcontrolexercises 3) Activityspecificprogressionsport,work,hobbies ActivitiesofSecondaryImportance: 1) FinalizationofROM 2) Finalizationofspecificdeficitsforcoreandscapularstability

PatientEducation
CounselinimportanceofgraduallyincreasingstresstotheshoulderwhilereturningtonormalADLs,workand recreationalactivitiesincludingheavylifting,repetitiveactivities,andoverheadsports. ROM PROM/Stretching/JointMobilizationsasneeded toaddressany remaining deficits.

NeuromuscularReeducation
Addressany remainingdeficitsattherotatorcuff,scapular,ortrunk.

Strength /Endurance/Power
Continue shoulderstrengtheningprogramasinitiated in Phase2withincreasingemphasisonhighspeed,multiplanar activitieswhichincorporatetheentirekineticchain. Graduallyprogressrehabilitationactivitiesto replicate demandingADL/workactivities Progressive returntoweightliftingprogram emphasizingthelarger,primarymoverUEmuscles(deltoid,latissimus dorsi,pectoralismajor) Startwithrelativelylightweightandhighrepetitions(setsof1525repetitions)andgraduallydecreaserepetitions andincreaseweightoveraseveralmonthperiod. SuggestedupperextremityexercisesforearlyPhase3 Bicepscurlsshoulderadducted(addedinPhase2) Tricepspressdownsorkickbacksshoulderadducted(addedinPhase2) Shouldershrugs Rows(scapularretraction)shoulderadducted Latbarpulldownsw/handsinfrontofthehead Dumbbelloverheadshoulderpressdonewithhandsstartinginfrontoftheshoulders(notintheabducted/ externally rotatedposition Pushupsaslongastheelbowsdonotflexpast90

 Suggested upperextremityexercisestobeaddedinintermediatePhase3 Isotonicpressingactivities(ex.chest/inclinepresses,dumbbell/barbellbench) Dumbbellshoulderraisesto90 Rows(scapularretraction)shoulderselevated Machine/barbellshoulderpresseswhich donotrequireendrangeabduction/externalrotation Pronerotatorcuff/scapularstrengthening(pronehorizontalabduction,ScapularMMTpositions,Hughston exercises) SuggestedupperextremityexercisestobeaddedinlatePhase3 Anyoverheadpresswithshouldersinabducted/ERposition(militarypress) Pectoralismajorflys Dead lift Powercleans Upperextremityexercisesthatarenotadvisableforthispatientpopulation Dips LatPullDownsormilitarypresswiththe barbehindhead Plyometricprogram (asnecessary) Criteriatoinitiateplyometricprogram Goalsofreturningtooverheadathleticsorotherworkorrecreational activitiesrequiringlargeamountsof upperextremity power Adequatestrengthofentireshouldergirdlemusculature Pain freew/basicADLsandcurrentstrengtheningprogram Atleast3weeksoftolerancetohighspeedmultiplanaractivitieswhichprogressivelymimicfunctional demands. Parameters Duetotheexplosive natureofthistypeofexercise,emphasisofplyometricsexercisesshouldbeonqualitynot quantity. Performafewtimesaweekandutilizemoderaterepetitions(approximately35setsof1520reps) Beginwithbeach ball/tennisballwith progressiontolightlyweightedballs(plyoballs) Sampleactivities: 2handedtosseswaistlevel overhead diagonal 1handedtosses(beginwitharmatsideandgraduallyincreasethe amountofshoulderabduction/ERand graduallydecrease UEsupport). IntervalSportProgramssuchasthrowingprograms,swimming,golfonceapprovedbyphysician (usuallyPOW16or longer).

MILESTONESTORETURNTOSPORT,WORK,HOBBIES: Clearancefromphysician Nocomplaintsofpainnorinstability RestorationofsufficientROMfortaskcompletion Fullstrength(5/5)ofrotatorcuffandscapularmusculature Adequateshouldergirdleendurancefordesiredactivity Regularcompletionofanindependentstrengthening/neuromuscularcontrolprogram Ifthepatientstruggleswithconfidenceorshoulderstability,astabilizingbracemaybeconsideredforreturntoactivity, butismostcommonlyusedonlyforcollisionsports.

DISCLAIMER
ThesegeneralrehabilitationguidelineswerecreatedbythemembershipoftheAmericanSocietyofShoulderandElbow Therapistsfortherehabilitationofvariousshoulderandelbowpathologies.Thesedocumentsaresimplytobeusedas guidelines.Thisinformationisprovidedforinformationalandeducationalpurposesonly.Thespecifictreatmentofa patientshouldbebasedonindividualneedsandthemedicalcaredeemednecessarybythetreatingphysicianand rehabilitationprofessional.ASSETtakesnoresponsibilityorassumesnoliabilityforimproperuseoftheseguidelines.We recommendyouconsultwithyourtreatingphysicianorrehabilitationprofessionalforspecificcoursesoftreatment.

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SPECIFICGUIDELINES
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