Total Shoulder Arthroplasty

Anatomy and Biomechanics

The shoulder is a complex structure that joins the arm to the body. It is comprised of three bones,
including the humerus (upper arm bone), scapula (shoulder blade), and clavicle (collarbone). The main
shoulder joint is a ball-and-socket joint where the ball-shaped head of the humerus attaches to a socket
on the scapula called the glenoid. The glenoid is much smaller than the head of the humerus. This
construct allows the shoulder to have a larger range of motion (ROM) than any other joint in the body.
Both the head of the humerus and glenoid are coated with smooth cartilage, which allow the bones to
glide easily on one another. This cartilage may naturally
wear down over time creating a rough surface between
the bones. Without smooth healthy cartilage the
shoulder also has a hard time producing the natural joint
“oil” (synovial fluid) that lubricates the shoulder during
movement. Collectively, these degenerative processes
that happen over time lead to the condition known as
osteoarthritis. This process can happen naturally
overtime, but can be more severe or develop quicker in
some people, especially after trauma.

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As degenerative changes in the shoulder

advance the joint becomes more and more painful and less and less
mobile. Osteoarthritis typically produces stiffness in the joint, especially
right after a period of immobility (i.e. first thing in the morning). The pain
in the joint may subside after moving around, but become worse again
with use of your arm. The pain in the joint may also affect sleeping. As the
condition of the joint deteriorates some people develop a sensation of
grinding or catching in the joint. It will become harder and harder to use
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your arm and eventually the shoulder may lose some of its range of motion.

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 Treatment Options
Regardless of the nature and severity of the osteoarthritis in your shoulder your physician will work with
you to determine what the best course of treatment will be. When degenerative changes are not severe
the associated pain and dysfunction may successfully be treated with rest, anti-inflammatory measures,
activity modification and physical therapy. After a thorough evaluation your physician and their staff
will recommend the most appropriate course of action to take.

Physical therapy is often recommended for treatment of pain and dysfunction associated with
osteoarthritis. The physical therapist will evaluate your mobility, flexibility and strength with the
purpose of determining any underlying deficits that contribute to increased stress on the painful joint.
You will be counseled on which activities you can safely continue and which should be avoided. The
physical therapist will teach you exercises that will help to reduce joint stress. In most cases this will
include strengthening and stretching the muscles around the entire shoulder complex as well as the
upper back.

When joint degeneration is severe and conservative measures are unsuccessful in restoring function
your physician may recommend a total shoulder replacement procedure.

Surgery
Total Shoulder Arthroplasty (Replacement) is a complex procedure
that involves the removal and replacement of both the ball and the
socket. First an incision is made, most commonly along the side or in
front of the arm, and the joint is exposed. The head of the humerus
(ball) is removed and the glenoid cavity (socket) is cleaned out. A
polyethylene plastic insert is placed in the glenoid and secured with
cement to form the new socket. Next the humeral stem is fit into
position. Depending on the fit of the stem and your surgeon’s
preference, cement may or may not be used to secure the stem.
Lastly a carefully fit metal ball is secured to the end of the humeral
stem and the shoulder is rejoined. http://drgordongroh.com/shoulder.html 1

Total Shoulder Arthroplasty is not an outpatient day surgery procedure. You will be required to spend a
few days in the hospital to recover. If the procedure and your early recovery goes well you will typically
be discharged in 2-3 days. Some more complex cases require a short stay in a rehab hospital following
the procedure.

Post-Operative Precautions
The new prosthetic joint is not as stable as a natural shoulder joint, and it needs to be protected while
the surrounding soft tissue structures heal after surgery. You must wear a sling per your doctor’s
instructions after your operation to allow for this healing to occur. This may be as long as 3-4 weeks.
Also, there are specific range of motion precautions you must follow after surgery:

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 While lying on your back, a small pillow or towel roll should be placed behind your elbow to
avoid stretching the repaired muscles and ligaments, i.e. you should always be able to see your
elbow in front of your body when lying on your back.
Do NOT place your operated arm behind your back or behind your head.
NO active ROM forward
You must observe these precautions for at least 6-8 weeks after your operation unless otherwise
instructed by your surgeon.

At Home
You will likely receive home care visits from a registered nurse and a physical therapist after being
discharged home. The nurse will help monitor your medical status and the physical therapist will help
you work to restore mobility, strength and tolerance for activity. You should replace your post-op
dressing 2-3 days after surgery, and have the nurse and physical therapist inspect your incision for signs
of infection. If you have staples closing your incision they will likely be scheduled to be removed around
10-14 days after the operation. Your home care physical therapist will work with your surgeon and their
staff to determine when you are ready to attend outpatient physical therapy.

Showering
You may shower after 3 days, as long as the incision is not draining. If the incision is draining try to keep
it from getting wet during showering by using a water-tight dressing.

Medication
Your surgeon will prescribe pain medicine for you after the operation. Please call the doctor’s office if
you have any questions regarding medication.

Driving
Your surgeon will tell you when you are ready to return to driving. Commonly, you are not permitted to
drive until your sling is off, which may take 3-4 weeks. You cannot drive while taking narcotics.

Ice
You should use ice or the cryotherapy machine on your shoulder after the operation for management of
pain and swelling. Ice should be applied 3-5 times a day for 10-20 minutes at a time. Always maintain
one layer between ice and the skin. Putting a pillow case over your ice pack works well for this. The
home care physical therapist can help you customize a plan on how and when to best apply ice to your
shoulder.

Post Operative Visits

Your first post-operative visit will be 10-14 days after the operation. At this visit you will meet with the
surgeon or the physician assistant who will look at your shoulder range of motion, examine your
incision, and discuss when it will be appropriate to make an appointment to begin outpatient physical
therapy. Your next visit will be around 6 weeks after the operation. At this visit you may have an X-ray

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 taken to make sure that the shoulder replacement components are aligned well. Additional follow up
visits to the doctor’s office will be based on your surgeon’s discretion.

Recovery/Time off Work

Recovering from Total Shoulder Arthroplasty surgery is not easy. It is very important to realize that the
recovery process is difficult and time consuming. You must be an active participant during this process,
performing daily exercises to ensure there is proper return of range of motion and strength. There is a
large amount of variability in the time it takes to fully recover from this procedure. It is usually
estimated that it will take at least 4-6 months for the patient to feel as though he or she has completely
returned to a pre-injury level of activity. Some cases may take as long as 9-12 months to make a full
recovery. People with desk jobs should plan to take at least 4 weeks off from work and should have an
extended absence plan in place should complications arise. People with more physical jobs that require
excessive weight bearing and manual labor will likely be out of work for at least 3-6 months. Recovery is
different in each case. Your individual time table for return to activities and work will be discussed by
your surgeon during post operative office visits.

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 Rehabilitation
This protocol has been adapted from Wilcox, Arslanian, and Millet’s protocol described in Rehabilitation Following Total
Shoulder Replacement, which was published in the Journal of Orthopedic and Sports Physical Therapy, December 2005; 35: 821-
836.
**The following is an outlined progression for rehab. Time tables are approximate and advancement
from phase to phase, as well as specific exercises performed, should be based on each individual
patient’s case and sound clinical judgment by the rehab professional. **
Phase 1: Immediate Post Op Phase (Surgery to Hospital Discharge)

Goals
Protect and allow healing of soft tissue
Control pain and swelling
Independence with activities of daily living (ADLs), ie. Dressing, toileting etc.
Independence with mobility
Independence with home exercise program

Precautions
Post-operative precautions (see page 1)
Limited shoulder AROM (May perform forward reaching with ADL’s in sagital plane)
NO lifting or weight-bearing with operated arm
NO reaching behind the back or behind the head

Recommended Exercises
AROM: hand, wrist, forearm, and elbow
PROM: shoulder flexion 0 to 140* as tolerated
IR to chest, ER to 30*
Pendulums
Scapular mobilizations (elevation/depression, retraction/protraction)

Guidelines
Perform PROM exercises 2-3x/day. Perform 10-15 repetitions of all elbow/wrist/hand exercises
and scapular mobilization 3-5 times a day. Use ice after PROM for 10-20 minutes.

Inpatient Plan of Care

Screen for sensory/motor deficits
Continuous Cryotherapy
Provide patient education for movement precautions and positioning to avoid shoulder
extension past 0* (to prevent subscapularis stretch)
Initiate exercise regimen
Discharge planning
Must teach caregiver PROM for supine forward flexion to be done at home

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 Phase 1(A): Passive ROM (PROM) phase (Hospital Discharge- Week 4)

Goals
Protect and allow healing of soft tissue
Control pain and swelling
Begin to restore range of motion (ROM)
Restore independent functional mobility
Educate the patient regarding their post-operative precautions

Precautions
Post-operative precautions (see page 2-3)
Limited shoulder AROM (May perform forward reaching with ADL’s in sagital plane)
NO lifting or weight-bearing with operated arm
Screen for sensory/motor deficits

Recommended Exercises
Range of Motion
Supine PROM: forward flexion, gentle ER to 30 degrees in scapular plane, IR to chest
o Surgeon may have specific ROM guidelines based on inter-operative findings
AROM: elbow, wrist, hand
Pendulum exercises
Progress to Active Assisted ROM (AAROM) shoulder flexion, ER, and IR in the scapular plane
by the end of this phase.
No Repetitive AROM exercises for Shoulder
Strength
Periscapular muscle AROM/isometric exercises
Functional Mobility
Bed mobility
Transfer training
Positioning (when in bed)
While supine, always place a small pillow or towel roll behind the operated arm’s elbow to
avoid shoulder hyperextension, stretching the anterior capsule, or stretching the
subscapularis.
Wean sling towards the end of this phase or per MD recommendation
o Encourage out of sling in sitting, Wear sling in public or when active around house

Guidelines
Perform PROM exercises 2-3x/day. Perform 10 repetitions of all elbow/wrist/hand exercises and
periscapular isometrics 3-5 times a day. Use ice after PROM for 10-20 minutes.

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 Criteria for Progression to Phase 2:
Good tolerance of PROM program with:
PROM flexion at least 90◦
PROM abduction at least 90◦
PROM ER in the plane of the scapula at least 30◦
PROM IR in the plane of the scapula at 30◦ of abduction at least 70◦

Phase 2: Active ROM (4 Weeks- 6 Weeks)

Goals
Restore full PROM
Begin restoring AROM
Control pain and swelling
Continue to protect healing tissue

Precautions
Post-operative precautions
NO heavy lifting or weight-bearing with operated arm
NO sudden jerking movements in operated shoulder
If poor shoulder mechanics are present, avoid repetitive shoulder AROM

Recommended Exercises
Range of Motion
Continue with PROM exercises and slowly progress to normal range
o Do not force passive ER
Initiate AROM: flexion, elevation in the scapular plane, IR, and ER
Joint Mobilizations
Gentle glenohumeral and scapulothoracic joint mobilizations as indicated
Strengthening
Initiate sub-maximal shoulder isometrics in neutral
Periscapular strengthening exercises as tolerated
May initiate gentle glenohumeral and scapulothoracic rhythmic stabilization

Guidelines
Perform 10-20 repetitions of all ROM exercises 2x/day. Perform 10-20 repetitions of isometric shoulder
exercises 1x/day, and 2-3 sets of 15-20 repetitions of periscapular strengthening exercises 1x/day.

Criteria for Progression to Phase 3:

Good tolerance of PROM/AROM, isometric program
PROM flexion at least 140◦, PROM abduction at least 120◦
PROM ER in plane of scapula at least 45◦,
PROM IR in plane of scapula measured at 30◦ of abduction at least 70◦

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 Phase 3: Strengthening (6-12 Weeks)

Goals
Restore normal AROM
Restore normal strength
Optimize neuromuscular control in the shoulder complex
Return to baseline functional activities

Precautions
Continue to avoid stress on the anterior capsule
NO heavy lifting (>5 pounds), pushing, or pulling
NO sudden jerking movements in operated shoulder

Recommended Exercises
Range of Motion and Stretching
Continue PROM as needed, progressing to gentle stretching
o Do not force passive ER
May initiate shoulder AAROM IR behind the back
Progress AROM shoulder flexion, scpation, ER, IR as needed
o Ensure correct scapulohumeral rythm
Joint Mobilizations
Glenohumeral and scapulothoracic joint mobilizations as indicated
Strengthening *Delay resisted strengthening until phase 4 if concomitant rotator cuff repair (supra,
infra, teres)
Resisted shoulder ER in the scapular plane
Delay resisted IR until 12 wks (unless otherwise indicated by MD)
Initiate supine shoulder elevation strengthening at progressive inclines
Progress to resisted flexion, abduction, and extension towards the end of this phase
Continue periscapular strengthening progression

Guidelines
Perform 10-20 repetitions of all ROM exercises daily. Hold all stretches 20-30 seconds for 2-3
repetitions, 2-3x/day. Perform 2-3 sets of 15-20 repetitions of all strengthening exercises 4-6x/week.

Criteria for Progression to Phase 4:

Tolerates AA/AROM/ strengthening
AROM flexion supine at least 140◦
AROM abduction supine at least 120◦
AROM ER in plane of scapula at least 60◦
AROM IR in plane of scapula supine in 30◦ of abduction at least 70◦
Active shoulder elevation against gravity with good mechanics to at least 120◦

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 Phase 4: Advanced Phase (12 Weeks and Beyond)

Goals
Maintain pain-free ROM
Maximize strength, power, and endurance
Maximize UE function
Progress weight-bearing tolerance
Work with PT and MD to create customized routine to allow return to appropriate sports/
recreational activities (i.e. golf, doubles tennis, cycling, gardening)

Precautions
Continue to avoid stressing the anterior capsule
Ensure gradual progression of strengthening program

Recommended Exercises
ROM and Flexibility
Continue AROM stretching exercises as indicated
Strengthening
Continue with all strengthening exercises increasing resistance and decreasing repetitions
Initiate and progress weight-bearing exercises

Functional Progression
Activity/sport-specific training exercises
Guidelines
Perform ROM and flexibility exercises daily.
Perform strengthening exercises 3-5x/ week, performing 2-3 sets of 10-15 repetitions.

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 Time Precautions Goals Recommended Exercises
Phase Dislocation Protect and allow ROM
1/1(A): precautions healing of soft Supine PROM: forward flexion, gentle ER in
Day 1 – 4 Limited FF AROM tissue scapular plane, IR to chest
Weeks NO lifting or Control pain and AROM: elbow, wrist, and hand
weightbearing swelling Pendulum exercises
with operated Begin to restore Progress to AAROM shoulder flexion, ER, and IR in
arm ROM the scapular plane by the end of this phase
Screen for Restore STRENGTH
sensory/motor independent Periscapular muscle isometrics
deficits functional FUNCTIONAL MOBILITY
PROM:FF to 140, mobility Bed mobility
IR to chest, ER to Educate the Transfer training
30 in scap plane patient regarding POSITIONING (when in bed)
their dislocation While supine, always place a small pillow or towel
precautions roll behind the operated arm’s elbow to avoid
shoulder hyperextension, stretching the anterior
capsule, or stretching the subscapularis
Wean sling towards the end of this phase
Phase 2: Dislocation Restore functional ROM
4 Weeks – precautions PROM Continue with PROM exercises until normal (no
6 Weeks NO heavy lifting Gradually restore forced Passive ER)
or weightbearing AROM Initiate AROM: flexion, elevation in the scapular
with operated Control pain and plane, IR, and ER
arm swelling Joint Mobilizations
No sudden Continue to Gentle glenohumeral and scapulothoracic joint
jerking protect healing mobilizations
movement in tissue Strengthening
operated Initiate sub-maximal shoulder isometrics in neutral
shoulder Periscapular strengthening exercises as tolerated
If poor shoulder Initiate glenohumeral and scapulothoracic
mechanics are rhythmic stabilization
present, avoid
repetitive
shoulder AROM
Phase 3: Continue to Restore normal ROM
6 Weeks – avoid stress on shoulder AROM Continue PROM as needed, progressing to gentle
12 Weeks the anterior Optimize stretching
capsule neuromuscular Initiate shoulder AAROM IR behind back,
NO heavy lifting control in the progressing to active stretching by the end of this
(>5 pounds), shoulder complex phase
pushing, or Return to baseline Progress AROM shoulder flexion, scaption, ER,
pulling UE functional and IR as needed
NO sudden activities Joint Mobilizations
jerking Glenohumeral and scapulothoracic joint
movements in mobilizations as indicated
operated Strengthening
shoulder Resisted shoulder ER and IR in scapular plane
Initiate supine shoulder elevation strengthening at
progressive inclines
Continue periscapular strengthening progression

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 Progress to resisted flexion, abduction, and
extension towards the end of this phase
Phase 4: Continue to Maintain pain- ROM
12 weeks avoid stressing free ROM Continue daily PROM and stretching exercises as
and Beyond the anterior Maximize indicated
capsule strength, power, Strengthening
Ensure gradual and endurance Continue with all strengthening exercises
progression of Maximize UE increasing resistance and decreasing repetitions
strengthening function Initiate and gradually progress weightbearing
program Progress exercises
weightbearing Functional Progressions
tolerance Activity/sport-specific training exercises
Work with PT and
MD to create
customized
routine to allow
return to
appropriate
sports/
recreational
activities (i.e. golf,
doubles tennis,
cycling, gardening

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