1. Protocol Guide

2. 2 days Post-op  Light compressive dressing/garment for biceps area. Sling or hinged elbow brace at 90 degrees neutral forearm for comfort. Gentle unlimited A/AAROM hand to shoulder  HEP 10 min 3 times per day and wound care  Clinic ROM program 3+ times per week and PRN wound checks/care 10 days Post-op  Continue HEP  Clinic program BTE light (1 to 2 pounds) resistance AROM hand to shoulder 3 times per week

3. 10days Post-op  Continue HEP  Clinic program BTE light (1 to 2 pounds) resistance AROM hand to shoulder 3 times per week 3wks Post-op  Continue HEP  UEB endurance exercises 3 times per week (At 3wks muscle should be scared in satisfactorily)  Wean from sling/brace wear by 4wks s/p

4. 4 wks Post-op  Continue HEP  Baseline BTE power test sup/pro. BTE progressive strengthening program 3 times per week (Ultimate Goal to have 70% sup/pro power of uninjured side) 6 wks Post-op  Start 1 month HEP progressive pushup program 8 wks Post-op  Transition to HEP progressive UE strengthening.  Clinic follow up monthly BTE power test sup/pro until goal achieved. May take up to 1yr. 12 wks Post-op  Start progressive pullup/chinup program

5. 7 days Post-op  Light compressive dressing/garment for biceps area. Posterior long arm splint at 90 degrees neutral rotation. AROM extension and pronation. PROM flexion and supination  Flexion and extension in neutral rotation with 65 degree extension block 1 to 4 wks Post-op  Progress to full AROM extension and pronation. Initially flexion place-and-hold exercises. AROM flexion from 90 degrees

6. 6 wks Post-op  Wean from splint to 8wks  4 to 8 wks Post-op  Progress to full AROM flexion Continue with 9 wk Post-op guidance from Dynamic Hinged brace protocol

7. 48 hours Post-op  Light compressive dressing/garment for biceps area  Posterior splint with elbow hinge locked at 90 degrees, forearm in neutral for 3weeks  AROM wrist and digits  Codman’s pendulum exercises  US, scar massage and edema control  Clinic program 3+ times per week

8. 3 wks Post-op  Dynamic component (theratube/band) applied to the posterior splint allowing resisted extension and passive flexion  From 3 rd to 6 th week progress to elbow extension 30 degree block  Gravity eliminated AROM out of splint in clinic with 30 degree extension block  Continue modalities  Initiate AROM shoulder without resistance

9. 6 to 9 wks Post-op  Progress dynamic splint to 0 degrees extension (10 degree increments per week)  Initiate clinic exercise program with gravity focusing on flexion and extension of elbow  Continue modalities  Continue flexion and extension of shoulder without resistance 9 wks Post-op  Continue splint without extension block  Initiate resistive exercises in clinic (shoulder, elbow and forearm against gravity)  Continue modalities as needed

10. 12 wks Post-op  Initiate progressive strengthening program elbow flexion and forearm supination  Continue modalities as needed 18 wks Post-op  Cleared for full use  Continue progressive strengthening program Ultimate Goals: AROM WNL compared to uninjured side 100% preinjury strength. Full use in all activities (airborne operations included) without pain

11. 3 to 5 days post-op  Light compressive dressing/garment for biceps area  Scar massage, edema control  Fabricate DySuFlex splint. Elbow extension block at post- op resting position (typically 90 degrees). Clinic ROM program 10 min 3+ times per week and wound checks/care  Each week elbow extension is increased 15 degrees from post op rest position  HEP 10 reps each hour within splint

12. 6wks post-op  Wean splint to discharge at 8 wks  Clinic AROM with gravity focusing on flexion and extension of elbow  Continue HEP  Continue with 9 wk Post-op guidance from Dynamic Hinged brace Protocol

14. 5days Post-op  Light compressive dressing/garment for biceps area  Dynamic Elbow hinge splint extension blocked at 100 degrees, forearm in neutral. Dynamic component (theratube/band) allowing resisted extension and passive flexion, resting position of 120 degrees  Clinic and home program gentle ROM all without pain: AAROM shoulder  Splint exercises 10 reps per hour AROM extension from120 to 100 degrees, with rubber band traction PROM flexion resting at 120

15. 5 days Post-op Continued  PROM forearm supination to neutral with elbow at 100  AROM hand, wrist  Sling wear for comfort over splint for night wear  Splint wear all times except therapy exercises and wound care  2 wks Post-op  Codman’s pendulum exercises with splint on  Ultrasound over wound area

16.  3 wks Post-op  Extension to 85 degrees. From 3 rd to 6 th week progress dynamic splint extension block by 15 degrees extension of elbow each week  Continue modalities  Initiate AROM shoulder without resistance  4 wks Post-op  Initiate Elbow flexion place-and –hold exercises  Extension to 70  Continue modalities

17. 5 wks Post-op  Initiate gravity eliminated AROM out of splint in clinic respecting current extension block of that week  Extension to 55  Continue modalities 6 wks Post-op  Extension to 40  Initiate Gentle AROM supination and pronation with elbow at 90 degrees. (Progress dynamic elbow splint by 10 degree increments per week)

18. 6 wks Post-op (continued)  Initiate clinic exercise program with gravity focusing on flexion and extension of elbow  Continue modalities  Continue flexion and extension of shoulder without resistance 10 wks Post-op  Continue splint wear PRN for protection without extension block.  Initiate gentle resistive exercises in clinic (shoulder, elbow and forearm against gravity)  Continue modalities as needed

19. 11 wks Post-op  Discharge splint 12 wks Post-op  Initiate progressive strengthening program elbow flexion and forearm supination  Continue modalities as needed 18 wks Post-op  Cleared for full us  Continue progressive strengthening program.  Ultimate Goals - AROM WNL compared to uninjured side,100% pre-injury strength. Full use in all activities without significant discomfort