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.