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This protocol is only a guideline and may be modified depending on the pre-operative and intra-operative findings. A physiotherapist who is experienced in knee rehabilitation should be consulted throughout the programme to supervise and where necessary individually modify your programme.

Aims of Rehabilitation:

To restore Range of Motion and Strength to the knee. The final goal is to minimize knee pain and improve your knee function to improve your quality of life.
0-2 weeks:
  • Intermittent cryotherapy to minimize joint swelling, Cryotherapy after exercises.
  • Circumferential compression dressing.
  • Elevate the affected limb to minimize swelling.
  • Ankle exercises for DVT prophylaxis.
  • Deep breathing exercises for basal atelectasis
Range of Motion / Strengthening Exercises:
  • Quadriceps sets, Gluteal sets.
  • Straight leg raises, supine.
  • Knee extensions supine over a roll.
  • Knee extensions from seated
  • Passive knee straightening with a heel roll supine.
  • Heel slides, seated and supine.
Functional Exercises:
  • Transfer lying to standing, and seated to standing.
  • Gait training with crutches, weight bearing as tolerated.
  • Into and out of a car.
  • Weight bear as tolerated.2
3-6 weeks:
  • Cryotherapy after exercises, heat packs may be used on the knee and thigh prior to exercises.
  • Gentle wound massage with Bio-oil or vitamin E cream (can be started at 4 weeks)
  • Circumferential compression dressing
  • Ankle exercises for DVT prophylaxis.
  • Patellar mobilization exercises.
  • Range of Motion / Strengthening Exercises
  • Isometric quads, hamstrings, gluteals, adductors.
  • Active and assisted range of motion exercises.
  • Supported standing heel raises, calf stretches, mini squats, hamstring curls.
Functional Activities:
  • Exercise bike (can be started once 90 degrees of flexion is achieved)
  • Gait – normalize gait, progress to a single point stick.
  • Increase endurance with longer walks and stairs.
  • Patients should be walking without aids by 6 weeks
7-12 weeks:
  • Patellar mobilization exercises.
  • Quads and hamstrings deep tissue massage.
Core strengthening exercises.
  • Squats and single leg stance mini-squats.
  • Resistance exercises for quadriceps, hamstrings, gluteals and adductors.
  • Active and assisted ROM exercises.
Functional Exercises:
  • Start driving using the affected leg.
  • Gait supervision without walking aids.
  • Lateral stepping.
  • Heel-toe walking.
13+ weeks:

Once the patient has achieved full extension and flexion >110°, normalized and unaided gait, and good muscle balance – institute an ongoing programme of regular exercise tailored to the patient.

This may include:
  • Regular walking
  • Exercise bike
  • Gentle gym workouts
  • Return to sport (golf, doubles tennis, lawn bowls, etc)
Encourage the patient to continue their exercise program indefinitely, to optimize the outcome from their surgery
The following is a generalized outline for rehabilitation following ACL reconstruction. The protocol may be modified if additional procedures, such as meniscus repair or microfracture, were performed.

Phase I: 1 – 14 days Goals:

  • Protect graft and graft fixation with use of brace and specific exercises.
  • Control inflammation and swelling.
  • Early range of motion (ROM) with emphasis on full extension, patella mobilizations and flexion.

Brace: Post op brace worn locked in extension for ambulation. May unlock for ROM exercises.

Weight bearing status: Weightbearing as tolerated with crutches and brace locked in extension. If meniscal repair or microfracture, nonweightbearing for 4 weeks.

Exercises

ROM exercises:
Passive extension – sit in a chair and place your heel on the edge of a stool or chair; relax thigh muscles and let the knee sag under its own weight until maximum extension is achieved.
Heel props – place rolled up towel under the heel and allow leg to relax
Flexion – limit to 90 degrees
Passive flexion – sit on chair/edge of bed and let knee bend under gravity; may use the other leg to support and control
flexion Heel slides – Use your good leg to pull the involved heel toward the buttocks, flexing the knee. Hold for 5 seconds; straighten the leg 2 sliding the heel downward and hold for 5 seconds.

Quadriceps sets in full extension

Ankle ROM
Phase II: Weeks 3 – 6 Goals:
  • Restore normal gait with stair climbing
  • Maintain full extension, progress toward full flexion range of motion
  • Protect graft and graft fixation
  • Increase hip, quadriceps, hamstring and calf strength
  • Increase proprioception
Brace: May wean out of brace when you demonstrate good quadriceps control
Weightbearing status: Weightbearing as tolerated, wean off crutches
Exercises Continue as above, maintaining full extension and progressing to 125 degrees Begin closed kinetic chain exercises Stationary bicycling, stairmaster: slow, progressing to low resistance Hamstring curls Hip abduction, adduction, extension, side lifting, heel raises At 4‐ 6 weeks, wall squats
Phase III: Weeks 6 – 12 Goals:
  • Full active range of motion
  • Increase strength
Exercises Stationary bicycling, stairmaster, elliptical: increases resistance Treadmill walking Swimming, water conditioning: flutter kick only Balance and proprioceptive training Closed chain quad strengthening: no knee flexion greater than 90 degrees with leg press
Phase IV: Months 3 – 6 Goals:
  • Improve strength, endurance and proprioception Begin agility training Exercises
  • May start jogging program, forward/straight running only
  • Continue and progress strengthening
  • Progress to running program at 5 months
  • Begin agility training at 5 months
  • Side steps
  • Cross overs
  • Figure 8 running o Shuttle running o One leg and two leg jumping o Cutting o Acceleration / deceleration / sprints / agility ladder drills
  • Initiate sport‐specific drills as appropriate
Phase V: 6 months post‐op Goals:
  • Maintain strength, endurance and proprioception
  • Safe return to sport Exercises
  • Gradual return to sports participation
  • Maintenance program for strength, endurance
Return to sports criteria: Full range of motion No swelling Good stability on ligament testing Full strength compared to other leg Completed sport‐specific functional progression Running and jumping without pain or limp
This is a generalized protocol and may need modifications. We recommended you perform these exercises under the supervision of your physiotherapist and also stick to your surgeon’s advice.
Phase 1: (1-3 weeks) Goals
  • Restore non-painful range of motion (ROM)
  • Retard muscular atrophy
  • Decrease pain/inflammation
  • Improve postural awareness
  • Minimize stress to healing structures
  • Independent with activities of daily living (ADLs)
  • Prevent muscular inhibition
  • Wean off sling
Precautions:
  • Care should be taken with abduction (with both active range of motion (AROM) and passive range of motion (PROM) to avoid unnecessary compression of subacromial structures
  • Creating or reinforcing poor movement patterns, such as excessive scapulothoracic motion with upper extremity elevation, should be avoided.
Range of Motion:
  • PROM (non-forceful flexion and abduction)
  • Active assisted range of motion (AAROM)
  • AROM
  • Pendulums
  • Pulleys
  • Cane exercises
Strengthening:
  • Isometrics: scapular musculature, deltoid, and rotator cuff as appropriate
Modalities:
  • Cryotherapy
Criteria for progression to phase 2:
  • Full active and passive ROM
  • Minimal pain and tenderness
Phase 2: Intermediate Phase (3-6 Weeks) Goals:
  • Regain and improve muscular strength
  • Normalize arthrokinematics
  • Improve neuromuscular control of shoulder complex
Exercises:
  • Initiate isotonic program with dumbbells
  • Strengthen shoulder musculature- isometric, isotonic (theraband internal and external rotation in 0 degrees abduction), Proprioceptive Neuromuscular Facilitation (PNF)
  • Strengthen scapulothoracic musculature- isometric, isotonic, PNF
  • Initiate upper extremity endurance exercises
Manual Treatment:
  • Joint mobilization to improve/restore arthrokinematics if indicated
  • Joint mobilization for pain modulation
Modalities:
  • Cryotherapy
  • Electrical stimulation - inferential current to decrease swelling and pain (as indicated and/or needed)
Criteria for Progression to Phase 3:
  • Full painless ROM
  • No pain or tenderness on examination
Phase 3: Dynamic (Advanced) Strengthening Phase: (6 weeks and beyond) Goals:
  • Improve strength, power, and endurance
  • Improve neuromuscular control
  • Prepare athlete to begin to throw, and perform similar overhead activities or other sport specific activities
Emphasis of Phase 3:
  • High speed, high energy strengthening exercises
  • Eccentric exercises
  • Diagonal patterns
Exercises:
  • Continue dumbbell strengthening (rotator cuff and deltoid)
  • Progress theraband exercises to 90/90 position for internal rotation and external rotation(slow/fast sets)
  • Theraband exercises for scapulothoracic musculature and biceps
  • Plyometrics for rotator cuff
  • PNF diagonal patterns
  • Isokinetics
  • Continue endurance exercises
The Bankart procedure is performed to increase anterior stability of the shoulder. The following is a guideline for progression of post-operative treatment. The program may however be modified based on your situation and operative findings.
Time required for full recovery is between 4-6 months.
General Information
Capsular repair becomes stressed with external rotation. Since the repair is made with the arm in neutral rotation, external rotation must be limited during early rehabilitation.
Sling:
  • Sling should be worn most of the times for 6 weeks, especially in uncontrolled environments (around dogs, kids, in crowds, Immobilization etc.).
  • Sling should be worn while sleeping for 6 weeks.
  • Sling may be removed in controlled environments for light activities like movement of the elbow and wrist.
  • It takes roughly 6 weeks to discontinue the sling.
Personal hygeine and clothing:
To wash under the operated arm, bend over at the waist and let the arm passively swing away from the body. It is safe to wash under the arm in this position. Keep your elbow slightly in front of your body; do not reach behind your body. When putting on clothing, lean forward. and pull the shirt up and over the operated arm first. Then put the other arm into the opposite sleeve. To remove the shirt, take the unoperated arm out of the sleeve first, and then slip the shirt off of the operated arm.
0-6 weeks after surgery
Rehabilitation Goals:
  • Protect the post-surgical shoulder
  • Activate the stabilizing muscles of the gleno-humeral and scapulo-thoracic joints
  • Full passive range of motion for shoulder flexion, abduction, internal rotation and external rotation to neutral.
Precautions:
  • No shoulder external rotation with abduction for 8 weeks to protect repaired tissues
Exercises:
Begin day 1:
  • Codman’s
  • Scapular stabilization without weights.
  • Elbow, wrist movements.
Begin week 4:
  • Gentle shoulder isometrics for internal rotation and external rotation (arm by side),flexion, extension, adduction and abduction
  • Passive range of motion for shoulder flexion ,abduction, internal rotation and external rotation (in abduction) to neutral
  • Hand gripping
  • Elbow, forearm, and wrist active range of motion
  • Cervical spine and scapular active range of motion
  • Desensitization techniques for axillary nerve distribution
  • Postural exercises
6-12 weeks after surgery: Goals:
  • Full shoulder active range of motion in all cardinal planes (sub-maximal with external rotation)
  • Progress shoulder external rotation range of motion gradually to prevent overstressing the repaired anterior tissues of the shoulder
  • Strengthen shoulder and scapular stabilizers in protected position (0° - 45° abduction)
  • Begin proprioceptive and dynamic neuromuscular control retraining
Precautions:
Avoid passive and forceful movements into shoulder external rotation, extension and horizontal abduction.
Exercises:
  • Active assisted and active range of motion in all cardinal planes - assessing scapular rhythm (gradually progress external rotation to full range at the end of 12 weeks)
  • Gentle shoulder mobilizations as needed
  • Rotator cuff strengthening in non-provocative positions (0° - 45° abduction)
  • Scapular strengthening and dynamic neuromuscular control
  • Cervical spine and scapular active range of motion
12-18 weeks after surgery: Goals:
  • Full shoulder active range of motion in all cardinal planes with normal scapulohumeral movement.
  • 5/5 rotator cuff strength at 90° abduction in the scapular plane
  • 5/5 peri-scapular strength
Precautions:
  • All exercises and activities to remain non-provocative and low to medium velocity
  • Avoid activities where there is a higher risk for falling or outside forces to be applied to the arm
  • No swimming, throwing or sports
Exercises:
Motion
  • Posterior glides if posterior capsule tightness is present. More aggressive ROM if limitations are still present Strength and Stabilization
  • Flexion in prone, horizontal abduction in prone, full can exercises, D1 and D2 diagonals in standing
  • Theraband/cable column/ dumbell (light resistance/high rep) internal and external rotation in 90° abduction and rowing
18-24 weeks after surgery: Goals:
  • Stability with higher velocity movements and change of direction movements.
  • 5/5 rotator cuff strength with multiple repetition testing at 90° abduction in the scapular plane
  • Full multi-plane shoulder active range of motion
Exercises:
Motion
  • Posterior glides if posterior capsule tightness is present Strength and Stabilization
  • Dumbbell and ball exercises that incorporate trunk rotation and control with rotator cuff strengthening at 90° abduction. Begin working towards more functional activities by emphasizing core and hip strength and control with shoulder exercises
  • TB/cable column/ dumbell IR/ER in 90 abduction and rowing
  • Higher velocity strengthening and control, such as the inertial, plyometrics, rapid Theraband drills
  • Plyometrics should start with 2 hands below shoulder height and progress to overhead, then back to below shoulder with one hand, progressing again to overhead
  • Begin education in sport specific biomechanics with very initial program for throwing, swimming or overhead racquet sports
Beyond 24 weeks after surgery:
Goals:
  • To demonstrate stability with higher velocity movements and change of direction movements that replicate sport specific patterns (including swimming, throwing, etc)
  • No apprehension or instability with high velocity overhead movements
  • Improve core and hip strength and mobility to eliminate any compensatory stresses to the shoulder
  • Work capacity cardiovascular endurance for specific sport or work demands
Exercises:
  • Initiate sport specific programs (throwing program, overhead racquet program or return to swimming program) depending on the athlete’s sport
  • High velocity strengthening and dynamic control, such as the inertial, plyometrics, rapid thera-band drills
This is a generalized protocol and may need modifications depending on the type and severity of tear. We recommended you perform these exercises under the supervision of your physiotherapist and also stick to your surgeon’s advice.
Phase I
(Weeks 1-6):
Goals:
  • Maintain integrity of repair
  • Diminish pain and inflammation
  • Prevent muscular inhibition, prevent stiffness
  • Regain range of motion
Precautions:
  • No active range of motion (AROM) of Shoulder
  • Maintain arm in sling, remove only for exercise
  • No lifting of objects
  • No shoulder motion behind back
  • No excessive stretching or sudden movements
  • No supporting of body weight by hands
  • Keep incision clean and dry
Exercises:
  • Abduction brace / sling: wear the sling most of the times. Come out of the sling every 2 hours to perform exercises.
  • Sleep in brace / sling
  • scapular pinches, shrugs; Neck ROM
  • Ball squeezes; active wrist, elbow movements, Cryotherapy for pain and inflammation
  • Pendulum Exercises
  • Start passive ROM to tolerance (at 15 days)
  • Supine passive elevation
  • Supine external rotation
  • Internal rotation (start after week 3)
Phase II (Week 6-12):
Goals:
  • Allow healing of soft tissue
  • Do not overstress healing tissue
  • Gradually restore full passive ROM
  • Decrease pain and inflammation
Precautions:
    • No lifting
    • No supporting of body weight by hands and arms
    • No excessive behind the back movements
    • No sudden jerking motions
Exercises:
  • Discontinue brace / sling at end of week 6
  • Gentle Scapular/glenohumeral joint mobilization as indicated to regain full passive ROM
  • Continue previous exercises in Phase I
  • Supine external Rotation with Abduction
  • External rotation @ 90o abduction
  • Supine Cross-Chest Stretch
  • wall stretches
  • overhead pullies
Active exercises:
  • Side-lying External Rotation
  • Prone Horizontal Arm Raises “T”
  • Prone row
  • Prone scaption “Y”
  • Prone extension
  • Active assisted elevation, progressing to: Standing Forward Flexion (scaption) with scapulohumeral rhythm
Resisted exercises:
  • Resisted forearm supination-pronation
  • Resisted wrist flexion-extension
  • Sub-maximimal isometric exercises: internal and external rotation at neutral
Phase III – (week 12-18):
Goals:
  • Maintain full non-painful active ROM
  • Continue strengthening
Exercises:
Continue stretching and dynamic strengthening exercises as before ADD: hands behind head stretch, sleeper stretches, doorway stretches.
  • Theraband strengthening:
  • External Rotation
  • Internal Rotation
  • Standing Forward Punch
  • Shoulder Shrug
  • Dynamic hug “W”’s
  • Seated Row
  • Biceps curls
Phase IV (week 18-24):
Goals:
  • Restore full motion
  • Restore full strength
  • Gradual return to normal activities
Exercises:
Stretching exercises as before Dynamic strengthening exercises as before, limit weight to 5 pounds. ADD:
  • Standing forward flexion “full-can” exercise
  • Prone external rotation at 90° abduction “U’s
  • Push-up with progression
Theraband exercises:
As before, add:
  • External rotation at 90°
  • Internal rotation at 90°
  • Standing ‘T’s
  • Diagonal up Diagonal down
Sports that involve throwing and the use of the arm in the overhead position are the most demanding on the rotator cuff. We will provide you specific instructions on when and how to return to sports. A rough guideline as to when to return to sport (minimum duration) is as follows:
Golf: 6 months
Weight Training: 6 months
Tennis: 6 -8 months
Swimming: 6-8 months
Throwing: 6 - 8 months
Before returning safely to your activity, you must have full range of motion, full strength and no swelling or pain. Your doctor or physical therapist will provide you with guidelines regarding your training.
Enclosed is your surgical pack for your surgery. Please go through the instructions and get back to Dr Srivatsa Subramanya if you have any queries.
Your anesthetist is Dr. Karthik Krishna. He or one of his team members will see you either the day before or on the day of surgery, depending on what surgery you are having. Please inform him about any health issues or medications that you are on.
Your physiotherapist : Your physio will take care of your rehab. He/she will be in touch with you before your operation.
Day case patients:
You must have someone available to drive you home from the hospital.
You will be required to stay in the hospital at least 3-4 hours or overnight depending on your procedure.
You must not operate any machinery at least 24 hours after your procedure.
You should have someone at home with you for at least 24 hours after you get there.
Detailed findings of your surgery will be given to you before discharge and Dr Srivatsa Subramanya will discuss the outcome of your surgery, before discharge and during your first post-operative visit.
Post-operative appointment:
This appointment will be provided upon your discharge from the hospital. If you do not receive this appointment, please feel free to contact us.
It is important that you attend this appointment, as a part of your ongoing treatment.
All medical certificates will be issued either before your discharge or during your post-operative visit.
Pre-operative instructions:
Use of crutches can be arranged for you at the hospital. Hair removal from your operative leg will be arranged on arrival at hospital. Please wear loose clothing to fit over a bandaged knee and appropriate footwear.
We apologise occasionally there can be a little wait before you are called in for your procedure. So please bring your iPod, a book to read or something to occupy your time whilst waiting. Please let Dr Srivatsa and the anesthetist know if there are any interim changes in your health or medications after your consultation or before surgery.
Commonly asked post-operative questions:
How soon can I drive?
If you have had an arthroscopy on your left knee, you can drive 24 hours after surgery. However, if you drive a manual transmission three days/ or when comfortable.
If you have had an arthroscopy on the right knee, you can drive at 3 days.
If you have had an anterior cruciate ligament reconstruction, you can drive at 3 weeks.
If you have had a unicompartmental knee replacement you can drive at 4-6 weeks, only after your review with Dr Srivatsa Subramanya.
If you have had a total knee replacement, you can drive at 6 weeks.
How soon can I swim?
Only after Dr Subramanya has reviewed your surgical incisions. The skin must be healed superficially to avoid bacteria entering your knee joint, through your incision site and causing infection.
Preoperative and post-operative exercises:
Dr Srivatsa usually advises of any required pre-operative rehab during your consultation. Following surgery, you will be given post-operative exercises by the physio in the hospital. Please practice these exercises 4 times daily until you see Dr Srivatsa. Further physio can be arranged after your post-operative visit.
If you were not seen by a physio whilst in the hospital, please do not see one until after your post-operative appointment.
Anterior cruciate ligament reconstruction
The anterior cruciate ligament is a large ligament, about the thickness of your little finger, inside your knee. It is responsible for keeping the knee stable when performing cutting, twisting or turning movements. Occasionally during sporting activities or falls, the force through the knee is too much for the ligament to withstand and it snaps ( other word used to include ACL tear, ACL rupture or ACL strain). At the time of injury, it is common to sustain other injuries including meniscal ( cartilage) tears and other ligament sprains.
Unfortunately, the ACL does not heal and so the knee will remain unstable. This may be acceptable in activities of daily living such as walking, but causes giving way during sport, or walking on uneven grounds or sometimes during use of stairs. Each episode of giving way causes some wear and tear of the knee and may eventually lead to arthritis. It is therefore most often recommended that an anterior cruciate ligament reconstruction is performed, if you are a young and active individual. Prior to your surgery, your doctor may advice you some physiotherapy to get your knee into good condition before surgery. It is called pre-hab.
On the day of surgery, you will be admitted to hospital and meet the nursing staff. They will explain the layout of the ward and prepare your knee for surgery. You will also meet the anesthetist and the assistant surgeon. The anesthetist will explain to you the details of anaesthesia and pain control.
Surgery:
Your knee will be examined under anaesthesia. A detailed arthroscopic examination of your knee will be performed to look at all the structures of the knee carefully. Any cartilage tears or damage inside the knee will be corrected during the same operation.
The reconstruction operation is performed with the arthroscope, with an additional cut to obtain the graft material (hamstring / patellar tendon / quadriceps tendon). Tunnels are drilled into the bone. The ACL graft is fixed into place using titanium button and titanium/bio screws. The operation takes about 60-90 minutes. The screws are left inside the bone and do not require removal.
The physiotherapist will see you on the day after surgery and once again explain the rehab programme. You will commence your various exercises and walking with crutches on the day after surgery.
Upon discharge from the hospital, you will be on crutches and should remain so for the first two weeks. You will be given pain medication, so be sure to take these if you have pain. You should leave the bandages on for the two weeks after the operation until you see Dr Subramanya. If they become loose, you may take them off and re-apply them. Little bit of blotting with blood is common and not of great concern. In case there is bleeding outside your dressing, please contact us.
You should perform your exercises each day, according to the instructions of the physio and the surgeon.
Dr Subramanya will see you two weeks following surgery to check the wounds have healed properly then direct your rehab program.
Anterior cruciate ligament reconstruction rehabilitation:
Following your ACL reconstruction, there are a number of post operative phases.
Phase one: The first stage is whilst you are in the hospital and this will be initially to recover from the operation. Should you require pain relief, this can be provided by the nursing staff with either injection or tablets. Your drain tubes ( if present) will be removed the day after surgery. You will be seen by the physiotherapist, who will initially help you to get out of the bed and commence walking on crutches and detail the exercises and therapies you must begin. You shall usually stay overnight and may be longer depending on your circumstances.
Phase two: After discharge, you will arrive home with pain medication, and you will be instructed when and how to take them. The first few days is really a resting phase when you should spend most of your time in bed or on the couch, with your knee out straight. You should ice the knee regularly and also ice the back of the thigh in the hamstring area. Keep walking to a minimum and leave your bandage on, keeping the knee dry and clean when showering.
During the second week, you may commence walking a bit more and you may commence full weight bearing as you feel comfortable. This is still in the resting phase, your formal physiotherapy will not commence until you have visited me at the two week mark. If you have any problems in this first two weeks, please feel free to contact me.
Phase three: You will see me at about the two week mark, where I will remove your dressings and check the wounds have healed. At this stage, I will refer you to a sports physician and /or physiotherapist. You will now progress through various stages of rehabilitation, concentrating initially on regaining full mobility of your knee, which should approximately take six to eight weeks. You will commence full weight bearing and should be walking freely at three to four weeks after the operation. You will commence various activities with your physiotherapist, which will include cycling, swimming and very light jogging.
Once you have gained good mobility, you may commence strengthening the thigh muscles in a gym and also should be able to start light sport specific training three to four months after surgery. A return to pivoting sports depends upon the stability of your knee, but more importantly the strength of your thigh muscles. It usually takes between 9 to 12 months.
Physiotherapist and / or sport physician and I will see you on a regular basis through your rehabilitation program and thereafter you will be seen once a year to assess your overall progress. Should you have any queries with regards to your rehabilitation program, please feel free to ask me.
The Bankart procedure is performed to increase anterior stability of the shoulder. The following is a guideline for progression of post-operative treatment. The program may however be modified based on your situation and operative findings.
Time required for full recovery is between 4-6 months.
General Information
There may be a loss of external rotation when compared to the other side, but the motion is usually adequate for most activities.
Capsular repair becomes stressed with external rotation. Since the repair is made with the arm in neutral rotation, external rotation must be limited during early rehabilitation.
Sling:
Sling should be worn most of the times for 6 weeks, especially in uncontrolled environments (around dogs, kids, in crowds, Immobilization etc.).
Sling should be worn while sleeping for 6 weeks.
Sling may be removed in controlled environments for light activities like movement of the elbow and wrist.
It takes roughly 6 weeks to discontinue the sling.
Personal hygeine and clothing:
To wash under the operated arm, bend over at the waist and let the arm passively swing away from the body. It is safe to wash under the arm in this position. Keep your elbow slightly in front of your body; do not reach behind your body. When putting on clothing, lean forward. and pull the shirt up and over the operated arm first. Then put the other arm into the opposite sleeve. To remove the shirt, take the unoperated arm out of the sleeve first, and then slip the shirt off of the operated arm.
0-6 weeks after surgery:
Rehabilitation Goals:
  • Protect the post-surgical shoulder
  • Activate the stabilizing muscles of the gleno-humeral and scapulo-thoracic joints
  • Full active and passive range of motion for shoulder flexion, abduction, internal rotation and external rotation to neutral.
Precautions:
  • Hypersensitivity in axillary nerve distribution is a common occurrence
  • No shoulder external rotation with abduction for 8 weeks to protect repaired tissues
Exercises:
Begin week 5,
  • Gentle shoulder isometrics for internal rotation and external rotation, flexion, extension, adduction and abduction
  • Active assisted and passive range of motion for shoulder flexion, abduction, internal rotation and external rotation to neutral, progressing to active range of motion at week 7
  • Hand gripping
  • Elbow, forearm, and wrist active range of motion
  • Cervical spine and scapular active range of motion
  • Desensitization techniques for axillary nerve distribution
  • Postural exercises
6-12 weeks after surgery: Goals:
  • Full shoulder active range of motion in all cardinal planes
  • Progress shoulder external rotation range of motion gradually to prevent overstressing the repaired anterior tissues of the shoulder
  • Strengthen shoulder and scapular stabilizers in protected position (0° - 45° abduction)
  • Begin proprioceptive and dynamic neuromuscular control retraining
Precautions:
Avoid passive and forceful movements into shoulder external rotation, extension and horizontal abduction.
Exercises:
  • Active assisted and active range of motion in all cardinal planes - assessing scapular rhythm (gradually progress external rotation to full range at the end of 12 weeks)
  • Gentle shoulder mobilizations as needed
  • Rotator cuff strengthening in non-provocative positions (0° - 45° abduction)
  • Scapular strengthening and dynamic neuromuscular control
  • Cervical spine and scapular active range of motion
12-18 weeks after surgery: Goals:
  • Full shoulder active range of motion in all cardinal planes with normal scapulohumeral movement.
  • 5/5 rotator cuff strength at 90° abduction in the scapular plane
  • 5/5 peri-scapular strength
Precautions:
  • All exercises and activities to remain non-provocative and low to medium velocity
  • Avoid activities where there is a higher risk for falling or outside forces to be applied to the arm
  • No swimming, throwing or sports
Exercises:
Motion
  • Posterior glides if posterior capsule tightness is present. More aggressive ROM if limitations are still present
Strength and Stabilization
  • Flexion in prone, horizontal abduction in prone, full can exercises, D1 and D2 diagonals in standing
  • Theraband/cable column/ dumbell (light resistance/high rep) internal and external rotation in 90° abduction and rowing
18-24 weeks after surgery: Goals:
  • Stability with higher velocity movements and change of direction movements.
  • 5/5 rotator cuff strength with multiple repetition testing at 90° abduction in the scapular plane
  • Full multi-plane shoulder active range of motion
Exercises:
Motion
  • Posterior glides if posterior capsule tightness is present
Strength and Stabilization
  • Dumbbell and ball exercises that incorporate trunk rotation and control with rotator cuff strengthening at 90° abduction. Begin working towards more functional activities by emphasizing core and hip strength and control with shoulder exercises
  • TB/cable column/ dumbell IR/ER in 90 abduction and rowing
  • Higher velocity strengthening and control, such as the inertial, plyometrics, rapid Theraband drills
  • Plyometrics should start with 2 hands below shoulder height and progress to overhead, then back to below shoulder with one hand, progressing again to overhead
  • Begin education in sport specific biomechanics with very initial program for throwing, swimming or overhead racquet sports
Beyond 24 weeks after surgery: Goals:
  • To demonstrate stability with higher velocity movements and change of direction movements that replicate sport specific patterns (including swimming, throwing, etc)
  • No apprehension or instability with high velocity overhead movements
  • Improve core and hip strength and mobility to eliminate any compensatory stresses to the shoulder
  • Work capacity cardiovascular endurance for specific sport or work demands
Exercises:
  • Initiate sport specific programs (throwing program, overhead racquet program or return to swimming program) depending on the athlete’s sport
  • High velocity strengthening and dynamic control, such as the inertial, plyometrics, rapid thera-band drills
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[/vc_column_text][/vc_column][vc_column width=”3/4″][vc_column_text]This protocol is only a guideline and may be modified depending on the pre-operative and intra-operative findings. A physiotherapist who is experienced in knee rehabilitation should be consulted throughout the programme to supervise and where necessary individually modify your programme.

Aims of Rehabilitation:

To restore Range of Motion and Strength to the knee. The final goal is to minimize knee pain and improve your knee function to improve your quality of life.

0-2 weeks:

  • Intermittent cryotherapy to minimize joint swelling, Cryotherapy after exercises.
  • Circumferential compression dressing.
  • Elevate the affected limb to minimize swelling.
  • Ankle exercises for DVT prophylaxis.
  • Deep breathing exercises for basal atelectasis

Range of Motion / Strengthening Exercises:

  • Quadriceps sets, Gluteal sets.
  • Straight leg raises, supine.
  • Knee extensions supine over a roll.
  • Knee extensions from seated
  • Passive knee straightening with a heel roll supine.
  • Heel slides, seated and supine.

Functional Exercises:

  • Transfer lying to standing, and seated to standing.
  • Gait training with crutches, weight bearing as tolerated.
  • Into and out of a car.
  • Weight bear as tolerated.2

3-6 weeks:

  • Cryotherapy after exercises, heat packs may be used on the knee and thigh prior to exercises.
  • Gentle wound massage with Bio-oil or vitamin E cream (can be started at 4 weeks)
  • Circumferential compression dressing
  • Ankle exercises for DVT prophylaxis.
  • Patellar mobilization exercises.
  • Range of Motion / Strengthening Exercises
  • Isometric quads, hamstrings, gluteals, adductors.
  • Active and assisted range of motion exercises.
  • Supported standing heel raises, calf stretches, mini squats, hamstring curls.

Functional Activities:

  • Exercise bike (can be started once 90 degrees of flexion is achieved)
  • Gait – normalize gait, progress to a single point stick.
  • Increase endurance with longer walks and stairs.
  • Patients should be walking without aids by 6 weeks

7-12 weeks:

  • Patellar mobilization exercises.
  • Quads and hamstrings deep tissue massage.

Core strengthening exercises.

  • Squats and single leg stance mini-squats.
  • Resistance exercises for quadriceps, hamstrings, gluteals and adductors.
  • Active and assisted ROM exercises.

Functional Exercises:

  • Start driving using the affected leg.
  • Gait supervision without walking aids.
  • Lateral stepping.
  • Heel-toe walking.

13+ weeks:

Once the patient has achieved full extension and flexion >110°, normalized and unaided gait, and good muscle balance – institute an ongoing programme of regular exercise tailored to the patient.

This may include:

  • Regular walking
  • Exercise bike
  • Gentle gym workouts
  • Return to sport (golf, doubles tennis, lawn bowls, etc)

Encourage the patient to continue their exercise program indefinitely, to optimize the outcome from their surgery[/vc_column_text][/vc_column][/vc_row]