21.1 Introduction

Reverse total shoulder arthroplasty is gaining more popularity as indications for its use continue to expand. Our understanding of the appropriate rehabilitation program following the procedure and the activities patients are able to perform is also expanding. In this chapter, we present the senior author’s postoperative rehabilitation protocol (► Table 21.1) and its rationale, as well as possible pitfalls to avoid. We also review the literature regarding return to activity and sports following surgery.

21.2 Rehabilitation Following Reverse Total Shoulder Arthroplasty

The rehabilitation following reverse shoulder arthroplasty for the most part follows the principles of any shoulder rehabilitation. It consists of three main phases. The first phase is a period of healing, the second phase is restoration of motion, and the third and final phase is restoration of strength and return to activities. Since most patients who undergo reverse shoulder replacement are older ¹ and may have fewer demands on their shoulder, it is important to understand the goals of the patient before proceeding with rehabilitation.

As with the rehabilitation from an anatomic shoulder replacement, the main step following the rehabilitation of reverse shoulder replacement is healing of the rotator cuff. Quite often though, the rotator cuff is completely torn prior to the procedure and, therefore, no rotator cuff repair is performed at the time of reverse shoulder arthroplasty. However, it is possible that the subscapularis was present at the time of surgery and was taken down and repaired. In this situation, protection of that subscapularis repair is needed during the rehabilitation phases. A latissimus dorsi transfer may also be concomitantly performed with a reverse shoulder replacement, ² and protecting this repair is important as well. It is important to communicate to the therapist as to whether a portion of the rotator cuff was repaired or if a tendon transfer was performed at the time of surgery.

21.3 Healing Phase

Immediately following the surgery, cryotherapy is initiated. Typically, these procedures are performed under regional nerve blocks ³ and as the nerve block wears off, concentration on hand, wrist, and elbow range of motion is initiated. The patient typically spends 2 or 3 days in the hospital following the procedure. ⁴ During that time, they will work with a physical and occupational therapist. The primary goal of working with the therapist while in the hospital is mobilization and restoration of gait. The secondary goals pertain to the shoulder. At our institution, we initiate distal range of motion including the hand, wrist, and elbow immediately after the block has worn off. Elbow range of motion is allowed even if a biceps tenodesis is performed, but will restrict resisted flexion and resisted supination to protect the long head of the biceps tenodesis. Pendulum exercises are initiated on postoperative day 1. Patients are allowed out of their sling in order to perform these exercises. Following the hospitalization, patients are typically sent home unless there are social situations at home that require them to be admitted to a subacute rehabilitation facility. Formal therapy is not initiated until after the first postoperative visit 10 to 14 days out from the surgery. From the time the patient is discharged from the hospital until the time that they follow up in the office, they will continue distal range of motion exercises, as well as pendulum exercises out of the sling, twice a day. Patients are instructed to wear their sling when not performing the exercises. Formal physical therapy is not initiated for the first 2 weeks because it is important to allow the surgical field to heal and the incision to heal. Postoperative hematoma is a complication that can occur and has been associated with early range of motion. ⁵