Rehabilitation of Post Shoulder

Arthroplasty

Oleh: Virginia Ainurridlo Nugroho (188071700011003)

PPDS IKFR FKUB Malang
Pembimbing : dr. Samiah Rachmawati SpKFR
Introduction
• Shoulder arthroplasty = Shoulder replacement surgery

• Shoulder replacement surgery can be done in one of

three ways.
- Hemiarthroplasty
- Total Arthroplasty
- Reverse Total Arthroplasty

UPMC Beacon Hospital, 2011. Guidelines for patients having a shoulder arthroplasty
UPMC Beacon Hospital, 2011. Guidelines for patients having a shoulder arthroplasty
• Hemiarthroplasty If the glenoid still has some articular
cartilage, replace only the humeral head

• Total arthroplasty  when the cartilage of both the humeral

head (the ball) and the glenoid (the socket) is worn away,
both parts of the joint must be replaced.

• Total reverse -> This procedure is most often used for patients
who have had a failed total shoulder replacement. It is
also helpful for patients who have had a complete tear of
the rotator cuff, especially those whose injuries have led to
an arthritic condition called cuff tear arthropathy
UPMC Beacon Hospital, 2011. Guidelines for patients having a shoulder arthroplasty
SHOULDER HEMIARTHROPLASTY
Indication
• primary arthritis (caput humeral arthritis)
• osteonecrosis without glenoid involvement
• proximal humerus fractures
• Rotator cuff arthropathy

https://www.orthobullets.com/shoulder-and-elbow/3074/shoulder-hemiarthroplasty
Contraindication
• active infection
• neuropathic joint
• coracoacromial ligament deficiency

https://www.orthobullets.com/shoulder-and-elbow/3074/shoulder-hemiarthroplasty
Complication
•Progressive glenoid arthrosis
• increased risk with
• young patients
• active patient
• treatment
• conversion to total shoulder arthroplasty 
•Tuberosity displacement/malunion
• one of the most common complications of shoulder
  when used to treat fracture
hemiarthroplasty
• treatment
• repositioning of the tuberosity with bone grafting
•Joint overstuffing
• may lead to
• stiffness
• accelerated arthritis of glenoid

https://www.orthobullets.com/shoulder-and-elbow/3074/shoulder-hemiarthroplasty
Rehabilitation of Shoulder Hemiarthroplasty

Time Frame Imobilization Restrictions Exercise

Phase 1 (0-6 Sling Avoid AAROM, Gripping
weeks) Immobilizer / AROM and exercises, elbow,
Brace with 15 strengthening. wrist and finger
degrees abduction Limit FF to 140°, ROM. Shoulder
x 6 weeks. Wear Abd to 90°, IR to pendulums (slow,
continuously chest level, ER to small circles),
except for Neutral. ROM PROM for
therapy, HEP and should be a slow shoulder in line
hygiene / bathing. stretch (not with restrictions.
forceful). Instruct on HEP
to perform twice
daily

Zurich, L., 2012. Proximal Humerus Fractures: Hemiarthroplasty Post-Operative Rehabilitation Protocol. Lake cook Ortho
Time Frame Imobilization Restrictions Exercise
Phase 2 (6-10 - PROM only until Gradually
weeks) 6 weeks. Allow increases PROM
full ROM for FF, exercises in line
limit IR to chest with restrictions.
level and ER to 30 Add AAROM at 6
degrees. No weeks and AROM
strengthening. at 8 weeks.
Instruct patient to Modalities used as
continue to needed.
protect shoulder.

Zurich, L., 2012. Proximal Humerus Fractures: Hemiarthroplasty Post-Operative Rehabilitation Protocol. Lake cook Ortho
Time Frame Imobilization Restrictions Exercise
Phase 3 (10- - Exercise Continue with shoulder
14 weeks) advancement PROM, AAROM and
should be gradual AROM (Goal is 75% or
and in slow greater of normal PROM
increments while by 12 weeks). At 10 weeks
avoiding pain. If begin shoulder isometric
patient develops strengthening with arms
pain, drop back to at side (IR, ER, scapular
early phase of stabilization). At 12 weeks
rehabilitation, add shoulder resistance
until pain free. strengthening exercises.
Allow full ROM Progression should be
without gradual and in slow
restrictions. increments while avoiding
pain initially with arms at
side. As strength and
function improve advance
to exercises with arms
away from body.

Zurich, L., 2012. Proximal Humerus Fractures: Hemiarthroplasty Post-Operative Rehabilitation Protocol. Lake cook Ortho
Time Frame Imobilization Restrictions Exercise
Phase 4 (14-26 - No specific ROM should be
weeks) restrictions. returning to normal; if
Patients ROM, not, continue to
strength and address with stretching
endurance and a HEP.
should be Progressive upper-
advanced body strengthening
progressively may be more
while avoiding aggressive after 16
pain weeks. Add plyometric
training for athletes at
18 weeks. Add
exercises simulating
work requirements or
sport at 18 weeks as
part of return to work /
sport program.

Zurich, L., 2012. Proximal Humerus Fractures: Hemiarthroplasty Post-Operative Rehabilitation Protocol. Lake cook Ortho
Time Frame Goal Restrictions Exercise
Phase 5 (+26 Restore normal No specific Aggressive upper-body
weeks) shoulder restrictions. strengthening and with
function and Advance initiation of plyometric
progress to progressively training and sports or
return to sport or while avoiding work specific training.
return to work. pain. If the Consider work
patient develops conditioning program
pain they are to based on patients job
return to earlier requirements and
stage of patient motivation.
rehabilitation.

Zurich, L., 2012. Proximal Humerus Fractures: Hemiarthroplasty Post-Operative Rehabilitation Protocol. Lake cook Ortho
SHOULDER TOTAL ARTHROPLASTY
Indication
• pain (anterior to posterior), especially at night,
and inability to perform activities of daily living

• posterior humeral head subluxation

https://www.orthobullets.com/shoulder-and-elbow/3075/total-shoulder-arthroplasty
Contraindication
• insufficient glenoid bone stock
• rotator cuff arthropathy
• deltoid dysfunction
• irreparable rotator cuff (hemiarthroplasty or
reverse total shoulder are preferable)  
▫ risk of loosening of the glenoid prosthesis is high
("rocking horse" phenomenon)
• active infection
• brachial plexus palsy
https://www.orthobullets.com/shoulder-and-elbow/3075/total-shoulder-arthroplasty
 Complication
• Glenoid looseningmost common cause of TSA failure (30% of primary OA revisions)
• risk factors
▫ insufficient glenoid bone stock
▫ rotator cuff deficiency
• Humeral stem loosening
▫ more common in RA and osteonecrosis
▫ rule out infection
• Subscapularis repair failure    
• Malposition of components
• Improper soft tissue balancing
▫ failure due to undiagnosed presence of rotator cuff tears
• Iatrogenic rotator cuff injury
▫ can occur if humeral neck osteotomy is inferior to level of rotator cuff insertion 
▫ overstuffing glenohumeral joint leading to attritional supraspinatus and subscapularis
tears 
• Stiffness
• Infection
• Neurologic injury : - axillary nerve is most commonly injured - musculocutaneous nerve can
be injured by retractor placement under conjoint tendon
https://www.orthobullets.com/shoulder-and-elbow/3075/total-shoulder-arthroplasty
Rehabilitation Total Shoulder Arthroplasty

Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic patient. Elsevier Health Sciences.
Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic patient. Elsevier Health Sciences.
Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic patient. Elsevier Health Sciences.
Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic patient. Elsevier Health Sciences.
Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic patient. Elsevier Health Sciences.
Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic patient. Elsevier Health Sciences.
Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic patient. Elsevier Health Sciences.
SHOULDER REVERSE TOTAL
ARTHROPLASTY
 Indication
• clinical conditions
▫ CTA
▫ pseudoparalysis 
 an inability to actively elevate the arm in the presence of free passive ROM and
in the absence of a neurologic lesion
 occurs secondary to irreparable rotator cuff tear in setting of glenohumeral
arthritis    
▫ rotator cuff insufficiency 'equivalent' 
 non-union or mal-union of the tuberosity following trauma or prior arthroplasty
▫ failed arthroplasty  
 when all other options have been exhausted
▫ rheumatoid arthritis
 only if glenoid bone stock is sufficient

https://www.orthobullets.com/shoulder-and-elbow/3076/reverse-shoulder-arthroplasty
Contraindication
• deltoid deficiency (axillary nerve palsy)  
• bony acromion deficiency
• glenoid osteoporosis
• active infection

https://www.orthobullets.com/shoulder-and-elbow/3076/reverse-shoulder-arthroplasty
Complication
• Scapular notching (common)
▫ related to impingement by the medial rim of the humeral cup during
adduction
▫ increased risk with superiorly placed glenoid component, or insufficient
inferior tilt of glenoid component on the native glenoid  
• Dislocation (2% - 3.4%)
▫ usually anterior instability
▫ increased risk with
 irreparable subscapularis (strongest risk) 
 proximal humeral bone loss
 failed prior arthroplasty
 proximal humeral nonunion
 fixed glenohumeral dislocation preop
 NOT related to condition of rotator cuff 

https://www.orthobullets.com/shoulder-and-elbow/3076/reverse-shoulder-arthroplasty
• Glenoid Loosening 
▫ glenoid prosthetic loosening is most common mechanism of failure
▫ treat using staged procedure to fill glenoid cavity with autogenous bone
and await incorporation with a hemiarthroplasty prior to reimplantation
of a new glenosphere
• Deep Infection
▫ susceptible to infection due to large subacromial dead space created by
reverse prosthesis
▫ most common organisms include propionibacterium
acnes and staphylococci
• Acromion and Scapular Spine Fractures
• Neurapraxia

https://www.orthobullets.com/shoulder-and-elbow/3076/reverse-shoulder-arthroplasty
Rehabilitation Reverse Total Shoulder
Arthroplasty

Boudreau S, Boudreau E. Higgins LD, Wilcox III R.B. Rehabilitation following reverse total shoulder arthroplasty. JOSPT. 2007. 37 (12): 734-744.
Garcia GH, Taylor SA, et al. Patient activity level after reverse total shoulder arthroplasty: what are patients doing? Am J of Sports Med. 2015. 43 (11): 2816-2821.
Boudreau S, Boudreau E. Higgins LD, Wilcox III R.B. Rehabilitation following reverse total shoulder arthroplasty. JOSPT. 2007. 37 (12): 734-744.
Garcia GH, Taylor SA, et al. Patient activity level after reverse total shoulder arthroplasty: what are patients doing? Am J of Sports Med. 2015. 43 (11): 2816-2821.
Boudreau S, Boudreau E. Higgins LD, Wilcox III R.B. Rehabilitation following reverse total shoulder arthroplasty. JOSPT. 2007. 37 (12): 734-744.
Garcia GH, Taylor SA, et al. Patient activity level after reverse total shoulder arthroplasty: what are patients doing? Am J of Sports Med. 2015. 43 (11): 2816-2821.
Boudreau S, Boudreau E. Higgins LD, Wilcox III R.B. Rehabilitation following reverse total shoulder arthroplasty. JOSPT. 2007. 37 (12): 734-744.
Garcia GH, Taylor SA, et al. Patient activity level after reverse total shoulder arthroplasty: what are patients doing? Am J of Sports Med. 2015. 43 (11): 2816-2821.
Boudreau S, Boudreau E. Higgins LD, Wilcox III R.B. Rehabilitation following reverse total shoulder arthroplasty. JOSPT. 2007. 37 (12): 734-744.
Garcia GH, Taylor SA, et al. Patient activity level after reverse total shoulder arthroplasty: what are patients doing? Am J of Sports Med. 2015. 43 (11): 2816-2821.
 Reference
• Boudreau S, Boudreau E. Higgins LD, Wilcox III R.B. Rehabilitation following
reverse total shoulder arthroplasty. JOSPT. 2007. 37 (12): 734-744.
• Garcia GH, Taylor SA, et al. Patient activity level after reverse total shoulder
arthroplasty: what are patients doing? Am J of Sports Med. 2015. 43 (11): 2816-2821.
• https://
www.orthobullets.com/shoulder-and-elbow/3076/reverse-shoulder-arthroplasty
• https://
www.orthobullets.com/shoulder-and-elbow/3074/shoulder-hemiarthroplasty
• https://
www.orthobullets.com/shoulder-and-elbow/3075/total-shoulder-arthroplasty
• Maxey, L. and Magnusson, J., 2013. Rehabilitation for the postsurgical orthopedic
patient. Elsevier Health Sciences.
• UPMC Beacon Hospital, 2011. Guidelines for patients having a shoulder arthroplasty
• Zurich, L., 2012. Proximal Humerus Fractures: Hemiarthroplasty Post-Operative
Rehabilitation Protocol. Lake cook Ortho