Postoperative Rehabilitation Protocol Arthroscopic Repair of Anterior Labrum

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 Arthroscopic Anterior Labral Repair.  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 anterior labral repair +/- bony Bankart repair.  If posterior or superior labral repair is performed the therapist should utilize that specific protocol.  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 (such as biceps tenodesis, distal clavicle excision, subscapularis tendon repair, etc).   

*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.  If the patient is an athlete they may not return to sports until cleared, typically 4-6 months post-op. 

*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 arthroscopic rotator cuff surgery...

  • 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.  Recovery of strength is correlated to tear size and therefore massive tears can take much longer to rehabilitate that small or standard tears. 

Goals: 

  1. PROM only. Max ROM goals (Forward Flexion 90, Scapular plane ER 30, 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 large intra-articular effusion, DVT/PE (pulmonary embolism), Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Grip strengthening
  2. Codman's (Pendulum) Exercises
  3. Core and Low Back Exercises
  4. Scapular elevation/depression, retraction/protraction
  5. Scapular orientation (emphasize posterior tilt)

Precautions:

  1. USE OF SLING!!! (except when bathing and performing home exercises) until 2 weeks post-op to reduce potential strain on the repair.  
  2. Avoid all AAROM/AROM shoulder
  3. Avoid lifting >1lbs
  4. Avoid all ROM (including passive) in ABDucted position and cross body motions

*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. End of Phase II ROM Goals: FF 160 degrees, ER 45 degrees scapular plane, NO ER in ABDucted plane.  ABD 160. No cross-body ADDuction until 6 weeks post-op
  2. May initiate AAROM shoulder at 2 weeks post-op if supervised by PT (pulley, wand, supine assisted ROM exercises)
  3. Encourage home exercises to be performed 3X/day 
  4. 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 ROM 

Therapeutic Exercises:

  1. Continue Phase I Therapeutic exercises 
  2. Incorporate Neck ROM exercises as necessary
  3. Advance Posterior capsule mobilizations, avoid stretch of anterior capsule
  4. Elbow by side-Increase ER to 45 max and IR as tolerated
  5. Begin cuff/deltoid isometrics and closed chain scapula exercises 

Precautions:

  1. May discontinue sling at 2 weeks for rest/sleep but should continue use during daytime/activity 
  2. No Lifting > 5 lbs

*Patient may potentially progress to Phase III at 4 weeks based on progress and physical therapist discretion

 

Phase III (Post-op Week 6-12)

Goals:

  1. End of Phase III goals: Full PROM and AROM 
  2. Establish baseline humeral head control 
  3. Initiation of ADLs and proprioception exercises below shoulder level
  4. No pain at rest.  Do not overstress healing tissue  

Therapeutic Exercises:

  1. Continue Phase I and Phase II exercises
  2. Begin resistive/strengthening exercises for scapular stabilizers
  3. Begin prone extensions
  4. Wall walks/slides, pulley exercises 
  5. Initiate Sub-maximal Rotator Cuff Isometrics
    1. May begin isotonic and gentle rotator cuff strengthening exercises (up to 10lbs) at 4-6 weeks if ROM acceptable and pain adequately controlled

Precautions:

  1. May advance ER (MAX 90 degrees until 10+ weeks) in ABDucted plane, unrestricted IR after 6 weeks in all planes 
  2. No pushing, pulling, loading
  3. No rapid movements (excessive/forceful muscle contractions)  
  4. No return to sport

Phase IV (Post-op Week 12-16)

Goals:

  1. Maintain full PROM and AROM 
  2. Continue Phase I, II and III exercises
  3. Progressive strengthening and complete functional activities/heavier ADLs below shoulder height
    1. Progress endurance before strength (ie. higher reps before adding resistance)

Therapeutic Exercises:

  1. Progress strengthening exercises

    1. Sidelying ER with increasing weight (start at 1 lb)
    2. Resisted IR/ER with TheraBand, progress to dumbbell or machine 
    3. Weighted scapular exercises (weights, tubing, seated row)
    4. Forward punches with pulley/band
    5. Dynamic Hug with bands
    6. Wall washes
  2. Continue scapular protraction/retraction/elevation/depression
    1. OK for manual resistance scapular motions
  3. Swiss ball slides up wall in flexion and scaption
  4. Latissimus eccentrics
  5. GH stabilization/mobilization exercises
  6. OK for cycling/running

Precautions:

  1. May advance ABDucted ER without restriction 
  2. No return to sport but may begin sport related rehab conditioning
  3. Limit strengthening exercises to 3X/wk to prevent rotator cuff tendonitis

Phase V (Post-op Week 16+)

Goals:

  1. Progress strengthening and return to weight room for athletes
  2. Achieve strength measurements comparable to contralateral extremity by 20-24 weeks post-op 
  3. Return to play 4-6 months post-op, including contact sports, only if cleared by physician
  4. Throwing athletes may not resume throwing program until 16-20 weeks or cleared by physician 

Therapeutic Exercises:

  1. Progress strengthening exercises as tolerated 
  2. Push ups (progressive: wall-->incline-->floor)
  3. 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