Recovery: Shoulder replacement

The operation

This operation can involve the replacement of the glenoid and humeral components (total shoulder replacement) or just the humeral component (hemiarthroplasty). The hemiarthroplasty may be chosen due to lack of glenoid bone stock, or because the rotator cuff musculature is not functional, or both. In most cases most of the subscapularis will have been detached and resutured. This will need protecting. The operation is done primarily for pain relief. Active movement regained will be dependent on the status of the rotator cuff.

An outpatient shoulder clinic appointment should take place two weeks following surgery.

Contraindications

To protect the subscapularis repair and to avoid the danger of dislocation (which is rare) avoid:

• abduction with external rotation for six weeks
• isometric/isotonic medial rotation exercises for four weeks
• external rotation for four weeks (check ROM with Mr. Cole)
• forced extension (e.g. pushing on arm with body forward, such as getting out of chair)
  

0–three weeks post-operation

The main emphasis is on regaining passive range (while protecting excessive lateral rotation) and facilitating active assisted movement.

i. wean out of sling (as pain and control allows)
ii. continue with hospital exercise programme

• pendular F/E, ABD/ADD
• supine; auto-assisted flexion – support at elbows or wrist
• pulleys - into elevation through flexion/scaption not abduction – with short lever
• assisted external rotation (within range obtained from Mr. Cole). If unsure, take to neutral and never force passively
  

iii. begin passive abduction (maintain shoulder in medial rotation)
iv. progress to active assisted flexion – supine to sitting. Short lever
v. begin isometric strengthening of all muscle groups except medial rotation

Three weeks post-operation

The main emphasis is on active assisted to active range of movement. Start gentle muscle rehabilitation. Facilitate movement.

i. wean out of sling (if not already)
ii. active assisted movements progressing to active – lying, sitting/standing – short lever
iii. start isometric medial rotation (if pain-free)
iv. exercises in water
v. functional use of arm at waist height – light tasks

Six weeks post-operation

The main emphasis is on improving quality of movement and endurance with reference to functional activities.

i. maximise active movements – correct abnormal movement patterning if able
ii. start on isotonic inferior cuff exercises – if pain-free (med/lat rotation> abduction)
iii. regain external rotation range
iv. increase use of arm for functional tasks gradually
v. progress strengthening – all groups, if indicated (function)

The recovery

Patients may be on treatment for over four months to help regain maximum range and activity from the shoulder. Appointments may be infrequent but contact to assess and progress the exercise programme is indicated to optimise the effect of surgery. Many patients will have had many months or years of problems with pain and disuse contributing to stiffness and muscle atrophy. Rehabilitation can be slow.

General points of rehabilitation Work towards functional goals. Pain relief is the main indication for surgery and is normally successful. Anti-gravity elevation may take between four and six weeks to achieve. Active range of movement will be dependent on the status of the rotator cuff and soft tissues. Some patients may have 'limited goals' as a result. People with primary OA will tend to do better (often no cuff damage).

Improvement can continue for up to two years. Encourage people to continue until they find no further improvement (or are fully functional).

With thanks to the Oxford Shoulder & Elbow Clinic, at the Nuffield Orthopaedic Centre for sharing their written physiotherapy guidance with us.