Anterior Stabilization of the Shoulder: Latarjet Protocol

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Progression to the next phase based on Clinical Criteria and/or Time Frames as Appropriate.

Phase I – Immediate Post Surgical Phase (approximately Weeks 1- 3)

Goals:

• Minimize shoulder pain and inflammatoryresponse
• Protect the integrity of the surgicalrepair
• Achieve gradual restoration of passive range of motion(PROM)
• Enhance/ensure adequate scapular function

Precautions/Patient Education:

• No active range of motion (AROM) of the operativeshoulder
• No excessive external rotation range of motion (ROM) / stretching. Stop at first end feel felt
• Remain in sling, only removing for showering. Shower with arm held atside
• No lifting of objects with operativeshoulder
• Keep incisions clean anddry
• Patient education regarding limited use of upper extremity despite the potential lack of or minimal pain or othersymptoms

Activity:

• Arm in sling except when performing distal upper extremityexercises
• (PROM)/Active-Assisted Range of Motion (AAROM)/ (AROM) elbowand wrist/hand
• Begin shoulder PROM (do not force any painfulmotion)
• Forward flexion and elevation totolerance
• Abduction in the plane of the scapula totolerance
• Internal rotation (IR) to 45 degrees at 30 degrees ofabduction
• External rotation (ER) in the plane of the scapula from 0-25 degrees; begin at 30-40 degrees of abduction; respect anterior capsule tissue integrity withER range of motion; (seek guidance from intraoperative measurements of external rotation ROM)

• Scapular clock exercises progressed to scapular isometricexercises
• Ballsqueezes
• Sleep with sling supporting operative shoulder, place a towel under the elbow to prevent shoulder hyperextension
• Frequent cryotherapy for pain andinflammation
• Patient education regarding posture, joint protection, positioning, hygiene,

Milestones to progress to phase II:

• Appropriate healing of the surgicalrepair
• Adherence to the precautions and immobilizationguidelines
• Achieved at least 100 degrees of passive forward elevation and 30 degreesof passive external rotation at 20 degreesabduction
• Completion of phase I activities without pain ordifficulty

Phase II – Intermediate Phase/ROM (approximately Week 4-9)

Goals:

• Minimize shoulder pain and inflammatoryresponse
• Protect the integrity of the surgicalrepair
• Achieve gradual restoration of(AROM)
• To be weaned from the sling by the end of week4-5
• Begin light waist levelactivites

Precautions:

• No active movement of shoulder till adequate PROM with goodmechanics
• No lifting with affected upperextremity
• No excessive external rotation ROM /stretching
• Do not perform activities or strengthening exercises that place an excessive load on the anterior capsule of the shoulder joint (i.e. no pushups, pec flys,etc..)
• Do not perform scaption with internal rotation (empty can) during any stage of rehabilitation due to the possibility ofimpingement

Early Phase II (approximately week 4):

• Progress shoulder PROM (do not force any painfulmotion)
• Forward flexion and elevation totolerance
• Abduction in the plane of the scapula totolerance
• IR to 45 degrees at 30 degrees of abduction
• ER to 0-45 degrees; begin at 30-40 degrees of abduction; respect anterior capsule tissue integrity with ER range of motion; seek guidance from intraoperative measurements of external rotation
• Glenohumeral joint mobilizations as indicated (Grade I, II) when ROM is significantly less than expected. Mobilizations should be done in directionsof limited motion and only until adequate ROM isgained.
• Address scapulothoracic and trunk mobility limitations. Scapulothoracic and thoracic spine joint mobilizations as indicated (Grade I, II, III) when ROM is significantly less than expected. Mobilizations should be done in directionsof limited and only until adequate ROM isgained.
• Begin incorporating posterior capsular stretching asindicated
• Cross body adductionstretch
• Side lying internal rotation stretch (sleeperstretch)
• Continued Cryotherapy for pain andinflammation
• Continued patient education: posture, joint protection, positioning, hygiene,etc.

Late Phase II (approximately Week 6):

• Progress shoulder PROM (do not force any painfulmotion)
• Forward flexion, elevation, and abduction in the plane of the scapula to tolerance
• IR as tolerated at multiple angles ofabduction
• ER to tolerance; progress to multiple angles of abduction once >/= 35 degrees at 0-40 degrees of abduction
• Glenohumeral and scapulothoracic joint mobilizations as indicated (Grade I-IV as appropriate)
• Progress to AA/AROM activities of the shoulder as tolerated with good shoulder mechanics (i.e. minimal to no scapulathoracic substitution with up to 90-110 degrees of elevation.)
• Begin rhythmic stabilizationdrills
• ER/IR in the scapularplane
• Flexion/extension and abduction/adduction at various angles ofelevation
• Continue AROM elbow, wrist, andhand
• Strengthen scapular retractors and upward rotators
• Initiate balanced AROM / strengtheningprogram
• Initially in low dynamicpositions
• Gain muscular endurance with high repetition of 30-50, low resistance1-3 lbs)
• Exercises should be progressive in terms of muscle demand / intensity, shoulder elevation, and stress on the anterior jointcapsule
• Nearly full elevation in the scapula plane should be achievedbefore beginning elevation in otherplanes
• All activities should be pain free and without substitutionpatterns
• Exercises should consist of both open and closed chain
  • Initiate ER/IR strengthening using exercise tubing at 0°of abduction (use towelroll)
  • Initiate sidelying ER with towelroll
  • Initiate manual resistance ER supine in scapular plane (light resistance)
  • Initiate prone rowing at 30/45/90 degrees of abduction to neutral armposition
• Continued cryotherapy for pain andinflammation
• Continued patient education: posture, joint protection, positioning, hygiene,etc.

Milestones to progress to phase III:

• Passive forward elevation at least 155degrees
• Passive external rotation within 8-10 degrees of contralateral side at 20 degrees abduction
• Passive external rotation at least 75 degrees at 90 degreesabduction
• Active forward elevation at least 145 degrees with goodmechanics
• Appropriate scapular posture at rest and dynamic scapular control with ROM and functionalactivities
• Completion of phase II activities without pain ordifficulty

Phase III - Strengthening Phase (approximately Week 10 – Week 15)

Goals:

• Normalize strength, endurance, neuromuscularcontrol
• Return to chest level full functionalactivities
• Gradual and planned buildup of stress to anterior jointcapsule

Precautions:

• Do not overstress the anterior capsule with aggressive overhead activities / strengthening
• Avoid contact sports/activities
• Do not perform strengthening or functional activities in a given plan until the patient has near full ROM and strength in that plane ofmovement
• Patient education regarding a gradual increase to shoulderactivities

Activity:

• Continue A/PROM asneeded/indicated
• Initiate biceps curls with light resistance, progress astolerated
• Initiate gradually progressed strengthening for pectoralis major and minor; avoid positions that excessively stress the anteriorcapsule
• Progress subscapularis strengthening to focus on both upper and lowersegment

Milestones to progress to phase IV:

• Passive forward elevationWNL
• Passive external rotation at all angles of abductionWNL
• Active forward elevation WNL with goodmechanics
• Appropriate rotator cuff and scapular muscular performance for chest level activities
• Completion of phase III activities without pain ordifficulty

Phase IV - Overhead Activities Phase / Return to activity phase (approximately Week 16-20)

Goals:

• Continue stretching and PROM asneeded/indicated
• Maintain full non-painfulAROM
• Return to full strenuous workactivities
• Return to full recreationalactivities

Precautions:

• Avoid excessive anterior capsulestress
• With weight lifting, avoid tricep dips, wide grip bench press, and no military press or lat pulls behind the head. Be sure to “always see yourelbows”
• Do not begin throwing, or overhead athletic moves until 4 months post-opor cleared byMD

Activity:

• Continue all exercises listedabove
  • Progress isotonic strengthening if patient demonstrates no compensatory strategies, is not painful, and has no residual soreness
• Strengthening overhead if ROM and strength below 90 degree elevation isgood
• Continue shoulder stretching and strengthening at least four times perweek
• Progressive return to upper extremity weight lifting program emphasizing the larger, primary upper extremity muscles (deltoid, latissimus dorsi, pectoralis major)
  • Start with relatively light weight and high repetitions (15-25)
• May do pushups as long as the elbows do not flex past 90degrees
• May initiate plyometrics/interval sports program if appropriate/cleared by PT and MD
• Can begin generalized upper extremity weight lifting with low weight, and high repetitions, being sure to follow weight liftingprecautions.
• May initiate pre injury level activities/ vigorous sports if appropriate / cleared by MD

Milestones to return to overhead work and sport activities:

• Clearance fromMD
• No complaints of pain orinstability
• Adequate ROM for taskcompletion
• Full strength and endurance of rotator cuff and scapular musculature for task completion

Regular completion of continued home exercise program