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Total Shoulder Arthroplasty


  • The primary objective in a total shoulder arthroplasty is anatomic reconstruction of the glenohumeral joint and appropriate soft-tissue balancing.  Dr. Charles Neer II, one of the pioneers of shoulder arthroplasty, has stated, "Shoulder replacement will fail without adequate rehabilitation."  Because TSA surgery largely involves soft tissue reconstruction, a significant factor in the success of the procedure is postoperative rehabilitation.

General Considerations

  • It is OK to have mild discomfort with exercises, but if it persists more than one hour, the intensity of the exercises must be decreased
  • If there is an increase in night pain, the program must be altered to decrease the intensity  
  • Maintain good upright shoulder girdle posture at all times and especially during sling use
  • Overall recovery may take up to 1 to 2 years and outcomes are primarily based on the status of the involved soft tissue
  • Early scapular muscle activity should be instituted
  • When wearing the sling, the shoulders should be back, the abduction pillow should be more on the side of the body (rather than over the front of the abdomen), and the fingers should be pointing forwards (see below)

Immediately After Surgery

  • The patient should get out of bed and mobilize as much as possible
  • Frequent cryotherapy (5x per day, 20 minutes each time)
  • Motion of the fingers, hand, and elbow are allowed to prevent swelling and stiffness
  • The sling (and attached pillow) is necessary for 4 weeks to protect the joint and allow tissues to heal

0-4 Weeks (Immobilization Phase)

  • For the first four weeks, the sling may be carefully removed for hygiene and therapy only
  • Sling is discontinued 4 weeks from date of surgery
  • Continue frequent cryotherapy
  • Begin passive forward flexion in supine to tolerance (no AROM)
  • Gentle ER in scapular plane to available PROM (usually documented in the operative note and is usually around 30 degrees)
  • Passive IR to chest
  • Active/AAROM of the elbow, wrist, hand, and cervical spine
  • Strict non-weight bearing until 3 months
  • NOTE:  Pay particular attention as to avoid stress on the anterior capsule.  The subscapularis repair has been know to fail with early, aggressive therapy

4-12 Weeks (Mobilization Phase)

  • Sling is discontinued 4 weeks from date of surgery but should continue to be used at night while sleeping until 6 weeks
  • Continue cryotherapy as needed
  • AAROM can begin during this time if patient is tolerating the PROM maneuvers
  • At 6 weeks, can begin active flexion, IR, ER, and abduction (but not extension)
  • Initiate assisted shoulder IR behind back stretch and progress to AROM as ROM allows
  • Strict non-weight bearing until 3 months
  • Begin sub-maximal pain-free deltoid isometrics in scapular plane
  • Begin assisted horizontal adduction
  • Gentle resisted exercise of the elbow, wrist, and hand
  • Initiate glenohumeral and scapulothoracic rhythmic stabilization

3-6 Months (Strengthening Phase)

  • Progress to AROM as tolerated
  • Continue PROM as needed to maintain ROM
  • Light passive stretching at end ranges
  • Progress IR stretch behind back from AAROM to AROM 
  • Begin resisted glenohumeral and scapular exercises as appropriate:  Therabands, light weights (1-5 lbs)
  • Emphasis should be placed on strengthening the scapular stabilizers
  • Begin plyometrics and proprioception later in this phase
  • Initiate work/sport specific drills or activities (i.e. golf, tennis, gardening) at 4-5 months
  • Can be transitioned to home program later in this phase

6-12 Months (Return to Activity Phase)

  • Typically patient is on a home exercise program by this point which should be performed 3-4 times per week
  • Return to sport, work, and prior activity level unrestricted based on physician approval and completion of rehabilitation program
  • Full AROM without restrictions
  • Advance strengthening as tolerated
  • Add total body conditioning, including strength and endurance training if appropriate
  • Maximum improvement is usually seen around 1-2 years post-op
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