Rehab

The success of the ream and run depends on the patient's ability to achieve and maintain assisted forward flexion to 150 degrees within the first week or so after surgery. 

The surgeon and the patient need to decide if this goal can be achieved with home, patient-conducted exercise or if the assistance of a physical therapist is needed.

It is very important that the sugeon and patient remain in close contact, especially during the first six weeks so that any issues can be identified and addressed.

The first six weeks after surgery

Please note that the below is a general set of guidelines. Since shoulders, patients and surgical details differ, the postoperative rehab programs recommended by the surgeon may differ as well. Patients should ask their surgeons to prescribe their specific rehabiliation program.

The most important exercise is assisted forward flexion as shown below and in this video.

The contralateral arm provides the stretch while the operated arm relaxes. The stretch is to the point of tightness, but not pain. The stretch is held for a full minute with relaxed breathing and muscle relaxation. Sets of 3 repetitions are carried out 5 times a day. 

This video shows great stretching technique by a man two weeks after a ream and run. 

Patients are shown how to track and record their range of motion. The image below shows the target of 150 degrees. Note that the back is flat on the table and not arched.

The ultimate  goal is excellent flexion as shown below, but this motion should not be forced or uncomfortable, especially in the first six weeks after surgery, to avoid overstressing the subscapularis repair.

We ask patients to send us photos taken from this view frequently during the few weeks after surgery ("game time") so we can track their progress. Again, 150 degrees of assisted flexion is the target (see below). If the shoulder is not at this target, we consider a manipulation under anesthesia. In this outpatient procedure, the patient is given a brief anesthetic and muscle relaxant while the surgeon takes the shoulder through a full range of motion, breaking up any scar tissue that may have formed.

An alternative exercise for gaining forward flexion is the table slide as shown below and in this video . This exercise is particularly helpful when the opposite shoulder is not able to provide good support for the surgical arm or when the surgical arm is heavy.

The pulley exercise is a good warmup, but it is not nearly as effective of a forward flexion stretching exercise as the previous two because of the tendency to arch the back.

External rotatation is limited to zero degrees (the handshake position) for the first 6 weeks after surgery to protect the subscapularis repair. 

During the early phases of post surgical rehabilitation, it may feel as though the shoulder is "slipping" when the arm is raised up forward. This is addressed by external rotation isometrics to strengthen the muscles behind the shoulder so that they provide the needed support by creating an anteriorly directed force (green arrow). 

Several important precautions need to be observed for the first six weeks after surgery. These all relate to protecting the repair of the subscapularis tendon while it heals.

1) The patient should not attempt to lift the shoulder under its own power (i.e. without the assistance of the other arm).

2) The patient should not allow the arm to be externally rotated beyond the "hand shake" position.

3) The patient should not internally rotate the arm against resistance.

Walking is great as long as precautions are taken to avoid falls.

The second six weeks

At six weeks we typically add two groups of exercises: advanced stretching and gentle strenthening. We continue to protect the subscapularis by avoiding stretching in external rotation and strengthening in internal rotation.

Advanced stretching is directed at gaining flexibility of the posterior shoulder capsule using four different exercises. The stretches are carried out to the point of tightness, but not pain. Each stretch is held for a full minute with relaxed breathing and muscle relaxation. Sets of 3 repetitions are carried out 5 times a day. 

Cross body adduction. In this exercise the opposite shoulder assists the shoulder across the front of the body as shown below and in this video.

Sleeper stretch. While lying on the operated shoulder with the arm at a right angle with the body, the patient rotates the foream downward towards the table as shown below and in this video.

Up the back. Here the opposite arm uses a towel to pull the hand up the back as shown below and in this video.

Sideways lean. The arm is placed on a table to the side. The patient leans to the side gently pushing the shoulder down as shown below and in this video.

Gentle strengthening. Successful strengthening depends on (1) high repetitions, (2) low load, and (3) keeping it comfortable. The progressive press is the most important strengthening exercise. It is shown below and in this video. Patients advance from one stage to the next when the shoulder can do 20 repetitions comfortably. In stage A the hands are close to each other holding a cloth or stick. The starting position is on the chest. The hands press up to the ceiling allowing the opposite arm to help the operated arm as much as necessary. When this can be accomplished with 20 repetitions, the patient advances to stage B which is similar to A except that the hands are further apart, requiring the operated arm to work more independently. In stage C the operated arm presses up by itself, initially without weight and then while holding a one pound weight in the hand. When this can be accomplished 20 times, the patient sits partially upright on a pillow or wedge or in a recliner (stage D) while pressing the weight up to ceiling. The angle of inclination is gradually increased as the shoulder gets stronger. In stage E the patient presses the weight to the ceiling while sitting or standing upright. The goal is to advance from one stage to the next only as rapidly as 20 repetitions can be carried out comfortably.

Additional gentle strengthing excises can be added as comfort permits.

Shoulder shrug. A light weight is held in the hand with the arm at the side. The shoulder is shrugged upwards. 

Rowing

Lat pull downs

At 3 months after surgery, the patient can progessively return to their activities as comfort permits. It is important that flexibility is monitored and maintained. The goal is full motion. Stiffness can lead to a suboptimal result. 

We always encourage patients to photos or videos demonstrating their function, such as that shown below.