Rehabilitation After Shoulder Arthroplasty

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Last Updated: Monday, February 4, 2013
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This is the information which might be shared with patients after a shoulder arthroplasty. Before it can be applied to a specific clinical situation however it needs to be tailored to the patient the surgery and the surgeon.

Goal of treatment

The goal of shoulder arthroplasty is to restore function to an impaired shoulder. Good shoulder function requires motion stability strength and smoothness. During the operation your doctor seeks to optimize your shoulder's motion and stability by balancing the soft tissues around your joint and releasing adhesions and contractures.

The smoothness of your joint is improved by the implantation of highly polished artificial joint surfaces. The stage is now set for you to continue the improvement in motion and stability and to develop some strength in your reconstructed shoulder with a simple but vitally important series of exercises.

Persistence and progressive improvement

The goal is to teach you how to successfully rehabilitate your shoulder. This requires the early gaining of excellent range of motion and the slow but progressive addition of strength coordination and endurance. Frequent gentle exercises have been proven much more effective than irregular forceful efforts. The goal is a smooth progression in activities without any episodes of soreness from overdoing it. Make sure that each stage of exercises can be performed comfortably and with the required number of repetitions before advancing to the next stage. If soreness does develop strengthening exercises are stopped but the range of motion exercises must be continued so that stiffness does not result. Nothing must interfere with the regular five-times-a-day conduct of the range of motion program.

Many years of shoulder disability cannot be reversed without persistent work over time on range of motion strength and coordination. The shoulder requires two years of rehabilitative exercises to reach maximal function after a shoulder replacement. If you are willing to commit to such a rehabilitative effort you will achieve maximum benefit from your shoulder arthroplasty. If you have any questions about this program please be sure to ask your doctor.

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Figure 1 - Continuous passive motion machine: motor-driven adjustable cam and pulley system
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Figure 2 - Motivation chart displays progress toward the discharge goals
Since primary goals of arthroplasty surgery are to provide motion and smoothness immediate postoperative passive motion is important. The immediate postoperative program is essentially the same as that used after the open release of a frozen shoulder. We use a simple motor-driven adjustable cam and pulley system which puts the shoulder through a 90 degree arc of flexion and a 45 degree arc of rotation. This is used for at least 24 of the first 48 postoperative hours. The patient is taught to use the opposite arm for assisted elevation and external rotation. A "motivation" chart is maintained on the wall of the patient's hospital room displaying progress toward the discharge goals of 140 degrees of elevation and 40 degrees of rotation. Grip and external rotation isometrics are started immediately. Unless a rotator cuff repair has been performed the patient is encouraged to use the shoulder as comfort permits for active elevation and activities of daily living. If rotator cuff repairs or osteotomies have been performed active motion and isometric cuff strengthening are delayed until healing has occurred.
Early motion

Early on after your operation the highest priority is maintaining the gains in motion achieved by your surgery. Because the muscles in the operated shoulder are expected to be weak after surgery one has to depend on other means to maintain the motion during the first critical weeks. We often use a passive motion machine immediately after surgery to move the arm gently through an arch of motion even while you are recovering from your anesthetic.

You will maintain and improve your shoulder reach using a routine which includes three basic maneuvers.

1. The Warm-Up Bend over letting the operated arm dangle comfortably in front of you and move it in gentle circles in a clockwise and counterclockwise direction with your hand pointing forward and with your hand pointing back. This is predominantly to loosen up the shoulder and to relax it.
2. Assisted Forward Flexion in the Supine Position Forward flexion is lifting your stiff arm up as high as it will go. To stretch your forward flexion lie flat on your back relax and grasp the wrist of the tight shoulder with your opposite hand. Here's a video of this exercise. Using the power in your opposite arm bring the stiff arm up as far as it is comfortable. Start holding it for 10 seconds and then work up to where you can hold it for a count of 100. Breathe slowly and deeply while the arm is moved. Repeat this stretch three times trying to help the arm up a little higher each time.

An alternative method of stretching to forward flexion is to use the "progressive forward lean." Here you sit beside a table shelf armchair back or other fixed object with your arm in a comfortable amount of elevation in Forward flexion. Then by leaning forward allow the fixed object to apply a gentle upward-directed force on the arm for a count of 100. The advantage of this method is that it does not require the help of the other arm and it can be sustained for a longer period of time.

3. The Pulley A pulley is mounted on a door with handles for both hands. Sit in a chair facing the door. Place one handle in the hand of the operated shoulder while it is relaxed at your side. Using the unoperated hand to pull down on the other handle gently raise the operated shoulder to a horizontal and then toward a vertical position. Again this exercise is performed with total relaxation of the operated arm. When the arm appears to stop because of stiffness you should concentrate on relaxing the operated arm trying to get even greater degrees of elevation. When you finally reach the apparent maximum in elevation hold it for a count of twenty while optimizing the relaxation.

It is essential that these range-of-motion exercises be performed at least five times a day. Maintaining the range of motion gained at surgery is one of the essential ingredients in restoring the function to your shoulder. There is no one more qualified to do that than you. Devise a system for registering your progress in these motion exercises. For example mark a spot on the bedpost that you can reach while lying on your back or mark the height on the door that you can reach with the pulley. Keeping track of your progress on a daily basis will make sure that you are moving forward and provide you with well-deserved positive feedback. Your doctor will help you keep track of your progress.

Other motion exercises are important to your rehabilitation. Your doctor will indicate the exercises you should do.

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Forward flexion

External rotation

External rotation is turning the arm out to the side while your elbow stays close to your body. External rotation is best stretched while you are lying on your back. Hold a cane yardstick broom handle or dowel in both hands. Bend both elbows to a right angle. Use steady gentle force from your normal arm to rotate the hand of the stiff shoulder out away from your body. Continue the rotation as far as it will go comfortably. Work up to holding it there for a count of 100. Repeat this exercise three times. Here's a video of this exercise.

An alternative method of stretching in external rotation is to hold onto a fixed object and gently turn your body away while holding your elbow at the side. The advantage of this method is that it does not require the help of the other arm and it can be sustained for a longer period of time.

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External rotation
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Figure 3 - Assisted forward flexion in the supine position
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Figure 4 - Progressive forward lean
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Figure 5 - External rotation while lying on back
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Figure 6 - External rotation by holding onto a fixed object
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Figure 7 - Internal rotation: Grasping a towel behind the back with both hands
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Figure 8 - Cross-body movement
Internal rotation

Internal rotation is the motion of reaching up the back. Grasp a towel behind your back in both hands. To stretch in internal rotation gently pull the hand of the stiff shoulder up your back. Work up to holding the maximum comfortable stretch for a count of 100. Repeat the exercise three times.

An alternative method of stretching in internal rotation is to hold onto a fixed object behind you with your hand as high up your back as it will easily reach. Then by bending your knees a gentle stretching force can be applied and sustained for a count of 100.

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Internal rotation

Cross-body movement

Cross body reach is reaching across your chest so that your elbow approaches your opposite shoulder. To stretch cross the body grasp the elbow of the stiff shoulder in your opposite hand and pull it toward the opposite shoulder. Work up to holding the maximum comfortable stretch for 100 seconds. Repeat the exercise three times.

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Crossbody movement

Water exercises

Water exercises are often very well tolerated by the shoulder after arthroplasty. Gentle movements of the arm in shoulder-deep water progressing slowly to swimming the breast stroke and then the crawl are very helpful in restoring strength coordination and endurance to the shoulder.

 

Comfortable activities with the operated arm are encouraged after surgery. Your doctor will determine which activites are appropriate for you at this time.

Determining appropriate activities

Your doctor will determine which of these activites are appropriate for you at this time:

  • Working on your grip by squeezing play putty foam or a tennis ball
  • Raising your hand to your face to eat and wash
  • Writing keyboarding sewing answering the telephone
  • Swinging the arm in a relaxed way at your side while walking

Fitness

Regular fitness exercise helps keep your joints supple. This "lubricating" effect is optimized if you perform a half-hour of aerobic exercise each day. This exercise may take a variety of forms including brisk walking jogging riding a stationary or mobile bicycle rowing climbing stairs or using a crosscountry skiing simulator. If you have concerns about your ability to carry out such an exercise program you should consult your general physician. It is not important that these exercises be carried out vigorously; it is only important that in addition to the stretching program a half hour of your day be devoted toward some form of aerobic exercise. Overall conditioning will have a direct positive effect on the recovery of your shoulder.

Driving

Driving is not advised after shoulder replacement until two conditions are met:

  1. it has been at least six weeks after the operation and
  2. the shoulder is comfortable enough and strong enough so that when you are standing you can raise it to the horizontal position straight out in front of you twenty times.

Using these criteria you can avoid placing the shoulder passengers other drivers and pedestrians at risk from a shoulder that cannot perform under emergency circumstances.

Strengthening of the shoulder after arthroplasty is a vital step in the restoration of function. However strengthening exercises early after the operation are not nearly as important as establishing motion. Therefore your doctor is likely to institute strengthening exercises only after you can achieve excellent motion and shoulder comfort.

Shoulders require good muscle strength and posture

After your prolonged shoulder arthritis and your shoulder replacement your muscles are expected to be weak and sore. In many cases a period of time for muscle healing is required before strengthening can be started. Please be sure that you do not do any strengthening exercises that are painful: this is NOT a "no pain no gain" situation. If you have any questions about the advisability of these strengthening exercises wait until you have checked with your doctor.

As you gain strength and coordination try to carry out progressively more of your usual activities concentrating on using smooth motions. Try to avoid actions that make your shoulder pop snap or catch. Swimming rowing and using cross country ski simulators are all good exercises for developing strength coordination and endurance. They also have the advantage of exercising both shoulders at the same time.

In general activities of the shoulder can be increased as the comfort range of motion and strength of the motion allow. It is essential that these activities be added gradually and progressively so that there is no risk of straining your muscles. A sudden increase in activity or abrupt jerky or forceful activities will jeopardize the comfort and function of your shoulder.

Progressive supine press

An important exercise is the progressive supine press. It is most effective for helping you regain the ability to use your arm in an elevated position. The nice thing about this exercise is that you can do it by yourself and can adjust your rate of progress according to what is most comfortable for you.

The exercise proceeds in small steps. Start by lying on your back grasping a washcloth with both hands together. Push the cloth straight up toward the ceiling. At the end of each push lift your entire shoulder off the bed or floor. When you can do this 20 times easily separate your hands an inch or so when you push the cloth toward the ceiling. This places slightly more of the load on the muscles of your weaker shoulder. As the exercise gets easier separate your hands more on the washcloth until you can push your hand toward the ceiling without any assistance from the opposite arm.

Practice this exercise with nothing in your hand until you are able to repeat it 20 times. Then take an empty pint container and perform the same movement pushing it toward the ceiling. Add water to increase the resistance slowly. When the container is full of water the weight is about one pound. Be sure that you can perform the movement comfortably 20 times at each stage before advancing to the next stage. When you can press one pound toward the ceiling 20 times the next step is to perform the exercise with your back propped up slightly on pillows or by using a recliner or garden chair. When 20 comfortable repetitions are possible increase the degree to which your back is propped up.

At each level push the shoulder all the way up. Continue this process until you are able to push the one pound weight 20 times toward the ceiling in a sitting position. Work for smooth slow controlled motions.

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Figure 9 - Progressive supine press
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Figure 10 - Bench press plus
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Figure 11 - Shoulder shrug
Rotator cuff muscles

The rotator cuff muscles are important shoulder muscles. They hold the ball properly aligned in the socket. They are strengthened by working against resistance in rotation internally (toward the body) and externally (away from the body). It is important that your shoulder have both strength and endurance of internal and external rotation. This means that you need to carry out at least five exercise sessions each day each taking only about five minutes. The muscles of the rotator cuff are strengthened by exercises in internal rotation and external rotation. Internal rotation (video) is strengthened by holding the elbow close to the side and trying to rotate the arm inward against resistance. This resistance can be isometric (unmoving) such as the opposite hand a wall or another fixed object. You can also use dynamic exercises against rubber tubing weights and pulleys or free weights while you lie on your side. External rotation (video) is strengthened by holding the elbow at the side and trying to rotate the arm outward against either isometric or dynamic resistance.

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Internal rotation
 
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External rotation

Trapezius and scapular muscles

A second important group of muscles the scapular muscles are those that control the posture of your shoulder blade on the chest wall. The purpose of these exercises is to strengthen these scapular muscles and to eliminate bad habits or posture that your shoulder may have developed. The largest and most important muscle groups are those which move your shoulder blade forward (the serratus and pectoralis) and those which lift the shoulder blade (the trapezius levator scapulae and rhomboids). The first group of muscles are strengthened by a bench press-type exercise performed while you lie on your back holding the bar with your hands about a meter (yard) apart. At first only the bar is used while you concentrate on powering the shoulder blade upward. When you lift your shoulder blade off the bed or table we call this the "press plus." The "plus" is important for training the shoulder blade muscles. Once you can control the bar alone for 20 repetitions add weight to the bar progressively up to about half your body weight. Never use a weight greater than what you can control for 20 repetitions. Once you feel confident in the shoulder you can start doing a one hand press using a 1 lb weight and building up to 20 percent of your body weight.

The second muscle group helps strengthen your shoulder during lifting at the side. Start with simple shoulder shrugs carried out with the arms holding some weight at the side lifting the point of your shoulders as high as they will go 20 times. It is important that both shoulders be exercised concurrently. Once the shoulder shrug becomes easy add weight 1 lb at a time to each hand keeping the number of repetitions at 20. With each shrug concentrate on lifting the tip of the shoulder.

The trapezius can also be strengthened by pulling against resistance.

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Bench press plus
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Shoulder shrug
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Pulling against resistance