Physical Therapist's Guide to Total Shoulder Replacement (Arthroplasty)
Total shoulder arthroplasty (TSA), often called a total shoulder replacement, is a surgical procedure in which part or all of the shoulder joint is replaced. It is estimated that 53,000 people in the United States have shoulder replacement surgery each year, according to the Agency for Healthcare Research and Quality. That number compares to the more than 900,000 Americans a year who have knee and hip replacement surgery. Physical therapists can help patients who undergo a TSA return to their previous levels of physical activity, including fitness training, or participation in sports like swimming or golf.
What is Total Shoulder Arthroplasty?
Total shoulder arthroplasty is a surgical procedure in which part or all of the shoulder joint is replaced. It is performed on the shoulder when medical interventions, such as other conservative surgeries, medication, and physical therapy no longer provide pain relief. The decision to have a TSA is made following consultation with your orthopedic surgeon and your physical therapist.
A shoulder replacement may be needed if you have any of the following conditions affecting the shoulder, causing severe shoulder pain and limiting your ability to use the affected shoulder:
- Rheumatoid arthritis
- Severe shoulder fracture
- Rotator cuff tear
- Rotator cuff tendinitis
- Osteonecrosis of the shoulder (death of the bone tissue at the head of the humerus)
A TSA involves removing the ends of the bone at the shoulder joint, and replacing them with artificial parts. The upper part of the arm bone (humerus) is shaped like a ball; it is called the "head" of the humerus. During a TSA, the head of the humerus is replaced by a metal ball. The socket that the head of the humerus sits in is called the glenoid fossa. During a TSA, the socket is replaced by a plastic cup.
Due to various physical limitations, your orthopedic surgeon may decide that you are a candidate for another form of TSA, such as:
- Shoulder hemiarthroplasty, where only the head of the humerus is replaced with a metal ball.
- Reverse TSA, where the metal ball and plastic socket are reversed. This procedure is recommended when the rotator cuff muscles of the shoulder are damaged. The plastic socket is attached to the top of the humerus, and the metal ball is attached to the socket. This procedure allows another shoulder muscle, called the deltoid, to take over for the damaged rotator cuff muscles, improving functional range of motion, strength, and stability of the shoulder
How Can a Physical Therapist Help?
Physical therapy plays a vital role in ensuring a safe recovery by improving shoulder function, and limiting pain following a TSA. Your physical therapist will work with you prior to and following your surgery, to help you safely return to your previous levels of activity, including performing household chores, job duties, and recreational activities.
The better physical condition your shoulder is in prior to surgery, the better your recovery will be. Your physical therapist will teach you exercises to build shoulder strength, and improve your shoulder and upper back movement to keep the shoulder as strong and mobile as possible up until the time of surgery.
Your physical therapist will educate you about precautions to take after surgery, such as wearing a sling to perform all activities, and gradually beginning to safely move your arm. If you are a smoker, quitting smoking will improve your healing process.
After your TSA, you will likely stay in the hospital for 2 to 3 days. If you have other medical conditions, such as diabetes or heart disease, your hospital stay may be a few days longer. Your shoulder will be placed in a sling for the next 2 to 6 weeks; you will be advised to not move your shoulder on your own.
Your physical therapy will begin within a day or two of your surgery. A hospital physical therapist will visit your room to teach you how to perform simple tasks like brushing your teeth, and tell you what movements (such as pushing, pulling, or reaching with the affected arm) you simply cannot perform. Your physical therapist will teach you how to get in and out of bed safely, how to get the sling on and off, and how to get dressed while keeping your shoulder in a safe position. You will also learn how to minimize pain and swelling in the area by applying an ice pack, and elevating the upper arm.
You may need some help from friends or family members with daily activities for the first few days or weeks after your surgery. You will not be able to drive for the first few weeks after surgery.
As You Recover
When you are discharged from the hospital, continuation of physical therapy is essential. Your surgeon and physical therapist will work as a team to ensure your safe recovery. Your physical therapist will teach you exercises that may include:
Range-of-Motion Exercises. It is important to not move your shoulder suddenly or with any force for the first 2 to 6 weeks following surgery, to allow proper healing. Your physical therapist will passively move your shoulder in different directions to allow you to safely begin regaining movement. Your physical therapist will also teach you gentle exercises to perform at home. You will also learn range-of-motion exercises for the elbow and hand, so these joints do not get stiff from being held in a sling. Squeezing a ball or putty will help keep your grip strong, while your shoulder recovers. You will use ice packs on the shoulder and elevate your arm on pillows to allow gravity to help reduce the swelling in the shoulder, as instructed by your physical therapist.
Strengthening Exercises. As your shoulder mobility returns within a few weeks or months, your physical therapist will guide you through a shoulder strengthening program. You may use resistive bands and weights to perform gentle strengthening exercises.
Functional Training. Your physical therapist will help you regain everyday shoulder movements, such as reaching into a cupboard, reaching behind your body to tuck in your shirt, or reaching across your body to fasten a seat belt.
Job and Sport-Specific Training. Your physical therapist will design a personalized program to enable you to resume your job tasks without pain. These may include reaching, pushing, or carrying movements. You will also receive sport-specific training if you are planning to return to a sport. Your physical therapist will create a specialized home or fitness-center exercise program based on your individual needs, to be continued long after formal physical therapy has been completed.
Can this Injury or Condition be Prevented?
If you begin noticing your shoulder is painful and you are losing the ability to move your shoulder, a physical therapist can help. A properly designed exercise program can delay or even help you avoid surgery. A physical therapist will teach you specific, safe exercises to improve your shoulder flexibility and strength, and teach you how to manage your pain. Proper nutrition and physical activity will keep all of your joints healthy. Avoiding smoking is essential for proper healing and overall recovery from any injury.
Real Life Experiences
Charles is a 59-year-old golfer and swimmer with a history of osteoarthritis that began when he was 45 years old. Recently, Charles began to notice an increase in pain and difficulty when he reached overhead with his right arm. He also noticed that he couldn't throw a ball like he used to, and his shoulder was hurting during his golf swing and swim stroke. Just this month, Charles began to have difficulty shifting gears while driving, and realized that he could no longer lift his arm to reach into the cupboard to get his coffee cup. He called his doctor.
Charles's doctor took his medical history and thoroughly examined his shoulder. He diagnosed severe shoulder arthritis. He referred Charles to an orthopedic surgeon, who scheduled Charles for a TSA. Charles had a presurgery consultation with his physical therapist to learn what to expect from his recovery after surgery. His physical therapist explained how to wear and use a sling, and how to manage any pain or swelling. He also showed Charles the exercises that he would be performing.
The first day after his surgery, Charles' hospital physical therapist visited his room to teach him some deep-breathing exercises to keep his lungs inflated and reduce any risk of developing complications, such as pnemonia. She taught him how to properly use his sling, and guided him through a few gentle elbow and hand exercises. She also showed him how to safely get in and out of bed and a chair, without putting pressure on his right shoulder.
The second day after surgery, Charles' physical therapist taught him how to remove the sling safely to perform gentle pendulum exercises that helps to keep the shoulder from getting stiff. He learned how to avoid using his right shoulder at all other times, and to keep it in the sling, except when doing the pendulum exercises, and gentle elbow and hand exercises. He learned safe techniques for washing and other activities of daily living, including putting on a shirt.
The third day after surgery was Charles' last day in the hospital. His physical therapist helped him make arrangements for outpatient physical therapy.
Charles began his outpatient physical therapy just days after his TSA. His physical therapist performed passive movements with his right shoulder to ensure that it regained full mobility. She designed a home-exercise program for him, continuing the pendulum exercises and active elbow and hand exercises, as well as conservative shoulder blade squeezes.
As his shoulder strength and movement began to be restored, Charles' physical therapist added "active assisted" exercises (movement patterns assisted by a pulley or by the opposite shoulder) to gently increase his right shoulder mobility. She taught Charles how to squeeze a tennis ball a few times a day to improve his grip strength. Charles also learned how to apply an ice pack, and elevate his right shoulder at home and after each physical therapy session.
Eight weeks following his TSA, Charles was able to reach his right arm farther overhead than he was able to before his surgery!
After 12 weeks, under the guidance of his physical therapist, Charles has more shoulder motion and much less pain than he had prior to his TSA. He is able to slowly return to golf and swimming by performing his guided exercises, which target specific muscles needed to safely return to these activities. He began with gently swinging a golf club, and now he is able to perform a full golf swing.
Now, 4 months after his TSA, Charles reaches into his cupboard each Saturday morning for his coffee cup, and enjoys a healthy breakfast before heading out to the golf course for a pain-free round of golf. His scores are better than in many recent years, and he plans to lead his team to a league championship!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a total shoulder arthroplasty condition/injury. However, you may want to consider:
- A physical therapist who is experienced in treating people with an orthopedic condition/injury. Some physical therapists have a practice with an orthopedic, manual therapy, and sports medicine focus.
- A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedics physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have underlying shoulder or orthopedic conditions.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment ofcervical radiculopathy. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
ScienceDaily. Published July 13, 2009. Accessed February 11, 2015
Golant A, Christoforou D, Zuckerman JD, Kwon YW. Return to sports after shoulder arthroplasty: a survey of surgeons' preferences. J Shoulder Elbow Surg. 2012;21(4):554–560. Article Summary in PubMed.
Schumann K, Flury MP, Schwyzer HK, Simmen BR, Drerup S, Goldhahn J. Sports activity after anatomical total shoulder arthroplasty. Am J Sports Med. 2010;38(10):2097–2105. Article Summary in PubMed.
Boardman ND III, Cofield RH, Bengtson KA, Little R, Jones MC, Rowland CM. Rehabilitation after total shoulder arthroplasty. J Arthroplasty. 2001;16(4):483–486. Article Summary in PubMed.
Wirth MA, Rockwood CA Jr. Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am. 1996;78(4):603–616. Article Summary in PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Julie A. Mulcahy, PT, MPT. Reviewed by the MoveForwardPT.com editorial board.
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