South Shore - Protocols - PDF-A - 05.05.2019

South Shore - Orthopedics
https://www.southshoreorthopedics.com/resources/rehab-protocols/#1482259836303-b1653919-dc3a
Bankart Repair
Rotator Cuff Impingement
Rotator Cuff Repair
Shoulder
Sub-Acromial Decompression
Total Shoulder Replacement
vSLAP Repair
ACL Prevention Program
ACL Non-Operative Management
ACL Reconstruction
Knee
Partial Meniscectomy
Patellofemoral-Chondromalacia
Quad Patella Tendon Repair
Total Knee Replacement
Hip Arthritis
Hip Hip Bursitis-Tendinitis
Iliotibial Band Pain
Total Hip Replacement
Ankle Sprain
Foot and Ankle
High Ankle Sprain
Plantar Fasciitis
Spine Cervical Radiculopathy
Lumbar Disc Herniation
Concussion Post-Concussion Syndrome
Bankart Repair Protocol
Anatomy and Biomechanics
The shoulder is a wonderfully complex joint that is made up of the ball
and socket connection between the humerus (ball) and the glenoid
portion of the scapula (socket). The socket portion of the joint is not
naturally deep. For this reason the shoulder is the most mobile joint in
the body. Due to the lack of boney coverage the shoulder’s proper
function and stability is largely dependent on the soft tissues that
surround it.
The glenoid labrum is a fibrocartilage rim that surrounds the edge of the
glenoid fossa (socket). It serves to deepen the socket and provide a suction effect on the head of the
humerus (ball), thus improving the stability of the naturally shallow joint. The labrum can be damaged
or torn in many different ways. When the shoulder is traumatically or repetitively dislocated, the front
(anterior) part of the labrum is often torn. This is called a Bankart tear and may or may not be
accompanied by damage to the head of the humerus as it dislocates.
Treatment Options
Regardless of how the labrum is torn your physician will work with you to
determine what the best course of treatment will be. In many cases the
pain and dysfunction associated with a Bankart tear can be successfully
treated with rest, anti-inflammatory measures, activity modification and
Physical Therapy. When conservative measures are unsuccessful in
restoring function you and your physician may elect to have the torn labrum
repaired.
Surgery
Labral repair surgery involves re-anchoring and suturing or trimming away the
torn piece of cartilage. The procedure is usually performed arthroscopically
and is, in most cases an outpatient day surgery procedure. This means that it
is very rare to have to spend the night in the hospital. If damage to the labrum
or other tissue is extensive your surgeon may have to use an open incision
rather than an arthroscope to complete the procedure. Regardless, of
whether the procedure is open or arthroscopic all patients will likely be home
on the same day as surgery.
South Shore Hospital Orthopedic, Spine and Sports Therapy Page 1

in Clinical Collaboration with South Shore Orthopedics
Recovery/Time off Work
Recovering from labral repair surgery is not easy. It is very important that the patient knows that the
recovery process is difficult and time consuming. He or she must be an active participant during this
process, performing daily exercises to ensure there is proper return of range of motion and strength.
There is a large amount of variability in the time it takes to fully recover from this procedure. It is
usually estimated that it will take at least 4-6 months to feel as though you have completely regained
the use of your arm. Some cases may take as long as 9-12 months to make a full recovery. People with
desk jobs should plan to take at least 1 week off from work. Those with jobs that require physical
activity and lifting will likely be out of work for at least 4-6 months. Recovery is different in each case.
Your individual time table for return to activities and work will be discussed by your surgeon during post
operative office visits.
Post Operative Visits

Your first post-op visit to the doctor’s office will be approximately 7-10 days after the operation. At this
visit your stitches will be removed and you will review the surgery with the doctor or his or her physician
assistant. At this time you will most likely be cleared to make an appointment to begin Physical Therapy.
You should also plan to check in with your surgeon at 6, 12, and 24 weeks after the operation.
At Home
You may remove your post-op dressing 2 days after the operation and replace it as needed. Do not
remove the strips of tape (steri-strips) that are across your incision. Allow them to fall off on their own.
You may shower after 2 days, but use a water-tight dressing until your sutures are removed. Bathing
without getting the shoulder wet or sponge baths are a good alternative. You may wash under the
affected arm by leaning forward and letting the arm dangle. Do not attempt to actively move your arm
at the shoulder joint for any reason until your doctor allows you. You may remove your sling several
times a day and gently move your hand, wrist and elbow and perform shoulder pendulum exercises.
Medication
Your surgeon will prescribe pain medicine for you after the operation. Please call the doctor’s office if
you have any questions regarding medication.
Ice
You must use ice on your shoulder after the operation for management of pain and swelling. Ice should
be applied 3-5 times a day for 10-20 minutes at a time. Always maintain one layer between ice and the
skin. Putting a pillow case over your ice pack works well for this.
Sling
You will be provided with a sling to wear after the operation. You should wear this sling most of the
time for at least the first 2 weeks after the operation. Remove it when bathing/showering, or to do your
exercises. It is recommended that you continue to sleep in the sling and wear it when you are out in a

crowd for the first 4 weeks after the operation. If your case is atypical your doctor may have custom
guidelines for you regarding use of the sling.
Sleeping
You may sleep with a pillow propped under your arm to keep it slightly away from the body. For many
patients lying flat is uncomfortable at first. It is generally easier to sleep propped up or in a recliner for a
short period of time after the operation. Do not attempt to sleep on your operated shoulder for at least
6 weeks.

Rehabilitation
**The following is an outlined progression for rehab. Time tables are approximate and advancement
from phase to phase as well as specific exercises performed should be based on each individual
patient’s case and sound clinical judgment by the rehab professional. **
Phase 1 (0-4 Weeks) Passive ROM Phase
Goals
Control Pain and Swelling
Protect Healing Tissue
Begin to Restore Range of Motion
Precautions
Do not actively reach overhead.
Do not actively reach arm behind your head.
Do not lift anything with your arm.
Do not let your arm rotate away from your body
Recommended Exercises
*See passive ROM limitations in chart on page 8*
Pendulums
Standing Scapular Mobility (no resistance)
Supine or Standing Passive External Rotation
Supine, Seated or Standing Passive Shoulder Flexion (elevation)
Passive Internal Rotation (starting at 2 wks post op)
Sub-maximal Isometric Shoulder Internal and External Rotation
Ball Squeeze
Guidelines
Perform these exercises 3-5 times a day. Do 1-2 sets of 10-20 repetitions of each exercise.
Phase 2 (4-8 Weeks) Active ROM Phase
Goals
Continued protection of healing tissue
Continue to improve ROM
Initiate gentle peri-scapular and rotator cuff strengthening
Begin using your arm for daily activities in front of body only

Precautions
Discontinue use of sling if you have not already
Be careful with raising your arm, especially overhead, and away from your body
Continue to avoid lifting or carrying anything
ROM
Continue passive ROM with physical therapist
Pendulums
Supine stick flexion and table slides
Internal Rotation
Strengthening (Resistance Band or Body Weight Against Gravity) beginning at 6 wks post-op.
Row
Prone Extension
Prone Horizontal Abduction
Standing/Prone Scaption
Internal Rotation (Neutral)
External Rotation (Neutral)
Dynamic Strengthening with Physical Therapist
Gentle proprioceptive and rythmic stabilization drills with therapist
Guidelines
Perform all ROM and Strengthening exercises once a day. Do 2-3 sets of 15-20 repetitions.
Phase 3 (8-12 Weeks) Strengthening Phase
Goals
Continue to acquire normal ROM (both passive and active)
Progress strengthening of rotator cuff and shoulder blade muscle groups
Begin limited use arm for daily activities in all planes
Precautions
No lifting away from your body or overhead greater than 1 or 2 pounds
Caution with repetitive use of arm especially overhead
Stop activity if it causes pain in shoulder
Range of Motion
Continue passive ROM with physical therapist as needed gradually progress to full ROM
Continue ROM exercises from phase 2 until ROM is normalized
Gentle progression of abduction angle with external rotation stretch
Gentle supine or standing cross body stretch
Gentle sidelying internal rotation stretch (“sleeper”) *caution to not cause impingment*

Strengthening (Resistance Band or Dumbbell)
Row
Prone Extension
Standing Scaption with progression to Prone
Internal Rotation
External Rotation
Dynamic Strengthening
Manual Resistance Rythmic Stabilization
Proprioceptive Drills (90⁰ of Elevation or Below)
Guidelines
Perform ROM and stretching exercises once a day until normal ROM is achieved. Do 2 sets of 15-20
Reps. Once normal ROM is achieved continue exercises to maintain ROM 3-5 times a week.
Perform strengthening exercises 3-5 times a week. Do 2-3 sets of 15-20 Reps. Strict attention must be
paid to scapulohumeral rhythm with completion of all strengthening exercises.
Phase 4 (12-24 Weeks) Sport Specific and Return to Activity Phase
Goals
Progress to normal ROM and strength
Continue to encourage progressive use of arm for functional daily activity
Precautions
Encourage return to full use of arm for daily activities
Pay particular attention to scapulohumeral rhythm especially with abduction and overhead activity
Discuss return to sport and activity plan with physician
ROM and Stretching
Continue ROM and stretching exercises from phase 2-3
Strengthening
Continue strengthening exercises from phase 3
IR/ER strengthening at 90 deg of abduction
May begin supervised weight training pending surgeons clearance
Progress manual resistance patterns
Progress proprioceptive drills to include rhythmic stabilization
Slowly progress to overhead proprioceptive and plyometric drills
Push up progression

Guidelines
Perform ROM and stretching program 1-3 times a week to maintain normal ROM. Do 1-2 sets of 15-20
Reps. Perform ROM and stretching more frequently in any planes of motion that are still deficient
Perform strengthening 3 times a week. Do 2-3 sets of 15-20 Reps.

Recommended
Time Focus Range of Motion Precautions
Exercises
Phase 1 *Tissue Healing *Flexion Passive/Active ROM *Sling 0-4 Weeks or
0-4 Weeks *Decrease Pain and 90-100⁰ (0-2 wks) Pendulums per MD Instruction
Inflammation As Tol (after 2 wks) Scapular Retraction *Limit ROM
*Start Early Passive *ER in Neutral Shoulder Shrugs Especially ER
ROM with Attention 5-10⁰ (0-2 wks) Passive External Rotation *No Excessive
to Restrictions 30⁰ (2-6 wks) Passive Flexion Shoulder Extension
*ER in Scap Plane Passive Internal Rotation (at 2 wks *No Active ER,
15⁰ (0-2 wks) post op) Extension,
30⁰ (2-4 wks) Strengthening Abduction
*IR in Scap Plane Submaximal Isometric ER/IR
45⁰ (0-2 wks) Ball Squeeze
60⁰ (2-4 wks)
Phase 2 *Improve ROM with *Flexion Passive ROM *No Resisted
4-8 Weeks Careful Progression Progress As Continue PROM Exercises Activity/Lifting
of IR/ER Tolerated Active Assisted ROM *Avoid Repetitive
*Slow Transition to * ER in Neutral Supine/Standing Flexion Motion Overhead
Strengthening after 30⁰ (4-6 wks) Crossbody Adduction (6-8wks) and in Rotation
MD Follow Up Slowly Progress (after Active ROM Against Gravity (6-8 Away from Body
6 wks) wks) *Must have good
*ER in Scap Plane Sidelying ER Scapular Control
45⁰ (4-6 wks) Standing Scaption with Active ROM
60⁰ (6-8 wks) Prone Row and Strengthening
*IR in Scap Plane Prone Extension *Never Force ROM
Slowly Progress (after Prone Horizontal Abduction especially ER
4 wks)
Prone Scaption
*Abduction
Strengthening (6-8 wks)
Limit to 90⁰ (0-6
T-Band IR/ER (in 0⁰ Abd)
wks)
*Work from full IR to 0⁰ ER*
Dynamic Progressions (6-8 wks)
Gentle Rhythmic Stabilization and
Proprioceptive Drills
Phase 3 *Progressive * ER in Neutral Passive ROM *No Heavy or
8-12 Weeks Strengthening Slowly Progress to Continue as Needed Repetitive
*Continued Normal by 12 wks Active Assisted/Active ROM and Overhead
Attention to ROM if *ER in Scap Plane Stretching Lifting/Reaching
Still Deficient Slowly Progress to Continue Phase 2 Exercises *Limited Return to
Normal by 12 wks
*Establish Proper Wall Slide Gym Lifting Late in
*ER/IR in 90⁰ Abd
Scapulohumeral Sidelying IR (“Sleeper”) Phase 3 per MD
Begin at 8 wks and
Rhythm Slowly Progress to Progressive Abd Angle with ER Discretion
*Enhance Normal by 12 wks Supine/Standing Cross Body *Dynamic
Proprioception Strengthening (Dumbell/T-band) Progressions if Pain
Row Free/Full ROM with
Prone Extension all ROM and
Prone Horizontal Abduction Strengthening
Standing/Prone Scaption Exercises
Internal Rotation *Never Force ROM
External Rotation especially ER
“W” (Row/ER)
Bicep Curl
Dynamic Progressions
Rhythmic Stabilization

Phase 4 *Progress *Continue to work Active Assisted/Active/Stretch *Progress Gym
12-24 Weeks strengthening toward normal ROM in Continue Phase 3 As Needed Lifting per MD
*Regain use of arm all planes Strengthening Discretion
for all daily activities. Continue T-band and Dumbbell *Avoid Activities
*Prepare for Return Progressions from Phase 3 that Cause
to Sport and Physical Progress to Diagonal Patterns Shoulder Pain
Activity IR/ER at 90⁰ Abd *Begin Progressive
May Begin Limited Weight Training Return to Sports
Dynamic Progressions and Physical
Pushup Progression Activity Program
Continue Proprioceptive Drills After MD
Plyometrics/Rebounder Evaluation
Progress to Overhead
Manual Resistance Patterns
*Reviewed by Michael Geary, MD

Rotator Cuff Impingement/Tendinopathy
The shoulder is a wonderfully complex joint that is made up of

the ball and socket connection between the humerus (ball) and
the glenoid portion of the scapula (socket). The socket portion
of the joint is not naturally deep. For this reason the shoulder is
the most mobile joint in the body. Due to the lack of boney
coverage the shoulder’s proper function and stability is largely
dependent on the soft tissues that surround it.
The rotator cuff is a group of four tendons that attach to the ball
of the shoulder joint. They surround the ball much like the cuff
of a sleeve fits snuggly around the wrist. When the arm is
moved away from the body or over the head the tendons act to
hold the ball in the socket correctly so that smooth fluid motion
can be achieved. Sometimes these tendons as well as the subacromial bursa (fluid filled cushion on top
of the tendon) can get irritated and inflamed causing a condition known as shoulder tendinopathy.
This inflammation can come about for one several reasons. It can be the result of simple overuse of the
arm, especially with overhead activity. Tendinopathy can also develop if the shoulder is moving
incorrectly. When the shoulder blade is allowed to sit in a rounded position and the rotator cuff is weak
and can’t stabilize the ball in the socket then the humerus and the acromian process come too close
together during shoulder movement. This creates a pinching of the soft tissue between the two pieces
of bone. This pinching is known as shoulder impingement and can be very painful and debilitating.

Treatment Options
Effective treatment of tendinopathy and impingement

syndrome begins with a thorough orthopedic
examination to determine the root cause of the
dysfunction. Once the exam and diagnostic process is
complete your physician will work with you to determine
the most appropriate course of action for treatment. In
most cases tendinopathy or impingement is first treated
conservatively. This may include rest, anti-inflammatory
medication, and activity modification. Your doctor may
refer you to Physical Therapy to work on reducing the
inflammation in your shoulder and correcting any deficits
in strength or range of motion that are present. If the
inflammation in your shoulder does not resolve with
these conservative measures your doctor may elect to
inject an anti-inflammatory medication (cortisone)
directly into the subacromial space. This can be a very effective treatment for reducing inflammation
enough to allow Physical Therapy exercise to work effectively. In rare occasions shoulder impingement
and tendinopathy are resistant to all forms of conservative treatment. In these rare cases you and your
doctor may elect have arthroscopic surgery performed to fix the source of the inflammation. This may
include removal of a bone spur or debridement of an inflamed bursa.

Rehabilitation
**The following is an outlined progression for rehab. Time tables are approximate. Advancement
from phase to phase, as well as specific exercises performed, should be based on each individual
patient’s case and sound clinical judgment on the part of the rehab professional. **
Phase 1 Acute Phase
Goals
Reduce Pain and Inflammation
Protect Injured Tissue
Improve ROM Without Aggravating Injury
Precautions
Avoid any activities that create increased pain
Limit use of arm for lifting, pushing, pulling and carrying activities
Pendulums
Passive Internal Rotation
*Perform ROM exercises gently with the goal of reducing muscle guarding and pain
Guidelines For Progression

Before progressing to the subacute phase the shoulder should be less painful at rest and with
movement. Increased pain with passive ROM should be seen more at “end range” and less with
initiation of movement.

Phase 2 Subacute Phase
Goals
Continued protection of injured/healing tissue
Continue to improve passive and active ROM
Initiate Active ROM with Proper Scapulohumeral Rythm
Precautions
No repetitive use of arm especially overhead
Avoid putting arm in positions that create increased pain/”pinching”
Avoid heavy loads with strengthening exercises
Range of Motion
Continue Active Assisted ROM
Supine Active Assisted Flexion
Standing or Supine Active Assisted ER (neutral, scapular plane, 90 deg of abduction)
Active Assisted IR and Horizontal Adduction
Strengthening
*Stress gentle strengthening with low resistance and high repetition*
Resistance Band
Scapular Retraction
Internal Rotation
External Rotation
Bodyweight/Dumbbell
Standing Scaption (“open can”) with progression to prone
Prone Extension
Guidelines for Progression

Before advancing to the progressive strengthening phase the shoulder should be able to actively move
in all planes of motion without experiencing increased pain or “pinching.”

Phase 3 Progressive Strengthening Phase
Goals
Continue to acquire normal ROM if still deficient
Progressively strengthen rotator cuff and peri-scapular muscle groups
Restore functional use of arm
Limitations
Caution with repetitive overhead activity and lifting in frontal plane (abduction)
Avoid activity if it causes pain in shoulder
ROM
Continue Active Assisted ROM if necessary
Add side-lying IR stretch (“sleeper”) stretch and cross body stretch if necessary
*Begin to progressively increase resistance and reduce frequency of strengthening exercises*
Scapular Retraction
Prone Extension
Internal Rotation with progression to 90 deg of abduction
External Rotation with progression to 90 deg of abduction
Progress to Diagonal Patterns
Rythmic Stabilization
Push Up Progression

Before progressing to the sports specific phase the shoulder should be pain free in all planes of motion
and strength should be excellent.

Phase 4 Sport Specific Phase
Goals
Maintain normal ROM and strength
Continue to encourage progressive use of arm for functional activity and return to sport
Precautions
Encourage slow progression back to sport and high level activity
Work with orthopedic doctor or physical therapist regarding specific plan for return to sport/activity
ROM and Stretching
Continue as directed by physical therapist
Strengthening
Continue strengthening 2-3 times a week.
Work with physical therapist to determine which exercises should be continued
Guidelines for Return to Activity

Work with physician or physical therapist for specific plan for return to sport and activity. Step by step
progressions should allow for gradual return to high level activities.

Range of Recommended
Phase Focus Precautions
Motion Exercises
Acute *Reduce Pain *Gentle ROM ROM *Do not perform

and progression Pendulums any activity or
Inflammation *Focus on Scapular Mobility exercise that
*Protect Injured Passive and Passive/Assisted External causes sharp pain
Tissue Active Assisted Rotation in shoulder
*Improve ROM ROM in pain Passive/Assisted Flexion *Avoid lifting arm
Without free range Passive/Assisted Internal away from body or
Aggravating Rotation overhead
Injury
Subacute *Continue *Continue pain- ROM *Stress Proper

protection of free assisted Supine Active Assisted Scapulo-humeral
injured/healing ROM in all Flexion Rhythm with
tissue planes Standing or Supine Active Active ROM
Continue to *Carefully Assisted ER (neutral, scapular *Avoid Repetitive
improve passive progress active plane, 90 deg of abduction) Abduction Motion
and assisted elevation with Active Assisted IR and in Coronal Plane or
ROM particular Horizontal Adduction Overhead Motion
*Initiate Active attention to *Stress Low
ROM with scapula- Strengthening Resistance and
Proper humeral T-band High Repetition
Scapulohumeral rhythm Scapular Retraction with Strengthening
Rythm Internal Rotation Exercises
*Initiate gentle External Rotation
peri-scapular Bodyweight/Dumbbell
and rotator cuff Side-lying External Rotation
strengthening Standing Scaption (“open
can”) with progression to
prone
Prone Extension

Rehab *Continue to Maintain Full ROM *No Heavy or
acquire normal Passive/Active Continue Active Assisted Repetitive
ROM if still ROM ROM if necessary Overhead
deficient Side-lying IR stretch and cross Lifting/Reaching
*Progressively body stretch as needed *Limited Return to
strengthen Gym Lifting Under
rotator cuff and Strengthening Supervision
peri-scapular Scapular Retraction *Begin to Increase
muscle groups Prone Extension Load and Decrease
*Restore Prone Horizontal Abduction Volume/Frequency
functional use of Standing/Prone Scaption of Strengthening
arm Internal Rotation with Exercises
progression to 90 deg of
abduction
External Rotation with
progression to 90 deg of
abduction
Progress to Diagonal
Manual Resistance Patterns
Rythmic Stabilization
Proprioceptive Drills
Push Up Progression
Sport Gradual Return Maintain Full ROM *Return to Sports
Specific to Sports and Passive/Active Continue as Needed and Physical
Physical Activity ROM Activity per
Strengthening Surgeon/Physical
Continue T-band and Peri- Therapist
scapular Progressions 3 x Evaluation
Week as Needed *Achieve Full Pain
Free ROM and
Dynamic Progressions Excellent Strength
Continue Proprioceptive Before Progression
Drills During Return to Sport 2- Back to Sport
3 x Week

Rotator Cuff Repair Protocol
The shoulder is a wonderfully complex joint that is made up of the ball and socket connection between
the humerus (ball) and the glenoid portion of the scapula (socket). The socket portion of the joint is not
naturally deep. For this reason the shoulder is the most mobile joint in the body. Due to the lack of
bony coverage the shoulder’s proper function and stability is largely dependent on the soft tissues that
surround it.
The rotator cuff is a group of four tendons that attach to

the ball of the shoulder joint. They surround the ball much
like the cuff of a sleeve fits snuggly around the wrist. When
the arm is moved away from the body or over the head the
tendons act to hold the ball in the socket correctly so that
smooth fluid motion can be achieved. When one or more
of these tendons is torn it becomes very difficult to use the
arm to complete even the most basic activities of daily
living. A tear in the rotator cuff can happen during a
trauma to the shoulder or simply over time with repetitive,
stressful activity.
Treatment Options
Regardless of how the tendon is torn your physician will work with you to determine what the best
course of treatment will be. In many cases a small, partial thickness tear can be treated conservatively.
This may include Physical Therapy, anti-inflammatory medication, rest, and activity modification. When
conservative measures are unsuccessful in restoring function you and your physician may elect to have
the torn tendon repaired.

Surgery
Rotator cuff repair surgery can now be performed arthroscopically and is

in most cases an outpatient day surgery procedure. This means that it is
very rare to have to spend the night in the hospital. If damage to the
rotator cuff is extensive your surgeon may have to use an open incision
rather than an arthroscope to complete the procedure. Regardless if
the procedure is open or arthroscopic all patients will likely be home on
the same day as surgery.
Having a torn rotator cuff repaired is not an easy undertaking. It is very important that the patient
knows that the recovery process is difficult and time consuming. He or she must be an active participant
during this process, performing daily exercises to ensure there is proper return of range of motion and
strength. There is a large amount of variability in the time it takes to fully recover from this procedure.
It is usually estimated that it will take at least six months to feel as though you have completely regained
the use of your arm. Some cases may take as long as a year to make a full recovery. People with desk
jobs should plan to take at least one week off from work. Manual laborers will likely be out of work for
at least six months. Recovery is different in each case your individual time table for return to activities
and work will be discussed by your surgeon during post operative office visits.
Your first post-op visit to the doctor’s office will be approximately 10 days after the operation. At this
visit your stitches will be removed and you will review the surgery with the surgeon or his assistant. At
this time you will most likely be cleared to make an appointment to begin rehab. You should also plan
to check in with your surgeon at 6, 12, and 24 weeks after the operation.
At Home
You may remove your post-op dressing two days after the operation and replace it as needed. Do not
remove the tape (steri-strips) that are across your incision. Allow them to fall off on their own. You may
shower after two days, but use a water-tight dressing until your sutures are removed. Bathing without
getting the shoulder wet or sponge baths are a good alternative. You may wash under the affected arm
by leaning forward and letting the arm dangle. Do not attempt to actively move your arm at the
shoulder joint for any reason until cleared by your physician or therapist. You may move your hand,
wrist and elbow when your arm is out of the sling, but do not lift or carry anything with your operated
arm until cleared your physician or therapist.

Driving
You will be permitted to drive after surgery following approval from your doctor. Generally you should
expect to not be able to drive for four to six weeks following the operation. You are not permitted to
drive while wearing your sling or while on narcotic medication.
Medication
Your surgeon will prescribe you pain medicine after the operation. You may not take anti-inflammatory
medication like Advil, Ibuprofen, or Aleve for at least 12 weeks after the operation as it may
compromise the healing tendon. You may take Tylenol as needed. Please call the doctor’s office if you
have any questions regarding medication.
Ice
Sling
You will be provided with a sling to wear after the operation. You should wear this sling all of the time
(even for sleeping) and should remove it only when bathing/showering, or to do your exercises. Most
patients will be required to use a sling for 4-6 weeks after the operation.
Sleeping
You should sleep with your sling on and a pillow propped under your arm to keep it slightly away from
the body. For many patients lying flat is very uncomfortable. It is generally easier to sleep propped up
or in a recliner after the operation. Do not attempt to sleep on your operated shoulder for at least 6
weeks.

Rehabilitation
Phase 1 (0-6 Weeks) Passive Range of Motion (ROM) Phase
Goals
Protect Healing Tendon

Restore Passive ROM of the Shoulder
Precautions
Do not start Passive Internal Rotation until 2 weeks post-op.
Do not perform any Active ROM of the shoulder.
Use sling for at least four weeks or as instructed by physician.
Pendulums
Passive Internal Rotation (starting at 2 weeks post-op)
Passive Horizontal Adduction
Ball Squeeze
Guidelines

Goals
Continued protection of healing tendon
Continue to improve passive ROM and initiate progression of active assisted and active ROM
Progress to Active ROM against gravity by end of phase
Initiate gentle sub-maximal rotator cuff isometrics
Precautions
Be careful with raising your arm away from your body only lift your arm to the front not to the side
Do not use your arm to pick anything up or carry anything
Passive ROM and Stretching
Continue exercises from Phase 1 until each can be progressed to active assisted or active motion
Supine Passive External Rotation in scapular plane progressing to 90 deg of Abduction
Active Assisted Progressing to Active ROM
Supine stick flexion with progression to standing active shoulder flexion/scaption
Table slides in flexion with progression to wall slides
Supine or standing cross body stretch
Sidelying internal rotation stretch **caution to not cause impingement
Sidelying external rotation
Prone row, extension, horizontal abduction, scaption (by end of phase 2)
Strengthening
Sub-maximal isometric internal and external rotation
Guidelines
Perform these exercises once a day. Do 2-3 sets of 15-20 repetitions.

Phase 3 (12 - 24 Weeks) Strengthening Phase
Goals
Continue to focus on restoration of ROM, biomechanics and strength
Initiate progressive strengthening of rotator cuff and peri-scapular muscle groups
Begin to use arm for daily activities
Precautions
Caution with lifting especially away from body and overhead
Caution with repetitive use of arm
Passive ROM and Stretching
Continue on own and with therapist as needed
Active Assisted and Active ROM
Scapular Retraction
Prone Extension
Internal Rotation
External Rotation
Progress to Diagonal Patterns and Multi-Planar/Functional Planes of Motion
Push Up Progression
Guidelines

Phase 4 (24 Weeks - 1 Year) Return to Sport/Activity Phase
Goals
Maintain normal ROM and strength
Continue to encourage progressive use of arm for functional activity and return to sport
Precautions
Work with surgeon or physical therapist regarding specific return to sport/activity plan
ROM and Stretching
Strengthening
Continue to progress strengthening program from phase 3
Guidelines
Perform ROM and stretching program 1-3 times a week to maintain normal ROM.
Do 1-2 sets of 15-20 Reps.
Perform strengthening 2-3 times a week. Do 2-3 sets of 15-20 Reps.

Time Focus Precautions
Motion Exercises
Phase 1 Passive ROM *Passive ROM Passive *No Active
0-6 Weeks Tissue Healing as tolerated Pendulums Reaching
*Do not Force Scapular Mobility *Sling at all times
Painful Motion Passive External Rotation for 4-6 weeks or
(Minimize Passive Flexion per MD discretion
Muscle Passive Horizontal Adduction *ROM
Guarding) Passive Internal Rotation (2wks restrictions may
*No Isolated post-op) be different for
Abduction Ball Squeeze complex repair
*No Active
Elevation
Phase 2 Active Assisted *Progress to Passive *No Resisted
6-12 ROM with Full ROM in all Continue PROM Exercises Activity/Lifting
Weeks Transition to Planes Passive ER Progressing to 90⁰ Abd *Avoid Repetitive
Active ROM after *Transition Abduction
MD Follow Up from PROM to Active Assisted/Stretching Motion in
AA and AROM Supine/Standing Flexion, Coronal Plane
Horizontal Adduction, Sidelying IR *Must have good
Scapular Control
Isometrics with
Sub-max IR/ER Progressions
Active Progressions
Sidelying ER
Standing Scaption
Prone Row
Prone Extension
Prone Scaption
Phase 3 Progressive Maintain Full Passive *No Heavy or
12-24 Strengthening Passive/Active Continue as Needed Repetitive
Weeks with Continued ROM Overhead
Attention to Active Assisted/ Active Lifting/Reaching
ROM if Still Continue as Needed *Limited Return
Deficient to Gym Lifting
Strengthening (Dumbell/T-band) Late in Phase 3
Row per MD
Prone Extension Discretion
Prone Horizontal Abduction *Dynamic
Standing/Prone Scaption Progressions at
Internal Rotation 16 Weeks if Pain
External Rotation Free/Full ROM
Progress to Diagonals and with all ROM and
Functional Planes Strengthening
Exercises

Dynamic Progressions(16 Wks)
Push Up Progression
Phase 4 Return to Sports Maintain Full Active Assisted/Active *Return to Sports
24 Weeks- and Physical Passive/Active Continue as Needed Daily and Physical
1 Year Activity if ROM ROM Activity per
and strength are Strengthening Surgeons
adequate Continue Resistance Band and Evaluation
Peri-scapular Progressions 2-3 x *Progress Gym
Week Lifting per MD
Discretion
Continue Proprioceptive Drills
During Return to Sport 2-3 x Week

SLAP Repair Protocol

the humerus (ball) and the glenoid portion of the scapula (socket). The socket portion of the joint is not
naturally deep. For this reason the shoulder is the most mobile joint in the body. Due to the lack of
boney coverage the shoulder’s proper function and stability is largely dependent on the soft tissues that
surround it.
The glenoid labrum is a fibrocartilage rim that surrounds the edge of
the glenoid fossa (socket). It serves to deepen the socket and
provide suction effect on the head of the humerus (ball), thus
improving the stability of the naturally shallow joint. The labrum can
be damaged or torn in many different ways. When the superior
(upper) part of the labrum is torn it is often termed a SLAP tear. This
acronym stands for superior labrum from anterior to posterior. A
SLAP tear can happen traumatically or in response to repetitive
activity like throwing.
Treatment Options
Regardless of how the labrum is torn your physician will work with you to determine what the best
course of treatment will be. In many cases the pain and dysfunction associated with a SLAP tear can be
successfully treated with rest, anti-inflammatory measures, activity modification and Physical Therapy.
When conservative measures are unsuccessful in restoring function you and your physician may elect to
have the torn labrum repaired.
Surgery
Labral repair surgery involves re-anchoring or trimming the torn
piece of cartilage. The procedure is usually performed
arthroscopically and is, in most cases an outpatient day surgery
procedure. This means that it is very rare to have to spend the
night in the hospital. If damage to the labrum or other tissue is
extensive your surgeon may have to use an open incision rather
than an arthroscope to complete the procedure. Regardless, of
whether the procedure is open or arthroscopic all patients will likely be home on the same day as
surgery.

Recovering from labral repair surgery is not easy. It is very important that the patient knows that the
usually estimated that it will take at least 4-6 months to feel as though you have completely regained
the use of your arm. Some cases may take as long as 9-12 months to make a full recovery. People with
desk jobs should plan to take at least 1 week off from work. Manual laborers will likely be out of work
for at least 4-6 months. Recovery is different in each case. Your individual time table for return to
activities and work will be discussed by your surgeon during post operative office visits.

visit your stitches will be removed and you will review the surgery with the surgeon or his assistant. At
this time you will most likely be cleared to make an appointment to begin Physical Therapy. You should
also plan to check in with your surgeon at 6, 12, and 24 weeks after the operation.
At Home
remove the strips of tape (steri-strips) that are across your incision. Allow them to fall off on their own.
without getting the shoulder wet or sponge baths are a good alternative. You may wash under the
affected arm by leaning forward and letting the arm dangle. Do not attempt to actively move your arm
at the shoulder joint for any reason until your doctor allows you. You may remove your sling several
times a day and gently move your hand, wrist and elbow and perform shoulder pendulum exercises.
Medication
Ice
Sling
You will be provided with a sling to wear after the operation. You should wear this sling most of the
time for at least the first 2 weeks after the operation. Remove it when bathing/showering, or to do your
exercises. Some patients may require the use of the sling for the first 4 weeks after the operation. Your
doctor will give you specific instructions regarding how long you should use your sling.

Sleeping
You may sleep with a pillow propped under your arm to keep it slightly away from the body. For many
patients lying flat is uncomfortable at first. It is generally easier to sleep propped up or in a recliner for a
6 weeks.

Rehabilitation
Phase 1 (0-4 Weeks) Passive ROM Phase
Goals
Precautions
Do not actively reach arm behind back.
Do not actively reach overhead.
Do not actively reach arm behind your head.
Pendulums
Sub-maximal Isometric Shoulder Internal and External Rotation
Ball Squeeze
Guidelines
Goals
Begin using your arm for daily activities in front of body only

Precautions
Be careful with raising your arm, especially overhead, away from your body and behind you
Continue to avoid lifting or carrying anything heavy
ROM
Pendulums
Supine stick flexion and table slides
Internal Rotation
Strengthening (Resistance Band or Body Weight Against Gravity)
Row
Prone Extension
Internal Rotation (Neutral) *work from full IR to neutral*
External Rotation (Neutral) *work from full IR to neutral*
Dynamic Strengthening with Physical Therapist
Gentle proprioceptive drills
Rythmic stabilization with therapist
Guidelines
Perform all ROM and Strengthening exercises once a day. Do 2-3 sets of 15-20 repetitions.
Goals
Progress strengthening of rotator cuff and shoulder blade muscle groups
Begin to use arm for daily activities in all planes
Precautions
Range of Motion
Continue passive ROM with physical therapist as needed gradually progress to full ROM
Gentle progression of abduction angle with external rotation stretch

Gentle sidelying internal rotation stretch (“sleeper”) *caution to not cause impingement*
Row
Prone Extension
Standing Scaption with progression to Prone
Internal Rotation
External Rotation
Guidelines
paid to scapula-humeral rhythm with completion of all strengthening exercises.
Phase 4 (12-16 Weeks) Sport Specific Phase
Goals
Progress to normal ROM and strength
Precautions
Pay particular attention to scapula-humeral rhythm especially with abduction and overhead activity
Still restricted from return to sports
ROM and Stretching
Strengthening
Push up progression

Guidelines
Phase 5 (16-24 Weeks) Return to Activity Phase
Goals
Maintain adequate ROM and strength
Continue progressive dynamic strengthening
Begin return to sport progressions pending surgeon’s clearance
Precautions
Gradual return to sport pending surgeon’s clearance
Work with surgeon or Physical Therapist to develop specific return to sport progression
ROM and Stretching
Continue ROM and stretching exercises in any planes of motion that are deficient
Continue cross body stretch and sidelying internal rotation stretch following workouts
Strengthening
Progress Manual Resistance Patterns
Progress Proprioceptive, Plyometric, Rebounder Drills to include overhead
Guidelines
Perform 1-2 sets of 15-20 repetitions of ROM and stretching exercises 1-3 times a week in all deficient
planes of motion. Perform 1 set of 15-20 repetitions of ROM and stretching exercises after all return to
sport activities.
Perform 2-3 sets of 15-20 repetitions of all strengthening exercises 2-3 times a week. Perform dynamic
strengthening program 1-2 times a week while undergoing return to sport progression.

Recommended
Exercises
Phase 1 *Passive ROM *Flexion as Passive *Sling 0-4 Weeks or
0-4 Weeks *Tissue Healing Tolerated Pendulums per MD Instruction
*0-2 Weeks ER to Scapular Retraction *No ER with Arm in
15⁰ IR to 45⁰ in Shoulder Shrugs Abduction
Scapular Plane Passive External Rotation *No Excessive
*2-4 Weeks ER to Passive Flexion Shoulder Extension
30⁰ IR to 60⁰ in Passive Internal Rotation
Scapular Plane, Strengthening
Abduction to 80⁰ Sub-maximal Isometric ER/IR
Ball Squeeze
Phase 2 *Improve ROM with *Continue Flexion Passive *No Resisted
4-8 Weeks Careful Progression as Tolerated Continue PROM Exercises Activity/Lifting
of IR/ER *Beginning at 4 Gentle Passive ER at 90⁰ Abd Starting at *Avoid Repetitive
*Slow Transition to Weeks ER to 50⁰ IR 6 Weeks Motion Overhead
Strengthening after to 60⁰ (in 45⁰ of and in Coronal
MD Follow Up Abduction) Active Assisted Plane
*Beginning at 6 Supine/Standing Flexion, Horizontal *Must have good
Weeks Gently Adduction, Hand Behind Head ER, Scapular Control
Progress to ER at Sidelying IR with Active ROM
90⁰ of Abduction and Strengthening
Strengthening *Be Cautious with
T-Band IR/ER (in 0⁰ Abd) Progression of ER
*Work from full IR to 0⁰ ER ROM
Active Motion Against Gravity

Sidelying ER
Standing Scaption
Prone Row
Prone Extension
Prone Scaption
Phase 3 *Progressive *Gradually Progress Passive *No Heavy or
8-12 Weeks Strengthening to Full Passive ROM Continue as Needed Repetitive
*Continued Overhead
Attention to ROM if Active Assisted/Active/Stretch Lifting/Reaching
Still Deficient Continue Phase 2 Exercises *Limited Return to
*Establish Proper Wall Slide Gym Lifting Late in
Scapulo-humeral Sidelying IR (“Sleeper”) Phase 3 per MD
Rythm Hands Behind Head ER Discretion
Supine/Standing Cross Body *Dynamic
Progressions if Pain
Strengthening (Dumbbell/T-band) Free/Full ROM with
Row all ROM and
Prone Extension Strengthening
Prone Horizontal Abduction Exercises
Internal Rotation
External Rotation
“W” (Row/ER)
Bicep Curl

Phase 4 *Progress *Maintain Full Active Assisted/Active/Stretch *Still Avoid Return
12-16 Weeks strengthening Passive/Active ROM Continue Phase 3 As Needed to Sports and
*Regain use of arm Physical Activity
for all daily activities. Strengthening *Progress Gym
Continue T-band and Dumbbell Lifting per MD
Progressions from Phase 3 Discretion
Progress to Diagonal Patterns *Avoid Activities
IR/ER at 90⁰ Abd that Cause
May Begin Limited Weight Training Shoulder Pain
Pushup Progression
Plyometrics/Rebounder
Phase 5 *Prepare for Return *Continue Active Assisted/Active/Stretch *Begin Progressive
16-24 Weeks to Sport and Physical Stretching Program Continue Phase 3 As Needed Return to Sports
Activity and Physical
Strengthening Activity Program
Continue T-band and Dumbbell After MD
Progressions from Phase 4 Evaluation
May Carefully Progress Weight Training *Careful
Progression of
Dynamic Progressions Weight Training
Continue Pushup Progression
Progress to Overhead with
Plyometrics/Rebounder

Subacromial Decompression Protocol
the humerus (ball) and the glenoid portion of the
scapula (socket). The socket portion of the joint is not
naturally deep. For this reason, the shoulder is the most
mobile joint in the body. Due to the lack of boney
coverage the shoulder’s proper function and stability is
largely dependent on the soft tissues that surround it.
The shoulder joint is extremely important when the arm

is used during activities that involve lifting, pushing and
pulling, but especially when the arm is repetitively placed
overhead. Over time with continual repetitive activity
the soft tissues and joint surfaces of the shoulder are
subject to wear and tear and degeneration. The soft
tissue around the joint can become irritated and
inflamed and excess bone (spurs) can form as a result. These inflammatory or degenerative changes
often leave the shoulder feeling achy and sore during everyday activities.
Treatment Options
Regardless of nature or extent of the degeneration in the shoulder your physician will work with you to
determine what the best course of treatment will be. In many cases the pain and dysfunction associated
with degenerative changes can be successfully treated with rest, anti-inflammatory measures, activity
modification and Physical Therapy. When these conservative measures are unsuccessful in restoring
function your physician may recommend that you undergo arthroscopic surgery to remove the irritated,
degenerative tissue in the shoulder.

Surgery
The subacromial decompression procedure involves removing tissue

from the front part of the shoulder. This part of the shoulder is
referred to as the subacromial space, as it is located below the
outcropping of bone on the scapula (shoulder blade) know as the
acromian process. During the procedure the end of the acromian
process and any inflamed tissue including the subacromial bursa is
debrided. This creates more room in the front of the shoulder so
that the tendons of the rotator cuff can move freely without getting
irritated or pinched. The procedure is performed arthroscopically
and is, in most cases an outpatient day surgery. This means that it
is very rare to have to spend the night in the hospital.
Before undergoing subacromial decompression surgery your doctor will discuss the recovery process
with you. It is very important that the patient knows that the recovery process is fairly difficult and time
consuming. He or she must be an active participant during this process, performing daily exercises to
ensure there is proper return of the shoulder’s range of motion and strength. There is a large amount of
variability in the time it takes to fully recover from this procedure and is typically dependant on the
extent of the damage that needs to be fixed. It is usually estimated that it will take at least 3-4 months
to feel as though you have completely regained the use of your arm. Some cases may take as long as 6-
9 months to make a full recovery. People with desk jobs should plan to take at least 1 week off from
work. Those with jobs that require physical activity and lifting will likely be out of work for at least 3
months. Recovery is different in each case. Your individual time table for return to activities and work
will be discussed by your surgeon during post operative office visits.
visit any stitches you have will be removed and you will review the surgery with the doctor or his
assistant. At this time you will most likely be cleared to make an appointment to begin Physical Therapy.
You should also plan to check in with your surgeon at 6 and 12 weeks after the operation. The surgeon
may create a different timetable for postoperative office visits if your case warrants it.
At Home
remove the tape (steri-strips) that is across your incisions. Allow them to fall off on their own. You may
shower after 2 days, but use a water-tight dressing until your sutures are removed. Bathing without
getting the shoulder wet or sponge baths are a good alternative. You may wash under the affected arm
by leaning forward and letting the arm dangle. You may move your arm in front of your body, but not

out to the side until your doctor allows you. You may remove your sling several times a day and gently
move your hand, wrist and elbow and perform shoulder pendulum exercises.
Medication
Ice
be applied 3-5 times a day for 10-20 minutes at a time until the postoperative inflammation has
resolved. Always maintain one layer between ice and the skin. Putting a pillow case over your ice pack
works well for this.
Sling
You will be provided with a sling to wear after the operation. Remove it when bathing/showering, or to
do your exercises. You should remove the sling several times a day to perform pendulum exercises as
instructed. Wear the sling most of the time (especially when out in public) until you see your doctor for
your first post op visit. Most patients use their sling for about 2 weeks. If your case is atypical your
doctor may have custom guidelines for you regarding use of the sling.
Sleeping
You may sleep with a pillow propped under your arm to keep it slightly away from the body if you need
to. For many patients lying flat is uncomfortable at first. It is generally easier to sleep propped up for a
6 weeks.

Rehabilitation
Phase 1 (0-2 Weeks) ROM Phase
Goals
Precautions
Do not actively use your arm for reaching, especially overhead.
Pendulums
Passive Horizontal Adduction
Guidelines
Goals
Begin using your arm for daily activities in front of body
Precautions
Be careful with raising your arm, especially overhead, and away from your body
Continue to avoid lifting or carrying anything

ROM
Pendulums
Supine Stick Flexion
Table Slides with progression to Wall Slides
Supine or Standing Passive External Rotation with gentle progression of abduction angle
AROM Against Gravity
Prone Row
Prone Extension
Sidelying External Rotation
Guidelines
Perform all exercises once a day. Do 2-3 sets of 15-20 repetitions.
Goals
Progressive strengthening of rotator cuff and shoulder blade muscle groups
Begin limited use arm for daily activities in all planes
Precautions
Range of Motion
Continue passive ROM with physical therapist as needed
Strengthening (Resistance Band or Dumbell)
Row
Prone Extension
Internal Rotation
External Rotation

Guidelines
Phase 4 (12 Weeks +) Sport Specific and Return to Activity Phase
Goals
Achieve normal ROM and strength
Precautions
Pay particular attention to scapulohumeral rhythm especially with abduction and overhead activity
Discuss return to sport and activity plan with physician
ROM and Stretching
Continue ROM and stretching exercises from phase 2-3 as needed
Strengthening
IR/ER strengthening at 90 deg of abduction
Slowly progress to overhead proprioceptive and plyometric drills
Push up progression
Guidelines

Recommended
Exercises
Phase 1 *Tissue Healing *PROM with PT as Passive/Active ROM *Sling 0-2
0-2 Weeks *Decrease Pain tolerated in all Pendulums Weeks or per
and planes Scapular Mobility MD Instruction
Inflammation *Avoid AROM in Passive External Rotation *Limit Active
*Start Early Coronal Plane Passive Flexion ROM
Passive ROM Passive Internal Rotation *Limit Use of
with Attention to Passive Horizontal Adduction Arm, Especially
Restrictions Overhead and
in Abduction
Phase 2 *Continue to *Continue Passive Passive ROM *No Resisted
2-6 Weeks Decrease Pain ROM as tolerated. Continue PROM Exercises Activity/Lifting
and *Slowly Encourage Active Assisted ROM *Avoid
Inflammation Pain Free Active Supine to Standing Flexion Repetitive
*Improve Passive ROM Cross-body Adduction Motion
and Active ROM Progress Abd angle with ER Especially
Active ROM Against Gravity Overhead
Sidelying ER *Must have
Prone Row good Scapular
Prone Extension Control with
Prone Horizontal Abduction Active ROM
Against Gravity
Phase 3 *Progressive *Passive and Passive ROM *No Heavy or
6-12 Strengthening Active ROM as Continue as Needed Repetitive
Weeks *Continued tolerated in all Active Assisted/Active ROM Overhead
Attention to planes and Stretching Lifting/Reaching
ROM if Still Continue Phase 2 Exercises *Dynamic
Deficient Strengthening (Dumbbell/T- Progressions if
*Establish Proper band) Pain Free/Full
Scapulohumeral Row ROM with all
Rhythm Prone Extension ROM and
*Enhance Prone Horizontal Abduction Strengthening
Proprioception Standing/Prone Scaption Exercises
Internal Rotation
External Rotation
“W” (Row/ER)
Bicep Curl

Phase 4 *Progress *Continue ROM/Stretch * Return to
12 Weeks + strengthening Stretching Continue Phase 3 As Needed Gym Lifting per
*Regain use of Program as Strengthening MD Approval
arm for all daily needed. Continue T-band and *Avoid
activities. Dumbbell Progressions from Activities that
*Prepare for Phase 3 Cause Shoulder
Return to Sport Progress to Diagonal Patterns Pain
and Physical IR/ER at 90⁰ Abd *Begin
Activity May Begin Limited Weight Progressive
Training Return to
Dynamic Progressions Sports and
Pushup Progression Physical Activity
Continue Proprioceptive Drills Program After
Plyometrics/Rebounder MD Evaluation

Total Shoulder Arthroplasty

The shoulder is a complex structure that joins the arm to the body. It is comprised of three bones,
including the humerus (upper arm bone), scapula (shoulder blade), and clavicle (collarbone). The main
shoulder joint is a ball-and-socket joint where the ball-shaped head of the humerus attaches to a socket
on the scapula called the glenoid. The glenoid is much smaller than the head of the humerus. This
construct allows the shoulder to have a larger range of motion (ROM) than any other joint in the body.
Both the head of the humerus and glenoid are coated with smooth cartilage, which allow the bones to
glide easily on one another. This cartilage may naturally
wear down over time creating a rough surface between
the bones. Without smooth healthy cartilage the
shoulder also has a hard time producing the natural joint
“oil” (synovial fluid) that lubricates the shoulder during
movement. Collectively, these degenerative processes
that happen over time lead to the condition known as
osteoarthritis. This process can happen naturally
overtime, but can be more severe or develop quicker in
some people, especially after trauma.
http://orthoinfo.aaos.org/topic.cfm?topi 1
As degenerative changes in the shoulder

advance the joint becomes more and more painful and less and less
mobile. Osteoarthritis typically produces stiffness in the joint, especially
right after a period of immobility (i.e. first thing in the morning). The pain
in the joint may subside after moving around, but become worse again
with use of your arm. The pain in the joint may also affect sleeping. As the
condition of the joint deteriorates some people develop a sensation of
grinding or catching in the joint. It will become harder and harder to use
http://www.ourhealthnetwork.com/conditio 1
your arm and eventually the shoulder may lose some of its range of motion.

Treatment Options
Regardless of the nature and severity of the osteoarthritis in your shoulder your physician will work with
you to determine what the best course of treatment will be. When degenerative changes are not severe
the associated pain and dysfunction may successfully be treated with rest, anti-inflammatory measures,
activity modification and physical therapy. After a thorough evaluation your physician and their staff
will recommend the most appropriate course of action to take.
Physical therapy is often recommended for treatment of pain and dysfunction associated with
osteoarthritis. The physical therapist will evaluate your mobility, flexibility and strength with the
purpose of determining any underlying deficits that contribute to increased stress on the painful joint.
You will be counseled on which activities you can safely continue and which should be avoided. The
physical therapist will teach you exercises that will help to reduce joint stress. In most cases this will
include strengthening and stretching the muscles around the entire shoulder complex as well as the
upper back.
When joint degeneration is severe and conservative measures are unsuccessful in restoring function
your physician may recommend a total shoulder replacement procedure.
Surgery
Total Shoulder Arthroplasty (Replacement) is a complex procedure
that involves the removal and replacement of both the ball and the
socket. First an incision is made, most commonly along the side or in
front of the arm, and the joint is exposed. The head of the humerus
(ball) is removed and the glenoid cavity (socket) is cleaned out. A
polyethylene plastic insert is placed in the glenoid and secured with
cement to form the new socket. Next the humeral stem is fit into
position. Depending on the fit of the stem and your surgeon’s
preference, cement may or may not be used to secure the stem.
Lastly a carefully fit metal ball is secured to the end of the humeral
stem and the shoulder is rejoined. http://drgordongroh.com/shoulder.html 1
Total Shoulder Arthroplasty is not an outpatient day surgery procedure. You will be required to spend a
few days in the hospital to recover. If the procedure and your early recovery goes well you will typically
be discharged in 2-3 days. Some more complex cases require a short stay in a rehab hospital following
the procedure.
Post-Operative Precautions
The new prosthetic joint is not as stable as a natural shoulder joint, and it needs to be protected while
the surrounding soft tissue structures heal after surgery. You must wear a sling per your doctor’s
instructions after your operation to allow for this healing to occur. This may be as long as 3-4 weeks.
Also, there are specific range of motion precautions you must follow after surgery:

While lying on your back, a small pillow or towel roll should be placed behind your elbow to
avoid stretching the repaired muscles and ligaments, i.e. you should always be able to see your
elbow in front of your body when lying on your back.
Do NOT place your operated arm behind your back or behind your head.
NO active ROM forward
You must observe these precautions for at least 6-8 weeks after your operation unless otherwise
instructed by your surgeon.
At Home
You will likely receive home care visits from a registered nurse and a physical therapist after being
discharged home. The nurse will help monitor your medical status and the physical therapist will help
you work to restore mobility, strength and tolerance for activity. You should replace your post-op
dressing 2-3 days after surgery, and have the nurse and physical therapist inspect your incision for signs
of infection. If you have staples closing your incision they will likely be scheduled to be removed around
10-14 days after the operation. Your home care physical therapist will work with your surgeon and their
staff to determine when you are ready to attend outpatient physical therapy.
Showering
You may shower after 3 days, as long as the incision is not draining. If the incision is draining try to keep
it from getting wet during showering by using a water-tight dressing.
Medication
Driving
Your surgeon will tell you when you are ready to return to driving. Commonly, you are not permitted to
drive until your sling is off, which may take 3-4 weeks. You cannot drive while taking narcotics.
Ice
You should use ice or the cryotherapy machine on your shoulder after the operation for management of
pain and swelling. Ice should be applied 3-5 times a day for 10-20 minutes at a time. Always maintain
one layer between ice and the skin. Putting a pillow case over your ice pack works well for this. The
home care physical therapist can help you customize a plan on how and when to best apply ice to your
shoulder.

Your first post-operative visit will be 10-14 days after the operation. At this visit you will meet with the
surgeon or the physician assistant who will look at your shoulder range of motion, examine your
incision, and discuss when it will be appropriate to make an appointment to begin outpatient physical
therapy. Your next visit will be around 6 weeks after the operation. At this visit you may have an X-ray

taken to make sure that the shoulder replacement components are aligned well. Additional follow up
visits to the doctor’s office will be based on your surgeon’s discretion.

Recovering from Total Shoulder Arthroplasty surgery is not easy. It is very important to realize that the
recovery process is difficult and time consuming. You must be an active participant during this process,
performing daily exercises to ensure there is proper return of range of motion and strength. There is a
large amount of variability in the time it takes to fully recover from this procedure. It is usually
estimated that it will take at least 4-6 months for the patient to feel as though he or she has completely
returned to a pre-injury level of activity. Some cases may take as long as 9-12 months to make a full
recovery. People with desk jobs should plan to take at least 4 weeks off from work and should have an
extended absence plan in place should complications arise. People with more physical jobs that require
excessive weight bearing and manual labor will likely be out of work for at least 3-6 months. Recovery is
different in each case. Your individual time table for return to activities and work will be discussed by
your surgeon during post operative office visits.

Rehabilitation
This protocol has been adapted from Wilcox, Arslanian, and Millet’s protocol described in Rehabilitation Following Total
Shoulder Replacement, which was published in the Journal of Orthopedic and Sports Physical Therapy, December 2005; 35: 821-
836.
Phase 1: Immediate Post Op Phase (Surgery to Hospital Discharge)
Goals
Protect and allow healing of soft tissue
Control pain and swelling
Independence with activities of daily living (ADLs), ie. Dressing, toileting etc.
Independence with mobility
Independence with home exercise program
Precautions
Post-operative precautions (see page 1)
Limited shoulder AROM (May perform forward reaching with ADL’s in sagital plane)
NO lifting or weight-bearing with operated arm
NO reaching behind the back or behind the head
AROM: hand, wrist, forearm, and elbow
PROM: shoulder flexion 0 to 140* as tolerated
IR to chest, ER to 30*
Pendulums
Scapular mobilizations (elevation/depression, retraction/protraction)
Guidelines
Perform PROM exercises 2-3x/day. Perform 10-15 repetitions of all elbow/wrist/hand exercises
and scapular mobilization 3-5 times a day. Use ice after PROM for 10-20 minutes.
Inpatient Plan of Care

Screen for sensory/motor deficits
Continuous Cryotherapy
Provide patient education for movement precautions and positioning to avoid shoulder
extension past 0* (to prevent subscapularis stretch)
Initiate exercise regimen
Discharge planning
Must teach caregiver PROM for supine forward flexion to be done at home

Phase 1(A): Passive ROM (PROM) phase (Hospital Discharge- Week 4)
Goals
Protect and allow healing of soft tissue
Begin to restore range of motion (ROM)
Restore independent functional mobility
Educate the patient regarding their post-operative precautions
Precautions
Post-operative precautions (see page 2-3)
Limited shoulder AROM (May perform forward reaching with ADL’s in sagital plane)
NO lifting or weight-bearing with operated arm
Screen for sensory/motor deficits
Range of Motion
Supine PROM: forward flexion, gentle ER to 30 degrees in scapular plane, IR to chest
o Surgeon may have specific ROM guidelines based on inter-operative findings
AROM: elbow, wrist, hand
Pendulum exercises
Progress to Active Assisted ROM (AAROM) shoulder flexion, ER, and IR in the scapular plane
by the end of this phase.
No Repetitive AROM exercises for Shoulder
Strength
Periscapular muscle AROM/isometric exercises
Functional Mobility
Bed mobility
Transfer training
Positioning (when in bed)
While supine, always place a small pillow or towel roll behind the operated arm’s elbow to
avoid shoulder hyperextension, stretching the anterior capsule, or stretching the
subscapularis.
Wean sling towards the end of this phase or per MD recommendation
o Encourage out of sling in sitting, Wear sling in public or when active around house
Guidelines
Perform PROM exercises 2-3x/day. Perform 10 repetitions of all elbow/wrist/hand exercises and
periscapular isometrics 3-5 times a day. Use ice after PROM for 10-20 minutes.

Criteria for Progression to Phase 2:
Good tolerance of PROM program with:
PROM flexion at least 90◦
PROM abduction at least 90◦
PROM ER in the plane of the scapula at least 30◦
PROM IR in the plane of the scapula at 30◦ of abduction at least 70◦
Phase 2: Active ROM (4 Weeks- 6 Weeks)
Goals
Restore full PROM
Begin restoring AROM
Continue to protect healing tissue
Precautions
Post-operative precautions
NO heavy lifting or weight-bearing with operated arm
NO sudden jerking movements in operated shoulder
If poor shoulder mechanics are present, avoid repetitive shoulder AROM
Range of Motion
Continue with PROM exercises and slowly progress to normal range
o Do not force passive ER
Initiate AROM: flexion, elevation in the scapular plane, IR, and ER
Joint Mobilizations
Gentle glenohumeral and scapulothoracic joint mobilizations as indicated
Strengthening
Initiate sub-maximal shoulder isometrics in neutral
Periscapular strengthening exercises as tolerated
May initiate gentle glenohumeral and scapulothoracic rhythmic stabilization
Guidelines
Perform 10-20 repetitions of all ROM exercises 2x/day. Perform 10-20 repetitions of isometric shoulder
exercises 1x/day, and 2-3 sets of 15-20 repetitions of periscapular strengthening exercises 1x/day.

Good tolerance of PROM/AROM, isometric program
PROM flexion at least 140◦, PROM abduction at least 120◦
PROM ER in plane of scapula at least 45◦,
PROM IR in plane of scapula measured at 30◦ of abduction at least 70◦

Phase 3: Strengthening (6-12 Weeks)
Goals
Restore normal AROM
Restore normal strength
Optimize neuromuscular control in the shoulder complex
Return to baseline functional activities
Precautions
Continue to avoid stress on the anterior capsule
NO heavy lifting (>5 pounds), pushing, or pulling
NO sudden jerking movements in operated shoulder
Range of Motion and Stretching
Continue PROM as needed, progressing to gentle stretching
o Do not force passive ER
May initiate shoulder AAROM IR behind the back
Progress AROM shoulder flexion, scpation, ER, IR as needed
o Ensure correct scapulohumeral rythm
Joint Mobilizations
Glenohumeral and scapulothoracic joint mobilizations as indicated
Strengthening *Delay resisted strengthening until phase 4 if concomitant rotator cuff repair (supra,
infra, teres)
Resisted shoulder ER in the scapular plane
Delay resisted IR until 12 wks (unless otherwise indicated by MD)
Initiate supine shoulder elevation strengthening at progressive inclines
Progress to resisted flexion, abduction, and extension towards the end of this phase
Continue periscapular strengthening progression
Guidelines
Perform 10-20 repetitions of all ROM exercises daily. Hold all stretches 20-30 seconds for 2-3
repetitions, 2-3x/day. Perform 2-3 sets of 15-20 repetitions of all strengthening exercises 4-6x/week.

Tolerates AA/AROM/ strengthening
AROM flexion supine at least 140◦
AROM abduction supine at least 120◦
AROM ER in plane of scapula at least 60◦
AROM IR in plane of scapula supine in 30◦ of abduction at least 70◦
Active shoulder elevation against gravity with good mechanics to at least 120◦

Phase 4: Advanced Phase (12 Weeks and Beyond)
Goals
Maintain pain-free ROM
Maximize strength, power, and endurance
Maximize UE function
Progress weight-bearing tolerance
Work with PT and MD to create customized routine to allow return to appropriate sports/
recreational activities (i.e. golf, doubles tennis, cycling, gardening)
Precautions
Continue to avoid stressing the anterior capsule
Ensure gradual progression of strengthening program
ROM and Flexibility
Continue AROM stretching exercises as indicated
Strengthening
Continue with all strengthening exercises increasing resistance and decreasing repetitions
Initiate and progress weight-bearing exercises
Functional Progression
Activity/sport-specific training exercises
Guidelines
Perform ROM and flexibility exercises daily.
Perform strengthening exercises 3-5x/ week, performing 2-3 sets of 10-15 repetitions.

Time Precautions Goals Recommended Exercises
Phase Dislocation Protect and allow ROM
1/1(A): precautions healing of soft Supine PROM: forward flexion, gentle ER in
Day 1 – 4 Limited FF AROM tissue scapular plane, IR to chest
Weeks NO lifting or Control pain and AROM: elbow, wrist, and hand
weightbearing swelling Pendulum exercises
with operated Begin to restore Progress to AAROM shoulder flexion, ER, and IR in
arm ROM the scapular plane by the end of this phase
Screen for Restore STRENGTH
sensory/motor independent Periscapular muscle isometrics
deficits functional FUNCTIONAL MOBILITY
PROM:FF to 140, mobility Bed mobility
IR to chest, ER to Educate the Transfer training
30 in scap plane patient regarding POSITIONING (when in bed)
their dislocation While supine, always place a small pillow or towel
precautions roll behind the operated arm’s elbow to avoid
shoulder hyperextension, stretching the anterior
capsule, or stretching the subscapularis
Wean sling towards the end of this phase
Phase 2: Dislocation Restore functional ROM
4 Weeks – precautions PROM Continue with PROM exercises until normal (no
6 Weeks NO heavy lifting Gradually restore forced Passive ER)
or weightbearing AROM Initiate AROM: flexion, elevation in the scapular
with operated Control pain and plane, IR, and ER
arm swelling Joint Mobilizations
No sudden Continue to Gentle glenohumeral and scapulothoracic joint
jerking protect healing mobilizations
movement in tissue Strengthening
operated Initiate sub-maximal shoulder isometrics in neutral
shoulder Periscapular strengthening exercises as tolerated
If poor shoulder Initiate glenohumeral and scapulothoracic
mechanics are rhythmic stabilization
present, avoid
repetitive
shoulder AROM
Phase 3: Continue to Restore normal ROM
6 Weeks – avoid stress on shoulder AROM Continue PROM as needed, progressing to gentle
12 Weeks the anterior Optimize stretching
capsule neuromuscular Initiate shoulder AAROM IR behind back,
NO heavy lifting control in the progressing to active stretching by the end of this
(>5 pounds), shoulder complex phase
pushing, or Return to baseline Progress AROM shoulder flexion, scaption, ER,
pulling UE functional and IR as needed
NO sudden activities Joint Mobilizations
jerking Glenohumeral and scapulothoracic joint
movements in mobilizations as indicated
operated Strengthening
shoulder Resisted shoulder ER and IR in scapular plane
Initiate supine shoulder elevation strengthening at
progressive inclines
Continue periscapular strengthening progression

Progress to resisted flexion, abduction, and
extension towards the end of this phase
Phase 4: Continue to Maintain pain- ROM
12 weeks avoid stressing free ROM Continue daily PROM and stretching exercises as
and Beyond the anterior Maximize indicated
capsule strength, power, Strengthening
Ensure gradual and endurance Continue with all strengthening exercises
progression of Maximize UE increasing resistance and decreasing repetitions
strengthening function Initiate and gradually progress weightbearing
program Progress exercises
weightbearing Functional Progressions
tolerance Activity/sport-specific training exercises
Work with PT and
MD to create
customized
routine to allow
return to
appropriate
sports/
recreational
activities (i.e. golf,
doubles tennis,
cycling, gardening

ACL Non-Operative Protocol

The knee is a hinge joint connecting the femur and tibia bones. It is
held together by several important ligaments. The most important
ligament to the knee’s stability is the Anterior Cruciate Ligament (ACL).
The ACL attaches from the front part of the tibia to the back part of the
femur. The purpose of this ligament is to keep the tibia from sliding
forward and rotating on the femur. For this reason, the ACL is most
susceptible to injury when twisting or rotational forces are placed on
the knee. Although this can happen with contact, approximately 70%
of ACL tears occur during non-contact events when athletes are cutting,
decelerating or landing from a jump. After the ACL is torn, the knee is
less stable and it becomes difficult to maintain a high level of activity
without the knee buckling or giving way. It is particularly difficult to perform the repetitive cutting and
pivoting that is required in many sports.
Treatment Options
Regardless of how the ACL is torn, your physician will work with you to determine a personalized course
of treatment. People participating in sports or work related activities that require a lot of pivoting,
cutting, or jumping may decide to have surgery. Depending on your lifestyle, however; conservative
treatment may be the best option. In the case of an isolated ACL tear with no other ligamentous or
cartilage involvement, the associated pain and dysfunction can be successfully treated with physical
therapy.
The initial course of treatment in physical therapy includes rest, anti-inflammatory measures and activity
modification. After the swelling resolves and normal range of motion and strength is achieved, a
decision between you and your physician can be made to determine further treatment options. If a
non-surgical approach is chosen, it is imperative to maintain the strength, balance, and range of motion
you gained in physical therapy to avoid further injury. At this juncture, many people elect to use a
sports brace and limit their participation in activities that require a lot of pivoting, cutting or jumping. If
conservative measures are unsuccessful and recurrent buckling persists, you and your physician may
elect to have the ACL reconstructed.

Recovering from a torn ACL is not an easy process. It can be a long and difficult recovery that requires a
tremendous commitment to rehabilitation. You must be an active participant during this process,
performing daily exercises to ensure the return of your range of motion and strength. Recovery for a
non-operative ACL tear is variable and largely dependent on your goals. People with desk jobs may take
up to one week off from work due to pain. Manual laborers can be out of work for up to 6-8 weeks.
Athletes will not be able to return to their sport immediately and will have to avoid cutting, pivoting,
and jumping. Some people can cope with their injury and return to sports but typically require at least
8-10 weeks of physical therapy. Ultimately, return to sport and work is dependent on how you progress
in therapy and whether you continue to have episodes of knee buckling. Recovery is different for every
individual. Your personal time table for return to activities and work will be addressed by your
physician and physical therapist throughout your course of treatment.
At Home
Immediately after the injury, resting and icing your knee can help control swelling and reduce some of
your pain. Ice should be applied 3-5 times a day for 10-20 minutes at a time. Always maintain one layer
between the ice and your skin. A pillow case or paper towel serves as a good barrier to protect your
skin.
Your surgeon may prescribe pain medicine for you after your injury. Please call the doctor’s office if you
have any questions regarding medication.
As a result of the injury, your knee is unstable and your thigh muscles can become extremely weak. It
may be difficult to support the weight of your body when walking for the first few days. Crutches
and/or a brace may be provided by your doctor to protect the knee from continued episodes of giving
way and allow your knee to recover. Once the strength in your leg begins to return and you can
demonstrate normal walking mechanics, your physical therapist will instruct you to wean away from the
crutches. This typically takes less than 1-2 weeks.
Surgery
Sometimes, conservative treatment is unsuccessful and recurrent
buckling persists. In this case, you and your physician may decide
to have the ACL reconstructed. ACL reconstruction surgery is not
a primary repair procedure. This means that the ligament ends
cannot simply be sewn back together. The new ACL must come
from another source and grafted into place in the knee. There are
a few different graft options used for the ACL graft and each
patient should consult with his or her surgeon to determine the
best choice. During the procedure, a tunnel is drilled through the tibia and the new ACL graft is passed
through it and anchored into place. Regardless of what type of graft is used, having an ACL
reconstruction requires a significant commitment to physical therapy. Recovery is variable and
rehabilitation can take anywhere from 6 months to a year.

Rehabilitation
Phase 1 (Acute Phase)
Goals
Restore pain free ROM
Improve flexibility
Normalize gait mechanics
Establish good quadriceps activation
Precautions
WBAT with crutches until demonstrates normal gait mechanics
Alert physician if patient reports episodes of knee buckling
Range of Motion
Patella mobilization (Medial/Lateral, Superior/Inferior) 2 Sets of 20 Repetitions
Belt stretch (calf/hamstring) Hold 30 Seconds 3-5 Repetitions
Heel slides 2 Sets of 20 Repetitions
Prone quad stretch Hold 30 Seconds 3-5 Repetitions
Cycle (minimal resistance) 10-15 Minutes Daily
Strength
Quad sets 2-3 Sets of 20 Repetitions
Add sets 2-3 Sets of 20 Repetitions
SLR *(no Lag)* 2-3 Sets of 10-20 Repetitions
Hip Abd/Add/Ext/ER (against gravity) 2-3 Sets of 10-20 Repetitions
Body weight squats (partial range) 2-3 Sets of 10-20 Repetitions
Standing TKE with Theraband/cable column 2-3 Sets of 10-20
Standing or prone hamstring curls 2-3 Sets of 10-20 Repetitions
Heel raises 2-3 Sets of 10-20 Repetitions
Guidelines
Swelling and ROM deficits must be resolved before progressing to next phase. Use exercise bike daily if
possible for 10-15 minutes. Perform ROM exercises 3-5 times a day. Perform strengthening exercises 1
time a day.

Phase 2 (Sub-Acute/Strengthening Phase)
Goals
Avoid patella femoral pain
Maintain ROM and flexibility
Restore muscle strength
Improve neuromuscular control
Precautions
D/C crutches if have not already
Range of Motion
Continue ROM and initiate LE flexibility exercises
Cycle/elliptical 10-15 Minutes
Strengthening
Continue Open Chain hip and knee strength from phase 1 progress with ankle weights
Hamstring strengthening (progress from standing curl, leg curl machine, to curl on pball, single
leg dead lift) 2-3 Sets of 15-20 Repetitions
Leg press (progress from double-limb to single limb) 2-3 Sets of 15-20 Repetitions
Step-up progressions (forward and lateral) 2-3 Sets of 15-20 Repetitions
Squat progression (limit to 90 degrees) 2-3 Sets of 15-20 Repetitions
Plank, side plank, single-limb bridge 2 Sets of 30 seconds each (15 seconds each leg with bridge)
Proprioception
Static Single-limb balance 3 Sets of 30-60 seconds (progress eyes open to eyes closed, foam,
BOSU, *sport specific if applicable)
Guidelines
Perform all ROM and flexibility exercises once a day. If possible, cycle daily. Perform strengthening
exercises 3-5 times a week (frequency and volume programmed by PT).
Phase 3 (Limited Return to Activity Phase)
Goals
Avoid patella femoral pain
Maintain ROM and flexibility
Progress with single leg strengthening to maximize strength
Progress dynamic proprioception exercises to maximize neuromuscular control
Initiate plyometrics and light jogging
Gradually begin return to sport activities pending physician’s clearance

Precautions
Must avoid patella femoral stress
Caution pivoting and lateral movements
Range of Motion and Flexibility
Continue ROM and flexibility exercises as needed
Cardio
Cycle/elliptical/treadmill with progressive resistance
Strengthening
Continue progressing Phase 2 strengthening exercises
Step-up progressions (increase height of step) 2-3 Sets of 15-20 Repetitions
Single-limb dead lift 2-3 Sets of 15-20 Repetitions
Static lunge progressions (forward/backward/lateral) 2 Sets of 50 feet
Proprioception
Single-limb balance with perturbations 3 Sets of 30-60 seconds (progress eyes open to eyes
closed, foam, BOSU, *sport specific if applicable)
Plyometrcs *emphasize eccentric control, avoiding increased trunk flexion, dynamic genu valgum, and
femoral internal rotation, must have appropriate strength to progress to plyometric program* (see page
7 for more detailed progression)
Simple double-limb jumps
Complex double-limb jumps
Guidelines
Perform stretching program daily. Cardio exercise is recommended 3-5 times a week for 20-30 minutes.
Perform strengthening/proprioception exercises 3 times a week. Perform plyometric/jumping exercises
2 times a week. Monitor increased swelling with plyometrics. Decrease intensity if swelling persists.
Strict attention must be paid to form and to minimize patella femoral pain with exercises.
Phase 4 (Return to Activity/Sport Phase)
Goals
Maintain adequate ROM, flexibility and strength
Continue progressive/dynamic strengthening, proprioceptive, plyometric and agility training
Achieve adequate strength to return to sport (pending physician’s clearance)
Precautions
Limited and controlled lateral movements
Gradual return to sport pending physician’s clearance
Work with physician and physical therapist to develop specific return to sport progression

Stretching
Continue daily lower extremity stretching
Cardio
Continue cardio program and progress intensity and duration
Strengthening
Continue strengthening program from phase 3 (increase load and decrease repetition)
Progress from static to dynamic lunges
Proprioception
Continue advanced proprioceptive training (increase difficulty of drills)
Plyometrics *emphasize eccentric control, avoiding increased trunk flexion, dynamic genu valgum and
femoral internal rotation *(see page 7 for more detailed progression)
Single-limb jumps
Combination double-limb jumps
Combination single-limb jumps
Sport Specific Drills
Initiate sports specific drills
Begin speed/agility program (see page 8)
Guidelines
Perform stretching program daily. Cardio program is recommended 3-5 times a week for 20-40 minutes
Perform strengthening/proprioception exercises 3 times a week. Perform plyometric/jumping/agility
exercises 2 times a week. Perform return to sport activities as directed by physician and physical
therapist. Alert physician if patient reports episodes of knee buckling.

Jumping/Plyometric Progression
Phase 3 *Limit 60-90 foot contacts per workout
Simple Double-limb
Wall jumps
Double-limb hops (anterior/posterior and medial/lateral over line)
Box jump (6-8 inches max)
Complex Double-limb
Double-limb jump (for distance)
Double-limb jump (for height)
Double-limb jump (with 90⁰ or 180⁰ turn)
Double-limb lateral jump/lateral box jump (side to side)
Depth jump (6-8 inches max)
*Focus on sticking each landing with good form in frontal and sagittal planes. Stress a soft landing with
good eccentric control.*
Phase 4 *Limit 90-120 foot contacts per workout
Single Limb
Heiden/speed skater hop
Single-limb hop (distance, height, lateral, 90⁰/180⁰ turn)
Single-limb bounding
Single-limb box jumps (6-8 inches max)
Single-limb depth jumps (6-8 inches max)
*Focus on sticking each landing with good form in frontal and sagittal planes. Stress a soft landing with
Combination Jumps (Double-limb)

Repetitive double-limb jumps (distance, height, lateral, turns)
Jump for distance into jump for height
Depth jump to jump for distance/height
Depth jump to jump with 90⁰ turn
Combination Jumps (Single-limb)

Repetitive single-limb jumps (distance, height, lateral, 90⁰/180⁰ turn)
Jump for distance into jump for height
Depth jump to jump for distance/height
Depth jump to jump with 90⁰ turn
*String jumps together. Focus on quickly moving from jump to jump.*

Speed/Agility Progression
*Work with physical therapist to establish proper warm-up and cool down before and after each
workout agility session.*
End of Phase 3/Phase 4

Forward/Backward Sprinting
Workout 1: Sprint 50-100 yards at ½ speed 10 reps.
Workout 2: Sprint 50-100 yards at ½ speed 5 reps. Sprint 50-100 yards at ¾ speed 10 reps
Workout 3: Sprint 100 yards at ½ speed 2 reps. Sprint 100 yards at ¾ speed 5 reps. Sprint 50-
100 yards at full speed 5 reps. Backpedal 50 yards at ½ speed 5 reps.
Workout 4: Sprint 100 yards at ½ speed 1 rep. Sprint 100 yards at ¾ speed 2 reps. Sprint 50
yards at full speed 5 reps and 100 yards at full speed 5 reps. Backpedal 50 yards at ¾ speed 5
reps.
Phase 4
Basic Change of Direction
*Begin each workout with sprinting and backpedaling 50 yards (2 reps at ½ speed, 5 reps at full speed)
Workout 5: T drill 3 reps at ½ speed, forward/backpedal shuttle 5/10/20 yard 3 reps at ½ speed
Workout 6: T drill 3 reps full speed, forward/backpedal shuttle 5/10/20 yards 3 reps full speed,
box drill with shuffling 3 reps at ½ speed
Workout 7: Box drill with shuffling 3 reps at full speed, 10 yard shuttle run (quick direction
change) 3 reps at full speed, Z drill 6 reps at ¾ speed
Workout 8: Box drill with cuts 3 reps at full speed, 10 yard shuttle run (quick direction change) 3
reps at full speed, Z drill 6 reps at full speed
Advanced Drills
Work with physical therapist to develop sport specific drills. Perform drills from previous weeks with
use of ball, stick, etc. Perform drills seen in typical sports practice with supervision.

Weight Bearing
Time and Gait Focus Range of Motion Recommended Exercises Precautions
Phase 1 *WBAT with *Control pain and *Emphasize knee ROM *Minimize joint
Acute Phase crutches and swelling extension equal to Patella mobilization, calf/hamstring effusion and
progress to FWB *Restore pain free ROM contralateral limb stretches, heel slides, prone quad edema
and d/c crutches *Restore normal gait *Goal is to achieve stretching, bicycle *Alert physician if
when patient can mechanics full flexion Strengthening patient reports
demonstrate *Establish good Quad/Add sets, SLR (no lag), hip episodes of knee
normal gait quadriceps activation Abd/Add/Ext/ER, partial range squats, buckling
mechanics standing TKE, standing or prone hamstring
curl, heel raises
Phase 2 *FWB *Maintain ROM and *Maintain full ROM ROM *Minimize joint
Sub-Acute flexibility and optimize LE Continue Phase 1 exercises and initiate LE effusion and
Phase *Progress strengthening flexibility flexibility exercises, bicycle/elliptical with edema
*Improve neuromuscular increased resistance *Alert physician if
control Strengthening patient reports
Continue Phase 1 strengthening, leg press, episodes of knee
leg curl machine, step-ups, squats, plank buckling
series, single-limb balance *Avoid patella
Proprioception femoral joint stress
Single-limb balance exercises
Phase 3 *Straight ahead *Maintain ROM and *Maintain full ROM ROM/Stretching *Alert physician if
Limited Return jogging per flexibility and optimize LE Continue ROM and flexibility exercises as patient reports
to physician *Maximize strength, flexibility needed episodes of knee
Activity/Sport approval initiate single leg Cardio buckling
exercises Bicycle/elliptical/treadmill with progressive *Avoid patella
*Maximize resistance femoral joint stress
neuromuscular control Strengthening especially with
*Initiate plyometrics and Progress Phase 2 strengthening, step-up plyometrics
light jogging progressions, single-limb dead lifts, static *Monitor increased
*Initiate return to lunges knee effusion with
sport/work activities Proprioception plyometrics
with physician approval Single-limb balance with perturbations *Caution pivoting
Plyometrics or lateral
Double-limb simple and complex movements
plyometrics *Not cleared to
return sports

Phase 4 *Sport specific * Maintain ROM, *Continue daily LE ROM/Stretching *Alert physician if
Return to program per flexibility, and strength stretching Continue daily stretching patient reports
Activity/Sport physician *Continue dynamic Cardio episodes of knee
clearance strengthening and Bicycle/elliptical/treadmill with progressive buckling
proprioceptive exercises resistance *Avoid patella
*Continue plyometrics Strengthening femoral joint stress
and initiate agility Progress Phase 3 strengthening, increase especially with
training load and decrease repetitions plyometrics
*Progress sport specific Proprioception *Monitor increased
drills Progress Phase 3 proprioceptive training knee effusion with
increasing difficulty of drills plyometrics
Plyometrics *Caution pivoting
Begin single-limb plyometrics, advance or lateral
double-limb and single-limb combination movements
jumps *Cleared for return
Sport Specific Drills to sport per
Begin speed and agility program physician

ACL Prevention Program

The knee is a hinge joint connecting the femur and tibia bones. It is held together by several important
ligaments. The most important ligament to the knee’s stability is the Anterior Cruciate Ligament (ACL).
The ACL attaches the front part of the tibia to the back part of the femur. The purpose of this ligament
is to keep the tibia from sliding forward and rotating on the femur.
Risk Factors
There are many factors that can increase the risk for an
ACL injury. Due to the ACL’s primary role in stabilizing the
knee joint, the ACL is most susceptible to injury when
twisting or rotational forces are placed on the knee.
Although this can happen with contact, approximately 70%
of ACL tears occur during non-contact events when
athletes are cutting, decelerating or landing from a jump.
Many studies have confirmed that muscle strength
imbalances, poor coordination and inadequate sports-
specific conditioning can increase the risk of an ACL injury.
Prevention
ACL prevention programs have been shown to reduce this risk of ACL injuries by establishing proper
jumping and cutting techniques. Our prevention program consists of three distinct components: a
dynamic warm-up, a strengthening regimen and a plyometric training series. This protocol targets the
muscles of the lower extremity that help support the knee. The progressive nature of our program
ensures the athlete establishes the balanced muscle strength necessary to execute proper jumping
mechanics. The initial focus on strength reduces the risk of knee cap pain that can be associated with
early plyometric training programs. Our program then builds off these strength gains and progresses
toward a comprehensive plyometric program simulating sport specific movement patterns. By
promoting gains in strength, coordination and power, this program is designed to improve your team’s
athletic performance and reduce their risk of an ACL injury.
It is extremely important that your athletes demonstrate proper technique during all of these exercises.
Athletes should be instructed to land each exercise softly with their knees slightly bent. Coaches should

emphasize a wide, athletic stance. Athletes should keep their knees and feet shoulder-width apart and
not let the knees collapse inward (“knock knees”) while jumping or landing. Landing with good control
and the correct posture will prevent injury and reinforce good mechanics.
This program is designed to be performed at the beginning of practice and serve as a warm-up. It
should only take 15-20 minutes to complete each phase. After completing six weeks of this progressive
strengthening and plyometric program, your team can transition to the maintenance phase. Performing
the advance plyometric series 2-3 times a week will help your team maintain their acquired strength,
power and coordination required to prevent future injury.
Phase 1 (0-2 weeks)

Strengthening Phase
Goals
Establish good core and lower extremity strength
Decrease patella femoral (knee cap) load
Prepare for plyometrics
Dynamic Warm-up (perform each exercise for 10-15 yards) 5 minutes

Knee-to-chest
Heel-to-butt
Figure four
Tin soldier walk
Jog
Shuttle run (perform with each leg leading)
Backward running
High knees
Butt kicks
Spiderman
Inch worm
Strengthening 10 minutes
Single-leg dead lift walk 10 yards
Forward lunge 10 yards
Lateral lunge 10 yards each way
Single-leg pelvic bridge 2 Sets of 10 Repetitions
Superman 2 Sets of 10 Repetitions
Plank 2 Sets of 30 seconds
Side plank 2 Sets of 30 seconds
Phase 2 (Week 3)

Balance/Proprioception Phase
Goals
Continue to improve core and lower extremity strength
Improve coordination, balance and reaction time
Prepare for plyometrics

Same as Phase 1.
Strengthening 10 minutes
Single-leg dead lift backwards walk 10 yards
Backward lunge 10 yards
Lateral lunge 10 yards each way
Single-leg pelvic bridge on ball (basketball, soccer ball, etc.) 2 Sets of 10 Repetitions each leg
Plank with punch 2 Sets of 30 seconds
Side plank with leg raise 2 Sets of 30 seconds
Balance/Proprioception 5 minutes
Single-leg balance with partner passing (basketball, soccer ball, etc.) 2 Sets of 30-60 seconds
each leg *maintain a slight bend in the knee and avoid knee collapsing inward (“knock
knee” posture)*
Phase 3 (Week 4-5)

Early Plyometric Phase
*In order to perform plyometrics safely, athletes must land each jump softly, maintain a slight bend in
the knees, keep knees shoulder-width apart and chest up*
Goals
Improve endurance and power
Continue to improve coordination, balance and reaction time
Stress good jumping and landing techniques

Same as Phase 1.
Balance/Proprioception 5 minutes
Single-leg balance with partner passing (basketball, soccer ball, etc.) 2 Sets of 30-60 seconds
each leg *maintain a slight bend in the knee and avoid knee collapsing inward (“knock
knee” posture)*
Plyometrics 10 minutes
Week 4: (perform each exercise for 30 seconds)

Simple Double-limb Jumps
Double-leg lateral hops over line- athlete stands to the left of the line, hops back and
forth over the line softly landing on the balls of the feet. Emphasize soft
landings, maintaining a slight bend in the knee.
Double-leg forward/backward hops over line- athlete stands behind the line, hops back
and forth over the line softly landing on the balls of the feet. Emphasize soft
landings, maintaining a slight bend in the knee.
Double-leg vertical jumps- athlete stands with hands at side, knees slightly bent and
jumps straight up for maximum height. Emphasize soft landings, maintaining a
slight bend in the knee. Hold each landing for 3-5 seconds.
Double-leg long jump- athlete stands with hands at side, knees slightly bent and hops
forward for distance. Emphasize soft landings, maintaining a slight bend in the
knee. Hold each landing for 3-5 seconds.

Combination Double-limb Jumps
Double-leg forward bound- athlete stands with hands at side, knees slightly bent and
hops forward 3 times for distance, holding the last jump. Emphasize soft
landings, controlled transitions and maintaining a slight bend in the knee.
Double-leg lateral bound- athlete stands with hands at side, knees slightly bent and
hops to the right, then quickly left and then back right. Emphasize soft landings,
controlled transitions and maintaining a slight bend in the knee.
Simple Single-limb Jumps
Heiden/speed skater hop- athlete stands on one leg with knee slightly bent then jumps
for maximum vertical height and lands on the opposite leg. Emphasize soft
landings, controlled transitions and maintaining a slight bend in the knee.
Single-leg forward/backward hop over line- athlete stands one leg, hops over the line
softly landing on the ball of the foot. Emphasize soft landings, controlled
transitions and maintaining a slight bend in the knee. Perform each leg.
Phase 4 (Week 6)
Advanced Plyometric Phase
*In order to perform plyometrics safely, athletes must land each jump softly, maintain a slight bend in
the knees, keep knees shoulder-width apart and chest up*
Goals
Improve endurance and power
Continue to improve coordination, balance and reaction time
Stress good jumping and landing techniques

Same as Phase 1.

Plyometrics 10 minutes
Complex Double-limb Jumps
Scissor jumps- athlete starts in a lunge with right leg forward, keeping the knee over the
ankle, push off with the right foot and bring the left leg forward. Avoid “knock
knees” with each landing. Emphasize soft landings, controlled transitions and
maintaining a bend in the knee.
Complex Single-limb Jumps
Single-leg bounding- athlete stands on one leg, knees slightly bent and hops forward 3
times for distance and holds the last jump. Emphasize soft landings, controlled
transitions and maintaining a slight bend in the knee. Perform with each leg.
Single-leg hop with 900 turn- athlete stands on one leg, knees slightly bent and hops 900
left, then back, alternating each direction. Emphasize soft landings, controlled
transitions and maintaining a slight bend in the knee. Perform with each leg.
Single-leg cross over hop (“Z hop”)- athlete stands on one leg, knees slightly bent and
hops at a diagonal forward, alternating both to the left and to the right.
Emphasize soft landings, controlled transitions and maintaining a slight bend in
the knee. Perform each leg.

Time Recommended
Goals Precautions
Exercises
Phase 1 Dynamic Warm-up *Increase core and lower *Monitor form, emphasize
(Week 0-2) Knee-to-chest, heel-to-butt, figure four, tin soldier extremity strength quick ballistic movements
walk, jog, shuttle run (perform with each leg *Decrease patella femoral *Keep hips and back level in
leading), backward running, high knees, butt kicks, (knee cap) load plank position
spiderman, inch worm *Prepare for plyometrics
Strengthening
Single-leg dead lift walk, forward lunge, lateral
lunge, single-leg pelvic bridge, superman, plank,
side plank
Phase 2 Dynamic Warm-up *Continue to increase core * Monitor form, keep knees
(Week 3) Continue same warm-up as Phase 1. and lower extremity strength slightly bent, hips level and
Strengthening *Improve coordination, chest up
Single-leg dead lift backwards walk, backward balance and reaction time
lunge, lateral lunge, single-leg pelvic bridge on ball, *Prepare for plyometrics
plank with punch, side plank with leg lift
Balance/Proprioception
Single-leg balance with partner passing (basketball,
soccer ball, etc.)
Phase 3 Dynamic Warm-up *Introduce plyometrics * Monitor form, land with
(Week 4-5) Continue same warm-up as Phase 1. *Instruct proper jumping and soft knees, knees shoulder
Plyometrics landing techniques width apart and chest up
Week 4: Double-leg lateral hops over line, double- *Increase endurance and
leg forward/backward hops over line, double-leg power
vertical jumps, double-leg long jump
Week 5: Double-leg forward bound, double-leg
lateral bound, heiden/speed skater hop, single-leg
forward/backward hop over line
Phase 4 Dynamic Warm-up *Demonstrate good jumping * Monitor form, land with
(Week 6) Continue same warm-up as Phase 1. and landing mechanics soft knees, knees shoulder
Plyometrics *Improve endurance and width apart and chest up
Week 6: Scissor jumps, single-leg bounding, single- power
0
leg hop with 90 turn, single-leg cross over hop (“Z *Transition to maintenance
hop”) phase

ACL Reconstruction Protocol
The knee is a simple hinge joint at the connection point between the
femur and tibia bones. It is held together by several important
ligaments. The most important of these to the knee’s stability is the
Anterior Cruciate Ligament (ACL). The ACL attaches from the front part
of the tibia to the back part of the femur. The purpose of this ligament
is to keep the tibia from sliding forward on the femur. For this reason,
the ACL is most susceptible to injury when rotational or twisting forces
are placed on the knee. Although this can happen during a contact
injury many ACL tears happen when athletes slow down and pivot or
when landing from a jump.
After the ACL is torn the knee is less stable and it becomes difficult to maintain a high level of activity
without the knee buckling or giving way. It is particularly difficult to perform the repetitive cutting and
pivoting that is required in many sports.
Treatment Options
Regardless of how the ACL is torn your physician will work with you to determine what the best course
of treatment will be. In the case of an isolated ACL tear (no other ligaments are involved) the associated
pain and dysfunction can be successfully treated with rest, anti-inflammatory measures, activity
modification and Physical Therapy. After the swelling resolves and range of motion and strength is
returned to the knee a decision can be made as to how to proceed. Many people elect to use a sports
brace and restrict their activity rather than undergo surgery to reconstruct the ACL. If a non-surgical
approach is taken the patient must understand that it is imperative that he or she maintain good
strength in his or her leg and avoid sports or activities that require pivoting or cutting. When
conservative measures are unsuccessful in restoring function you and your physician may elect to have
the torn ligament reconstructed.

In Clinical Collaboration with South Shore Orthopedics
Surgery
ACL reconstruction surgery is not a primary repair procedure.

This means that the ligament ends cannot simply be sewn back
together. The new ACL must come from another source and
grafted into place in the knee. There are a few different
options as to what tissue is used for the ACL graft (the three
most common are patella tendon, hamstring tendon, and
cadaver tendon) and each patient should consult with his or
her surgeon to determine the best choice. During the
procedure a tunnel is drilled through the tibia and the new ACL
graft is passed through it and anchored into place.
Regardless of what type of graft is used ACL reconstruction is typically an outpatient day surgery
procedure. This means that it is very rare to have to spend the night in the hospital and all patients will
likely be home on the same day as surgery.
Recovering from ACL reconstruction surgery is not easy. It is very important that the patient knows the
usually estimated that it will take at least 6 months for the patient to feel as though he or she has
completely returned to a pre-injury level of activity. Some cases may take as long as 9-12 months to
make a full recovery. People with desk jobs should plan to take at least 1 week off from work. Manual
laborers will likely be out of work for at least 4-6 months. Recovery is different in each case. Your
individual time table for return to activities and work will be discussed by your surgeon during post
visit your stitches will be removed and you will review the surgery with the surgeon or his/her assistant.
At this time you will most likely be cleared to make an appointment to begin Physical Therapy. You
should also plan to check in with your surgeon at 6, 12, and 24 weeks after the operation.

At Home
You should replace your post-op dressing 1 day after the operation. The dressing is no longer necessary
after two days as long as the incision is dry. Do not remove the strips of tape (steri-strips) that are
across your incision. Allow them to fall off on their own or to be removed at your doctor’s office visit.
You may shower after 2 days, but use a water-tight dressing until your sutures are removed. It is best to
use a shower bench if possible to avoid weight bearing on the surgical leg. Bathing without getting the
knee wet or sponge baths are another alternative.
Medication
Ice
You must use ice on your knee after the operation for management of pain and swelling. Ice should be
applied 3-5 times a day for 10-20 minutes at a time. Always maintain one layer between ice and the
Crutches
It is very important for you to use crutches after the surgery as instructed by your doctor or physical
therapist. Putting too much weight on your knee in the early phases of recovery can create excessive
and persistent swelling, poor gait mechanics and may cause undue stress on the healing ACL graft. For
Patella tendon grafts you will be allowed to bear as much weight as you can tolerate on your leg while
using your crutches right away after surgery. You may start to wean from the use of your crutches at 2
weeks post op. For Hamstring and Allograft ACL’s you will be partial weight bearing with crutches for
the first 4 weeks. You may progress to weight bearing as tolerated with crutches between weeks 4 and
6 and wean the use of your crutches at 6 weeks post op. In all cases proper gait pattern must be
achieved in order to discontinue use of assistive device!
Brace
After surgery your doctor may require you to wear a large hinged knee brace when walking. If your
doctor has specific instructions regarding the use of this brace then he or she will go over them with you
and your family after the operation, or at your first post operative appointment. Generally it is
recommended that you keep the brace locked in extension while walking and when sleeping for the first
two weeks after the operation. It is recommended that you unlock the brace when sitting to allow your
knee to move and bend. Allowing the brace to be unlocked while walking is generally based on how
well you recover muscle tone in your leg. You may need to use this knee brace for as long as four to six
weeks after the operation.

CPM
After the surgery your doctor may require you to use a CPM (continuous passive motion) machine. He
or she will provide specific instructions regarding the frequency and duration of how long you should
use the machine. The CPM is a machine that will bend and straighten your knee for you while you are
lying down on your back. The machine is typically prescribed for 1-2 weeks and is to be used for up to
10 hours a day. Your goal should be to achieve a range of motion of 0-100 degrees in the first week and
0-120 in the second week after surgery.
Driving
After ACL reconstruction you will not be allowed to drive as long as you are taking narcotic pain
medicine. If you had surgery on your left leg you may drive an automatic transmission car, if your doctor
allows you, as soon as you are no longer taking narcotics. If you had surgery on your right leg your
doctor will let you know when you are clear to drive. Driving is generally not permitted when your leg is
weak enough that you still need to use the post operative brace.

Rehabilitation
Phase 1 (0-2 Weeks)
Goals
Begin to Restore Range of Motion (ROM) Especially Full Extension
Establish Good Quadriceps Activation
Precautions
WBAT with Crutches for Patellar Tendon Graft
PWB with Crutches for Hamstring or Allograft
Bledsoe Brace locked in extension with ambulation and sleeping
Bledsoe Brace unlocked 0-90⁰ when non-weight bearing
Range of Motion
Heel Slides 2 Sets of 20 Repetitions
Assisted Knee Flexion/Extension in Sitting 2 Sets of 20 Repetitions
Heel Prop (passive extension) or Prone Hang 5 Minutes
Belt Stretch (Calf/Hamstring) Hold 30 Seconds 3-5 Repetitions
Ankle Pumps without resistance at least 2 Sets of 20 Repetitions
Strength
Quad Sets 2-3 Sets of 20 Repetitions
Hip Abd/Add/Extension (against gravity) 2-3 Sets of 10-20 Repetitions
Standing or Prone Hamstring Curls (unless Hamstring Graft) 2-3 Sets of 10-20 Repetitions
T-Band Ankle Pumps 2-3 Sets of 20-25 Repetitions
Guidelines
Use exercise bike daily if possible for 10-15 minutes. Perform Range of Motion exercises 3-5 times a
day. Perform Strengthening exercises 1 time a day.

Phase 2 (2-6 Weeks)
Goals
Normalize gait mechanics
Begin to establish return of lower extremity strength especially quadriceps
Precautions
Wean crutches with Patellar Tendon graft
Hamstring and Allograft PWB for 4 wks post op. Progress to WBAT at 4 wks post op and wean crutches
as appropriate.
OK to begin closed chain exercises, but maintain weight bearing restrictions with gait
Bledsoe brace 0-90⁰ with ambulation
*Must stress proper gait*
Range of Motion
Continue ROM exercises from Phase 1 until normal ROM is achieved
Cycle with increased resistance
*Ensure Proper Patellar Mobility*
Strengthening
Continue Quad Sets (as needed for VMO activation)
Continue 4 way SLR program (add ankle weight as needed)
Hamstring Curls (Patellar Tendon and Allograft Only)
Standing Terminal Knee Extension
Mini Squat and/or Wall Slide
Leg Press
Heel Raises
Single Leg Stance
*Minimize effusion before progressing closed chain exercise*
Guidelines
Perform all ROM and strengthening exercises once a day. Do 2-3 sets of 15-20 repetitions. Cycle daily if
possible.

Phase 3 (6-12 Weeks)
Goals
Avoid patellofemoral pain
Continue to maximize return of ROM and flexibility
Establish closed chain strength and proprioception
Precautions
Continue to stress proper gait
Must avoid patella femoral stress
No pivoting or lateral movements
No running
Continue ROM exercises from phase 1 if necessary
Add Lower Extremity stretching (Hamstring, Quadriceps, Calf, Glutes, Adductors, ITB, etc)
Cardio
Cycle with progressive resistance
Elliptical at 8 Weeks
Swimming at 6-8 Weeks
Strengthening
Continue Progression of 4 way SLR and Hamstring Curls with Ankle Weights
Gym Equipment (Leg Press, Ham Curl, Multi-Hip)
Squats to 90⁰
Begin Single Leg strengthening
Step Up Progressions (Forward Step Ups) *Forward Step Downs are not recommended due to increased patella
femoral load*
Static Forward/Backward Lunge
Proprioception
Single Leg Stance
Static Balance on Bosu/Wobble Board/Foam/Etc
Star Drill (single leg stance with reach)
Guidelines
Perform ROM and stretching exercises once a day until normal ROM is achieved. Hold stretches for 30
seconds and perform 2-3 repetitions of each.
Cardio exercise is recommended 3-5 times a week for 20-30 minutes.
paid to form and minimal patella femoral pain with exercises.

Goals
Continue to avoid patella femoral pain
Progress with single leg strengthening
Achieve adequate ROM and strength to begin jogging and plyometric training
Precautions
Straight ahead running only
No pivoting or cutting
No sports
ROM and Stretching
Continue daily stretching
Cardio
Continue cycle, elliptical, swimming
Begin return to running progression at 12 weeks post op (outlined by P.T. or Doctor)
Strengthening
Continue SLR Program and Gym Equipment Progression
Continue Step-Up Progressions (lateral step-ups, cross over step-ups) *Forward Step Downs are not
recommended due to increased patella femoral load*
Dynamic Lunge
Lateral Lunge
Progressive Single Leg Strengthening (single leg squat, split squat, single leg dead lift)
Proprioception
Dynamic Balance (Bosu/Foam/Etc)
Begin Plyometric/Jumping Progression (see page 10)
Guidelines
Perform stretching program daily. Hold stretches for 30 seconds and perform 2-3 repetitions of each.
Cardio program is recommended 3-5 times a week for 20-40 minutes
Perform strengthening/proprioception exercises 3 times a week. Do 2-3 sets of 15-20 Reps.
Perform plyometric/jumping exercises 2 times a week
Goals
Achieve adequate strength to begin return to sport progressions (pending surgeon’s clearance)

Precautions
Limited and controlled lateral movements
Gradual return to sport pending surgeon’s clearance (6 months or greater)
Stretching
Cardio
Strengthening
Continue strengthening program from phase 4 (increase load and decrease volume)
Proprioception
Continue and advance proprioceptive training (increase difficulty of drills)
Progress plyometric/jumping program
Begin speed/agility program (see page 11)
Guidelines
Perform plyometric/jumping/agility exercises 2 times a week
Perform return to sport activities as directed by P.T. or Doctor

Simple Double Limb (12-16 Weeks Post Op) *Limit 60 foot contacts per workout
Double Leg Hops (forward and backward over line)
Box Jump (6-8 inches max)
*Focus on sticking each landing with good form in frontal and sagital planes. Stress a soft landing with
Complex Double Limb (16-20 Weeks Post Op) *Limit 90 foot contacts per workout
Double Leg Jump (for distance)
Double Leg Jump (for height)
Double Leg Jump (with 90⁰ or 180⁰ turn)
Double Leg Lateral Jump/Lateral Box Jump (side to side)
Depth Jump (6-8 inches max)
Combination Jumps (begin at 18-20 weeks post op)

Repetitive Double Leg Jumps (distance, height, lateral, turns)
Jump for Distance into Jump for Height
Box Jump to Depth Jump
Depth Jump to Jump for Distance/Height
Single Limb (20-24 Weeks Post Op) *Limit 100-120 foot contacts per workout
Heiden Hop
Bounding
Single Leg Jumps (distance, height, lateral, 90⁰/180⁰ turn)
Single Leg Box Jumps (6-8 inches max)
Single Leg Depth Jumps (6-8 inches max)
Combination Jumps (Single Leg)

Repetitive Single Leg Jumps (distance, height, lateral, 90⁰/180⁰ turn)

*Work with P.T. to establish proper warm-up and cool down before and after each workout agility
session.*
Forward/Backward Sprinting (16-20 Weeks)

Week 1: Sprint 50-100 yards at ½ speed 10 reps.
Week 2: Sprint 50-100 yards at ½ speed 5 reps. Sprint 50-100 yards at ¾ speed 10 reps
Week 3: Sprint 100 yards at ½ speed 2 reps. Sprint 100 yards at ¾ speed 5 reps. Sprint 50-100 yards at
full speed 5 reps. Backpedal 50 yards at ½ speed 5 reps.
Week 4: Sprint 100 yards at ½ speed 1 rep. Sprint 100 yards at ¾ speed 2 reps. Sprint 50 yards at full
speed 5 reps and 100 yards at full speed 5 reps. Backpedal 50 yards at ¾ speed 5 reps.
Basic Change of Direction (20-24 Weeks)

Week 5: T drill 3 reps at ½ speed, forward/backpedal shuttle 5/10/20 yard 3 reps at ½ speed
Week 6: T drill 3 reps full speed, forward/backpedal shuttle 5/10/20 yards 3 reps full speed, box drill
with shuffling 3 reps at ½ speed
Week 7: Box drill with shuffling 3 reps at full speed, 10 yard shuttle run (quick direction change) 3 reps
at full speed, Z drill 6 reps at ¾ speed
Week 8: Box drill with cuts 3 reps at full speed, 10 yard shuttle run (quick direction change) 3 reps at full
speed, Z drill 6 reps at full speed
Advanced Drills (24 Weeks and Beyond)
Work with P.T. to develop sport specific drills. Perform drills from previous weeks with use of ball, stick,
etc. Perform drills seen in typical sports practice with supervision.

Weight
Time Bearing and Recommended
Focus Range of Motion Precautions
Gait Exercises
Phase 1 *WBAT *Wound Healing *Emphasize 0⁰ ROM *No Hamstring

0-2 Weeks (Patella *Protect ACL Graft Extension Heel Slides, Seated Assisted Strengthening for
Tendon) *Establish Early *Goal to Achieve Knee Flexion, heel prop, prone Hamstring Graft
*PWB ROM Especially 120⁰ of Flexion hang, cycle Patients
(Hamstring Extension *May Have Strengthening *Minimize Joint
and *Establish Good Specific ROM Quad Sets, SLR (no lag), Hip Effusion and
Allograft) Quadriceps Instructions if Abd/Add/Extension, Standing or Edema
*Bledsoe Contraction with Meniscal Repair Prone Hamstring Curl (unless
Brace 0-90⁰ Quad Set Hamstring Graft), T-band Ankle
in All Cases Pump
Phase 2 *Progress to *Continue to *Continue ROM *No Hamstring
2-6 Weeks FWB and d/c Protect ACL Graft Emphasis on 0⁰ of Continue Phase 1 Exercises until Strengthening for
Crutches *Progress ROM Extension normal ROM is achieved Hamstring Graft
When Gait is *Progress *Goal to Achieve Cycle with increased Resistance Patients
Normal Quadriceps Full Flexion by 6 Strengthening *Minimize Joint
(Patella Strengthening Weeks Continue Phase 1 Strengthening Effusion and
Tendon) *Establish Gait *May Have Add Standing T-band TKE, Mini Edema
*Continue Pattern Specific ROM Squat, Wall Slides, Leg Press, *Must Stress
PWB Instructions if Calf Raises Proper Gait
(Hamstring Meniscal Repair *Avoid Patella
and Femoral Joint
Allograft) Stress
*Continue
Bledsoe
Brace 0-90⁰
Phase 3 *Progress to *Normalize Gait *Continue to ROM/Stretching *Hamstring
6-12 Weeks FWB in all Mechanics Maintain Full Cycle, Continue ROM work as Strengthening
Cases *Progressive ROM needed. Start Lower Extremity Begins at Week 6
* Wean Weight Bearing *Begin Lower Stretching Program all Muscle for Hamstring
From Brace Strengthening Extremity Groups Graft Patients
as Gait Stretching Cardio *Continue to
Improves Program Cycle with Progressive Stress Proper
Resistance Gait
Elliptical at 8 Weeks *Continue to
Swimming at 6-8 Weeks Take Care Not to
Strengthening Overload Patella
Progress Open Chain SLR/Hip Femoral Joint
Program with Ankle Weights,
Gym Equipment Leg Press/Ham
Curl/ Multi-Hip, Squats to 90⁰,
Begin Transition to Single Leg
Strengthening, Step Ups, Static
Forward/Backward Lunge
Proprioception
Single Leg Stance, Static Balance
on Bosu/Wobble Board/Etc,
Star Drill Reach

Phase 4 *Straight * Progressive Single *Continue Lower ROM/Stretching * Continue to
12-16 Ahead Leg Strengthening Extremity Continue Daily Stretching Take Care Not to
Weeks Jogging per *Progressive Stretching Daily Cardio Overload Patella
MD Proprioceptive Cycle, Elliptical, Swimming, Femoral Joint
Approval Training Begin Jogging Progression at 12 *Consult With
*Begin Jumping Weeks Physician
Progressions Strengthening Regarding Use of
Continue SLR Program and Gym Sports Brace
Equipment, Progressive Single *Must Have Full
Leg Strengthening, Dynamic ROM, 70%
Lunge, Lateral Lunge Return of
Proprioception Strength and No
Dynamic Balance with Patella Femoral
Bosu/Foam/Etc Pain to Begin
Dynamic Progressions Jogging and
Begin Plyometric/Jumping Plyometric
Progression Progressions
Phase 5 *Lateral *Continue * Continue Lower ROM/Stretching * Must Have Full

16-24 Movement Preparation for Extremity Continue Daily Stretching ROM, 90%
Weeks per MD Return to Sport and Stretching Daily Cardio Return of
and Beyond Approval Physical Activity Cycle, Elliptical, Swim, Jog Strength and No
*Progressive Strengthening Patella Femoral
Strengthening and Continue SLR Program if Pain to Begin
Jumping Necessary, Continue Return to Sport
*Begin Progressive Strengthening From Phase 4 Progressions
Agility Drills With Heavier Loads
Proprioception
Continue Proprioceptive
Training From Phase 4
Advance Plyometric/Jumping,
Begin Lateral Agility Progression
Sport Specific Movements

Knee Arthroscopy (Meniscectomy)

The knee is a hinge joint at the connection point between the femur and
tibia bones. It is held together by several important ligaments. The
knee is also cushioned during weight bearing by two cartilaginous discs,
called the medial (inside) and lateral (outside) menisci. These menisci
provide shock absorption for the knee during weight bearing. Because
they are soft and rubbery these structures are vulnerable to tearing
when the knee is forcefully twisted during activity. This is known as a
traumatic tear. The meniscus can also break down and tear as a result
of repetitive loading stress over time. This type of tear is called a
degenerative tear.
Both traumatic and degenerative tears can create pain, swelling and locking in the knee. Meniscal tears
come in many shapes and sizes. There are many different categories or names to describe the specific
location or type of tear in the meniscus. Small tears can make it difficult to pivot, run or move laterally.
The larger a tear gets though, the more restrictive it is. Large tears can create a great deal of pain in the
knee making it difficult to walk normally. They occasionally even create a locking in the joint that will
not allow the knee to straighten or bend fully.
Treatment Options
No matter what type of meniscal tear is present your physician
will work with you to determine what the best course of
treatment will be. Small, degenerative meniscal tears are often
treated conservatively with rest, anti-inflammatory measures,
activity modification and Physical Therapy. Many times when the
inflammation is resolved and the patient is agreeable to reducing
the load bearing activity affecting the joint, surgery can be
avoided. If a non-surgical approach is taken the patient must
understand that it is imperative that he or she maintain good
strength in his or her leg and avoid sports or activities that require
pivoting or cutting. If the tear is large or if conservative measures
fail to alleviate the associated pain and joint dysfunction than the surgeon may elect to remove the tear
surgically with the use of an arthroscope.

Surgery
When the meniscal tear is removed the surgeon uses an
arthroscopic technique. Two small incisions are made in the front
part of the knee below the knee cap. Through one incision a
camera is inserted so that the surgeon can see the inside of the
knee joint on a monitor. The other incision is used to place a tool
into the joint that will clip and remove the torn piece of cartilage.
While the camera is inside the joint the surgeon uses this
opportunity to examine the rest of the knee to make sure it is
otherwise healthy.

It is very important that the patient knows that the recovery process after surgery requires that he or
she be an active participant, performing daily exercises to ensure there is proper return of range of
motion and strength to the knee. There is a large amount of variability in the time it takes to fully
recover from this procedure. It is usually estimated that it will take at least 4-6 weeks for the patient to
feel as though he or she has completely returned to a pre-injury level of activity. Some cases may take
as long as 2-3 months to make a full recovery. People with desk jobs should plan to take at least a few
days off from work. Manual laborers will likely be out of work for at least 4-6 weeks. Recovery is

visit your stitches will be removed and you will review the surgery with the surgeon or his/her staff. At
this time you may be asked to make an appointment to begin Physical Therapy. Your surgeon will also
discuss a plan for subsequent post operative office visits at this time, and will have you schedule them
accordingly.
At Home
You should replace your post-op dressing 1 day after the operation. The dressing is no longer necessary
after two days as long as the incisions are dry. Do not remove the strips of tape (steri-strips) that are
across your incision. Allow them to fall off on their own or to be removed at your doctor’s office visit.
without getting the knee wet or sponge baths are a good alternative.
Medication

Ice
applied 3-5 times a day for 10-20 minutes at a time until pain and swelling are minimized. Always
maintain one layer between ice and the skin. Putting a pillow case over your ice pack works well for
this.
Crutches
After meniscectomy surgery you will need to use crutches to help you walk for a several days. Starting
right after surgery you may put as much weight as you can tolerate on your operated leg while using
both crutches for support. After a few days if you can maintain proper heel toe gait you should switch
to using one crutch while walking. This crutch should be used on the opposite side of the operated
knee. After a few more days you may walk without crutches, but it is very important that you walk with
a normal gait and not limp. If you can not walk normally continue using your crutch or crutches until
you see your doctor or physical therapist.

Rehabilitation
Phase 1 (0-2 Weeks)
Goals
Restore Joint Range of Motion
Establish Normal Gait Pattern
Establish Hip and Knee Muscle Activation, Especially Quadriceps
Precautions
WBAT with Crutches until normal gait pattern is established
Limit time spent on feet standing or walking
No restrictions in ROM
Range of Motion
Heel Slides 2 Sets of 20 Repetitions
Assisted Knee Flexion/Extension in Sitting 2 Sets of 20 Repetitions
Heel Prop (passive extension) or Prone Hang 5 Minutes
Belt Stretch (Calf/Hamstring) Hold 30 Seconds 3-5 Repetitions
Strength
Quad Sets 2-3 Sets of 20 Repetitions
Hip Abd/Add/Extension (against gravity) 2-3 Sets of 10-20 Repetitions
Standing or Prone Hamstring Curls 2-3 Sets of 10-20 Repetitions
T-Band Ankle Pumps 2-3 Sets of 20-25 Repetitions
Guidelines
Use exercise bike daily if possible for 10-15 minutes. Perform Range of Motion exercises 3-5 times a
day. Perform Strengthening exercises 1 time a day.

Phase 2 (2-6 Weeks)
Goals
Continued Protection of Healing Tissue
Continue to Improve ROM
Continue to Stress Proper Gait Mechanics
Transition to Weight Bearing/Closed Chain Strengthening
Improve Lower Extremity Flexibility
Precautions
Continue to limit swelling in joint by limiting weight bearing activity
Must continue to stress proper gait
No running or sports until cleared by physician
Range of Motion
Continue ROM exercises from Phase 1 until normal ROM is achieved
Cycle with increased resistance
Add Lower Extremity stretching (Hamstring, Quadriceps, Calf, Glutes, Adductors, ITB, etc)
Cardio
Elliptical at 4 Weeks
Swimming at 4 Weeks
Strengthening
Continue 4 way SLR program (add ankle weight as needed)
Standing T-band TKE
Mini Squat and/or Wall Slide
Heel Raises
Gym Equipment at 2-4 weeks post op if pain free (Leg Press, Ham Curl, Multi-Hip)
Step Up Progressions at 4-6 Weeks post op if pain free (Forward Step Ups) *Forward Step Downs are not
Guidelines
Perform all ROM and Strengthening exercises (except gym equipment) once a day. Do 2-3 sets of 15-20
repetitions. Cycle daily if possible.

Goals
Avoid excessive joint stress and joint pain
Continue to maximize return of ROM and flexibility
Continue closed chain strength and proprioception
Precautions
Must avoid excess joint stress and keep closed chain exercises pain free
Begin lateral movement and return to activity progression per physician clearance
Begin return to running progression per physician clearance
Continue Lower Extremity Stretching (Hamstring, Quadriceps, Calf, Glutes, Adductors, ITB, etc)
Cardio
Elliptical
Swimming
May begin return to running progression at 6 weeks post op (outlined by P.T. or Physician)
Strengthening
Continue Progression of 4 way SLR with Ankle Weights
Continue Gym Equipment with progressive loads
Squats to 90⁰
Progressive Single Leg Strengthening (Squat and Lunge Variations)
Step Up Progressions (Forward and Lateral Step Ups) *Forward Step Downs are not recommended due to
increased patella femoral load*
Static Forward/Backward Lunge
Proprioception
Static and Dynamic Balance on Bosu/Wobble Board/Foam/Etc
Star Drill (single leg stance with reach)
May Begin Plyometric/Jumping Progression (see page 6) at 6 Weeks if approved by P.T. and
Physician
May Begin Speed/Agility Progression (see page 7) at 6 Weeks if approved by P.T. and Physician
Guidelines
Perform return to sport activities as directed by P.T. or Doctor

Simple Double Limb (6 Weeks Post Op) *Limit 60 foot contacts per workout
Double Leg Hops (forward and backward over line)
Box Jump (6-8 inches max)
Complex Double Limb (7 Weeks Post Op) *Limit 90 foot contacts per workout
Double Leg Jump (for distance)
Double Leg Jump (for height)
Double Leg Jump (with 90⁰ or 180⁰ turn)
Double Leg Lateral Jump/Lateral Box Jump (side to side)
Depth Jump (6-8 inches max)
Combination Jumps (begin at 18-20 weeks post op)

Repetitive Double Leg Jumps (distance, height, lateral, turns)
Single Limb (8 Weeks Post Op) *Limit 100-120 foot contacts per workout
Heiden Hop
Bounding
Single Leg Jumps (distance, height, lateral, 90⁰/180⁰ turn)
Single Leg Box Jumps (6-8 inches max)
Single Leg Depth Jumps (6-8 inches max)
Combination Jumps (Single Leg)

Repetitive Single Leg Jumps (distance, height, lateral, 90⁰/180⁰ turn)

*Work with P.T. to establish proper warm-up and cool down before and after each agility workout
session.*
Forward/Backward Sprinting (6 Weeks)

Sprint 50-100 yards at ½ speed 10 reps.
Sprint 50-100 yards at ¾ speed 10 reps
Backpedal 50 yards at ½ speed 5 reps.
Basic Change of Direction (7 Weeks)

*Begin each workout with sprinting and backpedaling 50 yards (2 reps at ½ speed, 5 reps at ¾ speed)
T drill 3 reps at ½ speed

Forward/backpedal shuttle 5/10/20 yard 3 reps at ½ speed
Box drill with shuffling or cutting 3 reps at ½ speed
Advanced Drills (8 Weeks and Beyond)
*Begin each workout with sprinting and backpedaling 50 yards (3 reps at ½ speed, 2 reps at ¾ speed and
5 reps at full speed)
Work with P.T. to develop sport specific drills. Perform drills from previous weeks with use of ball, stick,
etc. Perform drills seen in typical sports practice with supervision.

Weight
Gait Exercises
Phase 1 *WBAT *Wound Healing *Emphasize 0⁰ ROM *Minimize Joint

0-2 Weeks *D/C *Protect Joint Extension Heel Slides, Seated Assisted Effusion and
crutches *Establish Early *Goal to Achieve Knee Flexion, heel prop, prone Edema
When Gait ROM 120-135⁰ of hang, cycle *Monitor for Gait
Pattern in *Establish Good Flexion Strengthening Abnormalities
Normal Quadriceps *May Have Quad Sets, SLR (no lag), Hip
Contraction and Specific ROM Abd/Add/Extension, Standing or
proper gait Instructions if Prone Hamstring Curl, T-band
mechanics Meniscal Repair Ankle Pump
Phase 2 *Continue *Normalize Gait *Continue to ROM *Must Continue

2-6 Weeks to Stress Mechanics Stress Normal Continue Phase 1 Exercises until to Stress Proper
Proper Gait *Progressive ROM if Still normal ROM is achieved. Start Gait
Weight Bearing Limited Lower Extremity Stretching *Avoid Joint
Strengthening *Begin Lower Program all Muscle Groups. Stress and
Extremity Cycle with increased Resistance Swelling
Stretching Cardio *Emphasize No
Program Cycle with Progressive Joint Pain with
Resistance Exercise
Elliptical at 4 Weeks Progressions
Swimming at 4 Weeks
Strengthening
Progress Open Chain SLR/Hip
Program with Ankle Weights,
Gym Equipment (Leg Press,
Ham Curl, Etc) Squats to 90⁰,
Begin Transition to Single Leg
Strengthening, Step Ups, Static
Forward/Backward Lunge, Etc
Proprioception
Static and Dynamic Balance
with Bosu/Foam/Etc
Phase 3 *Straight *Continue *Continue Lower ROM/Stretching *Must have MD
6-12 Weeks Ahead Preparation for Extremity Continue Lower Extremity and P.T.
Jogging per Return to Sport and Stretching Stretching Program all Muscle Clearance for
Groups Daily
MD Physical Activity Program Daily Return Return to
Cardio
Approval *Progressive Cycle with Progressive Resistance Jogging, Dynamic
*Lateral Strengthening and Elliptical Progressions and
Movement Jumping Swimming Return to Sport.
per MD *Begin Progressive Begin Return to Run Program at 6
Approval Agility Drills Weeks
*Sport Strengthening
Specific Continue SLR Program and Gym
Equipment, Progressive Single Leg
Training
Strengthening, Dynamic Lunge,
Progression Lateral Lunge, Step Up Progressions
per MD Proprioception
Approval Static and Dynamic Balance with
Bosu/Foam/Etc
Begin Plyometric/Jumping and
Agility Progressions
Progress to Sport Specific Drills

Patellofemoral/Chondromalacia Protocol

The knee is composed of two joints, the tibiofemoral and the
patellofemoral. The patellofemoral joint is made up of the patella (knee
cap) and the groove of cartilage on the femur in which it sits. The purpose
of the patella and the patellofemoral joint is to allow for greater force
development through the quadriceps muscle by creating a fulcrum
mechanism as the knee is extended. This joint is subject to tremendous
forces when the knee is repetitively loaded in flexion and extension during
sports and physical activity.
Normally the knee cap slides up and down following the natural track of
the groove in the middle of the femur. When the knee cap fails to slide up and down evenly in the
groove this can create irritation of the cartilage on the underside of the knee cap. There are many
potential reasons as to why the patella would not accurately track within its groove. One reason is the
alignment of the bones of the leg and foot. Subtle abnormalities in alignment and boney structure can
cause the patella to sit in a position in which it will create uneven pressure and wear within the groove.
Another potential cause of increased load on the joint is improper pull and
tension from the connective tissue that surrounds the joint and the muscles
that control the movement of the patella. Tight structures surrounding the
patella can cause it to slide toward the outside of its groove when the
quadriceps is contracted. These tight structures also cause the patella to be
compressed into the groove as it slides up and down. Imbalance in strength
between the four heads of the quadriceps and weakness throughout the
muscles of the hip can also cause the patella to be improperly positioned
during weight bearing activities.
When the cartilage on the under surface of the knee cap has been
continually irritated for a long period of time it can begin to wear down and
degenerate. This condition is known as chondromalacia of the patella. This degeneration may be
responsible for the crunching and grinding noise heard in some patients when the knee is bent and
straightened. When significant chondromalacia is present this may undermine the knee’s ability to
respond well to conservative treatments.

Treatment Options
The severity, and resulting pain and dysfunction, of patellofemoral syndrome and chondromalacia varies
greatly in patients that are affected by it. In each case the physician and his or her staff evaluates the
individual case and determines the best plan of care for the patient. A period of rest followed by activity
modification may be enough to fix some cases. Use of anti-inflammatory medication and ice may also
be recommended. Active patients may be recommended to wear a brace that supports the knee cap
during activity. The physician and his or her staff may also ask the patient to undergo a course of
physical therapy to address the underlying mechanical causes of patellofemoral joint stress. If
conservative measures are unsuccessful in reducing pain and restoring function your physician may
discuss the potential need for arthroscopic surgery in rare cases. Recovery time from this injury is
different in each case. Your individual time table for return to activities will be discussed by your
physician and or physical therapist.
Relative Rest
Regardless of the specific mechanism (alignment, weakness, etc) patellofemoral syndrome is always
caused by the overloading of the patellofemoral joint. As the pain, inflammation and underlying cause
of the patellofemoral syndrome are treated the physician and/or physical therapist will likely
recommend that the patient refrain from participation in the activities that most provide stress to
injured joint. This does not always mean that the patient must stop all exercise. There are often forms
of exercise in which patellofemoral forces are reduced enough to allow for the patient to continue to
exercise while recovering. The patient should consult with the physician and/or physical therapist to
determine individualized exercise guidelines and restrictions.
Rehabilitation Philosophy
patellofemoral syndrome and chondromalacia of the patella. The physical therapist will evaluate the
patient’s mobility, flexibility and strength with the purpose of determining the underlying cause of the
abnormal stress on the patella. The patient will be counseled on which activities he or she can safely
continue and which should be avoided. The physical therapist will teach the patient the proper
exercises to reduce patellofemoral stress. In most cases this will include strengthening muscles about
the hip and knee that are weak and stretching ones that are tight.

Rehabilitation
**The following is an outlined progression for rehab. Advancement from phase to phase as well as
specific exercises performed should be based on each individual patient’s case and sound clinical
judgment by the rehab professional. **
Goals
Control Pain and Inflammation
Begin Pain Free Flexibility Exercises
Establish Quadriceps Activation
Establish Pain Free Knee ROM
Cycle with Minimal Resistance (if pain free)
Heel Slides (in pain free arc)
Lower Extremity Stretching (based on individual assessment)
Rectus Femoris
IT Band
Hamstring
Hip Rotators
Gastroc
Strength
Quad Sets (intensity and flexion angle guided by pain)
Guidelines
Perform range of motion exercises daily. Do 2-3 sets of 15-20 Reps. Perform stretching program daily.
Hold stretches for 30 seconds and perform 2-3 repetitions of each.

Phase 2 (Sub-acute Phase A)
Goals
Continued Protection of Injured Joint
Continue to Improve Flexibility
Begin to Strengthen Areas of Weakness/Instability
Cycle (slow progression of resistance)
Continue Flexibility From Phase 1
Strength
Begin Open Chain Strengthening (based on strength assessment)
Knee Extension (SAQ, If painful use LAQ in painfree arc)
Straight Leg Raise
Hip Abduction
Hip Extensors
Hip External Rotators
Hamstring Curls
Guidelines
Cardio program should be performed no more that 3-5 times a week for 20-35 minutes.
Perform strengthening exercises daily. Do 2-3 sets of 15-20 Reps.

Phase 3 (Sub-acute Phase B)
Goals
Continue to Avoid Exacerbation of Symptoms
Continue to Maximize Return of Strength and Flexibility
Establish Closed Chain Strength and Stability
Continue Cycle
Continue Lower Extremity Stretching from Phase 1 and 2
Cardio
Cycle with Progressive Resistance
Elliptical (if pain free)
Swimming
Strengthening
Continue Progression of Open Chain Program with Ankle Weights
Can Add Gym Equipment (Leg Press, Ham Curl, Multi-Hip)
Squats to 90⁰ (Stress Pain Free Range and Proper Frontal/Sagittal Plane Mechanics)
Step Up Progressions (Forward Step Ups, Lateral Step Ups) *Forward Step Downs are not recommended due
to increased patella femoral load*
Pain Free Closed Chain Hip Strengthening
Guidelines
Perform strengthening exercises 3 times a week. Do 2-3 sets of 15-20 Reps.

Phase 4 (Return to Sport/Activity Phase)
Goals
Continue to Avoid Patella Femoral Overload
Progress with Single Leg Strengthening
Achieve Adequate Strength and Flexibility to Return to Activity
Flexibility
Continue Daily Stretching
Cardio
Continue Cycle, Elliptical, Swimming
Return to Running Progression (outlined by Physician or Physical Therapist)
Strengthening
Continue SLR Program and Gym Equipment Progression
Continue Step-Up Progressions (lateral step-ups, cross over step-ups) *Forward Step Downs are not
Static Lunge
Lateral Lunge
Progressive Single Leg Strengthening (single leg squat, split squat, single leg dead lift)
Return to Sport
Work with Physician or Physical Therapist to Outline Progressive Return to Sport
Guidelines
Cardio program should be progressed in preparation for return to sport.

Recommended
Phase Emphasis Guidelines
Exercises
Phase 1 *Control Pain and ROM and Flexibility *ROM Daily 2-3 sets of 15-20
Acute Phase Inflammation Cycle (if pain free motion) Reps
*Re-establish Normal Heel Slides (in pain free arc) *Stretching Program Daily 2-3
ROM Lower Extremity Stretching Repetitions of 30 Seconds
*Establish Quadriceps • Rectus Femoris
Activation • IT Band
*Begin Pain Free • Hamstring
Flexibility Program • Hip Rotators
• Gastroc
*based on individual assessment
Strength
Quad Sets
*intensity and flexion angle guided by pain
Phase 2 * Continued ROM and Flexibility * Stretching Program Daily 2-

Sub-acute Protection of Injured Cycle (slow progression of resistance) 3 Repetitions of 30 Seconds
Phase A Joint Continue Flexibility From Phase 1 *Cardio program should be
*Continue to Improve performed no more that 3-5
Flexibility Strength times a week for 20-35
*Begin to Strengthen Begin Open Chain Strengthening minutes.
Areas of • Knee Extension (SAQ, If painful use LAQ *Perform strengthening
Weakness/Instability in painfree arc) exercises daily 2-3 sets of 15-
• Straight Leg Raise 20 Reps
• Hip Abduction
• Hip Extensors
• Hip External Rotators
• Hamstring Curls
Phase 3 * Continue to Avoid Flexibilty * Stretching Program Daily 2-
Sub-acute Exacerbation of Continue Lower Extremity Stretching from 3 Repetitions of 30 Seconds
Phase B Symptoms Phase 1 and 2 *Continue to Stress Proper
*Continue to Gait
Maximize Return of Cardio * Cardio program should be
Strength and Cycle with Progressive Resistance performed no more that 3-5
Flexibility Elliptical (if pain free) times a week for 20-45
*Establish Closed Swimming minutes.
Chain Strength and *Perform strengthening
Stability Strengthening exercises 3 times a week 2-3
Progress OKC Program with Ankle Weights sets of 15-20 Reps.
Can Add Gym Equipment
Squats to 90⁰ (Stress Pain Free Range)
Step Up Progressions (Forward Step Ups,
Lateral Step Ups) *Forward Step Downs are not
recommended due to increased patella femoral
load*

Phase 4 * Continue to Avoid Flexibility * Stretching Program Daily 2-
Sport Specific Patella Femoral Continue Daily Stretching 3 Repetitions of 30 Seconds
Phase Overload *Cardio program should be
*Progress with Single Cardio progressed in preparation for
Leg Strengthening Cycle, Elliptical, Swimming return to sport.
*Achieve Adequate Begin Return to Running Progression *Perform strengthening
Strength and exercises 3 times a week. Do
Flexibility to Return to Strengthening 2-3 sets of 15-20 Reps
Activity Continue OKC Program
Continue Gym Equipment Progression
Continue Step-Up Progressions (lateral step-
ups, cross over step-ups) *Forward Step Downs
are not recommended due to increased patella
femoral load*
Static Lunge
Lateral Lunge
Progressive Single Leg Strengthening (single leg
squat, split squat, single leg dead lift)
Return to Sport
Outlined by PT or MD

Quad/Patella Tendon Repair
The knee is composed of two joints, the tibiofemoral and the patellofemoral. The patellofemoral joint is
made up of the patella (knee cap) and the groove of cartilage on the femur in which it sits. The purpose
of the patella and the patellofemoral joint is to allow for greater force development through the
quadriceps muscle by creating a fulcrum mechanism as the knee is
extended (straightened). Normally the knee cap slides up and down
following the track of the groove in the middle of the femur. This joint
is subject to tremendous forces when the knee is repetitively loaded in
flexion and extension during sports and physical activity.
The Quadriceps muscle is anchored to the patella via the Quadriceps

tendon. The patella, in turn is anchored to the shin bone via the
patellar tendon (see picture above). When the tensile load through the
tendon is greater than the tissue can bear it will tear. These tears often
come in the form of one single traumatic event, but the the events
leading up to the tear may be a culmination of a series of actions
(repetitive microtrauma), or a medical predisposition for breakdown. http://orthoinfo.aaos.org/topiccfm?topic=A00512
Typically, a strong force such as an explosive jump, is required to
rupture the tendon. However, with a history of chronic tendon inflammation (tendinitis), the tendon
may be weakened and could tear with less force. Some medical conditions can also weaken the tendons
and make a tear more likely. These include, but are not limited to: aging and degenerative changes,
diabetes, kidney disease, and rheumatoid arthritis.
Regardless, when the Patellar or Quadriceps tendon tears there is often a tearing or popping sensation,
followed by pain and swelling. Additional symptoms include:
 An indentation above or below the patella where the tendon is torn

 Bruising
 Tenderness
 Muscle cramping
 The kneecap may move up into the thigh because it is no longer anchored
 Inability to straighten the knee
 Knee buckling or giving way
Treatment Options
The severity, and resulting dysfunction, of Patella/Quadriceps tendon tears,
varies greatly. In each case the physician and his or her staff evaluates the
http://orthoinfo.aaos.org/topiccfm?topic =A00512
individual case and determines the best plan of care for each patient. A
period of rest and modified activity, including the use of knee brace for 3‐6 weeks, may be enough to

manage some cases (usually minor partial tears). Use of anti‐inflammatory medication and ice may also
be recommended. The physician and his or her staff may also ask the patient to undergo a course of
physical therapy to address the underlying mechanical causes of patella femoral joint stress. In most
cases surgery is required to reattach the torn tendon to its attachment point.
http://orthoinfo.aaos.org/topiccfm?=A0051 http://orthoinfo.aaos.org/topiccfm?topic
2 =A00512 http://orthoinfo.aaos.org/topiccfm?topic=A00512
Surgery
Surgical repair reattaches the torn tendon to the bone. Patients who require surgery often do better if
the repair is performed early after the injury. Early repair may prevent the tendon from scarring and
retracting in a shortened position. The surgical technique and specific procedure can vary from case to
case. The goal of the procedure is always to restore the correct tension and positioning of the patella so
that the fulcrum mechanism can be maintained. The most common complications of patellar tendon
repair include weakness and loss of motion. Your doctor will likely require you to have physical therapy,
so as to minimize loss of strength and mobility. In most cases a full return to pre‐injury activity levels is
expected.

Recovering from Patellar/Quadriceps tendon repair surgery is not easy. It is very important that the
patient knows the recovery process is difficult and time consuming. He or she must be an active
participant during this process, performing daily exercises to ensure there is proper return of range of
motion and strength. There is a large amount of variability in the time it takes to fully recover from this
procedure. It is usually estimated that it will take at least 6 months for the patient to feel as though he
or she has completely returned to a pre‐injury level of activity. Some cases may take as long as a year to
make a full recovery. People with desk jobs should plan to take at least 1 week off from work. Manual
laborers will likely be out of work for at least 4‐6 months. Recovery is different in each case. Your
individual time table for return to activities and work will be discussed by your surgeon during post
Hospital Stay/Post Operative Visits

After having surgery to repair the Patellar/Quadriceps tendon you may be required to stay in the
hospital for a few days. You will be discharged home as soon as it is safe for you to be so. Your first
post‐op visit to the doctor’s office will be approximately two weeks after the operation. At this visit
your stitches will be removed and you will review the procedure with the surgeon or his/her assistant.
At this time you will most likely be cleared to make an appointment to begin Physical Therapy. Your
surgeon will determine the frequency of subsequent follow up visits.

At Home
You should replace your post‐op dressing daily and inspect your incision for signs of infection. If you
have staples closing your incision they will likely be scheduled to be removed around two weeks after
the operation. If your surgeon used stitches to close the wound do not remove the strips of tape (steri‐
strips) that are across your incision. Allow them to fall off on their own or to be removed at your
doctor’s office visit.
Medication
Ice
applied 3‐5 times a day for 10‐20 minutes at a time. Always maintain one layer of protection between
ice and the skin. Putting a pillow case or towel over your ice pack works well for this.
Walking
It is very important for you to use crutches (or a walker) after the surgery. Putting too much weight on
your knee in the early phases of recovery can create excessive and persistent swelling, poor gait
mechanics and may cause undue stress on the healing repair. You will be instructed on how much
weight you can bear on your leg while using your crutches (walker) right away after surgery. With your
doctor’s permission your therapist will instruct you on how to safely wean from using your crutches
(walker) after 2 weeks post op.
Brace
After surgery your doctor will require you to wear a hinged knee brace. If your doctor has specific
instructions regarding the use of this brace then he or she will go over them with you and your family
after the operation, or at your first post operative appointment. Generally, it is recommended that you
keep the brace locked in extension while walking at all times. The doctor will inform you when you may
walk with the brace unlocked. You may be allowed to unlock the brace to allow some bending when
sitting. Your doctor will tell you exactly how much you are allowed to bend your knee after the
operation. Generally, patients are not allowed to bend the knee past 90 degrees for the first six weeks
after surgery. You will need to use this knee brace for at least six weeks after the operation.
Driving
After surgery you will not be allowed to drive as long as you are taking narcotic pain medicine. If you
had surgery on your left leg you may drive an automatic transmission car, if your doctor allows you, as
soon as you are no longer taking narcotics. If you had surgery on your right leg your doctor will let you
know when you are clear to drive. Driving is generally not permitted when your leg is weak enough that
you still need to use the post operative brace.

Rehabilitation
Phase 1: Inpatient Phase (Surgery‐ Hospital Discharge)
Goals
Restore independent functional mobility
Work with Case Management to Develop Appropriate Discharge Plan
Precautions
WBAT with Crutches/Walker, unless otherwise ordered
Brace locked in extension at all times unless otherwise ordered
Range of Motion
Ankle pumps
Heel Prop (passive extension)
Contralateral leg exercise
Functional Mobility
Gait training on level surfaces
Stair training
Transfer training
ADL’s with adaptive equip as needed
Use a towel roll under ankle to promote knee extension
Never place anything under the operative knee. This can cause difficulty reaching the goal of full
extension.
Inpatient Plan of Care

Day of Surgery
Out of bed to chair
PT Evaluation
Post Op Day 1
PT service and OT Evaluation
Therapeutic Exercise including ROM, Strengthening, and Functional Mobility as appropriate
ADL Training as appropriate
Post Op Day 2‐Discharge
Progression of Therapeutic Exercise and Functional Mobility
Continued ADL Training

Phase 2 (Immediate Post Operative Phase Hospital Discharge ‐ 2 Weeks)
Goals
Begin to Restore Range of Motion (ROM) Especially Full Extension
Establish Good Quadriceps Activation
Precautions
WBAT with Crutches or walker (unless otherwise specified)
Brace locked in extension with ambulation and while sleeping
Brace unlocked when sitting (flexion angle per MD order)
Range of Motion
Heel Slides (with in flexion limitations) 2 Sets of 20 Repetitions
Assisted Knee Flexion/Extension in Sitting (within flexion limitations) 2 Sets of 20 Repetitions
Heel Prop (passive extension) 5 Minutes
Belt Stretch (Calf/Hamstring) Hold 30 Seconds 3‐5 Repetitions
Ankle Pumps without resistance at least 2 Sets of 20 Repetitions
Strength
Quad Sets 2‐3 Sets of 20 Repetitions
Guidelines
Perform Range of Motion and Strengthening exercises 3‐5 times a day as tolerated.
Phase 3 (Protected ROM Phase 2‐6 Weeks)
Goals
Continue to improve ROM (continue MD guided restrictions for flexion)
Continue to establish quad activation
Precautions
WBAT with progressive weaning of crutches or walker as able
Continue limited knee flexion (0‐90 degrees)
Brace locked with ambulation
Range of Motion
Continue ROM exercises from Phase 1 (slowly progress flexion to 90 degrees)
Strengthening
Continue Quad Sets (as needed for VMO activation)
Open chain hip abduction, extension, adduction (add ankle weight or resistance band as appropriate)
Active Knee Flexion (0‐90 degrees only)

Heel Raises
*No SLR or Open Chain Active Knee Extension Until 6 Wks*
Guidelines
Perform all ROM and strengthening exercises once a day. Do 2‐3 sets of 15‐20 repetitions.
Phase 4 (Early Strengthening Phase 6‐12 Weeks)
Goals
Progressive Restoration of Normal Knee Flexion
Wean from Brace and establish proper gait pattern
Begin closed chain strength and proprioceptive training (0‐30 degrees of flexion)
Precautions
Stress proper gait as wean from brace
Must avoid painful patella femoral stress and excessive loading
No running or ballistic movements
Continue ROM exercises from phase 1 and 2 (slowly progress to full knee flexion)
Add Lower Extremity stretching (Hamstring, Calf, Glutes, Adductors, ITB, etc)
*No Quadriceps Stretching until 12 wks
Cardio
Cycle with minimal resistance
Strengthening
Continue Progression of Open chain hip abduction, extension, adduction and Hamstring Curls
Squats to 30⁰
Low Load, Low Flexion Angle Leg Press
Closed Chain Terminal Knee Extension
Proprioception
Single Leg Stance
Static Balance on Bosu/Wobble Board/Foam/Etc
Guidelines
seconds and perform 2‐3 repetitions of each.
Cardio exercise is recommended 3‐5 times a week for 20‐30 minutes.
Perform strengthening exercises 3‐5 times a week. Do 2‐3 sets of 15‐20 Reps. Strict attention must be
paid to form and minimal patella femoral pain with exercises.

Phase 5 (Advanced Strengthening Phase 12‐24 Weeks)
Goals
Continue to avoid patella femoral and extensor mechanism pain
Progress to single leg strengthening with progressive increase in flexion angle
Precautions
No Running, Jumping, Plyometric Progressions until 20‐24 Wks (per MD)
No sports (gradual return to sports after 6 months)
ROM and Stretching
Add gentle Quadriceps stretching
Cardio
Continue cycle with increased resistance
Add elliptical, swimming
Strengthening
Continue SLR Program
Slow Progression to gym Equipment (Leg Press, Ham Curl, Multi‐Hip)
Begin Step‐Up Progressions (lateral step‐ups, cross over step‐ups) *Forward Step Downs are not
Lunge progression (static to dynamic)
Lateral Lunge
Progressive Single Leg Strengthening late in phase (single leg squat, split squat, single leg dead lift)
Proprioception
Dynamic Balance (Bosu/Foam/Etc)
May begin slow progression of jogging and agility training with MD approval at 20 Wks
Work with PT or MD to create patient specific plan
Jumping Progressions after 24 Wks with MD approval
Guidelines
Perform stretching program daily. Hold stretches for 30 seconds and perform 2‐3 repetitions of each.
Cardio program is recommended 3‐5 times a week for 20‐40 minutes
Perform strengthening/proprioception exercises 3 times a week. Do 2‐3 sets of 15‐20 Reps.
Perform dynamic progression exercises 2 times a week
Phase 6 (Return to Sport/Activity Phase 24 Weeks and Beyond)
Goals
Achieve adequate strength to begin return to sport progressions (pending surgeon’s clearance)

Precautions
Limited and controlled plyometric/ballistic movements
Gradual return to sport pending surgeon’s clearance (6‐9 months or greater)
Stretching
Cardio
Strengthening
Continue strengthening program from phase 4 (increase load and decrease volume)
Proprioception
Continue and advance proprioceptive training (increase difficulty of drills)
Progress plyometric/jumping program as outlined by PT or MD
Outline specific return to sport/activity program with PT and/or MD
Guidelines
Perform stretching program daily. Hold stretches for 30 seconds and perform 2‐3 repetitions of each.
Cardio program is recommended 3‐5 times a week for 20‐40 minutes
Perform strengthening/proprioception exercises 3 times a week. Do 2‐3 sets of 15‐20 Reps.
Perform return to sport activities as directed by P.T. or MD

Weight
Gait Exercises
Phase 1 *WBAT with *Control Pain and *Emphasize 0⁰ ROM *Protect Repair
Surgery crutches and Swelling Extension Ankle pumps *Limit Flexion per
to brace locked *Protect Repair *Limit Flexion per Heel Prop (passive extension) MD order
Discharge at 0⁰ *Restore MD order Contralateral leg exercise *Lock Brace with
independent *May Have Functional Mobility Weight Bearing
functional mobility Specific ROM Gait training on level surfaces
*Develop Instructions per Stair training
Appropriate MD Transfer training
Discharge Plan ADL’s with adaptive equip as
needed
Use a towel roll under ankle to
promote knee extension
Phase 2 *WBAT with *Wound Healing *Emphasize 0⁰ ROM *Limit Flexion per
0‐2 Weeks crutches and *Protect Repair Extension Heel Slides, Seated Assisted MD order
brace locked *Establish Early *Limit Flexion per Knee Flexion/Extension, heel *Minimize Joint
at 0⁰ ROM in Extension MD order prop, Effusion and
and limited Flexion *May Have Strengthening Edema
*Establish Good Specific ROM Quad Sets, Hip
Quadriceps Instructions per Abd/Add/Extension, Standing or
Contraction with MD Prone Hamstring Curl
Quad Set
Phase 3 *Progress *Continue to *Continue ROM *Still protective

2‐6 Weeks WBAT and Protect Repair Emphasis on 0⁰ of Continue Phase 1 Exercises: of repair so
wean *Progress ROM Extension slowly progress flexion to 90 progress flexion
crutches as slowly to 90⁰ of *Slowly progress degrees slowly
tolerated flexion over 6 Wks ROM to 90⁰ of Strengthening *Minimize Joint
*Continue *Continue flexion over 6 Quad Sets, Hip Effusion and
Brace locked isometric Wks Abd/Add/Extension, Standing or Edema
at 0⁰ for Quadriceps *May Have Prone Hamstring Curl * Stress Locked
ambulations Strengthening Specific ROM Brace with Gait
Instructions per *Avoid Patella
MD based on Femoral Joint
operative findings Stress
Phase 4 *Unlock *Normalize Gait *Slowly progress ROM/Stretching *Continue to

6‐12 Weeks Brace with Mechanics to full flexion Continue ROM work as needed. Take Care Not to
Gait. *Initiate Active *Begin Lower Start Lower Extremity Overload Patella
* Wean Knee Extension and Extremity Stretching Program of Femoral Joint
From Brace Isotonic Quad Stretching Hamstring, Calf, Hip Muscle
as Gait Strengthening in Program for Groups
Improves OKC and CKC uninvolved Cardio
and Quad muscle groups. Introduce Cycle with minimal
gets resistance
stronger Strengthening
Progress Open Chain Hip
Program, Add SLR and Active
Low Load Open Chain Knee
Extension
Squats or Wall Slides to 30⁰
Low Load, Low Flexion Angle

Leg Press
Closed Chain Terminal Knee Ext
Proprioception
Single Leg Stance,
Static Balance on Bosu/Wobble
Board/Etc
Phase 5 *Straight *Focus on regaining *Continue Lower ROM/Stretching * Continue to
12‐24 Ahead strength Extremity *Continue Daily Stretching Take Care Not to
Weeks Jogging per *Progress from Stretching Daily *Add Gentle Quad Stretch Overload Patella
MD Double leg to single *Initiate gentle Cardio Femoral Joint
Approval leg CKC Quad Stretching *Continue cycle with increased *Jogging
strengthening resistance generally held
through phase *Add elliptical, swimming until 20 Wks
Strengthening *Agility generally
*Continue SLR and Low Load held until 20 Wks
Open Chain Program *Jumping
* Slow Progression to gym generally held
Equipment (Leg Press, Ham until 24 Wks
Curl, Multi‐Hip)
Begin Step‐Up Progressions
(lateral step‐ups, cross over
step‐ups)
*Lunge progression (static to
dynamic)
Lateral Lunge
Progressive Single Leg
Strengthening late in phase
(single leg squat, split squat,
single leg dead lift, etc)
Proprioception
Dynamic Balance with
Bosu/Foam/Etc
*Jogging, agility, jumping all per
MD
Phase 6 *Return to *Continue * Continue Lower Stretching * Must Have Full
24 Weeks Sport per Preparation for Extremity Continue daily ROM, 90%
and Beyond MD Return to Sport and Stretching Daily Cardio Return of
Approval Physical Activity Continue cardio program and Strength and No
*Progressive progress intensity and duration Patella Femoral
Strengthening and Strengthening Pain to Begin
Jumping Continue strengthening Return to Sport
program from phase 4 (increase Progressions
load and decrease volume) * Gradual return
Proprioception to sport/activity
Continue and advance pending
proprioceptive training surgeon’s
Dynamic Progressions clearance (6‐9
Progress plyometric/jumping months or
program as outlined by PT or greater)
MD
Outline specific return to
sport/activity program with PT
and/or MD

Total Knee Arthroplasty

The knee is a simple hinge joint at the connection point between the femur and tibia bones. The
smooth articular cartilage surface of the femur sits on top of the
cushioning discs of fibrocartilage on the tibia known as the medial and
lateral meniscus. These smooth surfaces that make up the knee joint
will naturally wear down over time creating a rougher surface with
which to weight bear on. Without smooth healthy cartilage the knee
also has a hard time producing the natural joint oil (synovial fluid) that
lubricates the knee during movement. Collectively, these degenerative
processes that happen over time lead to the condition known as
osteoarthritis. This process happens naturally overtime to everyone,
but can be more severe or develop quicker in some people.
As degenerative changes in the knee advance the joint becomes more and more painful and less and
less mobile. Osteoarthritis typically produces stiffness in the joint and pain during weight bearing
activity, especially right after a period of immobility (ie when getting up after sitting for a long time).
The pain in the joint may subside after moving around, but become worse again when standing or
walking for long periods of time. As the condition of the joint deteriorates it will become harder and
harder to bear weight on it and eventually the joint may lose some of its range of motion.
Treatment Options
Regardless of the nature and severity of the osteoarthritis in your
knee your physician will work with you to determine what the best
course of treatment will be. When degenerative changes are not
severe the associated pain and dysfunction may successfully be
treated with rest, anti-inflammatory measures, activity
modification and physical therapy. After a thorough evaluation
your physician and their staff will recommend the most
appropriate course of action to take.

Physical therapy is often recommended for treatment of pain and
dysfunction associated with osteoarthritis. The physical therapist
will evaluate your mobility, flexibility and strength with the purpose
of determining any underlying deficits that contribute to increased
stress on the painful joint. You will be counseled on which activities
you can safely continue and which should be avoided. The physical
therapist will teach you exercises that will help to reduce joint stress.
In most cases this will include strengthening and stretching the
muscles around the hip and knee.
When joint degeneration is severe and conservative measures are

unsuccessful in restoring function your physician may recommend a
total knee replacement procedure.
Surgery
Total Knee Arthroplasty (Replacement) is a complex procedure that involves the removal and
replacement of both the tibial and femoral weight bearing surfaces of the knee. First the ends of both
bones are removed. Then metal implants are inserted into the ends of the femur and tibia. The metal
implant that is used on the tibial side of the joint has a polyethylene (plastic) piece attached to it that
serves as the weight bearing surface of the new joint. Your surgeon may elect to use bone cement to
help hold these implants in place. During the knee replacement procedure the undersurface of the knee
cap is often removed as well, and is replaced with a polyethylene cap. Some of the structural ligaments
of the knee may also be adjusted during the procedure so as to
assure that the knee is stable and well aligned after surgery.
Each patient will be required to go through a pre-operative

educational class which will review in detail the typical patient
experience in the early phases of recovery. Total Knee
Arthroplasty is not an outpatient day surgery procedure. You
will be required to spend a few days in the hospital to recover.
If the procedure and your early recovery goes well you will
typically be discharged in 3-5 days. Some more complex cases
require a short stay in a rehab hospital following the procedure.
At Home

dressing daily and have the nurse and physical therapist inspect your incision for signs of infection. If
you have staples closing your incision they will likely be scheduled to be removed around two weeks
after the operation. If your surgeon used stitches to close the wound do not remove the strips of tape
(steri-strips) that are across your incision. Allow them to fall off on their own or to be removed at your
doctor’s office visit. Your home care physical therapist will work with your surgeon and their staff to
determine when you are ready to attend outpatient physical therapy.
Showering
it from getting wet during showering by using a water-tight dressing. It is best to use a shower bench if
possible to avoid weight bearing on the surgical leg.
Medication
Ice
applied 3-5 times a day for 10-20 minutes at a time. Always maintain one layer between ice and the
skin. Putting a pillow case over your ice pack works well for this. The home care physical therapist can
help you customize a plan on how and when to best apply ice to your knee.

Your surgeon will determine when your first post-op visit will be. It may be as early as 10 days or as late
as 6 weeks after the operation. At this visit you will meet with the surgeon or their assistant. The
surgeon or assistant will look at your knee range of motion, examine your incision, and remove the
staples if needed. You will discuss when it will be appropriate to make an appointment to begin
outpatient physical therapy. You may have an X-ray taken to make sure that the knee replacement
components are aligned well. Additional follow up visits to the doctor’s office will be based on your
surgeon’s discretion.
Weight Bearing
After surgery you are allowed to put as much weight on your operated leg as you can tolerate (unless
otherwise indicated by your surgeon). For the first several weeks you will require the use of a walker or
crutches to help you walk. As your tolerance for weight bearing improves your physical therapist will
transition you to walking with a cane. Eventually, when your gait is normal you will be able to walk
without an assistive device. Most patients are able to walk without an assistive device by six weeks after
the operation. Remember, proper gait pattern must be achieved in order to discontinue use of assistive
devices.

CPM
After the surgery your doctor may require you to use a CPM (continuous passive motion) machine. This
is a machine that will bend and straighten your knee for you while you are lying down on your back. The
machine is typically prescribed for use while you are in the hospital. Depending on their preference and
how your range of motion is progressing, your surgeon may arrange for you to continue the use of the
CPM while at rehab or at home.

Recovering from Total Knee Arthroplasty surgery is not easy. It is very important that to realize that the

Rehabilitation
Phase 1: Post-op Phase (Day 1- Hospital Discharge)
Goals
• Control pain and swelling
• Protect healing tissue
• Begin to restore range of motion (ROM)
o Knee flexion at least 80 degrees
o Knee extension less than or equal to -10 degrees
• Establish lower extremity muscle activation
• Restore independent functional mobility
Precautions
• WBAT with crutches or walker unless otherwise ordered
• CPM per MD order
• Screen for sensory/motor deficits
• Screen for DVT
Range of Motion
• Passive knee flexion and extension
• Heel slides
• Active assisted knee flexion/extension in sitting
• Ankle pumps
Strength
• Quad sets
• Glut sets
• Hamstring sets
• Straight leg raises (SLR) *(no lag)*
Functional Mobility
• Gait training on level surfaces
• Stair training
• Transfer training
• Use a towel roll under ankle to promote knee extension
• Use a trochanter roll to maintain hip in neutral rotation and promote knee extension
• Never place anything under the operated knee

Guidelines
Perform 10 repetitions of all exercises 3-5 times a day. Use ice after exercising for 10-20 minutes.
Phase 2: Motion Phase (Hospital Discharge-6 Weeks)
Goals
• Continue to improve ROM with a goal of 0- 110 degrees
• Begin to restore muscle strength throughout the operated leg, with special focus on the
quadriceps
• Initiate proprioceptive training
• Initiate endurance training
• Normalize all functional mobility
• Wean all assistive devices, emphasizing normal gait pattern
Precautions
• WBAT with crutches or walker, progressing to cane, then weaning devices as appropriate
• Monitor for proper wound healing
• Monitor for signs of infection
• Monitor for increased swelling
Range of Motion
• Continue with all phase 1 ROM exercises
• Heel slide with towel
• Prone knee flexion
• Heel prop (towel under ankle) and/or prone knee hang to promote full extension
• Initiate stationary biking, starting with back and forth motion progressing to full revolutions
as able
Joint Mobilizations and Stretching
• Initiate patellofemoral and tibio-femoral joint mobilizations as indicated
• Initiate hamstring, gastroc/soleus, and quadriceps stretching
Strengthening
• Quad sets, glut sets, hamstring sets
• Use neuromuscular electrical stimulation (NMES) to quads if poor quadriceps recruitment is
present
• SLR without lag, add resistance towards the end of this phase
• Standing hip flexion/ abduction/ adduction/ extension
• Hip abduction/ adduction/ extension against gravity, add resistance towards the end of this
phase
• Progress to closed chain exercises including terminal knee extensions, mini-squats, step ups,
and mini-lunges by the end of this phase

Proprioception
• Single leg stance
Functional Mobility
• Gait training with appropriate device emphasizing normal gait pattern
• Stair training with appropriate device
Guidelines
Perform 10-20 repetitions of all ROM, strengthening, and strengthening exercises 3x/day. Hold stretches
for 30 seconds and perform 2-3 repetitions of each. Bike daily for 5-10 minutes if able.
Phase 3: Intermediate Phase (6-12 Weeks)
Goals
• Maximize knee ROM
• Restore normal LE strength, especially normal quadriceps function
• Return to baseline functional activities
Precautions
• Avoid high impact activities
• Avoid activities that require repeated pivoting/twisting
• Continue ROM exercises from phase 1 and 2
• Continue biking, adding mild to moderate resistance as tolerated
Joint Mobilizations
• Continue with phase 2 activities as indicated
Strengthening
• Continue with phase 2 exercises adding and increasing resistance as tolerated
• Add resistance machines as appropriate including leg press, hamstring curl, and 4-way hip
machine
• Emphasize eccentric control of quadriceps with closed chain exercises
Proprioception
• Static balance on Bosu/wobble board/foam/etc
• Add gentle agility exercises (i.e. tandem walk, side stepping, karaoke, backwards walking)
Endurance
• Biking program
• Begin walking program

Guidelines
seconds and perform 2-3 repetitions of each.
Perform strengthening exercises 3-5 times a week. Do 2-3 sets of 15-20 Reps.
Bike daily for ROM at least 10 minutes if able.
Progress to biking/walking for at 20-30 minutes 3x/week for endurance.

Goals
• Continue to improve strength to maximize functional outcomes
• Return to appropriate recreational activities (i.e. golf, doubles tennis, cycling)
Precautions
• Avoid high impact, and contact sports
• Avoid repetitive heavy lifting
ROM and Flexibility
• Continue daily ROM and stretching exercises
Strengthening
• Continue with all strengthening exercises increasing resistance and decreasing repetitions
Proprioception
• Continue with all phase 3 exercises, increasing difficulty as tolerated.
Endurance
• Continue with walking, biking, elliptical machine programs
Guidelines
Perform strengthening and proprioception exercises 3-5x/ week, performing 2-3 sets of 10-15
repetitions.
Continue endurance program 30-45 minutes 3x/ week.

Phase 1: • WBAT with crutches • Control pain and ROM
Day 1 – or walker unless swelling • P/AA/AROM knee flexion and extension
Hospital otherwise ordered by • ROM: knee flexion • Heel slides
D/C MD to at least 80◦, knee • Ankle pumps
• CPM per MD order extension <= -10◦ STRENGTH
• Screen for DVT • Establish LE muscle • Quad/glut/hamstring sets
• Screen for sensory/ activation • SLR (NO lag)
motor deficits • Restore FUNCTIONAL MOBILITY
independent • Gait training with appropriate assistive
functional mobility device on level surfaces
• Stair training
POSITIONING (when in bed)
• Towel roll under ankle to promote knee
extension
• Trochanter roll to maintain hip neutral
rotation and promote knee extension
• Never place anything under the operated
knee
Phase 2: • WBAT with crutches • ROM: 0 to at least ROM
Hospital or walker, 100◦ • Continue with all phase 1 exercises
D/C – 6 progressing to cane, • Normalize all • Heel slide with towel
weeks then weaning all functional mobility • Prone knee flexion
devices as • Wean all assistive • Heel prop and/or prone knee hang to
appropriate devices promote full extension
• Monitor for proper • Begin to restore LE • Initiate stationary biking
wound healing strength, especially Joint Mobilizations and Stretching
• Monitor for signs of quads • Initiate patellofemoral and tibio-femoral
infections • Initiate joint mobilizations as indicated
• Monitor for increased proprioceptive • Initiate hamstring, gastroc/soleus, and
swelling training quadriceps stretching
• Initiate endurance Strengthening
training • Quad/glut/ham sets
• Use NMES to quads if poor quad
recruitment in noted
• SLR without lag, adding resistance towards
the end of this phase
• Standing hip flexion/ abduction/ adduction
• Hip abduction/ adduction/ extension
against gravity, adding resistance towards
the end of this phase
• Closed chain exercises (TKEs, mini-squats,
step ups, mini-lunges) by the end of this
phase
Proprioception
Functional Mobility
• Gait training with appropriate device
emphasizing normal gait pattern

Phase 3: • Avoid high impact • Maximize knee ROM ROM
6-12 weeks activities • Restore normal LE • Continue phase 1 and 2 exercises
• Avoid activities that strength, especially Joint Mobilizations and Stretching
require repeated normal quad • Continue with phase 2 activities as
pivoting/ twisting function indicated
• Return to baseline Strengthening
functional activities • Continue with phase 2 exercises, increasing
resistance as tolerated
• Add resistance machines as appropriate (leg
press, hamstring curl, 4-way hip)
Proprioception
• Static balance on Bosu/wobble
board/foam/etc
• Add gentle agility exercises (i.e. tandem
walk, side stepping, karaoke, backwards
walking
Endurance
• Biking program, adding mild to moderate
resistance as tolerated
Phase 4: • Avoid high impact, • Continue to improve ROM
12 weeks and contact sports strength to • Continue daily ROM and stretching
and beyond • Avoid repetitive maximize functional exercises
heavy lifting outcomes Strengthening
• Work with PT and • Continue with all strengthening exercises
MD to create increasing resistance and decreasing
customized routine repetitions
to allow return to Proprioception
appropriate sports/ • Continue with all phase 3 exercises,
recreational increasing difficulty as tolerated
activities (i.e. golf, Endurance
doubles tennis, • Continue with walking, biking, elliptical
cycling, hiking) machine programs
Functional Progressions
• Activity/sport-specific training exercises

Hip OA

The hip is a ball and socket joint that occurs between the head of the femur (ball) and the acetabulum
of the pelvis (socket). It is surrounded by several layers of musculature and ligaments. Osteoarthritis
(OA) is commonly known as “wear-n-tear arthritis”, which occurs along the protective cartilage located
at the surface of the joint, in this case, the head of the femur and the acetabulum of the pelvis.
This protective cartilage wears away, leaving the bone exposed.
As we age, the water content of the cartilage increases, and the

protein makeup of cartilage degenerates. Eventually, cartilage can
further degenerate by chipping or forming tiny crevasses through
repetitive use. Osteoarthritis occurs when there is a loss of the
cartilage cushion between the bones of the joints. Over the years the
worn joints can become irritated and inflamed, causing pain and
swelling. Continued loss of cartilage will reduce the cushion and cause
friction between the bones, leading to pain and limitation of joint
mobility. This process also stimulates new bone outgrowths (spurs,
also referred to as osteophytes) to form around the joints. Regardless of the specific mechanism of how
arthritis develops in the hip, common signs and symptoms include:
• Pain in the joint during or after movement

• Tenderness with slight pressure
• Stiffness most noticeable in the morning and/or after long periods of
inactivity
• Inability to move the joint through full ROM (range of motion)
• May hear grinding/grating sensation with use of the joint
• May develop bone spurs.
The muscles surrounding the arthritic hip often become weak and atrophied.
There is often a reduction in the reflexive inhibition (muscle’s ability to relax
after being flexed or when not in use) and maximal force output of the muscles
around the hip as well. The sensitivity of the muscles’ proprioceptors also diminishes, limiting the ability
to detect and report information to the brain. The hip’s stability then becomes compromised, as the
muscles become less able to react in response to changes in stimuli. These changes ultimately result in
significant restrictions in activity and mobility, which reduce quality of life.

Treatment Option
Regardless of the nature and severity of the osteoarthritis in your hip, your physician will work with you
to determine what the best course of treatment will be. When degenerative changes are not severe the
associated pain and dysfunction may successfully be treated with rest, anti-inflammatory measures,
will recommend the most appropriate course of action to take. When joint degeneration is severe and
conservative measures are unsuccessful in restoring function your physician may recommend a total hip
replacement procedure.
include strengthening and stretching the muscles around the hip and knee, as well as strengthening your
core. Your treatment may also include manual techniques that are designed to improve the mobility of
the hip joint and reduce pain.

Rehabilitation
Phase 1 (Inflammatory Phase)

Goals
Control pain and inflammation
Begin pain free range of motion (ROM) and flexibility exercises
Establish pain free hip ROM
Range of motion and flexibility
Heel Slides
Supine Hip Internal/External Rotation
Gentle Bridging
Gentle Lower Extremity Stretching (based on individual assessment)
Gluteus maximus
IT Band/ Tensor Fascia Latae (TFL)
Hamstring
Hip Rotators
Iliopsoas /Rectus Femoris
Piriformis
Gentle Cycle if Tolerated
Guidelines

Goals
Continued protection of injured joint
Continue to improve flexibility
Begin to strengthen areas of weakness/instability
Continue ROM and Flexibility from Phase 1 as needed
Strength
Begin open chain strengthening (based on strength assessment)
Bridging exercises
Straight Leg Raise (SLR)
Hip Abduction
Hip Extension
Hip External Rotation
Quadraped positional exercises
SLS (single leg stance)
Guidelines

Goals
Continue to avoid exacerbation of symptoms
Continue to maximize return of strength and flexibility
Establish closed chain strength and stability
Continue cycle, may add walking
Continue lower extremity stretching from Phase 1 and 2
Strengthening
Continue progression of open chain program with ankle weights
Can add gym equipment (Leg Press, Multi-Hip, Cable Column Posterior Depression)
Pain free closed chain hip strengthening
Continued progression with SLS activities
Continued progression with bridging exercises (Physioball, Foam Roll)
Step Up Progressions (forward and Lateral)
Guidelines

Phase 4 (Return to sport/Activity Phase)
Goals
Continue to avoid hip overload
Achieve adequate strength and flexibility to return to activity
Flexibility
Cardio
Continue cycle, walking
Return to running/sport progression (outlined by physician or physical therapist)
Strengthening
Continue SLR/Open Chain program and gym equipment progression
Static lunge with progression to dynamic
Lateral lunge progressions
Progressive single leg strengthening (single leg squat, single leg dead lift, single leg ER)
Return to Sport
Work with physician or physical therapist to outline progressive return to sport
Guidelines
Perform strengthening exercises 3 times a week. Do 2-3 sets of 15-20 Reps

Recommended
Exercises
Phase 1 *Control Pain and ROM and Flexibility *ROM Daily 2-3 sets of 15-20
Acute Phase Inflammation Cycle (if pain free motion) Reps
*Re-establish Normal Heel Slides (in pain free arc) *Stretching Program Daily 2-3
ROM Supine Hip Rotation Repetitions of 30 Seconds
*Begin Pain Free Supine Bridge
Flexibility Program Lower Extremity Stretching
*Manual Therapy • Rectus Femoris/Iliopsoas
• IT Band/TFL
• Hamstring
• Hip Rotators
• Piriformis
• Gluteus Maximus
Phase 2 * Continued Protection ROM and Flexibility * Stretching Program Daily 2-3
Sub-acute of Injured Joint Cycle (slow progression of resistance) Repetitions of 30 Seconds
Phase A *Continue to Improve Continue ROM and Flexibility From Phase 1 *Cardio program should be
Flexibility Strength performed no more that 3-5
*Begin to Strengthen Begin Open Chain Strengthening times a week for 20-35 minutes.
Areas of • Bridging exercises *Perform strengthening exercises
Weakness/Instability • Quadraped positional exercises daily 2-3 sets of 15-20 Reps
• Straight Leg Raise
• Hip Abduction
• Hip Extensors
• Hip Rotators
• SLS (single leg stance)
Phase 3 * Continue to Avoid ROM and Flexibilty * Stretching Program Daily 2-3
Sub-acute Exacerbation of Continue Lower Extremity Stretching from Phase 1 Repetitions of 30 Seconds
Phase B Symptoms and 2 *Continue to Stress Proper Gait
*Continue to Maximize Continue cycle, may add walking * Cardio program should be
Return of Strength and Strengthening performed no more that 3-5
Flexibility Progress OKC Program with Ankle Weights times a week for 20-45 minutes.
*Establish Closed Chain Can Add Gym Equipment *Perform strengthening exercises
Strength and Stability Step Up Progressions (Forward Step Ups, Lateral Step 3 times a week 2-3 sets of 15-20
Ups) Reps.
Continue progression with SLS activities
Continue progression with bridging exercises
Phase 4 * Continue to avoid hip Flexibility * Stretching Program Daily 2-3
Sport Specific overload Continue daily stretching Repetitions of 30 Seconds
Phase *Progress with single leg Cardio *Cardio program should be
strengthening Cycle, walking, elliptical machine progressed in preparation for
*Achieve adequate Begin return to running progression per MD return to sport.
strength and flexibility to Strengthening *Perform strengthening exercises
return to activity Continue OKC program 3 times a week. Do 2-3 sets of
Continue gym equipment progression 15-20 Reps
Continue step-up progressions (lateral step-ups,
cross over step-ups)
Static lunge with progression to dynamic
Lateral lunge progressions
squat, single leg ER, single leg dead lift)
Return to Sport

Hip Bursitis/Tendinitis

The hip is a ball and socket joint that occurs between the head of the femur (ball) and the acetabulum of
the pelvis (socket). It is protected by several layers of muscles and ligaments that provide support for
the joint during weight bearing activity and movement. The hip incurs a lot of force during weight
bearing activity and is prone to being overworked. With repetitive, stressful activity supporting
structures like tendons and bursa can get irritated.
A bursa is a fluid filled sac that provides cushioning between a

piece of bone and the soft tissue that lies over top of it. The bursa
serves to reduce friction as the soft tissue (muscle, tendon, etc)
slides over top of the bone. When the soft tissue is overly taught
across the bone the bursa is compressed causing it to become
irritated and inflamed. This irritation is known as bursitis. There
are several bursa about the hip that can become irritated. The
most common source of irritation is the bursa around the greater
trochanter on the outside of the hip.
A tendon is the area of a muscle where it attaches to a bone. When a muscle is continually overused or
is generally too weak or too tight its tendon can become irritated. The stress that is put through the
muscle is greater than it can bare and so the tendinous attachment point incurs a tremendous amount
of force. Over time this repetitive stress and tension results in the fibers of the tendon becoming
irritated and inflamed. Some of the more common areas of tendinitis in the hip are the hip flexors,
hamstring and hip abductors.
Treatment Option
Recommendations for the treatment of overuse conditions like bursitis and tendinitis always begin with
relative rest. Regardless of the specific mechanism (alignment, weakness, etc) causing pain, the
physician and/or physical therapist will likely recommend that the patient refrain from participation in
the activities that most provide stress to injured joint. This does not always mean that the patient must
stop all exercise. The patient should consult with the physician and/or physical therapist to determine
individualized exercise guidelines and restrictions. When relative rest is not sufficient in improving
symptoms the physician may recommend the use of anti-inflammatory medication (either taken orally
or injected into the local site of inflammation).

Physical therapy is often recommended for treatment of pain and

dysfunction associated with the hip bursitis and tendinitis.
The physical therapist will evaluate the patient’s mobility, flexibility
and strength with the purpose of determining the underlying cause
of the abnormal stress on the hip. The patient will be counseled on
which activities he or she can safely continue and which should be
avoided. The physical therapist will teach the patient the proper
exercises to reduce stress on the hip. In most cases this will include
strengthening muscles about the hip and knee that are weak and
stretching ones that are tight.

Rehabilitation

Goals
Begin pain free flexibility exercises
Establish pain free hip ROM
Range of motion and flexibility
Lower extremity stretching (based on individual assessment)
Gluteus maximus
IT Band/ Tensor Fascia Latia (TFL)
Hamstring
Hip Rotators
Iliopsoas
Piriformis
Guidelines
Goals
Continued protection of injured joint
Continue flexibility from Phase 1
Strength
Bridging
Clamshells
Quadraped positional exercises
Straight leg raise (SLR)
Hip abduction
Hip extensors
Hip external rotators
SLS (single leg stance) drills
Guidelines
Goals
Continue cycle, add walking
Strengthening
Can add gym equipment (Leg Press, Multi-Hip, Post Depression)
Pain free closed chain hip strengthening
Step Ups (frontal and Lateral)
Continued progression with SLS activities
Guidelines
Phase 4 (Return to sport/Activity Phase)
Goals
Continue to avoid hip bursae overload
Flexibility

Cardio
Continue cycle, walking
Return to running progression (outlined by physician or physical therapist)
Strengthening
Continue SLR program and gym equipment progression
Static lunge/Split-Squat
Lateral lunge
Progressive single leg strengthening (single leg squat, single leg dead lift, single leg ER)
Return to Sport
Guidelines

Recommended
Exercises
Phase 1 *Control pain and ROM and Flexibility *ROM daily 2-3 sets of 15-20
Acute Phase inflammation Cycle (if pain free motion) reps
*Re-establish normal Pain free hip or knee active range of motion *Stretching program daily 2-3
ROM exercises (based on proximal or distal repetitions of 30 seconds
*Establish quadriceps involvement)
activation Lower Extremity Stretching
*Begin pain free • Rectus Femoris/Illiopsoas
Flexibility program • IT Band/Tensor Fascia Latia (TFL)
• Hamstring
• Hip Rotators
• Gluteus maximus

Phase 2 * Continued ROM and Flexibility * Stretching program daily 2-3
Sub-acute protection of injured Cycle (slow progression of resistance) repetitions of 30 seconds
Phase A joint Continue flexibility from Phase 1 *Cardio program should be
*Continue to improve performed no more that 3-5
flexibility Strength times a week for 20-35
*Begin to strengthen Begin open chain strengthening minutes.
areas of • Bridging *Perform strengthening
Weakness/instability • Clamshells exercises daily 2-3 sets of 15-
• Straight leg raise 20 Reps
• Hip abduction
• Hip extensors
• Hip external rotators
• Single leg stance (SLS) drills

Phase 3 * Continue to avoid Flexibilty * Stretching program daily 2-3
Sub-acute exacerbation of Continue lower extremity stretching from repetitions of 30 seconds
Phase B symptoms Phase 1 and 2 *Continue to stress proper
*Continue to gait
maximize return of Cardio * Cardio program should be
strength and flexibility Cycle with Progressive Resistance performed no more that 3-5
*Establish closed Walking/elliptical (if pain free) times a week for 20-45
chain strength and minutes.
stability Strengthening *Perform strengthening
Continue OKC progression exercises 3 times a week 2-3
Can add gym equipment (Leg press, Multi-hip) sets of 15-20 Reps.
Pain free closed chain hip strengthening (Step-
up progression, static/dynamic lunge
progression, etc)
Continued progression with SLS and
proprioceptive drills (add foam, balance disc,
etc.)
Progressive core stability (plank/side plank
progressions, etc.)

Phase 4 * Continue to avoid Flexibility * Stretching program daily 2-3
Sport Specific ITB overload Continue Daily Stretching repetitions of 30 seconds
Phase *Progress with single *Cardio program should be
leg strengthening Cardio progressed in preparation for
*Achieve adequate Cycle, elliptical, walking return to sport.
strength and flexibility Begin Return to Running Progression *Perform strengthening
to return to activity exercises 3 times a week. Do
Strengthening 2-3 sets of 15-20 Reps
Continue OKC Program
Continue Step-Up Progressions (Step-up
progression, static/dynamic lunge progression,
etc)
squat, single leg dead lift)
Plyometric Program: outlined by physical
therapist based on activity/sport
Return to Sport

Iliotibial Band Pain

The hip is a ball and socket joint that occurs between the head of the femur (ball) and the acetabulum
of the pelvis (socket). It is protected by several layers of muscles and ligaments. One of the structures
about the hip that is often a source of pain and dysfunction is the Iliotibial band (ITB). The ITB is a band
of connective tissue (fascia), that begins at the outer portion of the pelvis and travels along the outside
of the thigh, eventually connecting to the outside of the knee.
The muscle that connects to the ITB is known as the Tensor fascia latae muscle. Its primary action is to
abduct (move out to the side) and medially rotate (turn in) the hip. It also works as a stabilizer for hip
and knee during weight bearing activities.
The ITB can become painful anywhere along its distribution on the outside of the thigh, but it is most
commonly aggravated near its insertion points at the knee or hip.
This pain is often times the result of excessive friction created by
the ITB rubbing over top of boney structures near these insertion
points. This abnormal friction is often related to the performance
of repetitive activity (cycling, hiking, running, etc) in the presence
of poor biomechanical alignment or movement pattern
dysfunction (poor form). Pain can occur near hip joint and/or
along the shaft of the femur to the outside part of the knee.
Common causes can come from overuse of the muscle with such
activities as running/cycling/hiking/weight lifting (especially squats), biomechanically (i.e. leg length
discrepancy, bow-legged, high/low arches, excessive low leg rotation, poor hip stability/mechanics) or
poor form with movement (i.e. uneven running surfaces, excessive up/down hill, toe in when biking).
Treatment Options
Regardless of the specific mechanism (alignment, weakness, repetitive stress) ITB pain is generally
caused by the overloading or overworking of the soft tissue about the hip and/or knee joint. As the
pain, inflammation and underlying causes of the ITB pain are treated, the physician and/or physical
therapist will likely recommend that the patient refrain from participation in the activities that most
provide stress to injured joint. This does not always mean that the patient must stop all exercise. The
patient should consult with the physician and/or physical therapist to determine individualized exercise
guidelines and restrictions.

Physical therapy is often recommended for treatment of pain and dysfunction associated with the ITB,
be it at the knee (ITB Syndrome) or hip (tendonitis, bursitis, “Snapping Hip Syndrome”). The physical
therapist will evaluate the patient’s mobility, flexibility and strength with the purpose of determining
the underlying cause of the abnormal stress on the ITB. The patient will be counseled on which activities
he or she can safely continue and which should be avoided. The physical therapist will teach the patient
the proper exercises to reduce stress on the ITB. In most cases this will include strengthening muscles
about the hip and knee that are weak and stretching ones that are tight.
Treatment Progression
Physical therapy will likely occur through three phases of rehabilitation (inflammatory/maximum
protection phase, sub-acute/moderate protection phase, and return to sport and activity/minimal
protection phase). The therapist will choose the right course of action dependant on your individual
goals.

Rehabilitation
Phase 1 (Inflammatory Phase)

Goals
Begin pain free flexibility exercises
Establish pain free knee & hip ROM
Cycle with minimal resistance (if pain free)
Pain free hip or knee active range of motion exercises (based on proximal or distal involvement)
Pain free lower extremity stretching (based on individual assessment)
IT Band/ Tensor Fascia Latia (TFL)
Hamstring
Hip rotators
Iliopsoas
Gluteus maximus
Guidelines
Goals
Continued protection of injured tissue
Continue flexibility from Phase 1
Strength
Bridging
Clamshells

Straight leg raise
Hip abduction
Hip extensors
Hip external rotators
Single Leg Stance (SLS) Drills
Guidelines
Cycle program should be performed no more that 3-5 times a week for 20-35 minutes.
Goals
Continue cycle with progressive loading, add walking or elliptical program
Strengthening
Can add gym equipment (Leg press, Multi-hip)
Pain free closed chain hip strengthening (Step-Up Progressions, Static and Dynamic Lunge
Progressions, Etc)
Continued progression with SLS and proprioceptive drills (add foam, balance disc, etc)
Progressive core stability based on individual needs (plank/side plank progressions, etc)
Guidelines
Phase 4 (Return to Sport/Activity Phase)
Goals
Continue to avoid ITB overload

Flexibility
Cardio
Continue cycle, walking, elliptical
Return to running progression (outlined by physician or physical therapist)
Strengthening
Continue SLR program and gym equipment progression
Continue to progress closed chain hip strengthening (Step-Up Progressions, Static and Dynamic
Lunge Progressions, Etc)
Progressive single leg strengthening (single leg squat, split squat, single leg dead lift, single leg
ER)
Plyometric Program: outlined by physical therapist (based on patient’s activity/sport)
Return to Sport
Work with physician or physical therapist to Outline Progressive Return to Sport
Guidelines

Recommended
Exercises
Phase 1 *Control pain and ROM and Flexibility *ROM daily 2-3 sets of 15-20
Acute Phase inflammation Cycle (if pain free motion) reps
*Re-establish normal Pain free hip or knee active range of motion *Stretching program daily 2-3
ROM exercises (based on proximal or distal repetitions of 30 seconds
*Establish quadriceps involvement)
activation Lower Extremity Stretching
*Begin pain free • Rectus Femoris/Illiopsoas
Flexibility program • IT Band/Tensor Fascia Latia (TFL)
• Hamstring
• Hip Rotators
• Gluteus maximus

Phase 2 * Continued ROM and Flexibility * Stretching program daily 2-3
Sub-acute protection of injured Cycle (slow progression of resistance) repetitions of 30 seconds
Phase A joint Continue flexibility from Phase 1 *Cardio program should be
*Continue to improve performed no more that 3-5
flexibility Strength times a week for 20-35
*Begin to strengthen Begin open chain strengthening minutes.
areas of • Bridging *Perform strengthening
Weakness/instability • Clamshells exercises daily 2-3 sets of 15-
• Straight leg raise 20 Reps
• Hip abduction
• Hip extensors
• Hip external rotators
• Single leg stance (SLS) drills

Phase 3 * Continue to avoid Flexibilty * Stretching program daily 2-3
Sub-acute exacerbation of Continue lower extremity stretching from repetitions of 30 seconds
Phase B symptoms Phase 1 and 2 *Continue to stress proper
*Continue to gait
maximize return of Cardio * Cardio program should be
strength and flexibility Cycle with Progressive Resistance performed no more that 3-5
*Establish closed Walking/elliptical (if pain free) times a week for 20-45
chain strength and minutes.
stability Strengthening *Perform strengthening
Continue OKC progression exercises 3 times a week 2-3
Can add gym equipment (Leg press, Multi-hip) sets of 15-20 Reps.
Pain free closed chain hip strengthening (Step-
up progression, static/dynamic lunge
progression, etc)
Continued progression with SLS and
proprioceptive drills (add foam, balance disc,
etc.)
Progressive core stability (plank/side plank
progressions, etc.)

Phase 4 * Continue to avoid Flexibility * Stretching program daily 2-3
Sport Specific ITB overload Continue Daily Stretching repetitions of 30 seconds
Phase *Progress with single *Cardio program should be
leg strengthening Cardio progressed in preparation for
*Achieve adequate Cycle, elliptical, walking return to sport.
strength and flexibility Begin Return to Running Progression *Perform strengthening
to return to activity exercises 3 times a week. Do
Strengthening 2-3 sets of 15-20 Reps
Continue OKC Program
Continue Step-Up Progressions (Step-up
progression, static/dynamic lunge progression,
etc)
squat, single leg dead lift)
Plyometric Program: outlined by physical
therapist based on activity/sport
Return to Sport

Total Hip Arthroplasty

The hip is a ball and socket joint located where the thigh meets the pelvis. The upper end of the thigh
bone (head of the femur) is formed into a ball, which sits in the socket of the pelvic bone called the
acetabulum. The hip joint is a very stable joint due
to the natural deep fit of the head of the femur in
the acetabulum. It is also surrounded and
supported by strong ligaments and muscles. Both
the head of the femur and the acetabulum are
covered with smooth cartilage, which allow the
bones to easily glide on each other. This cartilage
will naturally wear down over time creating a
rougher surface with which to weight bear on.
Without smooth healthy cartilage the hip also has a
hard time producing the natural joint oil (synovial
fluid) that lubricates the hip during movement. http://web.ebscohost.com/rrc/detail?sid= 1
Collectively, these degenerative processes that

happen over time lead to the condition known as osteoarthritis. This process happens naturally
overtime, but can be more severe or develop quicker in some people.
As degenerative changes in the hip advance, the joint

becomes more and more painful and less and less mobile.
Osteoarthritis typically produces stiffness in the joint and pain
during weight bearing activity, especially right after a period of
immobility (i.e. first thing in the morning). The pain in the
joint may subside after moving around, but become worse
again when standing or walking for long periods of time. As
the condition of the joint deteriorates it will become harder
http://www.sonoranhipcenter.com/hip-arth 1 and harder to bear weight on it and eventually the joint may
lose some of its range of motion.

Treatment Options
Regardless of the nature and severity of the osteoarthritis in your hip your physician will work with you
to determine what the best course of treatment will be. When degenerative changes are not severe the
associated pain and dysfunction may successfully be treated with rest, anti-inflammatory measures,
will recommend the most appropriate course of action to take.
include strengthening and stretching the muscles around the hip and knee, as well as strengthening your
core.
When joint degeneration is severe and conservative measures are unsuccessful in restoring function
your physician may recommend a total hip replacement procedure.
Surgery
Total Hip Arthroplasty (Replacement) is a complex procedure that involves the removal and replacement
of both the head of the femur and the acetabulum. First an incision is made most commonly along the
side of the hip, and occasionally in front of the hip joint. Next the hip joint is exposed and the head and
neck of the femur are removed. Then the acetabulum is cleaned out and replaced with a metal shell,
and the femoral stem is fit into position. Your surgeon may or may not use cement to secure the stem.
Lastly, a carefully fitted “ball” is secured onto the
stem and the hip is rejoined.
Each patient will be required to go through a pre-

operative educational class which will review in
detail the typical patient experience in the early
phases of recovery. Total Hip Arthroplasty is not an
outpatient day surgery procedure. You will be
required to spend a few days in the hospital to
recover. If the procedure and your early recovery
http://web.ebscohost.com/rrc/detail?sid= 2 goes well you will typically be discharged in 2-3

days. Some more complex cases require a short
stay in a rehab hospital following the procedure.

Dislocation Precautions
The new prosthetic joint is not as stable as a natural hip joint. As a result, there are specific precautions
you must follow after surgery which vary according to the type of incision used during your surgery:
• Posterior Approach do NOT bend your hip more than 90 degrees, do NOT rotate your hip
inward, do NOT bring your hip in across your body beyond neutral (i.e. do not cross your legs),
NO combinations of these motions.
• Anterior Approach do NOT move your hip backwards behind you body, do NOT rotate your
hip outward, NO combinations of these motions; NO bridging (lifting your buttock of the bed
when lying on your back), NO lying on your stomach, and when lying flat on your back keep hip
bent at least 30 degrees.
• Global Precautions are a combination of the above precautions: do NOT bend your hip more
than 90 degrees, do NOT rotate your hip inward or outward (keep your knee and toe facing
forward), NO lying flat, NO lying on your stomach, and NO bridging.
You surgeon will instruct you which precautions to follow. You must observe these precautions for at
least 3 months or as recommended by your surgeon.
At Home
dressing one week after surgery, and have the nurse and physical therapist inspect your incision for
signs of infection. If you have staples closing your incision they will likely be scheduled to be removed
around 10-14 days after the operation. Your home care physical therapist will work with your surgeon
and their staff to determine when you are ready to attend outpatient physical therapy.
Showering
it from getting wet during showering by using a water-tight dressing. It is best to use a shower bench if
possible to assist with your balance.
Medication
Driving
Your surgeon will tell you when you are ready to return to driving. Commonly, you are not permitted to
drive for 6 weeks if you had your right hip replaced, and 4 weeks if you had your left hip replaced. You
cannot drive while taking narcotics.

Ice
You should use ice on your hip after the operation for management of pain and swelling. Ice should be
applied 3-5 times a day for 10-20 minutes at a time. Always maintain one layer between ice and the skin.
Putting a pillow case over your ice pack works well for this. The home care physical therapist can help
you customize a plan on how and when to best apply ice to your hip.

Your first post-operative visit will be 10 days after the operation. At this visit you will meet with the
surgeon or the physician assistant who will look at your hip range of motion and strength, examine your
incision, and remove the staples. Your next visit will be around 6 weeks after the operation. At this visit
you may have an X-ray taken to make sure that the hip replacement components are aligned well, and
you will discuss when it will be appropriate to make an appointment to begin outpatient physical
therapy. Additional follow up visits to the doctor’s office will be based on your surgeon’s discretion.
Weight Bearing
After surgery you are allowed to put as much weight on your operated leg as you can tolerate (unless
otherwise indicated by your surgeon). You must use some form of an assistive device for at least the first
six weeks after your surgery. Initially you will need to use a walker or crutches to help you walk. As your
tolerance for weight bearing improves your physical therapist will transition you to walking with a cane.
After six weeks you may receive clearance from your surgeon to transition off of your assistive device.
Remember, proper gait pattern must be achieved in order to discontinue use of assistive devices.

Recovering from Total Hip Arthroplasty surgery is not easy. It is very important that to realize that the

Rehabilitation
Phase 1: Post-op Phase (Day 1- Hospital Discharge)

Goals
• Control pain and swelling
• Protect healing tissue
• Begin to restore range of motion (ROM)
• Establish lower extremity muscle activation
• Restore independent functional mobility
• Educate the patient regarding their dislocation precautions
Precautions
• Dislocation precautions
• WBAT with crutches or walker unless otherwise ordered
• Screen for sensory/motor deficits
• Screen for DVT
(All exercises performed within the patient’s dislocation precautions)
Range of Motion
• Heel slides
• Ankle pumps
• Supine hip internal/external rotation
Strength
• Quad sets
• Glut sets
• Hamstring sets
• Supine hip abduction/adduction
• Long arc quads (LAQ)
• Seated hip flexion
Functional Mobility
• Bed mobility
• Gait training on level surfaces
• Stair training

• Posterior Precautions: ensure the foot of the bed is locked in a flat position
Anterior Precautions: foot of the bed is unlocked and slightly flexed.
• Use a trochanter roll to maintain hip in neutral rotation and promote knee extension
• Never place anything under the operated knee for posterior precautions.
Guidelines
Perform 10 repetitions of all exercises 3-5 times a day. Use ice after exercising for 10-20 minutes.
Phase 2: Mobility Phase (Hospital Discharge-6 Weeks)

Goals
• Begin to restore muscle strength throughout the operated leg
• Initiate proprioceptive training
• Initiate endurance training
• Normalize all functional mobility
• Demonstrate normal gait pattern with goal to wean all assistive devices at the end of this phase
(if permitted by surgeon)
Precautions
• WBAT with crutches or walker, progressing to cane
• Monitor for proper wound healing
• Monitor for signs of infection
• Monitor for increased swelling
Range of Motion
• Continue with all phase 1 ROM exercises
Stretching
• Initiate gentle hamstring, gastroc/soleus, and quadriceps stretching
Strengthening
• Continue quad sets, glut sets, hamstring sets
• Continue LAQ and seated hip flexion
• Bridging
• Standing hip flexion/ abduction/ adduction/ extension
• Progress to straight leg raises (SLR), hip abduction/ adduction/ extension against gravity
towards the end of this phase
• Progress to closed chain exercises including terminal knee extensions, mini-squats, step ups,
and mini-lunges by the end of this phase
Proprioception
• Weight shifting activities

Functional Mobility
• Gait training with appropriate device emphasizing normal gait pattern
Endurance
• Initiate stationary biking with minimal to no resistance 3-4 weeks post-op
Guidelines
Perform 10-20 repetitions of all ROM, strengthening, and strengthening exercises 3x/day. Hold stretches
for 30 seconds and perform 2-3 repetitions of each. Bike daily for 5-10 minutes if able.
Phase 3: Strengthening Phase (6-12 Weeks)

Goals
• Restore normal LE strength
• Return to baseline functional activities
Precautions
• Avoid high impact activities
• Avoid activities that require repeated pivoting/twisting
Range of Motion and Stretching
• Continue ROM exercises from phase 1 and 2 until ROM normalized
Strengthening
• Continue with phase 2 exercises adding and increasing resistance as tolerated
• Add resistance machines as appropriate including leg press, hamstring curl, and 4-way hip
machine
• Emphasize eccentric control of quadriceps and hip abductors with closed chain exercises
Proprioception
• Static balance on Bosu/wobble board/foam/etc
• Add gentle agility exercises (i.e. tandem walk, side stepping, backwards walking)
Endurance
• Continue biking, adding mild to moderate resistance as tolerated
Guidelines
Perform ROM and stretching exercises once a day. Hold stretches for 30 seconds and perform 2-3
repetitions of each.
Perform strengthening exercises 3-5 times a week. Do 2-3 sets of 15-20 Reps.
Progress to biking/walking for at 20-30 minutes 3x/week for endurance.

Goals
• Continue to improve strength to maximize functional outcomes
• Work with PT and MD to create customized routine to allow return to appropriate sports/
recreational activities (i.e. golf, doubles tennis, cycling, hiking)
Precautions
• Dislocation precautions according to surgeon’s orders
• Avoid high impact and contact sports
• Avoid repetitive heavy lifting
ROM and Flexibility
• Continue daily ROM and stretching exercises
Strengthening
• Continue with all strengthening exercises increasing resistance and decreasing repetitions
Proprioception
• Continue with all phase 3 exercises, increasing difficulty as tolerated.
Endurance
• Continue with walking, biking, elliptical machine programs
Functional Progression
Guidelines
Perform strengthening and proprioception exercises 3-5x/ week, performing 2-3 sets of 10-15
repetitions.
Continue endurance program 30-45 minutes 3x/ week.

Phase 1: • Dislocation • Control pain and ROM
Day 1 – precautions swelling • Heel slides
Hospital • WBAT with crutches • Begin to restore • Ankle pumps
D/C or walker unless ROM • Supine hip internal/external rotation
otherwise ordered • Establish LE muscle STRENGTH
• Screen for DVT activation • Quad/glut/hamstring sets
• Screen for sensory/ • Restore • Supine hip abduction/adduction
motor deficits independent • LAQs
functional mobility • Seated hip flexion
• Educate the patient FUNCTIONAL MOBILITY
regarding their • Bed mobility
dislocation • Transfer training
precautions • Gait training with appropriate assistive
device on level surfaces
• Stair training
POSITIONING (when in bed)
• Posterior Precautions: ensure the food of
the bed is locked in a flat position
Anterior Precautions: food of the bed is
unlocked and slightly flexed
• Trochanter roll to maintain hip neutral
rotation and promote knee extension
• Never place anything under the operated
knee for posterior precautions
Phase 2: • Dislocation • Begin to restore ROM
Hospital precautions muscle strength • Continue with all phase 1 exercises
D/C – 6 • WBAT with crutches throughout the Joint Mobilizations and Stretching
weeks or walker, operated leg • Initiate hamstring, gastroc/soleus, and
progressing to cane • Initiate quadriceps stretching
• Monitor for proper proprioceptive Strengthening
wound healing training • Quad/glut/ham sets
• Monitor for signs of • Initiate endurance • Continue with LAQ and seated hip flexion
infections training • Standing hip flexion/ abduction/ adduction
• Monitor for increased • Normalize all • Progress to SLRs, hip abduction/ adduction/
swelling functional mobility extension against gravity towards the end
• Demonstrate of this phase
normal gait pattern • Progress to closed chain exercises (TKEs,
with goal to wean all mini-squats, step ups, mini-lunges) by the
assistive devices at end of this phase
the end of this Proprioception
phase (if permitted • Weight shifting activities
by surgeon) • Single leg stance
Functional Mobility
• Gait training with appropriate device
emphasizing normal gait pattern
Endurance
• Initiate stationary biking with none to
minimal resistance 3-4 weeks post-op

Phase 3: • Dislocation • Restore normal LE ROM
6-12 weeks precautions strength, especially • Continue phase 1 and 2 exercises
• Avoid high impact normal quad Strengthening
activities function • Continue with phase 2 exercises, adding
• Avoid activities that • Return to baseline and increasing resistance as tolerated
require repeated functional activities • Add resistance machines as appropriate (leg
pivoting/ twisting press, hamstring curl, 4-way hip)
Proprioception
• Static balance on Bosu/wobble
board/foam/etc
• Add gentle agility exercises (i.e. tandem
walk, side stepping, backwards walking)
Endurance
• Continue biking program, adding mild to
moderate resistance as tolerated
Phase 4: • Dislocation • Continue to improve ROM
12 weeks precautions strength to • Continue daily ROM and stretching
and beyond according to maximize functional exercises as needed
surgeon’s orders outcomes Strengthening
• Avoid high impact, • Work with PT and • Continue with all strengthening exercises
and contact sports MD to create increasing resistance and decreasing
• Avoid repetitive customized routine repetitions
heavy lifting to allow return to Proprioception
appropriate sports/ • Continue with all phase 3 exercises,
recreational increasing difficulty as tolerated
activities (i.e. golf, Endurance
doubles tennis, • Continue with walking, biking, elliptical
cycling, hiking) machine programs
Functional Progressions

Ankle Sprain
Anatomy
Ligaments are the soft tissue structures in the body that give the joints their stability. When one of
these structures are overstretched, it is called a sprain. Ankle sprains account for almost 85 % of all
acute ankle injuries and are a very common injury in both active and sedentary individuals. The most
common ankle sprain is a lateral (outer) ankle sprain. This occurs typically when the foot is in a position
of being pointed down and turned inwards. There are three primary ligaments on the outside of the
ankle:
• Anterior talofibular ligament (ATFL)
• Calcaneofibular ligament (CFL)
• Posterior talofibular ligament (PTFL)
National Institute of Arthritis and Musculoskeletal and Skin Diseases
The inner portion of the ankle can also be sprained although it is much less common. The inner or
medial ankle ligament is called the deltoid ligament. The deltoid ligament is comprised of the following
four ligaments:
• Tibiocalcaneal ligament
• Tibionavicular ligament
• Anterior tibiotalar ligament
• Posterior tibiotalar ligament

Ankle sprains can be classified as the following:
• Grade 1 sprain - slight stretching and some minor damage to the fibers of the ligament.
• Grade 2 sprain - some partial tearing of the ligament. Abnormal looseness of the ankle joint is
found if moved in certain directions when tested
• Grade 3 sprain - complete tear of the ligament. Gross instability occurs if the ankle is moved in
certain directions when tested
When you sprain your ankle you will typically have pain and swelling located around the area of the
sprain. Generally it is painful as you bear weight on the leg and when you turn your ankle in and out.
You might develop some bruising as well around ankle.
Treatment
After spraining your ankle you should follow the PRICE guidelines. They are as follows:
 (P)rotect – Decrease weightbearing if painful

• Use of an assistive device such as crutches may be needed
• Use of a brace or walking boot may be needed depending on grade of the sprain or
if a fracture is found (your physical therapist or doctor will assist in making this
decision based on what they find on exam)
• Do not move your foot through a painful range of motion
 (R)est – Decreasing your activity in the early stages may be necessary to limit your chances
of further injury
 (I)ce – Cold provides short pain relief and also limits swelling by reducing the blood flow to
the area. Caution: when icing the injured area you should never apply the ice directly to the
skin and never leave the ice on for more than 15 minutes. Put a pillowcase or thin towel
between the ice and your skin. Longer exposure to the ice can lead to frostbite.
 (C)ompression – This can help reduce and limit new swelling from occurring. Some people
get pain relief as the swelling goes down. Increased swelling may also slow down the
healing process. ACE wraps are the easiest way to compress the ankle. If you feel that the
wrap is too tight or the foot is throbbing, just remove the wrap and re-apply.
 (E)levation – Elevating the leg can help control/decrease the swelling in the foot/ankle. It is
most effective when the foot is above the level of the heart. If you are lying on your back,
prop the foot on several pillows.
Not everyone that has had an ankle sprain requires immediate medical attention. However if you have
any of the following, you should call your doctor or go to the emergency room:
• Significant pain with moving the ankle or when walking

• Inability to put weight on the foot

• Pain over a bony part of your foot/ankle
• Pain not relieved by medication or ice
• Numbness in the foot, ankle or leg
• No change in your pain after several days
• If you are not sure how bad it is or how to care for it
Even with minor sprains, the ankles ability to respond to the forces and stresses it encounters while
walking or with sports, may be hampered. Symptoms may be still present up to 18 months post-sprain.
A brief course of physical therapy may lessen the likelihood of residual symptoms and decrease your
chances of re-injuring the ankle.
Surgery
Only about 10-20% of ankle sprains will result in chronic issues that may require surgery. Your surgeon
will discuss the options with you if this is necessary.

Rehabilitation
Phase 1 Acute Phase
Goals
• Decrease swelling
• Full pain-free ROM
• Muscle re-education
• Normal gait pattern
Precautions
• Use assistive device if gait is painful or if an abnormal gait pattern present
• Splint or brace may be needed for ambulation
• Do not move foot through a painful range of motion
Recommended Exercises/Treatment
• PRICE
• Modalities as indicated to decrease swelling and pain
• Manual therapy to increase range and decrease pain as appropriate
• Massage for edema control
• Pain-free active ROM in all planes
• Towel scrunch and/or marble pick up
• Isometric ankle strengthening
• Open chain hip strengthening
Guidelines to progress to Phase 2
• Minimal swelling and pain

• Near or full pain free range on motion
• Normal gait pattern without crutches

Phase 2 Strengthening (early):
Goals
• Full AROM
• Normal gait at higher speeds
Precautions
• Brace may be used with activity if needed

• Avoid exercise that causes more than moderate pain
• Continue modalities to manage pain and inflammation as needed

• Joint mobilization as indicated
• Resisted ankle exercises in all planes
• Initiate proprioception/balance exercises
• Aerobic/endurance activity with minimal weightbearing (i.e. biking, swimming…)
• Continue hip/knee/core strengthening
Guidelines to progress to Phase 3
• Minimal pain with activity

• Minimal swelling
• Pain free AROM and higher level gait
Phase 3 Functional Strengthening/Return to Sport
Goals
• Pain free functional weightbearing activity

• Advance strengthening
• Initiate sport specific exercise/agility
Precautions
• Avoid activity that causes pain greater than 3/10 on VAS

• Continuing bracing as needed for activity

• Continue general LE strengthening

• Continue ankle strengthening in all planes of motion
• Continue aerobic activity, return to weightbearing activity (running) as tolerated
• Progress proprioceptive/weightbearing/single leg exercises
• Initiate agility drills
• Initiate functional bracing if needed for sport/work
Criteria for discharge
• Full functional strength, balance and proprioception

• Painfree return to sports
• Knowledge of injury prevention/use of functional brace as needed

Phase Goals Precautions Recommended Exercises Criteria to Progress
to Next Phase
Phase 1 – • Decrease swelling • Use assistive device if • PRICE • Minimal swelling
Acute Phase • Full pain-free ROM gait is painful or if an • Modalities as indicated to and pain
• Muscle re-education abnormal gait pattern decrease swelling and pain • Near or full pain
• Normal gait pattern present • Manual therapy to increase free range on
• Splint or brace may be range and decrease pain as motion
needed for ambulation appropriate • Normal gait
• Do not move foot • Massage for edema control pattern without
through a painful range • Pain-free active ROM in all crutches
of motion planes
• Towel scrunch and/or
marble pick up
• Isometric ankle
strengthening
• Open chain hip
strengthening
Phase 2 – • Full AROM • Brace may be used with • Continue modalities to • Minimal pain with
Strengthening • Normal gait at higher activity if needed manage pain and activity
(Early) speeds • Avoid exercise that inflammation as needed • Minimal swelling
causes more than • Joint mobilization as • Pain free AROM
moderate pain indicated and higher level
• Resisted ankle exercises in gait
all planes
• Initiate proprioception/
balance exercises
• Aerobic/endurance
activity with minimal
weightbearing (i.e. biking,
swimming…)
• Continue hip/knee/core
strengthening
Phase 3 – • Pain free functional • Avoid activity that causes • Continue general LE • D/C to HEP if:
Functional weightbearing pain greater than 3/10 strengthening and ankle • Full functional
Strengthening activity on VAS strengthening in all planes strength, balance
• Advance • Continuing bracing as • Continue aerobic activity, and proprioception
strengthening needed for activity return to weightbearing • Painfree return to
• Initiate sport activity (running) as sports
specific exercise/ tolerated • Knowledge of
agility • Progress injury
proprioceptive/weightbea prevention/use of
ring/single leg exercises functional brace as
• Initiate agility drills needed
• Initiate functional bracing
if needed for sport/work

References
1. Ivins D. Acute ankle sprain: An update. Am Fam Physician. 2006;74:1714-1720

2. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is
the clinical course of acute ankle sprains? A systematic literature review. Am J Med.
2008;121:324-331.
3. Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam
Physician. 2001;63:93-104

High Ankle Sprain (Syndesmosis Sprain)

The ankle is a complex joint made up three bones: the tibia, the fibula and the talus. These three bones
are connected by several ligaments that help stabilize the joint. When these ligaments are
overstretched, it is referred to as an ankle sprain. A “high” ankle sprain involves the ligaments
connecting the tibia and fibula just above the ankle joint, also known as the ankle mortise. The three
major syndesmotic ligaments are the anterior inferior tibiofibular ligament (AITFL), the posterior inferior
tibiofibular ligament (PITFL) and the interosseous ligament.
Mechanism of Injury
High ankle sprains are less common and account for
approximately 15% of all ankle sprains. Injuries to
the syndesmotic ligaments commonly occurs when
the ankle is planted and rotated resulting in a
shearing force between the tibia and fibula bones.
Athletes who participate in sports that involve
cutting and planting of the foot have the greatest
risk for ankle syndesmotic sprains. Swelling is not
always present with syndesmosis injuries but
walking, flexing the foot upward and rotating the
foot can be very painful.
National Institute of Arthritis and Musculoskeletal and Skin Diseases

Treatment Options
After your injury, your physician will work with you to determine a personalized course of treatment.
Recovery is different in each case, but “high” ankle sprains generally take longer to resolve than lateral
ankle sprains. Typically, high ankle sprains can be treated conservatively with physical therapy.
Immediately after injury, you may be non-weight bearing for up to 1-2 weeks to prevent further injury
and protect the ligaments. Your physician may decide to use a splint, brace or heel lift to help stabilize
and facilitate healing. Rest, ice, compression and elevation will help reduce the pain and swelling of the
ankle. Once the pain and swelling resolves, your physical therapist will advise you to begin bearing
weight on your ankle and progress your rehabilitation program according to your individual goals.

Surgery
If the syndesmotic injury is severe or a fracture is also present with the injury, conservative measures
are not the primary course of treatment and surgery is often indicated. Surgery can involve the use
syndesmotic fixation screws or suture fixation to stabilize the ankle mortise. Regardless of which
procedure you undergo, weight bearing can be restricted for 6 to 8 weeks following surgery and patients
gradually progress to a walking boot. A successive course of physical therapy is important to restore
range of motion, strength and function. Full recovery can take up to one year.
Rehabilitation
Phase 1
Acute Phase
Goals
Restore pain free ROM
Protect healing structures (splint, brace or heel lift)
Precautions
Often Non-Weight Bearing with Crutches with progression to CAM boot.
Avoid Painful Dorsiflexion and Eversion
Range of Motion
Ankle pumps
Ankle circles
Toe curls
Strength
Ankle isometrics (neutral PF, DF, INV and EV)
Hip Abd/Ext/ER isotonics
Guidelines
ROM deficits should be mostly resolved and minimal swelling present before progressing to next phase.
Avoid painful DF and eversion/ER of foot to limit shearing of ankle mortise and protect healing
structures. Perform ROM exercises 2-3 sets of 20 repetitions, 3-5 times a day. Perform strengthening

exercises 2-3 sets of 10 repetitions, once a day. Ice for 15-20 minutes with ankle elevated 3-5 times a
day.
Phase 2
Sub-Acute Phase
Goals
Maintain ROM and improve flexibility
Progressing WB’ing and normalize gait mechanics
Improve strength and initiate double-limb balance activities
Precautions
May continue to need CAM boot and or crutches for weight bearing.
Range of Motion/Stretching
Gastroc/soleus towel stretch
Seated tilt board/wobble board ROM
Cardio
Bicycle without resistance 10-15 minutes
Strength
Seated heel raises
Seated toe raises (pain free ROM)
Ankle isotonics with Theraband (PF, DF, INV and EV)
Body weight squat
Standing hip isotonics
Proprioception
Double-limb standing activities (advance to foam, tilt board, etc.)
Guidelines
Achieve full pain free ROM but continue to be cautious with DF and eversion/ER. Perform
ROM/stretching exercises 2-3 repetitions holding for 30 seconds, 2-3 times a day. Perform
strengthening exercises 2-3 sets of 20 repetitions, once a day. Perform proprioception exercises 3 sets of
30-60 seconds, once a day. Continue to ice for 15-20 minutes with ankle elevated once a day.
Phase 3
Strengthening Phase
Goals
Maximize strength and initiate CKC exercises
Maximize neuromuscular control and initiate single-limb exercises
Initiate treadmill walking
Precautions
Full Weight Bearing: but may continue to use a heel lift or ankle brace for protection
Range of Motion/Stretching
Gastroc/soleus wall stretch
Standing tilt board/wobble board ROM
Cardio
Bicycle/elliptical/treadmill 10-15 minutes
Strength
Advance ankle isotonics with Theraband (PF, DF, INV and EV)
Heel raises (progress double-limb to single-limb)
Forward lunges (monitor ankle DF ROM)
Lateral lunges
Hip Abduction side stepping
Plank and side plank
Single-limb bridge
Proprioception
Single-limb standing activities (advance to foam, tilt board, etc.)
Balance step ups (forward, lateral, crossover, etc.)
Guidelines
Achieve normal ankle strength and end range DF and eversion/ER without pain. Patient should be able
to perform single-limb heel lift with good control. Perform ROM exercises once a day. Perform
strengthening exercises 2-3 sets of 15-20 repetitions, every other day. Perform proprioception exercises
every other day. Continue to ice for 15-20 minutes as needed.
Phase 4
Return to Activity/Sport Phase
Goals
Continue dynamic strengthening and proprioceptive exercises
Initiate jog-to-run progression
Initiate cutting, pivoting and sport specific drills

Precautions
Cleared to return to sport per physician
Range of Motion
Gastroc/soleus wall stretch
Standing tilt board/wobble board ROM
Cardio
Continue cycle and elliptical progressions. Jogging at progressive speeds without heel lift 10-15
minutes
Strength
Continue progressing Phase 3 exercises
Single-limb squat
Single-limb dead lift
Proprioception
Single-limb balance with perturbations (progress eyes open to eyes closed, foam, BOSU, *sport
specific if applicable)
Balance step ups on uneven surface (forward, lateral, crossover, *sports specific if applicable)
Plyometrcs *emphasize eccentric control, avoiding increased trunk flexion, dynamic genu valgum, and
femoral internal rotation *
Wall jumps- athlete stands by wall with arms up, hops vertically and lands softly on the balls of
the feet. Emphasize soft landings, maintaining a slight bend in the knee.
Double-leg vertical jumps- athlete stands with hands at side, knees slightly bent and jumps
straight up for maximum height. Emphasize soft landings, maintaining a slight bend in
the knee. Hold each landing for 3-5 seconds.
Heiden/speed skater hop- athlete stands on one leg with knee slightly bent then jumps for
maximum vertical height and lands on the opposite leg. Emphasize soft landings,
controlled transitions and maintaining a slight bend in the knee.
Initiate sports specific drills
Begin speed/agility program
Guidelines
Perform stretching program daily. Cardio exercise is recommended 3-5 times a week for 15-20 minutes.
Perform strengthening/proprioception exercises 3 times a week. Perform plyometric/jumping exercises
2 times a week. Monitor increased swelling with plyometrics. Decrease intensity if swelling persists.
Clear to return to sport per physician.

Weight
Focus Precautions
Gait Exercises
Phase 1 *NWB with *Control pain and Modalities *Minimize joint effusion
Acute Phase crutches swelling Ice, compression, ESTIM and edema
*Restore pain free ROM *Avoid forceful DF and
ROM Ankle pumps, ankle circles, toe curls rotation to protect healing
*Protect healing Strengthening structures
structures (splint, Ankle isometrics, hip AB/Ext/ER isotonics
brace or heel lift)
Phase 2 *WBAT with *Maintain ROM ROM *Avoid forceful DF and
Sub-Acute crutches or and flexibility Gastroc/soleus towel stretch, tilt rotation to protect healing
Phase CAM Boot *Progress WB and board/wobble board ROM structures
normalize gait Cardio
mechanics Bicycle without resistance
*Improve strength Strengthening
and initiate Ankle isotonics with Theraband, seated
double-limb heel raises, seated toe raises (pain free
balance exercises ROM), body weight squat
Proprioception
Double-limb standing activities on foam,
standing hip isotonics
Phase 3 *FWB but *Maximize ROM/Stretching *Avoid forceful DF and
Strengthening may strength, initiate Gastroc/soleus wall stretch, rotation to protect healing
Phase continue to CKC exercises standing tilt board/wobble board ROM structures
use heel lift *Maximize Cardio *Caution pivoting or lateral
or ankle neuromuscular Bicycle/elliptical/treadmill movements
brace for control, initiate Strengthening *Not cleared to return
protection single-limb Advance ankle isotonics with Theraband sports
exercises (PF, DF, INV and EV), heel raises
*Initiate treadmill (progress double-limb to single-limb),
walking forward lunges, lateral lunges, resisted
hip AB walks, plank and side plank,
single-limb bridge
Proprioception
Single-limb standing activities (advance
to foam, tilt board, etc), balance step ups
(forward, lateral, crossover, etc.)
Phase 4 *Sport *Continue dynamic ROM/Stretching *Cleared for return to sport
Return to specific strengthening and Gastroc/soleus wall stretch, standing tilt per physician
Activity/Sport program per proprioceptive board/wobble board ROM
physician exercises Cardio
clearance *Initiate jog-to-run Jogging at progressive speeds without
progression heel lift 10-15 minutes
*Initiate cutting, Strengthening
pivoting and sport Continue progressing Phase 3 exercises,
specific drills single-limb squat, single-limb dead lift
Proprioception
Single-limb balance with perturbations,
balance step ups on uneven surface
Plyometrics
Wall jump, double-leg vertical jumps,
heiden/speed skater hop
Initiate sports specific drills, begin
speed/agility program

Plantar Fasciitis
The plantar fascia is a thick band of connective tissue that starts at the front of your calcanues (heel
bone) and then connects to each of your phalanges (toe bones). The function of the plantar fascia is to
enhance the mechanics of the foot. As you walk the plantar fascia gives support to the arch of your foot
and improves the efficiency of the muscles.
Generally speaking, plantar fasciitis is a painful condition that results from extra stress put through the
bottom of the foot. There are a number of different reasons as to why you may have developed your
symptoms and typically there are a number of factors involved. The most common risk factors
associated with plantar fasciitis are:
• Tightness or weakness of the calf muscles

• Low or fallen arches (pes planus) or high arches
(pes cavus)
• Sudden gain in weight or obesity
• Sudden increase in exercise intensity or duration
• Change in walking or running surface (going from
a treadmill to trail running)
• Occupations involving prolonged standing
• Shoes with poor cushioning/support
•
The symptoms of plantar fasciitis can come on suddenly, but typically they will gradually worsen with
time. Symptoms include:
• Heel pain especially with first few steps in the morning or after being sedentary for a while
• Tenderness to pressure at the sole of your foot or heel
• Pain when standing on your tiptoes
You may have had an x-ray that showed you have a heel or bone spur. Although it could be giving you
some symptoms, it is not always the reason for the pain with plantar fasciitis.

Treatment Options
Due to the multi-factorial nature of plantar fasciitis, the treatment options will vary and are very much
patient specific after an evaluation by a medical professional. This treatment may include a course of
physical therapy, anti-inflammatory medications, ice, night splints, rest and activity modification, change
in foot wear and over the counter or custom orthotics. If symptoms do not resolve, then your physician
may decide to give you a corticosteroid injection. With more chronic cases, a treatment called
extracorporeal shockwave therapy may be recommended by your physician. In more extreme cases
where all conservative treatment fails, surgery to release the tight fascia can be performed.
Your physical therapist will perform a detailed examination to assess the strength and flexibility of your
legs. The goal of rehabilitation of plantar fasciitis is to decrease the stress on the tissues by restoring the
normal mechanics of the foot and leg. This is key for a full return to function and to minimize the
chances of your symptoms returning.
Treatment may include (this list is not meant to be all inclusive or exclusive. Your treating physical
therapist will set an appropriate treatment plan based on your specific impairments/findings):
Rest/Activity Modification: Your therapist may ask you to stop or modify any activity that is causing you
pain or discomfort. This is to allow the irritated tissues to heal and to stop further aggravation of the
tissue.
Stretching: Stretching the lower extremity muscles with a focus on the gastrocnemious/soleus (calf
muscle) complex.
Strengthening: You will be instructed in a personalized exercise program based on the initial evaluation
findings. Strengthening typically is focused on the ankle/foot muscles (posterior tibialis and foot
intrinsic) and the core musculature (abdominals, low back and hip muscles).
Modalities: Several adjunctive therapies could be used during your treatment by the physical therapist.
These include ultrasound, laser therapy or iontophoresis.
Massage: Massaging of the plantar fascia can be performed to help lengthen the tissue and to help
break up any scar tissue that may have formed.
Taping: Different taping techniques could be utilized to assist in restoring normal mechanics in the foot
and to help prevent new inflammation from occurring.
Night Splints: Night splints are either a hard or soft splint that is worn during the night while sleeping to
keep the calf muscles stretched out and to limit the amount of muscle tightening that occurs from the
foot being held in a shortened position at night.

Change in Footwear/Orthotics: Depending on your foot posture, your therapist may have you try a
different type of shoe (motion control vs shock absorption) to improve the mechanics in your foot. If
the mechanics cannot be controlled with a change in footwear, orthotics may be recommended. Due to
cost, it is typical to try over the counter orthotics prior to having custom orthotics made (if symptoms
continue).
Your therapist will give you a home exercise program which may include the stretching, strengthening
and self-massage techniques. You should attempt to limit any activity that makes your pain worse and
use ice to help with any pain/inflammation that you may experience from everyday activity. About 80-
90% of all people who experience plantar fasciitis will have complete resolution of their symptoms.

Cervical Radiculopathy
The neck or cervical spine is comprised of seven vertebral bones stacked in a column which support the
head. In between each of the vertebrae is an intervertebral disc. The spinal cord travels down inside of
the cervical spine in a bony cage. Arising from each vertebral level on each side of the cord are nerve
roots which exit out through holes in the cage and travel down to the neck, upper back, and arms.
These small holes through which the nerves exit are called foramen. The ceiling of each hole is made by
the vertebrae above and the floor of the hole is made by the vertebrae below.
Cervical radiculopathy is a painful condition in which a nerve becomes

pinched as it leaves the spinal cord. The pinched nerve is compressed
by either herniated disc material or by degenerative bony spurs arising
from the neck.1 The nerves travel into your neck, upper back and arms,
and can refer symptoms into these areas. Symptoms experienced can
be pain, numbness, tingling, weakness or a combination of these.
Treatment Options http://www.deukspine.com/pages/pinched-nerves
Effective treatment of radiculopathy begins with a thorough examination to determine the root cause of
the dysfunction. Once the exam and diagnostic process is complete your physician will work with you to
determine the most appropriate course of action for treatment. In most cases cervical radiculopathy is
first treated conservatively. This may include rest, anti-inflammatory medication, and activity
modification. Your doctor may refer you to physical therapy to work on reducing the compression and
inflammation of the nerves in your neck.
If the pain in your neck and arm does not resolve with these conservative
measures your doctor may recommend you to have an injection of anti-
inflammatory medication (cortisone) directly into the region of nerve
compression. This space is often referred to as the epidural space and the
injection is sometimes referred to as an “epidural” injection. This can be a
very effective treatment for reducing the inflammation enough to allow
physical therapy treatment to work effectively.
http://www.cervicalspinehelp.com/what-is-cervical-radiculopathy/

In some instances cervical radiculopathy is resistant to all forms of conservative treatment. In these
cases you and your doctor may decide that surgical management of the pain is the best option. This
procedure may include removal of the herniated disc material or bone spur to free the nerve from the
compression. Prior to undergoing surgery your doctor will discuss the procedure and recovery process
in detail.
The goals of physical therapy are to reduce the nerve compression, decrease pain, and restore function.
Currently the best approach to treatment involves multiple treatment strategies. Manual and/or
mechanical traction may be applied to your neck to unload the compressed nerve. Different modalities
utilizing heat or electrical stimulation may be used to reduce pain and decrease muscle guarding.
Hands-on manual techniques will be employed to loosen stiff neck and upper back joints and muscles to
help to maximize flexibility.2 Restoring strength to the deep stabilizing muscles in the front of your neck
and between your shoulder blades will improve your postural endurance which is needed to avoid
future aggravation of the nerve.3
Rehabilitation
Phase 1: ACUTE PHASE
Goals
• Reduce pain and inflammation

• Protect injured nerve and cervical spine
• Improve cervical range of motion (ROM) without an increase in radicular symptoms
• Improve thoracic ROM
• Improve posture
ROM
• Active cervical ROM within a pain-free range

• Active thoracic ROM
• Scapular retraction exercises
• Pectoral stretches
• Length wise foam roller use with head supported
*Perform ROM exercises gently with the goal of reducing muscle guarding and pain
If tolerated, deep neck flexor muscle activation is to be initiated

Before progressing to the subacute phase the neck and radiating symptoms should be less painful at rest
and with movement. Increased pain with passive ROM should be seen more at “end range” and less
with initiation of movement. Deep neck flexor activation should be achieved. The patient should have a
good knowledge of postural correction techniques and activities that alleviate symptoms.
Phase 2: SUBACUTE PHASE
Goals
• Continued protection of injured/healing tissue

• Increased passive and active ROM in the cervical and thoracic spines
• Increased strength of cervical and periscapular musculature endurance with longer duration
holds
• Decrease axial symptoms
• Abolish radicular symptoms
Precautions
Avoid any activity or exercise that reproduces radicular symptoms.
ROM
o Active cervical ROM working toward end range
o Active thoracic ROM working toward end range
o Scapular retraction exercises with resistance
o Pectoral stretches
o Continue lying over a foam roller with head supported
Strengthening: (low resistance and long duration holds)

o Deep neck flexors
o Neck extensor strengthening

• Resolution of radicular symptoms
• Mild axial cervical pain may remain
• The patient should have gained a majority of their available ROM back
• Good tolerance for strengthening
• (-) Spurlings test
• (-) ULTT

Phase 3: REHAB PHASE
Goals
• Continue to acquire normal ROM if still deficient

• Progressively continue to strengthen peri-scapular muscle groups with increased resistance
• Restore functional use of arm and neck
Precautions
Avoid any activity or exercise that reproduces radicular symptoms.
ROM
o Stretches to cervical spine musculature

o Continue with thoracic mobility exercises
o Continue with pectoral stretching
Strengthening (Theraband or Dumbell)
o “T,””Y,” and “I” progression (shoulder extension/ horizontal abduction/scaption)
o Cervical isometrics in all planes
Before progressing to the sports specific phase the cervical spine should be pain free in all planes of
motion and strength should be very good. Neck and arm symptoms should be gone.
Phase 4: SPORT SPECIFIC PHASE
Goals
• Restore normal ROM and strength

• Continue to encourage cervical spine use for functional activity and return to sport
Limitations
Work with orthopedic doctor or physical therapist regarding specific plan for return to sport/activity

ROM and Stretching
Continue with phase two and three exercises as directed by physical therapist
Strengthening
Continue with phase three strengthening 2-3 times a week.
Work with physical therapist to determine which exercises should be continued
Guidelines for Return to Activity
Work with physician or physical therapist for specific plan for return to sport and activity. Step by step
progressions should allow for gradual return to high level activities.
Phase Focus Precautions
Motion Exercises
Acute *Reduce pain *Gentle pain- ROM * Avoid any

and free cervical Active cervical ROM within a activity or
inflammation ROM pain-free range exercise that
Active thoracic ROM reproduces
*Protect injured *Pain-free Scapular retraction exercises radicular
nerve thoracic ROM Lying over a foam roller with symptoms.
progression head supported
*Improve
cervical ROM Strengthening
without radicular If tolerated, deep neck flexor
symptoms strengthening should be
initiated
*Manual therapy
to increase joint
mobility in the
cervical and
thoracic spines
*Traction
*Postural
correction and
retraining

Subacute *Reduce pain *Continue to ROM * Avoid any
and progress Continue active cervical ROM activity or
inflammation cervical ROM within a pain-free range exercise that
Continue active thoracic ROM reproduces
* Protect injured * Continue to Pectoral stretches radicular
nerve progress Scapular retraction exercises symptoms.
thoracic ROM Lying over a foam roller with
*Improve head supported
cervical ROM If tolerated, deep neck flexor
without radicular strengthening should be
symptoms initiated
*Improve Strengthening
thoracic ROM Progression of deep neck
flexor strengthening
Progression of neck extensor
strengthening
Strengthening of periscapular
muscles and thoracic extensors
Rehab * Restore full *Stretches to ROM * Avoid any
pain free cervical Cervical spine muscle stretches activity or
strength and musculature exercise that
ROM to cervical Strengthening reproduces
and thoracic Global neck strengthening radicular
spines  Strengthening of periscapular symptoms.
muscles and thoracic extensors
*Functional
endurance
training
Sport Gradual Return Maintain Full ROM *Return to

Specific to Sports and Passive/Active Continue as Needed Sports and
Physical Activity ROM Physical Activity
Strengthening per
Continue T-band and Peri- Surgeon/Physical
scapular Progressions 3 x/ Therapist
Week as Needed Evaluation
Dynamic Progressions *Achieve Full

Continue Proprioceptive Drills Pain Free ROM
During Return to Sport 2-3 x/ and Excellent
Week Strength Before
Progression Back
to Sport

References
1. Eubanks JD. Cervical radiculopathy: Nonoperative management of neck pain and radicular
symptoms. American Family Physician. 2010; 81(1):33-40.
2. Boyles R, Toy P, Mellon J, Hayes M, Hammer B. Effectiveness of manual physical therapy in
treatment of cervical radiculopathy: a systematic review. Journal of Manual & Manipulative
Therapy. 2011; 19(3):135-142.
3. Cleland JA, Fritz JM, Whitman JM, Heath R. Predictors of short-term outcome in people with a
clinical diagnosis of cervical radiculopathy. Phys Ther. 2007; 87(12):1619-1632.

Lumbar Disc Herniation/Bulge Protocol

The lumbar spine is made up of 5 load transferring bones called vertebrae. They are stacked in a column
with an intervertebral disc sandwiched between each
set of vertebrae. The lumbar spine comprises the 5
vertebrae that are below the thoracic vertebrae and
are labeled L1, L2, L3, L4, and L5 in descending order
starting from the top. The intervertebral discs are
numbered as well and are based upon the name of the
vertebrae above and below. The first lumbar disc is
labeled L1-2, and they are labeled sequentially down to
L5-S1. S1 represents the sacrum, and is identified as
the region of the spine that connects the spine to the
pelvis. The most common location for disc injury is at
L4-5 and L5-S1.
http://orthoinfo.aaos.org/topic.cfm?topic=A00575
Under normal circumstances the discs act to transfer and absorb loads traveling from our upper body to
our lower body. The discs are soft cartilaginous structures that are semi-elastic. They are comprised of
a softer central area called the nucleus and a thicker outer wall called the annulus. Subsequent to injury
or as we age the discs can slowly lose water content and become more fibrotic or stiff. When the disc
material herniates or bulges, a portion of the disc pushes out beyond its anatomical borders and may
inflame or compress some of the sensitive structures in its area. The name given to the disc injury (i.e.
bulge, herniation, extrusion) describes the extent and pathway of the disc material.
Common symptoms that you may feel as a result of a disc bulge or

herniation include central low back pain, pain that radiates into
your leg(s), sensation changes in the hips or legs, and/or weakness
in the muscles of the hips or legs. Pain in the low back can come
from muscle spasm and nerve irritation. Pain radiating to the legs
can be referred to as sciatica, as the nerve the message travels
down is the sciatic nerve. Sensation changes and weakness can be
caused by interruption of the normal pathway of signals between
your spinal cord and structures in your legs. Rarely, bowel and bladder problems related to the disc
http://orthoinfo.aaos.org/topic.cfm?topic=A0057

compression can occur. If you are experiencing problems with urination, problems having bowel
movements, or if you have numbness around the area of your genitals this may be a sign of cauda
equina syndrome, which is a medical emergency. You should consult a medical doctor immediately if
you are experiencing these symptoms.
Disc herniations and bulges are very common occurrences. Most diagnoses of disc herniations can be
made by a physician’s physical exam.
Treatment Options
Treatment depends upon the symptoms experienced by the patient, the physical exam findings, and any
diagnostic tests that have been done. The need for imaging will be determined by your physician. It is
common to find normal degenerative changes when imaging is performed and often disc abnormalities
are observed that may not be responsible for the current symptoms. The most common way of
managing and treating disc related symptoms are to begin conservatively and then become more
aggressive if the symptoms continue.
Most symptoms related to discs will improve with time and your body’s natural healing response,
therefore the first treatment involves no more than one day of rest and avoidance of activities that
would significantly aggravate your symptoms. During this time the initial use of ice to reduce
inflammation may be employed. After a few days switching to using applied heat, rubs, or gels may help
to alleviate muscle spasms.
Physical therapy is often recommended for the treatment of pain and restoration of functional deficits
associated with disc injury. The physical therapist will evaluate mobility, flexibility and strength with
the purpose of determining the underlying cause of the abnormal stress on the back. The patient will be
counseled on which activities they can safely continue and which should be avoided. The patient will
also be instructed in exercises, postures and positions that can alleviate symptoms. Physical therapy
involves learning the exercises to remain active and prevent muscle disuse. Remaining active while
avoiding specific activities that aggravate symptoms optimizes conservative recovery after disc injury.1
Physical therapists are experts in assisting people with disc injury to transition to more functional and
active lifestyles.
To reduce pain, decrease inflammation, and relax muscles that are in spasm, physicians may prescribe
oral medications. There are different classifications and strengths of medications that can be
prescribed. Some of the stronger or more potent medications can lead to drowsiness or even have
potential for addiction. Your physician is an excellent resource for advice pertaining to safe and
effective medications to take.
If oral medications are not adequately alleviating symptoms you and your physician may discuss having
you undergo an epidural steroid injection. This procedure involves injecting anti-inflammatory
medication directly into the area of compression. In many cases more than one injection is required to
achieve adequate symptom relief.

Surgery is reserved for disc injuries that present with nerve compression which has caused significant
weakness, cauda equina syndrome, or a rapidly declining neurological status. Surgery may be
considered if conservative care is unsuccessful. Surgery involves removing the disc material that is
causing the compression and freeing up the compressed nerve(s). Prior to undergoing surgery your
doctor will discuss the procedure and recovery process in detail.
Rehabilitation
Phase 1: ACUTE PHASE
Goals
Reduce muscle spasm
Establish positions and postures for sitting, sleeping and standing which reduce pain or are pain free
Continue to stay active and walk daily
Will be determined based on individual assessment and should reduce pain
Walking
These exercises will include gentle…
Stretching
Core muscle activation
ROM(Range of Motion)
Guidelines
Perform activities and exercises that minimize pain
Stay as active as possible
Avoid activities and positions that worsen symptoms

Phase 2: SUB-ACUTE PHASE
Goals
Progressive increase in activity level and distance walking
Begin to improve spinal and low extremity flexibility
Begin to strengthen areas of weakness
Begin abdominal and pelvic stabilization exercises
Active ROM of the spine and extremities
Lower extremity stretches
Strengthing
Initiation of core stabilization exercise progressions incorporating activation of transverses
abdominus and multifidi coordinated with hip musculature
• Quadruped (bird dog) progression
• Bridge progression
• Side plank (gluteus medius) progression
• Prone plank or hooklying abdominal progression
Light hip and lower extremity strengthening
Guidelines
Walk daily and stay as active as possible
Perform stretches daily
Perform stabilization exercises daily
Perform lower extremity strengthening 3 times per week
Begin functional movements such as squatting and bending
Phase 3: REHABILITATION PHASE
Goals
Aerobic conditioning
Restore spinal and lower extremity flexibility
Restore spinal and lower extremity muscular strength
Continue stabilization exercises progression
Perform functional lifting, bending and reaching activities with light resistance
Spinal stretches
Lower extremity stretches
Cardio
Walking, jogging, elliptical, swimming, etc

Strengthening
Continued progression of core stabilization exercises incorporating activation of transverses
abdominus and multifidi coordinated with hip musculature
• Side plank (gluteus medius) progression
• Prone plank or hooklying abdominal progression
• Use of exercise machines to strengthen spinal musculature
Hip and lower extremity strengthening
• Squat progression
• Lunge progression
• Use of exercise machines to strengthen lower extremities
Guidelines
Once good motor control and endurance within the core musculature is achieved then progression to
functional and activity specific movements can be undertaken
Phase 4: RETURN TO SPORT/ACTIVITY PHASE
Goals
Continue aerobic conditioning
Return to all functional activities
Achieve maximal strength and flexibility for return to sport/activity
Flexibility
Continue daily spinal and lower extremity stretching
Cardio
Continue aerobic exercise
Sport specific aerobic challenges
Strengthening
Transition to gym equipment
Progress to multiplanar ball stabilization exercises
Return to Sport
Guidelines

Recommended
Exercises
Phase 1 • Control pain and To be determined based upon individual • Perform activities and
Acute Phase Inflammation assessment and will include gentle stretching, exercise that minimize pain
• Reduce muscle ROM and core muscle activation. • Avoid activities and
spasm positions that worsen
• Establish pain free symptoms
positions and • Stay as active as possible
postures for sitting,
sleeping an standing
• Stay active/walk
Phase 2 • Continue to avoid ROM and Flexibility • Stay as active as possible
Sub-acute exacerbation of Lower extremity stretches • Perform strengthening and
Phase Symptoms Spinal stretches stabilization exercises 3
• Progressive increase times a week, 2- sets of 15-
in activity level and Strength 20 reps
distance walking Initiate core stabilization exercise progressions • Stretching program daily 2-
• Begin improving incorporate transverses abdominus and 3 repetitions of 30 seconds
spinal and LE multifidi coordinated with hip musculature • Begin functional
flexibility • Quadruped (bird dog) progression movements
• Begin lower • Bridge progression
extremity • Side plank (gluteus medius)
strengthening progression
• Begin abdominal • Prone plank or hooklying abdominal
and pelvic progression
stabilization Light hip and lower extremity strengthening
exercises
Function
Bending and squatting
Walk daily
Phase 3 • Continue to Flexibilty • Perform functional lifting,
Rehabilitation maximize return of Continue spinal and lower extremity stretching bending and reaching
Phase strength and • Stretching program daily 2-
flexibility Cardio 3 repetitions of 30 seconds
• Initiate functional Daily walking, jogging, swimming, elliptical or • Cardio program should be
activities aerobic conditioning performed no more that 3-
5 times a week for 20-45
Strengthening minutes
Continue progressed stabilization exercises • Perform strengthening
incorporating transverses abdominus and exercises 3 times a week, 2-
multifidi coordinated with hip musculature 3 sets of 15-20 reps
• Side plank (gluteus medius)
progression
• Prone plank or hooklying abdominal
progression
• Use of exercise machines to
strengthen spinal musculature
Hip and lower extremity strengthening
• Squat progression

• Lunge progression
• Use of exercise machines to
strengthen lower extremities
Phase 4 • Achieve adequate Flexibility • Stretching program daily 2-

Sport Specific strength and Continue Daily Stretching 3 repetitions of 30 seconds
Phase flexibility to return • Cardio program should be
to sport/activity Cardio progressed in preparation
Sport specific aerobic challenges for return to sport
• Perform strengthening
Strengthening exercises 3 times a week, 2-
Transition to Gym equipment 3 sets of 15-20 reps
Progress to multiplanar ball stabilization
exercises
Return to Sport
Reference:
1. Delitto A, George SZ, Van Dillen L, et al. Low back pain: Clinical guidelines linked to the international
classification of functioning, disability, and health from the orthopaedic section of the American Physical
Therapy Association. J Orthop Sports Phys Ther. 2012; 42(4): A1-A57.

Post-Concussion Syndrome
Anatomy of the injury:

The brain is a soft delicate structure encased in our skull, which protects it from external damage. It is
suspended within the skull in a liquid called cerebral spinal fluid. This liquid serves to cushion the brain from
damage. A concussion is a traumatic brain injury from a “jolt to the head” or a “bell ringer” that results in
the brain quickly shifting and pulling on the structures within the skull. An external impact is not always
necessary to produce a concussive force. This force can also result from the brain impacting the inside of
the skull as well as the straining of the tissues that support the brain when the body stops too quickly, like
in an auto accident. Regardless of the type of impact, the injury causes a chemical change within the brain
that alters its ability to function, even though structural damage is not always present. For this reason,
concussions are often not evident on diagnostic tests, like MRIs or CT scan imaging. Our nerves within the
brain are extremely sensitive to this chemical change. When these changes occur our nerves have difficulty
regulating some of our body’s basic functions, such as keeping our heart rate stable during exercise. This
chemical change within the nerves also disrupts our body’s coordination and balance.
Symptoms (what your child will feel)

- Headaches - Fogginess
- Dizziness - Vision changes
- Difficulty concentrating/remembering - Ringing in the ears
- Loss of balance - Fatigue/Drowsiness
- Sensitivity to light/noise - Nausea/Vomiting
Signs (what you will see in your child)

- Loss of balance - Forgetfulness/amnesia
- Acting disoriented - Dazed/confused
- Forgetting game scores or rules - Inappropriate emotions
- Personality changes - Slow to respond
- Poor coordination - Loss of consciousness (only
seen 10% of the time)
Treatment

After your child has been diagnosed with a concussion, the first step in treatment is REST! The brain is
extremely sensitive to further damage in the time following the concussion. This damage doesn’t have to
be the result of a physical injury. Daily stress and overuse of the brain can actually take away the focus on
healing and recovery. The most important course of treatment is to rest the brain as much as possible, both
physically (sports/activities) and cognitively (school). This sometimes means limiting school, sports, TV,
computer, cell phones and loud or crowded places. Recovery time for each child is unique for each case.
As symptoms start to subside, your doctor can provide help in determining when to return to cognitive and
physical activity.
Doctors Visits
If your child continues to experience symptoms beyond two weeks, they are recommended to see their
pediatrician or a concussion specialist. These visits are there to assist you and your child with any medical
management that may help their recovery as well with any academic or athletic accommodations that are
needed. In the Commonwealth of Massachusetts if your child is suspected to have a concussion, they will
not be able to return to athletics without written medical clearance by a certified physician.
ImPACT Testing
After your child’s injury, they may be asked to take a test to assess their neurocognitive
function (thinking ability). This test is administered and interpreted by trained
professionals only. The results can be used to measure progress, and will help determine
your child’s return to cognitive and physical activity.
What is Post-Concussion Syndrome?

Many concussions and their symptoms resolve within 7-10 days with proper rest. More severe cases of
concussion do carry the possibility that post-concussion syndrome can arise. Post-concussion syndrome
occurs when the brain is having difficulty healing and returning to its prior level of function. This normally
manifests as three or more symptoms lasting longer than four weeks. Treatment options frequently
include prolonged rest, academic accommodations, medications and physical therapy.
There is currently no treatment that will accelerate your child’s recovery from a concussion. However,
rehabilitation can treat secondary injuries such as vertigo, neck muscle strains, balance dysfunction, and
abnormal eye movements that stress the brain and slow its recovery time. By treating these injuries,
rehabilitation puts your child’s brain in its most optimal healing environment.
One of the goals of post-concussion rehabilitation is to increase blood flow and nutrients to the brain
during recovery. This will aide in healing, higher cognitive functioning, and help increase your child’s
tolerance to exercise. Research done under Dr. John Leddy indicate that closely monitored, progressive
increases in physical activity can in fact be performed safely to assist with decreasing these lingering
symptoms. Your child’s physical therapist will design and assist in administering an individualized exercise
plan, which will re-educate the brain to tolerate exercise and eventually return to athletics safely.

Rehabilitation
**The following is an outlined progression for rehab. Timetables are approximate and advancement
from phase to phase as well as specific exercises performed should be based on each individual patient’s
case and sound clinical judgment by the rehab professional. **
Pre-Rehab Phase:
Goals
Protect from further damage.
Decrease acute symptoms.
Promote adequate rest.
Precautions
No return to activity until cleared by MD.
Decrease physical and cognitive stimuli.
Guidelines
As symptoms start to subside, your doctor can provide help in determining when to return to cognitive and
physical activity
Phase 1:
Benign Paroxysmal Positional Vertigo (BPPV) (if applicable):

Criteria
Dizziness is a significant symptom lasting for longer than two weeks.
Usually lasting during short duration from 5-30 seconds. P
Patient reports dizziness or “room spinning” sensation.
Tests:
Hallpike-Dix Test
Roll Test
Treatment:
Canalith Repositioning Technique

Cervical/Thoracic Strain, Cervicogenic Headaches (if applicable):
Criteria
Consistent cervical pain at rest or with movement
Palpated tenderness through cervical and thoracic musculature
Palpated tenderness at suboccipital musculature with provocation of headache.
“Over the head” headaches with prolonged upright activities.
Tests:
Rule out peripheral neurological involvement; warrants a return to MD
Treatment
Sub-occupital release.
Cervical PROM/stretching.
Soft tissue mobilization, myofascial release.
Initiate postural strengthening
Cervical isometrics
Oculomotor Dysfunction(if applicable):

Criteria
Symptoms of double vision, difficulty ready and loss of balance.
Tests
Cranial Nerve Testing (II, III, IV, VI, VII)
VOR I, II, Cancellation
Convergence, Divergence
Saccades
Treatment
Cooksey- Cawthorne Exercises.
Habituation exercises
Gaze stabilization exercises in various positions.
Visual scanning exercises in various positions.
Balance Dysfunction (if applicable):

Criteria
Unable to walk a straight line with normal or narrow BOS
Frequent LOB reported.
Increased postural sway
Tests
Romberg Test
BESS (Balance Error Scoring System) test
Postural Perturbations
Righting reactions assessment
Coordination assessment
Treatment
Progressive balance training
Core strengthening
Postural strengthening
Initiate Light Phase I Exercise:

Criteria
No symptoms greater the 3/6 (according to Acute Concussion Evaluation from UPMC)

Progressive decrease in symptoms
Increased baseline HR
Tests
Exertional Assessment
Treatment
Initiate light cardiovascular exercise (30-40% Max HR)
Limited positional change and head movement
Static balance exercises
Minimal stimuli in exercise environment
Phase II Exercise
Criteria
Progressive decrease in symptoms at rest < 3/6 (according to Acute Concussion Evaluation from UPMC)
Symptoms continue to be provoked by exercise
Noted improvement in all applicable phase I symptoms
Treatment
Progress cardiovascular exercise to 40-60% Max HR
Initiate positional changes with head movement
Progress to dynamic balance exercises
Continue phase I treatment as needed
Phase III Exercise

Criteria
No symptoms at rest or during activity
Decreasing baseline HR
Treatment
Progress cardiovascular exercise with 60-80% Max HR
Progress postural changes with cardiovascular exertion
Progress to dynamic balance exercises with cardiovascular exertion
Increase environment stimuli
Initiate multi-step exercises
Phase IV (Functional) Exercise

Treatment
Progress cardiovascular exercise to 80-90% Max HR
Non-contact sport-specific training
Increase coordination and cardiovascular training
Increase reactionary neuromuscular re-education
Increase dynamic balance exercises
Phase V (Return to Play) Exercise:

Treatment
Cardiovascular exercise to 100% Max HR
Progress to return to play contact exercises

PHASE SYMPTOMS PLAN OF CARE
Phase I- Benign Paroxysmal -Dizziness is a significant Test: Hallpike-Dix, Roll Test
Positional Vertigo (BPPV) symptom lasting for longer than Treatment: Canalith
two weeks. Repositioning Techniques
-Usually lasting during short
duration from 5-30 seconds. P
-Patient experiencing “room
spinning” sensation.
Phase I- cervical/thoracic strain, -Consistent cervical pain at rest - Sub-occupital release.
cervicogenic headaches or with movement - Cervical PROM/stretching.
-Palpated tenderness through - Soft tissue mobilization,
cervical and thoracic myofascial release.
musculature - Initiate postural strengthening
-Palpated tenderness at - Initiate cervical Isometrics
suboccipital musculature with
provocation of headache.
-“Over the head” headaches
with prolonged upright activities.
Phase I- Oculomotor Dysfunction -Symptoms of double vision, Tests: Cranial Nerve Testing (II,
difficulty ready and loss of III, IV, VI, VII),VOR I, II,
balance. Cancellation, Convergence,
Divergence, Saccades
Treatment: Cooksey- Cawthorne
Exercises, Habituation exercises,
Gaze stabilization exercises in
various positions, Visual
scanning exercises in various
positions.
Phase I- Balance Dysfunction - Unable to walk a straight line Tests: Romberg Test,
with normal or narrow BOS BESS (Balance Error Scoring
- Frequent LOB reported. System) test, Postural
- Increased postural sway Perturbations, Righting reactions
assessment, Coordination
assessment
Treatment: Progressive balance
training, Core strengthening,
Postural strengthening
Phase I- Initiate light exercise -No symptoms greater the 3/6 Tests: Exertional Assessment
(according to Acute Concussion Treatment: Initiate light
Evaluation from UPMC) cardiovascular exercise (30-40%
-Progressive decrease in Max HR) , Limited positional
symptoms change and head movement,
-Increased baseline HR static balance exercises, minimal
stimuli in exercise environment

Phase II – Exercise - Progressive decrease in Treatment: Progress
symptoms at rest < 3/6 cardiovascular exercise to 40-
(according to Acute Concussion 60% Max HR, Initiate positional
Evaluation from UPMC) changes with head movement
- Symptoms continue to be Progress to dynamic balance
provoked by exercise exercises, Continue phase I
- Noted improvement in all treatment as needed
applicable phase I symptoms
Phase III- Exercise - No symptoms at rest or during Treatment: Progress
activity cardiovascular exercise with 60-
- Decreasing baseline HR 80% Max HR, Progress postural
changes with cardiovascular
exertion, Progress to dynamic
balance exercises with
cardiovascular exertion, Increase
environment stimuli, Initiate
multi-step exercises
Phase IV- Functional Exercise - No symptoms at rest or during Treatment: Progress
activity cardiovascular exercise to 80-
- Decreasing baseline HR 90% Max HR, Non-contact sport-
specific training, Increase
coordination and cardiovascular
training, Increase reactionary
neuromuscular re-education
Increase dynamic balance
exercises
Phase V- Return to Play Exercise - No symptoms at rest or during Treatment: Cardiovascular
activity exercise to 100% Max HR,
- Decreasing baseline HR Progress to return to play
contact exercises
*Reviewed by Janet Kent, MD


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South Shore - Orthopedics

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 1

Post Operative Visits

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 2

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 3

Phase 1 (0-4 Weeks) Passive ROM Phase

Phase 2 (4-8 Weeks) Active ROM Phase

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 4

Phase 3 (8-12 Weeks) Strengthening Phase

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 5

Phase 4 (12-24 Weeks) Sport Specific and Return to Activity Phase

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 6

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 7

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 8

*Reviewed by Michael Geary, MD

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 9

Anatomy and Biomechanics

The shoulder is a wonderfully complex joint that is made up of

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 1

Effective treatment of tendinopathy and impingement

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 2

Phase 1 Acute Phase

Guidelines For Progression

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 3

Guidelines for Progression

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 4

Guidelines for Progression

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 5

Guidelines for Return to Activity

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 6

Acute *Reduce Pain *Gentle ROM ROM *Do not perform

Subacute *Continue *Continue pain- ROM *Stress Proper

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 7

*Reviewed by Michael Geary, MD

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 8

Anatomy and Biomechanics

The rotator cuff is a group of four tendons that attach to

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 1

Rotator cuff repair surgery can now be performed arthroscopically and is

Recovery/Time off Work

Post Operative Visits

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 2

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 3

Phase 1 (0-6 Weeks) Passive Range of Motion (ROM) Phase

Protect Healing Tendon

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 4

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 5

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 6

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 7

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 8

*Reviewed by Michael Geary, MD

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 9

Anatomy and Biomechanics

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 1

Post Operative Visits

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 2

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 3

Phase 1 (0-4 Weeks) Passive ROM Phase

Phase 2 (4-8 Weeks) Active ROM Phase

South Shore Hospital Orthopedic, Spine and Sports Therapy Page 4

Acute Reduce Pain Gentle ROM ROM *Do not perform

Subacute Continue Continue pain- ROM *Stress Proper

String jumps together. Focus on quickly moving from jump to jump.