Rehabilitation after Reverse Total Shoulder Replacement for proximal humerus fracture

The procedure is performed through a deltopectoral approach. Following implantation of the prosthesis, the greater and lesser tuberosities (with the tendon attachments of the rotator cuff) are repaired to the humeral stem with strong sutures. The tuberosities need time to heal and thus need protection until healed. Healing will be monitored with x-rays at 6-8 weeks, 12-14 weeks and at 6 months. The need to protect the tuberosities has to be balanced against the risk of stiffness and muscle atrophy associated with prolonged immobilisation. Physiotherapy supervision is essential.

0-6 weeks:

Sling use:

  • Arm in a sling for comfort.
  • The sling is mainly worn when standing and walking or when going out of the house. The sling may be removed to perform exercises, and for bathing, dressing and at meal times. The sling may also be removed when sitting in an armchair provided that the arm can be rested on an armrest with an additional pillow, if required.
  • The sling may also be removed for sleeping at night. The elbow should rest on a pillow to avoid extension of the shoulder.
  • No lifting or supporting of bodyweight with involved limb. Avoid using operated arm to push out of bed or a chair.

Exercises:

  • Perform exercises for the hand, wrist and elbow to maintain mobility as well as pendular exercises. Encourage static deltoid activation and scapular exercises with shoulder shrugs.
  • After 3 weeks encourage passive-assisted elevation in flexion to 90˚ degrees whilst lying supine.
  • Start supine 90˚ glenohumeral static joint holds.
  • Encourage table slides to achieve 90˚ of passive flexion and abduction to 45˚.
  • Perform passive external rotation to 10˚or limit specified at surgery.
  • Avoid internal rotation behind the back.
  • Encourage functional use of the arm for simple tasks such as bathing, dressing and eating.

6-12 weeks:

Sling use:

  • Reduce reliance on sling and gradually discard. May be worn sparingly when going out.

Exercises:

  • Aim to restore glenohumeral and scapulothoracic motion and control.
  • Glenohumeral active-assisted ROM
    • Active-assisted supine glenohumeral flexion to 90˚
    • Gentle supine rhythmic stabilizations at 90˚ glenohumeral flexion
    • Continue passive external rotation to 20˚.
  • Perform scapular exercises.
  • Progress to active-assisted ROM exercises including overhead elevation as tolerated.
  • May start isometrics for deltoid.
  • Avoid free weights.

After 12 weeks:

Exercises:

  • Encourage functional use of limb.
  • May increase range in all directions including overhead and reaching behind the back.
  • Loaded active glenohumeral flexion from supine (short lever) using 0.5kg weight (or bottle of water).
  • Loaded active glenohumeral flexion progressions from supine to sitting through inclines of 10˚ (short lever to long lever)
  • Continue with ROM stretches including overhead elevation using rope and pulley and promoting active control.
  • Encourage gentle stretching in external rotation.

Ref: Blacknall and Neumann: Rehabilitation following reverse total shoulder replacement; Shoulder and elbow 2011.