Arthroscopic Acromioclavicular AC Joint Reconstruction Protocol

Physical therapy is a critical part of rehabilitation following an arthroscopic AC joint reconstruction. Dr. Benjamin Szerlip, an experienced orthopedic shoulder surgeon, recommends following a strict rehabilitation protocol to help you recover quickly and safely so you can get back to your regular activities, sports, and other recreational activities.

Rehab Protocols

Phase 1 – Immediate Post Surgical Phase

Phase 1 of your recovery lasts approximately 3 weeks. Your goals are to minimize shoulder pain and inflammation while protecting the integrity of your surgical repair. You work on gradually restoring your passive range of motion and restore your scapular function.

Of course, you need to take precautions to protect your shoulder as you recover. You must not engage in any active range of motion exercises, including extending, rotating, or stretching your arm. Don’t lift anything with your operative arm. You need to wear your sling all the time, only taking it off to shower and during your physical therapy. You also need to keep your incision clean and dry. 

During phase 1, you work on some activities to increase your range of motion and start to rebuild your strength. You and your physical therapist work on passive and active range of motion movements in your hand, wrist, and elbow. You will also work on passive range of motion movements including:

  • Forward flexion and elevation (lifting your arm in front of your and raising it as high as it can go)
  • Abduction of your shoulder (raising your arm to the side)
  • Internal rotation working to 45 degrees at 30 degrees of abduction
  • External rotation at varying degrees of abduction
  • Clock exercises
  • Ball squeezes

You need to sleep while wearing your sling and place a towel under your elbow to prevent hyperextension. You might also find that cryotherapy reduces your inflammation and pain. 

You need to reach specific criteria to move on to the next phase of your rehabilitation, including:

  • Showing appropriate healing
  • Following all immobilization and safety precautions
  • Reaching 90 degrees of passive forward elevation and 30 degrees of passive external rotation
  • Being able to complete phase 1 exercises without pain

Phase 2 – Intermediate Phase / ROM

Phase two usually lasts from week 4-9. During this time, you focus on minimizing your shoulder pain and swelling while gradually restoring your active range of motion and reducing the time you spend wearing your sling. You should continue to take precautions to protect your shoulder. You should:

  • Avoid active movements until your physical therapist gives you the all-clear
  • Don’t lift anything with your treated shoulder
  • Don’t perform any exercises that put force on your anterior capsule of your shoulder like push-ups and pectoral flyes
  • Don’t perform scaption (lift your arm at a 45-degree angle to your body with your hands facing inward)

You and your physical therapist continue to work on passive range of motion movements including:

  • Forward flexion and elevation
  • Abduction in the scapula plane (raising your arm to the side)
  • Internal rotation to 45 degrees at 30 degrees of abduction
  • External rotation building to 45 degrees at a 30-40 degree abduction
  • Glenohumeral (ball and socket) joint mobilizations (your physical therapist moves your arm in a controlled flapping motion at different angles)
  • Minimize mobility restrictions in your trunk and in the joint where your shoulder blade meets your ribs
  • Introduce posterior capsular stretching including crossbody adduction and side-lying internal rotation stretches

As you progress through phase 2, you increase your range of motion and begin to incorporate rhythmic stabilization drills and other active range of motion movements, including abductions and elevation. You continue to build strength in your shoulder, back, and chest with scapular retractor movements and upward rotators. You also work on active range of motion movements in your hand, wrist, and elbow.

By the end of phase two, you will work on adding low weight (1-3 pounds) to your exercises and increasing your repetitions. You should also be able to achieve nearly full elevation in the scapular plane (raising your arm to the side). Additionally, you will work on:

  • Internal and external rotations with resistance tubing
  • Side-lying external rotations with a towel roll
  • External rotations with manual resistance while you lie down with your arm extended to the side
  • Prone rowing at different angles of abduction ranging from neutral to 90 degrees


To progress to phase 3 of your rehabilitation, you need to achieve:


  • Passive forward elevation at least 120 degrees
  • Passive external rotation within 8-10 degrees of the opposite side at 20 degrees abduction
  • Passive external rotation at least 75 degrees at 90 degrees abduction
  • Active forward elevation at least 145 degrees with proper mechanics
  • Appropriate scapular posture at rest and dynamic scapular control with ROM
  • and functional activities
  • Completion of phase 2 activities without pain or difficulty

Phase 3 – Strengthening Phase

Phase 3 typically lasts from weeks 12-15, and you focus on rebuilding your strength, endurance, and neuromuscular control. Your goals are to return to full chest level functional activities and gradually increase the stress your shoulder can sustain. 

While building your shoulder strength, you need to take care not to over-stress your shoulder and avoid all contact sports and activities. You should also only progress as directed by your physical therapist. 

Phase 3 activities include:

  • Continuing with active and passive range of motion movements
  • Bicep curls with light resistance
  • Exercises for your chest muscles – avoid overstressing your shoulder joint
  • Progressive push-up movements using the wall, counter, and knees to build strength before performing toe push-ups
  • Crossbody diagonal movements with resistance tubing
  • Internal rotations with resistance bands at varying degrees of abduction
  • Forward punches

By the end of phase 3, you should be able to perform all movements without pain and to the full range of motion.

Phase 4 – Return to Activity Phase

Phase 4 lasts from week 16-24, and your goals are to maintain your passive and active range of motion stretches and exercises while you return to strenuous activity and full recreational activities. 

Even though you’re at the end of your rehabilitation, you still need to take care to protect your shoulder. For example, you can avoid excessive anterior capsule stress by avoiding movements like tricep dips, wide grip bench presses, and behind-the-head lat pulls. You should also avoid any throwing or overhead athletic movements until your surgeon clears you.

During phase 4, you continue with all the exercises and movements you’ve added during the previous 16 weeks. You will also add:

  • Isometric strengthening movements
  • Overhead range of motion movements
  • Progressive weight lifting with your arms, shoulders, chest, and back
  • Polymetric and interval training
  • Push-ups – elbows shouldn’t bend past 90 degrees
  • Return to sports training when cleared by your surgeon


By the end of your rehabilitation, your surgeon will clear you to return to all activities if you have no pain or instability, have restored your range of motion and the full strength and endurance of your rotator cuff. You should continue your exercises and stretches at home to maintain your range of motion, flexibility, and strength.