Post-Operative Therapy Total Shoulder Arthroplasty

Note: This pathway is designed to serve as a guide to rehabilitation. Indications for progression should be based on patient’s complete operative procedure, functional capacity and response to treatment.

Rehabilitation Phase | Phase 1 – Protective | Post-Operative Weeks 0-6

Goals: Decrease pain and inflammation, gradually increase PROM, prevention of muscular inhibition and associated suite atrophy.

General Precautions

• No active IR/extension
• No passive ER>40°, 0 to 4 weeks, if subscapularis repair is performed
• Keep incision clean and dry
• Sling wear and no active shoulder elevation for 4 weeks

Range of Motion

• Weeks 0 to 4: PROM, Supine AAROM no limits, as tolerated. Limit ER at side to 40 degrees for first 4 weeks
• Weeks 4 to 6: Gently start AROM and transition out of slingMay initiate Grade II/III capsular mobilization, in all ranges

Therapeutic Exercises

• Hand gripping and dexterity exercises, pronation/supination, as tolerated
• Initiate PROM elbow flexion/extension, progression to AROM exercises
• Introduction to AAROM pulleys/wand for flexion/extension, IR/ER
• Initiation of scapular retraction/depression exercises

Modalities

• Moist head pre-treatment, if incision is well-healed, to avoid erythema/swelling
• Cryotherapy post-treatment recommended 3 to 4 times daily at home
• Ultrasound, interferential electrical stimulation, HVGS to control pain and swelling
• FES for muscle re-eduction

Criteria for Progression: Non-painful PROM, within prescribed guidelines.

Rehabilitation Phase | Phase 2-Early Strengthening | Post-Operative Weeks 6-12

Goals: Decrease pain and inflammation and avoid overuse injuries, normalize strength and AROM, increase function capacity for daily activities. At 6 weeks, PROM should be equal to pre-op level.

Range of Motion

• Expand PROM to 160+° elevation
• 60° ER in neutral abduction
• Total rotation mobility of 80° at 45° abduction
• 90° abduction with 40° each, IR/ER
  • Considerations: Expand AROM with negative shrug sign
  • Grade II-IV capsular mobs with emphasis on posterionferior capsule

Therapeutic Exercises

• Initiate AAROM, progress to AROM, all panes
• Initiate sub maximal, pain free isometrics, weeks 4 to 6, from neutral
• Progress to isotonic strengthening, week 6+, for elbow/RC, with high volume and low intensity, to avoid overuse phenomena
  • Considerations: Initiate at neutral position, progressions made only without pain
• Scapular stabilizer strengthening
  • Initiate with CKC exercises
  • Scapular retraction, protraction, depression, shoulder shrugs

Modalities: continue PRN to control pain and inflammation

Criteria for Progression: Non-painful PROM, within prescribed guidelines.

Rehabilitation Phase | Phase 3 | Post-Operative Weeks 12+

Goals: facilitate continued gradual return to functional activity, normalized shoulder strength and AROM, control localized pain and inflammation, enhance neuromuscular control.

Therapeutic Exercise:

• Home Maintenance Program Goals:
  • Improve strength, power, endurance, neuromuscular control and proprioception
• Prepare for gradual and appropriate return to functional activities, including implementation of interval training, for recreation/sport activities, if cleared by physician
• ROM 2x per day, with frequency of 3 to 4 times weekly

Discharge Criteria

• Phase 3 progression criteria
• 4 to 4+/5 strength in all planes, involved shoulder
• Independence with understanding of precautions
• Evidence of independence/compliance with HEP

If shoulder is RC deficient, focus on increased stability and decreased mobility

Return to Functional Activity – use as a guide, as progress allows:

• Sedentary job: 3 weeks
• Stationary bike for exercise: 3 weeks
• Treadmill/walking aggressive: 6 weeks
• Driving: as early as 6 weeks
• Swimming: breaststroke 6 to 8 weeks, depending on progress
• Golf: 3 months