Rehabilitation Protocol After Shoulder Arthroscopy
Immediate Post-Operative Pain Management (First Priority)
Your post-arthroscopic shoulder rehabilitation must begin with aggressive multimodal pain control, as effective pain management directly impacts early rehabilitation participation and long-term functional outcomes. 1
Pharmacological Foundation (Start Pre-operatively or Intra-operatively)
- Paracetamol (acetaminophen) scheduled dosing - continue throughout the post-operative period 1
- NSAIDs or COX-2 inhibitors scheduled dosing - continue post-operatively unless contraindicated 1
- Intravenous dexamethasone single dose - prolongs nerve block duration, reduces analgesic requirements, and provides anti-emetic effects 1
- Reserve opioids strictly for rescue analgesia only - not as scheduled medication 1
Regional Anesthesia (Critical for Initial Pain Control)
- Interscalene brachial plexus block is the first-choice regional technique - either single-shot or continuous infusion provides superior pain control 1, 2
- Alternative: Suprascapular nerve block with or without axillary nerve block - use only if interscalene block is contraindicated or not feasible 1
- Do NOT use subacromial injections/infusions - evidence is inconsistent and does not support routine use 1
Critical Pitfall: Inadequate pain control in the first 48-72 hours will significantly impair patient participation in early mobilization exercises and compromise rehabilitation outcomes. 1
Immobilization Phase (Weeks 0-2)
Strict immobilization for 2 weeks post-operatively protects the healing rotator cuff repair. 3
- Complete shoulder immobilization in a sling for the first 2 weeks 3
- No active or passive range of motion exercises during this period 3
- Continue scheduled paracetamol and NSAIDs for pain control 1
- Apply cryotherapy in the first post-operative week for pain and swelling reduction 4
Protected Passive Range of Motion Phase (Weeks 2-6)
Begin staged introduction of protected passive range of motion at week 2, progressing gradually based on tissue healing and pain response. 3
Range of Motion Protocol
- Gentle passive range of motion exercises only - no active motion yet 3
- Focus specifically on external rotation and abduction to prevent adhesive capsulitis 1, 4, 5
- Perform exercises within pain-free range - avoid forcing motion 1, 4
- Gradually increase motion in conjunction with restoring proper joint alignment 1, 4, 5
Critical Restrictions
- NEVER use overhead pulleys - they encourage uncontrolled abduction and can disrupt the repair 4, 5
- Avoid aggressive passive stretching - can exacerbate pain and delay healing 4, 5
- Continue sling use between exercise sessions for protection 3
Adjunctive Therapies
- Apply local heat before exercise sessions for symptomatic relief 5
- Consider TENS (transcutaneous electrical nerve stimulation) - may reduce pain scores at 12 hours and day 7 post-operatively 1, 5
Active Range of Motion Phase (Weeks 6-12)
Transition to active range of motion exercises once passive motion is restored and pain is well-controlled. 3
- Begin active-assisted range of motion exercises progressing to full active motion 3
- Continue emphasis on external rotation and abduction 1, 4, 5
- Strengthen weak muscles in the shoulder girdle including scapular stabilizers 1, 4
- Re-establish proper mechanics of shoulder and spine 4
- Discontinue sling use once active motion is adequate 3
Common Pitfall: Patients often attempt to progress too quickly during this phase. Ensure pain-free motion is achieved before advancing to strengthening exercises. 4
Progressive Strengthening Phase (Week 12 Onward)
Begin progressive strengthening at 12 weeks post-operatively, focusing on rotator cuff and scapular stabilizer muscles. 3
Strengthening Protocol
- Rotator cuff strengthening exercises - gradual progressive resistance 3
- Scapular stabilizer strengthening 4
- Dynamic stabilization exercises 4
- Core and lumbopelvic strengthening as part of kinetic chain rehabilitation 4
Advanced Rehabilitation Options
- Functional dynamic orthoses may facilitate repetitive task-specific training 1, 4
- Neuromuscular electrical stimulation (NMES) can be considered for persistent weakness 1, 4, 5
- Repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) may be used as adjuncts 1, 4
Return to Activity Criteria
Do not return to normal activities until achieving pain-free motion and adequate strength. 4
- Pain-free active range of motion in all planes 4
- Adequate rotator cuff and scapular stabilizer strength 4
- Restoration of proper shoulder mechanics 4
- Duration typically 4-6 months depending on tear size and tissue quality 3
Critical Pitfall: Returning to activity too soon before adequate healing and strengthening leads to chronic pain, dysfunction, and potential re-tear. 4
Management of Persistent Pain Beyond Expected Timeline
If pain persists beyond 3 months despite appropriate rehabilitation:
- Re-evaluate for complications: adhesive capsulitis, complex regional pain syndrome (CRPS), or repair failure 1, 4, 5
- Assess for CRPS signs: edema, trophic skin changes, hyperaesthesia, limited range of motion 1, 5
- Consider subacromial corticosteroid injection if pain is related to bursal inflammation 1, 4, 5
- Consider botulinum toxin injections into subscapularis and pectoralis if pain is related to spasticity 1, 4, 5
- Trial oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) for CRPS 1, 5
- Obtain MRI to evaluate repair integrity if conservative measures fail 4