| Time | Day 0 | 0–2 weeks | 2–4 weeks | 4–6 weeks | 6–12 weeks | 12+ weeks |
| Immobilisation & Protection | Sling and abduction/external rotation brace as instructed (often ~3 weeks)[1]. Prevent weight-bearing on arm. | Continue sling (usually 3–4 weeks); remove only for hygiene and gentle exercises. | Wean off sling as advised; use in periods of discomfort only. | Sling use generally discontinued; begin light shoulder use. | No formal immobilisation; full graft protection relies on exercise limits. | Arm free of brace; continue to avoid overstress on transfer. |
| Mobilisation/Exercises | Start pendular shoulder exercises and passive ROM in brace (abduction/flexion/ER only) as pain allows[1]. Maintain elbow/hand mobility. | Continue gentle passive-assisted ROM in safe ranges (abduction, flexion). Scapular “setting” exercise | Begin active-assisted ROM (safe abduction/elevation/scaption). Avoid internal rotation beyond neutral. | Gradually increase active ROM; integrate deltoid and remaining cuff function. Aim for near-full ROM. | Progress strengthening of deltoid, scapular stabilisers and transferred muscle (e.g. with resistance bands). | Advance strengthening and functional training. Full loading of shoulder permitted around 12 weeks[1]. Continue functional and task-specific rehab. |
| Activity | Elbow/wrist/hand movements and grip exercises. | As tolerated, limited light activities (e.g. feeding); avoid lifting even light objects. | Light activities only (no more than a cup of tea in hand) in short lever. Maintain elbow/wrist/hand fitness. | Increase ROM in all planes within comfort; begin very light isometric deltoid. | Gentle progression to functional use; may drive if pain-free and off strong analgesics; start supervised strengthening. | Return to most daily activities; avoid full heavy lifting or overhead work until 4–6 months. Strength/endurance focus. |
Key clinical points: Immobilisation protects the tendon transfer. Early passive ROM (abduction/flexion/ER in brace) may begin within days. Active use is delayed until tendon healing (typically ~4–6 weeks), and no heavy lifting or resisted IR until several months. Full arm function often takes many months – the RNOH notes that maximal recovery can take over 1 year with ~50–70% strength improvement by 1 year. Return to activity should be guided by pain and graft healing (tissues are weakest in the first 12 weeks).
Movement restrictions: Avoid lifting >5 kg or sudden jerks with the operated arm for at least 12 weeks; no combined abduction/external rotation or internal rotation stress early on.
Return to function (approximate): Sedentary/desk work at ~6–8 weeks (once sling discontinued). Manual/maintenance work at ~3–4 months (if light duties). High-demand overhead sports or heavy manual work only after 6–12 months, when strength has recovered.
