Physical Therapy Protocols

Pre-op education

Instruct the patient in ankle pumps, quad sets, seated knee flexion, supine SLR, hamstring stretches, gait training with crutches and protection of the graft.

Post-op Program

POD 1-2

1. Ankle pumps: 20-25 per hour
2. Active flexion as tolerated
3. Gait with crutches and brace locked in full extension. (WBAT)
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change: remove bulky dressing, leave clear dressing in place
7. Sleep with brace locked in full extension
8. Quad sets
9. Encourage full extension and flexion to 90

POW 1-4

1. Continue as above
2. Start SLR’s: start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Progress active flexion and encourage full extension
5. Passive ROM to 90, progress as tolerated
6. With good quad control, may wean from brace. Usually by 2 weeks.
7. Teach gait training. Emphasize heel-toe, good quad isolation, normal knee flexion and push-off.
8. Start the following open chain exercises
   1. Sidelying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance.
9. Begin closed chain knee exercises
   ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 4-12

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. leg press
   4. squats
   5. lunges (front/side/back)
   6. step-ups
   7. leg curls
   8. hip strengthening
   9. resisted walking
3. Exercises for balance and proprioception
   1. progress from local to whole body
      1. mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 12-28

1. Continue as above but slowly progress weight and decrease reps (8-10)
2. Progress walking to a fast walk then walk/jog on treadmill
3. Begin jumping rope.
4. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. jog

POW 28 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria — 9 months

• Satisfactory clinical exam
• <10% isokinetic strength deficit (Leg Press)
• Completion of sport replication activity
• Single leg hop test

Pre-op education

Instruct the patient in ankle pumps, quad sets, seated knee flexion, supine SLR, hamstring stretches, gait training with crutches and protection of the graft.

Post-op program

POD 1-2

1. Ankle pumps: 20-25 per hour
2. Active flexion as tolerated
3. Gait with crutches and brace locked in full extension. (WBAT)
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change: remove bulky dressing, leave clear dressing in place
7. Sleep with brace locked in full extension
8. Quad sets
9. Encourage full extension and flexion to 90

POW 1-4

1. Continue as above
2. Start SLR’s: start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Progress active flexion and encourage full extension
5. Passive ROM to 90, progress as tolerated
6. With good quad control, may wean from brace. Usually by 2 weeks.
7. Teach gait training, emphasizing heel-toe, good quad isolation, normal knee flexion and push-off.
8. Start the following open chain exercises
   1. Sidelying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance without resistance and progress as tolerated.
9. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 4-10

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. progress from double to single leg and concentric to eccentric
   3. emphasis on closed chain activities only
      1. leg press
      2. squats
      3. lunges (front/side/back)
      4. step-ups
      5. leg curls
      6. hip strengthening
      7. resisted walking
3. Exercises for balance and proprioception -progress from local to whole body
   1. mini-tramp
   2. Sport cord
   3. Slide board
   4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 10-18

1. Continue as above but slowly progress weight and decrease reps (8-10)
2. Progress walking to a fast walk then walk/jog on treadmill. Usually begin jogging by 10 weeks.
3. Begin jumping rope.
4. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. jog

POW 18 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Pre-op education

Instruct the patient in ankle pumps, quad sets, seated knee flexion, supine SLR, hamstring stretches, gait training with crutches and protection of the graft.

Post-op program

POD 1-2

1. Ankle pumps: 20-25 per hour
2. Active flexion as tolerated
3. Gait with crutches and brace locked in full extension. (WBAT)
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change:  remove bulky dressing, leave clear dressing in place
7. Sleep with brace locked in full extension
8. Quad sets

POW 1-4

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Progress active flexion and encourage full extension
5. Begin passive ROM to 90
6. With good quad control, may wean from brace.  Usually in 2 -3 weeks.
7. Teach gait training.  Emphasize heel-toe, good quad isolation, normal knee flexion and push-off.
8. Start the following open chain exercises:
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: begin level and progress to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 4-10

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Leg press
      2. Squats
      3. Lunges (front/side/back)
      4. Step-ups
      5. Leg curls
      6. Hip strengthening
      7. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 10-16

1. Continue as above but slowly progress weight and decrease reps (8-10)
   1. Increase load
   2. Decrease time and increase power
2. Progress walking to a fast walk then walk/jog on treadmill.
   ?Typically begin jogging around 10 weeks.
   1. High knee march
   2. Figure of “8”
3. Begin jumping rope.
   1. Shuttle

POW 16 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Phase I protective phase

Goals

• Minimize pain and inflammatory response
• Achieve ROM goals
• Establish stable scapula

Weeks 0 to 6

1. Elbow, wrist and hand AROM (EWH)
2. Codman’s pendulum exercises as tolerated
3. Supine passive forward elevation in plane of scapula (PFE) to tolerance
   1. 10 reps, 2 x day
4. Supine passive external rotation (PER) to tolerance with T-stick in
   1. 0-20 degrees flexion and 20 degrees abduction
   2. 10 reps, 2 x day
5. C-spine AROM
6. Ice
7. Positioning full time in sling with abduction pillow
8. Shoulder shrugs and retractions (no weight)
9. ***Pain control modalities PRN
10. ***Aquatics PROM after sutures are out
11. Slowly progress PROM to full in all planes
12. Complications/Cautions
    1. If pain level is not dissipating, decrease intensity and volume of exercises.
    2. Assure normal neurovascular status
    3. No AAROM or AROM until 6 weeks
    4. No Pulley until 6 weeks

Weeks 6 to 12

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable at 6 weeks
3. Achieve PROM goals in FE (full)
4. Achieve PROM goals in ER at 20 deg and 90 deg abduction (full)
5. Initiate posterior capsule stretching
6. Isometrics, keeping elbow flexed to 90 degrees
   1.  Sub maximal, pain free
7. Theraband scapula retractions
8. ***Aquatics
9. ***Mobilizations PRN
10. ***Trunk stabilization/strengthening
11. Start AAFE and progress to AFE
12. Start periscapular strengthening
13.  Very low weight and high repetitions
14. Cautions
    1. Do not initiate rotator cuff strengthening until 12 weeks

Phase II progressive strengthening

Goals

• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power
• Increase functional activities

Months 3 to 4

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula, deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula
   1.  Rhythmic stabilization or slow reversal hold
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening
    1.  Isolated pain free, elbow by side
12. Progress to isotonic dumbbell exercises for deltoid, supraspinatus
    1.  Up to 3 lbs max
13. Cautions
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain level is low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress only without signs of increasing inflammation
    4. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2x/day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 4 to 6

1. Stretching PRN
2. Continue deltoid/cuff/and scapula strengthening as above
   1.  5lbs max for isotonic strengthening
   2. Follow the below progression:
      1. Prone isotonic strengthening PRN
      2. Decreasing amounts of external stabilization provided to shoulder girdle
      3. Integrate functional patterns
      4. Increase speed of movements
      5. Integrate kinesthetic awareness drills into strengthening activities
      6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Month 6 to 8

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening program
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
   4. 2-handed tosses at
      1. Waist level
      2. Overhead
      3. Diagonal
   5. 1-handed stability drills
   6. 1-handed tosses
      1. vary amount of abduction, UE support, amount of protected ER
4. May begin Interval Throwing Program after 3-6 weeks of plyometrics
5. Initiate progressive replication of demanding ADL/work activities

Discharge/return to sport criteria

1. PROM WNL for ADL’s/work/sports
2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
3. Complete plyometric program, if applicable
4. Complete interval return to sport program, if applicable

Phase I immediate post-operative phase (restrictive motion)

Goals

• Protect the anatomic repair
• Prevent negative effects of immobilization
• Promote dynamic stability
• Decrease pain and inflammation

Weeks 0 to 4

1. Sling for 4 weeks
2. Sleep in immobilizer for 4 weeks
3. Elbow, wrist and hand ROM exercises
4. Hand gripping exercises
5. ***No active elbow flexion
6. Cryotherapy, modalities as indicated
7. No AROM, ER, extension or abduction

 Week 4

1. Discontinue sling at 4 weeks
2. May use immobilizer for sleep
3. ROM exercises (PROM and AAROM)
   1. Flexion to 90-110
   2. Abduction to 75-85
   3. ER in scapular plane to 15-20
   4. IR in scapular plane to 55-60
4. Progress ROM and initiate AROM after 4 weeks
5. Continue modalities and cryotherapy

Weeks 4 to 6

1. Gradually improve ROM
   1. Flexion:  140
   2. ER at 45 degrees abduction:  25-30
   3. IR at 45 degrees abduction:  55-60
2. PNF manual resistance
3. May initiate gentle stretching
4. Posterior Capsular Stretching
5. No biceps strengthening

Phase II intermediate phase (moderate protection)

Goals

• Gradually restore full ROM
• Preserve the integrity of the surgical repair
• Restore muscular strength and balance

Weeks 6 to 10

1. Gradually progress ROM
   1. Full flexion
   2. ER at 90 abduction:  45-70
   3. IR at 90 abduction:  60-70
2. Initiate exercise tubing ER and IR (arm at side)
3. Initiate isotonic dumbbell exercises for deltoid, supraspinatus
   1. up to 3 lbs. max (once full AFE is achieved)
4. PNF strengthening

Weeks 10 to 14

1. Slightly more aggressive strengthening
2. Continue all stretching exercises
3. ***Progress ROM to functional demands

Phase III minimal protection phase

Goals

• Establish and maintain full ROM
• Improve muscular strength, power and endurance
• Gradually initiate functional activities

Criteria to enter phase III

1. Full pain-free ROM
2. Satisfactory stability
3. Strength improving
4. No pain or tenderness

Weeks 14 to 18

1. Continue all stretching exercises
2. Continue strengthening exercises
   1. Fundamental throwing exercises
   2. PNF manual resistance
   3. Endurance training
   4. Initiate light plyometrics
   5. Light swimming
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula.
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
      1. 2-handed tosses
         1. overhand
         2. Underhand
         3. Diagonal
      2. 1-handed stability drills
      3. 1-handed tosses (vary amount of abduction, UE support, amount of protected ER)

Weeks 18 to 20

1. Continue all above exercises
2. Initiate ITP

Phase IV advanced strengthening phase

Goals

• Enhance strength, power and endurance
• Progress functional activities
• Maintain shoulder mobility

Criteria to enter phase IV

1. Full pain-free ROM
2. Satisfactory static stability
3. Strength 75-80% of contralateral side
4. No pain or tenderness

Weeks 20 to 24

1. Continue flexibility exercises
2. Continue isotonic strengthening program
3. PNF manual resistance patterns
4. Plyometric strengthening
5. Progress ITP

Phase V return to activity phase (6 to 9 months after surgery)

1. Gradually progress sport activities to unrestricted
2. Discharge/Return to sport criteria
   1. PROM WNL for ADL’s/work/sports
   2. MMT 5/5 shoulder girdle and/or satisfactory isokinetic test
   3. Complete plyometric program, if applicable
   4. Complete interval return to sport program, if applicable

POD 1

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive forward elevation in plane of scapula (PFE) to tolerance
   1. 10-20 reps, 2 x day
3. Supine passive external rotation (PER) to tolerance
   1. T-stick in 0-20 degrees flexion and 20 degrees abduction
   2. 10-20 reps, 2 x day
4. C-spine AROM
5. Ice
6. Positioning full time in sling until block has worn off
7. Shoulder shrugs and retractions (no weight)
8. ***Pain control modalities PRN
9. D/C sling as tolerated
10. Slowly achieve full PROM in all planes
11. Complications/cautions
    1. If pain level is not dissipating, decrease intensity and volume of exercises.
    2. Assure normal neurovascular status

Weeks 1 to 4

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable
3. Achieve PROM goals to full in FE
4. Achieve PROM goals in ER at 20 deg and 90 deg abduction to full
5. Initiate posterior capsule stretching
6. Isometrics, keeping elbow flexed to 90 degrees
   1. Sub maximal, pain free
7. Theraband scapula retractions
8. ***Aquatics
9. ***Mobilizations PRN
10. ***Trunk stabilization/strengthening
11. Start AAFE and progress to AFE
12. Start periscapular strengthening
    1. Very low weight and high repetitions
13. Cautions
    1. Do not initiate rotator cuff strengthening until 3-4 weeks and until night pain has subsided and overall pain level is low

Weeks 4 to 8

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula, deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula
   1. Rhythmic stabilization or slow reversal hold
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening
12. Isolated pain free, elbow by side
13. Progress to isotonic dumbbell exercises for deltoid and supraspinatus
14. Cautions
    1. Assure normal scapulohumeral rhythm with AAFE and AFE
    2. Strengthening program should progress only without signs of increasing inflammation
    3. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2 x day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 2 to 6

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening as above with the following progressions:
   1. Prone isotonic strengthening PRN
   2. Decreasing amounts of external stabilization provided to shoulder girdle
   3. Integrate functional patterns
   4. Increase speed of movements
   5. Integrate kinesthetic awareness drills into strengthening activities
   6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Phase I: immediate post-operative phase (restrictive motion)

Goals

• Protect the anatomic repair
• Prevent negative effects of immobilization
• Promote dynamic stability
• Decrease pain and inflammation

Weeks 0 to 4

1. Sling for 4 weeks
2. Sleep in immobilizer for 4 weeks
3. Elbow and hand ROM exercises
4. Hand gripping exercises
5. ***No active ER or extension or abduction
6. No passive or active motion at the shoulder
7. Cryotherapy and modalities as indicated

Week 4

1. Discontinue sling at 4 weeks
2. May use immobilizer for sleep
3. ROM exercises (PROM and AAROM)
   1. Flexion to 90-110
   2. Abduction to 75-85
   3. ER in scapular plane to 15-20
   4. IR in scapular plane to 55-60
4. Progress ROM and initiate AROM after 4 weeks
5. Continue modalities and cryotherapy

Weeks 5 to 6

1. Gradually improve ROM
   1. Flexion: 140
   2. ER at 45 degrees abduction: 25-30
   3. IR at 45 degrees abduction: 55-60
2. PNF manual resistance
3. May initiate gentle stretching
4. Posterior Capsular Stretching

Phase II:  intermediate phase (moderate protection)

Goals

• Gradually restore full ROM
• Preserve the integrity of the surgical repair
• Restore muscular strength and balance

Weeks 6 to 10

Gradually progress ROM

• Full flexion
  • ER at 90 abduction: 45-70
  • IR at 90 abduction: 60-70
• Initiate exercise tubing ER and IR (arm at side)
• Initiate isotonic dumbbell exercises for deltoid, supraspinatus, up to 3 lbs. max (once full AFE is achieved)
• PNF strengthening

Weeks 10 to 14

• Slightly more aggressive strengthening
• Continue all stretching exercises
• ***Progress ROM to functional demands

Phase III: minimal protection phase

Goals

• Establish and maintain full ROM
• Improve muscular strength, power and endurance
• Gradually initiate functional activities

Criteria to enter phase III

1. Full pain-free ROM
2. Satisfactory stability
3. Strength improving
4. No pain or tenderness

Weeks 14 to 18

1. Continue all stretching exercises
2. Continue strengthening exercises
   1. Fundamental throwing exercises
   2. PNF manual resistance
   3. Endurance training
   4. Initiate light plyometrics
   5. Light swimming
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula.
   2. QD at most
   3. Begin with beach ball/tennis ball progress to weighted balls
      1. 2-handed tosses
         1. overhand
         2. Underhand
         3. Diagonal
      2. 1-handed stability drills
      3. 1-handed tosses (vary amount of abduction, UE support, amount of protected ER)

Weeks 18 to 20

1. Continue all above exercises
2. Initiate ITP

Phase IV: advanced strengthening phase

Goals

• Enhance strength, power and endurance
• Progress functional activities
• Maintain shoulder mobility

Criteria to enter phase IV

1. Full pain-free ROM
2. Satisfactory static stability
3. Strength 75-80% of contralateral side
4. No pain or tenderness

Weeks 20 to 24

1. Continue flexibility exercises
2. Continue isotonic strengthening program
3. PNF manual resistance patterns
4. Plyometric strengthening
5. Progress ITP

Phase V: return to activity phase (6 to 9 months after surgery)

1. Gradually progress sport activities to unrestricted
2. Discharge/Return to sport criteria
   1. PROM WNL for ADL’s/work/sports
   2. MMT 5/5 shoulder girdle and/or satisfactory isokinetic test
   3. Complete plyometric program, if applicable
   4. Complete interval return to sport program, if applicable

POW 1-2

1. Patellar Mobilizations
2. Cryotherapy
3. Quad sets
4. SLR’s: supine
5. May use e-stim to promote quad recruitment
6. Progress ROM to full actively and passively
7. Teach gait training
   1. Emphasize heel-toe, good quad isolation, normal knee flexion and push-off
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 2-4

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Leg press
      2. Squats
      3. Lunges (front/side/back)
      4. Step-ups
      5. Leg curls
      6. Hip strengthening
      7. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 4-6

1. Continue as above but slowly progress weight and decrease reps (8-10)
   1. Increase load
   2. Decrease time and increase power
2. Progress walking to a fast walk then walk/jog on treadmill
   1. High knee march
   2. Figure of “8”
3. Begin jumping rope.
   1. Shuttle

POW 6 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

ROM Goals

• POW2
  • PFE: 60°-90°
  • PER@20: 0°-20°
  • PER@90: N/A
  • AFE: N/A
• POW6
  • PFE: 90°-120°
  • PER@20: 20°-30°
  • PER@90: N/A
  • AFE: to 90°
• POW9
  • PFE: 130°-155°
  • PER@20: 30°-45°
  • PER@90: 45°-60°
  • AFE: 90°-120°
• POW12
  • PFE: 140°-WNL
  • PER@20: 30°-WNL
  • PER@90: 75°-WNL
  • AFE: 120°-WNL

Phase I protective phase) – NO PROM UNTIL POW 2

Goals

• Minimize pain and inflammatory response
• Achieve ROM goals
• Establish stable scapula

Weeks 0 to 6

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive external rotation (PER)
   1. T-stick in 0-20 deg flexion and 20 deg abduction
   2. 10 reps, 2 x day
3. Supine passive forward elevation in plane of scapula
   1. 90 after the first 2 weeks
   2. 10-20 reps, 2 x day
   3. Do not begin passive forward elevation until 2 weeks post op
4. C-spine AROM
5. Ice
6. Positioning full time in sling with abduction pillow
7. Shoulder shrugs and retractions (no weight)
8. ***Pain control modalities PRN
9. Complications/Cautions
   1. If pain level is not dissipating, decrease intensity and volume of exercises.
   2. Assure normal neurovascular status
   3. No AAROM or AROM until 6 weeks
   4. No pulley until 6 weeks

Weeks 6 to 12

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable
3. Progress PROM goals
4. Achieve PROM goals in ER at 20 degrees and 90 degrees abduction
5. Start AAFE and progress to AFE
6. Initiate posterior capsule stretching
7. Isometrics, keeping elbow flexed to 90 degrees (Sub maximal, pain free)
8. Theraband scapula retractions
9. ***Aquatics
10. ***Mobilizations PRN
11. ***Trunk stabilization/strengthening
12. Start periscapular strengthening with very low weight and high repetitions
13. Cautions
    1. Do not initiate rotator cuff strengthening until 12 weeks and until night pain has subsided and overall pain level is low

Phase II progressive strengthening

Goals

• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power
• Increase functional activities

Months 3 to 4

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold)
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening (isolated pain free, elbow by side)
12. Progress to isotonic dumbbell exercises for deltoid, supraspinatus, up to 3 lbs max
13. Cautions
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain level is low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress only without signs of increasing inflammation
    4. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2 x day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 4 to 6

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening as above (5lbs max for isotonic strengthening) with the following progressions:
   1. Prone isotonic strengthening PRN
   2. Decreasing amounts of external stabilization provided to shoulder girdle
   3. Integrate functional patterns
   4. Increase speed of movements
   5. Integrate kinesthetic awareness drills into strengthening activities
   6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Month 6 to 8

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening program
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
   4. 2-handed tosses
      1. waist level
      2. Overhead
      3. Diagonal
   5. 1-handed stability drills
   6. 1-handed tosses (vary amount of abduction, UE support, amount of protected ER)
4. May begin Interval Throwing Program after 3-6  weeks of plyometrics
5. Initiate progressive replication of demanding ADL/work activities

Discharge/return to sport criteria

1. PROM WNL for ADL’s/work/sports
2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
3. Complete plyometric program, if applicable
4. Complete interval return to sport program, if applicable

Phase I protective phase)

Goals

• Minimize pain and inflammatory response
• Achieve ROM goals
• Establish stable scapula

Weeks 0 to 8

1. Elbow, wrist and hand AROM (EWH)
2. Passive forward elevation in plane of scapula (PFE) (supine ) to 90 after the first 6 weeks; 10-20 reps, 2 x day. Do not begin PROM until 6 weeks post op.
3. Supine passive external rotation (PER) to tolerance with T-stick in 0-20 degrees flexion and 20 degrees abduction; 10-20 reps, 2 x day beginning week 6.
4. C-spine AROM
5. Ice
6. Positioning full time in sling with abduction pillow
7. Shoulder shrugs and retractions (no weight)
8. ***Pain control modalities PRN
9. Complications/Cautions
   1. If pain level is not dissipating, decrease intensity and volume of exercises.
   2. Assure normal neurovascular status
   3. No AAROM or AROM until 12 weeks

Weeks 8 to 12

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable
3. Progress PROM goals to full in all planes
4. Achieve  PROM goals in ER at 20 degrees and 90 degrees abduction (full)
5. Start AAFE and progress to AFEat 12 weeks
6. Initiate posterior capsule stretching
7. Isometrics, keeping elbow flexed to 90 degrees (Sub maximal, pain free)
8. Theraband scapula retractions
9. ***Aquatics
10. ***Mobilizations PRN
11. ***Trunk stabilization/strengthening
12. Start periscapular strengthening with very low weight and high repetitions
13. Cautions
    1. Do not initiate rotator cuff strengthening until 16 weeks and until night pain has subsided and overallpain level is low

Phase II progressive strengthening)

Goals

• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power
• Increase functional activities

Months 3 to 4

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold)
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening (isolatedpain free, elbow by side)
12. Progress to isotonic dumbbell exercises for deltoid,supraspinatus, up to 3 lbs max
13. Cautions
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain levelis low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress onlywithout signs of increasing inflammation
    4. Strengthening program should emphasizehigh repetitions, low weight and should beperformed a maximum of 2 x day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 4 to 6

1. Stretching PRN
2. Continue deltoid/cuff/and scapula strengthening asabove (5lbs max for isotonic strengthening) with thefollowing progressions
   1. Prone isotonic strengthening PRN
   2. Decreasing amounts of external stabilization provided to shoulder girdle
   3. Integrate functional patterns
   4. Increase speed of movements
   5. Integrate kinesthetic awareness drills into strengthening activities
   6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Month 6 to 8

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening program
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuffand scapula
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
   4. 2-handed tosses
      1. waist-level
      2. overhead
      3. diagonal
   5. 1-handed stability drills
   6. 1-handed tosses (vary amount of abduction, UE support, amount of protectedER)
4. May begin Interval Throwing Program after 3-6 weeks of plyometrics
5. Initiate progressive replication of demanding ADL/work activities

Discharge/return to sport criteria

1. PROM WNL for ADL’s/work/sports
2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
3. Complete plyometric program, if applicable
4. Complete interval return to sport program, if applicable

POD 1

1. Ankle pumps: 20-25 per hour
2. Active flexion to 90 as tolerated
3. Strict NWB.  Brace locked in extension at all times unless performing exercises.
4. Gait with crutches.
5. Patellar mobilizations
6. Polar care/ cryotherapy
7. Dressing change: remove bulky dressing, leave clear dressing intact
8. Quad sets

POW 1-4

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Continue active flexion and encourage full extension
5. Begin active ROM to full at 4 weeks
6. Gait training with assistive device
7. Continue NWB
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Encourage upper extremity strengthening for overall conditioning

POW 4-12

1. Continue as above
2. Be sure to advance knee to full ROM
3. Begin weight bearing
   1. Progress from PWB to WBAT with brace locked in extension.
   2. Unlock brace at 6 weeks
   3. D/C brace at 8 weeks
4. Aquatic therapy may start at 8 weeks for LE strengthening
5. Stationary bike with low resistance and seat up high to avoid hyperflexion
6. Standing terminal knee extension with theraband.
7. May increase resistance on stationary bike at 10 weeks

POW 12-16

1. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press with very light weights at 12 weeks
   7. Stationary bike
2. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. Jog
3. Continue modalities
4. Encourage upper extremity strengthening for overall conditioning

POW 16-20

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Leg press
      2. Squats
      3. Lunges (front/side/back)
      4. Step-ups
      5. Leg curls
      6. Hip strengthening
      7. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 20 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

POD 1

1. Ankle pumps – 20-25 per hour
2. Active flexion to 90 as tolerated
3. Gait with crutches.  Strict NWB.
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change
7. Quad sets
8. CPM – 6 hours per day for 6 – 8 weeks
9. Encourage upper extremity strengthening for overall conditioning

POW 1-6

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Continue active flexion and encourage full extension
5. Progress ROM to full
6. Gait training with assistive device – NWB
7. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
8. Stationary bike with low resistance

POW 6-12

1. Continue as above
2. Begin weight bearing.  Progress from PWB to WBAT
3. Aquatic therapy may start at 6 weeks for LE strengthening
4. Standing terminal knee extension with theraband
5. May increase resistance on stationary bike at 8 weeks

POW 12-16

1. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES. 
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press with very light weights at 12 weeks
   7. Stationary bike
2. Continue modalities
3. Encourage upper extremity strengthening for overall conditioning
4. Continue modalities

POW 16-20

1. Continue as above
2. Progress exercises for building strength and endurance
   1. -4-6 sets of 15-20 reps
   2. -progress from double to single leg and concentric to eccentric
   3. -emphasis on closed chain activities only
      1. leg press
      2. squats (short arc)
      3. lunges (front/side/back)
      4. step-ups
      5. leg curls
      6. hip strengthening
      7. resisted walking
3. Exercises for balance and proprioception
   1. -progress from local to whole body
      1. mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking/progress to jogging
   5. Aquatic exercise

POW 20 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

General Goals

1. Restore normal joint function
   1. Control pain and inflammation
   2. Restore range of motion
   3. Restore muscle strength
   4. Improve proprioception and agility
   5. Restore endurance
2. Return to pre-injury unrestricted and sporting activity
   1. 90% muscle strength and endurance as determined by isokinetic testing or functional hop test
   2. Functional hop test
      1. 3 consecutive SLH for distance (90% of contralateral normal)

Post-Op Phases

Phase I: 0-4 weeks

1. Brace
   1. Protected weight bearing. NWB in brace
   2. SLR with no extension lag
   3. Good quad control
2. Exercises
   1. Quad sets (SLR’s) hourly  +/- e-stim (4 directions)
   2. Ankle pumps, HS and gluteal sets
   3. Active extension from 90-50 degrees out of brace
   4. * Patella Mobs – superior/inferior and med/lat
   5. AROM/PROM exercises – (0-90 degrees)
   6. Hip flexor exercises, hip abductor exercises

Phase II: 5-8 weeks

1. Criteria to progress to phase II
   1. Minimal swelling
   2. Gait with full extension
   3. Ability to lock knee while weight bearing
2. Can discontinue brace beginning week 5
3. Advance to FWB/no crutches over this phase
4. Exercises
   1. Increase AROM/ PROM beyond 90 degrees: no limits
   2. Stationary bike: no resistance
      1. Advance duration as tolerated
   3. Resisted gastroc/soleus exercises with theraband only
   4. Progress to bilateral toe raises and then to unilateral toe raises
   5. Resisted hamstring curls with therabands
   6. Step-ups (lateral and forward) on 2-4 inch steps
      1. Increase at own individuals pace
   7. Forward and backward walking with theraband around thighs
   8. Ankle weights to SLR if no extension lag.

Phase III: 9-12 weeks

1. Criteria to progress to phase III
   1. Full active extension and 110 degrees of flexion
   2. No extension lag
   3. Good quad control on single leg stance
   4. Stairs foot over foot
   5. WBAT
2. Program
   1. Stationary cycle with light resistance
      1. RPM>80
      2. Progress to 15-20 minutes per day
   2. Leg Press or Total Gym 40-45 degrees knee flexion toward full extension
   3. Calf raises using leg machine to add resistance
   4. Proprioception exercises
      1. Balance Board/BABS
      2. Theraband “kicks” (wt bear on operative leg)
      3. Pool program if available
      4. Resistance Walking (forward/backward)
      5. Hip exercises (all muscle groups)
3. Stairstepper or seated Kinitron if no anterior knee pain
   1. Begin for 1-5 minutes
   2. Short steps (4-6”) Can gradually increase time to 15 minutes

Phase IV: 12 weeks +

1. Criteria to progress to phase IV
   1. Full AROM
   2. Normal gait
   3. No swelling or pain
2. Program
   1. Increase intensity and resistance for exercises above
   2. Heel taps
   3. Start light agility drills
      1. Carioca
      2. Single-leg hopping on total gym
   4. Slow lunges with tubing
3. Exercises at 16 weeks
   1. Perform isokinetic testing (180deg/sec) or single leg hop 3 consecutive for distance
   2. Begin light jogging on treadmill
   3. Lunges and side-to-side and front-back agility work
      1. Side-to-side jumps and hops
      2. Side-to-side steps
   4. Single leg hopping off total gym
   5. Braiding
   6. Jumping rope
4. Weight machines
   1. Increase weight and intensity for all lower extremity muscle groups
   2. 10% increases weekly
   3. Open and closed chain exercises
   4. Plyometrics
5. HEP

The Non-Surgical Progressive Throwing Program is designed for minor injuries to the shoulder. It covers a period of three and a half to four weeks.  For more involved injuries and post-surgical shoulders, please refer to the Surgical Progressive Throwing Program.

During warm-up, it is important to use heat prior to stretching (e.g., hot pack, whirlpool, hot shower, etc.). Heat increases circulation and activates some of the natural lubricants of the body. Perform stretching exercises after applying the heat modality and then proceed with the throwing program. Use ice after throwing to reduce cellular damage and decrease the inflammatory response to microtrauma.

1. Proceed through each step in order, one step per day (DO NOT SKIP STEPS).
2. Rest one day in between each step.
3. Proceed to the next step only if you are able to throw without pain or discomfort.
4. If at any time during any step you experience pain or discomfort, STOP AND REST. If the pain or discomfort is not relived after your day of rest, do not proceed with the next step. Rest an additional day if necessary and repeat the step in which you experienced the discomfort before progressing to a new step.

STEP 1

Toss the ball (no wind-up), not more than 20 feet. Tossing should be limited to 2-3 sessions, 10-15 min/session.

STEP 2

Increase the tossing distance to 30 – 40 feet. Continue 2-3 sessions, 10-15 min/session.

STEP 3

Lob the ball (playing catch with an easy wind-up) not more than 30 feet.
Continue 2-3 sessions, 10 -15 min/session.

STEP 4

Increase the distance to 40 – 50 feet while still lobbing the ball (easy wind-up).
Schedule the throwing program and strengthening program on alternate days.
Increase the throwing time to 15-20 min/session, 2-3 sessions.

STEP 5

Increase the distance to 60 feet while still lobbing the ball with an occasional straight throw at not more than one-half (1/2) speed. Increase the throwing time to 20 – 25 minutes per session.

STEP 6

Perform long, easy throws from the mid-outfield (150 – 200 feet), getting the ball barely back to home plate on 5 – 6 bounces. This is to be performed for 20 – 25 minutes per session.

STEP 7

Perform long, easy throws from the deepest portion of the outfield, with the ball barely getting back to home plate on numerous bounces. This is to be performed for 25 – 30 minutes per session.

STEP 8

Execute stronger throws from the mid-outfield, getting the ball back to home plate on 1 – 2 bounces. This should be performed approximately 30 – 35 minutes per session.

STEP 9

Perform short, crisp throws with a relatively straight trajectory from the short outfield on one bounce back to home plate. These throws should not be performed for more than 30 minutes.
Continue with your body conditioning program (i.e., strength, flexibility, and endurance). Days in which strengthening and throwing programs occur on the same day, schedule the throwing program in the morning and the strengthening program in the afternoon.

STEP 10

Return to throwing from your normal position (e.g., from the mound if you are a pitcher). The throw should be at one-half to three-fourths speed, with emphasis on technique and accuracy. A throwing session should not be more than 25 minutes.

STEP 11

Throw from your normal position at three-fourths to full speed. Throwing sessions should not be more than 30 minutes.

STEP 12

Simulate a game day situation. Warm-up with the appropriate number of pitches and throw your average number of innings. Take the usual rest breaks between innings. Return to the normal pitching regimen or routine based on input from the team doctor, physical therapist, athletic trainer, coach, and most important of all, the athlete.

If problems arise, contact your therapist, athletic trainer or physician.

POD 1

1. Ankle pumps: 20-25 per hour
2. Active/active assisted knee flexion to 30 degrees as tolerated
3. Strict NWB. Brace locked in extension at all times unless performing exercises.
4. Gait with crutches
5. Patellar mobilizations
6. Polar care/ cryotherapy
7. Dressing change: remove bulky dressing, leave clear dressing intact
8. Quad sets

POW 1-6

1. Continue as above
2. Start SLR’s: start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Continue active flexion and encourage full extension
5. Progress ROM 10 deg per week to achieve 90 deg by 6 weeks
6. Gait training with assistive device
7. Begin WBAT with brace locked in extension at 4 weeks
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Encourage upper extremity strengthening for overall conditioning

POW 6-12

1. Continue as above
2. Be sure to advance knee to full ROM starting at 6 weeks
3. Unlock brace at 8 weeks
4. D/C brace at 10 weeks
5. Aquatic therapy may start at 8 weeks for LE strengthening
6. Stationary bike with low resistance and seat up high to avoid hyperflexion
7. Standing terminal knee extension with theraband
8. May increase resistance on stationary bike at 10 weeks

POW 12-16

1. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press with very light weights at 12 weeks
   7. Stationary bike
2. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. Jog
3. Continue modalities
4. Encourage upper extremity strengthening for overall conditioning

POW 16-20

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Squats, leg press
      2. Lunges (front/side/back)
      3. Step-ups
      4. Leg curls
      5. Hip strengthening
      6. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 20 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Pre-op education

Instruct the patient in ankle pumps, quad sets, seated knee flexion, supine SLR, hamstring stretches, gait training with crutches and protection of the graft

Post-op program

POD 1

1. Ankle pumps: 20-25 per hour
2. Active flexion as tolerated
3. Gait with crutches and brace locked in full extension. (WBAT)
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change
7. Sleep with brace locked in full extension
8. Quad sets
9. Encourage full extension and flexion to 90

POW 1-4

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Progress active flexion to 90 and encourage full extension
5. ROM 0 to 90

POW 4-8

1.  Continue as above
2. Progress flexion to 120 as tolerated.
3. With good quad control, may wean from brace.  Usually in 4-6 weeks.
4. Teach gait training, emphasizing heel-toe, good quad isolation, normal knee flexion and push-off.
5. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
6. Standing hamstring curls to tolerance.
7. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES. 
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
8. Encourage upper extremity strengthening for overall conditioning
9. Continue modalities

POW 8-16

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. -Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Leg press
      2. Squats
      3. Lunges (front/side/back)
      4. Step-ups
      5. Leg curls
      6. Hip strengthening
      7. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POM 4-6

1. Continue as above but slowly progress weight and decrease reps (8-10)
   1. Increase load
   2. Decrease time and increase power
2. Jog Progression
   1. Fast walk
   2. High knee march  
   3. Figure 8
   4. 4 way reaction drill
3. Begin jumping rope.

POM 6 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria-9 months

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Phase I immediate post-operative phase (restrictive motion)

Goals

• Protect the anatomic repair
• Prevent negative effects of immobilization
• Promote dynamic stability
• Decrease pain and inflammation

Weeks 0 to 4

1. Sling for 4 weeks in ER
2. Sleep in immobilizer for 4 weeks
3. Elbow and hand ROM exercises
4. Hand gripping exercises
5. ***No active IR or adduction
6. Cryotherapy, modalities as indicated

Week 4

1. Discontinue sling at 4 weeks
2. May use immobilizer for sleep
3. ROM exercises (PROM and AAROM)
   1. Flexion to 90-110 in scapular plane
   2. Abduction to 75-85
   3. ER in scapular plane to 30
   4. No IR
4. No active IR, adduction, or elevation
5. Continue isometrics, modalities and cryotherapy

Weeks 4 to 6

1. Gradually improve ROM, begin AROM in all planes at 4 weeks
   1. Flexion:140
   2. ER at 45 degrees abduction: 25-30
   3. IR to 20 with arm at side
2. Initiate exercise tubing ER (arm at side)
3. PNF manual resistance

Phase II intermediate phase (moderate protection)

Goals

• Gradually restore full ROM
• Preserve the integrity of the surgical repair
• Restore muscular strength and balance

Weeks 7 to 9

1. Gradually progress ROM
   1. Full flexion
   2. ER at 90 abduction: 45-70
   3. IR at neutral to belly
   4. Begin IR in 30 deg abduction to 30
2. Progress isotonic strengthening program
3. PNF strengthening
4. ****Protect posterior repair

Weeks 10 to 14

1. Slightly more aggressive strengthening
2. Continue all stretching exercises
3. ***Progress ROM to functional demands
4. Progress IR motion in abducted position.
5. May begin to increase IR at 90 deg of abduction (12 weeks)
6. ****Protect posterior repair

Phase III minimal protection phase

Goals

• Establish and maintain full ROM
• Improve muscular strength, power and endurance
• Gradually initiate functional activities

Criteria to enter phase III

1. Full pain-free ROM
2. Satisfactory stability
3. Strength improving
4. No pain or tenderness

Weeks 15 to 18

1. Continue all stretching exercises
2. Progress IR as tolerated
3. Continue strengthening exercises
   1. Fundamental throwing exercises
   2. PNF manual resistance
   3. Endurance training
   4. Initiate light plyometrics
   5. Light swimming

Weeks 18 to 21

1. Continue all above exercises
2. Initiate ITP

Phase IV advanced strengthening phase

Goals

• Enhance strength, power and endurance
• Progress functional activities
• Maintain shoulder mobility

Criteria to enter phase IV

1. Full pain-free ROM
2. Satisfactory static stability
3. Strength 75-80% of contralateral side
4. No pain or tenderness

Weeks 20 to 24

1. Continue flexibility exercises
2. Continue isotonic strengthening program
3. PNF manual resistance patterns
4. Plyometric strengthening
5. Progress ITP

Phase V return to activity phase (6 to 9 months after surgery)

Gradually progress sport activities to unrestricted participation.

The Post-Surgical Progressive Throwing Program is designed for post-surgical overhead athletes. It can also be used in non-surgical candidates with significant injuries. It covers a period of two and one-half to three months. For minor shoulder injuries, please refer to the Non-Surgical Progressive Throwing Program.

During warm-up, it is important to use heat prior to stretching (e.g., hot pack, whirlpool, hot shower, etc.). Heat increases circulation and activates some of the natural lubricants of the body. Perform stretching exercises after applying the heat modality and then proceed with the throwing program. Use ice after throwing to reduce cellular damage and decrease the inflammatory response to microtrauma.

1. Proceed through each step in order (DO NOT SKIP STEPS).
2. Proceed to the next step only if you are able to throw without pain or discomfort.
3. If at any time during any step you experience pain or discomfort, STOP AND REST. If the pain or discomfort is not relived after your day of rest, do not proceed with the next step. Rest an additional day if necessary and repeat the step in which you experienced the discomfort before progressing to a new step.

STEP 1

Toss the ball (no wind-up) on alternate days, not more than 20 feet. Tossing should be limited to 2 -3 times per week, 10 – 15 minutes per session, for one week.

STEP 2

Increase the tossing distance to 30 – 40 feet. Continue 2 – 3 times per week, 10 – 15 minutes per session, for one week.

STEP 3

Lob the ball (playing catch with an easy wind-up) not more than 30 feet. Continue 2 – 3 times per week, 10 – 15 minutes per session, for one week.

STEP 4

Increase the distance to 40 – 50 feet while still lobbing the ball (easy wind-up). Schedule the throwing program and strengthening program on alternate days. Increase the throwing time to 15 – 20 minutes per session, 2 – 3 times/week for one week.

STEP 5

Increase the distance to 60 feet while still lobbing the ball with an occasional straight throw at not more than one-half (1/2) speed. Increase the throwing time to 20 – 25 minutes per session, 2 – 3 times per week, for one week.

STEP 6

Perform long, easy throws from the mid-outfield (150 – 200 feet), getting the ball barely back to home plate on 5 – 6 bounces. This is to be performed for 20 – 25 minutes per session on two consecutive days. Then rest the arm for one day.
Repeat this sequence 3 times over a 9-day period. You may progress to the next step only if you are able to complete the throwing sequence without pain or discomfort. (THROW two days, REST one day x 3)

STEP 7

Perform long, easy throws from the deepest portion of the outfield, with the ball barely getting back to home plate on numerous bounces. This is to be performed for 25 – 30 minutes per session on two consecutive days. Then rest the arm for one day. Repeat the same routine over a 9-day period and progress to the next step if there is no pain or discomfort.

STEP 8

Execute stronger throws from the mid-outfield, getting the ball back to home plate on 1 – 2 bounces. This should be performed approximately 30 – 35 minutes per session on two consecutive days. Rest the arm for one day. Repeat the same routine 3 times over a 9-day period. If there is no pain or discomfort, progress to the next step.

STEP 9

Perform short, crisp throws with a relatively straight trajectory from the short outfield on one bounce back to home plate. These throws should not be performed more than 30 minutes on two consecutive days. Rest the arm for one day. Repeat this sequence over a 9-day period.
Continue your body conditioning program (i.e., strength, flexibility, and endurance). On days in which strengthening and throwing programs occur on the same day, schedule the throwing program in the morning and the strengthening program in the afternoon.
If you are able to throw without pain or discomfort, proceed to the next step.

STEP 10

Return to throwing from your normal position (e.g., from the mound if you are a pitcher). The throw should be at one-half to three-fourths speed, with emphasis on technique and accuracy. Throw for two consecutive days then rest the arm for one day. A throwing session should not be more than 25 minutes. Repeat this step over the next 9 days, then advance to the next step if there is no pain or discomfort.

STEP 11

Throw from your normal position at three-fourths to full speed. This should be done following the same 9-day sequence, throwing for two consecutive days and resting for one day. Throwing sessions should not be more than 30 minutes.

STEP 12

Simulate a game day situation. Warm-up with the appropriate number of pitches and throw your average number of innings. Take the usual rest breaks between innings. Repeat this simulation two to four times with a three to four day rest period in between. Return to the normal pitching regimen or routine based on input from the team doctor, physical therapist, athletic trainer, coach, and most important of all, the athlete.

If problems arise, contact your therapist, athletic trainer or physician.

The Progressive Throwing Program is designed so the athlete may achieve his or her individual throwing level safely without pain or complication.  It is structured to minimize the risk for re-injury by emphasizing warm-up, stretching, proper body mechanics, and the importance of weight training in the throwing athlete.  It should be supplemented with a weight training program and flexibility program to maintain the athlete in top physical condition. The weight program should be done on a throwing day and should emphasize high repetition and low weight.  The athlete should throw every other day and use the day between for flexibility and rest. 

Baseline requirements of throwing include

1. Clearance by the athlete’s physician
2.  Pain-free ROM
3. Adequate muscle power
4. Adequate muscle resistance to fatigue

Guidelines

1. Allow one day of rest between throwing sessions
2. Perform interval throwing program before engaging in strengthening routine
3. Complete two or three pain-free sessions at each phase without complication before advancing to the next phase

The athlete should warm-up by jogging, biking, or jumping rope to increase blood flow and increase muscular flexibility.  Following warm-up, stretching should be performed.  Emphasis should be placed on proper throwing and body mechanics.  The athlete should begin with warm-up throws (soft toss: » 5 yards or 30% of normal for 10-15 throws).

During the recovery process, the athlete may experience soreness and possibly a dull aching sensation in the muscles and tendons.  If the athlete experiences sharp pain, particularly in the joint, stop all throwing activity until the pain ceases and call the athlete’s physician if the pain continues.

It is essential that the thrower complete each individual phase with proper throwing and body mechanics without an increase in pain.  Once a phase has been completed, the athlete may then progress to the next phase.  In so doing, advancement is based on achieving goals rather than advancing at a specified time.  The program is based on an individual thrower, and because all throwers will vary, there is no set time for completion of the program.  This progression greatly decreases the chance for re-injury and provides the safest return to competition.

Phase I: 10 yards

• Step I first day
  • Warm-up throwing
  • 10 yards 25 throws 50%
  • Rest for 15 minutes
  • Warm-up throwing 60%
  • 10 yards 25 throws
• Step II subsequent days
  • Warm-up throwing
  • 10 yards 25 throws 50%
  • Rest for 15 minutes
  • Warm-up throwing
  • 10 yards 25 throws 60%
  • Rest for 15 minutes
  • Warm-up throwing
  • 10 yards 25 throws 70%

Phone II: 20 yards

• Step I first day
  • Warm-up throwing
  • 20 yards 25 throws 60%
  • Rest for 15 minutes
  • Warm-up throwing 70%
  • 20 yards 25 throws
• Step II subsequent days
  • Warm-up throwing
  • 20 yards 25 throws 60%
  • Rest for 15 minutes
  • Warm-up throwing
  • 20 yards 25 throws 70%
  • Rest for 15 minutes
  • Warm-up throwing
  • 20 yards 25 throws 80%

Phase III: 30 yards

• Step I first day
  • Warm-up throwing
  • 30 yards 15 throws 70%
  • Rest for 15 minutes
  • Warm-up throwing
  • 30 yards 15 throws 80%
• Step II subsequent days
  • Warm-up throwing
  • 30 yards 15 throws 70%
  • Rest for 15 minutes
  • Warm-up throwing
  • 30 yards 15 throws 80%
  • Rest for 15 minutes
  • Warm-up throwing
  • 30 yards 15 throws 90%

Phase IV: 40 yards

• Step I first day
  • Warm-up throwing
  • 40 yards 15 throws 80%
  • Rest for 15 minutes
  • Warm-up throwing
  • 40 yards 15 throws 90%
• Step II subsequent days
  • Warm-up throwing
  • 40 yards 15 throws 80%
  • Rest for 15 minutes
  • Warm-up throwing
  • 40 yards 15 throws 90%
  • Rest for 15 minutes
  • Warm-up throwing
  • 40 yards 15 throws 100%

Phase V: 50 yards (if possible)

• Step I first day
  • Warm-up throwing
  • 50 yards 10 throws 80%
  • Rest for 15 minutes
  • Warm-up throwing
  • 50 yards 10 throws 90%
• Step II subsequent days
  • Warm-up throwing
  • 50 yards 10 throws 80%
  • Rest for 15 minutes
  • Warm-up throwing
  • 50 yards 10 throws 90%
  • Rest for 15 minutes
  • Warm-up throwing
  • 10 yards 10 throws 100%

Phase VI: deep passes

• Step I first day
  • Warm-up throwing
  • Deep Route 10 throws
  • Rest for 15 minutes
  • Warm-up throwing
  • Deep Route 10 throws
• Step II subsequent days
  • Warm-up throwing
  • Deep Route 10 throws
  • Rest for 15 minutes
  • Warm-up throwing
  • Deep Route 10 throws
  • Rest for 15 minutes
  • Warm-up throwing
  • Deep Route 10 throws

Phase I protective phase

Goals

• Minimize pain and inflammatory response
• Achieve ROM goals
• Establish stable scapula

Weeks 0 to 6

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive forward elevation in plane of scapula (PFE) to tolerance
   1. 10 reps, 2 x day
3. Supine passive external rotation (PER) to tolerance
   1. T-stick in 0-20 deg flexion and 20 deg abduction
   2. 10 reps, 2 x day
   3. C-spine AROM
4. Ice
5. Positioning full time in sling with abduction pillow
6. Shoulder shrugs and retractions (no weight)
7. ***Pain control modalities PRN
8. ***Aquatics PROM after sutures are out
9. Slowly progress PROM to full in all planes
10. Complications/Cautions:
    1. If pain level is not dissipating, decrease intensity and volume of exercises.
    2. Assure normal neurovascular status
    3. No AAROM or AROM until 6 weeks
    4. No pulley until 6 weeks

Weeks 6 to 12

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable
3. Achieve PROM goals in FE (full)
4. Achieve PROM goals in ER at 20 deg and 90 deg abduction (full)
5. Initiate posterior capsule stretching
6. Isometrics, keeping elbow flexed to 90 degrees (Sub maximal, pain free)
7. Theraband scapula retractions
8. ***Aquatics
9. ***Mobilizations PRN
10. ***Trunk stabilization/strengthening
11. Start AAFE and progress to AFE
12. Start periscapular strengthening
    1. Very low weight and high repetitions
13. Cautions
    1. Do not initiate rotator cuff strengthening until 12 weeks

Phase II progressive strengthening

Goals

• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power
• Increase functional activities

Months 3 to 4

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold)
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening (isolated pain free, elbow by side)
12. Progress to isotonic dumbbell exercises for deltoid, supraspinatus
    1. Up to 3 lbs max
13. Cautions
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain level is low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress only without signs of increasing inflammation
    4. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2x/day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 4 to 6

1. Stretching PRN
2. Continue deltoid/cuff/and scapula strengthening as above (5lbs max for isotonic strengthening) with the following progressions:
   1. Prone isotonic strengthening PRN
   2. Decreasing amounts of external stabilization provided to shoulder girdle
   3. Integrate functional patterns
   4. Increase speed of movements
   5. Integrate kinesthetic awareness drills into strengthening activities
   6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Month 6 to 8

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening program
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
   4. 2-handed tosses
      1. Waist level
      2. Overhead
      3. Diagonal
   5. 1-handed stability drills
   6. 1-handed tosses (vary amount of abduction, UE support, amount of protected ER)
4. May begin Interval Throwing Program after 3-6 weeks of plyometrics
5. Initiate progressive replication of demanding ADL/work activities

Discharge/return to sport criteria

1. PROM WNL for ADL’s/work/sports
2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
3. Complete plyometric program, if applicable
4. Complete interval return to sport program, if applicable

POD 1

1. Ankle pumps: 20-25 per hour
2. Strict NWB.  Brace locked in extension at all times unless performing exercises.
3. Gait with crutches
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change
7. Quad sets in brace

POW 1-6

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine in brace
3. May use e-stim to promote quad recruitment
4. Encourage full extension
5. Progress ROM 10 deg per week beginning week 4 to achieve 90 deg by 8 weeks
6. Gait training with assistive device
7. Begin WBAT with brace locked in extension at 4 weeks
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
9. Encourage upper extremity strengthening for overall conditioning

POW 6-12

1. Continue as above
2. Be sure to advance knee to full ROM starting at 8 weeks
3. Unlock brace at 8 weeks to ambulate
4. D/C brace at 10 weeks
5. Aquatic therapy may start at 8 weeks for LE strengthening
6. Stationary bike with low resistance and seat up high to avoid hyperflexion
7. Standing terminal knee extension with theraband.
8. May increase resistance on stationary bike at 10 week

POW 12-16

1. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES. 
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press with very light weights at 12 weeks
   7. Stationary bike
2. Jog Progression
   1.  Fast walk
   2. High knee march  
   3.  Figure 8
   4. 4 way reaction drill
   5. Jog
3. Continue modalities
4. Encourage upper extremity strengthening for overall conditioning

POW 16-20

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Squats, leg press
      2. Lunges (front/side/back)
      3. Step-ups
      4. Leg curls
      5. Hip strengthening
      6. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 20 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

 

Exercise 1

Diagonal Pattern D2 Extension: Involved hand will grip tubing handle overhead and out to the side. Pull tubing down and across your body to the opposite side of leg. During the motion, lead with your thumb. Perform _______ sets of _______ repetitions _______ daily. 

Diagonal Pattern D2 Flexion: Gripping tubing handle in hand of involved arm, begin with arm out from side 45° and palm facing backward. After turning palm forward, proceed to flex elbow and bring arm up and over involved shoulder. Turn palm down and reverse to take arm to starting position. Exercise should be performed _______ sets of _______ repetitions _______ daily. 

Exercise 2

External Rotation at 0° Abduction: Stand with involved elbow fixed at side, elbow at 90° and involved arm across front of body. Grip tubing handle while the other end of tubing is fixed. Pull out arm, keeping elbow at side. Return tubing slowly and controlled. Perform _______ sets of _______ repetitions _______ times daily. 

Internal Rotation at 0° Abduction: Standing with elbow at side fixed at 90° and shoulder rotated out. Grip tubing handle while other end of tubing is fixed. Pull arm across body keeping elbow at side. Return tubing slowly and controlled. Perform _______ sets of _______ repetitions _______ times daily. 

(Optional) External Rotation at 90° Abduction: Stand with shoulder abducted 90°. Grip tubing handle while the other end is fixed straight ahead, slightly lower than the shoulder. Keeping shoulder abducted, rotate shoulder back keeping elbow at 90°. Return tubing and hand to start position.

Slow Speed Sets: (Slow and Controlled) Perform _______ sets of _______ repetitions _______ times daily.
Fast Speed Sets: Perform _______ sets of _______ repetitions _______ times daily. [

(Optional) Internal Rotation at 90° Abduction: Stand with shoulder abducted to 90°, externally rotated 90° and elbow bent to 90°. Keeping shoulder abducted, rotate shoulder forward, keeping elbow bent at 90°. Return tubing and hand to start position.

Slow Speed Sets: (Slow and Controlled) Perform _______ sets of _______ repetitions _______ times daily.
Fast Speed Sets: Perform _______ sets of _______ repetitions _______ times daily. 

Exercise 3

Shoulder Abduction to 90°: Stand with arm at side, elbow straight, and palm against side. Raise arm to the side, palm down, until arm reaches 90° (shoulder level). Perform _______ sets of _______ repetitions _______ times daily.

Exercise 4

Scaption, External Rotation: Stand with elbow straight and thumb up. Raise arm to shoulder level at 30° angle in front of body. Do not go above shoulder height. Hold 2 seconds and lower slowly. Perform _______ sets of _______ repetitions _______ times daily.

Exercise 5

Sidelying External Rotation: Lie on uninvolved side, with involved arm at side of body and elbow bent to 90°. Keeping the elbow of involved arm fixed to side, raise arm. Hold seconds and lower slowly. Perform _______ sets of _______ repetitions _______ times daily.

Exercise 6

Prone Horizontal Abduction (Neutral): Lie on table, face down, with involved arm hanging straight to the floor, and palm facing down. Raise arm out to the side, parallel to the floor. Hold 2 seconds and lower slowly. Perform _______ sets of _______ repetitions _______ times daily.

Prone Horizontal Abduction (Full ER, 100° ABD): Lie on table face down, with involved arm hanging straight to the floor, and thumb rotated up (hitchhiker). Raise arm out to the side with arm slightly in front of shoulder, parallel to the floor. Hold 2 seconds and lower slowly. Perform _______ sets of _______ repetitions _______ times daily.

Prone Rowing: Lying on your stomach with your involved arm hanging over the side of the table, dumbbell in hand and elbow straight. Slowly raise arm, bending elbow, and bring dumbbell as high as possible. Hold at the top for 2 seconds, then slowly lower. Perform _______ sets of _______ repetitions _______ times daily.

Prone Rowing into External Rotation: Lying on your stomach with your involved arm hanging over the side of the table, dumbbell in hand and elbow straight. Slowly raise arm, bending elbow, up to the level of the table. Pause one second. Then rotate shoulder upward until dumbbell is even with the table, keeping elbow at 90°. Hold at the top for 2 seconds, then slowly lower taking 2-3 seconds. Perform _______ sets of _______ repetitions _______ times daily.

Exercise 7

Press-ups: Seated on a chair or table, place both hands firmly on the sides of the chair or table, palm down and fingers pointed outward. Hands should be placed equal with shoulders. Slowly push downward through the hands to elevate your body. Hold the elevated position for 2 seconds and lower body slowly. Perform _______ sets of _______ repetitions _______ times daily.

Exercise 8

Push-ups: Start in the down position with arms in a comfortable position. Place hands no more than shoulder width apart. Push up as high as possible, rolling shoulders forward after elbows are straight. Start with a push-up into wall. Gradually progress to tabletop and eventually to floor as tolerable. Perform _______ sets of _______ repetitions _______ times daily.

Exercise 9

Elbow Flexion: Standing with arm against side and palm facing inward, bend elbow upward turning palm up as you progress. Hold 2 seconds and lower slowly. Perform _______ sets of _______ repetitions _______ times daily.

Elbow Extension (Abduction): Raise involved arm overhead. Provide support at elbow from uninvolved hand. Straighten arm overhead. Hold 2 seconds and lower slowly. Perform _______ sets of _______ repetitions _______ times daily.

Exercise 10

Wrist Extension: Supporting the forearm and with palm facing downward, raise weight in hand as far as possible. Hold 2 seconds and lower slowly. Perform _______ sets of _______ repetitions _______ times daily.

Wrist Flexion: Supporting the forearm and with palm facing upward, lower a weight in hand as far as possible and then curl it up as high as possible. Hold for 2 seconds and lower slowly.

Supination: Forearm supported on table with wrist in neutral position. Using a weight or hammer, roll wrist taking palm up. Hold for a 2 count and return to starting position. Perform _______ sets of _______ repetitions _______ times daily.

Pronation: Forearm should be supported on a table with wrist in neutral position. Using a weight or hammer, roll wrist taking palm down. Hold for a 2 count and return to starting position. Perform _______ sets of _______ repetitions _______ times daily.

Phase I protective phase

Goals

• Maintain stable prosthesis
• Minimize pain and inflammatory response
• Achieve staged ROM goals
• Establish stable scapula
• Initiate pain free rotator cuff and deltoid strengthening

Days 1 to 3

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive forward elevation in plane of scapula (PFE) to 90
   1. 10-20 reps, 2 x day
   2. Supine PFE by family member or using opposite arm
3. Supine passive external rotation (PE) to neutral
   1. T-stick in 20° flexion and 20° abduction
   2. 5-10 reps, 2x day
4. Codman’s pendulum exercises
5. C-spine AROM
6. Ice
7. Positioning full time in sling
8. Cautions
   1. Assure normal neurovascular status
   2. No lifting of involved arm
   3. Shoulder extension is limited. Elbow not to go behind midline of body

Weeks 1 to 2

1. Continue EWH
2. Shoulder shrugs and retractions (no weight)
3. Continue PFE. Progress to full as tolerated
4. Continue T-bar PER at 20° abduction
   1. Limit ER to 30 degrees if subscapularis repair performed
5. Isometrics, keeping elbow flexed to 90° (sub maximal, pain free)
6. **Manual scapula strengthening
7. **Pain control modalities PRN / Polar Care
8. Complications/Cautions
   1. If pain level is not dissipating, decrease intensity and volume of exercises
   2. Continue to limit shoulder extension past midline of body

Weeks 2 to 6

1. Heat/Ice PRN to help obtain motion
2. D/C sling at week 2 if no subscapularis repair
   1. Week 4 if subscapularis repair performed
3. Progress passive and AAROM ER exercises to full after week 3
4. Start AROM
5. Theraband scapula retractions
6. Progressive serratus anterior strengthening (isolated)
7. AAFE
8. Continue isometric abduction
9. **Pain control modalities PRN
10. **Aquatics AAROM→ AROM
11. **Trunk stabilization/strengthening
12. Cautions
    1. Do not initiate dynamic rotator cuff strengthening
    2. Assure normal scapulohumeral rhythm with AAFE

Phase II progressive strengthening

Goals

• Maintain stability of prosthesis
• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power

Weeks 6 to 9

1. Theraband ER strengthening (pain free, elbow by side)
   1. Week 7 or after
   2. Very light with high repetitions.
   3. Continue self stretching all planes to obtain PROM WFL
2. Advance scapula strengthening
3. AFE as tolerated to full
4. **Mobilizations PRN
5. **Aquatics** AROM
6. **Trunk stabilization/strengthening
7. Cautions
   1. Strengthening program should progress only without signs of increasing inflammation
   2. Strengthening program should emphasize high repetitions, very light resistance and should be performed a maximum of 2 x day

Weeks 9 to 12

1. Continue stretches PRN for PROM WFL
2. Advance theraband strengthening of cuff and scapula below shoulder level
3. Initiate isotonic dumbbell exercises for deltoid, supraspinatus
   1. Up to 2 lbs max (once nearly full AFE achieved)
4. **Mobilizations PRN
5. **Trunk stabilization/strengthening

Phase III return to activity/advanced conditioning

Goals

• Maintain stability of prosthesis
• Normalize strength, endurance and power for age
• Return to full ADL’s and recreational activities

Months 3 to 6

1. Light PFN or manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold) in pain free and comfortable range
2. Stretching PRN
3. Continue deltoid/cuff/scapula strengthening. Avoid overuse of deltoid.

Discharge/return to sport criteria

PROM WFL for ADL’s/work/sports
MMT 5/5 shoulder girdle
Successful return to functional activities

**Adjunctive exercises

Staged ROM Goals

• POW1
  • PFE: 120°
  • PER at 20° abd: 20°
  • PER at 90°: N/A
  • AFE: N/A
• POW3
  • PFE: 160°
  • PER at 20° abd: 20°
  • PER at 90°: N/A
  • AFE: N/A
• POW6
  • PFE: 180°
  • PER at 20° abd: 30°
  • PER at 90°: 30°
  • AFE: 90°
• POW9
  • PFE: WNL
  • PER at 20° abd: WNL
  • PER at 90°: 60° 
  • AFE: 120°+

Phase I protective phase

Goals

• Maintain stable prosthesis
• Minimize pain and inflammatory response
• Achieve staged ROM goals
• Establish stable scapula
• Initiate pain free rotator cuff and deltoid strengthening

Days 1 to 3

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive forward elevation in plane of scapula (PFE) to tolerance
   1. 10-20 reps, 2 x day
   2. Supine PFE by family member or using opposite arm
3. Supine passive external rotation (PE) to tolerance
   1. T-stick in 0-20° flexion and 20° abduction
   2. 5-10 reps, 2x day
4. Codman’s pendulum exercises
5. C-spine AROM
6. Ice
7. Positioning full time in sling
8. Cautions
   1. Assure normal neurovascular status
   2. No lifting of involved arm
   3. Shoulder extension is limited. Elbow not to go behind midline of body
   4. Protect the subscapularis repair

Weeks 1 to 4

1. Continue EWH
2. Shoulder shrugs and retractions (no weight)
3. PFE for the first 4 weeks
   1. Do not start AROM until 4 weeks
4. Continue T-bar PER at 20° abduction
5. Isometrics, keeping elbow flexed to 90° (sub maximal, pain free)
6. **Manual scapula strengthening
7. **Pain control modalities PRN / Polar Care
8. **Aquatics PROM, AROM activities (pain free)
9. Complications/cautions
   1. If pain level is not dissipating, decrease intensity and volume of exercises
   2. Continue to limit shoulder extension past midline of body
   3. Protect the subscapularis

Weeks 4 to 6

1. Heat/Ice PRN to help obtain motion
2. D/C sling as comfortable at week 4 and start AFE
3. Achieve staged PROM goals in FE
4. Achieve staged PROM goals in ER at 20° abduction
5. Theraband scapula retractions
6. Progressive serratus anterior strengthening (isolated)
7. AAFE (pulleys)
8. Continue isometric abduction
9. **Pain control modalities PRN
10. **Aquatics AAROM→ AROM
11. **Trunk stabilization/strengthening
12. Cautions
    1. Do not initiate dynamic rotator cuff strengthening
    2. Assure normal scapulohumeral rhythm with AAFE
    3. Protect the subscapularis

Phase II progressive strengthening

Goals

• Maintain stability of prosthesis
• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power

Weeks 6 to 9

1. Theraband ER strengthening (pain free, elbow by side)week 7 or after. Very light with high repetitions. No IR strengthening until 12 weeks.
2. Continue self stretching all planes to obtain PROM WFL
3. Advance scapula strengthening
4. **Mobilizations PRN
5. **Aquatics
6. **Trunk stabilization/strengthening
7. Cautions
   1. Strengthening program should progress only without signs of increasing inflammation
   2. Strengthening program should emphasize high repetitions, very light resistance and should be performed a maximum of 2 x day

Weeks 9 to 12

1. Continue stretches PRN for PROM WFL
2. Advance theraband strengthening of cuff and scapula below shoulder level
3. May begin IR strengthening at 12 weeks
4. Initiate isotonic dumbbell exercises for deltoid, supraspinatus
5. Up to 2 lbs max (once nearly full AFE achieved)
6. **Mobilizations PRN
7. **Trunk stabilization/strengthening
8. Cautions

Phase III return to activity/advanced conditioning

Goals

• Maintain stability of prosthesis
• Normalize strength, endurance and power for age
• Return to full ADL’s and recreational activities

Months 3 to 6

1. Begin IR strengthening
2. Light PFN or manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold) in pain free and comfortable range
3. Stretching PRN
4. Continue deltoid/cuff/scapula strengthening with the following progressions if needed:
   1. Decreasing amounts of external stabilization provided to shoulder girdle
   2. Integrate functional patterns
   3. Increase speed of movements
   4. Integrate kinesthetic awareness drills into strengthening activities
   5. Decrease in rest time to improve endurance
   6. Transition to maintenance deltoid/cuff/scapula strengthening program
   7. Once met D/C strength criteria
   8. Upon obtaining 85% of normal active ROM and MMT of a least 4/5 for rotator cuff and deltoid, modified sports activities are allowed (short irons and putting for golf, and ground strokes in tennis)

Discharge/return to sport criteria

1. PROM WFL for ADL’s/work/sports
2. MMT 5/5 shoulder girdle
3. Successful return to functional activities

**Adjunctive exercises

Staged ROM Goals

• POD 1
  • PFE: 75°
  • PER at 20° abd: 0-20°
  • PER at 90°: N/A
  • AFE: N/A
• POW 1
  • PFE: 100°
  • PER at 20° abd: 20°
  • PER at 90°: N/A
  • AFE: N/A
• POW 3
  • PFE: 120°
  • PER at 20° abd: 20°
  • PER at 90°: N/A
  • AFE: N/A
• POW 6
  • PFE: 140°
  • PER at 20° abd: 30°
  • PER at 90°: 30°
  • AFE: 90°
• POW 9
  • PFE: WNL
  • PER at 20° abd: WNL
  • PER at 90°: 60°
  • AFE: 120°+

Phase I protective phase

Goals

• Maintain stable prosthesis
• Minimize pain and inflammatory response
• Achieve staged ROM goals
• Establish stable scapula
• Initiate pain free rotator cuff and deltoid strengthening

Days 1 to 3

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive forward elevation in plane of scapula (PFE) to tolerance
   1. 5-10 reps, 2 x day
   2. Supine PFE by family member or using opposite arm
3. Supine passive external rotation (PE) to tolerance
   1. T-stick in 0- 20° flexion and 20° abduction
   2. 5-10 reps, 2x day
4. Codman’s pendulum exercises
5. C-spine AROM
6. Ice
7. Positioning full time in sling
8. Cautions
   1. Assure normal neurovascular status
   2. No lifting of involved arm
   3. Shoulder extension is limited. Elbow not to go behind midline of body
   4. Protect the subscapularis repair

Weeks 1 to 3

1. Continue EWH
2. Shoulder shrugs and retractions (no weight)
3. Continue PFE
4. Continue T-bar PER at 20° abduction
5. Isometrics, keeping elbow flexed to 90° (sub maximal, pain free)
6. **Manual scapula strengthening
7. **Pain control modalities PRN / Polar Care
8. **Aquatics PROM, AROM activities (pain free)
9. Complications/cautions
   1. If pain level is not dissipating, decrease intensity and volume of exercises
   2. Continue to limit shoulder extension past midline of body
   3. Protect the subscapularis

Weeks 3 to 6

1. Heat/Ice PRN to help obtain motion
2. D/C sling as comfortable at week 6
3. Achieve staged PROM goals in FE
4. Achieve staged PROM goals in ER at 20° abduction
5. Theraband scapula retractions
6. Progressive serratus anterior strengthening (isolated)
7. AAFE (pullys) to start at 4 weeks
8. Continue isometric abduction
9. **Pain control modalities PRN
10. **Aquatics AAROM→ AROM
11. **Trunk stabilization/strengthening
12. Cautions
    1. Do not initiate dynamic rotator cuff strengthening
    2. Assure normal scapulohumeral rhythm with AAFE
    3. Protect the subscapularis

Phase II progressive strengthening

Goals

• Maintain stability of prosthesis
• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power

Weeks 6 to 9

1. Theraband ER strengthening (pain free, elbow by side) week 7 or after. Very light with high repetitions.
2. No IR strengthening until 12 weeks.
3. Continue self stretching all planes to obtain PROM WFL
4. Advance scapula strengthening
5. AAFE→ AFE as tolerated
6. **Mobilizations PRN
7. **Aquatics
8. **Trunk stabilization/strengthening
9. Cautions
   1. Strengthening program should progress only without signs of increasing inflammation
   2. Strengthening program should emphasize high repetitions, very light resistance and should be performed a maximum of 2 x day

Weeks 9 to 12

1. Continue stretches PRN for PROM WFL
2. Advance theraband strengthening of cuff and scapula below shoulder level. May begin IR strengthening at 12 weeks.
3. Initiate isotonic dumbbell exercises for deltoid, supraspinatus, up to 2 lbs max (once nearly full AFE achieved)
4. **Mobilizations PRN
5. **Trunk stabilization/strengthening
6. Cautions

Phase III return to activity/advanced conditioning

Goals

• Maintain stability of prosthesis
• Normalize strength, endurance and power for age
• Return to full ADL’s and recreational activities

Months 3 to 6

1. Begin IR strengthening
2. Light PFN or manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold) in pain free and comfortable range
3. Stretching PRN
4. Continue deltoid/cuff/scapula strengthening with the following progressions if needed:
   1. Decreasing amounts of external stabilization provided to shoulder girdle
   2. Integrate functional patterns
   3. Increase speed of movements
   4. Integrate kinesthetic awareness drills into strengthening activities
   5. Decrease in rest time to improve endurance
   6. Transition to maintenance deltoid/cuff/scapula strengthening program
   7. Once met D/C strength criteria
   8. Upon obtaining 85% of normal active ROM and MMT of a least 4/5 for rotator cuff and deltoid, modified sports activities are allowed (short irons and putting for golf, and ground strokes in tennis)

Discharge/Return to sport criteria

1. PROM WFL for ADL’s/work/sports
2. MMT 5/5 shoulder girdle
3. Successful return to functional activities

**Adjunctive exercises

Phase I weeks 1-4

Goal is to protect and minimize pain and inflammation, initiate early motion
Weight bearing precautions:

• Debridement:  WB as tolerated
• Labral repair or osteoplasty:  TTWB for 3 weeks (may be up to 6 weeks if specified by MD)
• **Symmetrical gait pattern is important.  D/C of crutches is based on symmetrical gait pattern NOT PAIN LEVEL

ROM Precautions:

• ROM:  Flex 90° (10 days -2 weeks)
• Ext. 10° (10 days -2 weeks)—for labral repair only
• Abd. 25°  (10 days -2 weeks)—for labral repair only
• ER and IR: Gentle for 3 weeks

Limit sitting at 90 degrees or more due to anterior impingement
Lie prone 1 to 2 hours a day  (work up to this amount)

• Passive supine hip roll into IR: weeks 1-2
• Isometrics gluts, quads, HS, TrA: weeks 1-4
• Bike no resistance high seat: weeks 1-4
• PROM emphasize prone lying, IR, circumduction: weeks 1-4
• Heel slides: week 1-4
• Piriformis stretch: weeks 1-6
• Uninvolved knee to chest: weeks 1-4
• Grade 1 hip jt. Mobs: weeks 1-4
• Manual long axis traction: weeks 2-6
• C-R stretch for IR/ER: weeks 2-6
• Water walking with flotation (if no pain): weeks 2-6
• 3 way leg raises (abd, etc, add): weeks 3-6
• Water jogging with flotation device (if no pain): weeks 3-6

Phase 2 weeks 5-7 transitioning to strength

To move from phase 1 to 2: ROM must be 75% or equal to that of the other side. Must be able to perform hip abduction for Glut. Medius without TFL or Quadratus lumborum compensation.

• Double 1/3 knee bends (partial squats): weeks 5-6
• Bike with resistance: weeks 5-7
• Manual A/P mobilizations: weeks 5-7
• Hip flexor stretch (off bed, with chair, or kneeling; kneeling preferred): weeks 5-7
• Involved knee to chest, adductor stretch: weeks 5-7
• Seated resisted IR/ER (in less than 90 degrees flexion): weeks 5-7
• Leg press: weeks 5-7
• Double leg bridge: weeks 5-7
• Single leg bridge: weeks 5-9
• Freestyle swimming (non-competitive): weeks 5-7
• Wall sits with abductor band: weeks 6-7
• Elliptical/stair climber: weeks 6-9
• Side stepping with abductor band: weeks 7-9

Phase 3 weeks 8-12

To transition to this phase no trendelenburg gait present and full ROM with minimal complaints of pain. If not full ROM (symmetrical to other side) by 10 weeks then terminal stretches allowed with moderate pain is acceptable. Patients with labral repair may take 4 months to get full ER and IR.

• Standing resisted hip ER: weeks 7-9
• Lunges with lunges with trunk rotation: weeks 7-9
• Core ball stabilization progression: weeks 7-9
• Forward/backward/sideways with walking cord: weeks 7-9
• Golf progression (not for 3 months with repair): weeks 7-9
• Water bounding/plyometrics: week 9
• Initial agility drills – single plane (eccentric control and shock absorption is important to instruct patient): week 9

Phase 4 weeks 12+ sport-specific training

Need good psoas and piriformis flexibility and no trendelenburg sign

Can run at 4 months 

• Z-cuts/W-cuts: weeks 9-25
• Cariocas/Ghiradelli's: weeks 9-25
• Sports-specific drills: weeks 9-25
• Functional testing – sportcord test: weeks 17-25

Hip Rehab is important because the surgery corrects the mechanical deficits but the functional deficits are corrected in therapy.

Good form with exercises and core stabilization are key to a good outcome. Glut. Medius and maximus must function without compensation from hip flexors or quadratus lumborum to avoid anterior impingement

Pre-operative

• Stretch hip flexors
• Strengthen glut. Medius and maximus
• Core stabilization and transverse strengthening
• Stretch hip into ER and IR