PHYSIOTHERAPY  LED  POST  OPERATIVE  SHOULDER  CLINIC    

                                                   APPROVED  BY:  MR  ANDREW  SANKEY  ORTHOPAEDIC  CONSULTANT  SURGEON  


Weaver-­‐Dunn  Rehabilitation  Protocol  2010        Tendayi  Mutsopotsi  (Shoulder  Physiotherapist)  

  Weaver-­‐Dunn  Post-­‐Operative  Rehabilitation  Protocol    


  The purpose of this protocol is to provide the physiotherapist with a guideline for the postoperative rehabilitation course of a patient that has undergone and acromioclavicular joint stabilization following a dislocation. It is not intended to be a substitute for appropriate clinical decision-making regarding the progression of a patient’s post-operative course. The actual post surgical physiotherapy management must be based on the surgical approach, physical examination/findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist requires assistance in the progression of a post-operative patient they should consult with Mr. Andrew Sankey (Shoulder Consultant) or Mr. Tendayi Mutsopotsi (Specialist Shoulder Therapist)
Procedure Usually done as an open procedure where the dislocation is reduced. The coraco-acromial ligament is detached from the acromion and grafted into lateral end of the clavicle. The graft is protected in the early stages sutures passing over the clavicle attached to anchors in the coracoid. The patient may experience a small pop when the sutures give in at about 6 weeks. Please Note: graft is vulnerable to stretching between 6 and 12 weeks and will regain its maximum strength around 36 weeks post procedure. Goals • Regain FROM • Achieve good static and dynamic scapula control

Precautions   • Avoid  caudal  and  axial  loading   • Sling  maintained  for  about  6weeks     Day  1   • No  active  or  passive  shoulder  mobilization   • Home  cryotherapy  advice   • Commence  scapula  setting  and  postural  input  (forms  mainstay  of  rehabilitation)   • Advise  re  use  of  sling  and  pendular  positioning  for  washing  under  arm  only,  not  as   an  exercise   • Fold  arms,  rest  on  pillow/arm  chair  while  in  sling  if  positioning  the  arm  in  order  to   unload  the  ACJ  and  shoulder  girdle   • Emphasise  re  protection  of  the  graft  i.e.  avoiding  loading  for  12  weeks   • Commence  re  cervical,  elbow,  wrist  and  hand  exercises  

Weaver-­‐Dunn  Rehabilitation  Protocol  2010        Tendayi  Mutsopotsi  (Shoulder  Physiotherapist)  

Week 1 • • • • • • Continue protection in immobilizer or sling Patient out of immobilization for elbow, wrist and hand exercises Putty exercises May begin gentle Codman’s exercises May begin bicep/triceps isometrics May begin PROM to pt. tolerance

    Week  2   • Check  wound  and  remove  sutures   • Continue sling   • Continue Codman’s exercises   • Continue PROM   • May add light weight to hand and wrist   • May do weighted elbow exercises if supported   • May begin AAROM     Week  3   • Continue  AAROM  and  PROM  in  comfort  range   • May  begin  AROM   • Start  low  level  isometric  cuff     Week  4-­‐6   • May  discontinue  sling  and  emphasize  importance  of  posture   • AA  Flexion  in  supine  to  90°   • AA  External  rotation  in  supine   • Progress  scapula  exercises     Precautions   • Avoid  HBB  and  axial  loading  e.g.  carrying  shopping     Week  8   • Progress  to  FAROM  in  supine  and  90°  in  standing   • Start  phase  I  &  II  hands  behind  back   • Start  hands  behind  head   • Progress  scapula  control  and  strengthening   • Continue  being  cautious  about  axial  loading  to  protect  repair            

Weaver-­‐Dunn  Rehabilitation  Protocol  2010        Tendayi  Mutsopotsi  (Shoulder  Physiotherapist)  

Week  12   •  Start  Phase  III  and  FAROM  in  standing           Guidelines  to  return  to  activity     • Driving                                        8  weeks  to  stress  on  the  repair   • Work                                              2  weeks  (if  able  to  work  in  sling)   • Manual  labour          16-­‐24  weeks   • Non  contact  sport              24  weeks   • Contact  sport                              36  weeks     Milestone  driven     These  are  milestone  driven  guidelines  designed  to  provide  an  equitable  rehabilitation   service  to  all  of  our  patients.  They  will  also  limit  unnecessary  visits  to  the  outpatient  clinic   here  at  Chelsea  &  Westminster  by  helping  the  patient  and  therapist  to  identify  when   specialist  review  is  required.       If  patients  are  progressing  satisfactorily  and  meeting  milestones,  there  is  no  need  for  them   to  attend  clinic  routinely.         Failure  to  progress  or  variations  from  the  norm  should  be  the  main  reason  for  clinic   attendance.  Both  patients  and  therapists  can  book  clinic  visits  by  contacting  the  numbers   given  further  on  in  this  document.     Clinic  follow-­‐up  schedule  post-­‐op:      2weeks                                                                                                                                            6weeks                                                                                                                                          12  weeks                                                                                                                                          16-­‐24  weeks  (only  if  necessary)                            

Weaver-­‐Dunn  Rehabilitation  Protocol  2010        Tendayi  Mutsopotsi  (Shoulder  Physiotherapist)  

Failure  to  progress     If  a  patient  is  failing  to  progress,  then  consider  the  following:   Possible  problem   Pain  inhibition   Action   • Adequate  analgesia   • Keep  exercises  pain-­‐free   • Return  to  passive  ROM  if  necessary   until  pain  controlled   • Progressing  too  quickly  –  hold  back   • If  severe  night  pain/resting  pain  –   refer  to  Shoulder  Unit   • Increase  or  reduce  physiotherapy/   (HEP)  (max  2-­‐4x/day)  for  few   days/weeks  and  assess  difference   • Ensure  HEP  focuses  on  key   exercises  and  link  to  function   Decrease  activity  intensity   Assess  and  treat  accordingly   Passive  ROM  may  need  improving     Assess  and  treat  accordingly   • Ensure  passive  range  gained  first   • Consider  isometrics  through  range   • Rotation  dissociation  through  range   with  decreasing  support  and   increasing  resistance   • Ensure  not  progressing  through   Therabands  too  quickly   Work  on  scapula  stability  through   range  without  fixing  with  pec   major/lat  dorsi   Work  on  improving  core  stability   • Maintain  passive  ROM  as  able   • Use  physiological  and  accessory                mobilisations,  taking  into  account   end  feel  and  tissue  healing  times   Injection  can  be  useful     Please  contact  Mr.  Sankey  or   myself  immediately                                                                                

Patient  exercising  too  vigorously   Patient  not  doing  home  exercise   programme  (HEP)  regularly  enough  

Returned  to  activities  too  soon   Cervical/thoracic  pain  referral   Unable  to  gain  strength   Altered  neuropathodynamics   Poor  rotator  cuff  control  

Poor  scapula  control   Poor  core  stability   Secondary  frozen  shoulder      

Subacromial  Bursitis   Infection  

Also  consider  possible  complications  noted  previously         Weaver-­‐Dunn  Rehabilitation  Protocol  2010        Tendayi  Mutsopotsi  (Shoulder  Physiotherapist)  

    It  is  essential  you  contact  us  if  you  have  any  concerns:   THE SHOULDER TEAM   Mr.  Andrew  Sankey    (Shoulder  Consultant  Surgeon)                                              020  8746  8545   Tendayi  Mutsopotsi  (Specialist  Shoulder  Therapist)     020  87468404   Mr.  Austin  Navin  (Secretary)                                                                                                                                      020  8746  8545      

Weaver-­‐Dunn  Rehabilitation  Protocol  2010        Tendayi  Mutsopotsi  (Shoulder  Physiotherapist)  

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