Phase I: Protection Phase (Weeks 0–6)

Immobilisation:

• Sling in internal rotation to be worn full-time for 6 weeks (including during sleep) to protect the transfer.

• Removed only for hygiene and guided physiotherapy sessions.

Precautions:

• No active internal rotation.

• Avoid passive external rotation beyond neutral.

• Avoid shoulder extension past neutral.

• No lifting, pushing, or pulling with the operated arm.

Therapy:

• Hand, wrist, and elbow range of motion exercises.

• Passive and active-assisted shoulder flexion and abduction within comfort.

• Gentle pendulum exercises.

• Scapular setting and postural exercises.

Criteria to Progress:

• Pain controlled.

• Tolerating protected shoulder motion without increased symptoms.

Phase II: Active-Assisted Motion (Weeks 6–12)

Immobilisation:

• Discontinue sling use by Week 6, except for high-risk activities or public settings.

• Begin transitioning out of the sling for light functional activities.

Precautions:

• Avoid resisted internal rotation.

• Gradual progression of external rotation within comfort.

• Avoid forceful shoulder extension or combined extension–external rotation.

Therapy:

• Progress passive and active-assisted shoulder range of motion in all planes.

• Begin active shoulder motion below shoulder height.

• Gentle isometric strengthening of rotator cuff and scapular stabilisers (excluding internal rotation).

Criteria to Progress:

• Improving shoulder range of motion without apprehension.

• Good scapular control during active motion.

Phase III: Strengthening and Functional Mobility (Weeks 12–16)

Precautions:

• Avoid heavy or sudden internal rotation loading.

• Avoid forceful extension or pushing activities.

Therapy:

• Initiate light resisted internal rotation to retrain the transfer.

• Progressive strengthening of shoulder and scapular musculature.

• Functional strengthening below and gradually above shoulder height.

Criteria to Progress:

• Functional, pain-free range of motion.

• Improving strength and control of internal rotation.

Phase IV: Advanced Strengthening and Return to Activity (Months 4–6)

Precautions:

• Avoid high-load internal rotation or contact activities early in this phase.

Therapy:

• Advanced strengthening and endurance training.

• Sport- and work-specific rehabilitation.

Criteria to Discharge:

• Stable, pain-free shoulder range of motion.

• Functional internal rotation strength sufficient for daily and work activities.

• No pain or instability with resisted movements.

• Cleared by treating surgeon and therapist.

General Recommendations

Work:

• Office/desk work may resume after 4–6 weeks if pain is well controlled

• Manual labour should be deferred until 3–6 months depending on job demands

Driving:

• It is important that you are medically fit to return to driving and you feel safe to control the vehicle and take evasive action if needed.

Sports and Leisure:

• Gentle lower-limb and non–shoulder loading activities (e.g. walking, stationary cycling) may resume as comfort allows.

• Light recreational activities involving the shoulder may resume after 3–4 months

• Overhead sports, heavy lifting, and high-demand or contact activities should only. resume after full clearance by the treating surgeon, typically after 5–6 months.

Disclaimer: This protocol is intended as a general rehabilitation guide only. Rehabilitation progression should always be individualised and may be modified by A/Prof Ernstbrunner and the treating rehabilitation team based on the patient’s clinical progress, surgical findings, and individual circumstances.