Rehabilitation protocol after total shoulder arthroplasty

This comprehensive guide equips you with easy-to-understand exercises, simplified techniques, and achievable milestones for the total shoulder replacement rehabilitation protocol. This invaluable resource offers step-by-step instructions, simplified exercises, and practical techniques.

It is important that patients receive appropriate rehabilitation after total shoulder arthroplasty. Ideally, this should include a preoperative visit attended by the designated therapist, the patient, and their primary caregiver. The rehabilitation process is an individualized program, and the described total shoulder replacement protocol is recommended as a guideline for the therapist.

The protocol for total shoulder replacement consists of three phases, starting in week 0 and lasting 12 months after surgery.

Phases of the rehabilitation protocol for total shoulder replacement

PHASE 1: WEEKS 0-6

restrictions

These shoulder movements should be restricted after a total shoulder replacement, depending on the number of weeks:

• Week 1
  • 120-degree forward bend
  • 20-degree external rotation with the arm at the side
  • 75 degrees abduction with 0 degrees rotation
• Week 2
  • 140-degree forward bend
  • 40-degree external rotation with the arm at the side
  • 75 degrees abduction with 0 degrees rotation
  • No active internal rotation
  • No reverse extension

Immobilization

Baby sling: After 7–10 days, the baby sling is only used for convenience.

Pain control

Reducing pain and discomfort is crucial for recovery.

• Medications:
  • Anesthetic for 7–10 days after the operation,
  • NSAIDs for patients with persistent symptoms after surgery.
• Therapy modalities:
  • Ice, ultrasound, HVGS.
  • Moist heat before therapy; ice at the end of the session.

Movement

Shoulder:

• Goals:
  1. 140-degree forward bend.
  2. 40-degree external rotation.
  3. 75 Degrees Abduction.
• Exercises:
  • Start with Cadman pendulum exercises to encourage early movement.
  • Passive ROM exercises.
  • Capsular stretching of the anterior, posterior and inferior capsule by using the opposite arm to assist movement.
  • Actively supported movement exercises:
    • Shoulder flexion.
    • Shoulder extension.
    • Internal and external rotation.
  • Move on to active ROM exercises.

Elbow:

Passive to active progression:

• 0-130 Degrees.
• Pronation and supination are tolerated.

Muscle strengthening

Grip reinforcement only.

PHASE 2: WEEKS 6–12

Criteria for transitioning to Phase 2 :

• Minimal pain and sensitivity.
• Nearly complete movement.
• Intact subscapularis with no signs of tendon pain on resistance to internal rotation.

restrictions

• Increase the ROM targets
• 160-degree forward bend
• 60-degree external rotation with the arm at the side
• 90 degrees abduction with 40 degrees internal and external rotation

Immobilization :

None.

Pain control

• NSAIDs – for patients with persistent symptoms after surgery.
• Therapy modalities:
  • Ice, ultrasound, HVGS.
  • Moist heat before therapy; ice at the end of the session.

Movement:

Shoulder:

• Goals:
  • 160-degree forward bend.
  • 60-degree external rotation with the arm at the side.
  • 90 degrees abduction with 40 degrees internal and external rotation.
• Exercises:
  • Increase the active ROM in all directions.
  • Focus on passive stretching in the end ranges to maintain shoulder flexibility.
  • In cases of capsular restrictions, especially of the posterior capsule, use joint mobilization techniques.

Muscle strengthening

Strengthening the rotator cuff:

1. Only three times a week to avoid rotator cuff tendonitis, which occurs with overtraining.
2. Start with isometric strengthening in a closed kinetic chain: external rotation / abduction.
3. Progress in strengthening the open kinetic chain with Thera-Bands.
4. Exercises with the elbow bent at 90 degrees. The starting position is with the shoulder in a neutral position of 0 degrees of forward flexion. Abduction and external rotation.
5. The exercises are performed in a 45-degree arc in each of the five planes of movement.
6. Six color-coded bands are available: each offers increasing resistance from 1 to
   6 pounds in 1-pound increments.
7. The transition to the next hand usually occurs at intervals of 2 to 3 weeks. Patients are instructed not to proceed to the next band if they experience discomfort at their current level.
8. Theta band exercises allow for concentric and eccentric strengthening of the shoulder muscles and are a form of isotonic exercise (characterized by variable speed and fixed resistance):
   • External rotation.
   • Kidnapping.
   • Forward bend.
9. Progress in light isotonic dumbbell exercises:
   • External rotation.
   • Kidnapping.
   • Forward bend.

Strengthening of the scapular stabilizer:

1. Closed chain strengthening exercises.
2. Retraction of the scapula (rhomboid, middle trapezius).
3. Scapular protraction (serratus anterior).
4. Shoulder blade depression (Latissimus dorsum. Trapezius. Serratus anterior).
5. Shoulder shrug (trapezius, levator scapulae).

PHASE 3: FUN 3-12

Criteria for transitioning to Phase 3 :

• Completely pain-free ROM.
• Satisfactory physical examination.

Goals :

• Improve shoulder strength, power, and endurance.
• Improve neuromuscular control and shoulder proprioception.
• Prepare for a gradual return to functional activities.
• Training program for building maintenance:
  • ROM exercises twice daily.
  • The rotator cuff is strengthened three times a week.
  • Three times a week to strengthen the scapular stabilizer.

Movement :

• Achieve a movement that corresponds to the one on the contralateral side.
• Use both active and passive ROM exercises to maintain movement.

Muscle strengthening :

• Shoulder: Begin by strengthening internal rotation and extension: First with isometric strengthening using a closed chain, then continue with Thera-Band and light isotonic strengthening.
• Scapular stabilizers: Advances in strengthening the open and closed chain
• Strengthening the deltoid muscle: 8–12 repetitions for each exercise in three sets.
• Strengthening exercises only three times a week to prevent rotator cuff tendonitis.

Functional strengthening: Plyometric exercises

Maximum improvement is achieved after 12 to 18 months.

Warning signs

• Loss of movement
• Persistent pain

Treatment of complications

• These patients may need to return to previous routines.
• Increased use of the pain control modalities described above may be necessary.

References and more

1. Bullock GS, Garrigues GE, Ledbetter L, Kennedy J. A systematic review of proposed rehabilitation guidelines following anatomical and reverse shoulder arthroplasty. J Orthop Sports Phys Ther. 2019 May;49(5):337-346. doi: 10.2519/jospt.2019.8616. Epub April 25, 2019. PMID: 31021690.
2. Langohr GDG, Haverstock JP, Johnson JA, Athwal GS. Comparison of daily shoulder movements and frequency after anatomical and reverse shoulder arthroplasty. J Shoulder Elbow Surgery. 2018 Feb;27(2):325-332. doi: 10.1016/j.jse.2017.09.023. Epub 2017, November 10. PMID: 29133073.
3. Brown DD, Friedman RJ. Postoperative rehabilitation after total shoulder arthroplasty. Orthop Clin North Am. 1998 Jul;29(3):535-47. doi: 10.1016/s0030-5898(05)70027-4. PMID: 9706298 .