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.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 and then started range of motion (ROM) after the sling was removed. Several interesting findings came from this study: 1) There was no difference in ROM by 3 months after surgery, 2) Patients in the delayed group had a higher healing rate, 3) Patients who healed had better function at 1 year after surgery. Based on this study I am conservative with ROM 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 during this period:

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

4 to 8 weeks after surgery:Goal: Focus on ROMThe sling is discontinued at 4 weeks after surgery.Passive motion onlyEmphasize these ROM exercises:

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

8 weeks after surgery:Goal: Continue ROM, Add strengtheningBegin active-assist ROM, progressing to active motion as toleratedBegin strengthening with focus on:

• Wall washes
• "4-pack" strengthening exercises
• Resisted internal rotation
• Resisted external rotation
• Low row
• Biceps curl

4 months after surgery:Goal: 80% of ROM by 4 mosReturn to gym, with avoidance of activities with rapid acceleration (throwing, golf, tennis) or high impact (overhead lifting)-Golf: Ok for putting at 3 mos, chip at 4 mos, full swing 6 mosSix months after surgery:

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

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