Post-Operative Therapy Reverse Total Shoulder Arthroplasty

Post-Operative Therapy Reverse Total Shoulder Arthroplasty

Typical outpatient TP may begin at post-operative week 2 and physician preference may range from utilization of home health PT to family instruction in PROM techniques by referring surgeons. Surgeon may request specific start date, and specifically may request a more conservative recap in appropriate situations. In all cases, appropriate inflammation control, PROM, patient education and appropriate shoulder protection and care is focus.

Abduction Pillow:

• Use and recommendation will be case specific

Sling Wear:

• Week 1-2 with abduction pillow and sling, 24 hours/day
• Week 2-4, sling at 24 hours/day
• Gradual wean from sling between weeks 4-6
• During PT and during exercise, sling purposefully removed
• May be extended in case of a complication or in revision RSTA case

Movement Precaution (12 weeks):

• No extension beyond neutral
• No Adduction + IR combined motions
• No Extension + IR combined motion

Mobilizations:

• With RTSA, No mobilizations through GH junction directly at any time throughout rehabilitation
• Anatomical center of rotation shifted and convex/concave rule for arthrokinematics are not applicable, so standard mobilizations are not appropriate

Exceptions:

• Poor Bone Stock: Will delay start of protocol second to surgeon’s assessment of repair integrity

Acute Phase | Post-Op – Days 1 to 5

Goals: Promote patient comfort by controlling pain, promote joint healing, specifically soft tissues such as the deltoid

• Patient/family independence with joint protection, PROM, assisting with on/off of clothing, modalities and assistance with prescribed HEP
• Gradual increase PROM of shoudler
• Restore AAROM of elbow/wrist/hand
• Postural awareness
• No AROM, lifting, sudden movements, stretching of operative extremity
• Modalities:
  • Ice application 4-5 times/day for 15-20 minutes

Sub-acute Phase | Post-Op – Days 5 to 3 Weeks

Goals: Promote patient comfort by controlling pain, promote joint healing, specifically soft tissues such as the deltoid

• PROM continued, manual therapy for general shoulder PROM
• Appropriate progression of A/AAROM of elbow, wrist, hand
• Supine Self PROM into flexion
• Sub-maximal periscapular isometrics initiated
• Reinforce patient education with regard to use of abduction pillow
• Cervical AROM program with emphasis on maintenance of neutral posture
• Modalities: continue PRN

Protective Phase | Weeks 3 to 6

Goals: Facilitate healing of soft tissues local to joint, protect deltoid and restore/maintain PROM

• Range of Motion:
  • PROM guidelines – Scapular plane elevation not to exceed 120, ER at 30° abduction to 30-45°, IR at 30° abduction to 30-45°, grade I-II scapular mobilization , all planes
• Therapeutic Exercise:
  • Submaximal RC and periscapular stabilizer isometrics
• Modalities:
  • Interferential electrical stimulation and cryotherapy for pain modulation
  • FES for muscle re-education
  • Ultrasound/phonphoresis for control of inflammation

Weeks 5 to 6

• May progress AAROM activities, including wand/pulleys, initiate UBE AAROM

Ensure continued HEP compliance and wean from utilization of immobilizer, as tolerated

Strengthening Phase | Weeks 6 to 12

Goals: Initiate light strengthening, proprioception and periscapular stabilization, control pain/swelling

• Range of Motion:
  • Continue PROM scapular plane elevation to 130+°, ER/IR to Torrance at 30° abduction , grade II-III scapular mobilization, all planes
• Therapeutic exercises:
  • Isotonic periscapular progression, light isotonic RC progression with high volume and low intensity, remember that minimal isolated IR/ER will exist to neutral position
    • Considerations: avoid hyperextension
• Modalities: continue PRN

Functional Phase | Weeks 12+

Goals: Focus on progressive strengthening to restore force couple mechanics, enhance dynamic stabilization/neuromuscular control and increase strength, power and endurance to promote optimal tolerance to functional activity

• Range of Motion:
  • Continue PROM scapular plane elevation to tolerance, ER/IR to tolerance at 30° abduction, grade III scapular mobilization all planes
• Therapeutic Exercise:
  • Progression of AA exercises (UBE, proprioception and CKC mobility exercises, e.g., body blade, physioball)
  • Progression of periscapular activation with Teraband
  • Progression of gentle GH IR and ER isotonic strengthening
  • Progression of deltoid strengthening exercises
  • Progression wrist/hand/elbow exercises with resistance
    • Maintain high volume and gradually increase intensity levels
• Modalities: continue PRN

Discharge Criteria

• Patients to complete HEP 3 to 4x a week
• Painless AROM to be grossly WNL’s compared contralaterally
• MMT grade grossly 4/5 with flexion, abduction strength minimally, ideally 4+ to 5/5

Return to Activity:

• Sedentary job – 4 to 6 weeks
• Stationary bike for exercise – 3 weeks
• Treadmill/walking aggressive for exercise – 9 weeks
• Driving – as early as 6 to 9 weeks
• Swimming – breaststroke 9 weeks, depending on progress
• Tennis, golf 12 weeks, depending on progress
• Running at 12 weeks