Accelerated Rehabilitation of the Shoulder after Surgery
Authors: Lennard Funk, Kathleen Roney, Catherine Leftley
Reconstructive shoulder surgery, such as rotator cuff repair and shoulder stabilization, is now less invasive. The repair techniques are much stronger than in the past. However, rehabilitation protocols have not progressed with the advances in surgery of the shoulder. The advances in soft tissue shoulder surgery are identical to those in knee surgery. Accelerated rehabilitation has now become accepted for soft tissue reconstructions of the knee. These include pre-habilitation, immediate full passive range of motion exercises, cold compression and a heavily supervised accelerated strengthening program.
Standard shoulder protocols involve immobilization for up to 6 weeks, followed by range of motion and then strengthening at 3 months. The aims are to immobilize to allow healing, then motion and then strengthen. However, there is increasing evidence that immobilization has adverse effects on tendon healing and repair. Neurophysiological studies have shown that tendons are still activated despite sling immobilization. Shoulder stiffness is not uncommon and return to sports usually is more than six months.
Neurophysiological studies on shoulder exercises have given us a better understanding of the effects on muscle recruitment. Early closed chain exercises use little cuff activation and can be safely commenced soon after surgery. Early range of motion in the 'safe zone' does not put significant stresses on well-fixed repairs. Loading tendons early can improve the quality and strength of the repair, by way of mechanical adaptation.
Using this information, we developed very controlled and specific rehabilitation protocols for shoulder surgery. This is very similar to the accelerated protocols of knee surgery. The principle of the program is to mobilize and strengthen at the same time. We concentrate on exercises that combine core stability, scapula control, Proprioception, motion and strengthening. Prehabilitation is essential and return to sport determined by achieving specific goals, rather than particular time targets. We have used these protocols for over five years and found improved results in terms of rapid return to sports and lower failures than in the past.