Phase I: Protection Phase (Weeks 0–6)

Immobilisation:

• Gun-slinger brace 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 shoulder motion for the first 6 weeks.

• Avoid lifting, pushing, or pulling with the operated arm.

• No overhead reaching or crossing midline.

• Avoid internal rotation past neutral and excessive flexion or abduction.

• No passive internal rotation beyond neutral for the first 6 weeks.

Therapy:

• Initiate passive ROM exercises for forward flexion, abduction, and gentle external rotation.

• Pendulum exercises to promote circulation and reduce stiffness.

• Begin wrist, elbow, and hand exercises to prevent stiffness in these joints.

• Gentle scapular retraction exercises to prevent scapular winging and support shoulder function without stressing the repair.

• Begin light isometric exercises for the deltoid and surrounding muscles to maintain muscle activation without shoulder movement.

Criteria to Progress:

• No infection or complications at the surgical site.

• Adequate pain control with the arm in the sling.

• No signs of instability or excessive swelling.

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

Immobilisation:

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

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

Precautions:

• Avoid lifting greater than 1 kg during this phase.

• No overhead movements or pushing/pulling with the arm.

• No active external rotation beyond 20–30° for the first 8 weeks.

• Avoid internal rotation past neutral and excessive flexion or abduction.

• Limit the load placed on the transferred tendon to avoid overstressing it.

Therapy:

• Begin active- assisted ROM exercises using a pulley, wand, or cane for flexion, abduction, and external rotation.

• Emphasize slow, controlled movement, focusing on pain-free ranges.

• Continue isometric strengthening exercises for rotator cuff and deltoid.

• Begin scapular stabilization exercises to ensure proper alignment and muscle activation.

• Continue with wrist, elbow, and hand mobility exercises.

Criteria to Progress:

• Full passive ROM in forward flexion and external rotation (up to 45°).

• No significant pain during active-assisted ROM exercises.

• Improved scapular control and stability.

• No signs of excessive strain on the transferred tendon.

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

Precautions:

• Avoid overhead lifting or pushing.

• No internal rotation beyond neutral.

• Gradually increase load but avoid stressing the transferred tendon with excessive resistance.

Therapy:

• Gradually progress to full active ROM, including flexion, abduction, and external rotation (pain-free).

• Begin light resistance exercises with Theraband or light weights to strengthen the rotator cuff, deltoid, and scapular stabilizers.

• Continue scapular strengthening exercises, focusing on lower trapezius activation.

• Perform closed-chain exercises (e.g., wall push-ups) for shoulder stability.

• Introduce proprioceptive exercises to enhance shoulder joint stability.

Criteria to Progress:

• Full active ROM in all planes (flexion, abduction, external rotation) without pain.

• No pain during strengthening exercises.

• Improved scapular stability and strength.

• Ability to perform light functional tasks such as dressing and lifting light objects.

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

Precautions:

• Gradual return to lifting up to 5 kg by the end of Month 6.

• Avoid heavy lifting or overhead activities until cleared by the surgeon.

Therapy:

• Continue resistance training with progressively increasing load, focusing on rotator cuff, deltoid, and scapular stabilizers.

• Begin dynamic strengthening exercises, including functional tasks like overhead reaching, lifting, and carrying light objects.

• Introduce sport-specific drills or functional training as shoulder strength and stability improve.

• Continue core stability exercises to support shoulder function.

Criteria for Discharge:

• Strength at or near pre-injury levels (80–90% of contralateral side).

• Full, pain-free ROM in all planes.

• Ability to perform all functional activities without pain or difficulty.

• Surgeon clearance for return to work, sports, and recreational activities.

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.