Shoulder Arthroplasty

Updated Evidence-Based Insights (2023–2024)

Subscapularis Protection (TSR-specific)
- In anatomic TSR, subscapularis repair is critical.
- Avoid ER beyond neutral and resisted IR for at least 6–8 weeks.
- Reverse TSR often does not involve subscapularis repair and may tolerate ER earlier.
Reverse TSR (RTSR)
- Deltoid becomes primary mover. Focus is on elevation and scapular control, not rotation.
- Internal rotation behind the back often never fully recovers — not a rehab goal.
Sling Use
- 3–4 weeks typically; may be shorter in RTSR if deltoid activation is encouraged early.
ROM Priorities
- Flexion/scaption first
- Rotation only introduced when safe, depending on subscapularis status
- Functional > full ROM
Strength and Functional Work
- Start isometrics in neutral after 6 weeks
- Progress to light resistance by 12 weeks
- Return to full overhead function by ~16–24 weeks (depending on prosthesis type)

(For both TSR and RTSR, with notes for each)

Phase	Timeline	Goals & Interventions	Avoid
Phase 1: Protection & Early ROM	0–2 weeks	– Sling (except hygiene) – Pendulums – Elbow/wrist/hand ROM – Pillow under arm in bed – TSR: Protect subscapularis – RTSR: Begin active deltoid elevation if advised	– ER beyond neutral (TSR) – ABD/ER – IR behind back – Weight through limb
Phase 2: Assisted ROM & Sling Weaning	2–4 weeks	– Begin AAROM in flexion/scaption <90° – Table slides – ER to neutral – Wean sling during day – Continue scapular setting	– ER stretch – IR/resisted IR – Long lever activities
Phase 3: ROM Progression & Isometrics	4–6 weeks	– Flexion/scaption 90–120° – Gentle isometrics in neutral – Begin CKC scapular drills – ER to 30° in TSR if subscapularis intact	– ABD/ER combo – Weight through arm in extension
Phase 4: Strength Phase	6–12 weeks	– Progress AROM – Resistance bands – Supine work – Focus on deltoid (RTSR) and cuff (TSR) – ER >30° in TSR if stable	– Overhead load – Resisted IR until 12+ weeks (TSR)
Phase 5: Functional Rehab	12–16+ weeks	– Return to functional activity – Overhead tasks, pushing, reaching – CKC & eccentric work – Compensation strategies (if RC deficient)	– Forced ROM – Returning to overhead work without strength control

Feature	TSR	RTSR
Subscapularis	Repaired → protect early	Often not repaired
Prime mover	Rotator cuff + deltoid	Deltoid
Rehab goal	Restore full ROM	Functional ROM only
IR/ER	Prioritized later	Often limited by design
Strength focus	Cuff + deltoid	Deltoid, scapular stabilizers