🔑 Key Points About Shoulder Replacement Rehabilitation
- The subscapularis tendon is repaired or reattached during surgery: its healing is the limiting factor in all early progressions
- Avoid: reaching behind back, tucking shirt in, pushing up from chair with operated arm, or sleeping flat without arm support
- The deltoid muscle becomes the primary shoulder elevator: it must be re-educated throughout
- Full recovery and final ROM may take 12–18 months: most patients achieve functional (not full) ROM
- Outcome depends on underlying diagnosis (OA vs RA vs fracture), surgical technique, and patient effort
Phase 1
Immediate Post-operative: Day 1
Day 1 only🎯 Goals
- Learn to put sling on and take it off safely
- Understand activity restrictions
- Control pain and reduce swelling
- Keep elbow, wrist, and hand moving
⚠️ Precautions
- Sling with small pillow/towel roll under elbow: day and night for 4–6 weeks
- No active shoulder movement at all
- No weight-bearing through operated arm (no pushing up from chairs)
- No reaching overhead or behind back
- Sleep on back with towel roll: do NOT lie flat without support
- Keep wound dry: no soaking for 2 weeks
Exercises: Day 1
- Elbow bending and straightening: full range, slowly
- Wrist flexion/extension and circles
- Finger bending and straightening: all joints
- Gentle gripping: rolled cloth
- Ice: 15–20 min, multiple times per day
- Chin tucks: gently tuck chin in, hold 5 sec
Phase 2
Protection Phase: Tissue Healing
Day 2 – Week 6🎯 Goals
- Protect the subscapularis repair
- Maintain elbow, wrist, and hand movement
- Reduce pain and muscle guarding
- PROM shoulder flexion to 120° by Week 6
- PROM external rotation to 15–20°
⚠️ Precautions
- Sling at all times including sleeping: remove only for showering and exercises
- No active shoulder movement (AROM)
- External rotation PROM limited to 20° maximum
- No internal rotation exercises (stresses subscapularis repair)
- No pushing up from chair or bed with operated arm
- No driving for 4–6 weeks while in sling
- Light pain-free daily tasks only (brushing teeth, gentle dressing)
Exercises: Week 1–6
- Pendulums: lean forward, arm hangs, gentle small circles (no active muscle use)
- PROM flexion: lying down, good arm guides operated arm gently upward
- Table slide: sit at table, slide arm gently forward on cloth
- PROM external rotation (Week 4–6): to 20° only, in scapular plane
- Scapular retractions: squeeze shoulder blades gently in sling
- Neck stretches: upper trapezius and side bending
- Chin tucks in sitting and lying
- Continue elbow/wrist/hand AROM
- Ice 3–5 times daily
✅ Ready for Phase 3 When:
- PROM shoulder flexion to 120°
- PROM external rotation to 15–20°
- Minimal pain at rest and with exercises
Phase 3
Intermediate Phase: Increasing Movement
Week 6 – Week 10🎯 Goals
- Wean off sling gradually
- PROM flexion to 140°+
- PROM ER to 30°
- Begin active shoulder movement carefully
- Improve scapular strength and control
- Perform light daily activities independently
Exercises
- PROM elevation, ER, and abduction: increase range gradually
- Assisted elevation with cane/stick: supine then sitting
- Wall slide: stand at wall, slide arm up
- Active flexion in gravity-reduced position: lying down, raise arm
- Deltoid isometrics: flexion, extension, abduction against wall (submaximal)
- ER and IR isometrics at doorway: gentle, 5-sec holds
- Serratus anterior protraction: lying, push arm to ceiling
- Wrist strengthening with light weights
✅ Ready for Phase 4 When:
- PROM flexion ≥140°
- PROM ER to 30°
- Active shoulder flexion to 90° in standing with good scapular movement
- Can isometrically activate deltoid and scapular muscles
Phase 4
Advanced Strengthening
Week 10 – Week 16🎯 Goals
- Active flexion to 140° in lying, 120° standing
- PROM flexion to 160°, ER to 60°
- Return to functional daily activities
- Improve muscle strength and endurance
Exercises
- Active movement in all planes: focus on smooth, controlled motion
- Resistance band rows: seated and standing
- Resistance band extension
- ER and IR with resistance band: neutral then progressed
- Biceps curls, triceps extension
- Rhythmic stabilisation: ball on wall, quadruped (from Week 12)
- Posterior capsule stretch: cross-body
- Behind-back IR stretch (from Week 12): only if full extension achieved first
✅ Ready for Phase 5 When:
- PROM flexion 160°, ER 60°
- Active flexion 140° lying, 120° standing: normal scapular movement
- Pain-free with daily activities
Phase 5
Return to Activity
Week 16 – Week 24🎯 Goals
- Full pain-free functional ROM
- Restore functional strength
- Return to work, household, and recreational activities
- Independent with home programme
Exercises
- Continue and progress Phase 4 exercises
- Resistance band PNF patterns
- Work or sport-specific training as needed
- Home programme: 2–3 times/week lifelong for strength maintenance
Activity Guide
| Activity | Allowed? | When | Notes |
|---|---|---|---|
| Sling use | REQUIRED | 4–6 weeks | Day and night; remove only for showering and exercises |
| Elbow/wrist/hand movement | YES | Day 1 | Keep distal joints moving at all times |
| Light dressing/grooming (one arm) | CAUTION | Week 1 | No operated arm active movement; use good arm for most tasks |
| Driving | WAIT | Week 6–10 | Off sling, surgeon clearance; must be off strong painkillers |
| Two-wheeler | WAIT | Month 4+ | Risk of fall stressing repair; confirm with surgeon |
| Office/desk work (one hand) | CAUTION | Week 2–4 | In sling; operated arm resting; no mouse/keyboard initially |
| Light housework | CAUTION | Week 8–10 | No lifting, no reaching overhead, no behind-back tasks |
| Lifting (light: <0.5 kg) | CAUTION | Week 10–12 | Surgeon clearance; avoid sudden lifting |
| Swimming | WAIT | Month 4–5 | After wound healed and surgeon clears; gentle strokes only |
| Cricket batting / overhead sport | WAIT | Month 5–6+ | Surgeon clearance; avoid fast overhead activity long-term |
| Heavy lifting / manual work | WAIT | Month 6+ | Discuss with surgeon: may have permanent restrictions |
| Reaching behind back (tucking shirt) | AVOID | Avoid for 10–12 weeks | Stresses subscapularis repair: major cause of failure |
| Pushing up from chair/bed with operated arm | NEVER | 10–12 weeks | Most common cause of subscapularis re-tear post TSA |
🚨 When to Contact Us
🔴 Come to Hospital Immediately
- Sudden severe pain after a fall or jarring movement
- Shoulder feels as if it has "shifted" or "come out"
- High fever with wound redness, swelling or discharge
- Arm becomes cold, pale, or numb suddenly
🟡 Call Clinic Within 24 Hours
- Wound not healing or looking infected
- Pain not settling with rest and ice
- Shoulder stiffness not improving despite physio
- Sling feels uncomfortable, incorrect, or is causing skin problems
📅 Follow-up Schedule
🗓 Clinic Reviews
- 2 weeks: Wound check, suture removal
- 6 weeks: ROM, sling weaning, X-ray
- 3 months: Strength and function review
- 6 months: Full functional assessment
- 1 year: Annual X-ray and review
⚠️ Long-term Advice
- Home programme 2–3 times/week: lifelong
- Avoid heavy lifting overhead permanently
- Report any new clicking, catching, or giving way early
- Annual review to check implant longevity
🏠 Daily Life Tips
- Sleep on back with towel roll under elbow: not on side
- Dress operated arm first, undress last
- Never use operated arm to push up from low seat
- Use long-handled tools for dressing/shoe-lacing early on