Shoulder Procedures & Protocols
Shoulder Procedures and Physiotherapy Protocols
Recovery from shoulder surgery follows a general pattern, but every patient progresses at their own pace. The timelines below are guidelines rather than fixed rules. Dr Handford trusts the judgement of your treating physiotherapist to speed up or slow down each phase based on how you are actually progressing. Always follow the specific written instructions given to you at discharge and by your physiotherapist.
Arthroscopic Rotator Cuff Repair
Arthroscopic rotator cuff repair reattaches the torn tendon to the bone using small suture anchors, placed through a few small portals with a camera and fine instruments. It minimises soft tissue disruption, gives a clear view of the tear pattern, and is done as a day-only or overnight procedure. The aim is to restore strength, relieve night pain and return the shoulder to reliable function.
Full-thickness rotator cuff tears causing pain, weakness or night pain
Symptomatic partial-thickness tears that have failed non-surgical management
Acute traumatic tears with significant weakness
A failed course of physiotherapy, activity modification or injection
Physiotherapy Protocol
Dr Handford's protocol favours early, gently controlled motion within protected limits rather than a period of complete immobility.
Goals
- Protect the repair while the tendon heals to bone
- Maintain gentle motion within safe limits to reduce the risk of stiffness
Precautions
- Sling worn from waking in recovery
- Motion is active-assisted only, within limits: forward flexion to 60°, abduction to 60°, external rotation to neutral (0°)
- No active lifting or resisted movement of the shoulder
Exercises / Therapy
- Active-assisted range of motion within the above limits, commenced early
- Active range of motion of the hand and wrist
Review / Milestones
- Wound check at 2 weeks, with your GP or Dr Handford
Goals
- Progress to full active range of motion
- Wean out of the sling
Precautions
- Sling weaning begins at 6 weeks
- Resisted strengthening not yet commenced
Exercises / Therapy
- Active range of motion progressing towards a full, unrestricted range
- Light functional use of the arm
Review / Milestones
- Review with Dr Handford at 8 weeks
Goals
- Build rotator cuff and scapular strength
- Progress towards work, sport and overhead activity
Exercises / Therapy
- Resisted band exercises for the rotator cuff and scapular stabilisers
- Progressive strengthening and functional or sport-specific work as guided
Return to activity / sport
Recovery is gradual. Strengthening begins at 12 weeks, and most patients feel fully satisfied with their result somewhere between 3 and 6 months.
Mini-Open Rotator Cuff Repair
Mini-open repair combines an arthroscopic assessment and subacromial decompression with a small 3 to 5cm incision over the front of the shoulder, through which the tendon repair is completed directly. It suits larger or more complex tears where direct visualisation and fixation are of benefit. Clinical outcomes at final follow-up are comparable to the fully arthroscopic technique.
Larger or more complex rotator cuff tears
Tears where direct visualisation aids secure fixation
Revision rotator cuff surgery in select cases
Physiotherapy Protocol
The rehabilitation pathway follows Dr Handford's standard rotator cuff protocol of early, gently controlled motion. Because a small portion of deltoid is split to access the tendon, early protection of the deltoid origin is added, and early pain may settle slightly more slowly than after an all-arthroscopic repair, though outcomes converge by three months.
Goals
- Protect the tendon repair and deltoid split
- Maintain gentle motion within safe limits to reduce the risk of stiffness
Precautions
- Sling worn from waking in recovery
- Motion is active-assisted only, within limits: forward flexion to 60°, abduction to 60°, external rotation to neutral (0°)
- No active lifting or resisted movement of the shoulder
Exercises / Therapy
- Active-assisted range of motion within the above limits, commenced early
- Active range of motion of the hand and wrist
Review / Milestones
- Wound check at 2 weeks, with your GP or Dr Handford
Goals
- Progress to full active range of motion
- Wean out of the sling
Precautions
- Sling weaning begins at 6 weeks
- Resisted strengthening not yet commenced
Exercises / Therapy
- Active range of motion progressing towards a full, unrestricted range
- Light functional use of the arm
Review / Milestones
- Review with Dr Handford at 8 weeks
Goals
- Build rotator cuff and deltoid strength
- Progress towards work, sport and overhead activity
Exercises / Therapy
- Resisted band exercises
- Progressive strengthening and functional or sport-specific work as guided
Return to activity / sport
Recovery follows the same protocol and timeline as the arthroscopic technique. Strengthening begins at 12 weeks, with most patients feeling fully satisfied with their result somewhere between 3 and 6 months.
Reverse Total Shoulder Replacement
Reverse total shoulder replacement reverses the normal ball-and-socket anatomy, placing the ball on the shoulder blade and the socket on the arm bone. This lets the deltoid muscle power the arm when the rotator cuff is torn or deficient, restoring elevation and function even without an intact cuff.
Cuff tear arthropathy (arthritis with an irreparable rotator cuff)
Massive, irreparable rotator cuff tears with pseudoparalysis
Complex proximal humerus fractures in select patients
Failed prior shoulder replacement or repair
Physiotherapy Protocol
Indications for reverse shoulder replacement vary widely, and the pace of recovery depends heavily on how advanced the disease was before surgery and the condition of the deltoid and remaining muscles going in. Rehabilitation is generally more aggressive than after rotator cuff repair, as the reconstruction does not rely on tendon-to-bone healing in the same way.
Goals
- Encourage early motion to limit stiffness
- Protect the deltoid and reconstruction
Precautions
- Sling worn until discontinued at 4 to 6 weeks
- Motion is active-assisted only, within limits: forward flexion to 60°, abduction to 60°, external rotation to neutral (0°)
- Avoid combined internal rotation, adduction and extension, such as reaching behind the back or lower back, the position of highest dislocation risk
- No resisted exercise
Exercises / Therapy
- Active-assisted range of motion within the above limits, commenced from day 1
- Active range of motion of the hand and wrist
Review / Milestones
- Wound check at 2 weeks, with your GP or Dr Handford
Goals
- Discontinue the sling and begin active range of motion
- Progress towards a full, unrestricted range
Precautions
- No resisted strengthening until 12 weeks
Exercises / Therapy
- Active range of motion, commenced once the sling is discontinued at 4 to 6 weeks
- Light functional use of the arm
Review / Milestones
- Review with Dr Handford at 8 weeks, including an X-ray
Goals
- Build deltoid and scapular strength for daily function
Precautions
- Strengthen gradually. Early overload of the deltoid risks a stress fracture of the acromion or scapular spine
Exercises / Therapy
- Resisted band exercises for the deltoid and scapular stabilisers
- Progression to activities of daily living and low-demand recreational activity
Return to activity / sport
Recovery tends to progress a little faster than after rotator cuff repair, but both the pace and the ceiling of recovery vary widely between patients. Many continue to gain range and strength right up until a year after surgery. High-demand lifting and contact sport are not recommended after reverse shoulder replacement.
Anatomic Total Shoulder Replacement
Anatomic total shoulder replacement resurfaces the worn ball and socket with a metal humeral head and a plastic glenoid component, recreating the joint's normal anatomy. It is used when the rotator cuff is intact and the joint surfaces have worn out, most commonly from osteoarthritis, relieving pain and restoring reliable movement.
Glenohumeral osteoarthritis with an intact rotator cuff
Post-traumatic arthritis
Avascular necrosis of the humeral head
Failed prior surgery where the cuff remains functional
Physiotherapy Protocol
Because anatomic replacement requires takedown and repair of the subscapularis tendon, rehabilitation is deliberately slower and more protected than after reverse shoulder replacement, and follows a pathway similar to rotator cuff repair, prioritising early, gently controlled motion while the subscapularis heals.
Goals
- Protect the subscapularis repair and the new joint
- Maintain gentle motion within safe limits to reduce the risk of stiffness
Precautions
- Sling worn from waking in recovery
- Motion is active-assisted only, within limits: forward flexion to 60°, abduction to 60°, external rotation to neutral (0°)
- No active internal or external rotation
- No weight-bearing through the arm
Exercises / Therapy
- Active-assisted range of motion within the above limits, commenced early
- Active range of motion of the hand and wrist
Review / Milestones
- Wound check at 2 weeks, with your GP or Dr Handford
Goals
- Progress to full active range of motion
- Wean out of the sling
- Begin gentle active internal rotation once subscapularis healing allows
Precautions
- Sling weaning begins at 6 weeks
- Avoid forcing internal rotation behind the back
- Resisted strengthening not yet commenced
Exercises / Therapy
- Active range of motion progressing towards a full, unrestricted range
- Light functional use of the arm
Review / Milestones
- Review with Dr Handford at 8 weeks
Goals
- Build rotator cuff and scapular strength
- Progress towards normal activity
Exercises / Therapy
- Resisted band exercises for the rotator cuff and scapular stabilisers
- Progressive strengthening and low-impact recreational activity as guided
Return to activity / sport
Recovery generally tracks a little slower than reverse shoulder replacement, reflecting the need to protect the subscapularis repair. Strengthening begins at 12 weeks, with most patients feeling fully satisfied with their result somewhere between 3 and 6 months.
Latarjet Procedure
The Latarjet procedure treats recurrent shoulder instability by transferring a piece of bone, the coracoid, with its attached tendons to the front of the glenoid. This rebuilds the bony rim and adds a dynamic sling effect from the transferred tendon, providing reliable, durable stability for patients with significant bone loss or a previous failed stabilisation.
Recurrent anterior shoulder dislocation with significant glenoid bone loss
Failed prior soft-tissue (labral or Bankart) stabilisation
High-demand contact or collision athletes with instability
Physiotherapy Protocol
Rehabilitation initially focuses on protecting the transferred bone graft so it can securely unite with the glenoid, before gradually restoring motion and strength.
Goals
- Protect the graft and allow it to start uniting to the glenoid
Precautions
- Sling worn for 4 weeks
- No active shoulder movement beyond gentle self-care
- Avoid shoulder extension and combined extension or external rotation stretching
- No lifting with the operated arm
Exercises / Therapy
- Passive range of motion within the limits set by Dr Handford
- Active range of motion of the elbow, wrist and hand
- Pendulum exercises
Goals
- Progress motion while protecting the bone graft
Precautions
- Avoid excessive external rotation
- Avoid push-ups, bench-press-type movements or anything loading the front of the shoulder
Exercises / Therapy
- Active-assisted range of motion progressing towards full flexion and external rotation as tolerated
Goals
- Achieve full active range of motion
- Begin light strengthening
Exercises / Therapy
- Active range of motion
- Light rotator cuff and scapular strengthening
Goals
Non-contact sport is generally permitted from around 3 to 4 months once strength and motion are restored. Return to contact or collision sport is usually not before 4 to 6 months, and only with clearance following clinical and radiological review of graft healing.
- Build strength for sport-specific and contact demands
Return to activity / sport
Exercises / Therapy
- Progressive resistance training
- Sport-specific drills
Arthroscopic Anterior Stabilisation
Arthroscopic anterior stabilisation repairs the torn labrum to the front of the glenoid through small portals, using suture anchors to restore stability. Where bone loss is not significant, it is the preferred approach, addressing the underlying cause of instability with minimal soft tissue disruption. Significant glenoid bone loss or a previous failed stabilisation may favour the Latarjet procedure instead, and this will be discussed at the time of consultation.
Recurrent anterior shoulder dislocation or subluxation with minimal bone loss
Traumatic Bankart lesion in an active patient
Symptomatic anterior instability limiting activity or sport
Physiotherapy Protocol
Rehabilitation focuses on protecting the healing labral repair in the early weeks before gradually restoring motion and strength.
Goals
- Protect the labral and capsular repair
- Maintain elbow, wrist and hand mobility
Precautions
- Sling worn at all times, removed only for elbow exercises and hygiene
- External rotation restricted to neutral (0°); forward flexion and abduction to 45°
- No active or resisted shoulder movement
Exercises / Therapy
- Elbow, wrist and hand active range of motion
- Pendulum exercises and scapular retraction
- Cryotherapy as needed
Goals
- Progressively increase shoulder range of motion
- Protect the healing repair
Precautions
- Continue sling between sessions, weaning towards end of phase
- No resisted work in this phase
Exercises / Therapy
- Active-assisted range of motion in flexion, abduction and external rotation, progressed week to week
- Submaximal rotator cuff isometrics from around weeks 4 to 5 if comfortable
Goals
- Discontinue sling
- Progress towards full active range of motion
Precautions
- No resisted strengthening until week 8
Exercises / Therapy
- Active range of motion in all planes towards full range
- Scapular strengthening continued
- Posterior capsule stretching if indicated
Goals
- Restore rotator cuff and periscapular strength
- Achieve full, pain-free range of motion
Exercises / Therapy
- Resisted rotator cuff strengthening, progressing from closed-chain to open-chain work
- Progressive periscapular and deltoid strengthening
Return to activity / sport
Controlled gym-based strengthening is permitted from 3 months. Return to contact sport or high-risk activity is generally from 6 months, subject to clinical review and surgeon clearance.
Discuss your shoulder procedure
If you have questions about a procedure or your recovery protocol, book a consultation or speak with the practice team.
