Shoulder Replacement (Traditional)
Physical Therapy Protocol
Total Shoulder Arthroplasty (Standard)
Protocol
General Considerations
- Surgical Overview: TSA with subscapularis tenotomy requires protecting the tendon to ensure healing. Early mobilization is encouraged with appropriate precautions.
- Primary Goals:
- Protect the subscapularis tendon during recovery.
- Minimize pain and swelling.
- Gradually restore ROM and strength.
- Precautions: Avoid internal rotation (IR) and extension for the first 6 weeks. No lifting heavier than 5 lbs until clearance.
Phase I: Immediate Post-Operative Protection (Weeks 0–6)
- Key Focus and Precautions: Full-time sling use, including during sleep. No active IR or extension beyond neutral.
- Interventions:
- Pain Management: Cryotherapy and proper positioning.
- Hand/Wrist/Elbow AROM: Gentle mobility exercises.
- Scapular Exercises: Gentle scapular retraction and elevation.
- PROM (PT-Performed):
- Forward elevation: 0°–90°.
- External rotation (ER): 0°–20°.
- Criteria to Progress:
- Pain and swelling controlled.
- PROM: Forward elevation ≥90°, ER ≥20°.
Phase II: Active-Assisted Range of Motion (Weeks 6–12)
- Key Focus and Precautions: Initiate AAROM, avoiding IR and extension. No lifting >5 lbs.
- Interventions:
- AAROM: Supine forward elevation and ER (gentle assistance).
- Strengthening: Begin isometric deltoid exercises (flexion, abduction) without resistance.
- Criteria to Progress:
- AAROM without compensations.
- PROM: Forward elevation ≥120°, ER ≥30°.
Phase III: Active Range of Motion and Strengthening (Weeks 12–16)
- Key Focus and Precautions: Gradually increase AROM while protecting the subscapularis. Avoid overhead activities until 16 weeks.
- Interventions:
- AROM Progression: Forward flexion, abduction, ER to full ROM.
- Strengthening: Light resistance for deltoid and scapular stabilizers.
- Functional Movement: Begin light functional tasks like dressing and lifting small objects.
- Criteria to Progress:
- Full AROM without pain.
- Strength ≥4/5 in deltoid and scapular stabilizers.
Phase IV: Strengthening and Functional Progression (Weeks 16–24)
- Key Focus and Precautions: Strengthen shoulder for functional activities. Avoid high-stress overhead motions.
- Interventions:
- Strengthening: Progressive resistance with light weights.
- Functional Training: Start functional activities (e.g., lifting, carrying light bags).
- Criteria to Progress:
- Full pain-free ROM.
- Strength sufficient for ADLs.
Phase V: Advanced Strengthening and Return to Activity (Weeks 24–36+)
- Key Focus and Precautions: Return to higher-level activities. Gradual return to overhead motions once strength and stability are achieved.
- Interventions:
- Advanced Strengthening: Continue progressive resistance for deltoid and scapular muscles.
- Sports-Specific Training: Light activities such as golf, swimming, and gentle lifting.
- Criteria for Full Return:
- Pain-free function in ADLs and recreational activities.
- Shoulder strength ≥85% of contralateral side.
Key Notes for Progression
- Patient Education: Gentle use encouraged for daily tasks. No lifting or overhead activity until cleared.
- Criteria for Advancement: Strength ≥4/5, AROM ≥90% of contralateral side, pain-free function.
- Red Flags: Increased pain, swelling, or difficulty with ROM should prompt reassessment.