What is the Best Rehab After Shoulder Replacement?

Rehab after shoulder replacement is highly variable between surgeons. Unfortunately, much of the rehab after shoulder replacement has been based on opinion and training, rather than evidence. Very few studies have examined rehab after shoulder replacement.

What our randomized study found

In 2016, I published an article on rehab after total shoulder arthroplasty (TSA). In that study we randomized patients to either immediate or delayed range of motion. All patients wore a sling for 4 weeks. Those in the early group began moving the shoulder the day after surgery. Those in the delayed group performed hand, wrist, and elbow exercises only for 4 weeks, then started range of motion after the sling was removed.

Several interesting findings came from this study:

• There was no difference in range of motion by 3 months after surgery.
• Patients in the delayed group had a higher healing rate.
• Patients who healed had better function at 1 year after surgery.

Based on this study I am conservative with range of motion after TSA. Healing is higher when a period of rest is included, and ultimately the outcome is better when healing occurs. My protocol is as follows.

0 to 4 weeks after surgery

Goal: early recovery — decreased swelling and healing.

These patients use a sling for 4 weeks, which they may remove for showers and meals. Ball squeezes with the hand are encouraged throughout the day. Three times per day patients do the following exercises:

• Active elbow flexion and extension with the arm at the side
• Isometric scapular retraction exercises

4 to 8 weeks after surgery

Goal: focus on range of motion.

The sling is discontinued at 4 weeks after surgery. Passive motion only. Emphasize these exercises:

• Table slides
• Passive external rotation at the side with a stick
• Overhead rope and pulley

8 weeks after surgery

Goal: continue range of motion, add strengthening.

Begin active-assisted range of motion, progressing to active motion as tolerated. Begin strengthening with a focus on wall washes and the "4-pack" strengthening exercises:

• Resisted internal rotation
• Resisted external rotation
• Low row
• Biceps curl

4 months after surgery

Goal: 80% of range of motion by 4 months.

Return to gym, with avoidance of activities involving rapid acceleration (throwing, golf, tennis) or high impact (overhead lifting). For golf: putting is okay at 3 months, chipping at 4 months, full swing at 6 months.

Six months after surgery

• Full activity with no repetitive lifting over 25 lbs
• Anticipate gains for up to 1 year after surgery

Source: Immediate versus delayed passive range of motion following total shoulder arthroplasty.