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Shoulder
Replacement Therapy Rehabilitation Protocol
PREOPERATIVE PHYSICAL THERAPY:
MD: Prescription for out-patient pre-op appointment.
P.T.: Instruct patient in HEP - handout issued Pre-op P.T. evaluation to establish
baseline function Schedule post-op out-patient appointment for 7 days after proposed
surgery date
INPATIENT PHYSICAL THERAPY:
MD: Sign consult in chart to begin in-patient P.T. Issue prescription for out-patient
P.T., to begin post-op day #7
The prescription for Out-Patient Therapy:
1. Indicates the patient's diagnosis and rehab category, which falls into two
main groups:
Regular Program: After total shoulder replacement or hemiarthroplasty for most
conditions not associated with rotator cuff repair nor a fracture.
Limited Program: After total shoulder replacement or hemiarthroplasty which involved
a rotator cuff repair, or was done for a fracture. In this group, therapy is
aimed at maintaining joint stability by achieving less motion with reasonable
strength and function.
2. Indicates on the prescription form the amount of external rotation seen passively
at surgery to guide the initial passive motions phase of therapy.
P.T.:
• Instruct in sling or shoulder
immobilizer use
• Instruct
in AROM exercises; elbow, wrist, hand, and (Codmans as appropriate)
usually days 2
• Instruct
in regular icing techniques or cold therapy device (use as
much as possible out of 24 hours for 8-10 days)
• Monitor
for edema in forearm, hand, or finger
OUTPATIENT THERAPY
Phase I:
Post-Op day 7 - Week 4
Goals: decrease pain, decrease edema, increase shoulder motion, and educate regarding
joint protection
1. Passive range of motion (PROM) - limit external rotation to amount specified
on the prescription, and aim for 0 to 90 degrees of forward flexion by the end
of 2 weeks. From day 1 patients with a total shoulder replacement may do active
shoulder flexion in front of the plane of the scapula as pain allows.
2. Pendulum exercises - with the arm down at the side, the patient gently swings
the hand forward and backward, then side to side, and then clockwise and counterclockwise.
3. Active motion - initially, only the elbow, wrist and hand. Active shoulder
flexion as pain allows. Also work with the patient on grasping and gripping lightweight
objects.
4. Ice packs for 20 - 30 minutes intervals, especially at the end of the exercise
session; use home cold therapy device as much as possible out of 24 hours, for
8 - 10 days.
5. After 2 weeks begin isometric exercises: include isometric flexion, extension,
abduction, adduction, and internal and external rotation.
6. At Week 3 begin rope and pulley exercise.
7. Include aerobic exercises as medical condition permits since overall conditioning
will positively influence shoulder recovery.
8. Provide the patient with instructions for home exercises; instruct patient
on home use of sling or immobilizer outside of clothing.
9. Patient can generally use arm to eat, read, etc. in front of body (anterior
to plane of scapula) when feels comfortable lifts nothing heavier than a coffee
cup. There is no limit to forward flexion actively for patients with a total
shoulder replacement.
PHASE 2:
Weeks 5 - 10
Goals: decrease pain, increase active shoulder motion, begin to increase strength,
and improve functional activities. 1. Continue PROM exercises, and gently increase
external rotation as tolerated.
2. Continue pendulum exercises.
3. Begin AROM and AAROM (canes), limited to painfree arcs.
• assisted
elevation supine using uninvolved arm to assist.
• assisted
external rotation supine.
• assisted
flexion and extension of the shoulder.
• encourage
motion in flexion without scapular compensation
4. Wall walking with hands for forward flexion and elevation.
5. Continue isometrics.
6. Use exercise tubing emphasizing internal/external rotation, keeping elbow
at about 90 degrees.
7. May begin light weight (<5 lbs.) strengthening of only the biceps and triceps
(elbow motion). Elbow supported as needed.
8. Add scapular muscle strengthening exercise (trapezius, serratus anterior,
rhomboids and latissimus dorsi muscles).
9. Continue aerobic training as medical condition permits.
10. Continue ice, may add warmth, massage, and water exercises when indicated.
Ice after exercise and any athletic activity
11. Provide the patient with instructions for home therapy.
PHASE 3:
Week 11 and on Goals: progress active motion, increase musculature and strength,
and improve coordinated control of the shoulder for daily activities and work.
1. Continue to progress all elements from Phase 2.
2. Emphasize rope and pulley (flexion, abduction, and elevation) and exercise
tubing (internal and external rotation) to gradually increase range of motion.
• goal
for elevation - about 140 degrees (limited program - about
90 degrees).
• goal
for external rotation - about 40 degrees (limited program -
about 20 degrees).
• goal
for internal rotation - thumb to approx. L2 level (limited
program - about L5 level).
3. May begin light weight (<5lbs.) strengthening of the shoulder muscles (flexion,
extension, abduction, internal and external rotation) in addition to previous
biceps and triceps.
4. Continue aerobic training as tolerated, and modalities as appropriate.
5. Continue to progress home program.
NOTES:
1. With proper exercise motion, strength, and function continue to improve even
after one year.
2. The complication rate after surgery is about 5 - 8%. Listed complications
include infection, fracture, heterotopic bone formation, nerve injury, instability,
rotator cuff tear, and tuberosity nonunion. Therefore, look for clinical signs
and any unusual symptoms or lack of progress with therapy and report those to
the surgeon.
3. The therapy plan above only serves as a guide. Please be aware of specific
individualized patient instructions as written on the prescription or through
discussions with the surgeon.
