● Patient demonstrates the ability to isotonically activate all components of the deltoid and periscapular musculature and is gaining strength. PHASE III: MODERATED STRENGTHENING (weeks 12+) Goals ● Enhance functional use of operative extremity and advance functional activities. ● Enhance shoulder mechanics, muscular strength, power, and endurance. Precautions ● No lifting of objects heavier than 6 lb. with the operative up- per extremity. ● No sudden lifting or pushing activities. Weeks 12 to 16 ● Continue with previous program as indicated. ● Progress to gentle resisted flexion, elevation in standing as appropriate. Phase IV: Continued home program (4+ months postsurgery) Typically, the patient is on a HEP at this stage to be performed three or four times per week, with the focus on ● Continued strength gains. ● Continued progression toward a return to functional and recreational activities within limits, as identified by progress made during rehabilitation and outline by the surgeon and physical therapist. Criteria for discharge from skilled therapy Patient is able to maintain pain-free shoulder AROM, demonstrat- ing proper shoulder mechanics, typically, 80 to 120 degrees el- evation with functional ER of about 30 degrees. soft-tissue tensioning and component positioning are critical in the prevention of postoperative instability. Glenohumeral instabil- ity is the second-leading cause of complications associated with TSA (Bohsali, Wirth, &. Rockwood Jr., 2006). Instability can oc- cur in the anterior, superior, posterior, and inferior aspects of the shoulder following TSA. Periprosthetic humeral fracture can also occur following an un- constrained TSA, as well as intraoperative fractures of humerus or glenoid during surgery. Postoperative fractures are also present following TSA. Rotator cuff tears can also occur following this sur- gery and will complicate the rehabilitation process. Other complications may include neural injuries, infection, and deltoid muscle dysfunction secondary to an axillary nerve injury or deltoid muscle detachment. These types of injuries may lead to poor outcomes following TSA, and there can be a catastrophic loss of shoulder function following these types of complications. The rTSA has shown promising short-term results for the treat- ment of glenohumeral arthritis and massive rotator cuff tears and as a salvage procedure following failure of unconstrained TSA. shoulder flexion, abduction, and adduction ROM in performing the four ADLs. The ROM that was used for performing flexion, and extension did not change significantly from presurgery to postsurgery. The results of this study showed that TSA improves the ROM in ADLs. But when performing ADLs, TSA patients do not use the maximum available ROM in flexion, abduction, and adduction. In the analysis of ROM used for ADLs of the TSA pa- tients, it was determined that for combing hair, the participants used at least 73 degrees of glenohumeral elevation, which was comparable to the control groups. A study by Magermans and colleagues showed between a 20 de- gree and 100 degree use of glenohumeral elevation. This shows that the results of this study were comparable to the published data. Postsurgery, TSA usually allows patients to perform all re- quired ADLs painlessly. TSA patients were found to not be using their maximal available abduction ROM to perform ADLs at three
Weeks 6 to 8 ● Continue with PROM program.
● Begin shoulder active assisted ROM/AROM as appropriate. ○ Forward flexion and elevation in scapular plane in supine with progression to sitting and standing. ○ ER and IR in the scapular plane in supine with progression to sitting and standing. ● Begin gentle glenohumeral IR and ER submaximal pain-free isometrics. ● Initiate gentle scapulothoracic rhythmic stabilization and al- ternating isometrics in supine as appropriate. Begin gentle periscapular submaximal pain-free isotonic strengthening ex- ercises, typically toward the end of the eighth week. ● Progress strengthening of the elbow, wrist, and hand. ● Gentle glenohumeral and scapulothoracic joint mobilizations as indicated (Grades I and II). ● Continue use of cryotherapy as needed. ● Patient may begin to use hand of operative extremity for feed- ing and light ADLs. Weeks 9 to 12 ● Continue with previous exercise and functional activity pro- gression. ● Begin AROM supine forward flexion and elevation in the plane of the scapula with light weights (1 to 3 lb.) at varying degrees of trunk elevation as appropriate, for example, supine lawn chair progression with progression to sitting and standing. ● Progress to gentle glenohumeral IR and ER isotonic strength- ening exercises.
Criteria for progression to phase III ● Improving function of the shoulder.
Complications related to surgical procedures Complications can arise following TSA surgery, including implant loosening, dislocation, fracture, and persistent pain, which are more common in younger patients. Rates of complications associ- ated with TSA vary a great deal. The risks of shoulder arthroplasty need to be balanced against expected improvements for each individual patient, especially in older patients because of the high variability of complications that could occur. Component loosening of the glenoid and humeral components is a common event, and a majority of cases of loosening involved failure of the fixation of the glenoid component. Another issue that can occur is a mismatch between the glenoid and the humer- al head, which can lead to increased joint translation. The humeral component loosening can also be a complication of the surgery. Following TSA, stability of the glenohumeral joint is provided by the interplay of mechanisms that promote range of motion and purposeful function. Moderate loads placed on the shoulder joint are counteracted by the deltoid muscle and the rotator cuff. Large loads are counterbalanced by capsulolabral structure and bone structure. TSA can alter these complex interactions; as a result, Surgical outcomes of TSA and reverse TSA Motion analysis of the shoulder can be challenging because of the high range of motion of the shoulder. The clinical gold stan- dard of measuring shoulder range of motion is the goniometer. One study looked at motion patterns in activities of daily living at a three-year longitudinal follow-up after a total shoulder arthro- plasty. In this study, the control groups had no shoulder condi- tions at the time of examination upon study entry. No surgery was performed on the controls. The TSA group consisted of 10 patients with an intact rotator cuff who underwent TSA for primary glenohumeral OA and were examined the day before surgery and six months and three years after the shoulder replacement. Six months following surgery, almost all of the TSA patients were able to perform four ADLs. Three years postsurgery, all patients were able to carry out all ADLs. Although patients were able to perform all ADLs, the results of this study showed that they did not fully use the available maximum
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