PT Protocols

Reverse Total Shoulder Arthroplasty

Phase I (Protective Phase)

Goals:

  • Maintain stable prosthesis
  • Minimize pain and inflammatory response
  • Achieve staged ROM goals
  • Establish stable scapula
  • Initiate pain free rotator cuff and deltoid strengthening

Days 1 to 3

  1. Elbow, wrist and hand AROM (EWH)
  2. Supine passive forward elevation in plane of scapula (PFE) to 90
    1. 10-20 reps, 2 x day
    2. Supine PFE by family member or using opposite arm
  3. Supine passive external rotation (PE) to neutral
    1. T-stick in 20° flexion and 20° abduction
    2. 5-10 reps, 2x day
  4. Codman’s pendulum exercises
  5. C-spine AROM
  6. Ice
  7. Positioning full time in sling
  8. Cautions:
    1. Assure normal neurovascular status
    2. No lifting of involved arm
    3. Shoulder extension is limited. Elbow not to go behind midline of body

Weeks 1 to 2

  1. Continue EWH
  2. Shoulder shrugs and retractions (no weight)
  3. Continue PFE. Progress to full as tolerated
  4. Continue T-bar PER at 20° abduction
    1. Limit ER to 30 degrees if subscapularis repair performed
  5. Isometrics, keeping elbow flexed to 90° (sub maximal, pain free)
  6. **Manual scapula strengthening
  7. **Pain control modalities PRN / Polar Care
  8. Complications/Cautions:
    1. If pain level is not dissipating, decrease intensity and volume of exercises
    2. Continue to limit shoulder extension past midline of body

Weeks 2 to 6

  1. Heat/Ice PRN to help obtain motion
  2. D/C sling at week 2 if no subscapularis repair
    1. Week 4 if subscapularis repair performed
  3. Progress passive and AAROM ER exercises to full after week 3
  4. Start AROM
  5. Theraband scapula retractions
  6. Progressive serratus anterior strengthening (isolated)
  7. AAFE
  8. Continue isometric abduction
  9. **Pain control modalities PRN
  10. **Aquatics AAROM→ AROM
  11. **Trunk stabilization/strengthening
  12. Cautions:
    1. Do not initiate dynamic rotator cuff strengthening
    2. Assure normal scapulohumeral rhythm with AAFE

Phase II (Progressive Strengthening)

Goals:

  • Maintain stability of prosthesis
  • Achieve staged ROM goals
  • Eliminate shoulder pain
  • Improve strength, endurance and power

Weeks 6 to 9

  1. Theraband ER strengthening (pain free, elbow by side)
    1. Week 7 or after
    2. Very light with high repetitions.
    3. Continue self stretching all planes to obtain PROM WFL
  2. Advance scapula strengthening
  3. AFE as tolerated to full
  4. **Mobilizations PRN
  5. **Aquatics** AROM
  6. **Trunk stabilization/strengthening
  7. Cautions:
    1. Strengthening program should progress only without signs of increasing inflammation
    2. Strengthening program should emphasize high repetitions, very light resistance and should be performed a maximum of 2 x day

Weeks 9 to 12

  1. Continue stretches PRN for PROM WFL
  2. Advance theraband strengthening of cuff and scapula below shoulder level
  3. Initiate isotonic dumbbell exercises for deltoid, supraspinatus
    1. Up to 2 lbs max (once nearly full AFE achieved)
  4. **Mobilizations PRN
  5. **Trunk stabilization/strengthening

Phase III (Return to activity/Advanced conditioning)

Goals:

  • Maintain stability of prosthesis
  • Normalize strength, endurance and power for age
  • Return to full ADL’s and recreational activities

Months 3 to 6

  1. Light PFN or manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold) in pain free and comfortable range
  2. Stretching PRN
  3. Continue deltoid/cuff/scapula strengthening. Avoid overuse of deltoid.

Discharge/Return to sport criteria

  1. PROM WFL for ADL’s/work/sports
  2. MMT 5/5 shoulder girdle
  3. Successful return to functional activities

**Adjunctive exercises