Latarjet Procedure: Postoperative Rehabilitation Protocol

**Special thank you to my mentors and master surgeons at The University of Virginia Department of Orthopaedic Sports Medicine: Stephen Brockmeier MD, Eric Carson MD, David Diduch MD, Winston Gwathmey MD, Mark Miller MD.

PHASE I (weeks 1-3) – Immediate post-op phase
Goals:
• Minimize/control shoulder inflammation and pain
• Protection of surgical repair
• Gradual restoration of shoulder PROM
• Adequate scapular mobility and function
Patient education/precautions:
• NO AROM of the operative shoulder
• No excessive shoulder external rotation ROM/stretching. STOP at first felt end feel.
• WEAR SLING AT ALL TIMES. Remove only for showering with arm at side.
• No lifting of objects with operative shoulder/arm. Limit use of operative upper extremity.
• Sleep with sling supporting operative shoulder (towel placed under elbow to prevent shoulder extension)
• Education regarding posture, joint protection, positioning, etc.
Activity
• PROM/AAROM/AROM of elbow, wrist, and hand.
• Begin shoulder PROM (PT directed/administered)
o Forward flexion/elevation to tolerance
o Abduction in scapular plane to tolerance
o IR to 45 degrees at 30 degrees abduction
o ER in scapular plane from 0-25 degrees; begin at 30-45 degrees abduction.
o DO NOT FORCE ANY PAINFUL MOTION. RESPECT ANTERIOR CAPSULE INTEGRITY WITH ER.
• Scapular clock and isometric exercises.
• Ball squeezes
• Frequent ice/cryotherapy for pain and inflammation
Criteria to progress to Phase II
• Patient adherence to precautions and immobilization guidelines
• 100 degrees of passive forward elevation and 30 degrees of passive ER at 20 degrees abduction.
• Completion of phase I activities with minimal to no pain or difficulty.

Phase II (approximately weeks 4-9) -Intermediate Phase
Goals for phase II
• Minimize/control pain and inflammatory response
• Protection of surgical repair/integrity
• Achieve restoration of AROM gradually
• Wean from sling in weeks 6-7
• Initiate LIGHT waist level activities.
Patient education/Precautions
• No active
• shoulder movement until adequate PROM with good mechanics
• No lifting with operative shoulder/upper extremity
• No excessive ER ROM/stretching. Respect anterior capsule integrity
• No activities/exercises that place excessive load on anterior shoulder (push-ups, pectoralis flys, etc.)
• Avoid exercises that involve “empty can” /IR position in scaption due to risk of impingement
Activity
Early Phase II (approx. week 4)
• Progress shoulder PROM (do not force any painful motion)
• Forward flexion/elevation to tolerance
• Abduction in scapular plane to tolerance
• IR to 45 degrees at 30 degrees of abduction
• ER to 0-45 degrees at 30-40 degrees abduction
• Glenohumeral joint mobilizations as indicated when ROM significantly less than expected. Mobilization done in direction of limitation and discontinue once adequate ROM achieved
• Address scapulothoracic and trunk mobility limitations. Mobilizations done in direction of limitation and discontinued when ROM achieved
• Introduce posterior capsule stretching as indicated
• Continue ice/cyrotherapy for pain and inflammation

Late Phase II (approx. week 6)
• Progress shoulder PROM (do not force any painful motion)
• Forward flexion/elevation/abduction in scapular plane to tolerance
• IR as tolerated at multiple angles of abduction
• ER to tolerance at multiple angles of abduction ONCE ACHIEVE 35 DEGREES ER AT 0-40 DEGREES OF ABDUCTION.
• Glenohumeral and scapulothoracic joint mobilizations as indicated
• Progress to AAROM/AROM activities of shoulder as tolerated with good mechanics (minimal to no scapulothoracic substitution with up to 90-110 degrees of elevation)
• Begin rhythmic stabilization drills (IR/ER in scapular plane, flexion/extension and abduction/adduction at varying angles of shoulder elevation)
• Continue AROM elbow, wrist, and hand
• Strengthen scapular retractors and upward rotators
• Initiate balanced AROM/strengthening program
• Low dynamic positions initially
• Muscular endurance with high repetition (30-50), low resistance (1-3 lbs)
• Exercises should be progressive in terms of muscle demand/intensity, shoulder elevation, and stress on anterior joint capsule
• Achieve full elevation in scapular plane before beginning elevation in other planes
• All activities should be pain free and without substitution patterns
• Exercises both open and closed-chain
• No heavy lifting or plyometrics at this time
• Initiate “full can” scapular plane to 90 degrees elevation with good mechanics
• Initiate IR/ER strengthening with tubing at 0 degrees of abduction
• Sidelying ER with towel roll
• Manual resistance ER in scapular plane in supine position
• Prone scapular exercise (30/45/90 degrees abduction) in neutral arm position
Criteria to progress to phase III
• Forward elevation PROM at least 155 degrees and AROM 145 degrees with good mechanics
• ER PROM within 8-10 degrees of contralateral side at 20 degrees abduction
• ER PROM at least 75 degrees at 90 degrees abduction
• Appropriate scapular posture at rest and dynamic scapular control with ROM and functional activities.
• Completion of phase II activities with minimal to no pain or difficulty.

PHASE III (approximately weeks 10-15)
Goals
• Normalize strength, endurance, and neuromuscular control
• Return to chest level functional activities
• Gradual and planned progression of anterior joint capsule stress
Precautions
• No aggressive overhead activities/strengthening that overstress anterior joint capsule
• Avoid contact sports/activities
• No strengthening or functional activities in any plane until near full ROM and strength in that plane of movement
• Patient education regarding gradual increase of shoulder activities
Activities
• Continue AROM and PROM as needed/indicated
• Initiate biceps strengthening with light resistance, progress as tolerated
• Gradual progression of pectoralis major/minor (avoid positions of excessive stress to anterior joint capsule)
• Subscapularis strength progression (pushup plus, cross body diagonals, forward punch, IR resistance band at 0/45/90 degrees abduction, etc)
Criteria to progress to phase IV
• PROM forward elevation within normal limits
• PROM ER at all angle at all angles of shoulder abduction within normal limits
• AROM forward elevation within normal limits with good mechanics
• Good rotator cuff and scapular muscular performance for chest level activities
• Completion of phase III activities with minimal to no pain or difficulty

PhaseIV (approx.weeks 16-20) Overhead activities/return to activities phase
Goals
• Stretching and PROM as needed/indicated
• Maintain full non-painful AROM
• Return to full work activities
• Return to full recreational activities
Precautions
• Excessive anterior joint capsule stress
• Avoidance of “triceps dips, wide grip bench press, military press, or lat pulls behind head. Always “see your elbows” when weight lifting.
• No throwing or overhead athletic moves until 4 months post-op or cleared by MD.
Activity
• Continue all exercises from phase III
• Overhead strengthening if ROM and strength below 90 degrees elevation is good
• Shoulder stretching/strengthening at least 4 x a week
• Return to upper extremity weight lifting program with emphasis on larger, primary upper extremity muscles (deltoids, latissimus dorsi, pectoralis major)
• Push-ups with elbows not flexing past 90 degrees
• Plyometrics/interval sports program if appropriate/cleared by PT and MD
• May initiate pre injury level activities/vigorous sports if appropriate/cleared by MD