Guidelines for physiotherapy treatment of patients following an elective Reverse Total Shoulder replacement
TSR Phase 1 Protocol in PDF
TSR Phase 2 Protocol in PDF
CHECK THE OP-NOTES – if the deltoid has been detached then go cautiously with anterior deltoid re-training exs. A little stress on a healing tendon is good, too much is not.
Note: Subscapularis is released prior to the procedure and reattached at the end of the procedure. Check for Tenodesis of biceps tendon – normally the patient is allowed to actively flex and extend the elbow. No resisted exs for at least 6 weeks if there has been a biceps tenodesis.
Restrict external rotation to 0 degrees, for 6 weeks when a subscapularis repair has been performed
NO resisted external rotation for 3 months.
Post-op Day 0
Check type of anaesthetic, patient may have had a nerve block. If so make sure that the patient is aware that they need to protect the arm. Do not allow the arm to be left hanging unsupported or to lie on the arm or trap it against the arm rest of a chair.
Issue the early exercise sheet.
Encourage the patient to commence circulation exercises for the fingers hand and wrist.
Patient to wear a poly sling, until full feeling has returned to the arm.
Encourage the patient to commence oral analgesia prior to the nerve block wearing off.
Post-op Day 1
When the feeling has returned to the arm the patient may remove the sling for controlled exercises and then return the arm to the sling.
Ensure the patient takes regular analgesia.
Work on active finger, hand and wrist exercises.
Active elbow flexion and extension exercises.
Shoulder girdle exercises.
Check posture in sitting and walking.
Encourage patient to walk independently to the toilet.
Commence passive shoulder elevation and abduction with the patient in supine lying.
Commence self assisted elevation with arms folded to avoid external rotation.
Issue an ice band (ice pack compress) and teach the patient how to use it. (DO NOT use an ice band until the patient has full return of sensation.)
Post-op Day 2:
Continue all exercises as for day 1.
Commence pendular swinging exercises.
Teach patient to clean into the axilla by standing up allowing the arm to hang by the side and leaning the body to the same side as the operation. This allows the affected arm to hang away from the body, without having to lift it.
Commence scapular setting exercises.
Post-op day 3:
Use sling as advised by your physiotherapist or surgeon.
Patient may find it comfortable to hold a pillow under the arm, this can stay in situ when walking, sitting or lying. It helps to maintain the shoulder in the neutral scapular plane when lying. This avoids the discomfort of the arm falling into extension at the shoulder when lying flat on the bed.
Commence passive external rotation to neutral only.
Commence active/assisted flexion in supine (For fractures with reconstructed tuberosities, then this should be passive for 6 weeks).
Commence use of pullies in supine first, then progress to sitting.
Try to gain patient control of the arm in 90 degrees of shoulder flexion, when in supine.
Post-op day 4 onwards:
Continue all exercises as above until discharge.
Arrange out-patient physiotherapy to commence immediately.
Outpatient physiotherapy to week 6
Continue to use sling as advised by surgeon or physiotherapist.
Continue exercises in phase 1 as above until week 6
Aim for full passive flexion and abduction.
Gentle self assisted ROM exs.
Do not force the movement.
Encourage independence in all activities of daily living, keeping activities below 90 degrees shoulder flexion.
DO NOT lift anything heavier than a cup of tea.
Post-op week 6 – 12
Phase 2 above
Encourage active movement in all ranges.
Commence work on active external rotation
Commence working on control of the joint in supine lying.
Encourage gentle self stretching at end of range for flexion/extension
DO NOT force into internal or external rotation.
When the patient has a good active ROM commence gentle resisted exercises for flexion/extension and ab/adduction.
Continue use of pullies.
12 weeks onwards
Progress strengthening exercises.
Return to full function.
Guidelines for functional activities: discuss with your surgeon, the following are approximate times.
Driving: 6-12 weeks
Swimming: 12 weeks – commence with breast stroke only – no freestyle and gently progress to crawl as active ROM allows. Do not swim if the skin around the shoulder is un-healed, broken or damaged in any way.
Golf: 12 weeks
Sedentary work: 6 -12 weeks
Heavy manual work – not recommended.