Current Evidence Based Recommendations on Rehabilitation following Arthroscopic Shoulder Surgery: Rotator Cuff, Instability, Superior Labral Pathology, and Adhesive Capsulitis

Abstract

Purpose of Review

Arthroscopy has become increasingly popular for a addressing a wide variety of shoulder pathology. However, despite increasing interest, there is still much uncertainty and variability amongst providers regarding optimal post-operative rehabilitation. This review provides an overview of the evidence underlying common rehab protocols used following arthroscopic interventions for rotator cuff disease, shoulder instability, superior labral anterior to posterior (SLAP) tears and adhesive capsulitis.

Recent Findings

For small and medium sized rotator cuff tears, early motion protocols do not seem to affect healing or retear rates, however there is no difference with regards to long term functional outcomes when compared to standard motion protocols. For larger tears (> 3 cm), early active motion may be associated with impaired tendon integrity. Early range of motion following arthroscopic Bankart repair has not been shown to increase rate of recurrence, however the data on return to sport requires more granularity to effectively guide care. Further research needs to be done to compare rehab protocols following SLAP repair and arthroscopic capsular release.

Summary

Rehabilitation protocols following rotator cuff surgery and anterior shoulder stabilization have garnered the most research interest. However, there is still a need for larger higher-level studies examining the long-term effects of different rehab protocols. Regarding the arthroscopic management of other types of shoulder instability, SLAP tears and adhesive capsulitis, there is paucity of high-quality evidence. This knowledge gap likely underpins the variability in different rehab protocols seen in clinical practice, highlighting the need for more research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12178-024-09899-7.

Introduction

Over the last two decades, arthroscopic interventions for shoulder pathology have become increasingly popular [1, 2]. Improved understanding of shoulder pathology, technological advancements in arthroscopic hardware and implants and increased use of arthroscopy to treat other joint disorders have resulted in shoulder arthroscopy becoming the standard of care for certain procedures [1]. Today, shoulder arthroscopy is widely used to treat a variety of pathology, including rotator cuff disease, shoulder instability, superior labral anterior to posterior (SLAP) tears and adhesive capsulitis. However, despite widespread adoption, a considerable amount of variation exists with regards to post-operative rehabilitation protocols following shoulder arthroscopy [3••, 4, 5•, 6•, 7•]. Due to the need for increased mobility in the glenohumeral joint compared to other joints, joint stability and function are reliant on the interaction between osseous configuration, the glenoid labrum and surrounding musculature [4]. Thus, most rehabilitation protocols are guided by the principles of protecting repaired tissue, strengthening the rotator cuff and scapulothoracic musculature and maintaining range of motion (ROM). Although seemingly straightforward, there is still much debate around the optimal rehab protocols for the procedures listed above. Thus, the purpose of this narrative review is to provide a summary of the available literature on post-operative rehabilitation protocols for each of these procedures to help guide clinicians in their treatment decisions and identify areas for future investigation.

Rotator Cuff Surgery

Post operative rehabilitation following arthroscopic rotator cuff surgery has been widely investigated, however there is still considerable variation amongst providers regarding the duration of immobilisation, initiating active exercise and load progression [3••]. In terms of professional consensus, The American Society for Shoulder and Elbow Therapists (ASSET) released a consensus statement regarding their preferred algorithm for post operative rehabilitation following rotator cuff repair (RCR) [8••]. They advise a 2 week period of strict immobilization followed by staged introduction of protected, passive ROM from 2 to 6 weeks after surgery [8••]. This is followed by introduction of active ROM at 6 weeks with strengthening starting at post operative week 12 [8••]. At 20 weeks, advanced strengthening exercises for patients who engage in specific overhead tasks can be incorporated into rehabilitation [8••]. However, the American Academy of Orthopaedic Surgeons Clinical Practice Guideline (AAOS CPG) for the management of rotator cuff injuries provides less specific recommendations. It suggests that, in the absence of reliable evidence, supervised physical therapy is more appropriate than unsupervised home programs following rotator cuff repair (RCR) [9]. This statement alludes to the fact that, despite relatively large number of publications on the subject, the quality of the available evidence to guide post-operative rehabilitation following RCR is of variable quality.

The major considerations for any rehab protocol is finding the balance between the optimal environment for rotator cuff healing, while mitigating the risk of developing stiffness [3••]. The healing response following RCR has been described in three phases: inflammatory, proliferation and remodelling [3••]. The initial inflammatory phase, lasting approximately 14 days, relies on the mechanical strength of the repair construct while a weak scar is formed [3••]. During the following proliferation phase, the concentration of fibroblasts and collagen increases, serving to increase the strength of the repaired tendon [3••]. The final remodelling stage results in reorganisation of collagen fibers and tenocytes in the direction of mechanical stress and replacement of type III collagen with type I collagen [3••]. Animal studies have shown conflicting evidence for the role of mobilisation on tendon healing, however there appears to be a trade-off between the risk of compromising healing with precocious mobilisation versus the potential benefits of activity on the biomechanical strength of the healed tendon [10–12].

In clinical practice, the timing of mobilisation is something that is widely debated, with numerous studies being published on the topic [3••, 13–15]. A comprehensive meta-analysis performed by Mazuquin et al. (2018), which included data from 10 systematic reviews and 11 randomized controlled trials (RCTs), demonstrated that there was no statistically significant difference in tendon healing for patients undergoing early (0–4 weeks post op) or delayed (4–8 weeks post op) rehabilitation. Furthermore, no significant differences were found for ROM, pain or functional scores between these two groups [13]. The authors conclude that the optimal time to begin ‘substantial’ shoulder mobilisation is 3 to 4 weeks following surgery. Of note, they highlight the fact that there was very limited data for large tears (> 3 cm) amongst the papers included in their analysis. Another meta-analysis, performed by Kluczynski et al. (2015), examining the outcomes following early passive ROM (within 1 week post-op) vs delayed (3–6 weeks) did not find a difference in retear rates when looking exclusively at level 1 studies. However, when all eligible studies were included, it was found that early passive ROM was associated increased retear rates for massive (> 5 cm) tears [16]. Since the time of publication of these meta-analyses, other level 1 studies have been performed, providing further evidence to support that notion that early mobilisation is not harmful following repair of small and medium sized tears. A randomized controlled trial by Tirefort et al. (2019) evaluated 80 patients with these tears, randomizing half into a sling immobilisation group and the other into a ‘no sling’ group [14]. The ‘no sling group was found to have significantly improved internal rotation and active elevation up to 3 months following surgery, while sling use was associated with decreased Single Assessment Numeric Evaluation (SANE) scores and increased pain. No differences were noted in cuff integrity at 6 months. Sheps et al. (2019) examined 206 patients undergoing arthroscopic RCR for full thickness tears and randomized half of the participants to an early motion (EM) protocol, where they self-weaned from a sling and performed pain free ROM, while the other half were immobilised in a sling for the first 6 weeks [15]. At 6 weeks the EM group had significantly better forward flexion and abduction. However, no differences were noted in retear rates at 1 year post op, with no difference in ROM, pain, strength of health related quality of life (HRQoL) scores at 24 months [15]. Again the mean tear size for both of the treatment arms was < 3 cm. Ultimately, for small and medium sized tears, the current body of evidence suggests that EM protocols do not appear to impact healing or retear rates [3••]. However, despite some potential benefits in terms of early range of motion and pain control, the evidence does not suggest that there are significant long term benefits regarding these metrics or functional outcomes either [3••]. The paucity of high quality evidence for larger tears makes is difficult to formulate definitive recommendations regarding when to initiate ROM following repair of these injuries [3••]. Presently, there is some evidence to suggest early passive ROM is associated with an increased risk of retear for massive tears without out any clear benefit in terms of functional outcomes [3••, 13, 16].

Despite the current evidence, many clinicians still have reservations about initiating early passive ROM for small and medium sized tears [3••, 17]. Littlewood et al. (2021) surveyed 129 clinicians on their preferred post-operative rehab protocols for three theoretical case scenarios describing both medium and large tears [17]. For the case with a medium sized tear, close to half of the respondents still advocated for immobilisation for 4 to 6 weeks. To complicate matters, the goals and preferences of surgeons and therapists can differ, leading to conflicting treatment strategies. This was exemplified in a study Kane et al. (2020) which revealed that physical therapists preferred more progressive protocols with shorter periods of immobilisation compared to orthopaedic surgeons [18]. The authors highlight the fact that these discrepancies likely stem from contrasting beliefs amongst these different providers [18]. Therapists are likely more inclined to encourage early ROM in an effort to minimize stiffness, while surgeons may be concerned about the risk of retear [18]. While frustrating for providers, this kind of discrepancy can be confusing for patients and complicate care.

In terms of the type of sling use, some have advocated the use of abduction sling in an attempt to reduce strain on the repaired cuff tissue and promote a better environment for rotator cuff healing [3••]. However, an RCT conducted by Hollman et al. (2017) comparing an anti-rotation sling to abduction brace failed to show any difference in retear rates between the two groups [19]. Furthermore, no differences were observed in terms of pain, ROM or functional outcomes. Ghandour et al. (2019) performed an investigation comparing two similar slings which also demonstrated no difference in pain or patient reported outcomes [20].

Compared to protocols for early post-operative period following RCR, the later stages of rehabilitation have been subject to much less scrutiny. Currently, most protocols for the initiation of active exercises and load progression are based on expert opinion [3••]. A common approach is that recommended by the ASSET, with a temporal progression through passive ROM, active assisted movements, active motion and then resistance exercises [21••]. Although easy to employ, there is minimal evidence underpinning the temporal cut-offs that are currently used in clinical practice [3••, 22]. Kluczynski et al. (2016) performed a meta-analysis looking specifically looking at the impact of early (< 6 weeks) vs delayed (≥ 6 weeks) active motion rehab protocols on the structural integrity of rotator cuff repairs. Early active range of motion was only associated with impaired tendon integrity for tears < 3 cm that were treated with trans-osseus or single anchor repairs. However, for tears 3 cm or greater, the initiation of active ROM less than 6 weeks from surgery was associated with tendon defects for all repair types [22]. Based on these results, the authors recommend delaying active ROM by at least 6 weeks following RCR. However a small RCT involving 29 patients demonstrated that an accelerated rehab protocol that initiated active ROM at 3 weeks post op resulted in significantly better functional outcomes compared to a delayed protocol [23]. The discussion regarding the effects active motion on rotator cuff healing is further complicated by several EMG studies that have been published in the physical therapy literature [3••]. These investigations have demonstrated that the passive exercises used as part of standard rehab protocols, along with certain activities of daily living, actually produce more activity in the rotator cuff than many active exercises [24–26]. Ultimately, more high quality research needs to be done to provide a greater understanding of the effects of different types of active ROM on cuff healing in order to accurately guide rehabilitation protocols.

Our Recommendation

In keeping with the most up to date evidence, our rehab protocol for RCR follows 5 phases (Fig. 1, appendix 1), with progression contingent on meeting phase specific criteria for advancement. Phase 1 is the “maximum protection phase”, which usually lasts until 3 weeks post op. The goal of this phase is to protect the repair, decrease pain and inflammation and gradually work on ROM. Patients are encouraged to maintain sling mobilization during this period, except when performing exercises, which include PROM of the shoulder and AAROM while supine in the scapular plane. Once patients have normal scapular mobility and ROM distal to the shoulder, they can enter Phase 2 or the “moderate protection phase” (typically weeks 3 to 7). This phase involves progressing ROM to 80–100% of external rotation (ER) and elevation in the scapular plane. At this point, patients can discontinue their sling and continue AAROM exercises. They are also encouraged to work with their therapist on scapulo-humeral rhythm and neuromuscular control of the shoulder, emphasizing peri-scapular muscle strengthening. Active elevation of the shoulder is avoided until 6 weeks post op. Once the goals of phase 2 are reached, the third or “early strengthening” phase (weeks 7–12) is started. The goals at this point include restoring full PROM of the shoulder and gradual return to light ADLs. Patients can use wand exercises to restore ROM, focusing on improving internal rotation (IR), and active elevation in the scapular plane. Strengthening involves closed chain exercises at this point, with patients limiting overhead activity and shoulder “shrugs”. Phase 4 (weeks 12–20) consists of the “late strengthening phase”, where patients work through our ‘advanced shoulder strengthening’ protocol with the goal of restoring full strength of the scapular and RC musculature (appendix 2). Patients work with their therapist to progress periscapular and RC isotonics and initiate plyometrics below horizontal. They are also encouraged to work on posterior capsule flexibility and can progress to overhead activity once sufficient proximal stability is attainted. The final phase of formal rehab (weeks 20–24) is the “return to sport phase” where the goal is to maximize flexibility, strength, and neuromuscular control to meet the demands of sport or work. Patients progress to plyometrics above horizontal and continue isotonics and stabilization exercises. Overhead athletes can commence periodization and interval training. Full clearance for return to sport or demanding overhead activity is granted by the treating surgeon once patients demonstrate adequate strength and ROM of the shoulder, with a minimum target of 85% symmetry to the contra-lateral side. Patients are educated on independent exercises for maintenance and progression of function and are encouraged to continue them after the period of formal rehabilitation.

Fig. 1.

Five phase rotator cuff repair rehabilitation protocol

Shoulder Instability

Arthroscopic techniques for managing of shoulder instability have become increasingly popular [5•, 21••, 27]. The management of anterior instability has garnered the most attention, with the arthroscopic management of Bankart lesions being widely considered the standard of care for cases with isolated soft tissue injury or minimal bone loss [5•]. However, arthroscopic techniques for posterior instability, refractory multi-directional instability (MDI) and cases with significant glenoid bone loss are also becoming standard practice for many orthopaedic surgeons who manage these conditions.

Although arthroscopic Bankart repair is a treatment modality that is widely used, post-operative rehabilitation protocols are still highly variable [5•]. In 2010, The ASSET released a consensus guideline for rehabilitation following arthroscopic capsulo-labral repairs of the shoulder [21••]. Their recommendations included a period of complete shoulder immobilization for 4 weeks followed by staged recovery of full ROM over 3 month [21••]. Strengthening can commence at 6 weeks, with a goal to return to demanding work or sport by 6 months post-operatively [21••]. Despite these guidelines, a systematic review of the literature by McIsaac et al. (2022) revealed that there is still a considerable amount of heterogeneity regarding post-operative immobilization protocols, exercise parameters and targets for return to sport following arthroscopic Bankart repair [5•]. Their review also revealed that the evidence underlying current protocols is limited [5•]. In terms of the timing of shoulder mobilization, several investigations have compared early motion protocols to standard post-operative sling immobilization. Kim et al. (2003) performed an RCT comparing an accelerated rehab protocol with immediate post-operative rehabilitation to 3 weeks of immobilization in a sling [28]. The accelerated group regained functional ROM earlier and returned to functional activity faster, while experiencing less post-operative pain [28]. Recurrent instability and functional outcomes were not different between the two groups [28]. Gibson et al. (2016) published data from a case series of 34 professional athletes who underwent arthroscopic soft tissue Bankart repair who were treated with an accelerated motion protocol, which also included expedited return to play [29]. The recurrence rate in this series was 9%, which is similar to that previously reported for athletes undergoing traditional protocols, with a mean time to return to sport at only 11 weeks [29]. Although the available evidence seems to suggest that initiating ROM earlier on may not be harmful, McIsaac et al. (2022) highlight the fact that these studies fail to accurately characterize post operative strength or the level of play to which the athletes are returning [5•]. Similar to protocols following RCR, most of the milestones following arthroscopic Bankart repair are based on time from surgery. A systematic review by Ciccotti et al. found that 76% of all of the studies assessing return to play following anterior stabilization surgery use time as their sole criteria [30]. As post-operative strength and endurance ultimately dictate the degree to which patients can return to activity, future studies should focus on these parameters while also making an effort to better define and measure performance metrics [5•, 31].

The addition of a remplissage procedure to address concomitant Hill Sachs lesions during arthroscopic anterior stabilization is becoming increasingly popular [32]. The procedure involves fixation of the infraspinatus tendon and capsule into a Hill-Sachs defect and has been shown to decrease the rate of recurrence compared to isolated Bankart repair [32]. In their technique paper, Boileau et al. (2014) advised a post-operative rehab protocol similar to standard anterior stabilization procedures, with sling use for the initial 4 weeks and limited PROM [33]. AAROM and AROM can be started after 4 weeks, while avoiding strengthening until 8 weeks post-op [33]. Return to sport is restricted until 3 to 6 months [33]. Camus et al. (2018) performed a meta-analysis comparing isolated arthroscopic Bankart repairs to those combined with a remplissage and found that there were no differences in the rehab protocols used for either procedure [33]. Presently, there is no consensus regarding the optimal rehabilitation protocol following combined Bankart repair and remplissage.

Posterior shoulder instability occurs with a higher prevalence than originally believed [27]. Although conservative management is typically the first-line management for this condition, increased awareness has contributed to nearly one quarter of all current operative cases of glenohumeral stabilization being for posterior labral pathology [27, 34]. However, despite this trend, there is a paucity of literature regarding post-operative rehabilitation. In order address the need for clinical guidance Goldenberg et al. (2021) recently published the 5 phase post-operative protocol used at the Steadman Clinic [27]. Similar to protocols for anterior stabilization, the first phase emphasizes protecting the surgical repair [27]. Where this protocol differs is that the immobilization is limited to 2 weeks or, if the surgeon prefers, passive ROM can be initiated immediately [27]. Passive ROM is limited to 120° of forward flexion, 90° of abduction, external rotation to 30°, and internal rotation to the abdomen with the arm at the side [27]. The second phase, typically beginning at 6 weeks post-op, involves a progression to AAROM and then AROM [27]. Strengthening begins during phase 3, which starts at a minimum of 8 weeks post-op, with patients moving onto resistance training up until 12 weeks, where clearance for advanced strengthening can occur [27]. Once patients demonstrated dynamic control with posterior loading for the shoulder, they can move onto the sport specific phase of rehab [27].

The mainstay for the treatment of MDI is conservative management focussed on strengthening the rotator cuff and scapular stabilizers [35]. When conservative management failed, the traditional gold standard was open inferior capsular shift (OCS). However, today, the preferred surgical intervention is arthroscopic capsular plication (ACP) [35]. Chen et al. (2016) performed a meta-analysis of studies looking at the surgical management of MDI [36]. In their analysis they evaluated the rehab protocols used for both OCS and ACP and found a high degree of variability [36]. Different protocols immobilized patients for 2 to 6 weeks post-operatively followed by PROM and AAROM for 2 to 10 weeks [36]. Strengthening lasted for 1–6 months with the average time to return to sport being 6 months [36]. There was insufficient evidence to perform any comparisons between the different rehabilitation protocols used for patients treated with ACP [36].

Arthroscopic bone block augmentation procedures have recently been developed in attempt to mitigate some of the issues associated with open surgery [37, 38]. Currently, most of the literature on these procedures, which include arthroscopic Latarjet and allograft bone blocks, are limited to technique papers and smaller case series [37–39]. The recommended rehab protocols typically advise 2 weeks of immobilization followed by progressive passive ROM exercises until 6 weeks, where weight bearing and AROM can be initiated [37, 38]. Studies comparing different rehab protocols following arthroscopic bone block augmentation have yet to be published.

Our Recommendation

Our rehabilitation protocol following arthroscopic anterior stabilization involves 4 phases (Fig. 2, appendix 3) with a similar ‘graduated’ approach to our RCR protocol. The first phase, which lasts until 3 weeks post op, is the “maximum protection phase”. In our opinion, the primary goal during the immediate period following surgery is to protect the repair. Patient compliance with their shoulder immobilizer, when not participating in rehab, is emphasized. During this period AAROM can be carried out with elevation in scapular plane and ER to neutral. Scapular mobility and stability exercises are performed with the patient lying on their side and sub-maximal deltoid isometric strengthening is initiated. Once patients demonstrate an ability to ER to neutral and elevate to 90° in the scapular plane, they can progress to phase 2 (typically weeks 3–6). Patients are encouraged to continue AAROM exercises with the goal of achieving 45° of ER and 120° of elevation in scaption. Patients can usually discontinue shoulder immobilization at 4 weeks, with approval from their surgeon. Once the milestones for the second stage are achieved, phase 3 (weeks 6–12) can be initiated. This phase involves restoration of full ROM and strengthening. Patients initiate AAROM for IR and progress isotonic strengthening exercises for their rotator cuff and periscapular muscles. With the assistance from the therapist, they are encouraged to develop humeral head rhythmic stability and upper extremity endurance. The final phase of rehabilitation (weeks 12–20) prepares the patient for return to sport or full activity. Full upper extremity strengthening is started, and patients work on ER/IR in the 90°/90° position, with the goal of achieving an isokinetic ER/IR ratio of > 66%. Sport specific training is also initiated to allow for pain and apprehension-free return to activity. Final clearance for return to sport or specific overhead activities must be obtained from the treating surgeon and patients are encouraged to continue their sport-specific training independently.

Fig. 2.

Four phase anterior stabilization rehabilitation protocol

For posterior stabilization procedures, we follow a similar rehab protocol compared to that used for our anterior stabilization patients, with a few modifications. To protect the repaired posterior-ligamentous complex, we advise patients avoid posterior loading of the glenohumeral joint during the maximal protection period (phase 1). Motions where the shoulder is internally rotated and abducted, such as reaching behind the body, are also avoided in order to limit the stress on the repair [27]. In terms of strengthening, in addition to the standard exercises for the rotator cuff and periscapular muscles, particular attention is placed on the serratus anterior (SA). The SA plays an important role in posterior shoulder stability, serving to maintain the scapula’s position on the posterior thorax [27]. During early strengthening the ‘supine punch’, where the patient lies on their back and punches in the air with their shoulders in 90° of flexion and scapulae protracted, can be used to target the SA (Fig. 3) [27]. Later, once patients are cleared for closed kinetic chain movements, the ‘push up plus’ exercise can be introduced (Fig. 4) [27]. This exercise involves performing push ups with the shoulders protracted in an effort to engage the SA. Following posterior stabilization, patients also frequently experience excessive posterior capsular stiffness and shortening of the anterior musculature [27]. Thus, once cleared for full ROM, at around 6 weeks, patients are encouraged to work with their therapist on gentle, manual stretching of the posterior capsule.

Fig. 3.

The ‘supine punch’ exercise

Fig. 4.

The ‘push up plus’ exercise

Superior Labrum Anterior to Posterior (SLAP) Lesions

Often found in overhead and throwing athletes SLAP lesions can be a major source shoulder dysfunction [4]. As with many of the other shoulder conditions addressed in this review, initial management typically consists of conservative modalities focussed on pain reduction and restoring functional ROM [4, 6•]. Recently, as indications have narrowed, there has also been a shift away from surgical repair of SLAP lesions in favor of other procedures, such as biceps tenodesis, however patient specific indications are beyond the scope of this review [40, 41]. For those requiring surgical intervention, Manske and Prohaska (2010) provide a thorough overview of their recommended rehab protocols for different types of SLAP pathology, based on their review of the literature [6•]. For type I and III SLAP injuries, which involve labral fraying and a bucket handle labral tears, respectively, the typical management involves arthroscopic debridement. The recommended post operative protocol for these patients involves a brief period of sling wear for comfort followed by early PROM and AAROM, typically initiated at first post-operative visit [6•]. For those undergoing SLAP repair, typically type II and some type IV injuries where the biceps-labral complex has become detached from the superior glenoid, the protocol consists of 5 phases [6•]. Starting with an initial 6 week ‘protective’ period, patients are advised to keep their arm in sling for 4 weeks, however they can remove it to perform PROM exercises with no isolated biceps activity [6•]. At 5–6 weeks the AROM can be progressively initiated, without any biceps loading [6•]. Phase 2 starts at 7 weeks, with progression to full AROM [6•]. By 10 weeks biceps loading can commence with more aggressive rotator cuff and scapulothoracic strengthening [6•]. Phases 3 and 4 span the period from 13 to 26 weeks post-op and focus on regaining full ROM and building strength, with eventual return to play, phase 5, at 6–9 months [6•]. For cases where biceps tenodesis is performed, the authors recommend a full 10 weeks without any biceps activity [6•]. Hermanns et al. (2021) surveyed the SLAP protocols associated with US orthopaedic residency programs and private practice groups and, despite identifying some general trends, they found a high degree of variability in terms what was employed in practice [4]. Most protocols recommended sling use and immobilization for 4 weeks [4]. However, some protocols allowed early passive ROM and the details regarding timing and type of AAROM and AROM were highly variable [4] 80% of protocols set a target for full ROM by 12 weeks, but specifics the return to sport guidelines were not consistent [4]. Only 6% of protocols made changes to their protocols if a biceps tenodesis was performed [4]. Based on their findings, the authors of this investigation highlight the need for more standardized protocols for SLAP repair with detailed, sport specific recommendations for return to play [4].

Our Recommendation

Regarding our preferences for rehabilitation following SLAP repair, our protocol is similar to the one described above. However, in our experience, stiffness is a concern. Thus, we do prioritize early ROM and allow patients to discontinue their sling at two weeks if they can tolerate it. In terms of return to sport, this is determined on case-by-case basis. Athletes are encouraged to work with sport specific therapists who can guide them through the rehabilitation process. Final clearance for return to play should be made by the treating surgeon in collaboration with the athlete and their therapist.

Adhesive Capsulitis

Adhesive capsulitis or ‘Frozen Shoulder’, as it is colloquially referred to, can be source of significant pain and stiffness [7•]. Initially described in the nineteenth century, it is an enigmatic condition characterized acute or chronic inflammation and capsular fibrosis that leads to contracture of the glenohumeral joint [7•, 42]. Presently, there is no formal consensus regarding the standard treatment of adhesive capsulitis [7•]. First line treatment typically includes physical therapy and intra-articular steroid injections [7•, 42]. If these measures fail, arthroscopic capsular release (ACR) and manipulation under anaesthesia (MUA) can be entertained [7•, 19]. Willmore et al. (2022) preformed a review of the available literature on post-operative rehab for adhesive capsulitis [7•]. Despite a dearth of high quality studies, there was a clear trend favoring the initiation of early ROM, typically within 48 h of surgical intervention [7•]. Physical therapy protocols were variable, ranging from direct manipulation by therapists to home exercise pamphlets [7•]. Many studies did not specify the duration of rehab, however those that did typically recommended 10–12 weeks of therapy [7•]. The authors conclude that the high degree of variability in these protocols likely stems from the uncertainty surrounding the pathological drivers underlying adhesive capsulitis [7•]. A better understanding of the role of pain and the basic science underlying this condition may allow for more targeted interventions and rehab protocols in the future.

Our Recommendation

In our experience, the recommendations given to patients following ACR and MUA by many providers can be nebulous. To achieve optimal outcomes, clear instructions, and communication regarding the goals of rehab are critical for restoring function. We encourage patients start ROM exercises immediately after surgery. Since our patients are almost universally treated conservatively with physical therapy prior to being indicated for surgery, we encourage them to continue formal, structured therapy sessions post-operatively. Patients start with PROM and AAROM exercises in all directions of motion. Once wounds have healed, patients can start resistance band and free weight training to improve rotator cuff and peri-scapular muscle strengthening. Manual therapy can also be done at the therapist’s discretion. Physical therapy is usually continued for a minimum of 3 weeks; however the actual duration is usually tailored to their specific need. Patients are also put on a home stretching and strengthening program as an adjunct to their formal therapy sessions.

Conclusion

As arthroscopic interventions for addressing shoulder pathology become increasingly popular there is a need for clear guidelines for post-operative rehabilitation. Although there is a general understanding that the goals of rehab are to restore functional ROM and strength in the gleno-humeral joint, there seems to be a high degree of variability in post-operative rehab protocols for all the conditions discussed in this review. Currently, a majority of the research has been focussed on arthroscopic rotator cuff repair and anterior shoulder stabilization. Although some important questions regarding early range of motion have been asked for both procedures, it is still unclear if they have been effectively answered, as evidenced by the variability in rehab protocols. Regarding the later stages of rehab, higher quality evidence is needed to optimize strengthening protocols and formulate clear guidelines for return to sport. Similarly, for SLAP repairs and arthroscopic capsular release for adhesive capsulitis, the variability in rehab protocols is due to a dearth of evidence, which makes developing consensus protocols challenging.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

JC: made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

SS: made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

AR: made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Data Availability

No datasets were generated or analysed during the current study.

Compliance with Ethical Standards

Competing Interests

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by  any of the authors.