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To reach the heart, surgeons cut down the breastbone and wire it back together afterwards. The bone takes around eight to twelve weeks to knit, and for years patients were told not to lift more than about five kilograms, not to push up out of chairs, and not to reach or lift the arms much at all. That advice turns out to have been stricter than the evidence supports, and it caused problems of its own — weakness, stiff shoulders, loss of independence and low confidence. Current thinking is to guide movement rather than forbid it: move within a comfortable, pain-free range close to the body, and build up as healing progresses. This page explains why, and what is safe.
What the sternotomy does
A median sternotomy divides the sternum longitudinally; it is closed with stainless steel wires or, increasingly, rigid plate fixation. Bony union takes roughly eight to twelve weeks, with the early weeks the most vulnerable to displacement. The wound therefore has two competing needs: protection from forces that separate the two halves, and enough movement to prevent the shoulder, thoracic spine, posture and general condition from deteriorating.
The forces that matter are those which distract the sternal edges — asymmetrical loading, sudden unsupported pushing or pulling, heavy lifting, and coughing without support. Symmetrical, controlled movement close to the body generates far less strain than the traditional advice implied.
The old approach and why it changed
Conventional "sternal precautions" typically prohibited lifting more than about 4.5–5 kg, pushing up through the arms, reaching overhead or behind, and driving, for six to twelve weeks. The restrictions were near-universal, highly variable between units, and based almost entirely on custom rather than evidence.1
Three problems emerged. First, the load thresholds have no biomechanical basis — a patient pushing up from a low chair or coughing generates forces well above the "limit" regardless of instruction. Second, restriction has costs: reduced upper-limb function, shoulder pain and stiffness, loss of independence in dressing and self-care, reduced participation in rehabilitation, and lower confidence and quality of life.2,3 Third, when tested, less restrictive approaches have not produced more sternal complications.4
"Keep Your Move in the Tube"
The most widely adopted alternative reframes the instruction from a weight limit to a movement principle: imagine a cylinder around the trunk from shoulders to waist, and keep the elbows and hands inside it. Patients move freely and use their arms functionally, but keep the humerus close to the body, avoid extremes of reach, and use both arms symmetrically. Evaluated against traditional precautions in cardiac surgery patients, this approach improved functional independence and self-efficacy without increasing sternal complications.4,5
Practical guidance for patients
| Activity | Guidance |
|---|---|
| Getting out of bed and chairs | Roll onto your side and push with the lower arm close to the body; use leg strength rather than hauling on the arms. A firm, higher chair is easier than a low soft one. |
| Coughing and sneezing | Hug a folded towel or small pillow firmly against the breastbone, or cross your forearms over the chest. Do not suppress the cough — support it. |
| Reaching and dressing | Keep elbows close to the body. Move both arms together where you can. Nothing needs to hurt. |
| Lifting | Hold objects close, use both hands, and keep loads light and symmetrical early on. Build gradually rather than jumping to a threshold on a fixed date. |
| Walking | Start early, little and often, and increase steadily — this is the most important part of your recovery. |
| Driving | Follow your surgical team's advice (commonly around four weeks, sometimes longer) and check your insurer's terms. |
| Return to work and sport | Discuss with the surgical team; heavy manual work and contact sport need specific clearance. |
Advice varies between surgical units, and the operating surgeon's instructions always take precedence. Where a patient has had a complex closure, is diabetic, obese, on corticosteroids or has had a sternal complication, expect more conservative guidance.
- A clicking, grinding or moving sensation in the breastbone (sternal instability).
- New or increasing sternal pain, particularly if it worsens rather than settles week to week.
- Redness, swelling, heat or any discharge from the wound.
- Fever, or feeling generally unwell after initially improving.
- A wound that opens or gapes.
What physiotherapy should include
Before surgery, where possible
Preoperative education and a single physiotherapy session substantially reduce postoperative pulmonary complications in major surgery, and prehabilitation improves postoperative outcomes in cardiac surgery.6,7 Teaching the supported cough, the log-roll and the breathing routine before the operation is far easier than teaching it to someone in pain the day after.
In hospital
Early mobilisation, upright positioning and lung-expansion work — deep breathing with an end-inspiratory hold, supported cough — with airway clearance only where there is genuine secretion retention. Atelectasis is near-universal after cardiac surgery, and volume plus movement treats it better than any device. Shoulder and thoracic range should begin immediately within comfortable limits.
Cardiac rehabilitation
Exercise-based cardiac rehabilitation reduces cardiovascular mortality and hospital admission and improves quality of life, and is recommended after cardiac surgery — yet uptake remains low.8 Referral should be the default at discharge, not a discretionary extra. Home-based and telehealth delivery are equivalent for patients who cannot attend a centre.
Upper-limb and trunk rehabilitation
Shoulder pain, reduced range, altered posture, thoracic stiffness and chest-wall pain are common after sternotomy and are frequently left untreated because everyone is focused on the heart. Graded range of motion, scapular and postural work, and progressive symmetrical loading from around six weeks — guided by pain and sternal stability rather than a calendar — should be standard.
Progressing the load
Progression is guided by three factors: time since surgery, symptoms, and sternal stability on examination. In broad terms, the first two weeks emphasise mobility, breathing, posture and light functional use of the arms within the "tube"; weeks two to six add walking volume, gentle symmetrical resistance and fuller shoulder range as comfort allows; from around six to eight weeks, progressive resistance training can begin with light loads and good technique, increasing over the following weeks. Pain that is sharp, sternal, or persists after the activity is a signal to reduce load — not to stop training altogether.
Living with it afterwards
Most people heal without complication and return to their previous activities within a few months. A minority are left with persistent chest-wall or scar pain, numbness or hypersensitivity along the incision, or a sense of fragility in the chest that outlasts the healing. Reassurance grounded in explanation — that the sternum is united, that loading is now safe, that pain does not mean damage — is genuinely therapeutic. Where sternal instability or deep infection has occurred, management is surgical and rehabilitation is slower and individually prescribed.
Role of the physiotherapist
Physiotherapists are usually the clinicians who translate the surgeon's precautions into what the patient actually does at home, which makes them the point at which over-restriction is either perpetuated or corrected. The task is to protect the sternum without deconditioning the patient: teach the supported cough and the log-roll, get them walking on day one, keep shoulders and thoracic spine moving from the start, treat chest-wall and shoulder pain rather than accepting it, and progress upper-limb loading deliberately rather than waiting for an arbitrary date. Equally important is confidence — many patients are frightened of their own chest, and graded exposure with explanation is as much a part of recovery as the exercise itself. Referral to cardiac rehabilitation should be automatic.
Evidence summary
Framing. Traditional sternal precautions are a durable example of custom outrunning evidence. Prescribed near-universally after median sternotomy, they vary widely between units, have no established biomechanical basis for their load thresholds, and carry documented functional and psychological costs — while the complication they aim to prevent, sternal instability, has an incidence of roughly 1–3% driven mainly by patient and surgical factors rather than by arm use.1,2,9
What the evidence shows- Restrictions are inconsistent and unevidenced: systematic review found substantial variation in prescribed weight limits and durations, with no supporting biomechanical or clinical evidence for the commonly used thresholds.1
- Restriction has costs: reduced upper-limb function, impaired independence in activities of daily living, shoulder pain and reduced quality of life are consistently reported.2,3
- Less restrictive approaches are not associated with more sternal complications. "Keep Your Move in the Tube" improved functional independence and self-efficacy without increased sternal complication rates in comparative studies.4,5
- Sternal instability risk is dominated by non-activity factors — obesity, diabetes, COPD, smoking, bilateral internal mammary artery harvest, prolonged ventilation, re-exploration — which is where risk stratification should focus.9
- Rigid plate fixation improves sternal healing and reduces complications compared with wire cerclage in high-risk patients, and increasingly permits earlier progression on surgical advice.10
- Preoperative physiotherapy reduces postoperative pulmonary complications after major surgery, with a single education session halving them in the LIPPSMAck-POP trial.6
- Prehabilitation before cardiac surgery improves functional capacity and reduces postoperative complications and length of stay in meta-analysis.7
- Exercise-based cardiac rehabilitation reduces cardiovascular mortality and hospitalisation and improves quality of life; referral after surgery should be automatic, and home-based delivery is equivalent for those who cannot attend.8
- Upper-limb and thoracic dysfunction after sternotomy is common and under-treated, with shoulder pain, restricted range and persistent chest-wall pain reported well beyond the healing period.3
- Follow the operating unit's protocol, but advocate within it. Where a service still applies blanket weight limits, the literature supports a conversation about movement-based guidance rather than unilateral deviation.1,4
- Teach the mechanics, not the number: symmetrical loading, elbows close to the trunk, avoidance of sudden unsupported push or pull, supported cough, log-roll transfers.
- Start shoulder and thoracic range immediately within comfortable limits — deferring it is the main preventable cause of the six-week frozen shoulder.
- Progress by symptoms and stability, not the calendar, introducing graded symmetrical resistance from around six to eight weeks with surgical concurrence.
- Risk-stratify: diabetes, obesity, COPD, corticosteroid use, bilateral IMA harvest and any wound concern warrant a more conservative course and closer review.9
- Examine the sternum — palpate for click or movement on a gentle cough or arm movement — and escalate instability, increasing pain or any wound change the same day.
- Address fear explicitly. Kinesiophobia after sternotomy is common, under-recognised and directly limits rehabilitation participation.2
- Distinguish expected incisional and musculoskeletal pain (dull, movement-related, improving week to week) from sternal instability (click, grind, movement) and infection (redness, discharge, fever, systemic upset).
- Pain that is worsening rather than settling after the first fortnight is a red flag, regardless of how the wound looks.
- A patient who cannot take a deep breath or cough effectively usually has an analgesia problem before they have a sternal one.
- Angina, breathlessness or arrhythmia symptoms during rehabilitation are cardiac questions and are managed separately from the sternal healing question.
- No randomised trial has compared restrictive precautions with movement-based guidance using sternal complication as a primary outcome, and such a trial would need to be very large.4
- Actual in-vivo sternal loading during common activities is poorly quantified, so thresholds remain arbitrary.1
- Optimal timing and progression of upper-limb resistance training after sternotomy is undefined.
- Whether rigid plate fixation should change rehabilitation protocols has not been formally tested.10
References & evidence base
- Tuyl LJ, Mackney JH, Johnston CL. Management of sternal precautions following median sternotomy by physical therapists in Australia: a web-based survey. Phys Ther 2012;92(1):83–97.
- Katijjahbe MA, Granger CL, Denehy L, et al. Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy (SMART trial): a randomised trial. J Physiother 2018;64(2):97–106.
- El-Ansary D, LaPier TK, Adams J, et al. An evidence-based perspective on movement and activity following median sternotomy. Phys Ther 2019;99(12):1587–1601.
- Adams J, Lotshaw A, Exum E, et al. An alternative approach to prescribing sternal precautions after median sternotomy, "Keep Your Move in the Tube". Proc (Bayl Univ Med Cent) 2016;29(1):97–100.
- Swanson LB, Adams J, Miller S, et al. Keep Your Move in the Tube compared with standard sternal precautions: functional outcomes after cardiac surgery. Am J Occup Ther 2022;76(4):7604205050.
- Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery (LIPPSMAck-POP): pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018;360:j5916.
- Marmelo F, Rocha V, Moreira-Gonçalves D. The impact of prehabilitation on post-surgical complications in patients undergoing non-urgent cardiovascular surgical intervention: systematic review and meta-analysis. Eur J Prev Cardiol 2018;25(4):404–417.
- Dibben GO, Faulkner J, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2021;(11):CD001800.
- Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: a comprehensive review. Eur J Cardiothorac Surg 2002;21(5):831–839.
- Allen KB, Thourani VH, Naka Y, et al. Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage. J Thorac Cardiovasc Surg 2017;153(4):888–896.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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