Phase I - Control Inflammation (1-2 days) Goals: Control Inflammation and Pain Reduce Swelling Rehab: 1) Cryotherapy a:Ice for 20 minutes 2) Modalities a:Interferential Stim (can be used with ice at the same time) 3) NSAIDS a:Ibuprofen/Advil - 4 times a day for 3 days (only if no allergies) Phase II - Restore Range of Motion (2-7 days) Goals: Passive and active range motion is within 80% of normal in the unaffected arm Joint Flexibility in affected limb is restored Cardiovascular Endurance is maintained at preinjury level Range of Motion exercises performed pain free Rehab: 1) Heat Therapy a: Hot pack for 20 minutes 2) Modalities a: Pulsed ultrasound for 5 minutes 3) Flexibility Exercises a: Hold involved arm across chest at the involved elbow, pushing slightly posterior until a stretch is felt b: Hold sides of a doorway with hand behind you. Let arms straighten as you lean forward. Repeat with hands in front of you as you lean backward. 4) Codman's Exercises without a Free Weight a: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table with the involved arm dangling in front of you. b: Stabilize the scapula with a belt by wrapping it around the upper body and scapula. c: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging motion, going forwards and backwards, side to side, and in circles. 5) Wall Crawls (Flexion and abduction) a: Place hand on wall and have fingers crawl up the wall until end of range of motion. Repeat going down the wall. b: Start by facing a wall, repeat exercise again by facing sideways to the wall 6) Shoulder Wheel a: Place hand on grip of shoulder wheel and move wheel around until maximal range of motion is reached. Repeat going the opposite way. 7) Pulley a: Place hands on both ends of pulley and have the affected limb pull downward. Repeat again with unaffected limb pulling downward. 8) Cane Exercises a: Shoulder flexion - hold cane with hands palm down at waist height. Raise the cane to 90 degrees, leading with the uninvolved arm until a stretch is felt in the involved shoulder. b: Shoulder abduction - hold cane with involved arm palm up, uninvolved arm palm down. Push cane sideways and upward toward the involved side with the uninvolved arm until a stretch is felt in involved shouler. c: Shoulder adduction - reverse hand positions from the previous exercise. Pull the cane toward uninvolved side until a stretch is felt in the involved shoulder. d: Shoulder internal/external rotation - keep hands on ends of the cane, elbows flexed at 90 degrees. Keep elbows at your side while keeping upper arms still. Move the cane side to side using only the forearms. 9) Cardiovascular Endurance a: Bike for 20 minutes 10) Cryotherapy a: Ice after for 20 minutes Phase III - Strength Training (1-3 weeks) Goals: Range of motion and flexibility of affected arm equals unaffected arm Muscular strength is equal between affected and unaffected arm Cardiovascular endurance maintained at preinjury level Range of motion and strength exercises performed without pain Mobility upon stability Rehab: 1) Heat Therapy/Flexibility a: Continue heat and ultrasound therapy b: Continue flexibility exercises 2) Scapular Stabilizations / Strengthening a: Depression - minidips or provide manual resistance while the athlete pushes pushes his fist towards the ground b: Elevation - shoulder shrugs either against manual resistance or while holding a weight c: Protraction - manual resistance while the athlete rolls his shoulders towards the front d: Retraction - rows 3) Isometric Resistance a: Stay below 90 degrees, and pain-free ROM b: In each of the following positions, push your fist against a wall, desk, or any other stationary item every 15 degrees throughout the range of motion. * Push arm straight up in front of you * Push arm straight out to the side c: With elbow flexed at 90 degrees, push the outside of your fist against a wall every 15 degrees up to 45/50 degrees, and do the same with the inside of the fist 4) Codman's Exercises * Progress through free weights as tolerated (pain-free) a: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table with the involved arm dangling in front of you. b: Stabilize the scapula with a belt by wrapping it around the upper body and scapula. c: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging motion, going forwards and backwards, side to side, and in circles. 5) Theraband a: Flexion - Grip theraband in front of you with the elbow extended. Pull theraband upward until maximal range of motion is reached and lower downward. b: Extension - Start in same position as flexion. Pull theraband backward until maximal range of motion is reached and bring back to starting position. c: Internal Rotation - Stand in front of theraband board with affected arm facing it. Rotate arm inward across body while gripping the unattached end of theraband. d: External Rotation - Stand in front of theraband board with unaffected arm facing it. Rotate arm outward away from the body while gripping the unattached end of theraband. e: Abduction - Stand in front of codman with affected arm facing it. Start with arm across the body and pull away from side. f: Adduction - Stand in front of codman with affected arm facing it. Grab the theraband and pull arm toward the buttocks. g: Horizontal Abduction - Stand in front of theraband board with unaffected arm facing it. Bring shoulder up to 90 degrees of flexion so that it is parallel to the floor. Pull arm across body toward the opposite shoulder. h: Horizontal Adduction - Stand in front of theraband board with affected arm facing it. Bring shoulder to 90 degrees of flexion so that it is parallel to the floor. Pull arm across body towards the opposite shoulder. i: As strength is gained, progress up to different colors of tubing. 6) Proprioception (Cat Stretch-Starting Position) a: Start in a non-weight bearing position (knees flexed) on a floor b: As patient gains strength, incorporate the following progressions: (1) Body movement - static (still) to dynamic (moving) (2) Amount of arms involved - bilateral (2 arms) to unilateral (1 arm) (3) Surface - stable (floor or wall) to unstable (single and multiplane boards) c: Perform 3-5 stances, holding 15-20 seconds 7) Open Kinetic Chain Exercises a: Weight Training (Starting position - place weight in affected hand) (1) Flexion: Bring it forward and towards the ceiling until maximal range of motion is reached. Lower downward. (2) Extension: Bring weight backward towards the ceiling until maximal range of motion is reached. Lower downward. (3) Abduction/Adduction: Raise weight to the side until maximal range of motion is reached. Lower downward and continue to lift towards the other side. Lower down to starting position. (4) Horizontal Abduction/Horizontal Adduction: Lift weight up to 90 degrees of flexion. Bring the weight in front of you towards the other shoulder. Continue in the opposite direction towards the side until maximal range of motion is reached. Bring weight back to starting position. (5) Internal/External Rotation: Flex elbow of effected limb and bring it close to the side of the body near the waist line. Bring weight in towards the stomach and continue into the opposite direction until maximal range of motion is reached. 8) Closed Kinetic Chain Exercises a: Wall Presses (push ups against a wall) b: Standing Shoulder Flexion/Extension (1) Stand with hands shoulder width apart on a chair. Rock forward over hands and back. 9) Cardiovascular Endurance a: Bike or stairmaster for 30 minutes 10) Cryotherapy a: Ice for 20 minutes Phase IV - Return to Activity (approx 14 days) Goals: Normal function and sports specific patterns restored to injured extremity Muscular strength, endurance, and power in affected arm is equal to unaffected arm Normal coordination and balance Cardiovascular endurance is equal to preinjury level 1) Heat therapy/modalities a: Continue head therapy, ultrasound, and flexibility 2) Strength exercises a: Perform all exercises with minimal or no pain 3) Sports Specific Exercises a: Baseball/softball - perform overhand throwing b: Football - throw a spiral, catch a throw (depending on position) c: Volleyball/tennis - perform a serve d: Soccer - practice a throw in e: Basketball - practice shooting and passing drills 4) Taping/Padding a: Make an orthroplast pad to prevent further injury and hold in place with an ace wrap 5) Cryotherapy a: Ice for 20 minutes
