Shoulder Arthroplasty (Regular and Reverse) Rehab Protocol

Accelerated active-ROM, criterion-based — therapist reference

Physical Therapy Protocols · From Dr. Allred · Transcribed from the printed sheet · 6 sections

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If you have questions about a protocol or a specific patient, call the clinic where the surgery was performed.

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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.

Questions about this sheet? Call the clinic where the surgery was performed. I'm happy to talk through the plan. Numbers are at the top of this page, and every after-hours line is on the emergency numbers page.