Approximately 12 weeks to 6 months post-operative
Stage 3 rehabilitation begins once the patient has progressed satisfactorily through the early protective phases, the shoulder is clinically stable, and there is satisfactory graft healing on imaging where this has been obtained. By this stage, the focus shifts away from protection alone and toward restoring strength, endurance, proprioception and confidence in the shoulder.
The main goal is to return the patient toward normal functional use of the arm while continuing to respect the healing tissues.
Range of Motion
Range of motion should continue to improve toward a full functional range. Forward elevation and internal rotation can be progressed as tolerated, and external rotation may also be advanced more confidently at this stage. I would still avoid aggressive or forceful stretching into external rotation, particularly if this reproduces apprehension or anterior shoulder discomfort. The aim is to restore useful motion rather than to chase excessive external rotation at the expense of anterior stability.
Strengthening
Strengthening should now become a major component of rehabilitation. This should include progressive loading of the rotator cuff, deltoid and scapular stabilisers, with particular emphasis on good scapulothoracic mechanics and controlled movement. Serratus anterior, trapezius, rhomboids and the broader upper-limb kinetic chain should also be incorporated. Resistance can be gradually increased using therabands, light weights, cable work and controlled gym-based exercises. The emphasis should remain on quality of movement and control rather than simply increasing load.
Proprioception and Stability
Closed-chain and proprioceptive exercises are useful during this phase to restore dynamic stability around the shoulder. Wall-based exercises, ball-on-wall drills, rhythmic stabilisation and progressive perturbation exercises can be introduced and advanced according to the patient’s control and confidence. As strength improves, these can progress into more demanding overhead and sport-specific positions.
Return to the Gym
A gradual return to the gym is appropriate from this stage. Patients can recommence controlled resistance training with light loads initially and slowly increase resistance as tolerated. Heavy bench press, deep dips, maximal lifting, explosive pressing and uncontrolled positions of loaded abduction and external rotation should initially be avoided. These can be reconsidered later once strength, control and confidence have substantially improved.
Functional Use of the Arm
Functional use of the arm should also be increased progressively. From approximately 3 to 4 months, patients can begin to perform more demanding lifting, pushing, pulling and overhead tasks, provided these remain comfortable and well controlled. Manual workers should have their duties increased gradually rather than returning immediately to unrestricted heavy work.
Return to Sport
Sport-specific rehabilitation may also begin during this phase. Non-contact skills and controlled overhead drills can usually be introduced before unrestricted contact. Return to collision sport, contact sport or high-risk overhead activity should be based on function rather than time alone. The patient should have near-full functional range of motion, no instability or significant apprehension, good scapular mechanics, near-symmetrical strength compared with the opposite side, and satisfactory sport-specific control and confidence.
For most patients, unrestricted contact or collision sport is generally considered around 5 to 6 months or later, depending on the sport, strength recovery and graft healing.
When to Seek Review Earlier
Please refer the patient back earlier if there is recurrent instability, increasing apprehension, new or worsening anterior shoulder pain, sudden loss of movement or strength, neurological symptoms, persistent pain that is not settling with rehabilitation modification, or concern regarding the graft or hardware.