Total Shoulder Arthroplasty

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Standard rehabilitation protocol courtesy of Christopher Shultz, M.D.

Basic Exercises

You should wear your sling full time for the first 4 weeks, and when out of the house or sleeping from weeks 4-6. You should take off your sling at home starting post-operative day 2 and perform the following exercises 3-4 times per day, 10 sets at a time. Make sure you can see your elbow at all times when doing these exercises. Reaching behind your back can cause your shoulder to dislocate.

1. Supine forward flexion: Lie on your back. Hold the affected arm at the elbow with the opposite hand. Assisting with the opposite arm, lift the operated arm upward, as if the bring the arm overhead. Slowly lower the arm back to the bed. Repeat 10 times per session.

2. Wall walks: stand with your shoulder about 2 feet from the wall. Raise your arm to shoulder level and gently “walk” your fingers up the wall as high as you can. Hold for a few seconds. Then walk your fingers back down. Repeat 10 times. Move closer to the wall as you repeat. Build up to holding each stretch for 30 seconds.

3. Isometric shoulder abduction (the chicken wing): Resisting upward motion to the side, slowly and gently push your arm against the back of chair. Hold for 5 seconds, and then relax. Repeat 10 times per session.

4. Elbow stretch: 3 times per day, remove your sling and let gravity stretch your elbow full straight. Repeat this 10 times per session.

5. Posture: When you no longer need to wear your sling, it is important to stretch your back and shoulders to regain your pre surgery posture. Posture is important especially for a good functioning shoulder. Gently roll your shoulders a few times and squeeze your shoulder blades together. Gently hold this position for 10 seconds.

Physical Therapy Protocol

Phase I (surgery to 4 weeks after surgery)

Rehabilitation goals

Reduce pain and swelling in the shoulder after surgery

Maintain active range of motion (AROM) of the elbow, wrist and neck Protect healing of repaired tissues and implanted devices

Precautions

Use sling continuously except while doing therapy or light, protected activities – such as desk work, for 4 weeks

Wear sling while sleeping for 6 weeks

OK for active assist forward flexion

No active internal rotation for 6 weeks

External rotation range of motion limited to 30 degrees

Relative rest to reduce inflammation

Suggested therapeutic exercises

Elbow, wrist and neck AROM

Ball squeezes

Passive and active assistive range of motion (AAROM) for shoulder flexion and abduction to patient tolerance

Codmans/Pendulum exercises

Pain free isometrics for shoulder flexion, abduction, extension and external rotation

Cardiovascular exercise

Walking or stationary bike with sling on

No treadmill

Progression criteria

4 weeks after surgery

Phase II (begin after meeting Phase I criteria, usually 4-8 weeks after surgery)

Rehabilitation goals

Controlled restoration of passive and active assistive range of motion

Activate shoulder and scapular stabilizers in a protected position of 0 degrees to 30 degrees of shoulder abduction

Correct postural dysfunctions

Precautions

No lifting anything heavier than a coffee cup

Wean out of the sling slowly based on the safety of the environment during weeks 5 and 6. Discontinue use of the sling by the end of week 6

Wear sling while sleeping for 6 weeks

No active internal rotation for 6 weeks

External rotation range of motion limited to 30 degrees weeks 5 and 6, then to 45 degrees for weeks 7 and 8

Suggested therapeutic exercises

Passive and active assistive range of motion for the shoulder in all cardinal planes

Pain free, progressive, low resistance shoulder isotonics

Gentle, low velocity rhythmic stabilizations to patient tolerance

Scapular strengthening with the arm in neutral

Cervical spine and scapular active range of motions

Postural exercises

Core strengthening

Cardiovascular exercise

Walking or stationary bike

No treadmill or stair master

Avoid running and jumping because of landing impact

Progression criteria

8 weeks after surgery

Phase III (begin after meeting Phase II criteria, usually 8 weeks after surgery)

Rehabilitation goals

Functional shoulder range of motion in all planes

Normal (rated 5/5) strength for shoulder internal rotators and external rotators with the shoulder in 0 degrees of abduction

Correct any postural dysfunction

Precautions

External rotation range of motion limited to 60 degrees

No lifting more than 15 pounds

Suggested therapeutic exercises

Shoulder internal rotation and external rotation with theraband or weights that begin at 0 degrees of shoulder abduction-gradually increase shoulder abduction as strength improves

Open kinetic chain shoulder rhythmic stabilizations in supine (ie. stars or alphabet exercises)

Gentle closed kinetic chain shoulder and scapular stabilization drills-wall ball circles and patterns

Proprioceptive neuromuscular facilitation patterns

Side lying shoulder flexion

Scapular strengthening

Active, active assistive and passive range of motion at the shoulder as needed

Core strengthening

Begin trunk and hip mobility exercises

Cardiovascular exercise

Walking or stationary bike

No treadmill or stair master

Avoid running and jumping because of landing impact

Progression criteria

12 weeks after surgery

Phase IV (begin after meeting Phase III criteria, usually 12 weeks after surgery)

Rehabilitation goals

Normal (rated 5/5) rotator cuff strength and endurance at 90 degrees of shoulder abduction and scaption

Advance proprioceptive and dynamic neuromuscular control retraining

Achieve maximal shoulder external rotation (no limitations)

Correct postural dysfunctions with work and sport specific tasks

Develop strength and control for movements required for work or sport

Precautions

Soreness should go away within 12 hours of activities

Suggested therapeutic exercises

Multi-plane shoulder active range of motion with a gradual increase in the velocity of movement while making sure to assess scapular rhythm

Shoulder mobilization as needed

Rotator cuff strengthening in 90 degrees of shoulder abduction and overhead (beyond 90 degrees of shoulder abduction)

Scapular strengthening and dynamic neuromuscular control in open kinetic chain and closed kinetic chain positions

Core and lower body strengthening

Cardiovascular exercise

Walking, stationary bike or stair master

No treadmill or swimming

Begin light jogging and running if patient has normal (rated 5/5) rotator cuff strength in neutral and normal shoulder active range of motion

Progression criteria

Full shoulder active range of motion in all planes and multiplane movements

Phase V (begin after meeting Phase IV criteria, usually 18 weeks after surgery)

Rehabilitation goals

Normal strength and endurance of deltoid at 90 degrees of shoulder abduction and scaption

Advance proprioceptive and dynamic neuromuscular control retraining

Correct postural dysfunctions with work and sport specific tasks

Develop strength and control for movements required for work/sport

Develop work capacity cardiovascular endurance for work/sport

Precautions

None

Suggested therapeutic exercises

Multi-plane shoulder active range of motion with a gradual increase in the velocity of movement while making sure to assess scapular rhythm

Shoulder mobilization as needed

Rotator cuff strengthening in 90 degrees of shoulder abduction as well as in provocative positions and work/sport specific positions, including eccentric strengthening , endurance and velocity specific exercise

Scapular strengthening and dynamic neuromuscular control in overhead positions and work/sport specific positions

Work and sport specific strengthening

Core and lower body strengthening

Work specific program, golf program, swimming program or overhead

Cardiovascular exercise

Design to use work/sport specific energy systems

Progression criteria

May return to sport after receiving surgeon, athletic trainer of PT clearance Return to sport are based on meeting the goals of this phase

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