Postoperative Rehab Protocol AC Joint Reconstruction

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Acromioclavicular Joint Reconstruction.  It is by no means intended to replace or substitute the clinical decision making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

*This protocol applies to AC Joint Reconstruction.  There are many variables which can influence how conservative or aggressive the patient may be rehabilitated.  These include but are not limited to the following: Quality of tissue and integrity of repair, acute vs chronic tears, primary vs revision repair, and additional procedures.

*Return to work/activity will be based on the individual patient's profession and workplace demands, ability of employer to accommodate restrictions, and postoperative progress.

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

*A word about “pain” and management of anticipated discomfort following AC Joint Reconstruction...

  • Adequate management of pain is essential to progressing the patient’s mobility, strength, range of motion, and independence.  However, pain is a subjective measure and should be expected for weeks to months after surgery.  A divergence between the subjective complaints and objective findings observed by an experienced therapist should arouse concern and potential need for further consultation/evaluation.  



Phase I- Early Post-Operative Phase (Post-op Day 0-14)

The goal of physical therapy intervention during the early post-operative phase is to achieve progressive improvement in PROM (Passive Range of Motion) to prevent capsular adhesions and fibrosis.  Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential.  

Goals: 

  1. PROM only.  Max goals: FF 90 degrees, Scapular Plane ER/IR as tolerated, NO ADDuction, ABD 90
  2. Full AROM/PROM elbow/wrist/hand
  3. Proper posture, joint protection/positioning, don/doff sling appropriately
  4. Improve scapular mobility
  5. Implement use of nonpharmacologic modalities to control pain and swelling such as circulating cryotherapy pumps, manual massage, elevation of the extremity, etc

Assessment by Therapist:

  1. Assess surgical wounds for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess pre-treatment and post-treatment PROM
  5. Assess for signs of nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Grip strengthening
  2. Codman's (Pendulum) Exercises frequently at home 
  3. Core and Low Back Exercises
  4. Scapular elevation/depression, retraction/protraction
  5. Scapular orientation (emphasize posterior tilt)
  6. OK to begin elbow isometrics immediately 

Precautions:

  1. Sling use all times except bathing and during physical therapy sessions 
  2. Avoid lifting >5lbs and axial traction of arm 
  3. PROM only in supine position first 2 weeks 

*Patient may progress to Phase II after Phase I goals completed and minimum of 2 weeks post-op

Phase II (Post-op Week 2-6)

Goals:

  1. Phase II ROM Goals: FF 120, scapular plane ER/IR as tolerated, 45 degrees max ER/IR when arm ABDucted to 90 degrees, No ADDuction cross body maneuver, NO IR behind back, max 90 degrees ABDuction 
  2. Encourage home exercises to be performed 3X/day 
  3. Decrease swelling/inflammation (Ice, TENS unit, Dry Needling, Cupping, etc)

Assessment by Therapist:

  1. Assess frequency of narcotic and non-narcotic analgesic use 
  2. Assess pre-treatment and post-treatment PROM 

Therapeutic Exercises:

  1. Continue Phase I Therapeutic exercises 
  2. Incorporate Neck ROM exercises as necessary
  3. Advance Posterior capsule mobilizations
  4. Begin resistive/strengthening exercises for scapular stabilizers 
  5. Increase unresisted supination as tolerated  
  6. Initiate Sub-maximal Rotator Cuff Isometrics when 80% AROM achieved
    1. May begin isotonic and gentle rotator cuff strengthening exercises at 2 weeks if ROM acceptable and pain adequately controlled

Precautions:

  1. May remove sling at rest if arm supported, continue use when standing 
  2. No Lifting > 5 lbs or axial traction of arm 

*Patient may progress to Phase III after 6 weeks and when pain is considerably decreased. 

Phase III (Post-op Week 6-12)

Goals:

  1. Full PROM and AROM end of phase III.  Goal is to improve 15 degrees/week in all planes
  2. Initiation of ADLs and proprioception exercises above and below shoulder level
  3. No pain at rest

Therapeutic Exercises:

  1. Continue Phase I and Phase II exercises
  2. Wall walks/slides, pulley exercises 
  3. Bicep curls, standing and prone row, side lying ER, forward punch 

Precautions:

  1. No pushups, lifting weighted objects overhead 
  2. No rapid movements (excessive/forceful muscle contractions) 
  3. Avoid movements resulting in subacromial impingement pain 
  4. May discontinue sling at 6 weeks 
  5. OK to begin AAROM-->AROM, start in prone position.  Advance to standing AROM only if not having pain

Phase IV (Post-op Week 12-16)

Goals:

  1. Maintain Full PROM and AROM without pain 
  2. Continue Phase I, II and III exercises
  3. No throwing exercises 

Therapeutic Exercises:

  1. Increase reps and strength as tolerated including overhead 

Precautions:

  1. No overhead loading if any pain
  2. Avoid long lever exercises, avoid pushups/benchpress/fly 
  3. May run, bike, elliptical 

Phase V (Post-op Week 16+)

Goals:

  1. Maintain full ROM
  2. Achieve strength measurements comparable to contralateral extremity by 20-24 weeks post-op 
  3. Return to sport with approval from surgeon after 16 weeks 

Therapeutic Exercises:

  1. Progress rotator cuff strengthening as tolerated and sport specific exercises  
  2. Push up (progressive: wall-->incline-->floor)
  3. Introduce and advance overhead weighted exercises and begin plyometrics if indicated

Precautions: 

Do not advance strengthening exercises if patient experiencing painful response.  Goal is maximize endurance of movements before increasing loads