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Operative Rehabilitative Protocol

0-1 week

Àp Gauze and dressing removed in PT; replace ace or use Jobst stocking
Àp odalities including electrical stimulation for 20 minutes, biofeedback, and cryoboot
Àp ?yotherapy with ice, polar care, or cryocuff
Àp Patellar glides/mobilization
Àp  T with brace locked in extension and crutches
Yp ay unlock brace for passive RO 
Yp ?losed chain RO
Yp Goal 0-90 degrees
Àp utraight leg raises in all 4 planes progressing with ankle weights
Yp ork on isolated control of quad if no extensor lag with u R
Àp Prone extension stretch; goal extension symmetric to opposite side
Àp utart stationary bike; half revolutions forward and backward with progression to full
revolutions
Àp ?an start light exercises such as mini-dips, wall sits, step-ups, toe raises, 4 way tubing,
stork stands, etc
Àp utart treadmill for gait training if good control of quads without crutches

eek 1-2

Àp uuture removal [1oth day] and wound check; continue ace wrap for residualswelling;
may shower
Àp Open brace as flexion allows; extension should befull; should be  T
Àp ?ontinue previous weeks exercises, bicycling, and treadmill (forward and backward)
Àp dd Total Gym, hamstring curls, leg press, lunges (knee not to pass foot), stool walk,
stork stands, stairmaster, elliptical machine, row machine, TKE (closed chain)
Àp Dome exercises: u R¶s, calf pumps, 4-way tubing, calf and hamstring stretches,
cryotherapy

eek 2-3

Àp ay discontinue wrap if swelling allows


Àp race open during gait 0-120 degrees if quad control allows
Àp ?ontinue exercises in previous weeks, including home exercises
Àp egin squats, hack squats, versa climber, resisted walking, slide board, total gym hops
(low level)
Àp odalities continued: electrical stimulation, cryoboot, standing TKE¶s with theraband
behind knee

eek 3-4

Àp ssess possibility of removing brace; RO at least 0-120 degrees


Àp ?ontinue exercises in previous weeks, including home exercises
Àp orward and backward walking with change in direction
Àp utart shuffles, ?arioca, and double leg hops
Àp ore intense proprioceptive training
Àp odalities stopped if appropriate

eek 4-6

Àp Viscontinue brace and push for full RO


Àp 
?ontinue exercises in previous weeks with increased intensity, including home exercises
Àp dd jump rope, single leg hopping, and resisted lunges
Àp ncrease speed of exercises safely
Week 6-16p

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Week 16-20p

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Week 20-24p

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J pe 1: Pai ol after activit 

Àp 2 workload reduction


Àp ce massage or ice wrap after activity
Àp uymptom-free stretching and strengthening program (gastrocnemius, anterior and posterior
tibialis, peroneals)
Àp ?heck for pronation problems

J pe 2: Pai dri activit  ot restricti performace 

Àp 0 workload reduction


Àp ce massage or ice wrap after activity
Àp utretching and strengthening as above
Àp OuV¶s (loading dose, give 10-14 days)

J pe 3: Pai dri activit  restricti performace 

Àp Relative rest
Àp lternate activities (non-impact, symptom-free activities, cycling, swimming, Oordic Track)
Àp utretching and strengthening as above
Àp ce massage or ice wrap
Àp OuV¶s

J pe 4: Pai chroic remitti 

Àp Exhaustion of all conservative modalities


Àp mmobilization (cast boot)
Àp one stimulator
Àp uurgery

Retr to Activit 

Àp hen patient can tolerate alternate activites and rehabilitation for 4- weeks
Àp irst, alternate running with non-weight bearing exercise for 2-3 weeks
Àp Gradually increase mileage and intensity. Rule of too¶s
Yp Von¶t run too much, too soon or too fast and make sure your shoes are not too old

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Phase 1 (1-4 da s)

Àp Oonweightbearing with crutches


Àp Posterior splint in neutral position
Àp odalities to reduce pain and inflammation
Yp Electrical stimulation
Yp ?ryotherapy
Àp anual resistance exercises in 30 degrees of plantar flexion
Àp Resisted dorsiflexion (30O)
Àp ight passive dorsiflexion stretching with a towel

Phase 2 (da 4-5+)

Àp Partial weightbearing with crutches


Àp Vaily wear of  P brace
Àp Postacute modalities
Àp anual resistive exercises
Àp Vorsiflexion/plantarflexion full RO
Àp nitiate weightbearing exercises, walking and double toe raises
Àp ight proprioceptive exercises
Àp utretching

Phase 3 (da 6+)

Àp ull weightbearing
Àp odalities
Àp ?ontinue manual resistive exercises with inversion/eversion added
Àp unctional exercise
Yp Vouble toe raises, double-legged hopping, single toe raises, and single-legged hopping
Àp Progressive sport-specific drills
Àp Proprioceptive exercises
Àp alk, jog, run, cutting, explosive maneuvers
Àp  P/taping for return*

*thlete may return to activity when able to complete 1 single-legged hop off toes, has passes
functional testing, and is mentally ready to return
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Phase 1 (0-3 weeks post-op)

Àp Patient is immobilized in an abduction splint at 0-90 degrees internal rotation for 3 weeks.
Àp The abduction splint may be removed to allow the shoulder to adduct and for gentle passive
abduction, flexion, and external rotation exercises; 2 sets of 10 repetitions 2 times per day (Vo
not force external rotation).
Àp sometric abduction, horizontal adduction and external rotation.
Àp ctive elbow flexion and extension strengthening exercises. 
Àp ay squeeze a soft ball for hand/forearm muscle strengthening.

Phase 2 (3-6 weeks post-op)

Àp Oo longer required to wear abduction splint.


Àp ?ontinue passive RO exercises with emphasis on protecting anterior capsule.
Àp ctive internal rotation with the arm at the side and elbow flexed 90 degrees.
Àp ctive external rotation with the arm at the side and elbow flexed 90 degrees using rubber
tubing (as tolerated).
Àp ull active external rotation performed with the patient¶s pain-free RO.
Àp Perform active±assistive RO exercises (wand exercises, wall climbs, etc) and mobilization
techniques (as needed).
Àp ctive shoulder extension in the prone position; only extend the arm until it is level with the
trunk.
Àp dd shoulder shrugs.
Àp y 4- weeks, progress to external rotation in the side-lying position; patient lies on the
uninvolved side with the involved arm by the side of the body and elbow flexed 90 degrees.
Àp dd supraspinatus strengthening exercises. 
Àp dd active shoulder abduction to 90 degrees. 

Phase 3 (6-8 weeks post-op)

Àp ?ontinue strengthening exercises with emphasis on the rotator cuff muscles.


Àp dd shoulder flexion strengthening exercises. 
Àp dd horizontal adduction (from 1-20 degrees horizontal adduction to 90 degrees).
Àp ay begin upper body ergometer for endurance training starting at low resistances.

Phase 4 (2-4 moths post-op)

Àp Progress with resistive exercises as tolerated.


Àp y 2 months, patients should have full RO.
Àp ay include isokinetic strengthening and endurance exercises at the faster speeds (200+
degrees/sec) for shoulder internal and external rotation; the shoulder ispositioned in 1-20
degrees flexion to protect the anterior joint capsule.
Àp t 2 to 2-1/2 months, add push-ups lowering the body until the arms are level with the trunk.
egin with wall push-ups, progressing to modified push-ups (on knees) and then military push-
ups. The arms are positioned at 0-90 degrees abduction. Vo not lower the body causing the
arms to go past the body, which would stress the anterior capsule. 
Àp dd horizontal abduction to neutral.
Àp f patient has full RO, begin restoring normal scapulohumeral rhythm.

Phase 5 (4 moths post-op)

Àp ?ontinue progressing weights with emphasis on eccentric exercises. ay begin isokinetic
strength training for flexion and abduction. ay add training at the lower speeds with continued
emphasis on the higher speeds.
Àp Perform first isokinetic test evaluating strength and endurance in the following movement
patterns: internal and external rotation, flexion and extension, abduction and adduction. Each
movement pattern is tested on a different day (3 day period).
Àp f the isokinetic test indicates adequate strength and endurance (0 or above as compared to
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áhse 6 ( mohs pos-op)p

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Phase 1 (0-3 weeks post-op)

Àp Patient is immobilized in an abduction splint at 0-90 degrees internal rotation for 3 weeks.
Àp The abduction splint may be removed to allow the shoulder to adduct and for gentle passive
abduction, flexion, and external rotation exercises; 2 sets of 10 repetitions 2 times per day (Vo
not force external rotation).
Àp sometric abduction, horizontal adduction and external rotation.
Àp ctive elbow flexion and extension strengthening exercises. 
Àp ay squeeze a soft ball for hand/forearm muscle strengthening.

Phase 2 (3-6 weeks post-op)

Àp Oo longer required to wear abduction splint.


Àp ?ontinue passive RO exercises with emphasis on protecting anterior capsule.
Àp ctive internal rotation with the arm at the side and elbow flexed 90 degrees.
Àp ctive external rotation with the arm at the side and elbow flexed 90 degrees using rubber
tubing (as tolerated).
Àp ull active external rotation performed with the patient¶s pain-free RO.
Àp Perform active±assistive RO exercises (wand exercises, wall climbs, etc) and mobilization
techniques (as needed).
Àp ctive shoulder extension in the prone position; only extend the arm until it is level with the
trunk.
Àp dd shoulder shrugs.
Àp y 4- weeks, progress to external rotation in the side-lying position; patient lies on the
uninvolved side with the involved arm by the side of the body and elbow flexed 90 degrees. 
Àp dd supraspinatus strengthening exercises. 
Àp dd active shoulder abduction to 90 degrees. 

Phase 3 (6-8 weeks post-op)

Àp ?ontinue strengthening exercises with emphasis on the rotator cuff muscles.


Àp dd shoulder flexion strengthening exercises. 
Àp dd horizontal adduction (from 1-20 degrees horizontal adduction to 90 degrees).
Àp ay begin upper body ergometer for endurance trainingstarting at low resistances.

Phase 4 (2-4 moths post-op)

Àp Progress with resistive exercises as tolerated.


Àp y 2 months, patients should have full RO.
Àp ay include isokinetic strengthening and endurance exercises at the faster speeds (200+
degrees/sec) for shoulder internal and external rotation; the shoulder is positioned in 1-20
degrees flexion to protect the anterior joint capsule.
Àp t 2 to 2-1/2 months, add push-ups lowering the body until the arms are level with the trunk.
egin with wall push-ups, progressing to modified push-ups (on knees) and then military push-
ups. The arms are positioned at 0-90 degrees abduction. Vo not lower the body causing the
arms to go past the body, which would stress the anterior capsule. 
Àp dd horizontal abduction to neutral.
Àp f patient has full RO, begin restoring normal scapulohumeral rhythm.

Phase 5 (4 moths post-op)

Àp ?ontinue progressing weights with emphasis on eccentric exercises. ay begin isokinetic
strength training for flexion and abduction. ay add training at the lower speeds with continued
emphasis on the higher speeds.
Àp Perform first isokinetic test evaluating strength and endurance in the following movement
patterns: internal and external rotation, flexion and extension, abduction and adduction. Each
movement pattern is tested on a different day (3 day period).
Àp f the isokinetic test indicates adequate strength and endurance (0 or above as compared to
ss 
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Phase 1 (0-2 weeks) 

Àp uling immobilization at all times; hand, wrist, elbow exercises started

Phase 2 (2-3 weeks) 

Àp ?odman exercises, PRO 0-90 degrees flexion and abduction; external rotationin adduction to
neutral; avoid extension of arm behind body for 4 weeks
Àp Oo external rotation in abduction because of peel-back mechanism
Àp uling immobilization when not doing PRO regimen

Phase 3 (3-6 weeks) 

Àp Viscontinue sling and start progressive PRO to full as tolerated in all planes
Àp egin passive posterior capsular and internal rotation stretching
Àp egin passive and manual scapulothoracic mobility program
Àp egin external rotation in abduction
Àp llow use of operative extremity for light activities of daily living

Phase 4 (6-16 weeks) 

Àp ?ontinue all stretching and flexibility programs as above; RO should be full
Àp egin progressive strengthening of rotator cuff, scapular stabilizers, and deltoid
Àp t 10-12 weeks, biceps resistance and sports/work specific exercises instituted with goal of
normal function at 4 months

or Jhrowi Athlete:Phase 5 (4-6 moths) 

Àp egin interval throwing program on level surface (if applicable)


Àp ?ontinue stretching and strengthening regimen, with particular emphasis onposterior capsular
stretching

Phase 6 (6 moths) 

Àp egin throwing from mound

Phase 7 (7 moths) 

Àp llow full-velocity throwing from mound


Àp ?ontinue strengthening and posterior capsular stretching indefinitely

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The physical therapy rehabilitation for rotator cuff repair will vary in length depending on degree of
instability, acute versus chronic condition, strength/RO status, and activity demands.

Phase 1 (nitial 3 weeks post-surgery)

Àp Patient is immobilized for initial 3 weeks


Àp mmobilizer may be removed for gentle passive RO (flexion, abduction, external rotation) and
pendulum exercises
Àp Oo active flexion or abduction first 3 weeks
Àp utart shoulder shrugs, elbow/wrist RO, and ball squeezes

Phase 2 (3- weeks post-surgery)

Àp Oo longer required to wear immobilizer


Àp odalities as needed
Àp ?ontinue passive RO exercises
Àp dd active assist (wall climbs, wand) and pain-free active RO 
Àp dd joint mobilization as needed
Àp dd isometric exercises
Àp ctive internal/external rotation exercises with rubber tubing as tolerated
Àp ctive shoulder extension lying prone or standing (bending at the waist); avoid the shoulder
extended position by preventing arm movement beyond the plane of the body 
Àp ctive horizontal adduction (supine) as tolerated

Phase 3 (- weeks post-surgery)

Àp ?ontinue shoulder RO exercises as needed


Àp ?ontinue active internal/external rotation exercises with rubber tubing; as strength improves,
progress to free weights
Yp External rotation: performed lying prone with arm abducted to 90 degrees or side lying
with the arm at the side (perform through available range)
Yp nternal rotation: performed supine with the arm at the side and elbow flexed 90
degrees
Àp ctive shoulder abduction from 0-90 degrees
Àp dd supraspinatus strengthening exercise if 0-90 degrees motion available
Yp The movement should be pain free and performed in the scapular plane (about 20 -30
degrees forward of the coronal plane)
Àp ctive shoulder flexion through available RO as tolerated

Phase 4 (2-3 months post-surgery)

Àp uhould have full passive and active RO


Àp 
?ontinue isotonic exercises with emphasis on eccentric strengthening of the rotator cuff
Àp dd push-ups (should be pain-free); progress from wall to modified to military 
Àp dd shoulder bar hang exercise to increase RO in shoulder flexion and abduction
Àp ctive horizontal abduction (prone)
Àp åpper extremity proprioceptive neuromuscular fascilitation may be added
Yp uhoulder flexion/abduction/external rotation and extension/adduction/internal rotation
diagonals emphasized
Àp dd strengthening exercises to the elbow and wrist
Àp dd upper body ergometer for endurance and gentle plyometrics

Phase  (4 months post-surgery)

Àp dd advanced capsule stretches, as necessary


Àp ?ontinue to progress isotonic exercises
Àp dd military press exercise and total body conditioning program
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ith or ithot Acromioplast 


Phase 1 (irst 2 weeks post-op)

Àp uling up to 10 days; encourage use of involved joints and use ice QV
Àp Pendulum exercises; start post-operative day 1 in sling
Àp Gentle pain-free isometrics post-operative day 2 (avoid stressed abduction)
Àp Post-operative day 3 start passive RO; mobilization as needed, supine wand exercises,
humeral glides
Àp uecond week start active assistive RO against gravity (wand, wall climb, pulley, etc)
Yp utart into flexion and progress to abduction
Àp Progress to active RO against gravity (avoid impingement)
Àp Progressive mobilization and shoulder girdle flexibility exercises leading to full RO
Yp Goal full RO at  weeks

Phase 2 (3-6 weeks post-op)

Àp utart multiple angle isometrics in a low-medium force


Àp ulow speed isokinetics for internal and external rotation with dynamometer tilted at 1-30
degrees from horizontal
Yp ow force but high repetition program
Àp PO patterns with manual resistance at 4 weeks
Àp utart submaximal isotonic exercises below 90 degrees of elevation

Phase 3 (Greater tha 6 weeks) 

Àp arger arcs of motion with resistive exercise avoiding impingement


Yp aintain caution with overhead exercises
Yp ddress both muscle isolation and muscle synergy
Àp ull utilization of isokinteic speeds with incorporation of diagonal patterns
Àp ncrease emphasis of isotonic exercises, especially eccentric modes with throwers
Yp oderate weight, moderate repetition program
Àp egin functional progressive and lead-in to overhead activities at -12 weeks
Àp Progress to high weight low repetition program if indicated TER returning to functional
activities

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Operative Rehabilitative Protocol


Phase 1 (0-10 da s)

ÀJones dressing with splints


ÀTouch down weight bearing with crutches
Àsometric quads, quadriceps sets, straight leg raises

Phase 2 (10 da s to 6 weeks) 

À?ylinder cast
ÀTouch down weight bearing to partial weight bearing with crutches
Àsometric quadriceps strengthening

Phase 3 (6 weeks to 12 weeks) 

ÀPartial weight bearing with crutches or cane


À y 12 weeks, full weight bearing if films show union
ÀQuadriceps and hamstring strengthening
À?ane is used until able to walk without a limp
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Geeral Istrctios

Àp pply ice covered with a towel to knee for 2-3 days (1-20 minutes at a time).
Àp uwelling and bruising is normal. You may loosen dressing if needed.
Àp ow grade fevers (less than 101 degrees) are common after surgery. Veep breathing will help
with this. f your fever persists for more than a few days, or the wound gets more red, call my
office.
Àp The pain medication given to you can cause constipation, nausea and itching. You may switch to
Tyelenol or otrin when more comfortable.

- ercises

Àp Elevate your leg above the level of your heart for 2-3 days after surgery to decrease swelling. 
Àp You may place as much weight on operative leg as tolerated, unlessspecifically told not to.
Viscontinue crutches when you feel comfortable without them.
Àp hile sitting, start flexing and extending knee and ankle as comfort allows.
Àp utart straight leg raises 20-40 times, 3 times a day
Àp utart physical therapy within 2-3 days.

ada es

Àp Your dressing may show blood stains after surgery. This is expected. f the blood is still wet
after the first day, call my office.
Àp Remove all dressings and cover wounds with band-aids after three days.
Àp You may shower after 3 days.
Àp Vo not swim or submerge incisions in water for 2 weeks.

ork

Àp Your comfort level should be your guide for returning to work.


Àp ost people are able to return after the first post-operative visit. 

Importat

Àp Report any complications to my office immediately. Thisincludes excessive bleeding, wound


breakdown, increasing redness or pain, prolonged fever over 101 degrees, or increasing calf
pain.
Àp ?all office for follow-up appointment 10-14 days after surgery (if not scheduled)

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Geeral Istrctios 

Àp pply ice covered with a towel to ankle for 2-3 days (1-20 minutes at a time).
Àp uwelling and bruising is normal. Elevate ankle above the level of your heart to decrease this.
You may loosen dressing if needed.
Àp ow-grade fevers (less than 101 degrees) are common after surgery. Veep breathing will help
with this. f your fever persists for more than a few days, or the wound has increased redness,
call my office.
Àp The pain medication given to you can cause constipation, nausea and itching. You may switch to
Tyelenol or otrin when more comfortable.

- ercises

Àp You may place as much weight as you can tolerate on your leg unless specifically instructed not
to. You may discontinue crutches when you feel comfortable without them
Àp hile sitting, start moving your knee, ankle, and toes as comfort allows.
Àp utart physical therapy within 2-3 days.

ada es

Àp Your dressing may show blood stains after surgery. This is expected. f the blood isstill wet
after the first day, call my office.
Àp Remove all dressings and cover wounds with band-aids after three days.
Àp You may shower after  days.
Àp Vo not swim or submerge incisions in water for 2 weeks. 
Àp åse your ace wrap for compression when walking for 2 weeks.

ork

Àp Your comfort level should be your guide for returning to work.


Àp ost people are able to return after the first post-operative visit 

Importat

Àp Report any complications to my office immediately. This includes excessive bleeding, wound
breakdown, increasing redness or pain, prolonged fever over 101 degrees, or increasing calf
pain.
Àp ?all office for follow-up appointment 10-14 days after surgery (if not scheduled).


 

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Geeral Istrctios 

Àp pply ice covered with a towel to elbow for 2-3 days (1-20 minutes at a time).
Àp uwelling and bruising is normal. You may loosen dressing if needed.
Àp ow grade fevers (less than 101 degrees) are common after surgery. Veep breathing wi ll help
with this. f your fever persists for more than a few days, or the wound gets more red, call my
office.
Àp The pain medication given to you can cause constipation, nausea and itching. You may switch to
Tyelenol or otrin when more comfortable.

- ercises

Àp Elevate your hand/elbow above the level of your heart for 2-3 days after surgery to decrease
swelling. 
Àp f you were given a sling, this is for comfort only. Try to discontinue use of sling as soon as
possible to avoid stiffness. 
Àp utart to flex/extend the elbow as pain allows, unless immobilized in splint. utart squeezing a
tennis ball for grip strength.
Àp utart physical therapy within 2-3 days.

ada es

Àp Your dressing may show blood stains after surgery. This is expected. f the blood is still wet
after the first day, call my office.
Àp Remove all dressings and cover wounds with band-aids after three days.
Àp You may shower after 3 days.
Àp Vo not swim or submerge incisions in water for 2 weeks. 

ork

Àp Your comfort level should be your guide for returning towork.


Àp ost people are able to return after the first post-operative visit. 

Importat

Àp Report any complications to my office immediately. This includes excessive bleeding, wound
breakdown, increasing redness or pain, prolonged numbness or tingling, prolong ed fever over
101 degrees, or increasing calf pain.
Àp ?all office for follow-up appointment 10-14 days after surgery (if not scheduled).


 


 '
    

Oo-operative treatmet

The physical therapy rehabilitation for an posterior shoulder dislocation/subluxation will vary in length
depending on factors such as degree of instability, acute versus chronic condition, length of time
immobilized, strength and range of motion status, and performance/activity demands.

This program is in three phases and phases can overlap. n all exercises during phase 1 and 2, caution
must be applied in placing undue stress on the posterior joint capsule as dynamic joint stability is
restored. n isokinetic strength and endurance test is scheduled during the latter part of phase 2. The
focus of phase 3 is on progressive isotonic and isokinetic exercises in preparation for returning to the
prior activity level.

Phase 1

Àpply modalities as needed (heat, ice, electrotherapy, etc.).


ÀPerform range of motion exercises (passive, active-assist, active) as tolerated. or shoulder
abduction and external rotation, avoid stress to the anterior joint capsule by positioning the shoulder in
the scapular plane (about 20-30 degrees forward of the coronal plane). uhoulder hyperextension is
contraindicated.
Àutretch anterior cuff and capsule.
Àobilization (anterior glides as needed).
Àctive external rotation may be performed from 0 degrees rotation to full external rotation. rm is
positioned at side with elbow flexed 90 degrees. åse rubber tubing for resistance. f pain persists,
isometric exercises may be added. s strength improves, progress to using free weights, lying prone
with arm abducted to 90 degrees or sidelying with arm at side.

(p Prone: Perform the combined movements of horizontal abduction followed by external rotation
to protect posterior joint capsule.
)p uidelying: imit the degrees of internal rotation to protect theposterior capsule.

Àdd active internal rotation performed from full external rotation to 0 degrees rotation using rubber
tubing. imiting the degrees of internal rotation is necessary to avoid excessive stress to the posterior
capsule. f there is pain with active movements, strength can be maintatined by performing an
isometric contraction. The shoulder position may be adjusted to allow a pain free muscle contraction to
occur.
Àdd supraspinatus exercise, if adequate range of motion available (0-90 degrees). uhoulder is
positioned in the scapular plane about 20-30 degrees forward of the coronal plane.
Àctive shoulder flexion exercise through available range of motion.
Àctive shoulder abduction exercise to 90 degrees. 
Àuhoulder shrug exercise-avoid traction in the glenohumeral joint between repetitions by not allowing
the arms to drop completely. This will avoid an excessive inferior glide of the humeral head.
Àctive horizontal abduction exercise (posterior deltoid) in prone lying position. void excessive stress
to the posterior capsule by limiting movement from 4 degrees of horizontal adduction to full
horizontal abduction. 
Àdd forearm strengthening exercises (elbow and wrist).

Phase 2

À?ontinue anterior cuff/capsule stretch, mobilization, and range of motion exercises.


À?ontinue shoulder strengthening (emphasis on rotator cuff and posterior deltoid) with tubing and/or
free weights. Emphasize eccentric phase of contraction.
Àdd arm ergometer for endurance exercise.
Àdd push-ups. ovement should be pain free with emphasis on protecting the posterior capsule.
uhoulders are positioned in 0-90 degrees of abduction. ?   
   
 
 


  





  
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Phase 1 (nitial 3 weeks post-surgery)

Àp Vressing removed in therapy; gunslinger brace all times for three weeks
Àp rist and elbow RO as tolerated, ball squeezes

Phase 2 (3- weeks)

Àp utart gentle passive RO with shoulder flexion, abduction, external rotation
Yp Progress with internal rotation as needed
Yp dd active-assist (wand exercises) and shoulder shrugs
Yp Progress with isometric internal and external rotation with arm at side and elbow flexed
at 90 degrees (pain free contraction)
Yp s strength improves, add active external rotation with tubing (pain free)

Phase 3 (- weeks)

Àp ?ontinue passive and active-assist RO exercises; may add wall climbs
Àp Progress to free weights for external rotation in prone lying position with arm abducted to 90
degrees or sidelying with arm at the side
Yp Perform combined movements of horizontal abduction followed by external rotation to
protect posterior capsule
Yp f sidelying, limit degrees of internal rotation to protect capsule
Yp dd supraspinatus exercise if pain free and RO 0-90 degrees
Yp uhoulder positioned in scapular plane in 20-30 degrees forward of coronal plane
Yp dd active shoulder flexion through available RO and active abduction to 90 degrees

Phase 4 (2-3 months)

Àp uhould have full passive and active RO


Àp dd shoulder stretch/mobilization as needed
Àp dd push ups in 0-90 degrees of abduction (pain free)
Yp Vo not raise body beyond scapular plane
Yp egin with wall push ups
Yp ?ontinue isotonic strengthening with emphasis on rotator cuff and posterior deltoid
Yp ctive internal rotation with tubing and PO upper extremity patterns added
Yp lexion/abduction/external rotation diagonals emphasized
Yp utart ¼ of way in diagonal and limit range to latter ¾ to protect capsule
Yp Dorizontal abduction performed through increased range (starting position at 90 degrees
of horizontal abduction as tolerated)

Phase  (4 months)

Àp ?ontinue to progress weights as needed; emphasize eccentric cuff strengthening


Àp ?an add ergometer for endurance
Àp ?an add isokinetic strengthening at high speeds (200 plus degrees/second) for internal/exte
rnal
rotation with arm at side and horizontal abduction
Àp Oeed -10 pounds external and 1-20 pounds internal rotation prerequisite strength and pain
free shoulder motion before starting

Phase  ( months)

Àp sokinetic test
Àp ?ontinue to progress isotonic and isokinetic exercises (can add flexion/extension and
abduction/adduction)
Àp dd military press with weight directly over or behind head
Àp Total body conditioning and flexibility addressed

Phae 7 ( months)
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Operative Rehabilitative Protocol

Phase 1-Immobilit ad braci 

Àp ånlock brace to prescribed angles for range-of-motion exercises only on 1 and 2 post-op weeks
Àp eave unlocked at  weeks post-op: extension stop 10 degrees and flexion stop 0 degrees 
Àp uhower without brace on at  weeks post-op
Àp uleep without brace on at 10 weeks post-op
Àp åse functional brace at 1 weeks post-op for ambulation and exercise until 2 weeks post-op;
then exercise only
Àp Vonjoy 4 point P? brace or orthotist made brace

Phase 2-Ra e of motio

Àp egin passive range of motion 1 week post-op from 0 degrees extension to 40 degrees flexion;
increase 0 degrees extension and 10 degrees flexion per week beginning  weeks post -op for 2
weeks only, then lock at 10 degrees for 4 weeks
Àp ay increase PRO prn
Àp egin active range of motion 1 week post-op from 0 degrees extension to 40 degrees flexion;
increase 0 degrees extension and 10 degrees flexion per week beginning  weeks post -op
Àp ay increase RO prn

Phase 3-Pro ressive wei htbeari 

Àp egin weightbearing 12 weeks post-op; start with 2 body weight and increase 2 per
week-then continue on one crutch (7 body weight) until notified.
Yp wean from crutches as tolerated-total 1 weeks on crutches

Phase 4-Isometrics 

Àp Quad isometrics-spectrum isometrics


Àp utraight leg raises-may use weight up to 10 pounds
Àp Patella glides and tilts 3 times per day
Àp Oeuromuscular stimulation-quadriceps 3 times/day
Yp Vuration of 2 hours/session for  weeks until active quadriceps contraction

Phase 5-Isotoic pro ressive resistace e ercises (PR-) 

Àp Knee extension prohibited until  weeks post-op


Àp Knee flexion prohibited indefinitely
Àp ust wear brace during PRE¶s-prone until 1 weeks post-op
Àp Knee extension PRE
Yp ncrease prn from 0 degrees extension to 70 degrees flexion until 2weeks post-op;
then advance prn
Yp Oo limits on weight from 0 degrees extension to 40 degrees flexion

Àp eg press PRE
Yp ncrease prn from 0 degrees extension to 70 degrees flexion after  weeks post
-op, then
advance prn
Yp Oo limits on weight from 0 degrees extension to 40 degrees flexion

Phase 6-ctioal e ercises

Àp utart program 12 weeks post-op


-op
Yp Restrict RO to 10 degrees extension and 90 degrees flexion until 2 weeks post
Àp ini squats-20 weeks post-op
Àp uports cord-12 weeks post-op
Àp Tampoline-4 weeks post-op
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General nstructions

Àp pply ice covered with a towel to shoulder for 2-3 days (1-20 minutes at a time).
Àp uwelling and bruising is normal. You may loosen dressing if needed.
Àp ow grade fevers (less than 101 degrees) are common after surgery. Veep breathing will help
with this. f your fever persists for more than a few days, or the wound gets more red, call my
office.
Àp Your sling is for comfort only.
Àp The pain medication given to you can cause constipation, nausea and itching. You may switch to
Tyelenol or otrin when more comfortable.

- ercises

Àp ove and use your elbow and wrist as comfort; start squeezing a tennis ball.
Àp Oo lifting, pushing, and pulling for 1 week.
Àp utart ³pendulum´ exercises with arm in front of body.
Àp utart physical therapy within 2-3 days.

ada es

Àp Your dressing may show blood stains after surgery. This is expected. f the blood is still wet
after the first day, call my office.
Àp Remove all dressings and cover wounds with band-aids after three days.
Àp You may shower after 3 days.
Àp Vo not swim or submerge incisions in water for 2 weeks. 

ork

Àp Your comfort level should be your guide for returning to work.


Àp ost people are able to return after 2-3 weeks, depending on procedure performed. 

Importat

Àp Report any complications to my office immediately. This includes excessive bleeding, wound
breakdown, increasing redness or pain, prolonged fever over 101 degrees, or increasing calf
pain.
Àp ?all office for follow-up appointment 10-14 days after surgery (if not scheduled).


 
 

  
 




   

Rationale: The number of patellofemoral problems is increasing. Oo single cure exists for the treatment
of this problem. This suggested exercise program is divided into three goal-oriented phases. Paying
attention to the precautions and good education is paramount to success.

Phase 1-Acte phase

Goals: 

Àp Education
Àp Vecrease pain, swelling, palpable tenderness
Àp mprove gait deviations
Àp Restore normal mechanics

u ested treatmet: 

Àp odalities to include ice, phonophoresis, moist heat, and electrical stimulation


Àp Taping
Àp utretching for hamstrings, triceps surae, quadriceps, and iliotibial band
Àp utart with isometric strengthening
Àp mmobilizer and cane/crutches if acute

Precatios 

Àp Program should not increase symptoms


Àp Phase 2 begins when resting pain is resolved, swellingdecreased, and palpable tenderness is
moderate to minimal

Phase 2-ubacte phase

Goals: 

Àp alance length and strength of lower extremity musculature


Àp ncrease quadriceps strength (VO control)
Àp Good patellar mechanics

u ested treatmet 

Àp Exercises include quad sets, straight leg raises, wall squats, mini-squats, closed chain
strengthening (eg. ulow motion walking, leg press, step ups, resistive bends in weight-bearing,
be innovative with weight-bearing activities)
Àp ?ontinue stretching tight muscles
Àp Patellar mobilizations (medial glides and lateral tilts)
Àp Electrical stimulation to VO
Àp Orthotics to balance the foot
Àp Pain free biking (high seat with low resistance)
Àp Overall conditioning program (avoid open chain knee extension exercises )

Precatios 

Àp Vo not work through pain


Àp Program should not increase symptoms

Phase 3-ctioal phase

Goals 

Àp Pain free functional closed chain activities (steps, jogging, running, and sport specific activities)
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The pain you have on the inside of your elbow is due microtearingof the tendons coming off the
epicondyle (bone). This results in the formation of scar tissue with resultant pain. ?ontinued stress can
lead to a viscous cycle of pain and weakness. This is not a serious injury, but the pain can greatly
affect your capability to perform sports activities. 

e can keep you in training if you follow this treatment regimen:

uymptom ?ontrolling odalities

Àp Eliminate activities that are painful


Àp ?ontrast whirlpool
Yp  minutes hot whirlpool with active elbow
Àp electrical stimulation
Yp E.G.u. or interferential contact flexor carpi ulnaris distal and proximal (3 minutes daily
for a maximum of  days) 

Exercises

Àp Joint vibration-3 minutes


Àp uoft tissue longitudinal massage to flexor carpi ulnaris musculotendinous junction
Àp uubmaximal exercise
Yp rist flexion/extension (dumbbell)
Yp uupination/pronation (weight bar)
Yp rist ulnar deviation with elbow extended (weight bar)
Yp rist flexion ulnar deviation (weight bar)

Throwing orkout

Àp fter throwing, ice and compression wrap for 1 minutes with elbow extended

Repeat first two under exercises

ailure of baseline treatment

Àp utart iontophoresis (10 Dydrocortisone cream) continuous fashion 1. to 2/?2 every other
day over a course of 10 days

Àp Take anti-inflammatory medication (OuV¶u)


Àp ce the outside part of your knee three times a day
Àp Perform iliotibial band stretches six times a day
Àp f your pain is severe, we recommend you use a knee immobilizer and crutches for 3 days. 
Yp ear the immobilizer during the day and night; can removefor ice, stretching, and
bathing

Once you no longer have pain on the outside of your knee when you press on it, you will be able to do
everything except routine running for the next two weeks. Vuring these two weeks, you will participate
daily in the following regimen:

Àp Perform iliotibial band stretches


Àp Run until you feel tightness (not discomfort) on the outside of your knee
Àp Once you feel tightness on the outside of your knee, stop running and perform the stretches. Vo
not run anymore that day.
Àp Each day, do the stretches and run until you feel tightness; goal = 3 miles without tightness.

Take the medication and use ice until your season is completed

You may also need to augment your program with formal physical therapy
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%   


     

The pain you have on the outside of your elbow is due microtearing of the tendons coming off the
epicondyle (bone).This results in the formation of scar tissue with resultant pain. ?ontinued stress can
lead to a viscous cycle of pain and weakness. This is not a serious injury, but the pain can greatly
affect your capability to perform sports activities. e can keep you in training if you follow this
treatment regimen: cute (1-3 weeks from onset of symptoms) 

Àp odalities to relieve pain


Yp ce, OuV¶u, corticosteroid injection, cock-up wrist splint, cast
Àp Rehabilitation
Yp Rest until asymptomatic, then gradual resumption of normal activites; alter provocative
activities if possible

uubacute and ?hronic (>3 weeks from onset of symptoms)

Àp odalities for relief of pain


Yp Deat, OuV¶u, massage, ultrasonography, electrical stimulation, elbow sleeve or
counterforce forearm brace

Rehabilitation 

Yp Exercise: flexibility (alphabet tracing), strength (isometric) program for wrist extensors,
endurance (when pain-free, begin isokinetic program).
Yp Return to full activities when grip strength is normal and pain is absent 

n isometric strengthening program for forearm extensors can begin with the use of lightly resistive
therapeutic putty. s the patient grips the putty, the wrist extensors isometrically contract to stabilize
the wrist. sometric exercises allow strengthening of the muscle with less stress than occurs with
isotonic and isokinetic exercises. 

s the patient¶s level of pain decreases, generally within 3- weeks of initiation of treatmen, a
progressive resistive exercise program is started, with the goal of strengthening the wrist extensors,
forearm flexors, supinators, and pronators. sotonic and isokinetic exercises can also be used.

sotonic exercise occurs when the muscle works against resistance through available range -of-motion.
ree weights or exercise rubber bands can be used. ith isokinetic exercises, the speed of muscle
lengthening and contraction is controlled and resistance is varied.

 
# 


  

# 
   

0- weeks

Àp rm held in brace, slightly abducted in neutral rotation


Àp Gentle isometric exercises with elbow RO¶s

 weeks 

Àp Viscontinue brace and RO¶s gradually introduced slowly

12 weeks 

Àp Progressive strengthening

9-12 months 

Àp ?ontact sports

idirectional instability without posterior component 0-10 days 

Àp uling immobilization with elbow/wrist RO¶s

10 days to 2 weeks 

Àp 
sometrics and external rotation to 10 degrees, forward elevation 90 degrees

2-4 weeks 

Àp sometrics and external rotation to 30 degrees, forward elevation 140 degrees

4- weeks 

Àp External rotation to 40 degrees, forward elevation to 10 degrees


Àp Resistance exercises begun

 weeks 

Àp 
External rotation to 0 degrees, forward elevation 10 degrees with resistance exercises

3 months 

Àp External rotation increase from 0 degrees 


Àp utrengthening begins with arm in neutral below 90 degrees

4-12 months 

Àp Return to contact sports


 
#      *
 
  +   

Oo-operative treatmet

mpingement of the rotator cuff can be both anatomical and kinesiological in nature. t is best treated
when any kinesiological disturbances are treated first. This is usually accomplished by muscle
balancing and specific muscle training. This includes rest at the appropriate time and the use of non-
steroidal anti-inflammatories (OuV¶s). Proper training of the rotator cuff muscles for balance to
provide good scapulohumeral rhythm and conditioning of the rotator cuff and scapular muscles is
critical. n anatomic limitation to this program may be an underlying instability. This must be
considered when following this program.

Phase 1-Acte phase

Goals:

Àp imit pain (relative rest-avoiding provocative activity)


Àp Restore any lost motion
Àp Restore function to achieve V ¶s for personal hygiene 

Jreatmet recommedatios: 

Àp ce, sling if needed, electrical stimulation, gentle mobilization, OuV¶s

Precatios:

Àp Elimination of rest pain should be achieved quickly

Phase 2-ubacte phase 

Goals:

Àp Restore full motion


Àp Restore good glenohumeral and scapulohumeral rhythm
Àp 4/ strength of upper extremity muscles

Jreatmet recommedatios: 

Àp utart with active range of motion below shoulder level


Àp dd isometrics below shoulder level
Àp Theraband and light resistive activities below shoulder level
Àp upecific focus on internal and external rotators
Àp ctive motion above shoulder when strong resisted strength below 90 is present 
Àp Progress strengthening overhead from active to slight active to lightweight active resistive
range of motion
Àp Resistive fist,wrist, forearm, and elbow work included
Àp åpper extremity ergometer and water resistive activites used

Precatios:

Àp ll active and resistive motion should be muscle specific


Àp sometrics may need to be altered to not aggravate instability, if present

Phase 3-utre thei phase 

Goals:

Àp chieve / strength in all shoulder girdle muscles


Àp ull pain free range of motion and resistive range of motion
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The pain on the outside of your knee is due to inflammation (tendonitis) of the iliotibialband tendon.
This tendonitis is not a serious injury, but the pain can greatly affect your capability to perform sports
activities. You will experience pain on the outside of your knee when you run, go up and down stairs,
and when pivoting.

e can keep you in training if you follow this treatment regimen:

Àp Take anti-inflammatory medication.


Àp ce the outside of your knee three times a day.
Àp Perform the iliotibial band stretch six times a day.
Àp f your pain is severe, we may recommend you use a kneeimmobilizer and crutches for three
days. ear immobilizer during the day and night (You may remove for ice, stretching, and
bathing).

Once you no longer have pain on the outside of your knee when you press on it, you will be able to do
everything except routine running for the next two weeks. Vuring these two weeks, you will participate
daily in the following specific regimen:

Àp Perform iliotibial band stretches.


Àp Run until you feel tightness (not discomfort) on the outside of your knee. 
Àp Once you feel tightness on the outside of your knee, stop running and perform the stretches. Vo
not run anymore that day.
Àp 
Each day, do the stretches and run until you feel tightness; goal = 3 miles without tightness.

Take the medication and use ice until your season is completed.

 

  
J
   

Oo-operative treatmet

Phase 1-?ontrol swelling 

Àp Elevation
Àp ce compression
Àp OuV¶s
Àp ?rutches (2-3 days)

Phase 2-obilization

Àp Early, gentle range of motions


Àp ctive assisted/passive stretching (3 times per day)
Àp Deel lift

Phase 3-utrengthening (2 weeks post injury)

Àp Vorsiflexion
Àp Plantar flexion
Àp nversion/eversion

Phase 4-functional activities (3- weeks)

Àp Gradual resumption of activites


Àp chilles tenson taping may be used early
Àp ull return if
Yp ull range of motions
Yp Oo pain or tenderness
Yp utrength deficits less than 10


 
%   
 

     

Operative Rehabilitative Protocol

Pre-op phase

Àp Quad sets, straight leg raises, crutch training

Perioperative phase

Àp mmediate post-op: ?P 0-4 degrees)


Àp uecond post-op day:
Yp n hinged knee brace quad sets and ankle RO¶s
Yp utraight leg raises assisted or eccentric slow to avoid hemarthrosis
Yp Electrical stimulation as needed
Yp eightbearing as tolerate with crutches and brace locked in extension)

Post-operative Vays -7

Àp 20-2 straight leg raises in brace; no more than 40-0 three times a day
Àp Passively flexing 0-4 degrees
Àp Damstring setting and stretching
Àp Dip exercises in splint abduction, extension and adduction

eeks 1-3

Àp Obtain 4 degrees flexion in brace


Yp ctive hamstrings contraction and passive knee extensions

eeks 3-12

Àp ssisted RO¶s (patient should get to 40 degrees flexion by  weeks) 


Àp utraight leg raising, terminal extension, hamstring stretching, quad setting
Àp ean brace at 4- weeks and wean off crutches at - weeks

ate phase (12 weeks) ndefinite

Àp eights (low weights/high reps), bicycling (keep seat high) and functional activities
Àp Jogging or running is the last thing allowed
Àp Patient must be able to run without a limp; if limp occurs, stop running and continue weights
until swelling subsides
Àp Progressive running program
Yp 1st day: ¼ mile/run 100 yards/walk 100 yards
âp routine continued over time until patient can run ¼ mile
Yp 2nd week: ½ mile run (slow) three times per week
Yp 3rd week: ¾ mile run (slow) three times per week
Yp 4th week: 1 mile run (slow) three times per week
Yp th week: begin sprints 40 yard dash (1/2 speed) then ¾ speed and progress to full
speed
Yp th week: agility drills


 
c  
 

      

Phase 1-Acte Phase

Goals:

Àp imit pain, reduce swelling, and restore motion

Jreatmet Recommedatios: 

Àp ce, sling, e-stim, OuV¶s


Àp 
Pendulum exercises, gentle mobilization with passive and active assist through pain free arc

Precatio:

Àp Relative rest is important to reduce inflammation

Phase 2-ubacte Phase

Goals:p

Àp Eliminate pain, restore full active motion


Àp Restore good glenohumeral and scapulohumeral rhythm
Àp 4/ strength of upper extremity muscles including scapular stabilizers

Jreatmet Recommedatios: 

Àp odalities as needed
Àp utart with active RO through available range
Àp dd isometrics below shoulder level
Àp lexibility of the cervical, shoulder and scapular muscles
Àp Oon-involved upper extremity and bilateral lower extremity exercises

Precatios:

Àp ll active and isometric exercises should be muscle specific


Àp ll movements and activity increasing symptoms should be eliminated
Àp 
sometrics are to be modified (position change) if patients¶s symptoms are made worse

Phase 3-utre thei Phase

Goals:p

Àp ttain full pain-free RO and full pain-free resistive RO


Àp 
/ strength in all shoulder girdle muscles with perfect symmetrical scapulohumeral rhythm
Àp Oegative Oeer and Dawkin¶s sign

Jreatmet Recommedatios: 

Àp ?ontinue with ice, previous exercises


Àp Progress resistance to overhead and above horizontal
Àp dd resistance to scapular exercises
Àp ork on quality of motion, not just resistive training
Àp ork on balance of the rotator cuff muscles
Àp utart sport specific/work specific exercises
Àp eight-bearing upper extremity
Àp ater resistive exercises

Precatios:
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Operative Rehabilitative Protocol

Goals

Àp manage inflammation (cold therapy, OuV¶s, etc.)


Àp ?ontrolled gains in range of motion
Àp Early maintenance of strength
Àp mmediate weightbearing in full extension
Àp race-extension lock brace (E u)

Phase 1 (0-1 week)

Àp RO¶s (0-90 degrees non-weightbearing, patellar glides)


Àp eightbearing in full extension with brace locked
Àp ?ontrolled quadriceps strengthening, straight leg raises, quadsets, hip extension and flexion,
calf raises
Àp Keep brace locked in extension

Phase 2 (1-4 weeks)

Àp chieve 0-90 degrees of motion; continue patellar glides


Àp eightbearing as tolerated with brace locked
Àp ?ontinue strengthening as in phase 1

Phase 3 (4-6 weeks)

Àp dvance to normal range of motions


Àp Oo flexion loading beyond 90 degrees
Àp utrengthening
Yp dd mini-squats, closed chain exercises to quadriceps program, start hamstring curls,
continue hip/calf strengthening
Àp egin normal gait training (first unlock brace, then wean from brace)

Phase 4 (6 weeks)

Àp chieve normal range of motions and continue strengthening as in phase 3


Àp ?ontinue to avoid flexion loading beyond 90 degrees
Àp eightbearing as tolerated without brace

Phase 5 (> 6 weeks)

Àp Dome program

Phase 6 (4 moths)

Àp Resume athletic activity

Phase 7 (6 moths)

 
c

   

hat is arthritis?

rthritis is the gradual breakdown and damage to cartilage that function as "shock absorbers" at the
end off your bones. There are many forms, but osteoarthritis is the most common and occurs with
aging. Osteoarthritis is a disease of joint cartilage, mediated by inflammation, breakdown, and
eventual loss of this cartilage. 

The most common symptom is pain, usually worse at the end of the day. There may be swelling,
warmth, popping or grinding of the affected joints. Pain and stiffness may also occur afterlong periods
of inactivity, for example, sitting in a theater. Pain at rest or pain with decreased range of motion is
common with severe osteoarthritis. uymptoms can be intermittent, but are usually progressive.

Osteoarthritis is usually diagnosed from the history, physical, and radiographs. There is currently no
blood test for this diagnosis. lood tests may be helpful to exclude other arthritic conditions that can
mimic osteoarthritis. The most common radiographic findings of osteoarthritis are narrowingof the
joint "space" between adjacent bones, bony spur formation, and cyst formation. 

lthough we do not have a cure for osteoarthritis, there are modalities that may be employed to
improve symptoms. The goal of treatment is to reduce stress, pain and inflammation, while improving
and maintaining function and mobility. The program outlined below may be helpful to improving
symptoms of osteoarthritis.

Jotal uports Care Arthritis Pro ram 

utep 1

ake a commitment to improving the state of your joints

utep 2

 realistic weight loss plan


One extra pound translates to 4,000,000 pounds on your weight-bearing joints each year. uimple
techniques include reducing sugar and carbohydrate intake, eating a well balanced breakfast,
eliminating night snacks, drinking -10 glasses of water a day, regular, and consistent exercise 3 times
per week or more.

utep 3

åse regular exercise to reduce joint pain


uimple low-impact exercises can reduce pain, improve motion, and relieve feelings of depression
associated with arthritis. Exercises that are beneficial for joints include swimming, water aerobics,
walking, tai-chi, yoga, and eliptical gliders. Try and avoid high-impact activites such as running or
jogging.

utep 4

egin a strengthening program


uimple weight lifting exercises can promote increases strength and muscle mass at any age. enefits
include improved metabolism and stability around joints. pplying local heat before and cold packs
after exercise may relieve pain and inflammation.

utep 5

ear proper shoes


Good shoes may help decrease shock and load transferred to joints with walking. Typically, these
shoes should have a shock absorbing heel and sole (push), a stabilizing heel cup (squeeze), and a
strong shank (twist). uome better manufacturers include Rockport, uu, ephisto, Voc artens, and
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Oo-operative treatmet

The physical therapy rehabilitation for an anterior shoulder dislocation/subluxationwill vary in length
depending on factors such as degree of instability, acute versus chronic condition, length of time
immobilized, strength and range of motion status, and performance/activity demands. 

This program is in three phases and phases can overlap. n all exercises during phase 1 and 2, caution
must be applied in placing undue stress on the anterior joint capsule as dynamic joint stability is
restored. n isokinetic strength and endurance test is scheduled during the latter part of phase 2. The
focus of phase 3 is on progressive isotonic and isokinetic exercises in preparation for returning to the
prior activity level.


Phase 1

Àp pply modalities as needed (heat, ice, electrotherapy, etc.). 


Àp Perform range of motion exercises (passive, active-assist, active) as tolerated. or shoulder
abduction and external rotation, avoid stress to the anterior joint capsule by positioning the
shoulder in the scapular plane (about 20-30 degrees forward of the coronal plane). uhoulder
hyperextension is contraindicated.
Àp utretch posterior cuff and capsule.
Àp obilization (posterior glides as needed).
Àp ctive shoulder internal/external rotation exercises with rubber tubing. rm positioned at the
side with elbow flexed 90 degrees. void excessive stress to the anterior joint capsule by
limiting external rotation to no greater than a 4 degree range (as tolerated). f discomfort
persists, isometric exercises may be added. The shoulder position may be adjusted to allow a
pain free muscle contraction to occur.
Àp dd supraspinatus exercise in the scapular plane if adequate range of motion is available (0 -90
degree range).
Àp ctive shoulder flexion exercise through available range of motion.
Àp ctive shoulder abduction exercise to 90 degrees. aintain shoulder in the scapular plane to
avoid stress on the anterior joint capsule.
Àp uhoulder extension exercise-lying prone or standing (bending at the waist). void the shoulder
extended position by preventing arm movement beyond the plane of the body. This will
decrease excessive stress to the anterior joint capsule.
Àp uhoulder shrug exercise-avoid traction in the glenohumeral joint between repetitions by not
allowing the arms to drop completely. This will avoid an excessive inferior glide of the humeral
head.
Àp void horizontal adduction exercise-perform supine with the starting position in the scapular
plane.
Àp ctive shoulder internal/external rotation-progress to free weights.
Àp uhoulder internal rotation: perform sidelying with the involved side resting on the plinth.
Elevate or support the lateral chest wall (pillow, bolster, etc) to decrease the joint compression
on the involved shoulder.
Àp uhoulder external rotation: lie on the uninvolved side. void excessive stress to the anterior
joint capsule by limiting movement to no greater than 4-0 degrees of external rotation.
Àp dd forearm strengthening exercises (elbow and wrist). 

Phase 2

Àp ?ontinue posterior cuff/capsule stretch, mobilization, and range of motion exercises


Àp ?ontinue shoulder strengthening with tubing and/or freeweights. Emphasize eccentric phase of
contraction.
Àp dd arm ergometer for endurance exercise.
Àp dd push-ups. aintain proper alignment of the shoulders and elbows at the starting position.
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