Post-Operative Therapy Reverse Total Shoulder Arthroplasty
Note: This protocol 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.
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
Rehabilitation Phase | Phase 1 — Immediate Post-OP | Post-Operative Weeks 2-3
Goals
- Protect surgical repair
- Reduce swelling, minimize pain
- Maintain UE ROM in elbow, hand and wrist
- Gradually increase shoulder PROM
- Minimize muscle inhibition
- Patient education
Sling
- Neutral rotation
- Use of abduction pillow in 30-45 degrees abduction
- Use at night while sleeping
Precautions
- No shoulder AROM
- No shoulder AAROM
- No shoulder PROM in to IR
- No reaching behind back, especially in to internal rotation
- No lifting of objects
- No supporting of body weight with hands
- Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension
Intervention
- Swelling Management
- Ice, compression
- Range of motion/Mobility
- PROM: ER in the scapular plane to tolerance, Flex/Scaption </= 120 degrees, ABD </= 90 degrees, seated GH flexion table slide, pendulums, seated horizontal table slides
- AAROM: none
- AROM: elbow, hand, wrist
Criteria to Progress
- Gradual increase in shoulder PROM
- 0 degrees shoulder PROM in to IR
- Pain < 4/10
- No complications with Phase I
Rehabilitation Phase | Phase 2 — Intermediate Post-OP | Post-Operative Weeks 4-6
Goals
- Continue to protect surgical repair
- Reduce swelling, minimize pain
- Gradually increase shoulder PROM
- Initiate shoulder AAROM/AROM
- Initiate periscapular muscle activation
- Initiate deltoid activation (avoid shoulder extension when activating posterior deltoid)
- Patient education
Sling
- Use at night while sleeping
- Gradually start weaning sling over the next two weeks during the day
Precautions
- No reaching behind back, especially in to internal rotation
- No lifting of objects heavier than a coffee cup
- No supporting of body weight with hands
- Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension
Intervention
- Range of Motion
- AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane
- AROM: supine flexion, salutes, supine punch
- Strengthening
- Periscapular: scap retraction, standing scapular setting, supported scapular setting, low row, inferior glide
- Deltoid: isometrics in the scapular plane
Criteria to Progress
- 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
Rehabilitation Phase | Phase 3 — Intermediate Post-OP Contd | Post-Operative Weeks 7-8
Goals
- Minimize pain
- Gradually progress shoulder PROM, initiate shoulder PROM IR in the scapular plane
- Gradually progress shoulder AAROM
- Gradually progress shoulder AROM
- Progress deltoid strengthening
- Progress periscapular strengthening
- Initiate motor control exercise
- Patient education
Sling
- Discontinue
Precautions
- No reaching behind back beyond pant pocket
- No lifting of objects heavier than a coffee cup
- No supporting of body weight with hands
- Avoid shoulder hyperextension
Intervention
- Range of Motion
- PROM: Full in all planes, gradual PROM IR in scapular plane </=50 degrees
- AAROM: incline table slides, wall climbs, pulleys, seated shoulder elevation with cane with active lowering
- AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg
- Strengthening
- Periscapular: Row on physioball, serratus punches
- Deltoid: seated shoulder elevation with cane, seated shoulder elevation with cane with active lowering, ball roll on wall
- Motor Control
- IR/ER in scaption plane and Flex 90-125 (rhythmic stabilization) in supine
- Stretching
- Sidelying horizontal ADD, triceps and lats
Criteria to Progress
- 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
Rehabilitation Phase | Phase 4 — Transitional Post-OP | Post-Operative Weeks 9-11
Goals
- Maintain pain-free ROM
- Progress periscapular strengthening
- Progress deltoid strengthening
- Progress motor control exercise
- Improve dynamic shoulder stability
- Gradually restore shoulder strength and endurance
- Return to full functional activities
Precautions
- No lifting of heavy objects (> 10 lbs)
Intervention
- Range of Motion
- PROM: Full ROM in all planes
- Strengthening
- Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, robbery, lawnmowers, tripod, pointer
- Deltoid: gradually add resistance with deltoid exercise
- Motor Control
- IR/ER and Flex 90-125 (rhythmic stabilization)
- Quadruped alternating isometrics and ball stabilization on wall
- Field goals
- PNF – D1 diagonal lifts, PNF – D2 diagonal lifts
Criteria to Progress
- Performs all exercises demonstrating symmetric scapular mechanics
- Pain < 2/10
Rehabilitation Phase | Phase 5 — Advanced Strengthening | Post-Operative Weeks 12-16
Goals
- Maintain pain-free ROM
- Initiate RTC strengthening with a concomitant repair
- Improve shoulder strength and endurance
- Enhance functional use of upper extremity
Precautions
- No lifting of objects (> 15 lbs)
Intervention
- Strengthening
- Periscapular: Push-up plus on knees, “W” exercise, resistance band Ws, prone shoulder extension Is, dynamic hug, resistance band dynamic hug, resistance band forward punch, forward punch, T and Y, “T” exercise
- Deltoid: continue gradually increasing resisted flexion and scaption in functional positions
- Elbow: Bicep curl, resistance band bicep curls, and triceps
- Rotator cuff: internal external rotation isometrics, side-lying external rotation, Standing external rotation w/ resistance band, standing internal rotation w/ resistance band, internal rotation, external rotation, sidelying ABD→standing ABD
- Motor Control
- Resistance band PNF pattern, PNF – D1 diagonal lifts w/ resistance, diagonal-up, diagonal-down, wall slides w/ resistance band
Criteria to Progress
- 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
