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(v) Rehabilitation for shoulder arthroplasty

Article October 2015
DOI: 10.1016/j.mporth.2015.09.003

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MINI-SYMPOSIUM: SHOULDER

(v) Rehabilitation for

shoulder arthroplasty

Introduction
Shoulder arthroplasty is well established for patients with
advanced glenohumeral joint arthrosis who continue with
persistent pain and loss of function, despite conservative treatment. However shoulder replacement will fail without adequate
rehabilitation.1 The purpose of this paper is to provide a best
practice rehabilitation guideline for surgical trainees to optimize
functional outcomes, and meet the expectations of patients
following elective shoulder arthroplasty.

Carol Payne
Anju Jaggi
Andre Le Leu
Raffaele Garofalo
Marco Conti

Functional shoulder biomechanics

The function of the shoulder is subservient to that of the upper
limb, which is to grasp and manipulate objects, play a role in
communication, provide a major sensory input, support the body
weight, act as a weapon and a means of transmitting force.2 The
bones, joints, ligaments, muscles and tendons of the shoulder
and shoulder girdle function in a precise, co-ordinated and timely
manner to accommodate the demands of the upper limb. Interrelationships between joints are critical in providing a full,
functional range of movement whilst the soft tissue components
maintain joint relationships, withstand forces applied to joint
surfaces and stabilize the unsupported limb. An extensive range
of shoulder movement is essential if the hands are to have access
to all areas of the body and surrounding space during reaching
and overhead activities. The position of the scapula ensures the
shoulder muscles are working in their stronger, middle range
when the hands are performing intricate, gross and skilled
functions in the visual work space. Feeding is an important
function of the upper limb, and internal rotation of the shoulder
facilitates this activity to ensure that getting the hand to the
mouth requires minimal muscle activity. As there is a limited
need to have the hands behind the body, other than for a small
number of toileting and dressing activities, it appears to be of
little consequence that these movements utilize the end of joint
and muscle range. The integrity of this arrangement may be
compromised by the effects of ageing, adapted use over time, and
a less physically active lifestyle.2,3

Abstract
Shoulder arthroplasty is well established for the treatment of glenohumeral arthrosis, and patients may expect a significant improvement
in function and pain relief following surgery. Although there have
been advancements in the prosthetics and surgical techniques there
is a lack of evidence on the effectiveness of postoperative rehabilitation, which is key to the improvement of functional outcomes in a
growing elderly population. Current guidance is based on biomechanical factors and clinical consensus. This paper highlights the challenges
that ageing has on soft tissue healing and shoulder function, and the
importance of involving the patient early on in the decision making process. It discusses a common approach to the early implementation of
exercise-based rehabilitation programme for the anatomic replacement
with restoration of normal functional biomechanics, and for the reverse
shoulder arthroplasty where there is loss of normal functional anatomy.
The programme is initially aimed at protecting healing soft tissues, and
ensuring joint stability. It highlights the importance of a team approach
to rehabilitation that recognizes the need for effective communication
at all stages to guide safe and effective rehabilitation progression.
This paper details specific exercises that may be tailored to meet the
needs of the individual to optimize functional recovery and promote
self-responsibility.

Keywords arthroplasty; rehabilitation; rotator cuff; shoulder; therapeutic

exercise

Effect of ageing on shoulder function and disability

Age-related changes in structure of soft tissues i.e. degradation of
the matrix including embedded mechanoreceptors, and changes
in vascularization affect its capacity for synthesis and repair.4e6
In addition to bony changes and cartilage loss, capsuloligamentous fibrosis and muscle stiffness may be seen as restriction of active shoulder flexion, abduction, and external
rotation. Generalized muscle atrophy or fat infiltration associated
with degenerative rotator cuff pathology may present as a loss of
muscle strength and endurance. Imbalance in normal lengthtension relationships and humeral head migration with loss of
translational glide will further compromise the ability of the
muscles to initiate or sustain shoulder movements. Age-related
changes in the speed of nerve conduction affects the systems
ability to sense, process and respond to mechanical stimuli and
this results in loss of proprioception and sensorimotor control,
and poorer motor performance.6 Changes in mechanotransduction may be associated with the aetiology of age-related
disease e.g. arthrosis and tendinosis, and lead to pain of a mechanical or inflammatory nature.

Carol Payne DipPhys MSc MPhil Clinical Physiotherapy Specialist,

Physiotherapy Department, Level 2, East Out-patients, Norfolk and
Norwich University Hospital, Norwich, Norfolk, UK. Conflict of interest:
none.
Anju Jaggi BSc (Hons) Physiotherapy Consultant Physiotherapist, Royal
National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, UK.
Conflict of interest: none.
Andre Le Leu BSc BPhyty Clinical Specialist Physiotherapist, Sammy
Margo Physiotherapy, London, UK. Conflict of interest: none.
Raffaele Garofalo MD Chief of Upper Limb Unit Surgery, Department of
Orthopedic, F Miulli Hospital, Acquaviva delle Fonti-Ba, Italy. Conflict of
interest: none.
Marco Conti MD PhD Sport Medicine Specialist, Shoulder Surgery and
Rehabilitation, Human Physiology Research Doctor, Shoulder
Consultant of Humanitas Hospital e Rehab Unit, Milano, Italy. Conflict
of interest: none.

ORTHOPAEDICS AND TRAUMA --:-

2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

Pain, shoulder stiffness and weakness may affect an individuals ability to perform daily activities, including eating,
dressing and personal hygiene, work and recreation.7e10 The rate
of consultations in primary care for patients seeking treatment
for shoulder pain and disability is estimated at 2.36% in the
general population, and this rate rises with age to 3.9% in those
aged 80 years or over.11,12 This suggests that shoulder pain is a
significant cause of disability, particularly in the elderly.
Referral rates for specialist opinion
GP referral rates for specialist opinion are estimated as between
10 and 41% during the first year following presentation, and
28% at end of the third year of follow up.11,13 This suggests that
not only is shoulder pain a significant cause of morbidity, but
that not all shoulder problems resolve satisfactorily with conservative management. So, having explored alternative treatments e.g. lifestyle adaptations, medication, injections and
physical therapy modalities, the next step may be to consider
shoulder replacement surgery.

Decision making in shoulder arthroplasty

Figure 1 Concentric glenohumeral arthrosis in a 57 years old woman: the
acromion humeral distance is still conserved indicating a functioning
rotator cuff.

The purpose of shoulder replacement surgery is to use an

approach/technique that does not further compromise the
anatomy, to achieve solid fixation of durable implants, and to
restore normal patient-specific functional biomechanics. A
large number of different types of shoulder implants are
available i.e. resurfacing or replacement prostheses, with or
without a stem, all of which can be humeral or glenohumeral;
however there are just three important considerations: i) the
bone stock (quality); ii) glenoid morphology; and iii) the
integrity of the rotator cuff, that should be taken into account at
the surgical planning stage.
This section will discuss the rationale underpinning the use of
an anatomic total shoulder arthroplasty (TSA) for concentric
glenohumeral joint (GHJ) arthrosis, including the argument for
using a hemi-arthroplasty with glenoid involvement, and the
importance of balancing the soft tissues to restore normal functional biomechanics. It will then detail the rationale for the use of
the reverse shoulder arthroplasty (rTSA) for rotator cuff
arthropathy with superior migration of the humeral head and
loss of normal functional anatomy. The authors will highlight
common postoperative complications, biomechanical considerations for the development of a therapeutic exercise programme,
and identify issues that may indicate the need for caution for
rehabilitation progression.

The articular surface of the humeral head approximates to one

third of a sphere. Despite becoming slightly ellipsoid at the periphery, there is fairly constant 70e80% ratio of humeral head
radius to humeral head height. The size and position of the humeral head should be adequately restored; the superior aspect of
the head should sit 5 to 10 mm above the summit of greater
tuberosity to avoid overstuffing. Reported values of head shaft
angle average 130 . Any alteration in neck-shaft alignment at
surgery may shift the centre of rotation and change the length of
the rotator cuff. Similarly deltoid dysfunction may lead to
shoulder impingement; therefore it is important to restore both
the correct arc of rotation and match the prosthesis with the line
of the humeral head.
The centre of rotation of the humeral head normally lies
posterior-medially to the axis of the humeral shaft, with the
distance between the articular surface and centre of the canal
being termed humeral offset. The humeral head is also retroverted, with reported values of the angle between its centre and
the epicondylar axis ranging from 17.9e21.4 . More than any
other parameter, retroversion may be affected by age, sex, or
ethnicity and the value can vary between sides in the same individual.15 Surgeons should therefore account for natural variation by considering the 10 e15 carrying angle and visualizing
the insertion of the rotator cuff before performing humeral
osteotomy.
Longer stemmed implants i.e. extending beyond the curvature
of the humeral shaft assumed either a varus or valgus position
that in turn dictated the height of the humeral head. Shorter
stemmed implants were therefore developed as the consequence
of the migration of the centre of rotation superiorly was converting subscapularis and infraspinatus from abductors to adductors, thus increasing the load on the supraspinatus on flexion
and abduction. Figure 2 demonstrates how a third generation

Humeral anatomy and humeral implant

The indications for use of an unconstrained TSA are concentric
GHJ arthrosis in the absence of a biconcave or dysplastic glenoid
(Figure 1). The goal of surgery is to re-create a normal patientspecific humeral anatomy. Important parameters to consider
are the ratio of humeral head radius to humeral head height,
head shaft angle, humeral offset, humeral head retroversion, and
curvature of the humeral shaft.14 However it is only with the
development of the third generation of modular TSAs has it been
possible to reproduce the anatomy and 3-D geometry of the
proximal humerus with the potential to restore normal deltoid
and rotator cuff function.

ORTHOPAEDICS AND TRAUMA --:-

2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

provides predictable pain relief and functional improvement.16

However evidence suggests that glenoid erosion may be a predictor of poorer outcome, and loosening of the glenoid implant
remains a problem at mid and long term of follow-up.
Bony and soft tissue balancing
Bony balancing: the concept of bony balancing assumes the
modular components of the prosthesis are appropriately selected
and correctly implanted to restore the humeral anatomy to the
native dimensions. This in turn assumes the soft tissue restraints
and muscle forces are appropriately balanced.
Soft tissue balancing: the balance i.e. restoration of normal
length-tension relationships between the capsuloligamentous
structures and rotator cuff muscles following surgery is integral
to successful rehabilitation.
Subscapularis repair: the subscapularis tendon is detached
during the surgical approach to allow anterior dislocation of the
humeral head. Whilst evidence suggests the integrity of the
surgical repair i.e. load to failure, may depend on the surgical
technique used, studies have found little difference in repair
strength between osteotomy and tenotomy.17 Figure 3a and b
shows (a) subscapularis tendon detachment with small bone
chips from the greater tuberosity with Fiur suture (Nice loop)
passed in a trans-osseous manner, and (b) completed transosseous suture repair of the subscapularis tendon. The repair
should be protected during the early phase of rehabilitation as a
subscapularis deficiency has been implicated in poor long-term
results.17

Figure 2 A third generation total shoulder arthroplasty with restoration of

normal anatomy and centre of rotation.

TSA with more anatomic head sizes, variable offset, and

adjustable stems to account for variation in neck-shaft angle, has
been used to restore normal patient-specific anatomy and centre
of rotation.
Total shoulder replacement versus hemi-arthroplasty
The decision to perform a TSA or hemi-arthroplasty in concentric
GHJ arthrosis is related to glenoid involvement. A TSA should be
considered where there is good glenoid bone stock and soft tissue
support, as technical issues have improved to optimize restoration of normal glenoid biomechanics, and glenoid replacement

Rotator cuff repair: it is possible to repair a small full-thickness

tear of supraspinatus when performing a TSA; this also has implications for postoperative rehabilitation.

Figure 3 (a) Subscapularis tendon detachment with small bone chips from the greater tuberosity, with Fiur suture (Nice loop) passed in a trans-osseous
manner. (b) Completed trans-osseous suture repair of the subscapularis tendon.

ORTHOPAEDICS AND TRAUMA --:-

2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

Biomechanical rationale of reverse total shoulder replacement: Grammont designed the reverse prosthesis with a humeral
component in extreme valgus (155 ) to tension the deltoid and,
by lengthening the lever arm, compress the humeral socket and
glenosphere to stabilize the articulation. The design, with the
glenosphere directly centered on the surface of the glenoid, also
moved the centre of rotation of the shoulder joint medially to

enhance the torque produced by deltoid thereby allowing for a

more efficient deltoid moment arm (Figure 5).
Despite clinical improvements resulting from the use of
Grammont prosthesis medialization of the centre of humeral
rotation as close as possible to the glenoid bone surface to reduce
glenoid base-plate loosening, led to persistent pain and shoulder
impingement with resultant erosion of the scapula termed
notching.
Lateralization of glenosphere offset, or the use of a humeral
stem with a more anatomic neck-shaft angle are therefore
important considerations. More recent designs offer a lateralized glenosphere with a centre of rotation as much as 10 mm
lateral and 4 mm inferior to the surface of the glenoid, and a
more anatomic humeral neck-shaft angle (135 or 145 )
(Figure 6). Such implants reduce the limitation of adduction and
scapular notching, and improve impingement free active range
of movement. Lateralization also reduces the excessive medialization of the humerus with glenoid bone loss that can convert
deltoid into a distracting force and increases the risk of
dislocation.
Common complications of rTSA include instability or dislocation, and in the longer term implant failure. The rate is
dependent on overall component stability at the time of surgical
reconstruction, and the integrity of the remaining rotator cuff or
potential to repair or reconstruct soft tissues. An intact subscapularis may provide a restraint to the shoulder joint, however
if the subscapularis is irreparable the risk of instability or dislocation is increased. Also lateralization of the humerus closer to
its anatomic position has also been associated with improved
deltoid wrapping, and more anatomic muscle tensioning of the
internal and external rotators if present. Tendon repair of the
internal and external rotators should be protected during the
early phase of rehabilitation.

Figure 4 Eccentric glenohumeral arthrosis in a 75 year old woman: the

humeral head has migrated superiorly secondary to chronic rotator cuff
insufficiency.

Figure 5 Grammont type reverse total shoulder arthroplasty with a 155

valgus humeral component, and medialized centre of rotation.

Capsular release: during surgery, soft tissue restraints should

be evaluated to ensure that release has been adequate: subscapularis should allow at least 40 of external rotation; the
humeral head should translate 50% of the width of the glenoid
with a posteriorly directed force; and there should be 60 of
internal rotation with the arm abducted. If there is excessive
posterior translation, the humeral head size can be increased or
an eccentric head used, or posterior plication sutures could be
placed in the capsule.
Reverse shoulder arthroplasty
The indications for the rTSA are pain and poor shoulder elevation secondary to chronic rotator cuff insufficiency and with GHJ
arthrosis. With a massive irreparable rotator cuff tear the shear
forces generated by the deltoid are unopposed, and this results in
superior migration of the humeral head (Figure 4). The purpose
of the reverse ball-and-socket articulation is to provide a stable
glenohumeral fulcrum. By blocking superior migration of the
humerus during elevation of the arm the superiorly directed
translational forces of the deltoid are converted into a rotational
moment (torque). The resultant improvement in active forward
elevation may be in excess of 105 .18 Whilst modern generations
of rTSA vary in specific design they still adhere to Paul Grammonts core principles as demonstrated by the original modular
Delta III prosthesis.

ORTHOPAEDICS AND TRAUMA --:-

2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

history will determine level of help needed to maintain independent living e.g. personal care, household chores, shopping
etc., usual transport arrangements e.g. driving or travelling by
bus etc., current work status, and ability to take part in usual
sports and hobbies, i) to identify the patients short term needs
following surgery, and ii) to better understand what getting
back to normal may mean for the patient. Noting the impact of
shoulder on the patients role as a partner, carer or parent etc.
will help identify any provision needed for dependents in the
short term, and the importance of restoring usual family relationships, and social interactions. Screening tools may be used
to assess the impact of a long-term condition or emotional wellbeing to identify negative coping strategies, anxiety and depression, or kinesiophobia that may be associated with a poorer
outcome from treatment.3
Multidisciplinary communication
It is also very important to communicate with all members of the
multidisciplinary team (MDT), including Physiotherapists and
Occupational therapists, at the pre-operative planning stage to
share information to understand the patients priorities and expectations from surgery. This will in turn enable realistic treatment goals to be set. The patient should be provided with written
information developed with the involvement of a patient forum,
to ensure the individual is aware of what to expect at the time of
surgery, and to help them manage their postoperative recovery
e.g. how to support the weight of the dependent limb when
bathing and dressing, and eating etc. to avoid excessive loading
of healing tissues and exacerbation of symptoms. It will also help
guide them through the rehabilitation process to enable them to
be self-responsible e.g. to manage any conflict between the need
for relative rest and desire to resume driving etc., or when
planning a return to work.

Figure 6 More recent design of reverse total shoulder arthroplasty with a

neck-shaft angle of 145 , to demonstrate increased lateralization of the
humerus when compared to the Grammont design.

Patients with an intact teres minor may regain an average of 15

of active external rotation, however evidence suggest those with a
deficient teres minor who have no active external rotation are less
satisfied with overall function.18 Latissimus dorsi transfer to increase active external rotation merits particular attention following
rTSA, and this has implications for postoperative rehabilitation.
Conclusion
After total shoulder arthroplasty a significant improvement in
function and pain relief can be expected. The correct implant
should be chosen by the surgeon taking in account the grade and
type of shoulder arthrosis, the type of glenoid and integrity of the
rotator cuff and deltoid. Postoperative rehabilitation should take
into account the management of the implant and of soft tissues,
particularly the subscapularis after anatomic shoulder prosthesis
and the posterior rotator cuff in case of rTSA.

Patient reported outcome measures

Patient reported outcome measures (PROMs) also use a biopsychosocial approach to quantify the patients perception of
their current health related quality of life, and level of shoulder
function and disability, with respect to activity limitations and
participation restrictions. Use of a core set of relevant self-rated
questionnaires e.g. the EuroQol EQ-5D-5L instrument that provides a single index value for health status (www.euroqol.org/),
and the Disabilities of the Arm, Shoulder and Hand (DASH)
outcome measure that provides a summary score (0e100%) of
upper limb pain and function (http://dash.iwh.on.ca/), will
therefore assist in evaluating the effectiveness of shoulder
arthroplasty on physical, and psychosocial well-being, from the
patients perspective. Interval scores may be shared with patients
to assist with shared decisions on planning a return to usual
activities, or discharge from care.

Importance of effective communication

The General Medical Councils good practice guideline (www.
gmc-uk.org/) states that doctors should work in partnership
with patients, and work with colleagues in ways that best serve
patients interests. It is therefore important to take a comprehensive clinical history, with the use of screening tools as
appropriate to assess the impact of a shoulder problem on the
patient as a whole.

Rehabilitation and therapeutic exercise

Clinical history
Taking into account hand dominance, the impact of shoulder
pain, stiffness and weakness should be noted e.g. by observing
the patient undressing in the clinic, to identify any problems of
immobilization in a sling on independent living. Use of walking
aids should be noted to assess the likely impact of onehandedness on balance and mobility. Recording relevant social

ORTHOPAEDICS AND TRAUMA --:-

Rehabilitation facilitates the process of recovery to as normal a

condition as possible.19 It integrates evidence-based clinical
reasoning and the patients perspective, and through the provision of a tailored therapeutic exercise programme facilitates
postoperative recovery to achieve a health outcome that meets
the patients expectations. The principles of rehabilitation are

2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

how to rehabilitate the patient after replacement surgery.21 As

discussed, the majority of joint replacements are performed in an
ageing population so a holistic approach should consider general
health, cognitive deficits, psychological well-being, and social
stability.22
Rehabilitation for TSA is divided into 3 phases i.e. early,
middle and late, summarized in Table 1. Progression is guided by
the healing process, biomechanics and patient ability, however
the effect of loading, exercise and function at various time points
on the overall outcome of arthroplasty is poorly understood.21
For the purpose of this paper rehabilitation guidance is based
on experience and clinical consensus.

similar irrespective of the type of shoulder arthroplasty used; to

promote soft tissue healing, assist with pain control, restore
shoulder mobility, muscle strength and strength endurance,
optimize functional recovery, and facilitate self-responsibility
through movement and therapeutic exercise, together with the
use of manual therapy techniques, electrophysical modalities,
and education and advice.19 An early referral for postoperative
management should be made to include relevant clinical information, the primary pathology, details of the surgical approach,
intra-operative findings, the type of implant, and any limitations
e.g. that will impact on postoperative recovery/rehabilitation.
Key components of exercise-based rehabilitation
Before a tailored therapeutic exercise programme can be implemented it is necessary to perform a training needs analysis. This
is to assess the patients current level of upper limb function
against the functional requirements of their usual daily activities,
work and sports using physical performance tests.19,20 A dynamometer may be used to measure the force produced by individual muscles or muscle groups at all angles of the range of
motion, during different contractile activities i.e. isometric,
concentric, or eccentric, or to quantify the fatguability of a
muscle(s). However it is also possible to use an easily repeatable
functional task to test different aspects of physical performance
i.e.
i) ability to perform a task under load, initially using the arm
as a short lever before adding external weight, as a measure
of strength;
ii) time to task failure when using the arm either in a sustained manner or repetitively, as a measure of muscle
endurance/fatigue; and
iii) speed and accuracy of performing a more complex task, as
a measure sensorimotor control to test normal timing of
muscle activation along the kinetic chain, and quality of
movement patterns.
A note should also be made of pain provoked, and strategies
used and time taken for muscle recovery to guide rehabilitation
progression.
This information may be used to identify i) the goals of
therapeutic exercise, ii) the type of training needed i.e. resistance, endurance, or sensorimotor control, ii) the exercise prescription including the volume, intensity, and progression of
individual exercises that together comprise a rehabilitation programme, iii) the means by which the exercises will be carried out
e.g. assisted by a family member, use of free weights, attendance
at a pool, or exercise class etc. and iv) the functional test that will
be used to measure progress and adjust the exercise prescription
to ensure the patients goals are met.
The next section will detail specific biomechanical considerations that should be used to guide safe and effective rehabilitation progression following shoulder arthroplasty, and identify
specific exercises that may comprise a tailored rehabilitation
programme.

Early phase (protective 0e6 weeks)

This phase defines the initial 6 weeks following TSA, the primary
goal being to allow for osseous integration of the replacement
and healing of the soft tissues. Clearly this will be dependent on
the status of the soft tissues and bone quality prior to intervention as well as associated co-morbidities that could affect the rate
of repair and healing.
The majority of patients will require immobilization in a sling
both for comfort and to avoid risk of dislocation or early loosening. Most surgeons will advise a period of 6 weeks immobilization in a supportive brace to allow for the anterior capsule and
subscapularis to heal. The brace can be removed for gentle exercise, bathing and dressing whilst avoiding vulnerable positions. The shoulder will be vulnerable in a position of extension,
internal rotation and adduction, and placing the arm behind the
back or allowing it to drop into extension, and these should be
avoided.22 Both rTSA and revision arthroplasty are at particular
risk of dislocation due to rotator cuff deficiency or insufficiency,
so appropriate positioning in the immediate postoperative phase
is very important. When the patient is lying, pillows should be
placed behind the arm to avoid excessive extension and when
dressing, the patient should be guided to place the affected side
into garments first.
From day one, the patient should be encouraged to mobilize
the hand, wrist, elbow, neck and shoulder girdle. Scapular
dyskinesia is a recognized phenomenon in the management of
shoulder conditions and its early management is important in the
restoration of normal shoulder mechanics.23 Disruption of the
timing and recruitment of the periscapular muscles may create
impingement and further stress the glenohumeral structures so
particular attention to the trapezius and serratus anterior force
couple is encouraged.18,21,22 Simple scapula elevation/depression/retraction should be performed. Prompts to remind the
patient of good posture can be helpful, and placing coloured
stickers around the home can be a very simple but an effective
visual prompt to remind the patient especially when immobilized
in the brace.
The surgeon should identify the safe zone i.e. where the
patient can maintain range of motion without the risk of early
loosening/displacement. In those patients where the subscapularis has been repaired, external rotation (ER) should be
restricted to protect the repair. For the majority this tends to be
elevation to 90 and ER to neutral or 20e30 (Figures 7 and 8).
Early sub-maximal isometric muscle activation of the deltoid and
posterior rotator cuff should be encouraged (Figure 9), however

Rehabilitation for shoulder arthroplasty

Introduction
Although the number of shoulder replacements has increased
significantly there is a paucity of evidence based guidelines on

ORTHOPAEDICS AND TRAUMA --:-

2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

Summary of rehabilitation progression following shoulder arthroplasty

0e6 weeks
Early phase 1: Protection

Advice
Sling 6/52, can be removed for exercises
and washing/dressing with the use of collar and cuff.
C
No arm behind back for 6/52.
C
For 6/52 do not let arm fall back to rest
beyond midline of body. Use a pillow.
C
No resisted internal rotation (IR) to protect
subscapularis repair.
C
Encourage good posture.
C
Do not force into pain.
C

Exercises (should not exacerbate pain)

C
Neck movements.
C
Scapula rolls/shrugs.
C
Elbow/forearm/wrist/finger movements (if
biceps tenodesis no active flexion, extension only to 30)
C
AAROM GHJ Flexion 90 (e.g., lying, sitting).
C
AAROM GHJ external rotation (ER) to
neutral.
C
Isometric ER, extension, flexion (not IR).
C
Keep lower body active as appropriate i.e.,
walking, recumbent bike, squats.

6e12 weeks
Middle phase 2: Muscle activation

Advice
Wean from sling e starting in the home.
Could try 1 hour on/off. Build as comfort
allows.
C
Light use only at waist/chest height e i.e.
mug of water, plate, buttering bread,
brushing teeth, washing face, writing for
short periods. Pace activities.
C
Encourage good posture with an emphasis
on normal movement.
C
Do not force movement or into pain.
C

Exercises (should not exacerbate pain)

Cuff work; can start isometric SBSC,
progress dynamic control of cuff in
comfortable range with arm supported in
neutral i.e. crook or sitting. Can progress
cuff control arc, arm supported towards 90
abduction as able.
Do not load with weights too early (cuff 0.5
kg max)
C
AAROM; can progress as comfort allows.
i.e. roll ball table, forward lean reach, hand
up wall, correct scapula control during
movement.
C
Functional AROM; can progress range
naturally, as comfort allows, if has good
cuff activation and normal movement.
Consider anti-gravity with forward lean
reach.
C
Progress deltoid; work in low range with
low weights, consider eccentric programme if needed.
C

12 weeks plus
Late phase 3: Progress loading & normal
movement
Advice
Progress activities above chest height as
pain allows and without compensatory
movements.
C
Begin gradual weight bearing. May be able
to start re-using walking aid and driving as
comfort allows (see patient advice).
C
Avoid heavy lifting for 6 months.
C
Avoid contact activities: to be discussed
with consultant.
C

Exercises (should not exacerbate pain)

Cuff work; progress to unsupported if able.
Can begin with elbow supported against a
wall / progress to un-supported through
range.
C
Functional AROM; progress as able.
Monitor scapula-humeral rhythm and
address as needed. If tight consider
PPROM.
C
Progress deltoid; through range with
weights (up to 10 kg).
C
Increase power; biceps, triceps.
C
Gentle graded weight bearing exercises;
e.g. table/wall lean/push up plus.
C

N.B. TSA involves replacement of glenoid and humeral components; the procedure involves a delto-pectoral approach with the shoulder being dislocated anteriorly, and
subscapularis muscle being incised and repaired. This is a guideline only; any limitations and restrictions recorded in the patients operation note should take precedence. Consider the patients individual needs and use clinical reasoning.

Table 1

most clinicians will not advise isometrics into internal rotation in

order to protect subscapularis.18
At this early stage commonly prescribed exercises have
included pendulum (gravity minimized) or upright assisted exercises. Electromyographic (EMG) analysis has shown that significant increased activation between the two positions only
occurs in the anterior deltoid and that the changes in the activation levels of the rotator cuff are less significant indicating that
assisted elevation or supported elevation in the early stages of
rehabilitation could be safely prescribed without placing
increased stress on the rotator cuff.24 Such exercises do not
exceed 20% MVC and could safely be prescribed in the early
stages of rehabilitation however upright active exercises show a
statistically significant increase in muscular activities and

ORTHOPAEDICS AND TRAUMA --:-

therefore may be more appropriate later in a rehabilitation

programme.25
Middle phase (mobilize 6e12 weeks)
The majority of patients should begin to wean out of their brace
at the 6 week stage; this may be sooner for those patients undergoing surface replacement and unconstrained TSAs where the
rotator cuff integrity is reasonable. Dependent on bone quality, it
may be advisable to plan a check X-ray prior to mobilization
particularly in revision surgery to ensure osseous-integration of
the prosthesis.
The patient should be encouraged to use the arm for activities
of daily living in front of the body but still avoiding movements
behind the back or reaching to extremes. The patient can now be

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10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

postoperative management has been on passive stretching prior

to strengthening with an over protection to loading of the rotator
cuff. However this may lead to muscular imbalance creating
instability and impingement. To avoid a risk of gaining movement with poor stability graded active assisted exercises should
be encouraged. These can initially be performed in supported
positions either where the hand is in contact with a surface such
as sliding along table surfaces, incline boards or on a ball
(Figure 10). To gain selective recruitment of the internal and
external rotators, exercises can be performed in supine and
sitting positions where the weight of the arm and the scapula is
supported (Figures 11 and 12). An inability to gain range of
motion can be secondary to inappropriate co-contraction between agonist and antagonist muscle force couples rather than
capsular or joint stiffness.26
Exercises where the weight of the arm is supported may help
to reduce pain and muscle guarding allowing inhibition of
overactive muscles and restoring normal motor recruitment
patterns.26 External rotation should be encouraged even in
reverse polarity replacements to encourage the training of posterior deltoid and teres minor which will improve in the functional return of elevation.18 In addition the scapula-humeral
angle becomes limited due to contractions of the teres minor
and major insertions. Patients have to excessively protract the
scapula to try and gain shoulder elevation; this in turn may cause
a co-contraction problem between the rotator cuff and the
scapular stabilizers further restricting the active range of movement.27 Clinical experience tends to indicate that those patients
who fail to demonstrate a pure GHJ angle of 90 forward flexion
will not respond as well to an eccentric deltoid program. Contractures in this area may compromise the ability of the deltoid to
generate force as well as being a subtle source of persistent pain
postoperatively.
It is also recommended that early step and reach with the arm
on a supported surface can encourage balance reactions with
trunk activation helping the patient to regain confidence in
overall balance and gait (Figure 13). Studies have shown that
there is a direct correlation between shoulder pain, balance and
postural stability therefore early motor training of this function
should be sought especially in the elderly patient.28

Figure 7 Auto-assisted elevation.

Figure 8 Auto-assisted external rotation.

Figure 9 Isometric deltoid.

encouraged to assist movements beyond the safe zone, and

graded muscle activation with increasing range should be
encouraged.
The rotator cuff and deltoid are dynamic stabilizers of the
shoulder, and therefore as active movement is encouraged it is
key that recruitment of these muscles is enhanced to provide
stability with movement. Historically the emphasis of

ORTHOPAEDICS AND TRAUMA --:-

Figure 10 Supported elevation in upright position.

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MINI-SYMPOSIUM: SHOULDER

recruitment of the muscles. FES has been used widely to enhance

function in the hemiplegic shoulder29 and is now being used in
orthopaedic care. In those patients with significant deltoid
wasting FES pre- and post-surgery may help enhance function.
Persistent pain in the post-operative phase will inevitably
deliver a poor functional outcome. The clinician needs to remain
vigilant to low level infection which may be present particularly
in the early postoperative phase. A routine blood test and plain
radiograph will normally suffice as a standard screening process.
Other sources of pain can be somewhat more diffuse such as
ischaemic pain within the cuff or deltoid complex brought on by
an imbalance in the tensioning of the soft tissues, or a slightly
mismatched prosthesis. Referred pain sources can also develop
from the cervical spine due to poor tone in the scapula suspension muscles, and postural alignment. These issues can be helped
with the use of a simple shoulder support, off-load taping, and
pacing of activity levels.
The ability to detect loosening of the prosthesis without access
to imaging is a difficult skill even amongst expert clinicians. If
there is a suspicion that there has been a change in the structural
integrity of the GHJ then a plain X-ray should be ordered as a
minimum standard. Usually there are a number of features that
present to the clinician to raise the suspicion of loosening. The
most obvious change is a sudden loss in active range of movement coupled with an increase in pain, this is sometimes coupled
with a mild deformity in the contour of the shoulder. The more
subtle loosening problems tend to be associated with a slow and
gradual increase in pain particularly during rotational arcs of
movement where rotational torsion is placed on the prosthesis.
Maintaining a high-level of communication between all members
of the MDT will ensure these types of issues are identified early
on in the rehabilitation process.

Figure 11 Active rotation control in supine lying and supported scaption.

Figure 12 Active external rotation in sitting.

Late phase (functional restoration 3e6 months)

The primary aim in this phase is to increase strengthening and
restore functional independence. If the patient can demonstrate
good isometric strength and reasonable scapular humeral rhythm
into unsupported elevation then exercises challenging the
shoulder into semi-reclined or vertical positions with external
loading can be commenced (Figures 14 and 15). It is advisable to
keep weights low but encourage increased repetition. Isokinetic
exercises with the use of theraband can be used but may be
inappropriate for some patients with stemmed prosthesis and
revision surgery.18
It is at this stage functional day to day tasks can be incorporated into the rehabilitation program. Task specific activities
have been shown to be effective in cognitive motor retraining.30
So activities such as pushing up from a chair, getting up from the
floor, reaching into cupboards, light housework become good
functional exercises that the patient can do initially in the company of their therapist to gain confidence and ensure good
movement patterns are adopted.
The patient may return to driving and some moderate sporting
activities such as swimming. Heavy loaded activities and repetitive use above shoulder height should be avoided until the 6
month stage, and may need to be avoided long term to preserve
the longevity of the replacement. This advice is very much
bespoke to the patient and type of replacement and should be
discussed pre-operatively so that both clinician and patient

Figure 13 Step and reach supported elevation on a ball.

For some patients awareness of which muscles to recruit can

be challenging particularly if they have developed compensatory
strategies, and significant muscle wasting in the lead up to their
joint replacement. Biofeedback with the use of surface EMG,
mirrors and functional electrical stimulation (FES) can all be
useful adjuncts to enhance sensory input to facilitate motor

ORTHOPAEDICS AND TRAUMA --:-

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Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003

MINI-SYMPOSIUM: SHOULDER

Conclusion
Shoulder arthroplasty is well established for the treatment of
glenohumeral arthrosis, and patients may expect a significant
improvement in function and pain relief following surgery. We
highlighted the challenges that ageing has on soft tissue healing
and shoulder function, and the importance of involving the patient early on in the decision making process. We highlighted
that a team approach to rehabilitation is essential, and that
effective communication with all members of the MDT is
imperative to prevent avoidable complications, and to guide
postoperative recovery, and rehabilitation progression. We discussed the advancements in prosthetic design and surgical
techniques for the treatment of concentric GHJ arthrosis where
normal biomechanics are restored, and the main postoperative
priorities are to protect the integrity of healing soft tissues, specifically subscapularis, and maintain joint stability, and the use
of a rTSA for rotator cuff arthropathy where there is loss of
normal functional anatomy, and improving deltoid function and
the optimizing the function of the external rotators is key to
functional improvement. Early implementation of a safe and
effective exercise-based rehabilitation programme tailored to the
individual has been shown not only to optimise functional recovery but that it is more likely to meet the needs and expectations of the patient to promote self-responsibility.
A

Figure 14 Active elevation in semi-upright position.

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Acknowledgements
The authors would like to thank Jan Letocha and Jason Poon for their
help in preparing the photographs, and acknowledge the work of
Christina Liasides, Senior Physiotherapist, and the Shoulder & Elbow
Team, Royal National Orthopaedic Hospital, Stanmore in summarizing
rehabilitation progression following shoulder arthroplasty (Table 1).
The fee for this paper has been used to support therapist attendance
on a related course on optimizing outcomes from shoulder
arthroplasty.

11

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Please cite this article in press as: Payne C, et al., (v) Rehabilitation for shoulder arthroplasty, Orthopaedics and Trauma (2015), http://dx.doi.org/
10.1016/j.mporth.2015.09.003