| Time | Day 0 | 0–2 weeks | 2–4 weeks | 4–6 weeks | 6–12 weeks | 12+ weeks |
| Immobilisation & Protection | Long-arm shoulder immobiliser in maximal external rotation (ER) (often night brace). No shoulder movement | Continue immobiliser (remove only for hygiene); no pendulums or motion. | Sling (in ER) through 6–8 weeks; no active/internal rotation. | Brace usually discontinued around 6–8 weeks if surgeon agrees. | No brace; protect against internal rotation and heavy loading until tendon incorporation. | Return to functional use, but avoid stressing the transferred tendon. |
| Mobilisation/Exercises | Elbow/wrist/hand/finger mobility. Scapular retraction shrugs. | Continue distal limb exercises; begin gentle scapular setting and neck exercises. | From week 8, begin passive shoulder ER and elevation to 120°; AAROM as tolerated (no IR beyond neutral)[8]. | Progress to AROM in all planes by 12–16 weeks; introduce isometric rotator cuff and deltoid strengthening. | Advance shoulder strengthening (bands, light weights). By ~12 weeks, lifting limited to ≤5 kg | Full strengthening and functional rehab. Sports/work simulation as strength allows. |
| Activity | No lifting; arm resting in brace. | Gentle hand/arm activities (e.g. writing) while braced; walking/exercise bike for fitness. | Light ADLs permitted (e.g. feeding) within ER brace. No weight-bearing on arm. | Can use arm for simple tasks (e.g. dressing) without brace; still no heavy push/pull. | Gradual return to driving and desk work; resume light resistive exercises under guidance. | Return to most non-contact activities by ~4–6 months. Contact sports or heavy labor only after ~6–9 months once strength is adequate. |
Key clinical points: Lower trapezius transfer requires prolonged protection. The elbow and hand should be active, but the shoulder is held in maximal ER with minimal movement for ~6–8 weeks. Early ROM is limited; pendulum exercises are avoided. From ~8 weeks onward, gentle passive ER/elevation may begin, progressing to full AROM and isometric strengthening by ~12–16 weeks. Lifting heavier than 5 kg is typically not allowed until 3–4 months. Gradual strengthening continues up to 6+ months, focusing on scapular control and rotator-cuff activation.
Movement restrictions: Avoid all shoulder flexion/abduction beyond passive limits for first 8–12 weeks. No internal rotation past neutral for 8 weeks. No resisted rotator cuff or lifting for first 12 weeks.
Return to function: Sedentary work (~typing) by ~8–12 weeks (brace off). Light manual tasks by ~3–4 months. Sports/high activity delayed (often 6–9 months) until near-full strength is regained.
