Page ContentTotal Shoulder Arthroplasty/Hemiarthroplasty ProtocolThis protocol has been modified and is being used with permission from the BWH Sports and Shoulder Service.The purpose of our protocol is to provide the physician and therapist with a GUIDELINE of the postoperative therapy course after TSA or HHR. If the clinician or therapist has any questions, please consult with the referring surgeon.If additional procedures have been performed, please consult the referring surgeon. This is especially true in patients who have undergone rotator cuff repair, subscapularis augmentation with pectoralis major, revision settings and bone grafting. These patients are progressed to the next phase based on clinical exam and not length of time from surgery. Phase IImmediate Post Surgical PhaseGoalsAllow surgical inflammation to subside and allow healing of soft tissueGradual improvement in passive range of motion (PROM) of shoulder. Allow gentle active range of motion (AROM) of elbow/wrist/handDecrease muscular inhibitionGradual return to activities of daily living (ADLs) with assistance PrecautionsSling for 3 to 4 weeks at all times except for showerWhen lying supine, place small pillow under elbow to prevent shoulder extension. This will decrease tension on anterior structures, principally the subscapularis. The patient should always be able to see their elbows.NO shoulder AROM, lifting, pulling, pushingNO internal rotation or sudden external rotationNO shower for 5 days, sponge bath only – keep incision clean and dryNO soaking of wound (bath, Jacuzzi, swimming pool)No driving until sling removedPostoperative Day (POD) #1-2 (in hospital)Physical therapy with following limits: passive forward flexion in supine to tolerance, ER to 20-30 degrees (don’t force ER), IR to chest, AROM of elbow, wrist, hand (don’t force elbow extension as patients usually have had a biceps tenodesis at the time of surgery)Pendulum exercisesRecommend use of cryotherapy for pain, swelling and inflammation Phase II(O-6 Weeks)Continue previous exercisesContinue to progress PROM as motion allows following limits of surgeonBegin assisted flexion, elevation in the plane of the scapula, ER, IR in the scapular plane at 4 to 6 weeksProgress active distal extremity exercise to strengthening as appropriate If patient has not progressed with motion, DO NOT perform forceful stretching and mobilization/manipulation of tissue and joint. Rather, continue with gradual ROM and gentle mobilization (i.e. Grade I oscillations).Patient may progress to next phase when:Able to tolerate PROM programHas achieved at least 90° PROM forward flexion and elevation in the scapular planeHas achieved at least 45° PROM ER in plane of scapula or limit determined by intraoperative measurementHas achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction Phase IIAROM (6-10 weeks)GoalsRestore full passive ROMGradually restore active motionDo not overstress healing tissueRe-establish dynamic shoulder stabilityPrecautionsSling used only for sleeping, discontinued by week 8. Place pillow behind elbow so patient can see elbow at all timesNo lifting, pushing, pulling (empty tea cup is maximal weight)No supporting of body weight by hand on involved sideEarly Phase IIFocus on PROM and AROM in scapular plane continue with PROM, active assisted range of motion (AAROM)Scapular strengthening exercises as appropriateBegin assisted horizontal adductionProgress distal extremity exercises with light resistance as appropriateGentle glenohumeral and scapulothoracic joint mobilizations as indicatedInitiate glenohumeral and scapulothoracic rhythmic stabilizationContinue use of cryotherapy for pain and inflammation.Late Phase IIProgress scapular strengthening exercisesPatient may progress to next phase:Minimal painHas achieved at least 140° PROM forward flexion and elevation in the scapular plane.Has achieved at least 60+° PROM ER in plane of scapula, 70 degrees IR in 30 degrees of abductionAble to actively elevate shoulder against gravity with good mechanics to 100°. Phase IIIEarly Strengthening (10-14 weeks)GoalsGradual restoration of shoulder strength, power, and enduranceOptimize neuromuscular controlGradual return to functional activities with involved upper extremityPrecautionsNo heavy lifting of object greater than 5 lbs.No sudden lifting or pushing activitiesEarly Phase IIIContinue motion exercises, may start to improve IRResisted shoulder IR, ER in scapular planeBegin progressive supine active elevation strengthening (anterior deltoid) with light weights (1-2 lbs) at variable degrees of elevationLate Phase IIIResisted flexion, elevation in the plane of the scapula, extension (therabands / sport cords)Continue progressing IR, ER strengtheningProgress IR stretch behind back from AAROM to AROM as ROM allows (Pay particular attention as to avoid stress on the anterior capsule) Phase IVAdvanced strengthening (>14 weeks)GoalsMaintain non-painful AROMEnhance functional use of upper extremityImprove muscular strength, power and enduranceGradual return to more advanced functional activitiesPlease note patients with rheumatoid arthritis, fractures and other pathology will have different criteria for progression to the next phase. Their disease processes may limit gains when compared to other patients.