Phases of Rehabilitation after Shoulder Surgery

The surgery part of dealing with a shoulder injury frequently gets a lot of attention from both the patient and the surgeon, but it is typically the postoperative rehabilitation plan and program that dictates success (or failure) after a shoulder surgery.

The write-up below explains the four different phases of postoperative rehabilitation after a shoulder surgery. It is cited from AAOS 2017 Postoperative Orthopaedic Rehabilitation Chapter 5 Shoulder Instability Repairs.

​​Phase I
In the immediate postoperative period, ROM is restricted. The primary goal of this phase is to prevent excessive scarring by allowing movement, but avoiding overaggressive motion that may compromise the surgical repair.
 
For example, after an anterior stabilization procedure, external rotation is restricted, as this may overstress the capsulolabral repair. Submaximal and subpainful isometric contractions are also initiated during phase 1 to stimulate muscle training, neuromodulate pain, and prevent muscle atrophy that occurs as a result of immobilization.
 
Phase II
During this intermediate phase, the emphasis is on advancing shoulder mobility. Active assistive range of motion (AAROM) and PROM exercises are incorporated into the treatment program. The patient’s ROM and capsular end feel will be used to determine the rate of progression. Patients with sufficient ROM and a soft end feel will be progressed slower than a patient with restricted ROM and a hard end feel.
 
Joint-mobilization techniques are used to restore normal motion and to correct asymmetric capsular tightness. If one side of the capsule is excessively tight, the humeral head may translate in the opposite direction away from the tightness.
 
In an overhead athlete, the clinician will progress the stretching exercises to allow the athlete to obtain “thrower’s motion” of approximately 115° ± 5° ER to allow the athlete to return to throwing. Strengthening exercises can be progressed to include isolated rotator cuff and scapular exercises. Performing dynamic stabilization drills, manual resistance training, and proprioceptive neuromuscular facilitation (PNF) drills with rhythmic stabilizations can enhance neuromuscular control and reestablish muscular balance. During this phase, the “thrower’s ten exercise” program is typically initiated.
 
Phase III
Phase III is designed to maintain shoulder ROM while improving strength, power, and endurance. Strengthening exercises are progressed to restore optimal sufficient muscle ratios. Muscular balance and dynamic joint stability should be achieved before initiating aggressive strengthening exercises, such as plyometrics or functional activities.
 
During this phase, eccentric muscle training and proprioceptive training are emphasized. Muscular endurance training also is performed to enhance dynamic functional joint stability and to prevent fatigue-induced subluxation. Plyometric training drills are utilized to increase the athlete’s functional mobility and to gradually increase the functional stresses onto the shoulder joint.
 
Overhead athletes are also progressed to the thrower’s ten program to improve strength, endurance, and posture during this period.
 
Phase IV
During this phase, the goal is to increase the functional demands on the shoulder and return the patient to unrestricted sport or daily activities. Upon successful completion of the rehabilitation program and achieving the desired goals, the patient may initiate a gradual return to sport activity in a controlled manner.
 
Other goals of this phase are to maintain the patient’s muscular strength, dynamic stability, and functional motion established in the previous phase. Therefore, the patient is encouraged to maintain a stretching and strengthening program on an ongoing basis to maintain optimal shoulder function.