What To Expect After a Total Shoulder Replacement
Total shoulder replacement surgery involves removing the damaged ball and socket of the shoulder joint and replacing it with a functional metal joint to eliminate pain and restore function to the shoulder. Nearly 70,000 Americans undergo shoulder replacement surgery each year. Physical therapy after a total shoulder replacement is critical to regain full function, strength, mobility, and range of motion in the shoulder joint. The physical therapist not only helps the patient manage pain and swelling post-surgery but also guides the patient through a progressive shoulder and scapular strengthening program for optimal recovery.
Shoulder Anatomy
The shoulder is a ball and socket joint made up of the shoulder blade (scapula), upper arm bone (humerus), and the collarbone (clavicle). The head of the humerus fits into a rounded socket (the glenoid) in the shoulder blade that is surrounded by the labrum, which is strong fibrous tissue that deepens the shoulder socket, stabilizes the shoulder joint, and serves as an attachment point for ligaments and tendons of the shoulder. The surface of the humerus and shoulder blade are covered by cartilage that protects the bones and enables them to glide and move easily. A thin, smooth tissue called the synovial membrane covers the surfaces of the shoulder joint, creating fluid that lubricates the cartilage and eliminates friction in the shoulder.
The shoulder is also comprised of ligament and tendon groups that allow for the extreme mobility and range of motion of the shoulder. The rotator cuff is made up of four muscles that come together as tendons, forming a cuff of tissue around the head of the humerus. The biceps tendon attaches the biceps muscle to the bones of the shoulder and elbow joints, allowing for coordinated movement between the shoulder and arm. The shoulder joint capsule is the group of ligaments that encapsulate the ball and socket joint of the shoulder, connecting the humerus to the glenoid and stabilizing the joint.
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What is a Total Shoulder Replacement?
A total shoulder replacement removes the damaged ball and socket of the shoulder joint and replaces them with a functional metal, ceramic, or plastic joint to eliminate pain and restore function to the shoulder. While total shoulder replacements are not as common as total knee and hip replacements, nearly 70,000 people in the United States have shoulder replacement surgery each year. During a total joint replacement, a stainless steel metal ball is used to replace the humeral ball, which is attached to a titanium stem that keeps the ball attached to the arm while a polyethylene cup replaces the glenoid socket.
Total shoulder replacements are recommended for those who have such severe shoulder pain they cannot perform daily activities, have lost significant mobility and strength in the shoulder, and for whom conservative treatments like physical therapy and cortisone injections have not worked. Conditions that can lead to a total shoulder replacement surgery include osteoarthritis of the shoulder, rotator cuff tears or deficiencies, rheumatoid arthritis, osteonecrosis, or a shoulder fracture.
There are three types of total shoulder replacement surgeries performed:
Total Shoulder Arthroplasty: this involves removing the humeral head and the glenoid socket and replacing them with artificial parts (stainless steel metal ball for the humeral head and a polyethylene cup for the glenoid socket).
Shoulder Hemiarthroplasty: this involves a partial shoulder replacement in which only the head of the humerus is replaced with a metal ball.
Reverse Total Shoulder Arthroplasty: this involves a reversal of the ball and socket. It is performed when there is damage to the rotator cuff muscles of the shoulder. A plastic device is attached to the top of the humerus and a metal ball is attached to the socket. This allows the deltoid muscle to provide movement and compensate for the damaged rotator cuff muscles and tendons.
Following surgery, a patient will generally stay 1 to 3 nights in the hospital to ensure pain is controlled and that they are medically stable. In the hospital, physical therapy will start within a day or two post-surgery with simple exercises like getting in and out of bed and getting dressed. The shoulder will be immobilized in a sling for 3-6 weeks. During the first month post-surgery, do not lift anything heavier than five pounds and refrain from using the arm to lift, reach, push, or pull above waist level.
Post-Surgical Rehabilitation After a Total Shoulder Replacement
Physical therapy after a total shoulder replacement is critical to regain full function, strength, mobility, and range of motion in the shoulder joint. Prior to surgery, a patient can engage in pre-habilitation with a physical therapist, which is a customized exercise program to strengthen the shoulder, neck, and back muscles before surgery. The better physical condition the shoulder is in prior to surgery, the better and faster the recovery post-surgery. Following surgery, the physical therapist will conduct an assessment to determine the patient’s pain measure, range of motion, and strength as well as assess the surgical scar tissue to create a baseline of current functional status from which to customize the physical therapy program for optimal recovery.
Physical therapy treatment after a total shoulder replacement can include:
Modalities to manage pain and swelling: ice to decrease pain and control swelling, heat to relax muscles and improve blood flow to the shoulder’s tissues, TENS unit to help muscles contract properly post-surgery, and kinesiology taping to improve the muscular function of the shoulder.
Manual therapy to improve shoulder mobility using shoulder joint and soft tissue mobilizations, manual passive range of motion exercises, and scar tissue massage.
Therapeutic exercise and strengthening to restore function to the shoulder joint. Strengthening exercises are the main focus of rehabilitation and focus on the muscles of the upper back, shoulder, and arm. If a total shoulder replacement took place, rotator cuff strengthening is key, whereas if a reverse shoulder replacement surgery was conducted, strengthening of the deltoid muscle is critical to restore function to the shoulder. Exercise may include pendulum exercises, isometric strengthening, active range of motion exercises, strengthening using weights and resistance bands, and function-specific exercises.
Functional training as rehabilitation progresses to regain job and sport-specific movements.
There are five stages to post-operative rehabilitation:
Immediate Post-Op (0-3 weeks post-surgery): During this time, the physical therapist focuses on protecting the surgical repair, reducing swelling and pain, maintaining range of motion in the elbow, hand, and wrist, and gently engaging in passive shoulder range of motion training.
Intermediate Post-Op (4-6 weeks post-surgery): During this stage, the therapist maintains the progress from the first stage in terms of passive range of motion of the shoulder but also works to improve periscapular muscle activation and strength and initiates rotator cuff activation.
Intermediate Post-Op Continued (7-8 weeks post-surgery): During stage three, the therapist ensures that the shoulder tissue, particularly the anterior capsule, is not overstressed while improving the shoulder’s active range of motion, progressing periscapular and rotator cuff muscle strength, discontinuing the sling and beginning a gradual return to functional activities.
Transitional Post-Op (9-11 weeks post-surgery): In this stage, the therapist improves the shoulder’s active range of motion and works to improve dynamic shoulder stability and gradually restore shoulder strength and endurance.
Advanced Strengthening Post-Op (12-16 weeks post-surgery): During this final stage of rehabilitation, the focus is on maintaining pain-free range of motion, enhancing shoulder strength and endurance, and improving functional use of the upper extremity. The therapist continues rotator cuff and peri-scapular strengthening, progresses motor control training, and begins return to sport or work functional training.
Are you undergoing a total shoulder replacement soon or recently had shoulder replacement surgery? Work with our physical therapists to begin your journey to regaining function and strength in your shoulder!
