NPTE Rehab Protocols

Anterior/Anterolateral Total Hip Arthroplasty Precautions

Precautions

-No hip >90 deg

-No extension, ADD and ER past neutral

-No figure four position in sitting

These reduce risk of posterior dislocation

Posterior/Posterolateral Total Hip Arthroplasty Precautions

-No ADD or IR past neutral

-No flexion past 90 deg

-*approach has better outcomes on gait pattern restoration but highest risk for dislocation"

Protocol for THA: Phase 1

0-4 weeks

-precautions

-WBAT

-functional mobility

-avoid hip flexion contracture

Protocol for THA: Phase 2

4-6 weeks

-regain strength and endurance

-Restore ROM

-Hip ABD and ERs

-Gait, balance, stability

Protocol for THA: Phase 3

12 weeks

-Good ABD and ER strength

-Return to sport and higher level activities

TKA: Phase 1

1-4 weeks

-ROM 0-90 deg (EXTENSION PRIORITY)

-Control DVT, pain, swelling

-Ambulate

-3/5 to 4/5 quad strength

interventions:

-ankle pumps

-isometrics

-gait

-patellar mobs

TKA: Phase 2

4-8 weeks

-reduce swelling

-ROM 0-110

-4/5 to 5/5 strength

-unrestricted ADL function

-improve balance

Interventions:

-patellar mobs

-LE stretching

-closed chain strengthening

-tibiofemoral joint mobs as needed

-proprioceptive training

-aerobic exercise

TKA: Phase 3

8+ weeks

-maintenance program

-community ambulation

Interventions

-same as phase 2

-exercises sport specific or higher level activity

Total Shoulder Arthroplasty (TSA) with Intact Cuff: Phase 1

0-4 weeks

-<120 degrees elevation

-ER <30 degrees

-no active IR till 6 weeks

-grade 1-2 joint oscillation

-AROM scapula and elbow

-PROM and AAROM

(1-3 weeks supine -> AAROM sitting/standing week 4)

-light NWB iso shoulder muscles

-pendulums

Total Shoulder Arthroplasty (TSA) with Intact Cuff: Phase 2

4-12 weeks

-continue AROM

-No GH extension past neutral up to 6 weeks

-gradually increase GH rotation

-gentle stretching after 6-8 weeks

-Improve RTC stability and scap stabilizers

-submax isos and light WB through UE

-Delayed resisted rotation if RTC not intact

Total Shoulder Arthroplasty (TSA) with Intact Cuff: Phase 3

12+ weeks

-combined ADD/IR and Ext permitted

-progress end range self stretch

-progressive resistance exercises in functional patterns

-Closed chain stabilization

Reverse Total Shoulder Arthroplasty (rTSA): Phase 1

0-6 weeks

-ABD splint 24 hrs/day for 3-6 weeks

-no GH extension or IR

-ROM allowed: 0-20 ER and up to 90-120 elevation in scap plane

-after immobilizer: 1-2 oscillations, AROM scapular and elbow, pendulums, PROM only of GH joint, light NWB isos of scap and deltoid

Reverse Total Shoulder Arthroplasty (rTSA): Phase 2

6-12 weeks

-no GH extension or IR past neutral

-ROM allowed: 0-20 ER and up to 90-120 elevation in scap plane

-AAROM in supine --> sitting

-NWB isos submax

-delay resisted rotation for several weeks

-deltoid and scap stabilizers

-progress to low-resistance, dynamic strengthening of elbow and wrist

Reverse Total Shoulder Arthroplasty (rTSA): Phase 3

12+ weeks

-Gentle stretching within motions

-CKC

-UE functional patterns

RTC Repair Basics

-PROM or AAROM within SAFE and PAIN-FREE ranges based on surgeon

-Only PROM, non-assisted ROM for 6-8weeks after repair

-Minimize superior/anterior translation of humeral head

-do not allow active shoulder flex/ABD until patient can lift arm without hiking shoulder

RTC Repair Strengthening

-iso scap stabilizers with arm supported

-NWB for 6 weeks

-Delay dynamic strengthening for minimum of 8 weeks

-Avoid ER if supra and infra repairs OR

-Avoid IR if subscap repairs

RTC Repair Stretching

-avoid vigorous stretching, contract-relax or grade 3+ mobs for 6 weeks

-for supra/infra avoid IR

-for subscap avoid ER

SLAP Repair

-Limited PROM or AAROM elevation of arm to 60 deg for 0-2 weeks --> up to 90 deg at 3-4 weeks

-ER to neutral and IR to 45

-Avoid tensioning biceps (elbow ext with shoulder ext) for 4-6 weeks

-No active elbow flexion for 6 weeks and resisted biceps until 8-12 weeks

-No ABD and ER combined

Wrist-flexor Tendon Repair basics

-Wrist is immobilized after surgery for up to 5 days, unless

prolonged immobilization is necessary

-Zone I,II,III repair immobilization- 10° to 45° of wrist flexion

and from 40° to 70° of MCP flexion with the IP joints in full but

comfortable extension

-Exercises approaches to maintain tendon-gliding and prevent

adhesions :

Early controlled passive motion

Early controlled active motion

Wrist-Flexor Tendon Repair: Phase 1

0-3/5 weeks

-EALRY motion as much as possible but can be limited based on the splint used or if there has to be delayed mobility

-Movement should occur within first 5 days

-passive MCP, PIP, DIP flexion and extension

-Place and hold exercises

-minimum-tension, short arc motion

Wrist-Flexor Tendon Repair: Phase 2

4-8 weeks

-aim: *safely increase stress on repair tendon and achieve full active flexion/extension of wrist and glides of tendon

-place and hold exercises with gradual increase in tension

-AROM

-tendon gliding and blocking exercises 5-6 weeks

Wrist-Flexor Tendon Repair: Phase 3

8+ weeks

-resistance exercises

-dexterity exercises

-use of hand for light functional activities

Extensor Tendon Repair

-end of 4 weeks, achieve 70-80 deg active flexion and full extension of PIP joint

-Composite MCP, PIP, DIP flexion @ 4 weeks when splints discontinued

-by 6-8 weeks = low intensity exercises, gradual use of hand functional activities

Delayed mobilization: depends on extensor zone and no resisted exercises until 8-12 weeks

Achilles Tendon Repair WB

Conventional approach= 6 weeks immobilization and NWB

Early remobilization approach= immediate WB or after 1-2 weeks

Achilles Tendon Repair: Phase 1

0-4/6 weeks

-Active ROM of non-immobilized joints

-Muscle setting exercises (isos at 2 weeks)

-Weight shifting

Achilles Tendon Repair: Phase 2

4/6 -12 weeks

-weaning orthosis but add 1-1.5 cm heel lift in shoe at 6-8 week mark to transition into normal foot wear again

-Grade 3 mobs

-Self-stretch and AROM

-OKC strengthening of hip, knee, ankle and CKC heel raises

-balance and gait

Achilles Tendon Repair: Phase 3

12-16 weeks

-return to pre-injury level

-strengthening and endurance

-plyometric training and treadmill walking on incline, advance training