General Principles of Rehabilitation Following Shoulder Surgery

Fig. 9.1

(a) Shoulder flexion exercises near the table—beginning position, (b) ending position

After both arthroplasty types, isolated abduction movement in the frontal plane is avoided to prevent increased load on the posterior capsule. Initially, it is recommended to start flexion in scapular plane in supine position and continue to move in frontal plane in the following weeks [1, 2]. Particularly, it is known that performing isolated abduction increases the risk of dislocation in reverse shoulder arthroplasty with deltopectoral approach [2]. After both surgeries, while 90° of elevation is targeted for the first 4 weeks, it is aimed to reach 120° of elevation by the sixth week (Fig. 9.2a–c).

../images/429740_1_En_9_Chapter/429740_1_En_9_Fig2_HTML.png — Fig. 9.2

**(a)** Shoulder flexion exercises with ball—beginning position, **(b)** ending position

Deltoid isometric exercises at the fourth week, active joint motion at the sixth week, and IR-ER isometric exercises at the eighth week are recommended for superior approach in reverse shoulder arthroplasty [2].

If subscapularis repair is performed during shoulder arthroplasty, passive ER movement should start gradually and progress under control in 30° and 45° of abduction. IR is recommended to be initiated at the scapular plane at the sixth week after the surgery [1, 2].

Following shoulder arthroplasty, NMES can be applied to the posterior shoulder muscles and deltoid.

Six to 12 weeks after the surgery is considered as early strengthening phase. At the sixth week, active-assisted range of motion exercises start and active movements gradually replace them. Wand exercises are the most common active-assisted exercises (Fig. 9.3a–c). When it is difficult for the patient to proceed from active-assisted exercises to active movements, muscle activation needs to be increased by holding the arm independently at different angles. It is aimed to gain nearly similar active and passive range of motion by the 12th week.

../images/429740_1_En_9_Chapter/429740_1_En_9_Fig3_HTML.png — Fig. 9.3

**(a)** Shoulder flexion exercises with a stick in supine—beginning position, **(b)** ending position, **(c)** shoulder flexion exercises with a stick in standing

In the reverse shoulder arthroplasty, the primary muscle is the deltoid [2]. Depending on the design of the implant, the center of the joint is placed either inferiorly to enhance arm elevation by extending the length of deltoid or medially to facilitate external rotation. However, external rotation is limited in these patients. According to the results of a study, along with an increase in the activity level of anterior and lateral deltoid muscles, the activity of upper trapezius muscle also increases in patients with reverse shoulder arthroplasty [9]. In total shoulder arthroplasty, rotator cuff is considered as the primary muscle. One study reported that external rotation is better after total shoulder arthroplasty, and the deltoid and RC are the primary muscles in RSA and TSA, respectively [10].

In this phase, it is crucially important to increase the activation of the scapular muscles. A study comparing TSA and RSA reported that TSA results in more motion and consequently more scapulothoracic movements [11]. In RSA, however, more scapular motility is reported during arm elevation due to the increased upper trapezoidal activity [12]. Increased scapular activity has been shown to be a compensatory strategy during daily living activities. Particularly, the increased upper trapezium activity causes anterior tilting, internal rotation, and elevation of the scapula, which, in return, reduce the risk of squeezing in the scapular notch [13]. Hence, this scapular compensator movement of the patients is not attempted to be corrected. Originating from this compensational movement, clinical symptoms such as periscapular regional pain, subscapular bursitis, acromioclavicular joint problems, and scapular spine stress fractures are common among patients [13]. For these reasons, it is important to strengthen the muscles around the scapula within the rehabilitation program. Scapula retraction exercises are performed with the arms close to the trunk at sixth week (Fig. 9.4a, b). In the later phases of rehabilitation, it is important to further strengthen the muscles around the scapula.