Should Post Op Patients Stretch?

by Mitch Hauschildt, MA, ATC, CSCS

It struck me today when I was working with a post operative shoulder patient that stretching patients to gain range of motion doesn’t make much sense.  I haven’t done much stretching with my post ops in several years, but it seems to me that many people still are and I think that it is less than optimal care at its best and harmful at its worst.  

What got me thinking about this was a soccer player that had a shoulder labral repair in mid November and went home for a month over Christmas break and worked with a therapy clinic at home to keep her progressing forward.  When she left in mid December, she had great passive range of motion and was released from her sling and was allowed to begin light strengthening and stabilization work.  

Upon returning, the athlete’s range of motion has regressed and upon asking what she did over break, she said that her therapist had her doing a bunch of wall stretches, stick stretches, and towel stretches and little to no strength or stability training.

I try very hard not to talk poorly about other clinicians because at the end of the day, there is a time and place for everything and unless I’m there, it is hard for me to see what they were seeing.  But, I feel safe in saying that in this case, I just see the body differently than her therapist.  So, I want to explain my view as food for thought and if you agree, then you can approach things the same way that I do.  If another approach works for you, then go for it.  

My View on Post Op Range of Motion

I think we can all agree that one priority immediately after surgery is to improve range of motion.  If you don’t have a full range, you won’t have full stability.  But, the question is, how should we be improving that range of motion?  Most would say that the best way to improve range of motion is to stretch.  

That is true…sometimes.  

In the case of a post operative patient, I would argue that stretching rarely is the best way to improve range of motion.  Post op patients are restricted because they are threatened more than anything else.  Remember that the brain is constantly balancing danger and safety.  Surgery is an insult to the body, thus it will always make the brain sense danger.  When that happens, the brain goes into protection mode.  It spasms and tightens down in an effort to minimize the risk of further damage.  

I know a lot of people who justify stretching as a strategy to “break up” scar tissue.  But, honestly, that doesn’t make sense either.  Think about it.  The last thing that a surgeon does prior to closing up an incision is to take the joint through a full range of motion to make sure everything works the way they want it to.  Then, an hour later the patient wakes up from surgery and suddenly they can’t move.  Did they magically create scar tissue in that hour?  Heck no.  Their nervous system woke up, realized that things are quite right and locked things down.

I don’t know about you, but because of this I have rarely had good results stretching a threatened, spasmed muscle group.  It causes pain and rarely produces good results.  

So, if we don’t stretch, how do we improve post op range of motion?

Simple…manage threat.  It’s really that simple.  Reduce the threat to the brain and the range will come on its own.  That includes things like soft tissue work in a slow and intentional manner to down regulate tone in the area.  We can also use things like vibration, either locally or globally, to distract the nervous system and remap the area.  And, don’t underestimate the power of diaphragmatic breathing to reset the sympathetic nervous system.  

From there, we need to introduce stability to the body.  After surgery, local tissue typically shuts down.  That’s why we see so much atrophy.  Things that need to work end up falling asleep.  We quickly lose stability.  If we can begin to reintroduce stability to the system, you will be amazed how well the range will improve.

I always start with proximal stability because that is usually easy to train post operatively and it gives me a good foundation to work off of.  Then we can get to local stability.  And, training stability on the opposite side of the body can do wonders as well because of the motor learning that crosses over in the brain.

If we go back to a shoulder patient that is missing range of motion after a labral repair, I always start with soft tissue work around the shoulder, wherever they are sore and inflamed.  From there, I go to stability training at the core and trunk, such as dead bugs and bridges.  As we progress locally, I love using the handles on our PowerPlate vibration platforms to work on scapular stability and we also spend a lot of time training the grip to improve rotator cuff activity.  I like to mix in some floss bands to “hug” the shoulder as we work through a range of motion and feed the brain with a sense of stability.  I also like to perform active range of motion on the uninvolved arm.  

These are some high level thoughts, of course, but I can tell you that with this philosophy, I have progressed to the point that if I don’t have full passive flexion and abduction with a post operative shoulder by the end of their 3rd treatment with me, then I’m not working hard enough.  

Not only does managing threat improve their motion and make therapy comfortable for the patient, my surgeons love it.  They cringe at the thought of me aggressively stretching a patient (especially early on).  This allows me to keep them happy.  Its a win for everyone.

I hope you’ll take some time and rethink why you are doing what you are doing if you treat post operative patients and stop stretching them.  We can and should be doing things better.  And, keep in mind that the same approach works with every part of the body.  Use it and enjoy it.