INTRODUCTION AND EPIDEMIOLOGY
Joint replacement (arthroplasty) is a viable surgical option for individuals with pain and/or impairments of the shoulder related to arthropathy or joint disease that have been refractory to conservative treatment measures. In fact, the shoulder is the third most common region requiring joint replacement trailing the knee and hip, respectively (14). The number of shoulder arthroplasties performed annually in the United States increased dramatically (from 18,621 to 46,951) between 2000 and 2008 and is expected to reach 100,000 by 2020 given the increased aging population (14,15,31).
Traditional total shoulder arthroplasty (TSA) is indicated for individuals with degenerative glenohumeral joint osteoarthritis; however, positive outcomes are in part dependent upon an intact rotator cuff or a rotator cuff that is repairable. Although it is beyond the scope of this article to discuss traditional TSA, readers are encouraged to review the article by Salamh and Speer (29).
The most common indication for a reverse total shoulder arthroplasty (rTSA) is glenohumeral osteoarthritis in combination with a massive irreparable rotator cuff tear (Figure 1) ultimately resulting in pseudoparalysis (inability to raise the arm significantly due to a massive irreparable rotator cuff tear) of the arm (9,11,13,25,32). Specifically, the rotator cuff muscles responsible for elevating and externally rotating the arm are unable to be repaired. Other indications for rTSA include, but are not limited to failed TSA, failed hemiarthroplasty (partial shoulder replacement), fracture sequelae, instability, and tumors (2,3,8,9,11,12,16,18–20,22,33,34). Of the individuals undergoing shoulder arthroplasty, two-thirds are older than 65 years (15) and often have chronic preoperative impairments such as loss of range of motion, and the inability to raise their arm above their head. This will persist well beyond the patient's discharge from formal medical care and rehabilitation. In many instances, patients will turn to other professionals with knowledge of exercise after being discharged from formal rehabilitation services. It is in these cases that the strength and conditioning professional, with an understanding of postrehabilitation guidelines, may find themselves an important resource for prospective clients.
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Figure 1: Radiograph showing significant glenohumeral joint osteoarthritis and rotator cuff arthropathy.
The purpose of this article is to provide the strength and conditioning professional with an overview of postrehabilitation considerations for clients that have had the rTSA procedure, as it differs greatly from a traditional TSA and is often associated with lower overall expectations. A brief discussion of perioperative procedures as well as review of available evidence surrounding this topic will lay the groundwork for a discussion of postrehabilitation exercise programming. Progression and advancement of postrehabilitation variables will be highlighted in the context of safety and consensus.
SURGICAL TECHNIQUE AND IMPLICATION
Various surgical techniques as well as a variety of prosthetic designs exist for performing rTSA. Regardless of surgical technique, and to some degree prosthetic design, rTSA has been shown to dramatically reduce pain, increase function, and yield improvements in shoulder-specific measures of function such as range of motion and decreased pain (13,17,24,25,28).
The purpose of the rTSA is to replace the affected articulating joint surfaces with prosthetic components while reversing the natural glenohumeral joint biomechanics to allow for greater shoulder function. The obvious difference between a conventional TSA and rTSA is the convex humeral head is replaced with a concave component and the concave glenoid is replaced with a convex component in rTSA (Figure 2). Reversing the articulating surfaces in this manner shifts the center of rotation within the glenohumeral joint more medially and distally allowing for increased activation of the deltoid and ultimately improves function regarding shoulder elevation (reaching overhead) (13,24,25,32). The humeral component is a metal implant that is either press fit (driven into) into the humerus or cemented much like a conventional TSA except it contains a polyethylene convex humeral cup that acts as the articulating surface. The glenoid component consists of a metal baseplate with a central screw and usually 2–4 additional screws to allow for fixation to the glenoid. A metal glenosphere is then fixed to the baseplate once it is secured (Figure 3). With screw fixation of the baseplate to the glenoid, particular attention is necessary for placement of the central screw given the narrow width and depth of the bone surrounding the glenoid, which can be further compromised with the presence of osteoarthritis. Also, bone ingrowth is not predictable with use of screw fixation.
Figure 2: Radiograph showing anterior to posterior view of (A) Reverse total shoulder arthroplasty demonstrating the concave humeral component (white arrow) and convex glenoid component (red arrow) and (B) Total shoulder arthroplasty demonstrating the convex humeral component (white arrow) polyethylene concave glenoid component (black arrow).
Figure 3: Reverse total shoulder arthroplasty prosthetic components (courtesy: Arthrex Inc).
Procedures for rTSA vary from surgeon to surgeon, however, postoperative considerations and precautions are often similar and based upon evidence, injury reports, and consensus (5,7,35). An understanding of the surgical procedure is necessary to appreciate the postoperative restrictions as well as persistent impairments that the strength and conditioning professional may encounter.
The procedure generally is initiated with an incision starting just lateral to the coracoid process and extending 10–15 cm distally (down) along the anterior upper arm (Figure 4). An interval is then created between the deltoid and pectoralis major muscles and the deltoid is moved laterally (some surgeons prefer a superolateral approach, which is thought to lower the potential for dislocation but may not be desirable due to less visibility) (24). A portion of the pectoralis major tendon and latissimus dorsi tendon is then incised or released where they attach to the proximal humerus. A tenotomy (cutting of the tendon) is performed to the tendon of the long head of the biceps, which may or may not be reattached at the conclusion of surgery. A subscapularis tenotomy must be performed where it attaches to the humerus in order for the surgeon to access the glenohumeral joint, if the subscapularis is still intact. The remaining rotator cuff musculature that is still intact will remain untouched throughout the entire surgical procedure. At this point, the shoulder is progressively externally rotated and dislocated anteriorly.
Figure 4: Incision line for reverse total shoulder arthroplasty.
An oscillating saw is used to make a cut along the anatomical neck of the proximal humerus. The humerus is then sized for the appropriate stem (Figure 3), and this is press fit into the medullary canal of the humerus, most often times without the use of cement or any additional hardware. The glenoid is then reamed (shaped) to fit the shape of the glenoid component. Careful attention is needed to assess the amount of bone stock when placing the glenoid component. The glenoid component (Figure 3) consists of a baseplate with a central screw and usually an additional 2–4 screws, depending on the prosthetic device used, to affix the baseplate to the glenoid as well as a metal glenosphere that is then fixed to the baseplate.
The joint is then relocated into normal position and examined for appropriate fit of the prosthetic components. At this time, any other warranted procedures are performed such as capsular releases (cutting of the shoulder capsule). The subscapularis, pectoralis major, and latissimus dorsi muscles are then repaired (sutured back to their original insertion) and the deltopectoral interval closed. A postoperative radiograph of a right rTSA can be seen in Figure 2A.
POSTSURGICAL REHABILITATION
Physical therapists are the primary rehabilitation providers throughout the perioperative and postoperative care after rTSA. Physical therapists integrate a patient care model where they independently examine, evaluate, posit a prognosis, and provide interventions in an attempt to optimize outcomes following these procedures (1). Physical therapists must recognize that surgeons often have strict postoperative protocols that patients must follow and remain aware of these when determining interventions.
The progressive rehabilitation protocol after rTSA is primarily designed to protect the repair of the subscapularis tendon that was released and then repaired during the surgical procedure. While some may feel as though the progression and length of rehabilitation is due to placement of the prosthetic components, it is more often due to soft tissue structures compromised and repaired to access the glenohumeral joint during surgery. The prosthesis is stable when the patient leaves the operating room barring any complications; however, soft tissue takes considerable time to heal warranting restricted activities.
The literature discussing the rehabilitation process after rTSA is limited and largely based on consensus (5). Among the available literature, Boudreau et al. (5) outlined a rehabilitation program that consisted of 4 phases of rehabilitation with 3 main goals that include protection of the joint, activation of the deltoid, and establishing functional range of motion. It is essential for the strength and conditioning professional to have an understanding of the nature of the postoperative activity progression to better understand the conservative basis in the postrehabilitation phase. To follow is an overview (Table) of a postoperative protocol based on research, consensus as well as the authors' experience. Be aware that surgeons may have different protocols, and this is not intended for use with all patients after rTSA. Direct communication with the client's surgeon and physical therapist is advised.
Table: Postoperative milestones after reverse total shoulder arthroplasty
The first phase begins immediately after surgery and spans until the sixth postoperative week. All patients will be placed in a sling with many having an additional pillow (abduction pillow) between their elbow and side. The amount of time recommended for sling wear depends on whether or not the subscapularis was repaired during the surgical procedure. If the subscapularis was repaired, then a longer period of immobilization is typically recommended, which may be up to 6 weeks. Motion during this first phase is restricted to passive range of motion only while limiting external rotation to 30°, and flexion to 90° (preferable in the scapular plane) at the latter part of this stage. Additionally, patients are advised to avoid any lifting, movement into extension, and those activities requiring the hand to be placed on the back (Figure 5).
Figure 5: Hand behind the back position.
The second phase consists of the time from the sixth postoperative week to the twelfth postoperative week. During this phase, the progression from passive range of motion to active range of motion is made. This often begins with active assistive motions and close monitoring to ensure proper shoulder mechanics while attempting to provide dynamic shoulder stability. It is also in this stage that gentle submaximal isometric exercises concentrating on the deltoid, periscapular muscles, and the rotator cuff (if any of the rotator cuff musculature is intact). Precautions include limiting internal and external rotation, avoiding shoulder extension beyond neutral, and avoiding reaching toward a back pocket.
Phase 3 occurs at week 12 postoperatively and continues to progress strengthening if the individual is able to demonstrate appropriate shoulder muscle activation while maintaining proper form and shoulder mechanics. The focus remains on strengthening the deltoid and periscapular muscles in a pain-free manner to allow for greater functional use of the shoulder. At this time, many surgeons allow patients to move into previously restricted directions (3); however, each surgeon may have their own preferences.
The final phase, phase 4, is 4 months postoperative and beyond. At this time, the individual should be able to demonstrate pain-free shoulder active range of motion with functional activities. The individual should also demonstrate an understanding of the importance of a continued home exercise program and be able to demonstrate these exercises in a pain-free manner with good form. It is at this time that these individuals may find themselves seeking consultation from strength and conditioning professionals, as they transition to a more independent exercise program. Generally, precautions and limitations that should be adhered to indefinitely include, but are not limited to; no extension beyond neutral, no sudden motions involving pushing, pulling, and or lifting, as well as a lifting limit of 10–15 pounds in either upper extremity (5). It is important to note that precautions and limitations vary from surgeon to surgeon and among each individual.
POSTREHABILITATION COORDINATION OF CARE
Although physical therapists technically provide the rehabilitation care for individuals as they continue to have functional limitations related to initial illness, injury, or surgery, they are often limited in their ability to guide a patient to complete recovery for various reasons (6). In this instance, the physical therapist will counsel the patient and encourage them to pursue activities that will further improve their function and quality of life. Patients at this stage are often faced with the challenge of bridging activities from a regimented, health care professional driven rehabilitation process to a self-guided program (6). The transition to an independent program may be quite daunting to the patient who is unfamiliar with the principles of safe and effective exercise. This provides an opportunity for the strength and conditioning professional familiar with rTSA to bridge this gap. An open line of communication between the physical therapist and strength and conditioning professional can allow the patient to achieve their full potential after rTSA.
POSTREHABILITATION EXERCISE CONSIDERATIONS
RESIDUAL IMPAIRMENTS
When designing a postrehabilitation program for individuals having undergone rTSA, it is imperative to have a good understanding of the most common residual impairments after rTSA. The majority of individuals undergoing rTSA have an irreparable posterior rotator cuff (supraspinatus, infraspinatus, and possibly teres minor), which cannot be corrected surgically. At best, these individuals may have the teres minor still intact and possibly the subscapularis (5). Thus, these individuals will have to depend primarily on the deltoid musculature during shoulder elevation tasks and may have little to no ability to actively externally rotate the shoulder. This means that the emphasis in shoulder strengthening is no longer on the rotator cuff, as is the case with a majority of individuals with shoulder pathology, but instead shifts to the deltoid and periscapular musculature. It should be recognized that a more frequent complication after rTSA is stress fracture of the acromion process, which may occur in cases of overzealous deltoid strengthening (24,36).
Full active range of motion is not expected after rTSA, and the amount of both passive and active shoulder range of motion expected postoperatively is dependent on the preoperative condition of the shoulder and its surrounding musculature. Based on the authors' experience and current evidence, patients can generally expect a peak range of 120° with shoulder elevation, which is functional for most activities of daily living and household tasks, however, is inadequate to safely perform weight-training activities such as latissimus pull-downs or shoulder presses (4). This further emphasizes the importance of communication between the strength and conditioning professional, physical therapist, and surgeon given that the expectations for range of motion differ from one individual to another.
When considering range of motion restoration after rTSA, it is important to note that one of the most common postoperative complications is anterior dislocations. This is due to the vulnerability of the soft tissue from the anterior incision and surgical procedure, which involves an anterior dislocation of the glenohumeral joint. In fact, the incidence of instability has been reported between 2.4% and 31% regarding postoperative complications (5,11,28,36). The muscle bulk of the subscapularis provides a passive restraint that resists anterior dislocations. Anterior dislocations have been associated with insufficiency of the inferior portion of the subscapularis muscle (23). It is for this reason that combined motion activities such as reaching behind ones low back to tuck in a shirt or grab a wallet should be done with caution and no earlier than 12 weeks. Another potential limitation that has been alluded to previously is the integrity and function of the repaired subscapularis, if it is reparable. Given that during the surgical procedure, 1 or 2 of the main internal rotators of the glenohumeral joint, the subscapularis (if it is still intact), and pectoralis major, were incised and repaired, it is very common to see individuals with weakness in isolated internal rotation as discussed earlier. Protection of the subscapularis (so that it can adequately heal) often involves avoidance of resisted internal rotation and the combined abduction, horizontal extension, and external rotation position also referred to as the 90/90 or high-five position (Figure 6).
Figure 6: Shoulder in combined abduction, horizontal extension, and external rotation, also referred to as the 90/90 position.
COMPLICATIONS
Formal postoperative rehabilitation programs follow a particular progression of avoidance and protection of specific motions that are gradually lifted as the individual advances through the process. However, it is imperative that the strength and conditioning professional be aware of these precautions when designing a postrehabilitation program and that only the surgeon is in the best position to safely lift a precaution. Specific to rTSA, the strength and conditioning professional should be cognizant of the potential for dislocation as well as activities that may cause premature wear to prosthetic components.
SUBLUXATION/DISLOCATION
Zumstein et al. (36) performed a systematic review of the literature and reported that 7% of postoperative complications or problems after rTSA involved instability, second only to scapular notching in 782 cases. Subluxation and or dislocation after rTSA most commonly occurs anteriorly. Anterior subluxation and or dislocation after rTSA can be seen early in the rehabilitation process secondary to inadequate protection of the joint due to the weakness of the soft tissue. The integrity of the subscapularis preoperatively varies among individuals undergoing rTSA. If the subscapularis is no longer intact and irreparable, then it is unable to play a role in anterior shoulder stability. In the later stages, anterior subluxations, although rare, can be the result of posterior shoulder tightness in combination with or in isolation of decreased integrity of the subscapularis. This will most likely occur in positions of combined abduction, horizontal extension, and external rotation of the shoulder (Figure 6) as well as with internal rotation and adduction. Moreover, given the biomechanics of rTSA, combined motions may render the prosthetic joint unstable and eventually lead to dislocation. It is for this reason that reaching toward the back pocket, extending the arm beyond neutral as well as the high-five position is often limited by the surgeon for an undetermined amount of time. Although these limitations may seem rather strict, they are inconsequential for many as it is rare to be able to achieve extremes of motion such as the aforementioned positions after rTSA.
Given the risk for both anterior subluxation and or dislocation, it is important that these risk factors be evaluated before the implementation of a postrehabilitation program.
COMPONENT WEAR AND LOOSENING
Failure (loosening) and wear of the glenoid and humeral components was found to be responsible for 21% of postoperative complications after rTSA as reported in a systematic review of the literature by Zumstein et al. (36). Component failure can result in decreased function, increased pain, and need for further surgery. Numerous variables can contribute to premature glenoid failure, some of which physical therapists and strength and conditioning professionals can help to mitigate by using a progressive postrehabilitation program at a moderate activity level using low resistance and high repetitions. Weight bearing through the shoulder prosthesis during closed chain exercises such as push-ups and dips as well as extremes of motion during activities such as reaching toward the back pocket have all been shown to contribute to glenoid loosening after shoulder arthroplasty and should be avoided (7,10,21,26). Postoperatively, strength and conditioning professionals must recognize that there is a balance between the amount of activity needed to maintain muscular strength, function, and overall fitness with the amount and type of activity that could potentially lead to premature prosthetic wear (5). More specific questions regarding a particular individual's precautions as well as their recommended activity level can be answered by their physical therapist or surgeon.
EXERCISE PROGRAM DEVELOPMENT
There is little evidence that has investigated specific postrehabilitation exercise considerations for individuals who have undergone rTSA outside of general postoperative protocols. The following are recommendations based on the residual impairments that may be present among these individuals, current literature, and the authors' experience. The strength and conditioning professional should refer to the physical therapist and orthopedic surgeon regarding both the timing and type of certain activities appropriate for each patient after rTSA.
RESISTANCE TRAINING
Resistance training is a key component of a postrehabilitation program for individuals after rTSA. Many individuals may still have muscle performance deficits that would benefit from a regular resistance program targeting specific musculature or simply to maintain what strength they have gained during their rehabilitative efforts. Even in the later stages of rehabilitation, the shoulder, as a whole, is weak given the chronic nature of their shoulder pathology and rotator cuff arthropathy. When strengthening is appropriate after rTSA, the focus is on developing the strength within the deltoid and periscapular musculature to improve overall shoulder function and in most cases gain active elevation between 80 and 120° (5). It is important, however, to recognize that acromion process stress fractures may occur with unreasonable deltoid loading, thus, clear communication with the client and their symptoms is necessary. Soreness at the acromion process (tip of shoulder) and a decrease in overhead mobility may be suggestive of a complication and necessitates referral back to the surgeon.
An important element to consider among individuals after rTSA is that their ability to perform active external rotation of the shoulder may be very limited or nonexistent. This is due to the fact that the infraspinatus is not intact among these individuals, and if the teres minor is still intact, it has most often undergone degenerative changes and is unable to produce a great amount of force. It is important that both the individuals having undergone rTSA as well as the strength and conditioning professional have realistic expectations regarding this as an exercise program is being developed.
When developing exercises to target the subscapularis, form is critical among this population. Among individuals with significant internal rotation weakness, one must attempt to optimize subscapularis activation while avoiding compensatory mechanisms. Strengthening the pectoralis major, latissimus dorsi, and teres major can also improve internal rotation. A majority of these individuals will not be able to tolerate any more resistance than that of a thin elastic band and in severe cases of weakness, may only be able to perform isometric activation without altered mechanics for several months. Those with an ability to tolerate resistance provided by thin elastic bands may progress to more advanced exercises with strict adherence to form. As with any resistance program, proper warm-up and flexibility exercises can help to reduce the risk of potential injury. It is important to keep in mind that most of these patients will not have adequate mobility to perform certain exercises such as latissimus pull-downs or pectoral fly machine, thus, safe alternatives such as seated row or seated chest press may be used as a substitute provided range of motion precautions are adhered to (avoiding bringing the elbows back past the torso).
Another common area of weakness observed among individuals with shoulder pathology is that of the periscapular muscles (rhomboids, upper, middle, and lower trapezius, and latissimus dorsi). When targeting these muscles, it is important to realize that these individuals may also have concomitant degenerative joint disease in the cervical spine (30). Many exercises designed to strengthen this area are performed in prone (lying on stomach) or standing. Caution must be taken when performing these exercises, as there is the potential for anterior dislocation if the shoulder is allowed to move into extension beyond neutral (Figure 7). It is important to ensure that individuals are able to move through the entire range of available motion without altered shoulder mechanics or pain before resistance is added. More advanced exercises may ensue once good periscapular strength is present in conjunction with the strength and stability provided by the teres minor, subscapularis, and deltoid muscles.
Figure 7: Shoulder moving beyond neutral extension while in prone.
An area of particular importance after rTSA regarding strengthening is the deltoid. Electromyographic studies have shown that after rTSA, both the deltoid and upper trapezius activation is increased during active range of motion when compared with nonpathologic shoulders (24,32). This means the deltoid and upper trapezius are working harder but producing less motion given the altered biomechanics of the glenohumeral joint. It is important for the strength and conditioning professional to understand the biomechanical changes of the shoulder that occur allowing the deltoid to optimally function as an agonist during shoulder elevation activity (24,32). Since the deltoid's role changes, caution must be taken when training the muscle and avoiding overuse. When performing deltoid exercises, proper form must be used to ensure the optimal firing pattern for the deltoid and periscapular musculature. When motions are performed in the scapular plane, structures of the glenohumeral joint, particularly the supraspinatus and deltoid, are aligned optimally to perform shoulder elevation (27). A common problem during postoperative shoulder strengthening among this population is the occurrence of an acromial stress fracture (5,11,36), which further emphasizes the need for communication between the strength and conditioning professional, the treating physical therapist, and surgeon to closely monitor the individuals tolerance for activity.
It is also important to realize that a majority of individuals undergoing rTSA have been dealing with pain and limitations in the shoulder for several years. The chronic and severe nature of shoulder pathologies warranting rTSA lends itself to a myriad of deficits associated with the shoulder and neck. These individuals will most likely present with weakness in the periscapular musculature, and stiffness throughout the joint ultimately leading to poor mechanics. The strength and conditioning professional must understand that these factors will most likely still be present to some degree while participating in a postrehabilitation exercise program.
In addition to the information presented above, there are certain exercises and or positions that are advised against when performing resistance exercises in this population. The authors recommend that individuals do not use resistance bands above their head or >120°. Generally, the use of machines is preferred to free weights among these individuals, as there is a concern with shoulder instability. However, the client may require some adjustment of machines as the operative arm is typically longer after the surgery. The use of machines allows for the motion of the exercise to be more confined, whereas free weights will rely more heavily on the intrinsic shoulder musculature for stabilization, which may be weak in these individuals.
Overall, developing a resistance program that focuses on strengthening the deltoid, periscapular muscles, and rotator cuff (e.g., teres minor, subscapularis) while ensuring proper shoulder mechanics and being aware of compromising positions can help individuals improve their overall function after rTSA.
FLEXIBILITY EXERCISE
Flexibility is an important component that should be considered when developing a strength and conditioning program for individuals having undergone rTSA. However, unlike a traditional TSA, it is not expected that individuals will achieve full range of motion after rTSA. As mentioned above, the strength and conditioning professional can expect an average maximum range of 120° for elevation in these clients. Much of this is dependent on the state of their shoulder before surgery and what can be achieved during their rehabilitative efforts postoperatively. It is this variability in range of motion goals that makes it imperative to have considerable communication between the physical therapist and strength and conditioning professional regarding each case. Acceptable soft tissue management may include myofascial release, soft tissue mobilization, but should not involve stretching of the prosthetic joint. It is for this reason that individuals are advised not to perform motions that involve combined shoulder abduction, horizontal extension, and external rotation as seen with exercises such as military press (behind or in front of the neck), traditional rear squats, latissimus pull-downs, and straight bar bench press.
Communication between the physical therapist and strength and conditioning professional regarding the areas of shoulder tightness for each individual can help promote an effective and comprehensive flexibility program while maintaining shoulder integrity.
RETURN TO SPORT
The orthopedic surgeon should be consulted before individuals attempting to return to recreation sports or activities. Much of this is dependent on surgeon preference.
CONCLUSIONS
The number of joint replacement surgeries performed annually continues to rise and will most likely continue to do so in years to come. Individuals who have undergone rTSA often require an extensive bout of care to improve shoulder function because the preoperative condition was so chronic. Although a formal rehabilitation program carried out by a physical therapist has been shown effective at allowing these individuals to return to improved physical function postoperatively, there are usually functional limitations that are present beyond discharge (5). Individuals with functional limitations or those who seek a transition from formal rehabilitation to a daily fitness program can benefit from a guided postrehabilitation exercise program.
This presents an opportunity for the strength and conditioning professional to help bridge the gap between any residual impairment that may exist at the postrehabilitation stage and the point at which the individual's optimal physical function is realized. To appreciate this potential, the strength and conditioning professional must have a working knowledge of limitations, precautions, and considerations for individuals having undergone rTSA. An emphasis on maintaining optimal range of motion as well as creating a strong foundation of strength within the intrinsic shoulder musculature can help to maintain and or improve overall shoulder function in the future. Direct communication between the physical therapist and strength and conditioning professional can allow for a progressive postrehabilitation program aimed at restoring function while minimizing risk.
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