“DR. TREVOR” STEFANSKI, M.D.
Minimally Invasive Specialist
Shoulder Replacement (Traditional)
Physical Therapy Protocol
Total Shoulder Arthroplasty with Subscapularis Tenotomy - 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.