Minimally Invasive
Shoulder Replacement
Shoulder Replacement
Physical Therapy Protocol
Total Shoulder Arthroplasty (Minimally Invasive)
Physical Therapy Protocol
General Considerations
- Surgical Overview: Minimally invasive TSA with subscapularis-sparing involves preserving the subscapularis tendon, which allows for immediate use of the shoulder after the nerve block wears off, enabling early engagement in daily tasks without the need for a sling.
- Primary Goals:
- Protect the surgical site and facilitate healing.
- Gradually restore functional range of motion (ROM) and strength.
- Promote early, gentle shoulder activity.
- Precautions:
- No heavy lifting (>5 lbs) for the first 6 weeks.
- Avoid internal rotation (IR) beyond neutral and extreme overhead motion during the first 6–8 weeks.
Phase I: Immediate Post-Operative Recovery (Weeks 0–6)
- Key Focus and Precautions:
- No sling required.
- Gentle use of the shoulder allowed once the nerve block wears off (e.g., eating, dressing, light activities).
- No lifting >5 lbs until cleared.
- Avoid extreme IR and overhead motions during the first 6 weeks.
- Interventions:
- Pain Management: Cryotherapy and positioning to reduce swelling and discomfort.
- Hand/Wrist/Elbow AROM: Gentle mobility exercises for the distal joints.
- Gentle Scapular Exercises: Light scapular retraction, elevation, and depression.
- 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 and Early Strengthening (Weeks 6–12)
- Key Focus and Precautions:
- Begin Active-Assisted Range of Motion (AAROM) while avoiding IR and extension beyond neutral.
- No lifting >5 lbs.
- Interventions:
- AAROM: Supine forward elevation and ER (gentle assistance).
- Strengthening: Begin isometric deltoid exercises (flexion, abduction) without resistance.
- Functional Mobility: Encourage gentle use of the shoulder for daily activities.
- 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 active range of motion (AROM) while protecting healing tissues.
- Begin strengthening of deltoid and scapular stabilizers.
- Avoid lifting heavy loads or engaging in high-stress overhead activities.
- Interventions:
- AROM Progression: Forward flexion, abduction, ER to full ROM.
- Strengthening: Light resistance (1–2 lbs) for deltoid and scapular muscles.
- Functional Movements: Start functional tasks like dressing, light lifting, and reaching.
- 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:
- Continue strengthening shoulder muscles, focusing on functional activities.
- Gradually return to overhead motions and more dynamic tasks, but avoid high-stress overhead motions until 24 weeks.
- Interventions:
- Strengthening: Continue light resistance for deltoid, scapular muscles, and rotator cuff.
- Functional Training: Start functional activities like lifting light items overhead, carrying, and reaching.
- Sport-Specific Training: Begin light sport-specific activities like swimming, tennis, or golf (with modifications).
- Criteria to Progress:
- Full pain-free ROM.
- Strength sufficient for ADLs and light recreational activities.
Phase V: Advanced Strengthening and Return to Activity (Weeks 24–36+)
- Key Focus and Precautions:
- Return to higher-level activities once the shoulder has regained strength and stability.
- Full return to overhead lifting and sport-specific movements, once strength and ROM allow.
- Interventions:
- Advanced Strengthening: Continue with progressive resistance for deltoid, scapular stabilizers, and rotator cuff muscles.
- Sports-Specific Training: Continue sports-specific activities such as swimming, light tennis, and golf.
- Functional Lifting: Gradually increase overhead lifting and carrying heavier items.
- Criteria for Full Return:
- Pain-free function in ADLs and recreational activities.
- Shoulder strength ≥85% of contralateral side.
- Ability to perform overhead tasks and sport-specific movements without limitations.
Key Notes for Progression
- Patient Education: Immediate light use allowed post-surgery, but avoid heavy lifting or high-stress overhead motions for at least 6 weeks. Use the shoulder for daily activities but in a gentle, controlled manner.
- 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.