UW Shoulder and Elbow Academy: A ream and run rehabilitation program developed by a patient who's also a PT

Post-op Rehabilitation Protocol for Patients after the Ream & Run Procedure

Provided by

Congratulations on completing your ream and run procedure! In an effort to help you recover function as quickly as possible, this is a post-op protocol developed and used by physical therapist Colin Hoobler, PT,DPT, MS, who had a ream and run procedure at the University of Washington. This program includes strengthening, stretching and endurance exercise.

Note: This is the program used by Dr. Hoobler to successfully rehabilitate his shoulder. Patients having the ream and run procedure should discuss this program with their surgeon before implementing it.

Before starting, let’s review key concepts essential to your rehabilitation program.

1. “Rate of Perceived Exertion” (RPE)

RPE reflects how intensely you feel an activity and protects you from injury, promotes efficiency and guides program progression so that you are challenged at an appropriate level. For every exercise you perform, you should know what your RPE should be before starting and self-monitor during the exercise.

We use a 0 to 10 version:

10 maximum

7 very hard

5 hard

4 somewhat hard

3 moderate

2 light

1 very light

0 nothing

For example, if you walk at a leisurely pace you may feel an RPE level of 3 out of 10. If you start running, you may increase to an RPE level 7 out of 10.

If you are exercising independently, pay close attention to where you are on this scale so that you push hard enough to improve but without injury.

If you are in physical therapy, your physical therapist (PT) will monitor your RPE to ensure safety, effectiveness and proper progression.

2. Repetitions

The number of repetitions you perform depends on many factors (e.g., resistance, motivation, technique) and must be monitored. For example, if you want to achieve an RPE of 7 (i.e., “very hard”) out of 10 doing a strengthening exercise, we recommend doing a minimum of 25 repetitions with perfect technique when you’re cleared to initiate strengthening exercise (usually around 6 weeks post-op). Therefore, a resistance must be selected to allow 25 repetitions. If you cannot reach 25 repetitions, you are using too much resistance and should cut back.

The tempo of your repetitions is important to protect against injury while promoting strength and coordination. We recommend counting “one thousand one…” for each of the up and down phases to keep you within this range. Avoid sudden, jerking repetitions to minimize injury risk!

3. Sets

A set is a number of repetitions. For example, doing 1 set of 25 repetitions should take about one minute and might reach an RPE of 6 out of 10.

4. Specific Adaptation to Imposed Demand (SAID principle)

The SAID principle is a key sports medicine concept that will guide your rehabilitation program from the start and refers to your body’s ability to adapt to imposed stress. The SAID principle is a range of progress (adaptation) that correlates to RPE (i.e., RPE):

-----------------------------------------------------------------------------------------------------------

No stress Some stress Considerable stress A lot of stress Too much stress

No progress Some progress Considerable progress A lot of progress High injury risk!

In other words, exercise too little or not hard enough, and progress will be slow; exercise regularly and with moderate to high intensity and enjoy regular progress, but exercise with “excessive” intensity and injury risk skyrockets. The goal is to exercise at an intensity that promotes progress but not too intensely so as to avoid injury.

You are the most vulnerable immediately after surgery, particularly your subscapularis muscle, which was cut during surgery. Your rehabilitation program protects your subscapularis tendon at the start, then gradually stresses it more as you get farther away from your surgery date. Gradual stress is key to help tissues heal and avoid injury.

Begin Immediately

DAILY:

· Low load, prolonged stretching into shoulder elevation

Position your arm onto a firm surface until you achieve a stretch intensity of 2/10 (i.e., “light”) and hold for 8 minutes up to 10 minutes, 2 times/day (yes, minutes). Make sure the palm is either facing upward or the thumb is pointed toward the ceiling (avoids compression of sensitive tissues in your shoulder).

· Endurance exercise

Perform the elliptical, stairmaster, treadmill and/or stationary bike for 10 minutes/day at an intensity of 4/10. Move your arms naturally and keep your shoulders back (i.e., maintain an erect posture).

Work your way from walking to a slow jog to minimize shoulder stress. Keep shoulders back and avoid shrugging.

SShoulder external rotation (ER) isometrics

To start, stand up tall, pull your shoulder blades back and slightly move your elbow away from your body. Holding this position, slowly push the back of your surgical side’s hand against a wall and hold for 30 seconds, achieving an RPE of 4 out of 10. Repeat 5 times during the day.

· Shoulder pulley

To start, sit up tall, pull your shoulders blades back and grab the pulley handles with your palms facing upward. Slowly raise your surgical arm by pulling gently with your non-surgical arm, going as high as possible. Repeat 50 times daily.

Notice position of the hand. Keep shoulders back and avoid shrugging.

2 weeks

DAILY:

· Continue long stretch, endurance exercise, ER isometrics and pulley

Hold your long stretch 12 minutes, perform endurance exercise for 15 minutes and increase your ER isometric RPE to 5 out of 10.

· Counter squat with hip stretch between sets

See picture of counter squat and do 1 set of 30 repetitions, or achieve an RPE of 5 out of 10. After the set, stretch your hip (each side) for 60 seconds, achieving an RPE of 5 out of 10.

· Abdominal crunch

See picture of abdominal crunch exercise and do 1 set of 40 repetitions, or achieve an RPE of 5 out of 10.

Keep shoulders back, head up and belly in.

Calf stretch

See picture of calf stretch and do 1 set of a 60-second hold, or achieve an RPE of 5 out of 10.

6 weeks

DAILY:

· Continue long stretch twice per day and endurance exercise

· Continue other exercises and stretches

· Add quad and hamstring stretches between squat sets

See pictures of quad and hamstring stretches and do 1 set of a 60-second hold each, or achieve an RPE of 5 out of 10.

Minimize arching of your low back. Hold onto a stable object and stand tall.

8 weeks

DAILY:

· Continue long stretch twice per day and endurance exercise

· Continue other exercises and stretches

· Add eccentric loading of shoulder ER using cable or thera-band

See picture of eccentric loading of shoulder ER exercise and do 1 set of 10 repetitions (each repetition will take 5 seconds), or achieve an RPE of 4 out of 10.

10 weeks

DAILY:

· Continue long stretch once per day and endurance exercise

· Continue prior exercises and stretches

· Add seated row, lat pulldown

See videos of seated row and lat pulldown exercises at c.h. Physical Therapy and do 1 set of 25 repetitions each, or achieve an RPE of 4 out of 10.

12 weeks

DAILY:

· Continue long stretch once per day and endurance exercise

· Replace counter squat with lunge exercise

See video of lunge exercise at c.h. Physical Therapy and do 1 set of 25 repetitions each, or achieve an RPE of 5 out of 10.

· Replace eccentric loading of shoulder ER exercise with shoulder ER exercise

See video of shoulder ER exercise c.h. Physical Therapy and do 2 sets of 25 repetitions, or achieve an RPE of 5 out of 10.

14 weeks

DAILY:

· Continue long stretch once per day, endurance exercise

· Return to desired activity at limited duration/intensity per your surgeon

· Add push-up hold exercise