Total Shoulder Arthroplasty Guideline

Department of Rehabilitation Services

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Total Shoulder Arthroplasty

The intent of this resource is to provide clinicians with a general guideline of the

post-operative rehabilitation of patients undergoing a total shoulder arthroplasty

(TSA). This guideline is not intended to mandate the course of patient care. If

there are concerns regarding the patient’s clinical presentation, please consult

and collaborate with your colleagues and the referring physician as needed.

Progression through this guideline as well as overall expected goals are ultimately

determined by the pathology that led to the need of the TSA ranging from

osteoarthritis, rheumatoid arthritis, humeral fracture, etc. A review of the

patient’s past medical history and operative notes to determine the technique

that was used to complete the TSA (i.e. lesser tuberosity osteotomy, subscapularis

peel, or subscapularis tenodesis). Knowing your patient’s prior level of function

will also be helpful in establishing appropriate goals for the patient. A full course

of post-operative physical therapy for this patient population is between 4-6

months depending on the specific surgical interventions. Total recovery time

could be 12-18 months. While many may not regain full range of motion, most are

expected to achieve functional mobility. Outcome will depend on the patient’s

past medical history, pathology necessitating the TSA, and individual functional

goals. Virtual visits are appropriate for treatment sessions for this patient

population while completing assessments in person.

Background Information

In order to best use this guideline as part of your clinical decision-making process,

it is important to understand the various surgical techniques including what

anatomical structures are involved. This information as well as a familiarity with

current literature will help clinicians provide the best possible care for successful

rehabilitation. Typically, a TSA is performed through the deltopectoral interval,

and the surgeons visualize and access the glenohumeral joint through either a

lesser tuberosity osteotomy, subscapularis peel, or subscapularis tenodesis.

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Total Shoulder Arthroplasty Guideline

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Knowing which approach was performed is vital to a patient’s prognosis as

subscapularis dysfunction is associated with pain, weakness, and/or anterior

instability and ultimately failure. While studies have shown no significant

biomechanical difference between these techniques,

1

others have shown that

load-to-failure force of the repair is stronger with a lesser tuberosity osteotomy.

2

This may be due to bone-to-bone healing in the lesser tuberosity osteotomy

requiring less healing time which allows for acceleration of exercise progressions.

This process is theoretically slower for tendon-to-bone healing at the lesser

tuberosity involved in a subscapularis peel or tendon-to-tendon healing in a

subscapularis tenodesis.

Complication rates are low following TSA but range from anterosuperior

instability due to poor subscapularis function, posteroinferior instability, superior

rotator cuff tears, broken screws, and implant loosening.

3

,

4

If a subscapularis

repair is involved, studies have shown a failure rate between 13 and 47%.

5

According to Singh et al., the implant survivorship rate at 20 years is 81%.

6

Certain

factors that may affect patient success include medical history such as slowed

healing times due to diabetes and osteoporosis as well as lifestyle choices

including smoking.

Regardless of the technique of surgery performed, understanding the importance

of subscapularis healing in the rehabilitation process is important to a patient’s

success. However, there is no consensus in the literature on what that means for

the timing of progressions. In the first stage of post-operative care, it is important

to minimize subscapularis muscle activation and stress to allow for proper

healing. Therefore, exercise should be passive and limited in planes of motion. A

2016 study by Denard and Lätterman concluded that there were minimal negative

outcomes after delaying range of motion (ROM) to at least four weeks post-

operatively to allow for subscapularis healing while there is a risk of failure from a

lack of full tissue healing with immediate ROM.

7

Furthermore, studies have shown

no difference in long-term shoulder function between immediate and delayed

ROM.

8

A 2014 study suggested that prolonged immobilization is important for

older patients or for those who had larger cuff tears.

9

EMG studies have shown

minimal general muscle activation with small-diameter pendulums if performed

correctly,

10

as well as with passive flexion with table slides,

11

a cane, and manual

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Total Shoulder Arthroplasty Guideline

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PROM.

12

,

13

Other EMG studies demonstrated that pulley exercises are not passive

and therefore place healing tissue under increased stress.

14

,

15

Muraki et al. found

the greatest strain on the subscapularis in external rotation especially in

abduction.

16

Furthermore, it is vital to teach patients how to properly don and

doff a sling as studies have shown high subscapularis activity in these

movements.

17

Patients should also limit other independent movements during

activities of daily living (ADLs) to allow for subscapularis healing including avoiding

tucking in the back of a shirt, reaching into a back pocket, and reaching to

contralateral axilla as with bathing.

18

Patients can advance to the next rehabilitation stage if their pain is minimal and if

their motor control is optimal. Studies show that scapulothoracic motion

contributes significantly to shoulder motion following TSA, so periscapular

strengthening is important to promote scapular control while minimizing stress in

the glenohumeral joint.

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Deltoid, rotator cuff, and periscapular muscle

strengthening can begin once maximal functional ROM has been achieved and

based on the stages of tissue healing.

Later stages of post-operative rehabilitation are focused on strengthening and

regaining function. Gaunt et al.

demonstrated that maximum muscle activation of

the supraspinatus, infraspinatus, and anterior deltoid occurs with upright active

flexion,

20

and Cahill et al. highlighted that at 90 degrees of elevation, the force

through the glenohumeral joint is about ten times the weight of the upper

extremity.

21

Furthermore, much of the research done for rotator cuff repairs

suggests that loaded exercises should not be started earlier than 12 weeks to

allow for sufficient bone-to-tendon healing and integration.

22

When a patient is

pain-free, has good motor control, and has met other necessary requirements, it

is important to gradually introduce active and strengthening exercises.

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Total Shoulder Arthroplasty Guideline

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These time frames are just examples and can be adjusted based on the given procedure

Progression to the next phase based on achieving both Clinical Criteria as well as Time Frames. Variance from

this needs to be reviewed with surgeon. Suggestions for home exercise program (HEP) provided.

Phase I – Immediate Post-Surgical Phase (Day 1)

Goals

- Understanding how to don/doff sling

- Understanding activity restrictions for proper soft tissue healing

- Reduce pain and inflammation

Precautions

- Sleeping (6-8 weeks): wear sling with a small pillow or towel roll under entire upper arm

to avoid shoulder hyperextension and resulting strain on subscapularis as well as anterior

capsule

- Keep incision clean and dry (no soaking for 2 weeks)

Things to avoid

- Active range of motion (AROM)

- Weight-bearing through involved extremity (i.e. pushing up from seated position, rolling

over in bed, etc.)

Criteria for

progression to

the next phase

- Understands importance of sling use and adhering to instructions

- Avoids active movements to ensure proper soft tissue healing

- Independent in donning and doffing sling

Interventions:

Sling, immobilization strap, and/or abduction pillow

use

• Type per surgeon preference based on

surgical intervention

• Worn for 4-6 weeks depending on surgical

procedure and underlying pathology

necessitating TSA

• Can be removed for showering and to

complete rehabilitation home exercises

Elbow/Forearm AROM

• With upper arm at patient’s side

• Elbow flexion and extension focusing on full

ROM

• Forearm pronation and supination

• HEP: to be completed multiple times a day

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Wrist AROM

• With arm in sling or supported on table

• Wrist flexion, extension, ulnar deviation, and

radial deviation

• Wrist circles

• HEP: to be completed 3-5x a day

Hand/Finger AROM

• With arm in sling or supported on table

• Finger flexion and extension at every joint

• Gentle gripping activities

• HEP: to be completed 3-5x a day

Cryotherapy

• To control pain

• HEP: can be complete multiple times a day

15-20 minutes

Phase II – Protection Phase (Day 2 - Week 6)

Goals

- Allow for soft tissue healing

- Protect subscapularis tenodesis or lesser tuberosity osteotomy

- Reduce muscular guarding

- Become independent with ADLs, bed mobility, and transfers with modifications as needed

while wearing the sling

- Restore active range of motion elbow, wrist, and hand

Precautions

- Continued use of sling including when sleeping except when showering and with PT and

home exercises

- Light, pain-free ADLs only with modifications as needed (i.e. brushing teeth, dressing,

etc.)

- Keep incision clean and dry (no soaking for 2 weeks)

- Shoulder external rotation (ER) PROM limited to at most 20° to prevent passive tension

on repaired subscapularis tendon especially in abduction

- Shoulder internal rotation (IR) AROM and resisted exercises limited to prevent tension in

repaired subscapularis tendon

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Things to avoid

- Shoulder AROM (At 90° of elevation, the force through the glenohumeral joint is about

ten times the weight of the extremity; therefore, do not start active elevation too early to

allow for proper soft tissue healing)

- Stress on anterior shoulder

- Excessive shoulder motion behind the back especially into IR

- Excessive stretching or sudden movements especially into ER

- Painful ADLs

- Lifting activities (including drinking if subscapularis involved in surgery)

- Driving while in sling for 4-6 weeks

- Weight-bearing through involved extremity (i.e. pushing up from seated position, rolling

over in bed, etc.)

Criteria for

progression to

the next phase

- Minimal pain

- Flexion PROM at least 120°

- ER PROM 15-20°

NOTE: If the patient has not reached the above ROM, forceful stretching, PROM, and/or mobilization/manipulation

are not indicated. Continue with gradual ROM and mobilizations (Gr II for pain control and Gr III-IV for ROM and

capsular restrictions) while respecting soft tissue constraints.

Interventions (1 PT treatment session every 1-2 weeks including virtual visits):

PROM – Flexion and scaption

• In pain-free ROM

• Without placing undue stress on the soft

tissue structures or surgical repair

• Avoid stretching

PROM – ER

• To be started in weeks 4-6

• Through pain-free ROM

• To neutral at first to counter prolonged sling

use or to 20 degrees depending on surgical

approach

Scapulothoracic mobilizations

• With upper extremity supported in scapular

plane and neutral rotation

Glenohumeral Joint mobilizations

• Grade I-II for pain control

• Avoid overstraining anterior shoulder

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Total Shoulder Arthroplasty Guideline

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AAROM – Flexion

• In supine and sitting

• Through pain-free ROM

• HEP: to be completed 3-4x a day

Cervical AROM

• Through pain-free ROM

• Chin tucks in supine, sitting, and/or standing

• HEP: to be completed 2x a day

Cervical muscle stretches: upper trapezius, levator,

and scalenes

• Into pain-free range of motion

• Bilateral

• 3x30 second holds

• HEP: to be completed 2x a day

Scapular retractions

• With arm in sling and sitting in good posture

• Performed gently and through comfortable

ROM without straining anterior shoulder

structures

• HEP: to be completed 3-4x a day

Pendulums

• For muscle relaxation

• Discourage large movement to avoid

activation of rotator cuff muscles

• HEP: to be completed 3-4x a day

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Total Shoulder Arthroplasty Guideline

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Continue Elbow/Forearm and Hand/Wrist/Finger

AROM from previous stage

• HEP: to be completed 2x a day

Continue Cryotherapy

Phase III – Intermediate Phase (Weeks 6-10)

Goals

- Maximize ROM while allowing continued healing especially of the subscapularis or lesser

tuberosity osteotomy

- Optimize neuromuscular control

- Improve scapular strength

- Gradually weaning off sling excluding in uncontrolled environments (i.e. in crowds,

around dogs, etc.) for protection

- Be able to perform light ADLs independently and without pain

- Demonstrate the ability to isometrically activate all components of the deltoid as well as

scapular musculature

Precautions

- Repetitive active motions

Things to avoid

- Painful or more strenuous ADLs

- ADLs involving reaching into extension and IR causing stress to anterior shoulder

structures (i.e. reaching into back pocket, tucking in back of shirt, etc.)

- Lifting anything heavier than a cup of coffee

- Weight bearing through involved arm

Criteria for

progression to

the next phase

- Tolerates advanced PROM program

- Tolerates isometric program for muscle activation

- Flexion AROM 90° in standing with normal scapulohumeral mechanics

- Flexion PROM at least 140°

- ER PROM 30°

Interventions (1 PT treatment session every 1-2 weeks including virtual visits):

PROM – Flexion, scaption, ER, and abduction

• ER to be completed in neutral or scapular

plane

• Avoid increasing abduction as greatest strain

on subscapularis is with ER at 90 degrees

abduction

• In pain-free ROM

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Total Shoulder Arthroplasty Guideline

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Continue Scapulothoracic mobilizations from

previous stage

Continue Glenohumeral Joint mobilizations from

previous stage

• Grade III-IV for ROM and capsular

restrictions

AAROM – Flexion, scaption, ER, and abduction

• In pain-free range of motion

• Start with cane, table slides, etc.; then added

pulleys

• HEP: to be complete 3-4x a day for short hold

(times 2-3 seconds)

AROM – Flexion and scaption

• In pain-free ROM

• Focus on proper scapulohumeral rhythm and

body mechanics

• HEP: to be completed 2-3x a day for short

hold times (2-3 seconds)

Postural Exercises – Supine Serratus Anterior

Protraction

• Focus on eccentric scapular control on return

to start

• HEP: to be completed 2-4x a day

Isometrics – Deltoids

• Flexion and extension

• Submaximal pressure

• Pain-free

• 5 second holds

• HEP: to be completed 2-4x a day

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Total Shoulder Arthroplasty Guideline

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Isometrics – ER and IR

• To be completed initially starting at doorway

• Submaximal pressure

• Pain-free

• 5 second holds

• Progress to stepping against resistance band

at or after week 8

• HEP: to be completed 2x a day

Distal upper extremity strengthening

• Wrist flexion, extension, ulnar and radial

deviations, as well as forearm supination and

pronation

• Start with 1-3# hand weights

• HEP: to be completed 1x a day

Phase IV – Advanced Strengthening Phase (Week 10-16)

Goals

- Gradual increase in AROM

- Gradual return to functional activities

- Improve muscle strength and endurance

Precautions

- Repetitive shoulder exercises especially AROM in standing against gravity in the presence of poor

shoulder mechanics

Things to avoid

- Heavy lifting greater than 10#

- Sudden, jerking motions

- Heavy pushing or pulling motions

Criteria for

progression to

the next phase

- Functional/full ROM

- Flexion AROM at least 140° in supine and at least 120° in standing with good scapulohumeral

rhythm

- Flexion PROM 160°

- ER PROM 60°

- NOTE: if patient is limited in flexion ROM, use Levy Lawn Chair Progression Protocol

Interventions (1 PT treatment session a week):

AROM – all planes of motion

• Pain-free

• Focus on body mechanics

• HEP: to be completed 2-3x a day for

short holds times (2-3 seconds)

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Total Shoulder Arthroplasty Guideline

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Manual Rhythmic Stabilizations

• Patient in supine or standing (i.e. ball on

table, wall, etc.)

• Flexion

• IR/ER in 0° of elevation

• Submaximal and pain-free

Postural Strengthening

• Focus on body mechanics

• Rows with resistance bands

• Extensions with resistance bands

• HEP: to be completed 1-2x a day

Weight Bearing Exercises

• To be started at or after week 12

• Weight shifting, table/wall ball rolls, etc.

and gradually progress to quadruped

• To improve scapular stability

• HEP: to be completed 1-2x a day

Stretching – Posterior Capsule Stretch

• In pain-free ROM

• 3x30 second holds

• HEP: to be completed 2-3x a day

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Total Shoulder Arthroplasty Guideline

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Progressive Resistive Exercises

• Biceps curls

• Triceps extensions

• Bent-over rows

• IR and ER in neutral with resistance

bands or in sidelying

• Progress to bilateral GH ER at or after

week 12

• HEP: to be completed 1-2x a day

AAROM – Extension and behind the back cross

body adduction

• To be started at or after week 12

• In pain-free range of motion

• Focus on upright posture to avoid stress

on anterior shoulder structures

• HEP: to be complete 1-3x a day for short

hold (times 2-3 seconds)

Stretching – Shoulder IR Behind-the-Back with

Pulleys

• In pain-free ROM

• Focus on upright posture to avoid stress

on anterior shoulder structures

• 3x30 second holds

• HEP: to be completed 1-2x a day

Note: Add to program of those who have

achieved good shoulder extension and behind the

back cross adduction only; those with a limited

goal approach may not need to progress to this

exercise

Phase V – Return to Activity Phase (Weeks 16-24)

Goals

- Restore pain-free functional ROM

- Restore functional strength

- Progress weight bearing exercises as appropriate

Precautions

- Repetitive overhead lifting (communicate with surgeon for specifics)

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Things to avoid

- Activities and exercises that stress the anterior capsule and subscapularis (i.e. combined

abduction and ER exercises, throwing motions, goal post pectoralis stretching, etc.)

Interventions:

Continue exercises and stretches from previous

stage

• Progress resistance band interventions

as appropriate

• Progress to weights as appropriate

Proprioceptive Neuromuscular Facilitation

patterns

• In pain-free ROM

• With resistance bands and/or weights

Sports/Work-specific training

• As needed

• Focusing on proper mechanics including

scapulohumeral rhythm

Criteria for discharge from skilled therapy:

• Independence and compliance with home exercise program to be continued 2-3x a week for continued

improvement in muscle strength and endurance

• Able to maintain pain-free AROM in multiple planes of motion

• Normal scapulohumeral rhythm with upper extremity elevation

• Maximized functional use of affect upper extremity

• Restored functional strength of upper extremity

• Returned to advanced functional activities

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FREQUENTLY ASKED QUESTIONS

1) How long should a patient wear a sling?

• A patient can start to wean from the sling between 6 and 10 weeks depending on past

medical history, intraoperative intervention performed, and surgeon recommendations

2) What are the positional precautions after a total shoulder arthroplasty if a subscapularis repair is

performed?

• External rotation especially in an abducted position

• Hyperextension as with sleeping without a sling or towel roll for support, particularly in the

early post-operative phases

3) What are the initial active movement precautions following a total shoulder arthroplasty if a subscapularis

repair is performed?

• Active internal rotation with ADLs such as tucking in shirt

• Weight-bearing activities such as with sit-to-stands and bed moblity

• Driving

• Lifting ADLs

• Any movements that put stress on anterior shoulder structures

4) How long are these precautions necessary?

• Depending on the surgery performed, 10-12 weeks depending on past medical history,

intraoperative intervention performed, and surgeon recommendations

5) When is it appropriate to begin AA/AROM?

• Approximately 6 weeks post-operative based on past medical history, intraoperative findings,

surgical intervention performed, and surgeon recommendations

6) Why are these limitations so important for these patients?

• Most of the precautions in these rehabilitation guidelines, especially in stage II, are to protect

the subscapularis tenodesis or less tuberosity osteotomy to allow for increased soft tissue

healing. Failure of the subscapularis repair can lead to increased pain, weakness, anterior

shoulder instability, early glenoid loosening, and reduced patient-reported outcomes.

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Total Shoulder Arthroplasty Guideline

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REHABILITATION PHASE SUMMARY CHART

Phase

Precautions

Goals

Interventions

Immediate Post-

Surgical

(Day 1)

- Sling use as

instructed

- No AROM or

weight bearing (WB)

- Understand activity

restriction and sling use

- Decreased pain and

inflammation

- Elbow, forearm, wrist, hand, finger

AROM

- Cryotherapy

Protection

(Day 2 - Week 6)

- Sling use

- Light, pain-free

ADLs only

- No AROM

especially IR, ER

PROM >20°

- No WB

- No lifting

- No driving

- Protect subscapularis

- Tissue healing

- Restore active elbow,

wrist, and hand movement

- Decrease muscle guarding

- Independence in light

ADLs

- 120° flexion PROM

- 15-20° ER PROM

- Minimal pain

- Flexion and ER PROM

- Scapulothoracic mobilizations

- Glenohumeral joint mobilizations

(Gr I-II for pain control)

- Cervical AROM and stretches

- Scapular retractions

- Pendulums

Intermediate

(Weeks 6-10)

- No painful or

strenuous ADLs

- No lifting more

than coffee mug

- No WB

- No reaching into

extension and IR

- No repetitive

active motions

- Protect subscapularis

- Scapular strengthening

- Optimize neuromuscular

control

- Weaning from sling

- Tolerate isometric muscle

activation

- 90° flexion AROM in

standing

- >140° flexion PROM

- 30° ER PROM

- Flexion, scaption, ER, and

abduction PROM

- Scapulothoracic mobilizations

- Glenohumeral joint mobilizations

(Gr III-IV for joint mobility)

- Flexion, ER, abduction, and

scaption AAROM

- Deltoid, IR, and ER isometrics

- Serratus anterior protraction

- Distal upper extremity

strengthening

Advanced

Strengthening

(Weeks 10-16)

- No repetitive

activities especially

against gravity

- No lifting >10#

- No heavy

pushing/pulling

- No sudden jerking

motions

- Protect subscapularis

- Increase AROM

- Return to functional

activities

- Increase strength

- 140° flexion AROM

- 160° flexion PROM

- 60° ER PROM

- AROM all planes

- Rhythmic stabilizations

- Postural strengthening

- WB exercises

- Stretching (behind the back and

across the chest)

- Progressive Resistive Exerises

Return to Activity

(Weeks 16-24)

- Repetitive

overhead lifting

- Stress on

subscapuaris

(throwing, etc.)

- Protect subscapularis

- Restore pain-free

functional ROM and

strength

- Progress to WB exercises

- Continue with strengthening

program

- Proprioceptive Neuromuscular

Facilitation

- Work/Sports-specific training

Is a BWH clinical competency associated with the document: Yes

Author Reviewers

Rachel Laufer, PT August 2022 Reg B. Wilcox III, PT August 2022

Stephanie Boudreau, PT August 2022

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Total Shoulder Arthroplasty Guideline

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