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