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1 Rehabilitation Following Total and Reverse Shoulder Arthroplasty, PT, DPT, SCS, CSCS No Financial Disclosures Total Shoulder Arthroplasty Arthritic shoulder increasing in prevalence More active as we age Degenerative wear and tear Instability and traumatic injuries at earlier age Overall rise in total shoulder arthroplasty Surgical techniques and prostheses have advanced MikeReinold.com 1

2 Total Shoulder Arthroplasty Overall good results in reducing pain and restoring some function Dependent on underlying pathology Many factors reduce outcome potential Bone and soft tissue status Prior level of function Keys to TSA Rehabilitation Understand the surgical procedure Not just boney in nature Know the expected outcome of the specific patient Dependent on preoperative status and extent of pathology Protect the subscapularis Early controlled ROM Gradually strengthen Subscapularis Critical to successful outcome Deficiency correlated to shoulder instability and poor outcomes Edwards: JBJS 02; Gerber: JBJS 05; Edwards: JSES 09; Terrier et al: Clin Bio 13 Use of sling Limit ER PROM during early phases Avoid active IR motions such as behind back MikeReinold.com 2

3 Immediate ROM Comparison of immediate ROM and delaying 4 weeks Denard: JSES 16 Immediate ROM provides: Earlier restoration of ROM Early increase in functional scores Ultimately no difference in functional scores at 3m and ROM at 1 year Immediate ROM Lesser tuberosity osteotomy healing 82% of immediate ROM 96% of delayed ROM Limitation Started AAROM immediately Rope & pulley Stick AAROM McCann: CORR 93; Dockery: Ortho 98 RTC: 18 25% MVIC Deltoid: 21 43% MVIC MikeReinold.com 3

4 McCann: CORR 93; Dockery: Ortho 98 RTC: 5 9% MVIC Deltoid: 3 11% MVIC Rehabilitation Protocol Typical orthopedic and sports medicine approach Restore full strength and mobility Return to function as soon as possible Total shoulder approach Accept a loss of mobility and potential function Primary objective is protecting the surgery and reducing pain Timelines are minimums, not set in stone Several factors impact progression Rehabilitation Protocol 4 Phases of Rehabilitation Phase 1 Passive ROM Phase Phase 2 Active ROM Phase Phase 3 Baseline Strengthening Phase Phase 4 Advanced Strengthening Phase MikeReinold.com 4

5 Passive ROM Phase Usually 4-6 weeks in duration Goals Protect the repair and allow soft tissue healing Gradually progress PROM Precautions Avoid shoulder extension, behind the back Caution with ER and subscapularis Avoid AROM Passive ROM Phase Range of motion Sling for 3-4 weeks Pendulums to neuromodulate pain Passive ROM only Forward flexion and IR to tolerance ER in scapular plane Limit to 0-30 week 1-2 Progress to 45 weeks 4 Avoid excessive ER ROM Elbow/wrist/hand Strength Week 2 Begin isometrics for scapula Passive ROM Phase Criteria to progress No sooner than 4-6 weeks At least 90 flexion, At least 45 ER in scapular plane MikeReinold.com 5

6 Active ROM Phase Usually 2 weeks in duration Goals Restore full PROM Begin AROM Precautions Sling for sleeping only Avoid hyperextension of shoulder Active ROM Phase Range of motion May begin AROM Gradual improvement in IR Don t push too aggressively Grade I-II joint mobilizations as needed Caution with anterior mobilizations MikeReinold.com 6

7 Active ROM Phase Strength May begin shoulder isometrics Baseline rhythmic stabilization drills Begin scapular isotonic exercises Enhance Scapular Function Toledo et al: Biomech 12 Enhance Scapular Function MikeReinold.com 7

8 Enhance Scapular Function Active ROM Phase Criteria to progress No sooner than 6-8 weeks At least 140 flexion, At least 60 ER in scapular plane Able to actively elevate arm to shoulder height against gravity without shrug MikeReinold.com 8

9 Baseline Strengthening Phase May begin as early as week 6-8 Goals Restore strength and neuromuscular control Gradually return to functional activities Precautions No heavy lifting Gradual application of loads MikeReinold.com 9

10 Baseline Strengthening Phase Range of motion Continue to maximize P/AROM Progress joint mobilizations as needed Baseline Strengthening Phase Strength May begin shoulder isotonics General focus on low weight and high repetition sets Watch fatigue and shrug sign Enhance scapular function MikeReinold.com 10

11 Baseline Strengthening Phase Criteria to progress No sooner than 12 weeks At least 140 flexion, At least 60 ER in scapular plane Able to actively elevate arm to shoulder height against gravity without shrug Advanced Strengthening Phase May begin as early as week 12 Goals Maintain ROM Continue to gradually improve strength Enhance functional use of arm Independent home program Advanced Strengthening Phase Home exercise program 3-4 x per week Must continue throughout first year Maintain ROM Gradually progress strength Return to full activities at 4-6 months Low stress recreational sports MikeReinold.com 11

12 Reverse Total Shoulder Arthroplasty Reverse TSA Patients that are not candidates for TSA due to RTC deficiency Can not oppose superior humeral head migration Reverse the ball and socket design Reverse TSA Shifting center of rotation medially and inferiorly Increase deltoid moment arm compensates for RTC MikeReinold.com 12

13 Reverse TSA Higher risk of dislocation than TSA Anteroinferiorly RTSA most stable in 30 of ER Brace often used Initial immobilization period of 3-6 weeks Avoid IR and H.Add in early rehab Behind back activities avoided for 12 weeks Reverse TSA Focus on enhancing deltoid role in dynamic stability, maximizing ER strength Goal of 120 flexion and 30 ER. AROM of considered functional RTSA Postoperative Rehabilitation PROM similar to TSA No IR ROM for 6 weeks Begin in 60 abduction position Avoid cross body motions Deltoid and scapular isometrics week 1 AROM starts week 6 Isotonic week 8 ER/IR isometrics week 8 MikeReinold.com 13

14 Enhance Deltoid Function MikeReinold.com 14

15 Enhance Scapular Function Toledo et al: Biomech 12 Return to Activities and Sports Systematic review and meta-analysis Liu et al: Knee Surg Sports Trauma 17 85% return to previous activities: 93% of TSA 75% of rtsa Greater results in less demanding sports Golf, swimming, fitness, tennis Younger patient may be too active and have worse outcomes Military, mean age 46 (range 35-54) 46% complication and 23% reoperation rate due to component failure Kusnezov et al: Am J Ortho 16 MikeReinold.com 15

16 Must Understand the Surgery and Involved Tissue Protect the Repair and Subscapularis Early PROM with Caution MikeReinold.com 16

17 Gradually Restore ROM, Strength, and Function Thank You! MikeReinold.com 17