Postoperative Rehabilitation Protocol Total Shoulder Replacement

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Total Shoulder Replacement.  It is by no means intended to replace or substitute the clinical decision making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

*This protocol applies to Anatomic Total Shoulder Replacement only.  If Reverse Total Shoulder Replacement has been performed please refer to that specific protocol as there are different guidelines. 

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

*A word about “pain” and management of anticipated discomfort following Total Shoulder Replacement…

Adequate management of pain is essential to progressing the patient’s mobility, strength, range of motion, and independence.  However, pain is a subjective measure and should be expected for weeks to months after surgery.  A divergence between the subjective complaints and objective findings observed by an experienced therapist should arouse concern and potential need for further consultation/evaluation.  

 

Phase I- Early Post-Operative Phase (Post-op Day 0-14)

The goal of physical therapy intervention during the early post-operative phase is to achieve progressive improvement in PROM (Passive Range of Motion) to prevent capsular adhesions and fibrosis.  Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential.  

Goals: 

  1. PROM only: Max ROM: 90 degrees flexion, 0 ER, 45 degrees ABDuction 
  2. Full AROM/PROM elbow/wrist/hand
  3. Proper posture, joint protection/positioning, don/doff sling appropriately
  4. Improve scapular mobility
  5. Implement use of nonpharmacologic modalities to control pain and swelling such as circulating cryotherapy pumps, manual massage, elevation of the extremity, etc

Assessment by Therapist:

  1. Assess surgical wounds for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess pre-treatment and post-treatment PROM
  5. Assess for signs of hematoma, intra-articular effusion, DVT/PE (pulmonary embolism), Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Grip strengthening
  2. Codman's (Pendulum) Exercises
  3. Core and Low Back Exercises
  4. Scapular elevation/depression, retraction

Precautions:

  1. USE OF SLING!!!!  Necessary (except when bathing) until 4-6 weeks post-op to reduce potential strain on the repair.  
  2. Avoid all AROM
  3. Avoid lifting >1lbs and using extremity to "push up" out of seated position 
  4. Avoid extension beyond 0 degrees to prevent anterior capsular stretching 

*Patient may progress to Phase II after Phase I goals completed and minimum of 2 weeks post-op

Phase II (Post-op Week 2-6)

Goals:

  1. ROM limits: 130 degrees flexion, Scapular plane ER(0 degrees until 4 weeks, 30 degrees until 6 weeks), 0 degrees extension, 90 degrees ABDuction
  2. May begin AAROM at 2 weeks post-op if supervised by PT (pulley, wand, supine assisted ROM exercises) and pain sufficiently controlled 
  3. Encourage home exercises to be performed 3X/day 
  4. Decrease swelling/inflammation (Ice, TENS unit, Dry Needling, Cupping, etc)

Assessment by Therapist:

  1. Assess frequency of narcotic and non-narcotic analgesic use 
  2. Assess pre-treatment and post-treatment ROM 


Therapeutic Exercises:

Week 2-4

  1. Continue Phase I Therapeutic exercises 
  2. Incorporate Neck ROM exercises as necessary
  3. Advance Posterior capsule mobilizations, avoid stretch of anterior capsule until after phase II
  4. May begin sub-maximal isometrics in neutral position only 
  5. Progress resisted hand/wrist/elbow as appropriate 

Week 4-6

  1. Initiate scapulothoracic and glenohumeral joint mobilizations 
  2. Initiate scapulothoracic and glenohumeral rhythmic stabilizations 
  3. Begin AROM flexion, IR (unresisted), ER to 30 (elbow by side, unresisted), ABDuction 90 
  4. Begin isotonics against gravity as appropriate
  5. Cane (stick, PVC, etc.) AAROM Progressions FF (supine-->reclined-->standing) 

Precautions:

  1. Sling should be used until 4 weeks post-op unless patient is bathing, performing exercises at home, or under direct supervision by physical therapist.  Patient may remove the sling at home for brief periods while the arm is supported in slight abduction (approximately 30 degrees), such as sitting on the couch or in a recliner, and when able to demonstrate to therapist ability to perform strict PROM movements
  2. No Lifting > 1 lb or "pushing up" from seated position 

*Patient may progress to Phase III after 6 weeks, achieving PROM 0-130 degrees flexion, pain is considerably decreased, and the patient has undergone second post-op visit with xrays 

 

Phase III (Post-op Week 6-12)

Goals:

  1. End of Phase III goals: FF 140+ degrees, ABDuction 120+ degrees, ER 60 degrees
  2. Discontinuation of sling and analgesics 
  3. Continue PROM/AAROM and progress to AROM if minimal or no scapular compensation
  4. Establish baseline humeral head control 
  5. Initiation of ADLs and proprioception exercises below shoulder level
  6. No pain at rest

Therapeutic Exercises:

  1. Continue Phase I and Phase II exercises
  2. Begin resistive/strengthening exercises for scapular stabilizers 
  3. Continue wall walks/slides, pulley exercises 
  4. May begin to progress IR behind back stretch PROM-->AAROM-->AROM as tolerated after 6 weeks 
  5. Begin theraband and light weight strengthening exercises flexion and scapular plane ABDuction, IR, ER 

Precautions:

  1. May advance ER beyond 30 degrees ONLY after 6 weeks
  2. No excessive pushing, pulling, loading
  3. No rapid movements (excessive/forceful muscle contractions) 
  4. Avoid movements resulting in anterior capsule stretch if increased pain and if soft tissue healing is not complete 

Phase IV (Post-op Week 12-16)

Goals:

  1. Complete ADLs without assistance, enhance functional use of extremity
  2. Continue to improve ROM gradually 
  3. Continue Phase I, II and III exercises
  4. Progressive strengthening and complete functional activities/heavier ADLs below shoulder height
    1. Progress endurance before strength (ie. higher reps before adding resistance)

Therapeutic Exercises:

  1. Continue scapular protraction/retraction/elevation/depression
    1. OK for manual resistance scapular motions
  2. Latissimus eccentrics
  3. Continue GH stabilization/mobilization exercises
  4. OK for cycling/running

Precautions:

  1. Avoid combined movements stressing anterior capsule (ABDuction + ER) if pain 
  2. OK to progress resisted IR strengthening 
  3. No overhead loading if any pain
  4. Avoid long lever exercises with weight

Phase V (Post-op Week 16+)

Goals:

  1. Maintain PROM/AROM goals 
  2. Gradual return to moderately challenging functional activities

Therapeutic Exercises:

  1. Progressive strengthening exercises all planes
  2. Incorporate work related exercises based on demand 

Precautions: 

  1. Do not advance strengthening exercises if patient experiencing painful response.  Goal is maximize endurance of movements before increasing loads
  2. No return to sporting activities or work until cleared.  Most patients require 4-6 months before most recreational activities such as pickleball, gardening, golf, etc