Sternal precautions
- Bilateral upper limb activity post-sternotomy is recommended. This includes standing from a chair using both arms with equal pressure and use of gait aids that require bilateral upper limb support. Given the low incidence of post-operative pulmonary complications in this population, prophylactic deep breathing and coughing exercises should be used with caution
- A medication review may be necessary for those with a dry, non-productive cough secondary to medications (e.g., ACE inhibitors)
- Movement restrictions should be based on risk gauged by undertaking a sternal instability assessment
Sternal precautions have historically been recommended for all patients who have undergone a median sternotomy in an attempt to avoid excessive shearing and distractive forces at the sternal edges, which would compromise the healing sternum. However, the evidence for this premise has been drawn from expert opinion, institutional protocols and studies on cadaver and replica models.
There is significant variation in the clinical application of sternal precautions amongst institutions, with no consensus on the type and duration of time for which they are applied.[#balachandran-s-lee-a-royse-a-et-al.-2014] Recent studies have indicated that bilateral upper limb movements produce less movement and pain compared with unilateral upper limb elevation, whilst coughing increases movement and pain at the sternal edges.
TIP: Base sternal precautions on an individual’s medical history/risk factors, assessment findings of sternal stability and/or response to exercise as outlined in the sternal precautions algorithm.
Bilateral upper limb activity within patient comfort is advised.
Non-surgical management of sternal instability
For those with established sternal instability, a return to theatre for surgical re-wiring is often necessary. At times, this option is not available if bone quality is poor or confounding risk factors for re-operation exist. Non-surgical approaches involve external bracing and exercises.
1. External bracing (see example below) can be used to: [#el-ansary-d-waddington-g-adams-r.-2008]
- Minimise symptoms
- Provide an interim measure prior to surgical repair
- Prevent the progression of a minimally unstable sternum
Figure 3: “Qualibreath” – an orthopaedic stabilisation brace for a median sternotomy

Reproduced with permission from HjorthHealth, 2012
Specific considerations for women
All women should be encouraged to wear a supportive bra, with wide straps and no underwire, early in the post-operative period to ensure support of their breasts and minimise undue stress on the healing sternum and associated wound. An example of a bra designed specifically for this patient population is the “Qualibra” shown below.
Figure 4: “Qualibra” – an orthopaedic stabilisation brace for a median sternotomy

Reproduced with permission from HjorthHealth, 2012
2. Exercise prescription and activity
Patients with chronic sternal instability can improve stability and reduce pain by conducting trunk stabilisation exercises for 10 minutes, twice a day over a 6-week period. [#supportive-devices-arch-phys-med-rehabil-2008]
Upper limb exercise prescription
Bilateral upper limb resistance training using weights and pulleys may commence on entry into the outpatient exercise program.
This may include:
- Biceps curls/elbow flexion (biceps/brachialis, coracobrachialis)
- Triceps pull-down/elbow extension (triceps).
Caution: Activities to avoid until the sternum is confirmed as being stable:
- Unloaded extension of the upper limb beyond the plane of the body
- Bilateral resistance training using weights and pulleys that involve abduction or extension of the upper limbs (e.g., pectoral deck)
- Unilateral resistance training using weights and pulleys
Patients who have had a median sternotomy should be provided with education and Activity guidelines for the sternum following open heart surgery outlining current recommendations for daily activities.
These recommendations are listed below.
Encourage:
- Symmetrical movement for bilateral upper limb activities (e.g., pushing up from a chair)
- Good posture to avoid unilateral stress through the trunk and upper limbs
Avoid:
- Unilateral heavy activities
- Unnecessary driving until advised by the cardiologist/cardiac surgeon
The following activities should be kept to a minimum:
- All activities that involve overhead upper limb activity (i.e., hanging washing, high reaching)
- Pushing large objects (e.g., shopping trolley, lawn mower)
- Carrying weights > 5kgs (e.g., child, shopping bags)
- Heavy manual tasks including housework
- Swimming
The following activities should be avoided if sternal stability is poor:
- Trunk rotation
- Prolonged driving > 1 hour
- Swimming (all strokes)
- Upper limb resistance training
Sternal instability management guide
Sternal instability may be graded on a scale of 0-3 depending on the extent of bony disruption. [#el-ansary-d-waddington-g-adams-r.-trunk...-2007] The table below lists recommendations for the management of patients with sternal instability.
Table 2: Summary of sternal instability and associated management
Sternal instability |
Description |
Management |
Grade 0 |
Clinically stable sternum (no detectable motion) – normal |
Nil |
Grade 1 |
Minimally separated sternum (slight increase in motion upon testing – upper limb, trunk) |
Notification to cardiothoracic surgeon
Activity guidelines for the sternum following open heart surgery
Stabilisation exercises |
Grade 2 |
Partially separated sternum – regional (moderate increase in movement upon testing) |
Referral to cardiothoracic surgeon for review
Activity guidelines for the sternum following open heart surgery
Regular monitoring of sternal instability +/- orthopaedic bracing (sternal brace)
Stabilisation exercises |
Grade 3 |
Completely separated sternum – entire length (marked increase in motion upon special testing) |
Referral to cardiothoracic surgeon for review |
Managing sternal stability
- Early and ongoing assessment of the sternum is essential
- Manual assessment is a reliable indicator of sternal instability
- Sternal instability should be reported to the cardiac surgeon
- Activities and exercises should be modified for a patient with sternal instability