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Replacement of the damaged shoulder joint with an artificial prosthesis. The procedure involves reversing normal shoulder anatomy by placing an artificial humeral head (ball) on the scapula and a glenoid component (cup) on the humerus. This procedure allows the deltoid muscle to compensate for the lost rotator cuff function, which is essential for lifting the arm.

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Joint protection: There is a higher risk of shoulder dislocation following rTSA than a conventional TSA.

Avoidance of shoulder extension past neutral and the combination of shoulder adduction and internal rotation should be avoided for 12 weeks postoperatively.
Patients with rTSA don’t dislocate with the arm in abduction and external rotation.

They typically dislocate with the arm in internal rotation and adduction in conjunction with extension. As such, Tucking in a shirt or performing bathroom / personnel hygiene with the operative arm is a particularly dangerous activity particularly in the immediate peri-operative phase.

No shoulder motion behind back. (NO combined shoulder adduction, internal rotation, and extension.)

Precautions should be implemented for 12 weeks postoperatively unless surgeon specifically advises patient or therapist differently

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Post-Op Yellow Flags:

1. Persistent or Worsening Pain: Pain that does not improve over time

2. Limited Range of Motion (ROM): Slower-than-expected progress

3. Mild Swelling or Effusion: increasing swelling could suggest a developing infection or inflammation.

4. Unusual Clicking or Clunking: excessive or worsening noises might indicate instability or improper implant positioning.

5. Delayed Wound Healing

6. Mild Nerve Symptoms

Post-Op Red Flags:

1. Aseptic loosening of the glenoid component: most common complication (~30% of all shoulder replacements, but decreased with reverse total shoulder replacements 5)

2. Aseptic loosening of the humeral component

3. Dislocation - Rare but seen in excessive extension or IR

4. Periprosthetic fractures

5. Acromial/scapular spine fracture, most commonly a stress fracture 6

6. Hardware failure

7. Scapular notching - erosion of the scapular neck after rTSA

8. Infection - Fever, chills, redness/swelling, abnormal drainage

9. Axillary Nerve Palsy

10. Heterotopic ossification

11. Severe or Sudden Pain: New or severe pain may indicate dislocation, fracture, or implant failure.

12. Significant Swelling, Redness, or Warmth:

13. Fever or Chills: Systemic signs of infection

14. Obvious Joint Instability: A sense of the shoulder "giving way" or dislocation

15. Drainage from the Surgical Site: Persistent or purulent drainage

16. Sudden Loss of Function: An abrupt inability to move the arm

17. Severe Neurological Symptoms: Intense numbness, paralysis

18. Shortness of Breath or Chest Pain: Rare, but could suggest a pulmonary embolism

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DASH

ROM

Strength (MMT/Handheld Dyna)

Shoulder Pain and Disability Index (SPADI)

American Elbow and Shoulder Score (ASES)

Visual Analog Scale (VAS)

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Anatomic Total Shoulder replacement is performed by a surgeon who replaces damaged or pathologic bone with metal medical devices similar to the same anatomical make up of the shoulder. The metal implants allow for smooth gliding joints rather than arthritic or frictioned range of motion.

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PHASE I: IMMEDIATE POST-OP (2-3 WEEKS AFTER SURGERY)

Gradual increase in shoulder PROM

0 degrees shoulder PROM in to IR

Pain < 4/10

No complications with Phase I

PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY)

Gradual increase in shoulder PROM, AAROM, AROM

0 degrees shoulder PROM in to IR

Palpable muscle contraction felt in scapular musculature

Pain < 4/10

No complications with Phase II

PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY)

ROM goals**:

Elevation </= 140 degrees

ER </= 30 degrees in neutral

IR </= 50 degrees in scapular plane or back pocket

**PROM and AROM expectations are individualized and dependent upon ROM measurements attained in the OR post-operatively

Minimal to no substitution patterns with shoulder AROM

Pain < 4/10

PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY)

Performs all exercises demonstrating symmetric scapular mechanics

Pain < 2/10

PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY)

Clearance from MD and ALL milestone criteria have been met

Maintains pain-free PROM and AROM

Performs all exercises demonstrating symmetric scapular mechanics

QuickDASH

PENN

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Phase one:

1. Immobilization sling:

1. Neutral rotation

2. Use of abduction pillow in 30-45 degrees abduction

3. Use at night while sleeping

2. No shoulder AROM

3. No reaching behind back, especially internal rotation

4. No excessive shoulder external rotation or abduction

5. No lifting of objects

6. No supporting body weight with hands

7. Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension

Phase two:

1. Immobilization sling:

1. Use at night while sleeping

2. Gradually start weaning sling over the next two weeks during the day

2. No excessive shoulder external rotation or abduction

3. No lifting of objects heavier than a cup of coffee

4. No supporting body weight with hands

5. Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension

Phase three:

1. Discontinue immobilization sling

2. No lifting of heavy objects (>10 lb)

Phase four:

1. No lifting of heavy objects (>10 lbs)

2. Avoid exercises that put stress on the anterior shoulder capsule (ie.shoulder ER >80 degrees of ABD)

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1. Fever

2. Unresolving numbness/tingling

3. Excessive drainage from the incision

4. Uncontrolled pain

5. Excessive swelling/redness

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DASH

ROM

Strength (MMT/Handheld Dyna)

Shoulder Pain and Disability Index (SPADI)

American Elbow and Shoulder Score (ASES)

Visual Analog Scale (VAS)

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1. DASH

2. Quick DASH

3. The Penn Shoulder Score

4. ROM

5. VAS

6. Shoulder Pain and Disability Index

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Rehabilitation Phases with specific exercises and recommended dosages

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Rehabilitation Phases with specific exercises and recommended dosages

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Phase 1

Day 1 to

Week 1-2

Accelerated rehabilitation protocol—no immobilization

-The patient’s arm is placed in a master sling with a body belt for 24-48 hours (until the interscalene block wears off).

-When the Interscalene block wears off—Discard the sling

-Pendulum exercises, 1-2 minutes 3x day

-Passive ROM shoulder exercises in elevation and external rotation, and internal rotation in abduction in the scapular plane - 10-15 reps for 2-3 sets

-Stretching exercises hold for 10-30 seconds, 4x. Progress as tolerated.

Phase 2

Week 1-2 to Week 3-6

-Progress to AAROM and AROM shoulder exercises.

-Start Deltoid Rehabilitation regime - focus on Stage 1 and Stage 2 (see images below), complete 10-15 reps for 2-3 sets.

-Shoulder isometrics with 6/way (flex, ext abd, add, IR, and ER against wall), 8 reps x 3 sets, progress as tolerated by patient.

-Wall circles, ball rolling on wall for proprioception. 10 reps for 3 sets.

-Return to full ADLs as soon as possible

Phase 3

Week 4-6 and beyond

-Progress to AROM shoulder exercises

-Start Deltoid Rehabilitation regime - focus on Stage 3 and Stage 4 (see images below), complete 10-15 reps for 2-3 sets.

-Progress shoulder isometrics and proprioception, add resistance training for strengthening shoulder and scapular musculature as tolerated by patient.

Deltoid

Rehab

Regime

NOTE:

Throughout the first 6 weeks, the patient is NOT allowed to perform forceful movement with the behind his or her back and not to weight bear through the arm (Patients are instructed not to “push themselves out of chair”).

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Rehabilitation Phases with specific exercises and recommended dosages

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Rehabilitation Phases with specific exercises and recommended dosages

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Phase 1

Day 1 to

Week 1-2

Accelerated rehabilitation protocol—no immobilization

-The patient’s arm is placed in a master sling with a body belt for 24-48 hours (until the interscalene block wears off).

-When the Interscalene block wears off—Discard the sling

-Pendulum exercises, 1-2 minutes 3x day

-Passive ROM shoulder exercises in elevation and external rotation, and internal rotation in abduction in the scapular plane - 10-15 reps for 2-3 sets

-Stretching exercises hold for 10-30 seconds, 4x. Progress as tolerated.

Phase 2

Week 1-2 to Week 3-6

-Progress to AAROM and AROM shoulder exercises.

-Start Deltoid Rehabilitation regime - focus on Stage 1 and Stage 2 (see images below), complete 10-15 reps for 2-3 sets.

-Shoulder isometrics with 6/way (flex, ext abd, add, IR, and ER against wall), 8 reps x 3 sets, progress as tolerated by patient.

-Wall circles, ball rolling on wall for proprioception. 10 reps for 3 sets.

-Return to full ADLs as soon as possible

Phase 3

Week 4-6 and beyond

-Progress to AROM shoulder exercises

-Start Deltoid Rehabilitation regime - focus on Stage 3 and Stage 4 (see images below), complete 10-15 reps for 2-3 sets.

-Progress shoulder isometrics and proprioception, add resistance training for strengthening shoulder and scapular musculature as tolerated by patient.

Deltoid

Rehab

Regime

NOTE:

Throughout the first 6 weeks, the patient is NOT allowed to perform forceful movement with the behind his or her back and not to weight bear through the arm (Patients are instructed not to “push themselves out of chair”).

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1. Phase 1: 0-3 Weeks

1. Protect surgical repair & minimize muscle inhibition!

2. Maintain ROM in elbow, hand & wrist

3. Gradually increase shoulder PROM

Pendulum (2 min; CW, CCW, F/E, ADD/ABD)

Shoulder rolls (2 mins; forward & backward)

Seated table slides (30 reps; flexion/abduction)

Grade 2 PROM

2. Phase 2: 4-6 Weeks

1. Continue to protect surgical repair!

2. Increase shoulder PROM

3. Minimize substitution patterns with AAROM & AROM

4. Initiate ER RTC activation

ER, FLEX, EXT isometrics (2x15 reps)

Cane AAROM: Flexion, EXT, ER (2 mins ea direction)

3. Phase 3: 7-8 Weeks

1. Do not over stress to healing tissue!

2. Maintain previous PROM → improve AROM

1. Progress periscapular & RTC strength

3. Return to full functional activities

Pulleys (F/AB/IR, 2 min each)

Wall climbs (2 min)

Wall Angels (1 min, 3 reps)

4. Phase 4: 9-11 Weeks

1. Do not over stress healing tissue

2. Maintain pain free PROM

3. Continue improving AROM

4. Improve dynamic shoulder stability, strength, & endurance

Wall ball oscillations/hold (2 min)

Resistance band punches (30s)

5. Phase 5: 12-16 Weeks

1. Improve strength & endurance

2. Enhance functional use

Resistance band standing ER/IR at 90 3x15

T, Y, I on stability ball 3x10 reps each way

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PHASE I: IMMEDIATE POST-OP (2-3 WEEKS AFTER SURGERY)

Gradual increase in shoulder PROM

0 degrees shoulder PROM in to IR

Pain < 4/10

No complications with Phase I

PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY)

Gradual increase in shoulder PROM, AAROM, AROM

0 degrees shoulder PROM in to IR

Palpable muscle contraction felt in scapular musculature

Pain < 4/10

No complications with Phase II

PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY)

ROM goals**:

Elevation </= 140 degrees

ER </= 30 degrees in neutral

IR </= 50 degrees in scapular plane or back pocket

**PROM and AROM expectations are individualized and dependent upon ROM measurements attained in the OR post-operatively

Minimal to no substitution patterns with shoulder AROM

Pain < 4/10

PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY)

Performs all exercises demonstrating symmetric scapular mechanics

Pain < 2/10

PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY)

Clearance from MD and ALL milestone criteria have been met

Maintains pain-free PROM and AROM

Performs all exercises demonstrating symmetric scapular mechanics

QuickDASH

PENN

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1. Phase 1 → Phase 2

1. >/= 50% flexion, scaption (PROM)

2. </= 90 ABD (PROM)

3. </= 30 ER in scapular plane (PROM)

4. >/= 70 IR PROM in scapular plane (PROM)

5. Palpable contraction felt in scapular musculature

6. Pain <4/10

7. No complications

2. Phase 2 → 3

1. >/= 75% shoulder PROM flex, scaption, as compared to contralateral side

2. >/= 75% shoulder PROM IR in scapular plane as compared to contralateral side

3. 30 degrees of shoulder PROM ER in scapular plane

4. 90 degrees of shoulder PROM ABD

5. Minimal substitution patterns with AAROM

6. AROM shoulder elevation to 100 degrees with minimal substitution patterns

7. Pain <4/10

8. No complications with Phase II

3. Phase 3 → 4

1. Minimal to no substitution patterns with shoulder AROM

2. Pain < 4/10

4. Phase 4 → 5

1. Supine AROM Flex >/= 140 degrees

2. Supine AROM ABD >/= 120 degrees

3. Supine AROM ER in scapular plane >/= 60 degrees

4. Supine AROM IR in scapular plane >/= 70 degrees

5. AROM shoulder elevation to 120 degrees with minimal substitution patterns

6. Performs all exercises demonstrating symmetric scapular mechanics

7. Pain <2/10

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Return to Daily Activities:

1. Light Activities (e.g., dressing, eating): May resume as comfort allows, typically within the first few weeks post-surgery.

2. Driving: Generally permitted once the patient has adequate shoulder function and is no longer taking narcotic pain medications, often around 6-8 weeks postoperatively.
OHSU

Return to Work:

1. Sedentary or Light-Duty Jobs: Patients may return to work approximately 1 to 3 months post-surgery, depending on individual recovery and job requirements.
PMC

2. Moderate to Heavy-Duty Jobs: Return may be delayed up to 4 months or more, contingent on the physical demands of the job and the patient's rehabilitation progress.
PMC

Return to Sports:

1. Low-Demand Sports (e.g., swimming, golf, cycling): May resume around 3 months post-surgery, provided the patient has regained sufficient strength and ROM.
PMC

2. High-Demand Sports (e.g., tennis, basketball): Typically deferred until at least 6 months post-surgery, following comprehensive evaluation by the healthcare team to ensure shoulder stability and function.
PMC

Considerations:

Individual Variability: Recovery timelines can vary based on factors such as age, overall health, adherence to rehabilitation, and the specific demands of the desired activities.

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1. For the recreational or competitive athlete, return to sport decision making should be individualized and based upon factors including level of demand on the UE, contact vs non contact sport, frequency of participation.

2. Close discussion with the referring surgeon should be done prior to advancing to a return to sport rehabilitation program.

3. Research has shown that a majority of patients return to work after a TSA at an average of 2.3 months post-op.

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https://www.ncbi.nlm.nih.gov/books/NBK574545/

https://www.massgeneral.org/assets/mgh/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-reverse-shoulder-arthroplasty.pdf

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/reverse-total-shoulder-replacement

https://www.massgeneral.org/assets/mgh/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-reverse-shoulder-arthroplasty.pdf

https://med.virginia.edu/orthopaedic-surgery/wp-content/uploads/sites/242/2021/06/Reverse-Total-Shoulder-Arthroplasty.pdf

https://medicine.osu.edu/-/media/files/medicine/departments/sports-medicine/medical-professionals/shoulder-and-elbow/reversetotalshoulderarthroplasty.pdf?la=en&hash=3ABDFE4B8582034355506CDED491B2A8F80D6DC6

https://www.brighamandwomens.org/assets/bwh/patients-and-families/rehabilitation-services/pdfs/shoulder-reverse-total-shoulder-arthroplasty-protocol.pdf