● Ensure gradual progression of strengthening. Early Phase IV ● Typically, patient is on a home exercise program by this point to be performed three or four times per week. ● Gradually progress strengthening program. ● Gradual return to moderately challenging functional situa- tions. Late Phase IV (Typically, four to six months postsurgery.) ● Return to recreational hobbies, gardening, sports, golf, dou- bles tennis. Criteria for discharge from skilled physical therapy ● Patient is able to maintain nonpainful AROM. ● Maximized functional use of upper extremity. ● Maximized muscular strength, power, and endurance. ● Patient has returned to advanced functional activities. Deltoid function is also important following rTSA. Enhancement of deltoid function in the absence of the rotator cuff following rTSA is the most important concept of the postoperative strengthening phase of recovery. Stability and mobility of the shoulder joint large- ly depend on the deltoid and periscapular musculature. The reha - bilitation program and selection of exercises need to progressively emphasize the deltoid and periscapular musculature. Patients may experience great difficulty in recruiting the deltoid to become the primary mover for shoulder elevation. Biofeedback can be used to assist patients in learning recruitment strategies. Therapists can use biofeedback techniques to help improve deltoid recruitment, including verbal and tactile cues, surface electromyography, and rehabilitation ultrasound imaging. Clinicians will find that the operative upper extremity will demon- strate much higher deltoid recruitment than the uninvolved shoul- der following a successful rehabilitation program. Range of motion and functional expectations are set on a case-by- case basis. Any return of active shoulder rotation will depend on the postoperative condition of the teres minor. The expectations depend on the underlying pathology, the status of the external rotators, and the extent to which the deltoid and periscapular musculature can be rehabilitated. Patients who have a negative ER lag sign during the initial strengthening phase of rehabilita- tion progress quicker in terms of strength gains and functional progression. They have a tendency to demonstrate higher active elevation ROM at the time of discharge from physical therapy. Normal full active elevation of the shoulder is not expected fol- lowing rTSA, but functional active elevation of at least 105 de- grees should be anticipated. The status of the posterior cuff is critical to achieve shoulder elevation. Significant external rotation weakness presurgery may mean that the surgeon will consider a concomitant latissimus dorsi transfer. Active forward flexion with- out external rotation may create a dysfunctional upper extremity and lead to poor patient satisfaction regardless of the intensity and effort of the patient and physical therapist following surgery. The postoperative protocol for the rTSA physical therapy re - habilitation program is divided into four phases. Each phase is based upon postoperative timelines that respect the healing pro- cess and soft tissue parameters. Progression through each phase should depend on an evaluation-based method in conjunction with healing time frames to progress a patient through the pro- tocol based on intraoperative and postoperative findings, clinical presentation, and achievement of clinical goals and milestones. 1. Phase I is the immediate postsurgical, joint protection phase. 2. Phase II is the active range of motion and early strengthening phase. 3. Phase III is the moderate strengthening phase. 4. Phase IV is the independent, progressive home program phase.
● Able to actively elevate shoulder against gravity with good mechanics to at least 120 degrees. ● If previous ROM is not met, then patient is ready to progress when patient’s ROM is consistent with outcomes for patients with given underlying pathology. PHASE IV: ADVANCED STRENGTHENING PHASE (Not to begin before 12 weeks to allow for appropriate soft tissue healing and to ensure adequate ROM and initial strength.) Goals ● Maintain nonpainful AROM. ● Enhance functional use of involved upper extremity. ● Improve muscular strength, power, and endurance. ● Gradual return to more advanced functional activities. Precautions ● Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures—no combined ER and abduction above 80 degrees of abduction.
Specifics of physical therapy rehabilitation following reverse TSA Because of the rotator cuff being absent or minimally functional following a reverse total shoulder replacement, the rehabilitation for a patient following this procedure is different than the reha- bilitation following the traditional TSA. The biomechanics of the prosthesis are different. There is inherent potential for instabil- ity because of the design, which makes the precautions for rTSA unique and different from those of TSA and a hemiarthroplasty. The surgeon, physical therapist, and patient need to consider these factors when developing a postoperative treatment plan. The surgical approach also needs to be considered when devel- oping the postoperative protocol.
Traditionally, an rTSA procedure is performed via a deltopectoral approach, which minimizes surgical trauma to the anterior deltoid. But some surgeons use a superior approach that retracts the ante- rior deltoid from the anterior lateral one-third of the clavicle. This technique allows superior exposure to the glenohumeral joint be- tween the retracted anterior deltoid and the clavicle. The anterior deltoid is sutured back to its anatomical position during surgical closure; in these cases, early deltoid activity is contraindicated. Collaboration between the surgeon and the physical therapist is essential to ensure appropriate rehabilitation following rTSA. A number of factors can affect rehabilitation, including the patient’s preoperative shoulder status, type of implant used, the glenoid and humeral bone quality, the integrity of the remaining rotator cuff, concomitant rotator cuff repair or tendon transferred, and the overall component stability at the time of the surgical reconstruc- tion. There is variability in functional and ROM outcomes following rTSA, and patients need to be reminded that their shoulder me- chanics and function will have some limitations when compared to the other shoulder. Patients who live a more active lifestyle typi - cally require greater education in regards to their restrictions to ensure proper longevity of their new prosthesis and to decrease the risk of dislocation. Key postoperative rehabilitation concepts need to be considered when outlining the care for a patient fol- lowing rTSA, including joint protection, deltoid function, and es- tablishing appropriate functional and ROM expectations. Joint protection is important for initial postoperative positioning and initial activity. There is a higher risk of shoulder dislocation following rTSA than with the conventional TSA. Patients who un- dergo rTSA can dislocate with the surgical arm in internal rotation and adduction in conjunction with extension. This high-risk posi- tion allows the prosthesis to escape anteriorly and inferiorly, which is the position of greatest vulnerability for rTSA. Certain functional activities should be avoided. Tucking in a shirt and reaching be- hind one’s hip and lower back with the operative upper extremity are dangerous activities, especially during the immediate postop- erative phase, and should be the major postoperative precautions for no less than the first 12 weeks.
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