Upper Limb

Shoulder

Arthroscopic shoulder stabilisation

Arthroscopic shoulder stabilisation is performed for recurrent shoulder instability.

Before surgery

Pre-operative rehabilitation (‘pre-hab’) is recommended.

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Day 1 – 3 weeks During the first 3 weeks, you can expect to:

  • wear a sling (athletes can wean off sooner under guidance of club therapist)
  • learn axillary hygiene
  • learn postural awareness and scapular setting
  • be taught to perform the following:
    • core stability exercises (as appropriate)
    • proprioceptive exercises (minimal weightbearing below 90 degrees)
    • active assisted flexion (as comfortable)
    • active assisted external rotation (as comfortable)

Do not to force or stretch your shoulder

3 – 6 weeks During the next 3 weeks, you can expect to:

  • wean off the sling
  • progress active assisted to active ROM as comfortable

Do not force or stretch or stretch your shoulder

6 – 12 weeks During the next 6 weeks, you can expect to:

  • regain scapula and glenohumeral stability working for shoulder joint control rather than range
  • gradually increase range of motion
  • strengthen your shoulder
  • increase your proprioception through open and closed chain exercise
  • progress core stability exercises
  • incorporate sports-specific rehabilitation
  • engage in plyometrics and pertubation training
postop1

Milestones

Time after surgery What you can expect from your shoulder
Week 6 Active elevation to pre-surgery level
Week 12 Minimum 80% range of external rotation compared to asymptomatic side

Normal movement patterns throughout range

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job – as tolerated

Manual job – 3 months

Driving 6–8 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Golf 3 months
Lifting Avoid lifting heavy items for 3 months
Contact/high impact sports(eg rugby, AFL, martial arts, racket sports and surfing) 3 months

AC joint stabilisation

AC joint stabilisation is performed for AC joint dislocations.

Before surgery

Pre-operative rehabilitation (‘pre-hab’) is recommended.

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Day 1 – 3 weeks During the first 3 weeks, you can expect to:

  • wear a sling (athletes can wean off sooner under guidance of club therapist)
  • learn axillary hygiene
  • learn postural awareness and scapular setting
  • be taught to perform the following:
    • core stability exercises (as appropriate)
    • proprioceptive exercises (minimal weight bearing below 90 degrees)
    • active assisted flexion (as comfortable)
    • active assisted external rotation (as comfortable)

Do not to force or stretch your shoulder

3 – 6 weeks During the next 3 weeks, you can expect to:

  • wean off the sling
  • progress active assisted to active ROM as comfortable

Do not force or stretch or stretch your shoulder

6 – 12 weeks During the next 6 weeks, you can expect to:

  • regain scapula and glenohumeral stability working for shoulder joint control rather than range
  • gradually increase range of motion
  • strengthen your shoulder
  • increase your proprioception through open and closed chain exercise
  • progress core stability exercises
  • incorporate sports-specific rehabilitation
  • engage in plyometrics and pertubation training
postop12

Milestones

Time after surgery What you can expect from your shoulder
Week 6 Active elevation to pre-surgery level
Week 12 Minimum 80% range of external rotation compared to asymptomatic side

Normal movement patterns throughout range

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job – as tolerated

Manual job – 3 months

Driving 6–8 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Golf 3 months
Lifting Avoid lifting heavy items for 3 months
Contact/high impact sports(eg rugby, AFL, martial arts, racket sports and surfing) 3 months

 

Biceps Tenodesis

Biceps tenodesis is performed to repair a damaged or partially torn long head of the biceps tendon. The tendon is transposed from its origin on the glenoid to the humerus and fixed in place with screws or anchors.

Note: If a biceps tenodesis is performed as part of a rotator cuff repair, follow the rotator cuff repair protocol.

Before surgery

Pre-operative rehabilitation (‘pre-hab’) is recommended.

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Day 1 – 3 weeks During the first 3 weeks, you can expect to:

  • wear a master sling\
  • learn postural awareness and scapular setting
  • regain scapula and glenohumeral stability working for shoulder joint control rather than range
  • be taught to perform the following:
    • core stability exercises (as appropriate)
    • finger, wrist and radioulnar movements
    • active elbow flexion and extension in standing position (as tolerated)
    • active shoulder movement(as tolerated)

Avoid resisted elbow flexion and forced passive extension

3 – 6 weeks During the next 3 weeks, you can expect to:

  • wean off the sling
  • have your kinetic chain control assessed
  • be taught to perform:
    • kinetic chain control exercises (as required)
    • exercises to strengthen rotator cuff muscles
    • elbow flexion with light resistance (as tolerated)
6 – 12 weeks During the next 6 weeks, you can expect to:

  • engage in eccentric biceps exercises with scapula control (if required)
12 weeks + From 12 weeks, you can expect to:

  • engage in biceps strengthening exercises

Milestones

Time after surgery What you can expect from your shoulder
Week 6 Full active range of shoulder and elbow motion
Week 12 Full active range of elbow and shoulder movement with dynamic scapula stability throughout range (concentric and eccentric)

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job – as tolerated

Manual job – 3 months

Driving 6–8 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Golf 3 months
Lifting Avoid lifting heavy items for 3 months
Contact/high impact sports(eg rugby, AFL, martial arts, racket sports and surfing) 3 months

Reverse shoulder replacement

Reverse shoulder replacement surgery is performed for:

  • massive irreparable rotator cuff injury or cuff tear arthropathy
  • shoulder arthritis in the absence of a functional rotator cuff

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
In hospital
Day 0 Immediately after surgery, you will:

  • be fitted with a polysling and body belt (fitted in theatre)
  • start performing finger, wrist and elbow movements
  • commence working with your occupational therapist
Day 1 On the day after surgery, you can expect:

  • the body belt to be removed
  • to learn axillary hygiene
  • to be taught to perform:
    • pendular exercises
    • scapular setting
    • passive flexion in the scapula plane (as comfortable)
    • external rotation to neutral

Most people are discharged 1–2 days after surgery

At home
Day 5 – 3 weeks During this time, you will:

  • avoid resisted internal rotation or forced passive external rotation (reattached subscapularis muscle is vulnerable)
  • begin passive abduction (maintain shoulder in IR)
  • perform passive external rotation to neutral only
  • perform active assisted flexion in supine and progress to sitting position as soon as you are able
  • progress to active when possible
  • begin isometric strengthening of all muscle groups (except IR)
  • remove sling as able
  • perform functional reaching activities below 90 degrees
3 – 6 weeks During this time, your physiotherapist will:

  • encourage active movement into all ranges with some gentle self-stretching at the end of range.
  • add isometric IR
  • progress functional activities
6 weeks + From here, you will:

  • progress strengthening through range
  • regularly stretch the joint to the end of its available range

Your physiotherapist may perform soft tissue manipulation (if required)

Milestones

Time after surgery What you can expect from your shoulder
Week 3 50% of pre-surgery active range of motion
Week 6 Passive range of motion to at least pre-surgery level
Week 12 Active range of motion to at least pre-surgery level

Improvement continues for 18 months to 2 years and you should continue exercising until your maximum potential has been reached

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job –3 weeks

Manual job –as guided by your surgeon (typically between 3–6 months)

Driving 6weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Lifting Avoid lifting heavy items for 3 months, after then, as guided by your strength

Shoulder or clavicle fracture fixation

Shoulder or clavicle fixation is performed to repair fractures of the proximal humerus (upper arm bone), clavicle (collar bone) and scapula/glenoid (shoulder blade/joint).

After surgery
Rehabilitation protocol

This protocol is based on maintaining range of movement in the first phase and then gradually building strength in the middle to the last phase.

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

 

Time after surgery Physiotherapy/support
Day 1 – 3 weeks During the first 3 weeks, you can expect to:

  • wear an arm immobiliser
  • perform the following:
    • wrist/hand/finger exercises
    • elbow flexion/extension and rotation
    • shoulder girdle exercises
    • scapula setting exercises
    • passive range of motion movements in all directions (as tolerated)

Do not to force or stretch your shoulder

3 – 6 weeks During the next 3 weeks, you can expect to:

  • wean off the sling
  • begin active assisted exercises ensuring glenohumeral movement, not scapulothoracic

Do not force or stretch or stretch your shoulder

6 weeks + During the next 6 weeks, you can expect to:

  • progress to full active exercises in all ranges
  • begin rotator cuff strengthening (pain free)
  • engage in closed chain exercises
  • begin stretching the capsule
  • begin proprioceptive exercises
postop3

Milestones

Time after surgery What you can expect from your shoulder
Week 4 50% of pre-surgery passive range of motion
Week 6 Active range of motion 50% of pre-surgery level
Week 12 Active range of motion equal to pre-surgery level

Passive range of motion equal to pre-surgery level

Note: any acute loss of active movement should be referred to the next shoulder clinic

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job – as tolerated

Manual job – 3 months

Driving 6–8 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Golf 3 months
Lifting Avoid lifting heavy items for 3 months
Contact/high impact sports(eg rugby, AFL, martial arts, racket sports and surfing) 3 months

Shoulder SLAP repair

Shoulder superior labral anterior to posterior tear (SLAP) surgery is performed to repair damage to the origin of the long head of the biceps tendon.

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

 

Time after surgery Physiotherapy/support
Day 1 – 3 weeks During the first 3 weeks, you can expect to:

  • initially wear a sling, but wean off it
  • be taught postural awareness and scapular setting
  • be assessed for kinetic chain control and be given exercises if required
  • regain scapula and glenohumeral stability working for shoulder joint control rather than range
  • engage in the following:
    • passive range of motion exercises (as tolerated)
    • active assisted motion exercises (as tolerated)
    • closed chain exercises (as tolerated)
    • core stability exercises with sling (as appropriate)
3 – 6 weeks During the next 3 weeks, you can expect to:

  • progress to active glenohumeral flexion, abduction, internal and external rotation
  • start scapular stabiliser exercises
  • begin strengthening rotator cuff muscles
  • perform posterior complex stretching
  • increase your proprioception through open and closed chain exercises
6 – 12 weeks During the next 6 weeks, your physiotherapist will:

  • ensure posterior capsule mobility
  • perform manual therapy (if indicated) to eliminate any stiffness
  • assess biceps function and add in eccentric biceps exercises with scapula control (if required)
  • progress your program to include sports-specific rehab
12 weeks + From here you will be involved in:

  • biceps strengthening exercises

Milestones

Time after surgery What you can expect from your shoulder
Week 6 Full active range of elevation
Week 12 Full active range of movement with dynamic scapula stability throughout range (concentric and eccentric)

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job – as tolerated

Manual job – 3 months

Driving 6–8 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Golf 3 months
Lifting Avoid lifting heavy items for 3 months
Contact/high impact sports(eg rugby, AFL, martial arts, racket sports and surfing) 3 months

Rotator Cuff Repair

Rotator cuff repair is performed for painful symptomatic rotator cuff repair.

This protocol is based on maintaining range of movement in the first phase and then gradually building strength in the middle to the last phase.

Before surgery

Pre-operative rehabilitation (‘pre-hab’) is recommended. This involves:

  • range of motion exercises
  • maximising strength of deltoid, intact cuff muscles and scapula stabilisers

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Day 1 – 3 weeks During the first 3 weeks, you can expect to:

  • be fitted with a polysling and body belt (while in theatre)
  • be taught to perform the following:
    • wrist/hand/finger exercises
    • elbow flexion/extension and rotation
    • scapula setting exercises
    • pendular exercises
    • passive range of motion in all directions (as tolerated)
3 – 6 weeks During the next 3 weeks, you can expect to:

  • wean off the sling
  • perform gentle isometric exercises in neutral (as pain allows)
  • begin active assisted exercises ensuring glenohumeral movement, not scapulothoracic

Do not force or stretch or stretch your shoulder

6 weeks + From 6 weeks, you can expect to:

  • progress to full active exercises in all ranges
  • begin rotator cuff strengthening (pain free)
  • perform closed chain exercise
  • begin stretching the capsule
  • begin proprioceptive exercises

Milestones

Time after surgery What you can expect from your shoulder
Week 4 At least 50% of pre-surgery passive range of motion
Week 6 Active assisted range of motion equal to pre-surgery level
Week 12 Active range of motion equal to pre-surgery level

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job –3 weeks

Manual job –as guided by your surgeon (typically between 3 and 6 months)

Driving 6 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Golf 3 months
Lifting Avoid lifting heavy items for 3 months, from then, as guided by your strength
Contact/high impact sports(eg rugby, AFL, martial arts, racket sports and surfing) 3 months

Shoulder Replacement

Shoulder replacement is performed for severe shoulder arthritis where pain is the predominant feature.

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
In hospital
Day 0 Immediately after surgery, you will:

  • be fitted with a polysling and body belt (fitted in theatre)
  • start performing finger, wrist and elbow movements
  • commence working with your occupational therapist
Day 1 On the day after surgery, you can expect:

  • the body belt to be removed
  • to learn axillary hygiene
  • to be taught to perform:
    • pendular exercises
    • scapular setting
    • passive flexion in the scapula plane (as comfortable)
    • external rotation to neutral

Most people are discharged 1–2 days after surgery

At home
Day 5 – 3 weeks During this time, you will:

  • avoid resisted internal rotation or forced passive external rotation (reattached subscapularis muscle is vulnerable)
  • begin passive abduction (maintain shoulder in IR)
  • perform passive external rotation to neutral only
  • perform active assisted flexion in supine and progress to sitting position as soon as you are able
  • progress to active when possible
  • begin isometric strengthening of all muscle groups (except IR)
  • remove sling as able
  • perform functional reaching activities below 90 degrees
3 – 6 weeks During this time, your physiotherapist will:

  • encourage active movement into all ranges with some gentle self-stretching at the end of range.
  • add isometric IR
  • progress functional activities
6 weeks + From here, you will:

  • progress strengthening through range
  • regularly stretch the joint to the end of its available range

Your physiotherapist may perform soft tissue manipulation (if required)

Milestones

Time after surgery What you can expect from your shoulder
Week 3 50% of pre-surgery active range of motion
Week 6 Passive range of motion to at least pre-surgery level
Week 12 Active range of motion to at least pre-surgery level

Improvement continues for 18 months to 2 years and you should continue exercising until your maximum potential has been reached

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job –3 weeks

Manual job –as guided by your surgeon (typically between 3–6 months)

Driving 6 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Lifting Avoid lifting heavy items for 3 months, after then, as guided by your strength

Elbow

Distal Biceps Tendon Repair or Reconstruction

Distal biceps tendon repair or reconstruction is performed for:

  • an acute (within 3 weeks) traumatic distal biceps rupture
  • a chronic distal biceps tendon rupture

After surgery

Rehabilitation protocolfor an acute tear repair

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Day 1 – 2 weeks During the first 2 weeks, you can expect to:

  • perform pain-free active flexion and extension within limits of a sling
  • engage in full supination and pronation exercises
  • perform full active shoulder movements with your elbow in flexion
2 – 6 weeks During the next 4 weeks, you will:

  • perform active range of motion movement in all directions, to the point of mild stretch (but no over pressure)

Avoid sudden loading and unplanned movements for 6 weeks

6 – 12 weeks In the next 6 weeks, you can expect to:

  • continue to perform active range of motion exercises
  • introduce light resistance <2 kg through full range of motion
  • gradually increase resistance, keeping progress pain free with easy and good quality movement

Milestones for an acute tear repair

Time after surgery What you can expect from your elbow
Week 6 Full range of motion flexion/extension and rotation

Pain free, return to driving and working

Week 12 >90% strength in comparison to opposite side flexion/rotation

Rehabilitation protocol for a chronic tear repair

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

We recommend that you do not use a ‘theraband’ in your rehab program.

Time after surgery Physiotherapy/support
Day 1 – 2 weeks During the first 2 weeks, you can expect to:

  • perform pain-free active flexion and extension within limits of a sling
  • engage in full supination and pronation exercises
  • perform full active shoulder movements with your elbow in flexion
2 – 6 weeks During the next 4 weeks, you will:

  • perform active range of motion movement in all directions, to the point of mild stretch (but no over pressure)

Avoid sudden loading and unplanned movements for 6 weeks

6 – 12 weeks In the next 6 weeks, you can expect to:

  • continue to perform active range of motion exercises
  • introduce light resistance <2 kg through full range of motion
  • gradually increase resistance, keeping progress pain free with easy and good quality movement

Milestones for a chronic tear repair

Time after surgery What you can expect from your elbow
Week 6 Full range of motion flexion and rotation

Pain free, 50–70% extension range of motion compared to your other side

Week 12 <15 lag extension (80% of extension)

Full range of motion flexion/extension, rotation

Pain free, return to driving and working

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job –as tolerated

Manual job –12 weeks

Driving 6–8 weeks
Swimming Breaststroke – 6 weeks

Freestyle – 12 weeks

Golf 3 months
Lifting Avoid lifting heavy items for 3 months, from then, as guided by your strength
Contact/high impact sports(eg rugby, AFL, martial arts, racket sports and surfing) 3 months

Release of Stiff Elbow (arthrolysis)

Elbow arthrolysis is performed to release elbow stiffness following a traumatic injury or after surgery. It may be performed as open surgery or arthroscopically.

After surgery

Rehabilitation protocol

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Day 0 Immediately after surgery, you can expect to:

  • start passive range of motion activities under supervision of your physiotherapist if the local anaesthetic block is active
  • start active range of motion activities in all directions if there is no block (to the point of mild stretch, within the limits of pain)
6 weeks From 6 weeks, you will:

  • continue with active range of motion exercises in all directions
  • begin resistance exercises (if required)
postop6

Tennis elbow/Golfer Elbow Release

Tennis elbow or golfers elbow release is performed for refractory tennis or golfers elbow that has not been relieved by physiotherapy or platelet rich plasma (PRP) injection.

After surgery

Rehabilitation

Some of the physiotherapy terms may be unfamiliar to you at the moment. They will become clear as you work with your physiotherapist.

Time after surgery Physiotherapy/support
Day 1 – 2 weeks During the first 2 weeks, you can expect to:

  • perform full active range of motion into elbow flexion/extension and rotation
  • perform full active wrist flexion/extension within comfort (you should only feel a mild stretch at the end of range)

Your bandage will usually be taken down after 48 hours

2 – 6 weeks During the next 4 weeks, you will:

  • perform elbow strengthening exercises into flexion/extension
  • engage in a graduated resistance program for wrist extension/flexion (all exercises should be pain free range of motion with good quality movement and muscle activation)
  • initially start with eccentric exercises and progress to concentric loading
  • engage in graduated strengthening program into pronation

Your physiotherapist will continue to check that you have adequate pain control

6 weeks+ After 6 weeks, you can expect to:

  • increase heavy loading

Milestones

Time after surgery What you can expect from your elbow
Week 6 Full range of motion of elbow and wrist

 

Return to functional activities

Activity When you can expect to be able to do the activity
Return to work Sedentary job –2 weeks

Manual job –6 weeks

Driving 2–6 weeks
Swimming 6 weeks
Golf/racquet sports 12 months