Total Shoulder Replacement Rehab Protocol

This comprehensive guide equips you with easy-to-follow exercises, simplified techniques, and achievable milestones for Total Shoulder Replacement Rehab Protocol. This invaluable resource offers step-by-step guidance, simplified exercises, and practical techniques.

It is essential that patients receive proper rehabilitation after total shoulder arthroplasty. This should ideally include a preoperative visit that includes the specified therapist, patient, and primary caregiver. The rehabilitative process is an individual program, and the Total shoulder replacement protocol described is suggested as a guide for the therapist.

Total shoulder replacement protocol is composed of 3 stages, starting from week 0 and last for 12 months after surgery.

Total Shoulder Replacement Rehab Protocol Phases

PHASE 1: WEEKS 0-6

Restrictions

These shoulder motion should be restricted after total shoulder replacement based on the weeks:

• Week 1
  • 120 degrees of forward flexion
  • 20 degrees of external rotation with the arm at the side
  • 75 degrees of abduction with 0 degrees of rotation
• Week 2
  • 140 degrees of forward flexion
  • 40 degrees of external rotation with the arm at the side
  • 75 degrees of abduction with 0 degrees of rotation
  • No active internal rotation
  • No backward extension

See Also: Shoulder Range of Motion

Immobilization

Sling: After 7-10 days, sling used for comfort only.

Pain Control

Reduction of pain and discomfort is essential for recovery.

• Medications:
  • Narcotics for 7-10 days after surgery,
  • NSAIDs for patients with persistent discomfort after surgery.
• Therapeutic modalities:
  • Ice, ultrasound, HVGS.
  • Moist heat before therapy; ice at end of session.

Motion

Shoulder:

• Goals:
  1. 140 degrees of forward flexion.
  2. 40 degrees of external rotation.
  3. 75 degrees of abduction.
• Exercises:
  • Begin with Cadman pendulum exercises to promote early motion.
  • Passive ROM exercises.
  • Capsular stretching for the anterior, posterior, and inferior capsule by using the opposite arm to assist with motion.
  • Active-assisted motion exercises:
    • Shoulder flexion.
    • Shoulder extension.
    • Internal and external rotation.
  • Progress to active ROM exercises.

Elbow:

Passive-progress to active:

• 0-130 degrees.
• Pronation and supination as tolerated.

Muscle Strengthening

Grip strengthening only.

PHASE2: WEEKS 6-12

Criteria for Progression to Phase 2:

• Minimal pain and tenderness.
• Nearly complete motion.
• Intact subscapularis without evidence of tendon pain on resisted internal rotation.

Restrictions

• Increase ROM goals
• 160 degrees of forward flexion
• 60 degrees of external rotation with the arm at the side
• 90 degrees of abduction with 40 degrees of internal and external rotation

Immobilization:

None.

Pain Control

• NSAIDs-for patients with persistent discomfort after surgery.
• Therapeutic modalities:
  • Ice, ultrasound, HVGS.
  • Moist heat before therapy; ice at end of session.

Motion:

Shoulder:

• Goals:
  • 160 degrees of forward flexion.
  • 60 degrees of external rotation with the arm at the side.
  • 90 degrees of abduction with 40 degrees of internal and external rotation.
• Exercises:
  • Increase active ROM in all directions.
  • Focus on passive stretching at end ranges to maintain shoulder flexibility.
  • Use joint mobilization techniques for capsular restrictions, especially the posterior capsule.

Muscle Strengthening

Rotator cuff strengthening:

1. only three times per week to avoid rotator cuff tendinitis. which will occur with overtraining.
2. Begin with closed-chain isometric strengthening: External rotation / Abduction .
3. Progress to open-chain strengthening with Thera-Bands.
4. Exercises performed with the elbow flexed to 90 degrees Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion. abduction, and external rotation.
5. Exercises arc performed through an arc of 45 degrees in each of the five planes of motion.
6. Six color-coded bands arc available: each provides increasing resistance from I to
   6 pounds in increments of I pound.
7. Progression to the next hand occurs usually at 2- to 3-week intervals. Patients are instructed to not progress to the next band if there is any discomfort at the present level.
8. Theta-Band exercises permit concentric and eccentric strengthening of the shoulder muscles and arc a form of isotonic exercises (characterized by variable speed and fixed resistance):
   • External rotation.
   • Abduction.
   • Forward flexion.
9. Progress to light isotonic dumbbell exercises:
   • External rotation .
   • Abduction.
   • Forward flexion.

Scapular stabilizer strengthening:

1. Closed-chain strengthening exercises .
2. Scapular retraction (rhomboideus, middle trapezius).
3. Scapular protraction (serratus anterior).
4. Scapular depression (latissimus dorsi. trapezius. serratus anterior).
5. Shoulder shrugs (trapezius, levator scapulae).

PHASE 3: MONTHS 3-12

Criteria for Progression to Phase 3:

• Full painless ROM.
• Satisfactory physical examination.

Goals:

• Improve shoulder strength, power, and endurance.
• Improve neuromuscular control and shoulder proprioception.
• Prepare for gradual return to functional activities.
• Home maintenance exercise program:
  • ROM exercises two times a day.
  • Rotator cuff strengthening three times a week.
  • Scapular stabilizer strengthening three times a week.

Motion:

• Achieve motion equal to that on the contralateral side.
• Use both active and passive ROM exercises to maintain motion.

Muscle Strengthening:

• Shoulder: Begin internal rotation and extension strengthening: First closed-chain isometric strengthening and then advance to Thera-Band and lightweight isotonic strengthening
• Scapular stabilizers: Progress to open- and closed-chain strengthening
• Deltoid strengthening: 8-12 repetitions for each exercise for three sets
• Strengthening only three times per week to avoid rotator cuff tendinitis

Functional Strengthening: Plyometric exercises

Maximum improvement is achieved by 12 to 18 months.

Warning Signs

• Loss of motion
• Continued pain

Treatment of Complications

• These patients may need to move back to earlier routines
• May require increased use of pain control modalities as outlined above

References & More

1. Bullock GS, Garrigues GE, Ledbetter L, Kennedy J. A Systematic Review of Proposed Rehabilitation Guidelines Following Anatomic and Reverse Shoulder Arthroplasty. J Orthop Sports Phys Ther. 2019 May;49(5):337-346. doi: 10.2519/jospt.2019.8616. Epub 2019 Apr 25. PMID: 31021690.
2. Langohr GDG, Haverstock JP, Johnson JA, Athwal GS. Comparing daily shoulder motion and frequency after anatomic and reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2018 Feb;27(2):325-332. doi: 10.1016/j.jse.2017.09.023. Epub 2017 Nov 10. PMID: 29133073.
3. Brown DD, Friedman RJ. Postoperative rehabilitation following total shoulder arthroplasty. Orthop Clin North Am. 1998 Jul;29(3):535-47. doi: 10.1016/s0030-5898(05)70027-4. PMID: 9706298.