30 SECONDS OF THERAPY: THE ART OF SHOULDER RECOVERY

START

Start Using Protocols To Standardize Your Care

1. Hemi Shoulder Arthroplasty: (HSA)  (HSA Protocol) 

a. Phase I (0-6 weeks): Protect repair, initiate passive movement, prevent stiffness.

•  Exercises: Pendulum, forward elevation (≤120°), ER (≤20°), overhead pulley, cane-assisted ER.

• Precautions: Emphasize technique, limit elevation to protect subscapularis.

b. Phase II (6-12 weeks):  Improve ROM, introduce light strengthening.

• Exercises: Scapular exercises, rotator cuff isometrics, Theraband resistance, AAROM with wand.

• Progression: Increase reps (3x10), monitor for compensations.

c. Phase III (12+ weeks): Build endurance, restore function.

• Exercises: Rotator cuff isotonic, gravity-eliminated, Theraband, progressive resistance (0.25-1.25 kg), eccentric control.

• Progression: Strength below 60% 1RM, monitor for discomfort
  

 2. Total Shoulder Arthroplasty: (TSA) (TSA Protocol)

a. Phase I (0-6 Weeks): Joint protection, pain management, and restoring basic mobility.

• Exercises: Wrist, hand, and elbow movements; gentle passive/assisted shoulder exercises (near week 6).

• Progression: Advance to Phase II when the patient follows precautions and shows improved assisted movement.

b. Phase II (7-12 Weeks): Increase shoulder mobility, prevent overuse, and begin muscle activation.

• Exercises: Assisted/active shoulder movements, light isometric strengthening, and postural training.

• Progression: Move to Phase III when the patient shows controlled active motion and muscle engagement.

c. Phase III (12+ Weeks): Improve functional use, enhance strength, and ensure proper mechanics.

• Exercises: Progressive resistance training, wall slides, and controlled lifting (2-6 lbs max).

• Progression: Continue independent home exercises and functional strengthening.
  

3. Reverse Shoulder Arthroplasty: (RSA)  (RSA Protocol)

a. Immediate Post-Surgical (Day 1-2) Manage pain, prevent stress on repair, and educate on sling use.

• Restrictions: No active motion (AROM), no lifting, no weight-bearing.

• Exercises: Hand, wrist, elbow movements; cryotherapy for pain.

b. Protection (Day 2 - Week 6): Allow soft tissue healing, restore elbow/wrist movement.

• Restrictions: No shoulder AROM, lifting, or driving.

• Exercises: Passive ROM, scapular retractions, pendulums.

c. Intermediate (Weeks 6-10)Improve range of motion, neuromuscular control, and wean off sling.

• Restrictions: No lifting heavier than a coffee mug, weight-bearing, or extreme motions.

• Exercises: Assisted/active ROM, scapular strengthening, isometrics.

d. Advanced Strengthening (Weeks 10-16) Gradual strength building, return to functional tasks.

• Restrictions: No lifting over 10 lbs, sudden jerking, or heavy pushing/pulling.

• Exercises: Weight-bearing, progressive resistance, postural strengthening.

e. Return to Activity (Weeks 16-24) Restore pain-free ROM, strength, and functional use.

1. Restrictions: Avoid repetitive overhead lifting and stress on the subscapularis.

2. Exercises: Strength training, sport/work-specific training.
   

STOP 

 1. Movements to Avoid

a. (HSA)

• Overstretching the subscapularis repair can lead to instability or re-injury.

• Avoid excessive loading, as it can strain the healing shoulder and slow down recovery.

• Sudden or uncontrolled overhead motions may cause impingement, pain, or compromise joint integrity.

b. (TSA)  

• Avoid shoulder external rotation beyond 30° and abduction beyond 90° for the first 6 weeks.

• Avoid lifting, pushing, and pulling for 12 weeks.

• Avoid weight-bearing on the operative arm (e.g., using the arm to push up from a chair).

c. (RSA)

• Avoid shoulder extension beyond neutral.

• Avoid the combination of shoulder adduction, extension, and internal rotation.

• No pushing, pulling, or lifting objects >1-2 lbs for 12 weeks.

  
  

2. Limiting Range of Motion: 

a. (HSA)

• Expected Shoulder Flexion: ~120° to 140°

• Time Frame: 6 to 12 months (varies based on rotator cuff condition and rehab progression)

Reference: Fehringer EV, Kopjar B, Boorman RS, Churchill RS, Smith KL, Matsen FA III. Characterizing the functional improvement after shoulder arthroplasty for osteoarthritis. J Bone Joint Surg Am. 2002;84(8):1349-1353.

b. (TSA)

• Expected Shoulder Flexion: ~155°

• Time Frame: ~9 months of rehabilitation.

Reference: Rugg CM, Coughlan MJ, Lansdown DA. Anatomic total shoulder arthroplasty: indications, techniques, and outcomes. Curr Rev Musculoskelet Med. 2019;12(4):542-553.

c. (RSA)

•    Expected Shoulder Flexion: ~105° to 140°

•   Time Frame: 9 to 12 months, depending on deltoid function and rehab progress.

Reference: Boudreau S, Boudreau ED, Higgins LD, Wilcox RB. Rehabilitation following reverse total shoulder arthroplasty. J Orthop Sports Phys Ther. 2007;37(12):734-743.

WHY 

1.Indications for Surgery

• (HSA) is indicated for severe humeral head fractures with an intact glenoid, preserving part of the natural joint.

• (TSA) is recommended for end-stage osteoarthritis or inflammatory arthritis with an intact rotator cuff.

• (RSA) is used for irreparable rotator cuff tears, complex fractures, or failed TSA, relying on the deltoid for shoulder movement.

 2. Delaying Surgery

• Delaying surgical intervention for complex fractures or failed fixation leads to increased risk of avascular necrosis (AVN) with time. 

• Increased strain on the neck, back, and opposite shoulder, leading to discomfort and potential secondary injuries.

• Reduced shoulder mobility and muscle imbalance, making daily activities like reaching, lifting, and posture maintenance more difficult.