orthopedics specialists - shoulder, ankle & elbow rehabilitation physical therapy protocols

8/8/2019 Orthopedics Specialists - Shoulder, Ankle & Elbow Rehabilitation Physical Therapy Protocols

http://slidepdf.com/reader/full/orthopedics-specialists-shoulder-ankle-elbow-rehabilitation-physical 1/12

Kevin B. Freedman, M.D.Sports Medicine

27 South Bryn Mawr Ave

Bryn Mawr, PA 19010-3470

Phone: (610) 527-2727

Fax: (610) 527-1588

ARTHROSCOPIC ANTERIOR SHOULDER STABILIZATION

REHABILITATION PROTOCOL

RANGE OF IMMOBILIZER THERAPEUTIC

MOTION* EXERCISE

PHASE I Active/Active-Assistive: Worn at all times except Elbow/wrist/hand ROM, grip

0-4 weeks stretch to 20 of for hygiene and therapeutic strengthening, isometric in sling,external rotation, and exercise external/internal rotation exercises

90 of forward flexion - with elbow at side

internal rotation to

stomach

Abduction to 45 degrees

No cross-body adduction

PHASE II Increase forward flexion to None Advance isometrics in phase I to use

4 - 8 weeks 140/40 ER at side/ 60 of a theraband, continue with elbow/

abduction/ IR behind back to wrist/hand ROM and grip strengthening,

waist begin prone extensions, and scapular

stabilizing exercises, gentle joint mobs

Modalities as needed

PHASE III Progress to full active None Advance theraband exercises to

8 - 12 weeks motion without discomfort use of weights, continue with and

Gentle passive stretching progress exercises in phase II

at end ranges Include RTC, deltoid, and scapular

stabilizers

PHASE IV Full without discomfort None Advance exercises in phase III, begin

12 weeks - functional progression to work/sport,

6 months** return to previous activity level*

begin upper body ergometer, proprioception

plyometrics

*Patient may return to the weight room at 3 months, if appropriate

**Patient may return to competitive sports, including contact sports, by 6 months, if approved

NOTE: For open stabilization, no internal rotation strengthening for first 6 wks






Phone: (610) 527-2727

Fax: (610) 527-1588

ARTHROSCOPIC ROTATOR CUFF REPAIR



MOTION EXERCISE***

PHASE I Passive range only - to Sling with supporting Codman's, elbow/wrist/hand ROM, grip

0 - 4 weeks tolerance - maintain elbow abduction pillow to be worn strengthening, isometric scapular

at or anterior to mid-axillary at all times except for stabilizationline while supine - limit hygiene and therapeutic

internal rotation at 90 to exercise

40 and behind back to T12

PHASE II 4-6 weeks: Gentle passive None 4-6 weeks: begin gentle active assistive/

4 - 8 weeks stretch to 160 of forward active exercises, begin gentle joint

flexion, 60 external rotation mobilizations (grades I and II), continue

at side, and abduction to 60- with phase I exercises

80 - increase internal 6-8 weeks: begin active exercises

rotation gently at 90 to 60 begin deltoid and biceps*

and behind back to T7-T8 strengthening

6-8 weeks: increase ROM

to tolerance

PHASE III Progress to full motion None Continue with scapular strengthening,

8 - 12 weeks without discomfort progress exercises in phase II, begin

internal/external rotation isometrics,

stretch posterior capsule when arm is

warmed-up

PHASE IV Full without discomfort None Advance exercises in phase III,

12 weeks - begin sport-specific activities, maintain

5 months flexibility, increase velocity of motion,

return to sports activities**

*If biceps tenodesis is concomitantly performed, NO biceps strengthening until 6 weeks post-operative

**If approved by physician

*** For larger tears, active exercise will not be allowed for 6 weeks

NOTE: For mini-open repairs, same protocol is followed






Phone: (610) 527-2727

Fax: (610) 527-1588

ARTHROSCOPIC SLAP REPAIR



MOTION* EXERCISE

PHASE I Active/Active-Assistive: Worn at all times except Elbow/wrist/hand ROM, grip

0-4 weeks stretch to 40 of for hygiene and therapeutic strengthening, isometric in sling,external rotation, and exercise external/internal rotation exercises

120 of forward flexion - with elbow at side

internal rotation to No resisted forward flexion or biceps

stomach until 6 weeks post-op

Abduction to 45 degrees

No cross-body adduction

PHASE II Increase forward flexion to None Advance isometrics in phase I to use

4 - 8 weeks 140/60 ER at side/ 60 of a theraband, continue with elbow/

abduction/ IR behind back to wrist/hand ROM and grip strengthening,

waist begin prone extensions, and scapular

stabilizing exercises, gentle joint mobs

Modalities as needed

PHASE III Progress to full active None Advance theraband exercises to

8 - 12 weeks motion without discomfort use of weights, continue with and

Gentle passive stretching progress exercises in phase II

at end ranges Include RTC, deltoid, and scapular

stabilizers

PHASE IV Full without discomfort None Advance exercises in phase III, begin

12 weeks - functional progression to work/sport,

6 months** return to previous activity level*

begin upper body ergometer, proprioception

plyometrics

Return to throwing at 4 1/2 months

Throw from pitcher's mound at 6 months

*Patient may return to the weight room at 3 months, if appropriate

**Patient may return to competitive sports, including contact sports, by 6 months, if approved






Phone: (610) 527-2727

Fax: (610) 527-1588

MULTIDIRECTIONAL INSTABILITY POST-STABILIZATION



MOTION EXERCISE

PHASE I 0-6 weeks: None Immobilized at all times (except 0-6 weeks: elbow/wrist ROM, grip

0 - 6 weeks for exercise) in flexion, abduction, strengtheningand 0 of rotation

PHASE II Begin active/active-assistive Sling worn for comfort only Continue with exercises in phase I,

6 - 12 weeks ROM - passive ROM to and at night begin active-assistive exercises, deltoid/

tolerance - ROM Goals: rotator cuff isometrics -

40 external rotation, 140 at 8 weeks: begin resistive exercises*

of flexion, 45 of abduction for scapular stabilizers, biceps, triceps,

and rotator cuff

No stretching or manipulation

PHASE III Gradual return to full active None Advance activities in phase II,

3 - 6 months ROM emphasize external rotation and

latissimus eccentrics and glenohumeral

stabilization, begin muscle endurance

activities (upper body ergometer)

Sport specific rehab at 4 1/2 months

Return to throwing at 6 months

No collision sports for 12 months

*Utilize exercise arcs that protect the posterior capsule from stress during resistive exercises, and keep

all strengthening exercises below the horizontal plane in this phase

**Limited return to sports activities






Phone: (610) 527-2727

Fax: (610) 527-1588

POSTERIOR STABILIZATION



MOTION EXERCISE

PHASE I 0-3 weeks: None Immobilized at all times (except 0-3 weeks: elbow/wrist ROM, grip

0 - 6 weeks for exercise) in flexion, abduction, strengthening3-6 weeks: begin passive and 0 of rotation 3-6 weeks: begin passive ROM

ROM - limit flexion to 90 , activities - Codman's, anterior capsule

internal rotation to 45 , and mobilizations

abduction to 90

PHASE II Begin active/active-assistive Sling worn for comfort only Continue with exercises in phase I,

6 - 12 weeks ROM - passive ROM to begin active-assistive exercises, deltoid/

tolerance - ROM Goals: rotator cuff isometrics -

full external rotation, 135 at 8 weeks: begin resistive exercises*

of flexion, 120 of abduction for scapular stabilizers, biceps, triceps,

and rotator cuff

PHASE III Gradual return to full active None Advance activities in phase II,

12 - 16 weeks ROM emphasize external rotation and

latissimus eccentrics and glenohumeral

stabilization, begin muscle endurance

activities (upper body ergometer)

PHASE IV Full and pain-free None Aggressive scapular stabilization and

4 - 6 months** eccentric strengthening, begin

plyometric and throwing/racquet program,

continue with endurance activities,

maintain ROM/flexibility

PHASE V Full and pain-free None Progress phase IV activities, return to

6 - 7 months full activity

*Utilize exercise arcs that protect the posterior capsule from stress during resistive exercises, and keep

all strengthening exercises below the horizontal plane in this phase

**Limited return to sports activities






Phone: (610) 527-2727

Fax: (610) 527-1588

SUBACROMIAL DECOMPRESSION/DISTAL CLAVICLE EXCISION*



MOTION EXERCISE

PHASE I Passive to active range as 0-2 weeks: sling to be Grip strengthening, pulleys/canes,

0 - 4 weeks tolerated worn for comfort only elbow/wrist/hand ROM, Codman's,ROM Goals: 2-4 weeks: discontinue NO resisted motions

140 forward flexion, use of sling

60 external rotation at side,

internal rotation behind back with

gentle posterior capsule stretching

PHASE II Increase range of motion None Begin light isometrics with arm at side,

4 - 8 weeks as tolerated rotator cuff and deltoid - advance to

ROM Goals: therabands as tolerated, passive160 forward flexion, stretching at end ranges to maintain

80 external rotation at side, flexibility

internal rotation with gentle Modalities as needed

posterior capsule stretching be-

hind back and at 90 of abduction

PHASE III Progress to full motion None Advance strengthening as tolerated,

8 - 12 weeks without discomfort begin eccentrically resisted motions and

closed chain activities

*If a distal clavicle excision is performed, horizontal adduction is restricted for 8 weeks post-op

*If biceps tenodesis is concomitantly performed, NO biceps strengthening until 6 weeks post-op






Phone: (610) 527-2727

Fax: (610) 527-1588

TOTAL SHOULDER REPLACEMENT



MOTION EXERCISE*

PHASE I Passive to active range Sling with abduction pillow Grip strengthening, pulleys/canes,

0 - 6 weeks as tolerated* for comfort elbow/wrist/hand active ROM - NO

ROM Goals: resisted internal rotation or extension

Week 1: 90 forward to protect subscapularis

flexion, 20 external

rotation at side, 75 max

abduction without rotation

Week 2: 120 forward

flexion, 40 external rotation

at side, 75 max abduction

without rotation

PHASE II Increase range of motion None Begin light resisted external

6 - 12 weeks as tolerated, begin active rotation, forward flexion, and

assistive/active internal abduction - concentric motions

rotation and extension as only, NO resisted internal rotation,

tolerated extension, or scapular retraction

PHASE III Progress to full motion None Begin resisted internal rotation and

12 weeks - without discomfort extension exercises, advance

12 months strength training as tolerated,begin eccentric motions and

closed chain activities

*NO active internal rotation or extension for 6 weeks post-operative






Phone: (610) 527-2727

Fax: (610) 527-1588

ACHILLES TENDON REPAIR


WEIGHT BRACE ROM THERAPEUTIC

BEARING EXERCISE

PHASE I 0-4 weeks: Non 0-2 weeks: splint 0-2 weeks: NO 0-2 weeks: NO physical therapy or

0 - 8 weeks weight bearing worn at all times physical therapy or motion2-4 weeks: locked motion 2-8 weeks: Inversion/eversion ROM,

4-8 weeks: as in 20 of plantar- 2-6 weeks: limit active stationary bike with brace on, knee/ hip

tolerated with flexion - worn at all dorsiflexion to 90 strengthening, joint mobilizations - NO

crutches and cam- times except for ex- with knee flexed at 90 passive heel cord stretching

walker ercise and hygiene* 6-8 weeks: ROM to

4-8 weeks: worn tolerance

during weight

bearing activities

PHASE II As tolerated with None Gain full and pain-free Begin light resistive dorsi/plantarf lexion

8 - 12 weeks crutches - discontinue exercises with knee flexed, inversion/

crutch use when eversion isometrics, continue with

gait is normalized bicycle and knee/hip strengthening

PHASE III Full with a normalized None Full and pain-free Progress phase II act ivities, begin

12 weeks - gait pattern inversion/eversion isotonics, aggressive

5 months dorsi/plantarflexion resistive exercises

with emphasis on plantar eccentrics

*More tenuous repairs may be required to be immobilized for up to 4 weeks post-operative






Phone: (610) 527-2727

Fax: (610) 527-1588

DISTAL BICEPS TENDON REPAIR



MOTION EXERCISE

PHASE I None Splint for first week Gentle wrist and shoulder ROM

0 - 2 weeks Elbow TROM at first post-op

visit

PHASE II Active extension to 30 Brace worn at all times (including Continue with wrist and shoulder ROM,

2 - 6 weeks in brace, passive flexion exercise) - removed for hygiene begin active extension to 30 , NO

as tolerated active flexion, gentle joint mobilizations

PHASE III Active extension to 0 in Worn at all times (including Continue to maintain wrist and shoulder

6 - 9 weeks brace exercise) - removed for hygiene f lexibility, begin rotator cuff/deltoid

isometrics, progress active extension

in brace, begin gentle flexion strength

PHASE IV Gently advance ROM to None Begin active flexion and extension

9 - 12 weeks tolerance against gravity, advance strengthening

in phase III to resistive, maintain flexibility/

ROM

PHASE V Gradual return to full and None Begin gentle flexion strengthening,

12 weeks - pain-free advance activities in phase IV

6 months

PHASE VI Full and pain-free None Return to full activity

6 months and

beyond






Phone: (610) 527-2727

Fax: (610) 527-1588

ELBOW MCL RECONSTRUCTION



MOTION EXERCISE

PHASE I2 - 4 weeks Passive ROM to tolerance Brace locked at 0 - 90 and to Scapular stabilizing exercises, gentle

be worn at all times rotator cuff strengthening, gentle hand/

wrist/shoulder ROM

PHASE II

4 - 6 weeks Begin AAROM to full flexion* Brace locked at 0 - 90 and to Advance exercises in phase I

be worn at all times

PHASE III

6 - 12 weeks Progress to full motion None Continue with scapular and rotator cuff

without discomfort strengthening, begin forearm resistance

exercises -first in flexion and then

advance to extension

PHASE IV

3 - 5 months Full and pain-free None Continue with shoulder strengthening,begin aggressive rotational exercises,

light tossing, and sport-specific activities

*No forced full flexion






Phone: (610) 527-2727

Fax: (610) 527-1588

LATERAL EPICONDYLITIS POST-OPERATIVE



MOTION EXERCISE*

PHASE I Passive ROM as tolerated Worn for first 5 days Gentle hand/wrist/elbow/shoulder

0-6 weeks post-operative stretching, isometric hand/wrist/elbow/

Counterforce brace for shoulder strengthening - avoid wrist

activities extension exercises for f irst 2 weeks

PHASE II Increase range of motion to full, None Advance strengthening exercises in

6 - 8 weeks begin active wrist extension phase I to resistive, maintain flexibility/

ROM, begin gentle active wrist extension

exercises

PHASE III Full and pain-free None Advance phase II activities, gradual

8 - 10 weeks progression toward return to full activity

*NO active wrist extension for 2 weeks post-operative

orthopedics specialists - shoulder, ankle & elbow rehabilitation physical therapy protocols

Documents