Dr. Richard F. Howard
Dr. Richard Howard

Medical School

Kirksville College of Osteopathic Medicine University of South Florida

Fellowship

Hand & Microsurgery Fellowship at the University of South Florida

Internship & Residency

Kirksville Osteopathic Medical Center

Office Hours

Monday through Friday 8:00 am to 5:00 pm

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Dr. Richard Howard earned his Bachelor of Science in Engineering from the United States Air Force Academy in Colorado Springs, Colorado. He obtained his Doctorate in Osteopathic Medicine from Kirksville College of Osteopathic Medicine in Kirksville, Missouri.

Dr. HowardDr. Howard served his transitional internship at Des Peres Hospital in St. Louis, Missouri. Hand and microsurgery fellowship training was completed at the University of South Florida in Tampa, Florida.

Dr. Howard served as a diplomat for the National Board of Medical Examiners, and the Chairman of the American Osteopathic Board of Orthopedic Surgery. He obtained his Certificate of Added Qualification in Hand Surgery from the American Osteopathic Board of Orthopedic Surgery in 1992, and he was recertified in 1998 and in 2017. He specializes in the evaluation, diagnosis and treatment of complex hand, wrist, elbow and shoulder disorders.

His educational appointments include being the Orthopedic Program Director for the Des Peres Hospital Orthopedic Residency Program and Assistant Clinical Professor of Orthopedic Surgery for St. Louis University School of Medicine.

Hospital and Surgical Center staffing privileges include Des Peres Hospital, St. Louis University Hospital, and Timberlake Surgery Center in Chesterfield, Missouri.

Professional Affiliations include:

American Society for Surgery of the Hand, American Academy of Orthopedic Surgery, American Osteopathic Academy of Orthopedics, the American Osteopathic Association, and the American Osteopathic Board of Orthopedic Surgery.

Board Certified Orthopedic Surgeon
Fellowship Trained in Hand, Upper Extremity, and Micro-Surgery

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Dr. Howard’s Protocols

Phase 1: Maximal Protective Phase (Weeks 0-6)

Goals:

  • Protect anatomy of the repair
  • Decrease pain and inflammation
  • Promote dynamic stability
  • Retard muscle atrophy

Precautions:

  • No active abduction, external rotation, or extension
  • No isolated biceps lifting with weight
  • Sling may be discontinued as pain permits

Exercises:

  • Pendulums
  • Self-PROM/AAROM in Flexion to tolerance
  • Self-PROM/AAROM in External Rotation to Neutral
  • Scapular, Shoulder, and Rotator Cuff Isometrics
  • Elbow, Wrist, Hand AROM
  • Modalities as needed

Phase 2: Intermediate Phase-Moderate Protection Phase (Weeks 6-10)

Goals:

  • Decrease pain and inflammation
  • Restore full PROM and AROM
  • Gradual increase in strength

Precautions:

  • Patients are not allowed to lift weight above the shoulder
  • Patients should not lift > 5 pounds.

Early Intermediate Phase (Weeks 5-7)

  • Gradually progress P/AROM
    • Flexion, Elevation in plane of Scapula to tolerance
    • Abduction to 145°
    • External Rotation to 45-50° at 45° Abduction
    • Internal Rotation to 55-60° at 45° Abduction
    • Extension to Tolerance
  • Initiate gentle rhythmic stabilization exercises
  • Initiate proprioceptive exercises
  • Initiate Rotator Cuff strengthening with arm in neutral
  • Strengthening exercises for the hand, wrist, elbow, and scapular musculature
  • Modalities as needed

Late Intermediate Phase (Weeks 8-14)

  • Gradually progress P/AROM
    • Flexion, Elevation in plane of Scapula, and Abduction to 180°
    • External Rotation to 90-95° at 90° Abduction
    • Internal Rotation to 70-75° at 90° Abduction
    • Extension to Tolerance
    • Continue distal Upper Extremity and scapular strengthening
  • Continue rhythmic stabilization
  • Initiate shoulder strengthening exercises with weights/theraband progressing as tolerated
  • Initiate “Thrower’s Ten” program
  • Modalities as needed

Criteria for Progression to Phase III

  • Full non-painful ROM
  • Good stability
  • Muscular strength, 4/5 or better
  • No pain or tenderness

Phase 3: Minimal Protection Phase (Weeks 14-20)

Goals:

  • Maintain full, non-painful AROM
  • Improve shoulder strength, power, and endurance
  • Improve neuromuscular control
  • Gradual return to functional activities

Early Minimal Protection Phase (Weeks 14-16)

  • Continue all stretching exercises (capsular strengthening)
  • Maintain thrower’s motion (especially external rotation)
  • Continue rotator cuff, shoulder, and periscapular strengthening exercises
  • Resisted PNF exercises
  • Endurance training
  • Initiate light plyometric exercises
  • Restricted sports actvities (light swimming, half golf swings)

Late Minimal Protection Phase (Weeks 16-206)

  • Continue all strengthening exercises
  • Continue all stretching and flexibility exercises
  • Continue “Thrower’s Ten” program
  • Continue plyometric program
  • Initiate interval sports program (e.g. throwing)

Criteria for Progression to Phase III

  • Full non-painful ROM
  • Satisfactory static stability
  • Muscular strength 75-80% of contralateral side
  • No pain or tenderness

Phase 4: Advanced Strengthening Phase (Weeks 14-20)

Goals:

  • Enhance shoulder strength, power, and endurance
  • Maintained shoulder stability
  • Progress functional activities

Weeks 20-26:

  • Continue flexibility exercises
  • Continue isometric strengthening exercises
  • PNF manual resistance patterns
  • Plyometric strengthening
  • Progress interval sports programs

Phase 5: Return to Activity Phase (Months 6-9)

Goals:

  • Gradually progress sports activities to unrestrictive participation
  • Continue strengthening and stretching program
 

Phase 1: Protective Phase (Weeks 0-6)

Goals:

  • Protect integrity of the repair
  • Decrease pain and inflammation
  • Gradually increase in ROM
  • Retard muscle atrophy

Precautions:

  • No active abduction or forward flexion
  • Patients are allowed to reach to their face but are instructed to avoid external rotation or reaching above their head.
  • Sling may be discontinued as pain permits

Exercises:

  • Pendulums
  • Self-PROM Flexion in Supine to a maximum of 90 degrees
  • Scapular Isometrics (primarily retraction)
  • Elbow, Wrist, Hand AROM
  • Modalities as needed

Phase 2: Intermediate Phase (Weeks 6-10)

Goals:

  • Decrease pain and inflammation
  • Restore full PROM and AROM
  • Gradual increase in strength

Precautions:

  • Patients are not allowed to lift weight above the shoulder
  • Patients should not lift > 5 pounds.

Early Intermediate Phase (Weeks 5-7)

  • Continue PROM as needed to achieve and maintain full ROM
  • Initiate AAROM exercises progressing to AROM as tolerated
  • Initiate gentle rhythmic stabilization exercises
  • Strengthening exercises for the hand, wrist, elbow, and scapular musculature
  • (Note: Biceps strengthening should be deferred until 8 weeks if patient underwent tenodesis)
  • Modalities as needed

Late Intermediate Phase (Weeks 8-10)

  • Continue PROM, AAROM, AROM to achieve and maintain full ROM
  • Continue distal Upper Extremity and scapular strengthening
  • Continue rhythmic stabilization
  • Initiate strengthening exercises with weights/theraband progressing as tolerated
  • Modalities as needed

Phase 3: Advanced Phase (Weeks 10-Discharge)

Goals:

  • Maintain full, non-painful AROM
  • Improve shoulder strengthening
  • Improve neuromuscular control
  • Gradual return to functional activities

Expectations:

  • 10-12 weeks – Patient should have achieved full active and passive range of motion
  • 12-16 weeks – Patients should be nearing normal strength and full range of motion

Early Advanced Phase (Weeks 10-12)

  • Continue and advance exercises above
  • General conditioning program

Late Advanced Phase (Weeks 12-Discharge)

  • Continue all strengthening exercises
  • Continue all flexibility exercises
  • Gradual progression of functional activities per patient needs

The intent of this protocol is to provide the clinician with guidelines of the postoperative rehabilitation of someone undergoing total shoulder arthroplasty or hemiarthroplasty. It is not intended to be a substitute for special instructions from Dr. Howard or clinical decision making regarding the progression of a patient’s postoperative course. The actual postsurgical physical therapy management must be based on surgical approach, physical exam/findings, individual progress, and/or the presence of postoperative complications. Please contact Dr. Howard with any questions.

Phase I: Immediate Post-Surgical Phase: Typically 0-4 weeks; 2 PT visits

Goals:

  • Allow healing of soft tissue
  • Maintain integrity of replaced joint
  • Gradually increase shoulder passive range of motion, restore elbow/wrist/ hand active range of motion
  • Reduce pain and inflammation
  • Reduce muscle inhibition
  • Independent with activities of daily living (ADLs) while maintaining integrity of replace joint

Precautions:

  • Sling should be worn for the first 7-10 days and then worn as needed for comfort
  • While lying supine, a small pillow or towel roll should be place behind the elbow to avoid shoulder hyperextension, anterior capsule stretch, or subscapularis stretch.
  • Avoid shoulder AROM into abduction or flexion past 90 degrees.
  • No lifting of objects
  • No internal rotation (IR) behind the back or resisted internal rotation
  • No supporting of body weight by hand on the involved side
  • No excessive stretching or sudden movements (especially into external rotation [ER])

Post-operative PT Visit #1: Typically 8-10 days post-operatively

  1. Supine passive forward flexion to 90 degrees (Hand to top of head)
  2. Passive IR to chest
  3. Active distal extremity exercises (elbow/wrist/hand)
  4. Pendulums
  5. Scapular sub-max isometrics (primarily retraction)
  6. Frequent cryotherapy for pain, swelling, and inflammation management
  7. Patient education regarding proper positioning and joint protection techniques.

Post-operative PT Visit #2: Typically 2-3 weeks post-operatively

  1. Continue previous exercises
  2. Passive ER to neutral with arm by side.
  3. Active-assisted exercises into flexion as tolerated – table slides to wall slides/walks
  4. Begin sub-maximal deltoid isometrics in neutral (avoid IR)
  5. Continue distal extremity AROM
  6. Continue PROM
  7. Continue cryotherapy as much as able for pain and inflammation management

Criteria for progression to the next phase:

  • Tolerates PROM program
  • Achieves at least 90 degrees of flexion
  • Achieves at least 0 degrees of external rotation
  • Achieves at least 70 degrees of internal rotation measured at 30 degrees abduction

Phase II: Early Strengthening Phase: Typically 4-6 weeks: 2-3x per week

Goals:

  • Restore full shoulder PROM
  • Gradually restore shoulder AROM
  • Control pain and inflammation
  • Allow continued healing of soft tissue
  • Re-establish dynamic shoulder stability

Precautions

  • While lying supine, a small pillow or towel roll should be place behind the elbow to avoid shoulder hyperextension, anterior capsule stretch, or subscapularis stretch.
  • In presence of poor shoulder mechanics, avoid repetitious shoulder AROM exercises/activity against gravity in standing.
  • No lifting of heavy objects objects (heavies than a coffee cup)
  • No supporting of body weight by hand on the involved side
  • No sudden jerking movements

Early Phase II: (typically 4-5 weeks)

  1. Continue with PROM/AAROM/Isometrics (slow progression of PROM into external rotation and abduction with arm externally rotated)
  2. Scapular strengthening
  3. AAROM pulleys flexion and abduction (as long as PROM >90 degrees)
  4. Begin assisted horizontal adduction
  5. Gentle glenohumeral and scapulohumeral mobilizations as indicated
  6. Initiate glenohumeral and scapulohumeral rhythmic stabalization
  7. Continue cryotherapy as much as able for pain and inflammation management

Late Phase II: (typically 6 weeks)

  1. Begin active flexion, internal rotation, external rotation, abduction in painfree range of motion
  2. Progress scapular strengthening
  3. Continue cryotherapy as much as able for pain and inflammation management

Criteria for progression to the next phase:

  • Tolerates PROM/AROM/isometric program
  • Achieves at least 140 degrees of flexion PROM
  • Achieves at least 120 degrees of abduction PROM
  • Achieves at least 60 degrees of external rotation PROM in plane of scapula
  • Achieves at least 70 degrees of internal rotation PROM measured in plan of scapula at 30 degrees abduction
  • Able to actively elevate the arm to 90 degrees with good mechanics in supine

Phase III: Moderate Strengthening Phase: Typically 6-12 weeks: 2-3x per week

Goals:

  • Restore shoulder AROM
  • Optimize neuromuscular control
  • Gradual return to functional activities with involved extremity

Precautions:

  • No heavy lifting of objects (> 5lbs)
  • No sudden lifting or pushing activities
  • No sudden jerking

Early Phase III: (typically 6-10 weeks)

  1. Continue PROM as needed to maintain ROM
  2. Advance PROM to stretching as appropriate (wand)
  3. Progress AROM exercises/activity as appropriate
  4. Initiate assisted shoulder internal rotation behind the back stretch
  5. Resisted shoulder internal and external rotation in scapular plane
  6. Begin light functional training
  7. Begin progressive supine active elevation strengthening (ant deltoid) with light weights (1-2lb) as tolerated
  8. Continued distal upper extremity strengthening and scapular strengthening

Late Phase III: (typically 10-12 weeks)

  1. Resisted flexion, abduction, extension (weights/theraband) in standing and/or prone
  2. Continue progressing internal and external rotation strengthening

Criteria for progression to the next phase:

  • Tolerates PROM/AROM/strengthening
  • Achieves at least 120 degrees of flexion AROM
  • Achieves at least 120 degrees of abduction AROM
  • Achieves at least 60 degrees of external rotation AROM in plane of scapula
  • Achieves at least 70 degrees of internal rotation AROM measured in plan of scapula at 30 degrees abduction

(Note: Patients that are rotator cuff deficint, goals and criteria must be more functionally based. Flexion and abduction should ideally be near 90 degrees with 30 degrees of external rotation and 70 degrees of internal rotation. Patient should be able to reach their hand to the top of their head to perform personal hygiene.)

Phase III: Advanced Strengthening Phase: Typically 10-12 weeks to MMI: 1x per week

Goals:

  • Maintain non-painful AROM
  • Enhance functional use of the upper extremity
  • Improve muscular strength, power, endurance
  • Gradual return to more advanced functional activities
  • Progress closed chain exercises as appropriate

Precautions

  • Avoid exercises that puts excessive stretch on anterior capsule (90-90 position)
  • Ensure gradual strengthening

Early Phase IV: Typically patients are on a HEP performed 3-4 days per week with PT progression 1 visit per week

  1. Gradually progressing strengthening program
  2. Gradual return to moderately challenging functional activities

Late Phase IV:

  1. Return to recreational hobbies including gardening, sports, golf, tennis

Criteria for discharge:

  • Maintain non-painful AROM
  • Maximized functional use of the upper extremity
  • Maximum strength, power, endurance
  • Return to activities/work

The intent of this protocol is to provide the clinician with guidelines of the postoperative rehabilitation of someone undergoing total shoulder arthroplasty or hemiarthroplasty. It is not intended to be a substitute for special instructions from Dr. Howard or clinical decision making regarding the progression of a patient’s postoperative course. The actual postsurgical physical therapy management must be based on surgical approach, physical exam/findings, individual progress, and/or the presence of postoperative complications. Please contact Dr. Howard with any questions.

Phase I: Immediate Post-Surgical Phase: Typically 0-4 weeks; 2 PT visits

Goals:

  • Allow healing of soft tissue
  • Maintain integrity of replaced joint
  • Gradually increase shoulder passive range of motion, restore elbow/wrist/ hand active range of motion
  • Reduce pain and inflammation
  • Reduce muscle inhibition
  • Independent with activities of daily living (ADLs) while maintaining integrity of replace joint

Precautions:

  • Sling should be worn for the first 7-10 days and then worn as needed for comfort
  • While lying supine, a small pillow or towel roll should be place behind the elbow to avoid shoulder hyperextension, anterior capsule stretch, or subscapularis stretch.
  • Avoid shoulder AROM into abduction or flexion past 90 degrees.
  • No lifting of objects
  • No internal rotation (IR) behind the back or resisted internal rotation
  • No supporting of body weight by hand on the involved side
  • No excessive stretching or sudden movements (especially into external rotation [ER])

Post-operative PT Visit #1: Typically 8-10 days post-operatively

  1. Supine passive forward flexion to 90 degrees (Hand to top of head)
  2. Passive IR to chest
  3. Active distal extremity exercises (elbow/wrist/hand)
  4. Pendulums
  5. Scapular sub-max isometrics (primarily retraction)
  6. Frequent cryotherapy for pain, swelling, and inflammation management
  7. Patient education regarding proper positioning and joint protection techniques.

Post-operative PT Visit #2: Typically 2-3 weeks post-operatively

  1. Continue previous exercises
  2. Passive ER to neutral with arm by side.
  3. Active-assisted exercises into flexion as tolerated – table slides to wall slides/walks
  4. Begin sub-maximal shoulder isometrics in neutral (avoid IR)
  5. Continue distal extremity AROM
  6. Continue PROM
  7. Continue cryotherapy as much as able for pain and inflammation management

Criteria for progression to the next phase:

  • Tolerates PROM program
  • Achieves at least 90 degrees of flexion
  • Achieves at least 0 degrees of external rotation
  • Achieves at least 70 degrees of internal rotation measured at 30 degrees abduction

Phase II: Early Strengthening Phase: Typically 4-6 weeks: 2-3x per week

Goals:

  • Restore full shoulder PROM
  • Gradually restore shoulder AROM
  • Control pain and inflammation
  • Allow continued healing of soft tissue
  • Re-establish dynamic shoulder stability

Precautions

  • While lying supine, a small pillow or towel roll should be place behind the elbow to avoid shoulder hyperextension, anterior capsule stretch, or subscapularis stretch.
  • In presence of poor shoulder mechanics, avoid repetitious shoulder AROM exercises/activity against gravity in standing.
  • No lifting of heavy objects objects (heavies than a coffee cup)
  • No supporting of body weight by hand on the involved side
  • No sudden jerking movements

Early Phase II: (typically 4-5 weeks)

  1. Continue with PROM/AAROM/Isometrics (slow progression of PROM into external rotation and abduction with arm externally rotated)
  2. Scapular strengthening
  3. AAROM pulleys flexion and abduction (as long as PROM >90 degrees)
  4. Begin assisted horizontal adduction
  5. Gentle glenohumeral and scapulohumeral mobilizations as indicated
  6. Initiate glenohumeral and scapulohumeral rhythmic stabalization
  7. Continue cryotherapy as much as able for pain and inflammation management

Late Phase II: (typically 6 weeks)

  1. Begin active flexion, internal rotation, external rotation, abduction in painfree range of motion
  2. Progress scapular strengthening
  3. Continue cryotherapy as much as able for pain and inflammation management

Criteria for progression to the next phase:

  • Tolerates PROM/AROM/isometric program
  • Achieves at least 140 degrees of flexion PROM
  • Achieves at least 120 degrees of abduction PROM
  • Achieves at least 60 degrees of external rotation PROM in plane of scapula
  • Achieves at least 70 degrees of internal rotation PROM measured in plan of scapula at 30 degrees abduction
  • Able to actively elevate the arm to 90 degrees with good mechanics in supine

Phase III: Moderate Strengthening Phase: Typically 6-12 weeks: 2-3x per week

Goals:

  • Restore shoulder AROM
  • Optimize neuromuscular control
  • Gradual return to functional activities with involved extremity

Precautions:

  • No heavy lifting of objects (> 5lbs)
  • No sudden lifting or pushing activities
  • No sudden jerking

Early Phase III: (typically 6-10 weeks)

  1. Continue PROM as needed to maintain ROM
  2. Advance PROM to stretching as appropriate (wand)
  3. Progress AROM exercises/activity as appropriate
  4. Initiate assisted shoulder internal rotation behind the back stretch
  5. Resisted shoulder internal and external rotation in scapular plane
  6. Begin light functional training
  7. Begin progressive supine active elevation strengthening (ant deltoid) with light weights (1-2lb) as tolerated
  8. Continued distal upper extremity strengthening and scapular strengthening

Late Phase III: (typically 10-12 weeks)

  1. Resisted flexion, abduction, extension (weights/theraband) in standing and/or prone
  2. Continue progressing internal and external rotation strengthening

Criteria for progression to the next phase:

  • Tolerates PROM/AROM/strengthening
  • Achieves at least 120 degrees of flexion AROM
  • Achieves at least 120 degrees of abduction AROM
  • Achieves at least 60 degrees of external rotation AROM in plane of scapula
  • Achieves at least 70 degrees of internal rotation AROM measured in plan of scapula at 30 degrees abduction

(Note: Patients that are rotator cuff deficint, goals and criteria must be more functionally based. Flexion and abduction should ideally be near 90 degrees with 30 degrees of external rotation and 70 degrees of internal rotation. Patient should be able to reach their hand to the top of their head to perform personal hygiene.)

Phase III: Advanced Strengthening Phase: Typically 10-12 weeks to MMI: 1x per week

Goals:

  • Maintain non-painful AROM
  • Enhance functional use of the upper extremity
  • Improve muscular strength, power, endurance
  • Gradual return to more advanced functional activities
  • Progress closed chain exercises as appropriate

Precautions

  • Avoid exercises that puts excessive stretch on anterior capsule (90-90 position)
  • Ensure gradual strengthening

Early Phase IV: Typically patients are on a HEP performed 3-4 days per week with PT progression 1 visit per week

  1. Gradually progressing strengthening program
  2. Gradual return to moderately challenging functional activities

Late Phase IV:

  1. Return to recreational hobbies including gardening, sports, golf, tennis

Criteria for discharge:

  • Maintain non-painful AROM
  • Maximized functional use of the upper extremity
  • Maximum strength, power, endurance
  • Return to activities/work