• 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

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)

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”).

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”).

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

• 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

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.

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

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