Reverse Shoulder Arthroplasty Protocol

Reverse Shoulder Arthroplasty (RSA) is a specialized surgical procedure designed for patients with severe shoulder arthritis accompanied by a massive, irreparable rotator cuff tear (rotator cuff tear arthropathy). By reversing the normal anatomy—placing the ball (glenosphere) on the shoulder blade and the socket on the arm bone—the joint bypasses the need for a functioning rotator cuff. Instead, the shoulder relies almost entirely on the deltoid muscle to lift the arm. Because the biomechanics are altered, rehabilitation requires specific precautions and a criteria-based progression to protect the joint, prevent dislocation, and maximize functional recovery.

Phase 1: Joint Protection and Passive Range of Motion (Weeks 0 - 6)

Primary Focus: Protect the healing joint and prosthesis, control pain and inflammation, and initiate early passive mobilization without placing stress on the healing soft tissues (especially the subscapularis if repaired).

• Sling Wear: Wear the sling at all times (including during sleep) for the first 6 weeks. It may be removed only for personal hygiene and performing the designated exercises.
• Precautions & Restrictions:
  • NO active shoulder movement (AROM). Do not attempt to raise the arm or reach using shoulder muscles.
  • NO combined internal rotation, adduction, and extension. Do not reach behind your back (e.g., to tuck in a shirt, fasten a belt, or perform toilet hygiene) as this position carries the highest risk of dislocating a reverse shoulder replacement.
  • NO shoulder extension. Do not allow the elbow to go behind the plane of the body (e.g., when lying down, place a pillow under the elbow to keep the arm supported in a slightly forward position).
  • NO weight bearing. Do not push up from a chair or bed using the surgical arm. Do not lift any objects.
  • External Rotation (ER) Limit: If the subscapularis muscle was repaired during surgery, restrict passive external rotation to neutral (0 degrees) or a maximum of 20 degrees as specified by the surgeon to protect the tendon repair.
• Suggested Exercises:
  • Passive Range of Motion (PROM): Forward flexion and elevation in the scapular plane (usually up to 90 degrees, progressing gradually to 120 degrees as tolerated).
  • Passive External Rotation (ER): Done gently in the scapular plane, keeping within the designated limits (0 to 20 degrees).
  • Distal Active ROM: Active movement of the elbow, wrist, and hand to prevent stiffness and promote circulation.
  • Pendulum Exercises: Gentle, passive distraction circles using gravity, keeping the arm completely relaxed.
  • Scapular Shrugs & Retractions: Gentle shoulder blade movements (elevation, depression, retraction) without moving the arm, helping maintain periscapular muscle tone.
• Criteria to Progress:
  • Well-controlled post-operative pain.
  • Completion of the full 6-week joint protection phase.
  • Passive forward elevation in the scapular plane of at least 90 degrees and passive external rotation to neutral (0 degrees).

Phase 2: Active-Assisted and Early Active Range of Motion (Weeks 6 - 12)

Primary Focus: Gradually wean from the sling, re-establish active control of the arm using the deltoid, and progress from assisted movements to independent active movement.

• Sling Discontinuation: Under the guidance of your therapist, gradually discontinue the sling during the day. The sling may still be recommended in crowded environments or during sleep if needed for comfort.
• Precautions & Restrictions:
  • STILL NO combined extension, internal rotation, and adduction. Reaching behind the back remains strictly restricted.
  • NO sudden lifting or jerking. Avoid lifting objects heavier than a cup of coffee (1-2 lbs).
  • Avoid compensating with the upper trapezius. Watch for \"shrugging\" when attempting to lift the arm.
• Suggested Exercises:
  • Active-Assisted Range of Motion (AAROM): Progressing forward elevation using a cane, pulley, or wall slides.
  • Active Range of Motion (AROM):
    • Initiate active elevation in the scapular plane, starting in a gravity-minimized position (e.g., lying on your back) and progressing to a reclined (semi-Fowler) position, and finally to standing.
    • Active external rotation in the scapular plane.
    • Gentle active internal rotation (non-loaded, moving the hand toward the abdomen only).
  • Submaximal Isometrics: Gentle, pain-free isometric contractions for the deltoid (anterior, middle, posterior) and periscapular muscles.
  • Periscapular Strengthening: Early strengthening of the scapular stabilizers (e.g., scapular clocks, rows with light resistance bands, submaximal serratus punches).
• Criteria to Progress:
  • Minimal or no pain with active-assisted exercises.
  • Discontinued sling wear without an increase in symptoms.
  • Active forward elevation in the scapular plane of at least 90-100 degrees with good scapular control (no excessive shrugging).
  • Active external rotation of at least 15-20 degrees.

Phase 3: Progressive Deltoid and Scapular Strengthening (Weeks 12 - 18)

Primary Focus: Build strength and endurance in the deltoid and scapular stabilizing muscles to optimize functional elevation, and re-establish neuromuscular control of the reconstructed joint.

• Precautions & Restrictions:
  • Avoid loading the shoulder in positions of extreme abduction or external rotation.
  • Do not lift objects heavier than 5-10 lbs.
  • Avoid rapid, explosive movements. Perform all exercises with controlled tempo.
• Suggested Exercises:
  • Isotonic Deltoid Strengthening: Light resistance bands or dumbbells (starting at 1-2 lbs, progressing slowly) for forward elevation in the scapular plane, abduction, and prone horizontal abduction.
  • Scapular Stabilization: Progress to resisted rows, lat pulldowns (avoiding extension behind the body), and serratus punches with resistance.
  • Rotator Cuff Strengthening (if applicable): Focus on the external rotators (teres minor and infraspinatus) using light resistance bands to help stabilize the joint during deltoid activation.
  • Dynamic Stabilization: Proprioceptive and rhythmic stabilization drills (e.g., gently holding the arm in space against light, multi-directional taps from the therapist).
• Criteria to Progress:
  • Active forward elevation of 120 degrees or more with good biomechanics.
  • Adequate strength (at least 4/5) of the deltoid and periscapular muscles.
  • Ability to perform light daily activities without pain or fatigue.

Phase 4: Advanced Functional Strengthening and Long-Term Maintenance (Weeks 18+)

Primary Focus: Maximize functional capacity, build endurance for activities of daily living (ADLs), and transition to a home-based maintenance program while understanding lifetime joint restrictions.

• Precautions & Restrictions (Lifetime Guidelines):
  • Lifetime Lifting Limit: To protect the prosthesis from premature wear, loosening, or fracture, avoid repetitive lifting of objects heavier than 10-15 lbs, and avoid single lifts exceeding 20-25 lbs.
  • Always maintain good posture. Rounded shoulders or poor thoracic extension will limit the deltoid's efficiency in lifting the arm.
• Suggested Exercises:
  • Functional Patterns: Reaching exercises simulating cabinet reaching, carrying light groceries, and self-care tasks.
  • Progressive Resistance: Slow progression of weights/bands for deltoid and scapular muscles, focusing on endurance (e.g., 3 sets of 15 repetitions).
  • Closed Kinetic Chain Exercises: Light wall push-ups or weight-bearing exercises to improve joint stability.
  • Recreational Activities: Gradual return to low-impact recreational activities (e.g., swimming, golf, gardening) as cleared by the surgeon.
• Goals for Completion:
  • Functional active forward elevation (typically 120 to 140 degrees).
  • Functional active external rotation (typically 20 to 30 degrees).
  • Independence in a home exercise program.
  • Satisfactory return to light work, hobbies, and activities of daily living.

These guidelines represent a standard rehabilitation protocol. Individual recovery rates vary significantly depending on the size of the repair, bone/tissue quality, and general patient health. Your surgeon may modify this protocol specifically for you.

Disclaimer: This protocol is for educational purposes and is not a substitute for professional medical advice. Always consult your surgeon or physical therapist before performing any exercises or modifying activity restrictions.