9 Keys to Post Op Shoulder Range of Motion

by Mitch Hauschildt, MA, ATC, CSCS

I have mentioned in many of my courses that I am typically able to get full passive range of motion within a few days following shoulder surgery or major shoulder injury with absolutely no passive stretching.  Because of time, I rarely get to go into details as to how it is that we can attain such impressive range of motion gains so early on without performing the traditional treatment techniques.

For today’s post, I’ll go over the high points of how this works and leave the door open in the future to the possibility of covering some or all of these topics in more detail.

Before I get into exactly how we do this, I think it’s important to understand what is restricting range of motion initially after shoulder trauma.  Once we understand what is causing it, then the treatment is much easier.

To understand what is causing the restriction, lets go into the operating room (OR).  If you have ever been in the OR to watch a shoulder surgery (or any orthopedic procedure for that matter), you will recall that one of the last things that a surgeon does prior to closing up the incision(s) is to take the joint through it’s full range of motion and they test the stability of the joint.  They are looking for any potential problems that may arise down the road so that they can fix them while they are still in there.

So, if they have full range of motion without any restrictions in the OR under anesthetic, what happens less than an hour later when they wake up and their shoulder is locked down?

The nervous system is what happens.  

The brain wakes up from its deep slumber thanks to anesthetic and begins to work as usual again.  The brain then understands that the joint has been disrupted and it’s natural reaction is to spasm and lock down the joint to prevent further damage.  Remember, the brain is all about survival.

The traditional thought as to why a joint is restricted after an injury is the mechanical model.  This basically states that the joint gets restricted due to some sort of a mechanical problem, such as scar tissue or a shortening of the capsule.  We need to understand that, while both are possible after a shoulder injury, neither take place within the first few days or weeks following an injury.  It takes time for those processes to take place.

Knowing this leads us to the conclusion that early restrictions are due to the nervous system’s response to the trauma.  It also reminds us as to why it is so important to improve range of motion very quickly to prevent the mechanical issues from ever becoming a problem.

I honestly wish that more orthopedic surgeons understood this because it really reinforces the necessity for early therapeutic interventions.  Far too many surgeons don’t prescribe therapy for the first 4-6 weeks following surgery or an injury, which makes gaining range of motion much, much more difficult because not only are the mechanical restrictions setting in, but the nervous system has been fed a steady diet of immobilization that entire time.

I also need to preface the rest of this post by making sure are all on the same page when I say range of motion and what I allow and don’t allow.  First, my patients stay in their sling for the full time that my surgeon wants (usually 4 weeks post op).  I take them out of their sling for therapy, but that is it.  I am aggressive, but we do need to protect the surgical repair.

Second, when I say full range of motion, I am speaking about flexion and abduction of the shoulder.  I am comfortable passively exploring their range of motion in these two planes once or twice per therapy session.  When I explore their motion, I basically put them supine on a table and passively distract their shoulder (to keep the humeral head off of a repaired labrum) and take them through each of the two ranges of motion until they tell me to stop.  When they have pain, we stop.  I am simply trying to get a good idea what their motion looks like.  I do this at the beginning and end of every session to see what I’ve gained and maintained between sessions.

I never perform static stretching during the initial healing  processing following the trauma as recommended by the physician.  Static stretching, especially with rotation, is a really good way to damage a surgical repair, so I recommend avoiding it early on.

Lastly, I always stay within the confines of the surgeon’s wishes.  Sometimes I disagree with their plan of care and I believe that I know better, but I also understand that if I want to damage my reputation (and ultimately referrals), crossing up a surgeon is a really good way to do it.  If there is something that they request that I disagree with, I take it upon myself to have a personal conversation with them, armed with all of the needed research, to justify my position.  This has proved very successful for me over the years with physicians and has earned me a lot of respect.

So, let’s get to the specifics.  These are the things that I hit very hard in their first few sessions.  If I can do these things early on, it sets the stage for a lot of success down the road.  There are a lot of things here, so many times the first few sessions take 90 minutes or longer, but the extra time is worth it to me for the success that I experience down the road.

1. Early Intervention:  As mentioned earlier, the sooner I can tap into the nervous system, the better shot that I have for success.  I recommend starting their rehab within the first 48 hours following their trauma.
2. Soft Tissue Work:  One of the first things I do after removing surgical dressings is to begin to prevent scar tissue from forming.  Incisions are notorious for scarring down to the layers of tissue below them.  I immediately start with light cross friction massage over the incision or portals.
3. Restore Normal Muscle Tone:  Because the brain is so locked in on stabilizing the joint, many of the muscles around the shoulder are hypertonic.  This is also due to the immobilization that takes place in a sling.  The typical areas that need to be addressed are the biceps, pec minor, subscapulars, traps, and scalenes.  We use a variety of methods to change the tone of these muscles including Positional Release Therapy (PRT), Instrumented Soft Tissue Mobilization (IASTM), Cupping, Massage, and so on.
4. Posterior and Inferior Joint Mobs:  Because I am trying hard to prevent a mechanical restriction, I need to perform some light mobs early on to keep the joint capsule from scarring down.
5. Manage Neurological Tension:  Due to the trauma and immobilization, managing neurological tension is important for managing pain.  We do this with a series of neuroglides to their tolerance.
6. Gripping Activities:  Grip strength is directly related to rotator cuff activity.  Working on grip in various positions has a direct impact on stability early on in the rehab process.
7. Diaphragmatic Breathing:  If they can’t breath correctly, they won’t have proximal stability.  Teaching breathing (and managing tension in the abdomen) is very important to start the stability process.  The diaphragm is also very important for neurological control of movement in general.
8. Proximal Stability:  If the body doesn’t have proximal stability, it won’t have distal mobility.  The brain will seek stability somewhere, so if it doesn’t find it proximally, it will restrict motion at the joints that we are trying to release.  For the early shoulder rehab patient, this includes bridging (with core activation), TRX Retractions, TRX Planks, and Farmer’s Carries.
9. Sequencing:  Because the stabilizing muscles of the trunk are supposed to work in an anticipatory manner, they are supposed to turn on first and off last with any movement.  When they don’t work in the correct sequence, proximal stability is difficult at best.  Movements to improve sequencing include TRX March and Core Engaged Leg Lowering.

There are some other interventions that can be mixed in as well, but if you follow this sequence it will give you a great game plan for setting up your patients for big time success with their shoulder injury.

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