Treatment for a Total Shoulder Replacement and a Reverse Total Shoulder Replacement

Our last 2 blogs discussed what a total shoulder replacement or arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) are and why one might need these procedures.  Now let’s discuss how to properly rehabilitate the shoulder following these procedures.

Immediately following surgery there will be many restrictions regarding use of the shoulder and these precautions are important.  The shoulder is still in its healing stage and performing certain motions too early can disrupt the healing process or damage the repairs that the surgeon performed.  Certain aspects of rehab immediately following a TSA and rTSA are the same.  A sling is to be worn continuously for 3-4 weeks post-operatively, a towel should be placed under the elbow when lying on your back, there should be no active lifting of the arm or any objects, no bearing weight through the operated arm, and no soaking in water.  These restrictions are gradually reduced as rehab progresses.  For example, after 4-6 weeks a patient can begin lifting a coffee cup with the operated arm, but should not lift greater than 5 lbs until the surgeon permits.

Certain precautions are also exclusive to the type of replacement performed.  For a TSA, external rotation (rotating the arm outward) is to be restricted to 30 degrees of rotation initially in order to maintain the integrity of the structures in the front (anterior) of the shoulder.  This is gradually progressed throughout rehab, but precaution is still taken to avoid excessive stress even 12 weeks after surgery.  Active internal rotation (rotation inward) is avoided until 6 weeks post-op as well in order to protect the healing muscles.  With a rTSA, you should not attempt to reach behind your back following surgery because combined internal rotation and extension (backward reaching) motions could potentially dislocate the shoulder.  Activation of the deltoid muscle by lifting out to the side is to be restricted for 4 to 6 weeks in a rTSA in order for the muscle to heal properly following surgery.  Healing of this muscle is important due to the fact that the deltoid will be the muscle that primarily moves the arm following a rTSA.

Passive range of motion (PROM) is an essential component to Phase 1 of rehab for a TSA and rTSA.  For this treatment, either a therapist or a trained family member moves the arm within the available ranges, not with the goal of “stretching”.  The repeated movement assists with regaining proper motion in the shoulder without stressing the healing structures.  As passive motion is regained, active motion (patient actively moving the body part) can be restored in the elbow, wrist, and hand.  These areas can become weak due to lack of use following surgery; therefore, they will also require strengthening in the course of rehab.  The shoulder blade area is another region that should not be forgotten.  Having a stable shoulder blade is like having a good foundation on a house; without it, the shoulder will not move properly or be as stable once active movements can be performed. 

Active assistive range of motion (AAROM) will also be performed in the early stages of rehab.  These exercises involve active use of the arm while assisting with an outside source. For example, an individual can hold onto a stick with both arms and attempt to lift the stick overhead.  The operated arm ends up actively lifting while having assistance from the stick and non-operated arm.  Isometric exercises are typically utilized in phase 1 as well.  These exercises involve gentle activation of the shoulder muscles through pressure without actively lifting or moving the arm.

Phase 2 of rehab begins active range of motion (AROM) which involves actively lifting the arm without any assistance.  The weight of the arm itself serves as resistance which is why this phase is not to be started until 4-6 weeks following a TSA and 6 weeks following a rTSA.  Activation of the deltoid muscle following a rTSA will also begin at this stage.

Phase 3 in a TSA starts at 6 weeks at which point more stretching may occur as well as the beginning stages of resisted rotation exercises.  Later stages of Phase 2 in a rTSA also allows gentle resistance to be added.  Phase 4 of a TSA and Phase 3 of a rTSA are not to begin until 12 weeks following surgery and these stages are when more advanced strengthening exercises can occur via the use of weights, resistance bands, or other equipment and exercises that provides resistance to the arm.  Even after in clinic rehab is completed, an individual who has had a TSA or rTSA will still need to perform exercises in the form of a home exercise program (HEP) to further progress strength, improve function, and maintain the improvements that have already been gained.

While many restrictions are in place and rehabilitation can take was seems like a very long time, the process is important in order to prevent reinjury or damage to the various structures in the shoulder.  As discussed in our last blog, full active motion is not expected following a rTSA; however, more normalized function is expected in both a TSA and rTSA around 3-4 months following surgery and final results are expected approximately 1 year after surgery.  We hope that this blog was informative.  If you have any questions on this topic or any others in which you are interested, feel free to leave any questions, comments, or suggestions. Thank you for reading and stay active.

Resources:

http://www.brighamandwomens.org/Patients_Visitors/pcs/rehabilitationservices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Shoulder%20-%20Total%20Shoulder%20Arthroplasty%20protocol.pdf

http://www.billrobertsonmd.com/pdf/shoulder-arthroplasty-rehab-protocol.pdf

http://www.bidmc.org/Centers-and-Departments/Departments/Orthopaedic-Surgery/Services-and-Programs/Sports-Medicine/For-Referring-Physicians/~/media/Files/CentersandDepartments/Orthopaedic/Sports%20Medicine/Rehab%20Protocols/Shoulder%20Arthroplasty%20protocol.ashx

http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical%20therapy%20standards%20of%20care%20and%20protocols/shoulder_reverse_tsa_protocol.pdf

http://www.jospt.org/doi/pdf/10.2519/jospt.2007.2562

http://www.billrobertsonmd.com/pdf/reverse-total-shoulder-arthroplasty-rehab-protocol.pdf

http://www.universityorthopedics.com/assets/rhode-island-providence-reverse-total-shoulder-replacement-post-op-rehab.pdf

 

What is a Reverse Total Shoulder Replacement?

Our last blog discussed the purpose and benefit of a total shoulder replacement or arthroplasty (TSA).  Today’s blog will discuss what a reverse total shoulder arthroplasty (rTSA) is and why someone might need one.

Why would someone have a reverse total shoulder replacement versus a typical TSA?  This particular procedure is used for conditions including non-repairable rotator cuff damage in conjunction with arthritis, complex shoulder fractures, and revisions of failed conventional TSAs.  For more information about the anatomy and function of the rotator cuff, check out our past blog on the topic here. A traditional TSA can be very beneficial for pain related to arthritis at the shoulder; but if the rotator cuff is not functioning properly, then the traditional TSA will not be effective in restoring function to the shoulder.  The structure of a rTSA allows muscles other than those of the rotator cuff to assist with movement; therefore, it is a more viable option for individuals who have a non-functioning rotator cuff.

What is the structure of a rTSA? The normal anatomy of the shoulder is a ball and socket joint with the ball being the top of the humerus (upper arm bone) and the socket being the glenoid (cup like structure at the edge of the shoulder blade).  A rTSA reverses the ball and socket components of the shoulder anatomy.  Instead of the humerus forming the ball, an artificial metal ball is attached to the glenoid surface; and instead of the glenoid forming the socket, the head of the humerus is taken off and replaced with a plastic artificial socket.  This gives the deltoid muscle (a muscle that lays overtop of the rotator cuff) a biomechanical advantage in order to lift and move the arm.  If there is severe enough weakness in the muscles that rotate the shoulder outward (external rotators), then a surgeon may also perform a tendon transfer using the tendon from the latissimus dorsi muscle.

What can be expected from rehab following a rTSA?  The expectations for range of motion and strength are a little different between a TSA and a rTSA.  In the case of a rTSA, full motion is not expected.  Even though the deltoid muscle has the ability to lift the arm, it is not capable of producing the same range of motion as when the rotator cuff muscles are intact.  There is also the potential for external rotator weakness as previously discussed.  If a tendon transfer is not performed to correct a severe degree of external rotation weakness, then this will also limit the mobility of the arm following surgery.  Despite the limitation in full motion, satisfaction following a rTSA is typically very high.

Stay tuned for our next blog which discusses the rehab parameters for both a TSA and rTSA.  We hope that this blog was informative.  If you have any questions on this topic or any others in which you are interested, feel free to leave any questions, comments, or suggestions.

Resources:

http://orthoinfo.aaos.org/topic.cfm?topic=A00504

http://www.mayoclinic.org/reverse-shoulder-replacement-video/vid-20086567

http://www.jospt.org/doi/pdf/10.2519/jospt.2007.2562

http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical%20therapy%20standards%20of%20care%20and%20protocols/shoulder_reverse_tsa_protocol.pdf

Are You In Need of a Total Shoulder Replacement?

Most people are at least somewhat familiar with total knee replacements, even if you don’t understand the full scope of the procedure; but total shoulder replacements are not quite as publicized.  Total shoulder replacements are a common procedure for shoulder ailments, but they are still far less common than total knee and total hip replacements.

Why does one undergo a total shoulder replacement?  Often pain from arthritis spurs an individual to decide to have a total shoulder replacement, also known as a total shoulder arthroplasty (TSA).  Osteoarthritis is also referred to a degenerative joint disease and results from gradual “wear and tear” on the joint from an accumulation of life’s activities.  The cartilage that typically protects the ends of the bones wears away which results in “bone on bone” rubbing at the shoulder joint when the arm is moved.  Arthritis can also develop in the shoulder from a traumatic injury like a fracture (broken bone) of the shoulder or arm, chronic rotator cuff injuries or weakness, or other injuries to the shoulder area that cause instability.  These injuries can result in a loss of function and the need for a TSA in the future.  Arthritis typically effects people around the age of 50, but can occur at a younger age especially if an injury occurred at the joint earlier in life.  Rheumatoid arthritis is a different arthritic condition that causes chronic inflammation around the joint resulting in cartilage loss, pain, and stiffness.  This condition usually presents itself earlier in life around the age of 30 and can also lead to the need for a TSA.  Another condition that can also lead to joint damage and the need for a TSA is avascular necrosis.  This condition occurs when the blood supply to the bone is disrupted resulting in degeneration of the joint.  It can occur for a variety of reasons including chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease, and heavy alcohol use.

What does a total shoulder replacement entail?  The extent of a total shoulder replacement can vary based on the amount of damage along the joint surfaces.  The shoulder joint is what is called a ball and socket joint.  The top of the humerus bone which is located along the upper arm forms the ball of the joint and the socket of the joint is what is called the glenoid.  The glenoid is actually a portion of the shoulder blade that makes a shallow cup-like socket for the ball of the humerus to sit in.  The ball, the socket, or both can be replaced by removing the damaged portion of the joint and replacing it with an artificial component called a prosthesis.

Is a shoulder replacement right for you?  Conservative treatments like physical therapy for the shoulder should be attempted prior to undergoing a total shoulder replacement, because arthritis can often be managed with exercise programs and adjustments in form during various activities; but the condition can become severe enough that a TSA is the only option.  Severe shoulder pain that interferes with daily function, moderate to severe pain at rest that disrupts sleep, loss of motion or weakness at the shoulder that effects function, and a failure to improve with conservative treatments like physical therapy, anti-inflammatory medications, or cortisone injections are all reasons to consider a total shoulder replacement.  Individuals with depression, obesity, diabetes, Parkinson’s disease, multiple previous shoulder surgeries, shoulder joint infections, rotator cuff deficiency, and severely altered shoulder anatomy are not ideal candidates for the procedure.  Individuals with rotator cuff deficiency may instead be candidates for a reverse total shoulder replacement.  This procedure will be discussed more in depth in our next blog.  Talk to your doctor or physical therapist if you feel that a TSA may be right for you.

Resources:

http://orthoinfo.aaos.org/topic.cfm?topic=A00094

http://www.orthop.washington.edu/MatsenTSA.pdf

http://my.clevelandclinic.org/health/treatments_and_procedures/hic_Total_Shoulder_Joint_Replacement

 

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