Following surgery, patients are immediately placed into a shoulder immobilizer and begin a strict physical therapy regimen on the first postoperative day. The rehabilitation protocol is tailored to the exact nature of the surgery with alterations for other included procedures such as a SLAP repair. Again, the importance of closely supervised rehabilitation cannot be overemphasized in the presence of a thermally treated shoulder. Both surgeon and therapist must be familiar with the nuances involved in nurturing TACS patients because they represent one of the greatest therapy challenges in all of orthopedics—"loose enough to throw, but stable enough to prevent symptoms."10,33 Essentially, we are seeking to reach a "normal" rotational laxity for throwers, which certainly differs from the nonthrowing population.
Complete details of the rehabilitation protocol following TACS are beyond the scope of this chapter, but some of the basic principles follow.10,26,33,34 During the first 4 weeks, a simple sling is worn during the day, while a shoulder immobilizer is used for sleeping. Weeks 1 and 2 focus on gentle passive and active-assisted range-of-motion exercises, but not stretching, along with anti-inflammatory modalities. Excessive external rotation and abduction are avoided. Weeks 3 and 4 see a progression of motion to established goals, but not beyond. Light external/ internal rotation tubing is begun with gradual progression of applied loads. Motion continues to advance during weeks 5 and 6 with progression to 75 degrees of external rotation (with the shoulder abducted 90 degrees) by the end of week 6. The Thrower's Ten program can be started in the sixth week. Full range of motion is expected by week 8, and full functional overhead thrower's range of motion by week 12. More aggressive strengthening can be undertaken by week 10. Weeks 12 to 22 are spent maintaining range of motion, improving dynamic stability, and increasing muscular strength. If satisfactory stability and strength have been achieved by 4 months following surgery and the patient is completely pain and GIRD free, an interval throwing program is initiated. The interval throwing program must be highly structured with advancement based on the individual's symptoms. Return to competition is rarely accomplished in less than 7 months, with pitchers and catchers expected to be closer to 11 months from their surgical date.
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