Companion to the Shoulder Arthroplasty Protocol Sheet (perioperative pathway) and the patient shoulder replacement guides. Terminology here matches what patients are taught in those guides.
Shared Principles
- Accelerated active motion: PT begins within ~1 week; sling for comfort and weaned as pain allows (not strict immobilization) — most patients are out of it by ~4 weeks, sooner indoors.
- Progression is criterion-based; timelines are guidelines. Early gentle active motion is used as soon as it is comfortable.
- Exception: arthroplasty for fracture or with a tuberosity repair follows a more protected, delayed-motion course.
What the Patient Arrives With
- Interscalene block at surgery — arm numb and flail-weak for the first 12–24 h. Not a nerve injury; numbness or weakness persisting beyond ~24 h should be reported.
- Waterproof antimicrobial (silver) dressing, left undisturbed 5–7 days — showering with it on is expected. Sutures/staples out at the ~2-week visit.
- Scheduled multimodal analgesia (dexamethasone 16 mg PO on POD 1; celecoxib or an OTC NSAID; acetaminophen 1,000 mg q8h); opioids rescue only. Encourage pre-medication before therapy in the early weeks.
- Aspirin 81 mg BID × 2 weeks for VTE prophylaxis (or a DOAC if elevated-risk). Walking is unrestricted from day one — legs are unaffected.
Anatomic TSA — Protect the Subscapularis
Precautions (first ~6 weeks): no resisted or active internal rotation; limit end-range passive external rotation; avoid the behind-the-back position. (Taught to patients as “no reaching behind your back and no forcing the arm outward for six weeks.”)
- Weeks 0–2: sling for comfort; pendulums; PROM/AAROM flexion and scaption; ER limited to ~30°; submaximal isometrics (avoid IR); elbow/wrist/hand AROM.
- Weeks 2–6: progress PROM/AAROM toward near-full flexion/abduction and begin active motion; advance ER to full by ~6 weeks (shorter timeline is appropriate for TSA); scapular and cuff isometrics.
- Weeks 6–12: full active ROM; begin active/resisted internal rotation and progressive rotator-cuff and periscapular strengthening; dynamic stabilization.
- Months 3–6: advanced strengthening and functional/return-to-activity work; criterion-based return (~4–6 months).
Reverse TSA — Deltoid-Dependent; Avoid the Dislocation Position
Precautions: avoid combined internal rotation + adduction + extension (taught to patients as “reaching behind your back with the elbow tucked in and the arm turned inward”); no hand-behind-back for ~12 weeks; no forced extension past neutral. ER limited to ~30–45° for ~6–8 weeks.
- Weeks 0–2: sling for comfort; begin early deltoid isometrics/activation; pendulums; PROM/AAROM flexion and scaption; ER limited; elbow/wrist/hand AROM.
- Weeks 2–6: progress PROM/AAROM flexion and abduction and begin active-assisted → active elevation; advance ER to ~45° by ~6–8 weeks; continue deltoid and scapular activation.
- Weeks 6–12: progress active ROM; deltoid and periscapular strengthening; light functional use — still avoid the hand-behind-back position until ~12 weeks.
- Months 3–6: advanced strengthening and functional work; low-demand activity favored; criterion-based return (~4–6 months).
Return to Activity (Both)
- Criterion-based: functional pain-free ROM, restored strength for the task, and no instability.
- Weeks 0–6: no meaningful load with the operative arm — patients are taught “nothing heavier than a coffee cup,” and specifically no pushing up out of a chair with that arm and no pulling doors. Light functional use at table height is fine. Progressive loading begins after ~6 weeks; long-term commonly up to ~25 lb intermittently at or below shoulder level. Heavy/overhead lifting is discouraged — especially after reverse TSA.
- Running/jumping deferred until rotator-cuff/deltoid strength and control are restored.
References
- Effectiveness of early versus delayed rehabilitation following total shoulder replacement: a systematic review. PMC8807994.
- Early vs. delayed rehabilitation after reverse total shoulder arthroplasty: randomized single-blinded trial. J Shoulder Elbow Surg, 2019–2020.
- No difference in complications between two-week vs. six-week sling immobilization after RTSA. J Shoulder Elbow Surg, 2023.
- Bullock GS, et al. A Systematic Review of Proposed Rehabilitation Guidelines Following Anatomic and Reverse Shoulder Arthroplasty. JOSPT, 2019.
- Return to Sport After Shoulder Arthroplasty: a scoping review. PMC12863409.
Anatomic and reverse tracks share an accelerated, criterion-based framework but differ in precautions and timing. Individualize to intraoperative findings, tissue quality, and surgeon direction.