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Phase 1 (Initial 3 weeks post-surgery)

• Dressing removed in therapy; gunslinger brace all times for three weeks
• Wrist and elbow ROM as tolerated, ball squeezes

Phase 2 (3-6 weeks)

• Start gentle passive ROM with shoulder flexion, abduction, external rotation
  • Progress with internal rotation as needed
  • Add active-assist (wand exercises) and shoulder shrugs
  • Progress with isometric internal and external rotation with arm at side and elbow flexed at 90 degrees (pain free contraction)
  • As strength improves, add active external rotation with tubing (pain free)

Phase 3 (6-8 weeks)

• Continue passive and active-assist ROM exercises; may add wall climbs
• Progress to free weights for external rotation in prone lying position with arm abducted to 90 degrees or sidelying with arm at the side
  • Perform combined movements of horizontal abduction followed by external rotation to protect posterior capsule
  • If sidelying, limit degrees of internal rotation to protect capsule
  • Add supraspinatus exercise if pain free and ROM 0-90 degrees
  • Shoulder positioned in scapular plane in 20-30 degrees forward of coronal plane
  • Add active shoulder flexion through available ROM and active abduction to 90 degrees

Phase 4 (2-3 months)

• Should have full passive and active ROM
• Add shoulder stretch/mobilization as needed
• Add push ups in 80-90 degrees of abduction (pain free)
  • Do not raise body beyond scapular plane
  • Begin with wall push ups
  • Continue isotonic strengthening with emphasis on rotator cuff and posterior deltoid
  • Active internal rotation with tubing and PNF upper extremity patterns added
  • Flexion/abduction/external rotation diagonals emphasized
  • Start ¼ of way in diagonal and limit range to latter ¾ to protect capsule
  • Horizontal abduction performed through increased range (starting position at 90 degrees of horizontal abduction as tolerated)

Phase 5 (4 months)

• Continue to progress weights as needed; emphasize eccentric cuff strengthening
• Can add ergometer for endurance
• Can add isokinetic strengthening at high speeds (200 plus degrees/second) for internal/external rotation with arm at side and horizontal abduction
• Need 5-10 pounds external and 15-20 pounds internal rotation prerequisite strength and pain free shoulder motion before starting

Phase 6 (5 months)

• Isokinetic test
• Continue to progress isotonic and isokinetic exercises (can add flexion/extension and abduction/adduction)
• Add military press with weight directly over or behind head
• Total body conditioning and flexibility addressed

Phae 7 (6 months)

• Second isokinetic test
• Should have 80% strength and endurance as compared to opposite side before proceeding with sport specific activities
• Continue total body conditioning
• Start practicing skills specific to work or sport activity if indicated
• Use heat prior to stretching and ice after activity