Anatomic Total Shoulder Arthroplasty
Muscle-Sparing Technique

Physical Therapy Protocol

Phase I – Immediate Post-Op (0–3 Weeks)

Goals:

• Protect surgical site and minimize inflammation
• Reduce pain and swelling
• Maintain elbow, wrist, and hand mobility
• Gradually increase shoulder PROM
• Minimize muscle inhibition
• Educate patient

Precautions / Restrictions:

• Sling for comfort only (most patients use for 1–2 weeks to minimize soreness and swelling)
• OK for immediate light use but no lifting >1 lb
• No reaching behind back or excessive internal rotation
• Avoid excessive external rotation or abduction
• No pushing, pulling, or weight-bearing through arms
• Place pillow/towel under elbow when lying on back

Therapeutic Exercises:

• PROM: ER ≤30° (scapular plane), IR to beltline, Flexion/scaption to tolerance, Abduction ≤90°, Pendulums, Table slides
• AAROM: Active-assisted flexion
• AROM: Elbow, wrist, hand
• Periscapular Strengthening (Week 2): Scapular retraction, prone retraction, supported setting, inferior glide, low rows
• Ball squeezes

Criteria to Progress:

• PROM flexion/scaption ≥50% of opposite side
• Abduction PROM ≤90°
• ER PROM ≤30°
• IR PROM ≥70°
• Pain < 4/10, no complications

Phase II – Intermediate Post-Op (Weeks 4–6)

Goals:

• Continue protecting repair and restoring PROM
• Begin gradual use of affected arm
• Improve scapular control and RTC activation
• Begin gentle light ADLs

Precautions / Restrictions:

• Wean off sling fully if still using
• Progress bearing weight as tolerated at 4 weeks
• Avoid excessive abduction or ER

Therapeutic Exercises:

• Continue Phase I exercises
• PROM: Full ROM except ER ≤30°, Abduction ≤90°
• AAROM: Cane flexion/ER, Washcloth press, Cane elevation
• AROM: Supine flexion, Salutes, Supine punches
• Strengthening: ER isometrics, Ball rows, Serratus punches, Biceps curls and triceps (light resistance)
• Motor Control: Rhythmic stabilization (ER/Flexion 90–125°)
• Stretching: Sidelying horizontal adduction

Criteria to Progress:

• PROM ≥75% of contralateral side
• ER PROM = 30°, Abduction PROM = 90°
• AROM elevation ≥100°
• Minimal substitution patterns
• Pain < 4/10

Phase III – Controlled Strengthening (Weeks 7–8)

Goals:

• Minimize pain
• Maintain full PROM
• Progress WBAT and strengthening
• Advance AROM and scapular control
• Begin early functional tasks

Precautions:

• No lifting >10 lbs
• Begin WBAT progression as tolerated starting at 4 weeks

Therapeutic Exercises:

• Continue all prior interventions
• ROM: Full AROM/AAROM in all planes
• Strengthening: Band ER/IR, Side-lying ER, Scapular retraction, Lawn mowers
• Motor Control: Quadruped stabilization, PNF D1/D2 lifts
• Stretching: IR with towel, Sidelying horizontal adduction, Sleeper stretch

Criteria to Progress:

• Good scapular mechanics with AROM
• Pain < 4/10

Phase IV – Transitional Phase (Weeks 9–11)

Goals:

• Maintain pain-free motion
• Progress functional strength and endurance
• Normalize use of arm for light activity and ADLs

Precautions:

• Avoid ER >80° abduction
• No heavy overhead lifting

Therapeutic Exercises:

• Continue previous activities
• Strengthening: Band Ws, Dynamic hug, Push-up plus (knees), Tripod holds
• Motor Control: Wall slides with resistance, PNF with resistance

Criteria to Progress:

• Supine AROM Flex ≥140°, Abduction ≥120°, ER ≥60°, IR ≥70°
• AROM elevation to ≥120° with good mechanics
• Pain < 2/10

Phase V – Advanced Strengthening (Weeks 12–16)

Goals:

• Maintain full, pain-free ROM
• Restore strength, stability, and endurance
• Return to normal daily and light recreational activities

Therapeutic Exercises:

• Continue prior interventions
• Strengthening: ER/IR at 90°, T/Y exercises, Wall and floor push-ups
• Motor Control: Overhead rhythmic stabilization, Alternating isometrics

Criteria for Full Return:

• Clearance from surgeon
• Functional, pain-free ROM
• Scapular symmetry with movement
• Strength ≥85% of contralateral side