Phase 1 Goals: This phase focuses on diminishing pain, promoting limited joint motion to prevent the negative effects of immobilization while protecting the repair, and promoting recruitment of the shoulder musculature.

Week 0-2

• Sling for 4 weeks; sleep in sling for 4 weeks (come out for HEP 2-3 x day)
• Continuous use of cryotherapy/modalities for pain and swelling control
• Wrist and hand ROM/hand gripping exercises
• Submaximal, subpainful deltoid and RC isometrics all directions
• Passive and gentle AAROM exercise in supine
  • Flexion to 60-75° week 1; to 90° week 2
  • Abduction forward of scapular plane to 60°
  • ER to 10°-15° in scapular plane
  • IR to 45° in scapular plane
  • No active Extension, Abduction or ER

Precautions: NO Biceps contractions/elbow flexion exercises 
No rotating the arm outward or holding objects in the hand over 2 lbs.

Week 3-4

• Discontinue sling at 4 weeks
• Continue gentle PROM and AAROM exercises
  • Flexion to 110°
  • Abduction 75°-85°
  • ER in scapular plane to 25°-30°
  • IR in scapular plane to 55°-60°
• Initiate rhythmic stabilization drills and proprioception training
• Continue isometrics and cryotherapy
• Scar massage at week 4 based on patients’ tolerance and tissue healing constraints

Precautions: NO Biceps strengthening or holding objects in hand over 2 lbs. 
No active extension or elevation, limit ER to restrictions

Week 5-6

• Gradually improve ROM
  • Flexion to 145°
  • ER at 45° abduction: 45-50°
  • IR at 45° abduction: 55-60°
• May initiate gentle IR/ER RANGE OF MOTION at 90° abducted position (in scapular plane)
• Initiate tubing IR/ER, start tubing row to 0°
• PNF light manual resistance
• Initiate active shoulder abduction
• Initiate prone row, prone extension to 0°, and prone horizontal abduction

Precautions: NO Biceps Strengthening

Phase 2 Goals: This phase focuses on restoring full ROM (week 10), preserve the integrity of the repair, restore muscular strength and balance, and normalize joint Kinematics.

Week 7-9

• Gradually progress ROM
  • Flexion to 180°
  • Horizontal abduction at 120°
  • ER to 90° abduction: 90-95°
  • IR at 60° abduction: 55-70°
• Continue to progress isotonic strengthening program
• Start light biceps work against gravity only with light resistance added over 6 weeks
• Initiate Throwers Ten Program (except 90/90 ex.)

Week 10-12

• Initiate slightly more aggressive strengthening
  • Mod/high velocity IR/ER isokinetics at modified neutral
• Progress ER to throwers motion (depends on individual)
  • ER at 90° abduction to 100-110°
• Continue stretching (emphasis on horizontal adduction, IR) and capsular stretches

Phase 3 Goals: This phase focuses on establishing and maintaining full ROM, improving muscular strength, power and endurance and gradually incorporate functional activities.

Week 12-14

• Initiate strengthening in 90/90 position
  • Prone LR, tubing MR, tubing LR, etc.
• Initiate bilateral plyometrics program (plyoballs, two handed throwbacks, etc)

Week 14-16

• Continue capsular stretching
• Maintain throwers motion (especially ER)
• Continue strengthening exercises
  • Throwers Ten Program
  • PNF manual resistance
  • Endurance Training (UBE, Bodyblade)
  • Initiate Unilateral plyometrics program (ball on wall, plyoball throwbacks, etc)
• Restricted sport activity (light swimming, half golf swings)

Week 16-20

• Continue to progress strengthening
  • Low/Mod IR/ER isokinetics at modified neutral
  • Mod/High IR/ER isokinetics at 90/90 abduction
• Continue manual resistance exercises
• Continue Throwers Ten and other shoulder strengthening exercises
• Continue Plyometric Program
• Initiate Interval Sport Program (i.e. Interval Throwing Program)

Phase 4 Goals: This phase focuses on enhancing muscular strength, power and endurance, progressing functional activities, and maintaining shoulder mobility.

Weeks 20-26

• Continue strengthening program with emphasis on power (isotonic, manuals, isokinetics)
• Continue flexibility exercises
• Progress interval sport program

Phase 5 Goals: This phase incorporates a gradual return to sport activities, maintaining full strength, mobility, and stability of the shoulder.

Month 6-9

• Gradually progress sport activities to unrestrictive participation
• Mound throwing program initiated at 26 weeks (6 months/2 weeks)
• Continue with comprehensive posterior shoulder stretching
• Continue with comprehensive RC/shoulder strengthening maintenance program