Arthroscopic  Shoulder  Anterior  Stabilisation  
 
                                                         PHYSIOTHERAPY  LED  POST  OPERATIVE  SHOULDER  CLINIC  
 
COMPILED  BY:  TENDAYI  MUTSOPOTSI  BSc.  HPT  (Hons)  MSc.  ORTHO-­‐MED  MCSP  MSOM  
   
                                                 
               APPROVED  BY:  MR  ANDREW  SANKEY  ORTHOPAEDIC  CONSULTANT  SURGEON  
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
  

 
 
Arthroscopic  Anterior  Stabilisation  (With  or  Without  Bankart  Repair)  
 
The purpose of this protocol is to provide the physiotherapist with a guideline for the post- operative
rehabilitation course of a patient that has undergone an Arthroscopic Anterior Stabilisation (With or
without Bankart repair). 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)

Please Note:

The arthroscopic Bankart repair progresses more conservatively than an open procedure due to fixation
methods that initially post-op may not be as stable. The protocol is divided into phases. Each phase is
adaptable based on the individual and special circumstances. Immediately post-operatively, exercises
must be modified so as not to place unnecessary stress of the anterior joint capsule of the shoulder.
Early passive range of motion is highly beneficial to enhance circulation within the joint to promote
healing. The overall goals of the surgical procedure and rehabilitation are to:
• Control pain and inflammation
• Regain normal upper extremity strength and endurance
• Regain normal shoulder range of motion
• Achieve the level of function based on the orthopedic and patient goals
The physical therapy should be initiated within the first week and one half to two full weeks post-op.
The supervised rehabilitation program is to be supplemented by a home fitness program where the
patient performs the given exercises at home or at a gym facility.

Important post-operative signs to monitor include:

Return to activity requires both time and clinical evaluation. To most safely and efficiently return to
normal or high level of functional activity, the patient requires adequate strength, flexibility, and
endurance. Functional evaluation including strength and range of motion testing is one method of
evaluating a patient’s readiness to return to activity. Return to intense activities following an
arthroscopic Bankart repair requires both a strenuous strengthening and range of motion program along
with a period of time to allow for tissue healing. Symptoms such as pain, swelling, or instability should
be monitored (advise patient accordingly).
 
 
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
  
PHASE  I:              (0-­‐2  WEEKS)  
 
Immediate  Post  Surgical  Phase:  (Day  1  to  2  weeks)  
 
Goals:    
•        Patient  Education  
• Immobilization  to  protect  repair    
•          Diminish  pain  and  inflammation    
 
Precautions:    
•  Remain  in  body  belt  (2-­‐3  weeks),  only  removing  for  showering  and  elbow/wrist  ROM    
•  No  PROM/  AROM  of  shoulder.  Can  do  ER  to  neutral  up  to  4  weeks  
•  No  lifting  of  objects  with  operative  shoulder  and  Keep  incisions  clean  and  dry    
 
Week  1-­‐3    
 
•  Body  belt  at  all  times    
•  PROM/AROM  elbow  and  wrist  only  +  Ball  squeezes  
•  Sleep  with  body  belt  supporting  operative  shoulder    
•  Shower  with  arm  held  at  your  side    
•  Cryotherapy  for  pain  and  inflammation    
•  Patient  education:  posture,  joint  protection,  positioning,  hygiene,  etc.    
•  Begin  isometrics  week  3    
 
PHASE  II:      (2-­‐6  WEEKS)  
 
Protection  Phase/PROM  (Week  4  and  5)  
   
Goals:    
•  Gradually  restore  PROM  of  shoulder    
•  Do  not  overstress  healing  tissue    
 
Precautions:    
• Follow  surgeon’s  specific  PROM  restrictions-­‐  primarily  for  external  rotation    
• No  lifting  and  No  PROM/stretching  of  the  anterior  capsule  in  the  90/90  positions.    
 
Criteria  for  progression  to  the  next  phase:    
 
•  Full  flexion  and  internal  rotation  PROM    
•  PROM  30  degrees  of  external  rotation  at  the  side    
 
 
 
 
 
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
  
Week  4-­‐5    
•  Continue  use  of  sling  and  Pendulum  exercises  
•  PROM:  Full  flexion,  Full  Internal  rotation,  and  External  rotation  to  30°  
•  Continue  cryotherapy  as  needed    
•  Continue  all  precautions  and  joint  protection  
 
PHASE  III:      (6-­‐12  Weeks)  
 
Intermediate  phase/AROM  (Week  6  and  7)  
 
Goals:    
• Continue  to  increase  external  rotation  PROM  gradually    
• Full  AROM  and  Independence  with  ADL’s    
 
Precautions:    
• Wean  from  Sling  and  No  lifting  with  affected  arm  
• Can  begin  gentle  external  rotation  stretching  in  the  90/90  (8  weeks)  
 
Week  6  and  7    
 
• AROM  of  shoulder  and  Progress  to  full  AROM  against  gravity      
• Begin  incorporating  more  aggressive  posterior  capsular  stretching    
• Cross  arm  stretch  and  Side  lying  internal  rotation  stretch    
• Posterior/inferior  gleno-­‐humeral  joint  mobilization    
• Begin  gentle  rhythmic  stabilization  techniques  for  rotator  cuff  musculature    
                           strength.  
 
 Week  8  –  Week  12  (Strengthening  Phase)    
 
Goals:    
• Continue  to  increase  external  rotation  PROM  gradually    
• Maintain  full  non-­‐painful  AROM    
• Improve  muscular  strength,  stability  and  endurance    
•  Gradual  return  to  full  functional  activities  
 
Precautions:    
• Be  sure  not  to  stress  the  anterior  capsule  with  aggressive  overhead  strengthening    
• Avoid  contact  sports/activities    
 
Week  8-­‐10    
 
•  Continue  stretching  and  PROM  and  Initiate  strengthening  program  (elastic  resistance)  
     ER/IR  with  elbow  at  the  side  of  the  body,  Forward  punch,  Seated  row  
•  Rhythmic  stabilization  exercises    
•  Initiate  strengthening  program  (elastic  resistance)    
   Shoulder  shrug,  Seated  row,  Bicep  curls,  Lat  pulls,  Triceps  extensions,  Push-­‐up  plus  
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
  
Week  10-­‐12    
 
•  Continue  all  exercises  listed  above  including  Continue  stretching  and  PROM    
•  Begin  gentle  strengthening  overhead,  avoiding  excessive  anterior  capsule  stress    
     ER/IR  in  the  90/90  positions,  D1/D2  flexion  and  extension  diagonals    
 
PHASE  IV:    
Return  to  activity  phase  (12-­‐20  WEEKS)  
 
Goal:    
• Increase  strength,  endurance  and  ROM  to  the  functional  level  required  by  the  patient.  
•  Gradual  return  to  strenuous  work  activities    
• Gradual  return  to  recreational  activities    
• Gradual  return  to  sports  activities    
 
Precautions:    
• Do  not  begin  throwing,  or  overhead  athletic  moves  until  4  months  post-­‐op    
• No  exercises/activities  that  increase  pain,  cause  apprehension  or  reinforce  abnormal  
muscle  patterning.  
• With  weight  lifting:    Avoid  wide  grip  bench  press  and  No  military  press  or  lat  pulls  behind  
the  head.  Be  sure  to  “always  see  your  elbows”  
 
Treatment  
 
Patient  education:  Encourage  paced  return  to  normal  activities  and  lifting;  encourage  normal  
movement  patterns  during  functional  activities;  advise  patients  of  ongoing  improvements  for  up  
to  one  year.  
 
Exercises:      
• Full  ROM  with  controlled  stretching  to  achieve  functional  range  if  necessary.  
• Advanced  scapula  stabiliser  and  rotator  cuff  rehabilitation  through  range  -­‐  include  speed  
and  ballistic  work  as  appropriate.  
• Kinetic  chain/balance  work  incorporating  core  stability  and  lower  limbs  as  needed.  
• Advanced  proprioceptive  work  –  include  PNF  to  regain  rotation  control  through  range  
• Functional  activities  –  review  functional  goals;  refer  to  Occupational  Therapy  if  needed.    
Ensure  sports  specific/work  specific  activities  retrained.    May  need  to  consider  graduated  
throwing  programme.  
• Can  begin  golf,  tennis  (no  serves  until  4  mo.),  etc.    
• Can  begin  weight  lifting  with  low  weight,  and  high  repetitions,  being  sure  to  follow  weight  
lifting  precautions.  
 
Activities:  Return  to  moderate  –  heavy  work.    May  need  to  modify  duties  if  requires  heavy  
overhead  work  (anterior  stabilisation)  or  heavy  pushing,  upper  limb  weight  bearing  (posterior  
stabilisation).    
 
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
  
Week  16-­‐20    
 
• May  initiate  interval  sports  program  if  appropriate    
• Swimming  –all  strokes.      
• Return  to  sports  e.g.  football,  golf,  racquet  sports,  and  martial  arts  at  6-­‐8  months.  
 
Returning to functional activities
 

Returning to Sedentary job: as tolerated Manual job: 3 months

Swimming Breaststroke: 6 weeks Freestyle: 12 weeks

Golf At least 3 Months

 
 
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.  
 
Milestones  for  discharge:  
 
1. Achieved  time  and  patient  specific  functional  goals.  
2. Achieved  90-­‐100%  of  contralateral  shoulder  active  ROM.  
3. Patient  has  a  negative  lag  sign  (i.e.  active  equals  passive  range)  with  dynamic  rotation  
control  at  0°  abd,  45°  abd,  90°  abd.    
4. Patient  has  no  apprehension  with  specific  movements  and  activities.  
 
Failure  to  meet  milestones:  
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
  
1. Refer  to/discuss  with  Shoulder  and  Elbow  Unit  
2. Consider  possible  reasons  for  failure  to  progress  and  act  accordingly  (see  below).  
3. Continue  with  outpatient  physiotherapy  while  patient  is  still  making  progress.  
 
Clinic  follow-­‐up  schedule:  2,  6,  12,  and  16-­‐24  weeks  (only  if  necessary)  
 
 
Failure  to  progress  
 
If  a  patient  is  failing  to  progress,  then  consider  the  following:  
 
Possible  problem   Action    
Pain  inhibition   • 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    
Patient  exercising  too  vigorously   • Increase  or  reduce  physiotherapy/    
Patient  not  doing  home  exercise   (HEP)  (max  2-­‐4x/day)  for  few    
programme  (HEP)  regularly  enough   days/weeks  and  assess  difference    
• Ensure  HEP  focuses  on  key    
exercises  and  link  to  function    
Returned  to  activities  too  soon   Decrease  activity  intensity    
Cervical/thoracic  pain  referral   Assess  and  treat  accordingly    
 
Unable  to  gain  strength   Passive  ROM  may  need  improving    
 
Altered  neuropathodynamics   Assess  and  treat  accordingly  
 
Poor  rotator  cuff  control   • 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    
Poor  scapula  control   Work  on  scapula  stability  through    
range  without  fixing  with  pec    
major/lat  dorsi    
Poor  core  stability   Work  on  improving  core  stability    
Secondary  frozen  shoulder     • Maintain  passive  ROM  as  able    
• Use  physiological  and  accessory    
             mobilisations,  taking  into  account    
             end  feel  and  tissue  healing  times    
 
It  is  essential  you  contact  us  if  you  have  any  concerns.      
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
THE SHOULDER UNIT TEAM
 
Shoulder Consultant: Mr. Andrew Sankey 0208 746 8545
Shoulder Therapist: Mr. Tendayi Mutsopotsi 0208 746 8404
Secretary: 0208 746 8545
 
 

Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)